WAC 246-976-881   Trauma quality improvement programs for designated trauma care services.  (1) All designated levels I - V and pediatric levels I - III trauma services must have a quality assessment and improvement program conducted by the multidisciplinary trauma committee that reflects and demonstrates a process for continuous quality improvement consistent with your written scope of trauma service, with:

     (a) An organizational structure that facilitates the process of quality assurance and improvement and identifies the authority to change policies, procedures, and protocols that address the care of the trauma patient;

     (b) Developments of standards of quality care;

     (c) A process for monitoring compliance with or adherence to the standards;

     (d) A process of peer review to evaluate specific cases or problems identified by the monitoring process;

     (e) A process for correcting problems or deficiencies;

     (f) A process to analyze and evaluate the effect of corrective action;

     (g) A process to insure that confidentiality of patient and provider information is maintained according to the standards of RCW 70.41.200 and 70.168.090.

     (2) Designated levels I and II trauma rehabilitation services and level I pediatric trauma rehabilitation services shall have a quality assessment and improvement program that reflects and demonstrates a process for continuous quality improvement in the delivery of trauma care, with:

     (a) An organizational structure and plan that facilitates the process of quality assurance and improvement and identified the authority to change policies, procedures, and protocols that address the care of the major trauma patient;

     (b) Participation of members of the multidisciplinary trauma rehabilitation team, including involvement of the trauma rehabilitation coordinator of the referring acute trauma care service;

     (c) Development of outcome standards;

     (d) A process for monitoring compliance with or adherence to the outcome standards;

     (e) A process of internal peer review to evaluate specific cases or problems identified by the outcome monitoring process;

     (f) A process for implementing corrective action to address problems or deficiencies;

     (g) A process to analyze and evaluate the effect of corrective action;

     (h) A process to insure that confidentiality of patient and provider information is maintained according to the standards of RCW 70.41.200 and 70.168.090.

     (3) A designated level III trauma rehabilitation service shall have an organized trauma rehabilitation quality assessment and improvement program that reflects and demonstrates a process for continuous quality improvement in the delivery of trauma care, with:

     (a) A special audit process for rehabilitation trauma patients to identify the trauma rehabilitation outcome standards and indicators which monitor this program;

     (b) A multidisciplinary team, to include the physician identified as responsible for coordination of rehabilitation trauma activities;

     (c) A process to insure that confidentiality of patient and provider information is maintained according to the standards of RCW 70.41.200 and 70.168.090.



[Statutory Authority: RCW 70.168.060 and 70.168.070. 04-01-041, § 246-976-881, filed 12/10/03, effective 1/10/04. Statutory Authority: Chapter 70.168 RCW. 98-04-038, § 246-976-881, filed 1/29/98, effective 3/1/98.]