WAC 246-50-020   Coordinated quality improvement program -- Components.  A program under the provisions of RCW 43.70.510 shall include, at a minimum:

     (1) The following components:

     (a) A governing body;

     (b) A committee, appointed by the governing body, with a broad representation of the services offered, responsible for:

     (i) Reviewing services rendered, both retrospectively and prospectively, to improve the quality of health care by measuring key characteristics such as effectiveness, accuracy, timeliness, and cost;

     (ii) Reviewing categories and methodologies of services rendered and to be rendered with the goal of improving health care outcomes;

     (iii) Overseeing and coordinating the program;

     (iv) Ensuring information gathered for the program is reviewed and used to revise health care policies and procedures; and

     (v) Reporting to the governing body, at least semiannually, on program activities and actions taken as a result of those activities;

     (c) Periodic evaluation of each provider under the purview of the program, including mental and physical capacity, competence in delivering health care, and verification of current credentials;

     (d) A procedure for promptly resolving all complaints pertaining to accidents, injuries, treatment and other events that may result in claims of health care malpractice;

     (e) A method for continually collecting and maintaining information concerning:

     (i) Experience with negative health care outcomes and injurious incidents; and

     (ii) Professional liability premiums, settlements, awards, costs for injury prevention and safety improvement activities;

     (f) A method for maintaining information gathered under the purview of the program concerning a provider in that provider's personnel or credential file, assuring patient confidentiality;

     (g) A process for reporting accidents, injuries, negative health outcomes, and other pertinent information to the quality improvement committee;

     (h) A process assuring compliance with reporting requirements to appropriate local, state and federal authorities;

     (i) A method for identifying documents and records created specifically for and collected and maintained by the quality improvement committee;

     (j) Educational activities for personnel engaged in health care activities, including, but not limited to:

     (i) Quality improvement;

     (ii) Safety and injury prevention;

     (iii) Responsibilities for reporting professional misconduct;

     (iv) Legal aspects of providing health care;

     (v) Improving communication with health care recipients; and

     (vi) Causes of malpractice claims; or

     (2) Components determined by the department to be substantially equivalent to subsection (1) of this section.



[Statutory Authority: RCW 43.70.510. 94-24-001, § 246-50-020, filed 11/23/94, effective 12/24/94.]