RCW 70.41.200
Quality improvement and medical malpractice
prevention program -- Quality improvement committee -- Sanction and
grievance procedures -- Information collection, reporting, and
sharing. (Effective until July 1, 2009.)
(1) Every hospital
shall maintain a coordinated quality improvement program for the
improvement of the quality of health care services rendered to
patients and the identification and prevention of medical
malpractice. The program shall include at least the following:
(a) The establishment of a quality improvement committee
with the responsibility to review the services rendered in the
hospital, both retrospectively and prospectively, in order to
improve the quality of medical care of patients and to prevent
medical malpractice. The committee shall oversee and coordinate
the quality improvement and medical malpractice prevention
program and shall ensure that information gathered pursuant to
the program is used to review and to revise hospital policies and
procedures;
(b) A medical staff privileges sanction procedure through
which credentials, physical and mental capacity, and competence
in delivering health care services are periodically reviewed as
part of an evaluation of staff privileges;
(c) The periodic review of the credentials, physical and
mental capacity, and competence in delivering health care
services of all persons who are employed or associated with the
hospital;
(d) A procedure for the prompt resolution of grievances by
patients or their representatives related to accidents, injuries,
treatment, and other events that may result in claims of medical
malpractice;
(e) The maintenance and continuous collection of information
concerning the hospital's experience with negative health care
outcomes and incidents injurious to patients including health
care-associated infections as defined in RCW 43.70.056, patient
grievances, professional liability premiums, settlements, awards,
costs incurred by the hospital for patient injury prevention, and
safety improvement activities;
(f) The maintenance of relevant and appropriate information
gathered pursuant to (a) through (e) of this subsection
concerning individual physicians within the physician's personnel
or credential file maintained by the hospital;
(g) Education programs dealing with quality improvement,
patient safety, medication errors, injury prevention, infection
control, staff responsibility to report professional misconduct,
the legal aspects of patient care, improved communication with
patients, and causes of malpractice claims for staff personnel
engaged in patient care activities; and
(h) Policies to ensure compliance with the reporting
requirements of this section.
(2) Any person who, in substantial good faith, provides
information to further the purposes of the quality improvement
and medical malpractice prevention program or who, in substantial
good faith, participates on the quality improvement committee
shall not be subject to an action for civil damages or other
relief as a result of such activity. Any person or entity
participating in a coordinated quality improvement program that,
in substantial good faith, shares information or documents with
one or more other programs, committees, or boards under
subsection (8) of this section is not subject to an action for
civil damages or other relief as a result of the activity. For
the purposes of this section, sharing information is presumed to
be in substantial good faith. However, the presumption may be
rebutted upon a showing of clear, cogent, and convincing evidence
that the information shared was knowingly false or deliberately
misleading.
(3) Information and documents, including complaints and
incident reports, created specifically for, and collected and
maintained by, a quality improvement committee are not subject to
review or disclosure, except as provided in this section, or
discovery or introduction into evidence in any civil action, and
no person who was in attendance at a meeting of such committee or
who participated in the creation, collection, or maintenance of
information or documents specifically for the committee shall be
permitted or required to testify in any civil action as to the
content of such proceedings or the documents and information
prepared specifically for the committee. This subsection does
not preclude: (a) In any civil action, the discovery of the
identity of persons involved in the medical care that is the
basis of the civil action whose involvement was independent of
any quality improvement activity; (b) in any civil action, the
testimony of any person concerning the facts which form the basis
for the institution of such proceedings of which the person had
personal knowledge acquired independently of such proceedings;
(c) in any civil action by a health care provider regarding the
restriction or revocation of that individual's clinical or staff
privileges, introduction into evidence information collected and
maintained by quality improvement committees regarding such
health care provider; (d) in any civil action, disclosure of the
fact that staff privileges were terminated or restricted,
including the specific restrictions imposed, if any and the
reasons for the restrictions; or (e) in any civil action,
discovery and introduction into evidence of the patient's medical
records required by regulation of the department of health to be
made regarding the care and treatment received.
(4) Each quality improvement committee shall, on at least a
semiannual basis, report to the governing board of the hospital
in which the committee is located. The report shall review the
quality improvement activities conducted by the committee, and
any actions taken as a result of those activities.
(5) The department of health shall adopt such rules as are
deemed appropriate to effectuate the purposes of this section.
(6) The medical quality assurance commission or the board of
osteopathic medicine and surgery, as appropriate, may review and
audit the records of committee decisions in which a physician's
privileges are terminated or restricted. Each hospital shall
produce and make accessible to the commission or board the
appropriate records and otherwise facilitate the review and
audit. Information so gained shall not be subject to the
discovery process and confidentiality shall be respected as
required by subsection (3) of this section. Failure of a
hospital to comply with this subsection is punishable by a civil
penalty not to exceed two hundred fifty dollars.
(7) The department, the joint commission on accreditation of
health care organizations, and any other accrediting organization
may review and audit the records of a quality improvement
committee or peer review committee in connection with their
inspection and review of hospitals. Information so obtained
shall not be subject to the discovery process, and
confidentiality shall be respected as required by subsection (3)
of this section. Each hospital shall produce and make accessible
to the department the appropriate records and otherwise
facilitate the review and audit.
(8) A coordinated quality improvement program may share
information and documents, including complaints and incident
reports, created specifically for, and collected and maintained
by, a quality improvement committee or a peer review committee
under RCW 4.24.250 with one or more other coordinated quality
improvement programs maintained in accordance with this section
or RCW 43.70.510, a quality assurance committee maintained in
accordance with RCW 18.20.390 or 74.42.640, or a peer review
committee under RCW 4.24.250, for the improvement of the quality
of health care services rendered to patients and the
identification and prevention of medical malpractice. The
privacy protections of chapter 70.02 RCW and the federal health
insurance portability and accountability act of 1996 and its
implementing regulations apply to the sharing of individually
identifiable patient information held by a coordinated quality
improvement program. Any rules necessary to implement this
section shall meet the requirements of applicable federal and
state privacy laws. Information and documents disclosed by one
coordinated quality improvement program to another coordinated
quality improvement program or a peer review committee under RCW 4.24.250 and any information and documents created or maintained
as a result of the sharing of information and documents shall not
be subject to the discovery process and confidentiality shall be
respected as required by subsection (3) of this section, RCW 18.20.390 (6) and (8), 74.42.640 (7) and (9), and 4.24.250.
(9) A hospital that operates a nursing home as defined in
RCW 18.51.010 may conduct quality improvement activities for both
the hospital and the nursing home through a quality improvement
committee under this section, and such activities shall be
subject to the provisions of subsections (2) through (8) of this
section.
(10) Violation of this section shall not be considered
negligence per se.
[2007 c 261 § 3. Prior: 2005 c 291 § 3; 2005 c 33 § 7; 2004 c 145 § 3; 2000 c 6 § 3; 1994 sp.s. c 9 § 742; 1993 c 492 § 415; 1991 c 3 § 336; 1987 c 269 § 5; 1986 c 300 § 4.]
NOTES:
Findings -- 2007 c 261: See note following RCW 43.70.056.
Findings -- 2005 c 33: See note following RCW 18.20.390.
Severability -- Headings and captions not law -- Effective date -- 1994 sp.s. c 9: See RCW 18.79.900 through 18.79.902.
Findings--Intent -- 1993 c 492: See notes following RCW 43.20.050.
Short title -- Severability -- Savings -- Captions not law -- Reservation of legislative power -- Effective dates -- 1993 c 492: See RCW 43.72.910 through 43.72.915.
Legislative findings -- Severability -- 1986 c 300: See notes following RCW 18.57.245.
Board of osteopathic medicine and surgery: Chapter 18.57 RCW.
Medical quality assurance commission: Chapter 18.71 RCW.
RCW 70.41.200
Quality improvement and medical malpractice
prevention program -- Quality improvement committee -- Sanction and
grievance procedures -- Information collection, reporting, and
sharing. (Effective July 1, 2009.)
(1) Every hospital shall
maintain a coordinated quality improvement program for the
improvement of the quality of health care services rendered to
patients and the identification and prevention of medical
malpractice. The program shall include at least the following:
(a) The establishment of a quality improvement committee
with the responsibility to review the services rendered in the
hospital, both retrospectively and prospectively, in order to
improve the quality of medical care of patients and to prevent
medical malpractice. The committee shall oversee and coordinate
the quality improvement and medical malpractice prevention
program and shall ensure that information gathered pursuant to
the program is used to review and to revise hospital policies and
procedures;
(b) A medical staff privileges sanction procedure through
which credentials, physical and mental capacity, and competence
in delivering health care services are periodically reviewed as
part of an evaluation of staff privileges;
(c) The periodic review of the credentials, physical and
mental capacity, and competence in delivering health care
services of all persons who are employed or associated with the
hospital;
(d) A procedure for the prompt resolution of grievances by
patients or their representatives related to accidents, injuries,
treatment, and other events that may result in claims of medical
malpractice;
(e) The maintenance and continuous collection of information
concerning the hospital's experience with negative health care
outcomes and incidents injurious to patients including health
care-associated infections as defined in RCW 43.70.056, patient
grievances, professional liability premiums, settlements, awards,
costs incurred by the hospital for patient injury prevention, and
safety improvement activities;
(f) The maintenance of relevant and appropriate information
gathered pursuant to (a) through (e) of this subsection
concerning individual physicians within the physician's personnel
or credential file maintained by the hospital;
(g) Education programs dealing with quality improvement,
patient safety, medication errors, injury prevention, infection
control, staff responsibility to report professional misconduct,
the legal aspects of patient care, improved communication with
patients, and causes of malpractice claims for staff personnel
engaged in patient care activities; and
(h) Policies to ensure compliance with the reporting
requirements of this section.
(2) Any person who, in substantial good faith, provides
information to further the purposes of the quality improvement
and medical malpractice prevention program or who, in substantial
good faith, participates on the quality improvement committee
shall not be subject to an action for civil damages or other
relief as a result of such activity. Any person or entity
participating in a coordinated quality improvement program that,
in substantial good faith, shares information or documents with
one or more other programs, committees, or boards under
subsection (8) of this section is not subject to an action for
civil damages or other relief as a result of the activity. For
the purposes of this section, sharing information is presumed to
be in substantial good faith. However, the presumption may be
rebutted upon a showing of clear, cogent, and convincing evidence
that the information shared was knowingly false or deliberately
misleading.
(3) Information and documents, including complaints and
incident reports, created specifically for, and collected and
maintained by, a quality improvement committee are not subject to
review or disclosure, except as provided in this section, or
discovery or introduction into evidence in any civil action, and
no person who was in attendance at a meeting of such committee or
who participated in the creation, collection, or maintenance of
information or documents specifically for the committee shall be
permitted or required to testify in any civil action as to the
content of such proceedings or the documents and information
prepared specifically for the committee. This subsection does
not preclude: (a) In any civil action, the discovery of the
identity of persons involved in the medical care that is the
basis of the civil action whose involvement was independent of
any quality improvement activity; (b) in any civil action, the
testimony of any person concerning the facts which form the basis
for the institution of such proceedings of which the person had
personal knowledge acquired independently of such proceedings;
(c) in any civil action by a health care provider regarding the
restriction or revocation of that individual's clinical or staff
privileges, introduction into evidence information collected and
maintained by quality improvement committees regarding such
health care provider; (d) in any civil action, disclosure of the
fact that staff privileges were terminated or restricted,
including the specific restrictions imposed, if any and the
reasons for the restrictions; or (e) in any civil action,
discovery and introduction into evidence of the patient's medical
records required by regulation of the department of health to be
made regarding the care and treatment received.
(4) Each quality improvement committee shall, on at least a
semiannual basis, report to the governing board of the hospital
in which the committee is located. The report shall review the
quality improvement activities conducted by the committee, and
any actions taken as a result of those activities.
(5) The department of health shall adopt such rules as are
deemed appropriate to effectuate the purposes of this section.
(6) The medical quality assurance commission or the board of
osteopathic medicine and surgery, as appropriate, may review and
audit the records of committee decisions in which a physician's
privileges are terminated or restricted. Each hospital shall
produce and make accessible to the commission or board the
appropriate records and otherwise facilitate the review and
audit. Information so gained shall not be subject to the
discovery process and confidentiality shall be respected as
required by subsection (3) of this section. Failure of a
hospital to comply with this subsection is punishable by a civil
penalty not to exceed two hundred fifty dollars.
(7) The department, the joint commission on accreditation of
health care organizations, and any other accrediting organization
may review and audit the records of a quality improvement
committee or peer review committee in connection with their
inspection and review of hospitals. Information so obtained
shall not be subject to the discovery process, and
confidentiality shall be respected as required by subsection (3)
of this section. Each hospital shall produce and make accessible
to the department the appropriate records and otherwise
facilitate the review and audit.
(8) A coordinated quality improvement program may share
information and documents, including complaints and incident
reports, created specifically for, and collected and maintained
by, a quality improvement committee or a peer review committee
under RCW 4.24.250 with one or more other coordinated quality
improvement programs maintained in accordance with this section
or RCW 43.70.510, a coordinated quality improvement committee
maintained by an ambulatory surgical facility under RCW 70.230.070, a quality assurance committee maintained in
accordance with RCW 18.20.390 or 74.42.640, or a peer review
committee under RCW 4.24.250, for the improvement of the quality
of health care services rendered to patients and the
identification and prevention of medical malpractice. The
privacy protections of chapter 70.02 RCW and the federal health
insurance portability and accountability act of 1996 and its
implementing regulations apply to the sharing of individually
identifiable patient information held by a coordinated quality
improvement program. Any rules necessary to implement this
section shall meet the requirements of applicable federal and
state privacy laws. Information and documents disclosed by one
coordinated quality improvement program to another coordinated
quality improvement program or a peer review committee under RCW 4.24.250 and any information and documents created or maintained
as a result of the sharing of information and documents shall not
be subject to the discovery process and confidentiality shall be
respected as required by subsection (3) of this section, RCW 18.20.390 (6) and (8), 74.42.640 (7) and (9), and 4.24.250.
(9) A hospital that operates a nursing home as defined in
RCW 18.51.010 may conduct quality improvement activities for both
the hospital and the nursing home through a quality improvement
committee under this section, and such activities shall be
subject to the provisions of subsections (2) through (8) of this
section.
(10) Violation of this section shall not be considered
negligence per se.
[2007 c 273 § 22; 2007 c 261 § 3. Prior: 2005 c 291 § 3; 2005 c 33 § 7; 2004 c 145 § 3; 2000 c 6 § 3; 1994 sp.s. c 9 § 742; 1993 c 492 § 415; 1991 c 3 § 336; 1987 c 269 § 5; 1986 c 300 § 4.]
NOTES:
Reviser's note: This section was amended by 2007 c 261 § 3 and by 2007 c 273 § 22, each without reference to the other. Both amendments are incorporated in the publication of this section under RCW 1.12.025(2). For rule of construction, see RCW 1.12.025(1).
Effective date -- Implementation -- 2007 c 273: See RCW 70.230.900 and 70.230.901.
Finding -- 2007 c 261: See note following RCW 43.70.056.
Findings -- 2005 c 33: See note following RCW 18.20.390.
Severability -- Headings and captions not law -- Effective date -- 1994 sp.s. c 9: See RCW 18.79.900 through 18.79.902.
Findings--Intent -- 1993 c 492: See notes following RCW 43.20.050.
Short title -- Severability -- Savings -- Captions not law -- Reservation of legislative power -- Effective dates -- 1993 c 492: See RCW 43.72.910 through 43.72.915.
Legislative findings -- Severability -- 1986 c 300: See notes following RCW 18.57.245.
Board of osteopathic medicine and surgery: Chapter 18.57 RCW.
Medical quality assurance commission: Chapter 18.71 RCW.