(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 and EMS 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.