credentialing_v3.csv

Owner: Dr. Kenji Tanaka

Uploaded: 5 Aug 2026

Version: v1

Size: 443.3 MB

0%Quality

Document Gaps Summary:3 Gaps FoundCritical: 1Major: 1Minor: 1

Quality Assessment

This document satisfies the core requirement baseline but would benefit from a refreshed review signature before survey.

Classification:credentialing

Effective year:2024

Review due:Q2 2027

What this document proves

Measurable element alignments and explainability trace

MMU.1Major Gap (F-0238)

Medication use organised and governed by a responsible pharmacy structure (paraphrased)

MMU.1

credentialing_v3.csv

Documented Policy Evidence

Verification Gap Detected

MMU.3Critical Gap (F-0142)

Medication storage, labelling and independent double-check before administration (paraphrased)

MMU.3

credentialing_v3.csv

Documented Policy Evidence

Verification Gap Detected

Open findings related to this document (3)

critical

F-0142

Open

Independent double-check for high-alert medications not consistently performed at administration; self-assessment claimed 94% but evidence supports 71% and observed practice 68%.

Target requirement: MMU.3

high

F-0238

awaiting-verification

Evidence gap identified for MMU.1 during mock surveyor; requires documented remediation. (demonstration)

Target requirement: MMU.1

low

F-0253

Open

Evidence gap identified for MMU.1 during mock surveyor; requires documented remediation. (demonstration)

Target requirement: MMU.1