Every hospital licensed in this state and its insurance carrier shall cooperatively, as part of their administrative functions, establish an internal risk management program which shall include at least the following components:

(1)  An in-hospital grievance or complaint mechanism designed to process and resolve as promptly and effectively as possible grievances by patients or their representatives related to incidents, billing, inadequacies in treatment, and other factors known to influence malpractice claims and suits. The mechanism shall include appointment of a representative accountable to the hospital administration who shall anticipate and monitor on a day-to-day basis the grievances and administer the mechanism;

(2)  The continuous collection of data by each hospital with respect to its negative health care outcomes (whether or not they give rise to claims), patient grievances, claims, suits, professional liability premiums, settlements, awards, allocated and administrative costs of claims handling, costs of patient injury prevention and safety engineering activities, and other relevant statistics and information;

(3)  Medical care evaluation mechanisms, which shall include but not be limited to, tissue committees or medical audit committees, to review the appropriateness of procedures performed, to periodically assess the quality of medical care being provided at the institution, and to pass on the necessity of surgery;

(4)  Education programs for the hospital’s staff personnel engaged in patient care activities dealing with patient safety, medical injury prevention, the legal aspects of patient care, problems of communication and rapport with patients, and other relevant factors known to influence malpractice claims and suits.