WAC 246-320-136. Leadership

This section describes leadership's role in assuring care is provided consistently throughout the hospital and according to patient and community needs. The hospital leaders must: (1) Appoint or assign a nurse at the executive level to: (a) Direct the nursing services; and (b) Approve patient care policies, nursing practices and procedures; (2) Establish hospital-wide patient care services appropriate for the patients served and available resources which includes: (a) Approving department specific scope of services; (b) Integrating and coordinating patient care services; (c) Standardizing the uniform performance of patient care processes; (d) Establishing a hospital-approved procedure for double checking certain drugs, biologicals, and agents by appropriately licensed personnel; and (e) Ensuring immediate access and appropriate dosages for emergency drugs; (3) Adopt and implement policies and procedures which define standards of care for each specialty service; (4) Provide practitioner oversight for each specialty service with experience in those specialized services. Specialized services include, but are not limited to: (a) Surgery; (b) Anesthesia; (c) Obstetrics; (d) Neonatal; (e) Pediatrics; (f) Critical or intensive care; (g) Alcohol or substance abuse; (h) Psychiatric; (i) Emergency; and (j) Dialysis; (5) Provide all patients access to safe and appropriate care; (6) Adopt and implement policies and procedures addressing patient care and nursing practices; (7) Require that individuals conducting business in the hospital comply with hospital policies and procedures; (8) Establish and implement processes for: (a) Gathering, assessing and acting on information regarding patient and family satisfaction with the services provided; (b) Posting the complaint hotline notice according to RCW 70.41.330 ; and (c) Providing patients written billing statements according to RCW 70.41.400 ; (9) Plan, promote, and conduct organization-wide performance-improvement activities according to WAC 246-320-171 ; (10) Adopt and implement policies and procedures concerning abandoned newborn babies and hospitals as a safe haven according to RCW 13.34.360 ; (11) Adopt and implement policies and procedures to require that suspected abuse, assault, sexual assault or other possible crime is reported within forty-eight hours to local police or the appropriate law enforcement agency according to RCW 26.44.030 .