WAC 246-330-115. Governance

This section outlines the organizational guidance and oversight responsibilities of ambulatory surgical facility resources and staff to support safe patient care. An ambulatory surgical facility must have a governing authority that is responsible for determining, implementing, monitoring and revising policies and procedures covering the operation of the facility that includes: (1) Selecting and periodically evaluating a chief executive officer or administrator; (2) Appointing and periodically reviewing a medical staff; (3) Approving the medical staff bylaws; (4) Reporting practitioners according to RCW 70.230.120 ; (5) Informing patients of any unanticipated outcomes according to RCW 70.230.150 ; (6) Establishing and approving a coordinated quality performance improvement plan according to RCW 70.230.080 ; (7) Establishing and approving a facility safety and emergency training program according to RCW 70.230.060 ; (8) Reporting adverse events and conducting root cause analyses according to chapter 246-302 WAC; (9) Providing a patient and family grievance process including a time frame for resolving each grievance according to RCW 70.230.080 (1)(d); (10) Defining who can give and receive patient care orders that are consistent with professional licensing laws; and (11) Defining who can authenticate written or electronic orders for all drugs, intravenous solutions, blood, and medical treatments that are consistent with professional licensing laws.