Current through Register Vol. 24-06, March 15, 2024
(1) The department will:
(a) Develop guidelines for a regional EMS/TC
system quality assurance and improvement program including:
(i) Purpose and principles of the
program;
(ii) Establishing and
maintaining the program;
(iii)
Process;
(iv) Membership of the
quality assurance and improvement program committee;
(v) Authority and responsibilities of the
quality assurance and improvement program committee;
(b) Review and approve written regional
quality assurance and improvement plans;
(c) Provide trauma registry data to regional
quality assurance and improvement programs in the following formats:
(i) Quarterly standard reports;
(ii) Ad hoc reports as requested according to
department guidelines.
(2) Levels I, II, and III, and Level I, II
and III pediatric trauma care services must:
(a) Establish, coordinate and participate in
regional EMS/TC systems quality assurance and improvement programs;
(b) Ensure participation in the regional
quality assurance and improvement program of:
(i) Their trauma service director or
codirector; and
(ii) The RN who
coordinates the trauma service;
(c) Ensure maintenance and continuation of
the regional quality assurance and improvement program.
(3) The regional quality assurance and
improvement program committee must include:
(a) At least one member of each designated
facility's medical staff;
(b) The
RN coordinator of each designated trauma service;
(c) An EMS provider.
(4) The regional quality assurance program
must invite the MPD and all other health care providers and facilities
providing trauma care in the region, to participate in the regional trauma
quality assurance program.
(5) The
regional quality assurance and improvement program may invite:
(a) One or more regional EMS/TC council
members;
(b) A trauma care provider
who does not work or reside in the region.
(6) The regional quality assurance and
improvement program must include a written plan for implementation including:
(a) Operational policies and procedures that
detail committee actions and processes;
(b) Audit filters for adult and pediatric
patients;
(c) Monitoring compliance
with the requirements of chapter 70.168 RCW and this chapter;
(d) Policies and procedures for notifying the
department and the regional EMS/TC council of identified regional or statewide
trauma system issues, and any recommendations;
(e) Policies regarding confidentiality of:
(i) Information related to provider's and
facility's clinical care, and patient outcomes, in accordance with chapter
70.168 RCW;
(ii) Quality assurance
and improvement committee minutes, records, and reports in accordance with
RCW
70.168.090(4), including a
requirement that each attendee of a regional quality assurance and improvement
committee meeting is informed in writing of the confidentiality requirement.
Information identifying individual patients may not be publicly disclosed
without the patient's consent.
Statutory Authority:
Chapters
18.71,
18.73, and 70.168 RCW. 00-08-102,
§ 246-976-910, filed 4/5/00, effective 5/6/00. Statutory Authority:
RCW
43.70.040 and
chapters
18.71,
18.73 and 70.168 RCW. 93-01-148
(Order 323), § 246-976-910, filed 12/23/92, effective
1/23/93.
