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.