The purpose of this section is to ensure that performance improvement activities of clinical staff result in continuous improvement of client health outcomes.

Each childbirth center licensee must maintain a quality improvement program to assure the quality of care and services provided that includes, at a minimum:

(1) A complaint process that includes a procedure for the receipt, investigation, and disposition of complaints regarding services;

(2) A method to identify, monitor and evaluate:

(a) Services; and

(b) Referral, transfer, consultation, and transport experience and plans; and

(c) Complications of pregnancy, labor and postpartum; and

(d) Other aspects of services which affect quality care.

(3) A method to identify, evaluate, monitor and correct problems identified by clients, families, clinical staff, volunteers, students or consultants.

(4) A method to identify, evaluate, monitor and correct problems associated with events reported to the department in WAC 246-329-045 (3)(a) through (l) and (4)(a) and (b) as required by chapter 70.56 RCW.

(5) A method to monitor, evaluate and modify as needed corrective actions taken.

(6) A system to assess client satisfaction.