This section requires development of a medical staff structure, consistent with clinical competence, to ensure a safe patient care environment.

The medical staff must:

(1) Be accountable to the governing body;

(2) Adopt bylaws, rules, regulations, and organizational structure including an appointment and reappointment process;

(3) Be legally and professionally qualified for the positions to which they are appointed and for the performance of privileges in accordance with recommendations from qualified medical personnel;

(4) Periodically review and reappraise medical staff privileges using peer review data;

(5) Periodically review and amend the scope of procedures performed in the ambulatory surgical facility;

(6) If the ambulatory surgical facility assigns patient care responsibilities to practitioners other than physicians, it must have established policies and procedures, approved by the governing body, for overseeing and evaluating their clinical activities; and

(7) Report practitioners for discipline of unprofessional conduct according to RCW 70.230.120.