Staff qualifications and education
Assesses hospital governance, standardized clinical protocols, staff adherence, and documented evidentiary compliance for staff qualifications and education.
Trend Direction
up (+1%)
Identified compliance findings in SQE (5)
Evidence gap identified for SQE.14 during learner evaluation; requires documented remediation. (demonstration)
Evidence gap identified for SQE.14 during document analysis; requires documented remediation. (demonstration)
Evidence gap identified for SQE.5 during self-assessment; requires documented remediation. (demonstration)
Evidence gap identified for SQE.14 during learner evaluation; requires documented remediation. (demonstration)
Evidence gap identified for SQE.14 during mock surveyor; requires documented remediation. (demonstration)
Requirements & Measurable Elements
17 total requirementsRequirement | Standard text (paraphrased) | Criticality | Measurable Elements | Status |
|---|---|---|---|---|
| SQE.5 | Staff files include verified qualifications and orientation records (paraphrased) hr-file | medium | 2 of 3 met80% | Partial |
| SQE.14 | Medical staff credentialing and privileging kept current (paraphrased) hr-filecommittee | high | 3 of 4 met78% | Partial |
| SQE.4 | Staff qualifications and education — control 4: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 4 of 4 met93% | Met |
| SQE.5 | Staff qualifications and education — control 5: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 5 of 6 met86% | Met |
| SQE.6 | Staff qualifications and education — control 6: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met73% | Partial |
| SQE.7 | Staff qualifications and education — control 7: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met69% | Partial |
| SQE.8 | Staff qualifications and education — control 8: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 3 of 4 met84% | Partial |
| SQE.9 | Staff qualifications and education — control 9: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met89% | Met |
| SQE.10 | Staff qualifications and education — control 10: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 3 met71% | Partial |
| SQE.11 | Staff qualifications and education — control 11: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 5 of 6 met80% | Partial |
| SQE.12 | Staff qualifications and education — control 12: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 5 of 6 met91% | Met |
| SQE.13 | Staff qualifications and education — control 13: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 3 of 3 met84% | Partial |
| SQE.14 | Staff qualifications and education — control 14: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 3 met86% | Met |
| SQE.15 | Staff qualifications and education — control 15: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 5 of 5 met90% | Met |
| SQE.16 | Staff qualifications and education — control 16: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 3 of 4 met81% | Partial |
| SQE.17 | Staff qualifications and education — control 17: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 2 of 3 met68% | Partial |
| SQE.18 | Staff qualifications and education — control 18: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 2 of 3 met78% | Partial |