A program under the provisions of RCW 43.70.510 shall include, at a minimum:

1. (1) The following components, as modified and approved by the department to reflect the structural organization of the health care entity:

   1. (a) A governing body;

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

      1. (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;
      2. (ii) Reviewing categories and methodologies of services rendered and to be rendered with the goal of improving health care outcomes;
      3. (iii) Overseeing and coordinating the program;
      4. (iv) Ensuring information gathered for the program is reviewed and used to revise health care policies and procedures; and
      5. (v) Reporting to the governing body, at least semiannually, on program activities and actions taken as a result of those activities;
   3. (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;
   4. (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;

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

      1. (i) Experience with negative health care outcomes and injurious incidents; and
      2. (ii) Professional liability premiums, settlements, awards, costs for injury prevention and safety improvement activities;
   6. (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;
   7. (g) A process for reporting accidents, injuries, negative health outcomes, and other pertinent information to the quality improvement committee;
   8. (h) A process assuring compliance with reporting requirements to appropriate local, state, and federal authorities;
   9. (i) A method for identifying documents and records created specifically for and collected and maintained by the quality improvement committee;

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

       1. (i) Quality improvement;
       2. (ii) Safety and injury prevention;
       3. (iii) Responsibilities for reporting professional misconduct;
       4. (iv) Legal aspects of providing health care;
       5. (v) Improving communication with health care recipients; and
       6. (vi) Causes of malpractice claims; or
2. (2) Components determined by the department to be substantially equivalent to those listed in subsection (1) of this section.

[Statutory Authority: RCW 43.70.510 and 43.70.250(2). WSR 21-09-077, § 246-50-020, filed 4/20/21, effective 5/21/21. Statutory Authority: RCW 43.70.510. WSR 94-24-001, § 246-50-020, filed 11/23/94, effective 12/24/94.]