Quality and patient safety
Assesses hospital governance, standardized clinical protocols, staff adherence, and documented evidentiary compliance for quality and patient safety.
Trend Direction
up (+1%)
Identified compliance findings in QPS (3)
Evidence gap identified for QPS.7 during document analysis; requires documented remediation. (demonstration)
Evidence gap identified for QPS.7 during self-assessment; requires documented remediation. (demonstration)
Evidence gap identified for QPS.7 during document analysis; requires documented remediation. (demonstration)
Requirements & Measurable Elements
20 total requirementsRequirement | Standard text (paraphrased) | Criticality | Measurable Elements | Status |
|---|---|---|---|---|
| QPS.7 | Sentinel events analysed with structured root-cause review (paraphrased) policyrca | high | 4 of 5 met72% | Partial |
| QPS.3 | Quality and patient safety — control 3: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met76% | Partial |
| QPS.4 | Quality and patient safety — control 4: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 3 met84% | Partial |
| QPS.5 | Quality and patient safety — control 5: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 2 of 4 met58% | Gap |
| QPS.6 | Quality and patient safety — control 6: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met58% | Gap |
| QPS.7 | Quality and patient safety — control 7: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 6 met68% | Partial |
| QPS.8 | Quality and patient safety — control 8: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 4 of 5 met76% | Partial |
| QPS.9 | Quality and patient safety — control 9: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 5 met64% | Gap |
| QPS.10 | Quality and patient safety — control 10: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met82% | Partial |
| QPS.11 | Quality and patient safety — control 11: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 3 of 5 met60% | Gap |
| QPS.12 | Quality and patient safety — control 12: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 5 met62% | Gap |
| QPS.13 | Quality and patient safety — control 13: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met69% | Partial |
| QPS.14 | Quality and patient safety — control 14: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met76% | Partial |
| QPS.15 | Quality and patient safety — control 15: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met80% | Partial |
| QPS.16 | Quality and patient safety — control 16: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 5 met62% | Gap |
| QPS.17 | Quality and patient safety — control 17: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met76% | Partial |
| QPS.18 | Quality and patient safety — control 18: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 5 of 6 met84% | Partial |
| QPS.19 | Quality and patient safety — control 19: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 2 of 3 met78% | Partial |
| QPS.20 | Quality and patient safety — control 20: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 3 met57% | Gap |
| QPS.21 | Quality and patient safety — control 21: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met78% | Partial |