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

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

(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 those listed in subsection (1) of this section.