PDFWAC 246-324-040
Governing body and administration.
The governing body shall:
(1) Adopt written policies concerning the purposes, operation and maintenance of the hospital, and the safety, care and treatment of patients;
(2) Provide staff, facilities, equipment, supplies and services to meet the needs of patients within the purposes of the hospital;
(3) Establish and maintain a current written organizational plan delineating positions, responsibilities, authorities, and relationships of positions within the hospital;
(4) Appoint an administrator responsible for implementing the policies adopted by the governing body;
(5) Appoint a physician as medical director responsible for directing and supervising medical treatment and patient care twenty-four hours per day;
(6) Maintain an organized professional staff accountable to the governing body;
(7) Appoint and periodically reappoint the professional staff;
(8) Require and approve professional staff bylaws and rules concerning, at a minimum:
(a) Organization of the professional staff;
(b) Delineation of privileges;
(c) Requirements for membership;
(d) Specific mechanisms for appointing and reappointing members;
(e) Granting, renewing and revising clinical privileges;
(f) Self-government;
(g) Required functions;
(h) Accountability to the governing body; and
(i) Mechanisms to monitor and evaluate quality of care and clinical performance; and
(9) Require that each person admitted to the hospital is under the care of a professional staff member with clinical privileges.