WAC 246-330-155. Coordinated quality improvement program

The purpose of this section is to ensure the establishment and on-going maintenance of a coordinated quality improvement program. The intent is to improve the quality of health care services provided to patients and to identify and prevent medical malpractice. An ambulatory surgical facility must: (1) Have a facility-wide approach to process design and performance measurement, assessment, and improving patient care services according to RCW 70.230.080 including, but not limited to: (a) A written performance improvement plan that is periodically evaluated; (b) Performance improvement activities that are interdisciplinary and include at least one member of the governing authority; (c) Prioritize performance improvement activities; (d) Implement and monitor actions taken to improve performance; (e) Education programs dealing with performance improvement, patient safety, medication errors, injury prevention; and (f) Review serious or unanticipated patient outcomes in a timely manner. (2) Systematically collect, measure and assess data on processes and outcomes related to patient care and organization functions; (3) Collect, measure and assess data including, but not limited to: (a) Operative, other invasive, and noninvasive procedures that place patients at risk; (b) Infection rates, pathogen distributions and antimicrobial susceptibility profiles; (c) Death; (d) Medication management or administration related to wrong medication, wrong dose, wrong time, near misses and any other medication errors and incidents; (e) Injuries, falls, restraint use, negative health outcomes and incidents injurious to patients in the ambulatory surgical facility; (f) Adverse events according to chapter 246-302 WAC; (g) Discrepancies or patterns between preoperative and postoperative (including pathologic) diagnosis, including pathologic review of specimens removed during surgical or invasive procedures; (h) Adverse drug reactions (as defined by the ambulatory surgical facility); (i) Confirmed transfusion reactions; (j) Patient grievances, needs, expectations, and satisfaction; and (k) Quality control and risk management activities.