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.