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PDFWAC 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.
[Statutory Authority: Chapter 70.56 RCW. WSR 12-16-057, § 246-330-155, filed 7/30/12, effective 10/1/12. Statutory Authority: Chapter 70.230 RCW. WSR 09-09-032, § 246-330-155, filed 4/7/09, effective 5/8/09.]
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