credentialing_v4.xlsx

Owner: Dr. Priya Sharma

Uploaded: 16 Aug 2026

Version: v1

Size: 101.2 MB

0%Quality

Document Gaps Summary:1 Gaps FoundCritical: 1Major: 0Minor: 0

Quality Assessment

Quality is below the acceptable evidence threshold. Lacks required verification elements and requires immediate hospital revision.

Classification:credentialing

Effective year:2024

Review due:Q2 2027

Measurable element alignments and explainability trace

PFR.2Critical Gap (GAP-1102)

Patient and family rights — control 2: documented process, responsible owner and evidence of practice (paraphrased)

PFR.2

credentialing_v4.xlsx

Documented Policy Evidence

Verification Gap Detected

critical

GAP-1102

Open

Documentation gap in credentialing_v4.xlsx: Policy requires verified committee endorsement and alignment with JCI PFR Measurable Elements.

Target requirement: PFR.2