PDFWAC 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. WSR 94-24-001, § 246-50-020, filed 11/23/94, effective 12/24/94.]