Section 246-330-155 - Coordinated quality improvement programThe 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;(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.Wash. Admin. Code § 246-330-155
Statutory Authority: Chapter 70.56 RCW. 12-16-057, § 246-330-155, filed 7/30/12, effective 10/1/12. Statutory Authority: Chapter 70.230 RCW. 09-09-032, § 246-330-155, filed 4/7/09, effective 5/8/09.