This section describes leadership's role in assuring care is provided consistently throughout the hospital and according to patient and community needs.

The hospital leaders must:

1. (1) Appoint or assign a nurse at the executive level to:

   1. (a) Direct the nursing services; and
   2. (b) Approve patient care policies, nursing practices and procedures;

2. (2) Establish hospital-wide patient care services appropriate for the patients served and available resources which includes:

   1. (a) Approving department specific scope of services;
   2. (b) Integrating and coordinating patient care services;
   3. (c) Standardizing the uniform performance of patient care processes;
   4. (d) Establishing a hospital-approved procedure for double checking certain drugs, biologicals, and agents by appropriately licensed personnel; and
   5. (e) Ensuring immediate access and appropriate dosages for emergency drugs;
3. (3) Adopt and implement policies and procedures which define standards of care for each specialty service;

4. (4) Provide practitioner oversight for each specialty service with experience in those specialized services. Specialized services include, but are not limited to:

   1. (a) Surgery;
   2. (b) Anesthesia;
   3. (c) Obstetrics;
   4. (d) Neonatal;
   5. (e) Pediatrics;
   6. (f) Critical or intensive care;
   7. (g) Alcohol or substance abuse;
   8. (h) Psychiatric;
   9. (i) Emergency; and
   10. (j) Dialysis;
5. (5) Provide all patients access to safe and appropriate care;
6. (6) Adopt and implement policies and procedures addressing patient care and nursing practices;
7. (7) Require that individuals conducting business in the hospital comply with hospital policies and procedures;

8. (8) Establish and implement processes for:

   1. (a) Gathering, assessing and acting on information regarding patient and family satisfaction with the services provided;
   2. (b) Posting the complaint hotline notice according to RCW 70.41.330; and
   3. (c) Providing patients written billing statements according to RCW 70.41.400;
9. (9) Plan, promote, and conduct organization-wide performance-improvement activities according to WAC 246-320-171;
10. (10) Adopt and implement policies and procedures concerning abandoned newborn babies and hospitals as a safe haven according to RCW 13.34.360;
11. (11) Adopt and implement policies and procedures to require that suspected abuse, assault, sexual assault or other possible crime is reported within forty-eight hours to local police or the appropriate law enforcement agency according to RCW 26.44.030.

[Statutory Authority: Chapter 70.41 RCW and RCW 43.70.040. WSR 09-07-050, § 246-320-136, filed 3/11/09, effective 4/11/09.]