Standards & requirements
Searchable directory of all JCI 8th Edition international healthcare standards, measurable elements, and evidentiary requirements for Metropolitan General Hospital.
Across 14 JCI 8th Edition Chapters
Evidence verified & complete
Some elements pending verification
Requires hospital action plan
Requirement | Chapter | Standard Description (Paraphrased) | Criticality | Measurable Elements | Status |
|---|---|---|---|---|---|
| IPSG.1 | IPSG | Patient identification: two approved identifiers verified before any care activity (paraphrased) policyauditobservation | critical | 4 of 4 met96% | Met |
| IPSG.2 | IPSG | Effective communication: verbal and telephone orders read back and confirmed (paraphrased) policytraining | high | 4 of 5 met88% | Met |
| IPSG.3 | IPSG | Safety of high-alert medications, including concentrated electrolytes (paraphrased) policyinventoryobservation | critical | 4 of 6 met63% | Gap |
| IPSG.4 | IPSG | Correct site, procedure and patient verified before surgery (paraphrased) checklistaudit | critical | 4 of 4 met90% | Met |
| IPSG.6 | IPSG | Reducing patient harm from falls through assessment and reassessment (paraphrased) policyassessment | high | 3 of 4 met82% | Partial |
| MMU.1 | MMU | Medication use organised and governed by a responsible pharmacy structure (paraphrased) policyorg-chart | high | 4 of 5 met70% | Partial |
| MMU.3 | MMU | Medication storage, labelling and independent double-check before administration (paraphrased) policytrainingobservationaudit | critical | 4 of 6 met61% | Gap |
| MMU.4 | MMU | Prescribing and ordering governed by defined, authorised processes (paraphrased) policyaudit | high | 2 of 3 met66% | Partial |
| MMU.5 | MMU | Preparation and dispensing performed in a clean, controlled manner (paraphrased) policyobservation | high | 3 of 5 met68% | Partial |
| MMU.6 | MMU | Administration verified against order with independent second check for high-alert drugs (paraphrased) trainingobservationaudit | critical | 4 of 6 met59% | Gap |
| MMU.7 | MMU | Medication effects monitored and adverse events reported (paraphrased) policyreports | medium | 2 of 3 met74% | Partial |
| PCI.5 | PCI | Hand-hygiene programme with monitored compliance (paraphrased) policyauditobservation | high | 4 of 6 met67% | Partial |
| PCI.7 | PCI | Sterilisation and single-use device handling controls (paraphrased) policylogs | high | 3 of 4 met64% | Gap |
| PCI.8 | PCI | Safe management of sharps and infectious waste (paraphrased) policyobservation | high | 3 of 5 met60% | Gap |
| FMS.4 | FMS | Fire and life-safety programme with maintained egress (paraphrased) policydrillobservation | critical | 2 of 3 met66% | Partial |
| FMS.7 | FMS | Fire-fighting equipment inspected and unobstructed (paraphrased) inspectionobservation | high | 3 of 5 met62% | Gap |
| FMS.8 | FMS | Medical equipment inspected, tested and maintained (paraphrased) cmmslogs | high | 2 of 3 met70% | Partial |
| SQE.5 | SQE | Staff files include verified qualifications and orientation records (paraphrased) hr-file | medium | 2 of 3 met80% | Partial |
| SQE.14 | SQE | Medical staff credentialing and privileging kept current (paraphrased) hr-filecommittee | high | 3 of 4 met78% | Partial |
| QPS.7 | QPS | Sentinel events analysed with structured root-cause review (paraphrased) policyrca | high | 4 of 5 met72% | Partial |
| IPSG.7 | IPSG | International patient safety goals — control 7: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met81% | Partial |
| IPSG.8 | IPSG | International patient safety goals — control 8: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 5 of 6 met87% | Met |
| IPSG.9 | IPSG | International patient safety goals — control 9: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met85% | Met |
| IPSG.10 | IPSG | International patient safety goals — control 10: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 5 of 6 met87% | Met |
| IPSG.11 | IPSG | International patient safety goals — control 11: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 3 of 4 met67% | Partial |
| IPSG.12 | IPSG | International patient safety goals — control 12: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met72% | Partial |
| IPSG.13 | IPSG | International patient safety goals — control 13: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 3 met66% | Partial |
| IPSG.14 | IPSG | International patient safety goals — control 14: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met81% | Partial |
| IPSG.15 | IPSG | International patient safety goals — control 15: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 3 met96% | Met |
| IPSG.16 | IPSG | International patient safety goals — control 16: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 5 of 6 met81% | Partial |
| IPSG.17 | IPSG | International patient safety goals — control 17: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met82% | Partial |
| IPSG.18 | IPSG | International patient safety goals — control 18: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 3 of 4 met77% | Partial |
| IPSG.19 | IPSG | International patient safety goals — control 19: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 4 of 5 met71% | Partial |
| IPSG.20 | IPSG | International patient safety goals — control 20: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 3 met98% | Met |
| IPSG.21 | IPSG | International patient safety goals — control 21: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 3 of 4 met85% | Met |
| IPSG.22 | IPSG | International patient safety goals — control 22: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 3 met77% | Partial |
| IPSG.23 | IPSG | International patient safety goals — control 23: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 5 of 6 met85% | Met |
| ACC.2 | ACC | Access to care and continuity — control 2: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met75% | Partial |
| ACC.3 | ACC | Access to care and continuity — control 3: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met83% | Partial |
| ACC.4 | ACC | Access to care and continuity — control 4: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 4 met99% | Met |
| ACC.5 | ACC | Access to care and continuity — control 5: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 4 met89% | Met |
| ACC.6 | ACC | Access to care and continuity — control 6: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 6 of 6 met99% | Met |
| ACC.7 | ACC | Access to care and continuity — control 7: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 5 of 6 met75% | Partial |
| ACC.8 | ACC | Access to care and continuity — control 8: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 5 of 6 met77% | Partial |
| ACC.9 | ACC | Access to care and continuity — control 9: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 3 of 4 met71% | Partial |
| ACC.10 | ACC | Access to care and continuity — control 10: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 3 met97% | Met |
| ACC.11 | ACC | Access to care and continuity — control 11: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met81% | Partial |
| ACC.12 | ACC | Access to care and continuity — control 12: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met74% | Partial |
| ACC.13 | ACC | Access to care and continuity — control 13: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 3 of 3 met93% | Met |
| ACC.14 | ACC | Access to care and continuity — control 14: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 2 of 3 met75% | Partial |
| ACC.15 | ACC | Access to care and continuity — control 15: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 5 of 5 met99% | Met |
| ACC.16 | ACC | Access to care and continuity — control 16: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 3 met84% | Partial |
| ACC.17 | ACC | Access to care and continuity — control 17: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 5 of 6 met89% | Met |
| ACC.18 | ACC | Access to care and continuity — control 18: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 3 met91% | Met |
| PFR.2 | PFR | Patient and family rights — control 2: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 2 of 3 met67% | Partial |
| PFR.3 | PFR | Patient and family rights — control 3: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 3 of 5 met66% | Partial |
| PFR.4 | PFR | Patient and family rights — control 4: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 4 of 5 met82% | Partial |
| PFR.5 | PFR | Patient and family rights — control 5: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met76% | Partial |
| PFR.6 | PFR | Patient and family rights — control 6: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met72% | Partial |
| PFR.7 | PFR | Patient and family rights — control 7: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met84% | Partial |
| PFR.8 | PFR | Patient and family rights — control 8: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 6 of 6 met95% | Met |
| PFR.9 | PFR | Patient and family rights — control 9: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 3 met69% | Partial |
| PFR.10 | PFR | Patient and family rights — control 10: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 4 of 6 met70% | Partial |
| PFR.11 | PFR | Patient and family rights — control 11: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met81% | Partial |
| PFR.12 | PFR | Patient and family rights — control 12: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 5 of 6 met84% | Partial |
| PFR.13 | PFR | Patient and family rights — control 13: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 5 of 5 met94% | Met |
| PFR.14 | PFR | Patient and family rights — control 14: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met89% | Met |
| PFR.15 | PFR | Patient and family rights — control 15: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 3 of 4 met74% | Partial |
| PFR.16 | PFR | Patient and family rights — control 16: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 2 of 3 met81% | Partial |
| PFR.17 | PFR | Patient and family rights — control 17: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met81% | Partial |
| AOP.2 | AOP | Assessment of patients — control 2: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 6 of 6 met92% | Met |
| AOP.3 | AOP | Assessment of patients — control 3: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 6 met69% | Partial |
| AOP.4 | AOP | Assessment of patients — control 4: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 6 of 6 met95% | Met |
| AOP.5 | AOP | Assessment of patients — control 5: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 5 of 6 met83% | Partial |
| AOP.6 | AOP | Assessment of patients — control 6: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 5 met63% | Gap |
| AOP.7 | AOP | Assessment of patients — control 7: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 5 of 6 met84% | Partial |
| AOP.8 | AOP | Assessment of patients — control 8: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 5 of 6 met82% | Partial |
| AOP.9 | AOP | Assessment of patients — control 9: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met71% | Partial |
| AOP.10 | AOP | Assessment of patients — control 10: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 4 of 5 met83% | Partial |
| AOP.11 | AOP | Assessment of patients — control 11: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 3 of 4 met65% | Partial |
| AOP.12 | AOP | Assessment of patients — control 12: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 4 of 4 met89% | Met |
| AOP.13 | AOP | Assessment of patients — control 13: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 5 of 5 met93% | Met |
| AOP.14 | AOP | Assessment of patients — control 14: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 4 of 6 met72% | Partial |
| AOP.15 | AOP | Assessment of patients — control 15: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met86% | Met |
| AOP.16 | AOP | Assessment of patients — control 16: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 4 met61% | Gap |
| AOP.17 | AOP | Assessment of patients — control 17: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 4 of 4 met93% | Met |
| AOP.18 | AOP | Assessment of patients — control 18: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 4 of 6 met65% | Partial |
| AOP.19 | AOP | Assessment of patients — control 19: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met76% | Partial |
| AOP.20 | AOP | Assessment of patients — control 20: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 4 of 5 met71% | Partial |
| COP.2 | COP | Care of patients — control 2: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 2 of 3 met80% | Partial |
| COP.3 | COP | Care of patients — control 3: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 4 of 4 met92% | Met |
| COP.4 | COP | Care of patients — control 4: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met81% | Partial |
| COP.5 | COP | Care of patients — control 5: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 4 of 6 met63% | Gap |
| COP.6 | COP | Care of patients — control 6: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 4 of 6 met60% | Gap |
| COP.7 | COP | Care of patients — control 7: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 2 of 3 met64% | Gap |
| COP.8 | COP | Care of patients — control 8: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 3 met91% | Met |
| COP.9 | COP | Care of patients — control 9: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 3 of 4 met80% | Partial |
| COP.10 | COP | Care of patients — control 10: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 2 of 4 met61% | Gap |
| COP.11 | COP | Care of patients — control 11: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 4 of 5 met75% | Partial |
| COP.12 | COP | Care of patients — control 12: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 4 of 6 met60% | Gap |
| COP.13 | COP | Care of patients — control 13: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 6 met59% | Gap |
| COP.14 | COP | Care of patients — control 14: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 3 of 3 met87% | Met |
| COP.15 | COP | Care of patients — control 15: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 6 met62% | Gap |
| COP.16 | COP | Care of patients — control 16: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met71% | Partial |
| COP.17 | COP | Care of patients — control 17: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 5 of 6 met76% | Partial |
| COP.18 | COP | Care of patients — control 18: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met75% | Partial |
| COP.19 | COP | Care of patients — control 19: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 6 met65% | Partial |
| COP.20 | COP | Care of patients — control 20: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 2 of 3 met66% | Partial |
| COP.21 | COP | Care of patients — control 21: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 4 of 6 met68% | Partial |
| ASC.2 | ASC | Anaesthesia and surgical care — control 2: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 2 of 3 met73% | Partial |
| ASC.3 | ASC | Anaesthesia and surgical care — control 3: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met87% | Met |
| ASC.4 | ASC | Anaesthesia and surgical care — control 4: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 3 met80% | Partial |
| ASC.5 | ASC | Anaesthesia and surgical care — control 5: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 3 of 3 met92% | Met |
| ASC.6 | ASC | Anaesthesia and surgical care — control 6: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 4 met92% | Met |
| ASC.7 | ASC | Anaesthesia and surgical care — control 7: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 3 of 4 met73% | Partial |
| ASC.8 | ASC | Anaesthesia and surgical care — control 8: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 3 met87% | Met |
| ASC.9 | ASC | Anaesthesia and surgical care — control 9: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met87% | Met |
| ASC.10 | ASC | Anaesthesia and surgical care — control 10: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 3 of 5 met66% | Partial |
| ASC.11 | ASC | Anaesthesia and surgical care — control 11: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 3 of 4 met69% | Partial |
| ASC.12 | ASC | Anaesthesia and surgical care — control 12: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met70% | Partial |
| ASC.13 | ASC | Anaesthesia and surgical care — control 13: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met63% | Gap |
| ASC.14 | ASC | Anaesthesia and surgical care — control 14: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 3 of 4 met81% | Partial |
| ASC.15 | ASC | Anaesthesia and surgical care — control 15: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 2 of 3 met82% | Partial |
| ASC.16 | ASC | Anaesthesia and surgical care — control 16: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 4 of 5 met83% | Partial |
| ASC.17 | ASC | Anaesthesia and surgical care — control 17: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 3 met87% | Met |
| ASC.18 | ASC | Anaesthesia and surgical care — control 18: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met85% | Met |
| MMU.8 | MMU | Medication management and use — control 8: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 4 met56% | Gap |
| MMU.9 | MMU | Medication management and use — control 9: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 2 of 3 met51% | Gap |
| MMU.10 | MMU | Medication management and use — control 10: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met72% | Partial |
| MMU.11 | MMU | Medication management and use — control 11: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 4 met54% | Gap |
| MMU.12 | MMU | Medication management and use — control 12: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 5 met68% | Partial |
| MMU.13 | MMU | Medication management and use — control 13: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 6 met54% | Gap |
| MMU.14 | MMU | Medication management and use — control 14: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 3 met65% | Partial |
| MMU.15 | MMU | Medication management and use — control 15: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 4 met47% | Gap |
| MMU.16 | MMU | Medication management and use — control 16: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met63% | Gap |
| MMU.17 | MMU | Medication management and use — control 17: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 2 of 4 met51% | Gap |
| MMU.18 | MMU | Medication management and use — control 18: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 2 of 3 met65% | Partial |
| MMU.19 | MMU | Medication management and use — control 19: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 5 of 6 met77% | Partial |
| MMU.20 | MMU | Medication management and use — control 20: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 3 of 4 met71% | Partial |
| MMU.21 | MMU | Medication management and use — control 21: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 2 of 3 met73% | Partial |
| MMU.22 | MMU | Medication management and use — control 22: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 4 of 6 met71% | Partial |
| MMU.23 | MMU | Medication management and use — control 23: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met73% | Partial |
| PFE.2 | PFE | Patient and family education — control 2: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 5 of 6 met84% | Partial |
| PFE.3 | PFE | Patient and family education — control 3: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 5 of 6 met78% | Partial |
| PFE.4 | PFE | Patient and family education — control 4: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 4 of 6 met69% | Partial |
| PFE.5 | PFE | Patient and family education — control 5: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 4 of 4 met88% | Met |
| PFE.6 | PFE | Patient and family education — control 6: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 5 of 6 met87% | Met |
| PFE.7 | PFE | Patient and family education — control 7: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 3 met97% | Met |
| PFE.8 | PFE | Patient and family education — control 8: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met85% | Met |
| PFE.9 | PFE | Patient and family education — control 9: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 2 of 3 met80% | Partial |
| PFE.10 | PFE | Patient and family education — control 10: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 5 of 6 met82% | Partial |
| PFE.11 | PFE | Patient and family education — control 11: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 4 of 5 met88% | Met |
| PFE.12 | PFE | Patient and family education — control 12: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 4 of 5 met83% | Partial |
| PFE.13 | PFE | Patient and family education — control 13: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 3 of 4 met77% | Partial |
| PFE.14 | PFE | Patient and family education — control 14: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 5 of 5 met99% | Met |
| PFE.15 | PFE | Patient and family education — control 15: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 5 of 5 met99% | Met |
| QPS.3 | QPS | Quality and patient safety — control 3: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met76% | Partial |
| QPS.4 | QPS | Quality and patient safety — control 4: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 3 met84% | Partial |
| QPS.5 | QPS | Quality and patient safety — control 5: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 2 of 4 met58% | Gap |
| QPS.6 | QPS | Quality and patient safety — control 6: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met58% | Gap |
| QPS.7 | QPS | Quality and patient safety — control 7: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 6 met68% | Partial |
| QPS.8 | QPS | Quality and patient safety — control 8: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 4 of 5 met76% | Partial |
| QPS.9 | QPS | Quality and patient safety — control 9: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 5 met64% | Gap |
| QPS.10 | QPS | Quality and patient safety — control 10: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met82% | Partial |
| QPS.11 | QPS | Quality and patient safety — control 11: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 3 of 5 met60% | Gap |
| QPS.12 | QPS | Quality and patient safety — control 12: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 5 met62% | Gap |
| QPS.13 | QPS | Quality and patient safety — control 13: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met69% | Partial |
| QPS.14 | QPS | Quality and patient safety — control 14: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met76% | Partial |
| QPS.15 | QPS | Quality and patient safety — control 15: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met80% | Partial |
| QPS.16 | QPS | Quality and patient safety — control 16: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 5 met62% | Gap |
| QPS.17 | QPS | Quality and patient safety — control 17: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met76% | Partial |
| QPS.18 | QPS | Quality and patient safety — control 18: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 5 of 6 met84% | Partial |
| QPS.19 | QPS | Quality and patient safety — control 19: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 2 of 3 met78% | Partial |
| QPS.20 | QPS | Quality and patient safety — control 20: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 3 met57% | Gap |
| QPS.21 | QPS | Quality and patient safety — control 21: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met78% | Partial |
| PCI.5 | PCI | Prevention and control of infection — control 5: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 2 of 3 met56% | Gap |
| PCI.6 | PCI | Prevention and control of infection — control 6: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 4 of 6 met72% | Partial |
| PCI.7 | PCI | Prevention and control of infection — control 7: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 3 of 5 met69% | Partial |
| PCI.8 | PCI | Prevention and control of infection — control 8: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 4 met54% | Gap |
| PCI.9 | PCI | Prevention and control of infection — control 9: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met56% | Gap |
| PCI.10 | PCI | Prevention and control of infection — control 10: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 4 met59% | Gap |
| PCI.11 | PCI | Prevention and control of infection — control 11: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 5 met63% | Gap |
| PCI.12 | PCI | Prevention and control of infection — control 12: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 2 of 3 met53% | Gap |
| PCI.13 | PCI | Prevention and control of infection — control 13: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 5 met49% | Gap |
| PCI.14 | PCI | Prevention and control of infection — control 14: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 3 of 4 met79% | Partial |
| PCI.15 | PCI | Prevention and control of infection — control 15: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met54% | Gap |
| PCI.16 | PCI | Prevention and control of infection — control 16: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 4 of 5 met75% | Partial |
| PCI.17 | PCI | Prevention and control of infection — control 17: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 2 of 5 met47% | Gap |
| PCI.18 | PCI | Prevention and control of infection — control 18: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met51% | Gap |
| PCI.19 | PCI | Prevention and control of infection — control 19: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 4 met61% | Gap |
| PCI.20 | PCI | Prevention and control of infection — control 20: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 6 met54% | Gap |
| PCI.21 | PCI | Prevention and control of infection — control 21: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 6 met52% | Gap |
| GLD.2 | GLD | Governance, leadership, direction — control 2: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 3 of 4 met80% | Partial |
| GLD.3 | GLD | Governance, leadership, direction — control 3: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 2 of 3 met81% | Partial |
| GLD.4 | GLD | Governance, leadership, direction — control 4: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met78% | Partial |
| GLD.5 | GLD | Governance, leadership, direction — control 5: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 3 met88% | Met |
| GLD.6 | GLD | Governance, leadership, direction — control 6: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 4 of 5 met70% | Partial |
| GLD.7 | GLD | Governance, leadership, direction — control 7: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 5 of 6 met78% | Partial |
| GLD.8 | GLD | Governance, leadership, direction — control 8: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 3 of 3 met98% | Met |
| GLD.9 | GLD | Governance, leadership, direction — control 9: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 4 of 5 met81% | Partial |
| GLD.10 | GLD | Governance, leadership, direction — control 10: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 3 of 3 met91% | Met |
| GLD.11 | GLD | Governance, leadership, direction — control 11: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 5 of 6 met81% | Partial |
| GLD.12 | GLD | Governance, leadership, direction — control 12: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 6 met72% | Partial |
| GLD.13 | GLD | Governance, leadership, direction — control 13: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met83% | Partial |
| GLD.14 | GLD | Governance, leadership, direction — control 14: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 5 of 6 met89% | Met |
| GLD.15 | GLD | Governance, leadership, direction — control 15: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met64% | Gap |
| GLD.16 | GLD | Governance, leadership, direction — control 16: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 3 of 4 met67% | Partial |
| GLD.17 | GLD | Governance, leadership, direction — control 17: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 4 of 5 met83% | Partial |
| FMS.5 | FMS | Facility management and safety — control 5: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 3 met75% | Partial |
| FMS.6 | FMS | Facility management and safety — control 6: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 3 met66% | Partial |
| FMS.7 | FMS | Facility management and safety — control 7: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 4 of 6 met64% | Gap |
| FMS.8 | FMS | Facility management and safety — control 8: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 3 of 6 met53% | Gap |
| FMS.9 | FMS | Facility management and safety — control 9: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met61% | Gap |
| FMS.10 | FMS | Facility management and safety — control 10: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met82% | Partial |
| FMS.11 | FMS | Facility management and safety — control 11: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 3 of 4 met69% | Partial |
| FMS.12 | FMS | Facility management and safety — control 12: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 5 of 6 met80% | Partial |
| FMS.13 | FMS | Facility management and safety — control 13: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met79% | Partial |
| FMS.14 | FMS | Facility management and safety — control 14: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 5 met56% | Gap |
| FMS.15 | FMS | Facility management and safety — control 15: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 4 of 6 met64% | Gap |
| FMS.16 | FMS | Facility management and safety — control 16: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 3 of 4 met82% | Partial |
| FMS.17 | FMS | Facility management and safety — control 17: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 4 met62% | Gap |
| FMS.18 | FMS | Facility management and safety — control 18: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 3 met67% | Partial |
| FMS.19 | FMS | Facility management and safety — control 19: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 5 of 6 met80% | Partial |
| FMS.20 | FMS | Facility management and safety — control 20: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met55% | Gap |
| SQE.4 | SQE | Staff qualifications and education — control 4: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 4 of 4 met93% | Met |
| SQE.5 | SQE | Staff qualifications and education — control 5: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 5 of 6 met86% | Met |
| SQE.6 | SQE | Staff qualifications and education — control 6: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met73% | Partial |
| SQE.7 | SQE | Staff qualifications and education — control 7: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met69% | Partial |
| SQE.8 | SQE | Staff qualifications and education — control 8: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 3 of 4 met84% | Partial |
| SQE.9 | SQE | Staff qualifications and education — control 9: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met89% | Met |
| SQE.10 | SQE | Staff qualifications and education — control 10: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 3 met71% | Partial |
| SQE.11 | SQE | Staff qualifications and education — control 11: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 5 of 6 met80% | Partial |
| SQE.12 | SQE | Staff qualifications and education — control 12: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 5 of 6 met91% | Met |
| SQE.13 | SQE | Staff qualifications and education — control 13: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 3 of 3 met84% | Partial |
| SQE.14 | SQE | Staff qualifications and education — control 14: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 3 met86% | Met |
| SQE.15 | SQE | Staff qualifications and education — control 15: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 5 of 5 met90% | Met |
| SQE.16 | SQE | Staff qualifications and education — control 16: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 3 of 4 met81% | Partial |
| SQE.17 | SQE | Staff qualifications and education — control 17: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 2 of 3 met68% | Partial |
| SQE.18 | SQE | Staff qualifications and education — control 18: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 2 of 3 met78% | Partial |
| MOI.2 | MOI | Management of information — control 2: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 6 of 6 met99% | Met |
| MOI.3 | MOI | Management of information — control 3: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 2 of 3 met73% | Partial |
| MOI.4 | MOI | Management of information — control 4: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 5 of 6 met81% | Partial |
| MOI.5 | MOI | Management of information — control 5: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 6 of 6 met96% | Met |
| MOI.6 | MOI | Management of information — control 6: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 5 met68% | Partial |
| MOI.7 | MOI | Management of information — control 7: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 3 of 3 met88% | Met |
| MOI.8 | MOI | Management of information — control 8: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 6 of 6 met96% | Met |
| MOI.9 | MOI | Management of information — control 9: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 4 of 6 met65% | Partial |
| MOI.10 | MOI | Management of information — control 10: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 4 met91% | Met |
| MOI.11 | MOI | Management of information — control 11: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 2 of 3 met78% | Partial |
| MOI.12 | MOI | Management of information — control 12: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met85% | Met |
| MOI.13 | MOI | Management of information — control 13: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met72% | Partial |
| MOI.14 | MOI | Management of information — control 14: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 4 of 4 met94% | Met |
| MOI.15 | MOI | Management of information — control 15: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 5 of 5 met99% | Met |
| MOI.16 | MOI | Management of information — control 16: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met78% | Partial |
| MOI.17 | MOI | Management of information — control 17: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met68% | Partial |