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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.
[Statutory Authority: Chapter 70.41 RCW and RCW 43.70.040. WSR 09-07-050, ยง 246-320-136, filed 3/11/09, effective 4/11/09.]
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