Quality & Accreditation: Incident reporting, audits, indicators and accreditation evidence

Quality, safety and research governance: KPIs with targets, audits and findings, CAPA, accreditation standards for JCI, SafeCare and NABH, controlled policies and committees; the incident register with investigation and root-cause analysis; and the research office with protocols, IRB review, consent, enrolment and adverse-event reporting.

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Works with

HMS Core

Quality & Accreditation in the Bridge HMS Suite: Incident reporting, audits, indicators and accreditation evidence

Audits that end in action

Clinical and accreditation audits, their findings and the CAPAs that close them with evidence.

Policies and committees, controlled

Controlled policies with versions and review dates, committee meetings with minutes, and committee actions followed up.

Incidents investigated, lessons kept

Incident reports, investigation action plans, committee reviews and the board dashboard.

Accreditation standards

The standards of JCI, SafeCare, NABH or your national body, mapped to evidence.

The research office, from protocol to close-out

Study protocols, IRB reviews and approvals, enrolled participants with consent, adverse events and protocol amendments.

What's inside

Everything in Quality & Accreditation

50 items in 9 areas, every one shipping with the app today.

KPI & Quality Indicators
- Hospital Quality KPI LibraryCentral register of quality indicators with name, unique code, unit of measure and full numerator/denominator definitions.
- Seeded 30+ Indicator CatalogShips a preloaded library of 32 globally recognized hospital quality indicators ready to measure out of the box.
- Seven Indicator CategoriesClassifies each KPI as Clinical Quality, Patient Safety, Access/Throughput, Efficiency, Financial, Satisfaction or Staff/Workforce.
- Targets & Traffic-Light ThresholdsEach KPI stores a target plus warning and critical thresholds for automatic status color-coding.
- Direction-Aware ScoringKPIs flag whether higher-is-better or lower-is-better so status is judged correctly for each metric.
- Reporting Frequency GovernanceSets each indicator's cadence as daily, weekly, monthly, quarterly or annually.
KPI Measurement & Analytics
- Period Result CaptureRecords numerator, denominator and period start/end for each KPI reporting window.
- Automatic Rate CalculationComputes the measured value as numerator/denominator x 100, or raw numerator when no denominator is given.
- Automatic Status EvaluationDerives On Target / Warning / Critical status from the value against the KPI's targets and direction.
- Color-coded Measurement ListList view highlights rows green, amber or red by measurement status for instant scanning.
- Facility-Scoped MeasurementsTies each measurement to a hospital facility, defaulting to the user's or company's facility.
- Compiled-By AttributionRecords who compiled each measurement, defaulting to the current user.
Audits & Findings
- Quality & Accreditation AuditsManages audits with reference, title, scope, lead auditor, date, facility and overall score.
- Eight Audit TypesSupports internal, external, mock JCI, mock NABH, SafeCare, mock ISQua, regulatory MoH and peer-review audits.
- Sequenced Audit ReferencesAuto-numbers audits with an AUD/year/nnnn sequence on creation.
- Audit Lifecycle WorkflowDrives audits through Planned, In Progress, Draft Report, Final Report and Closed states via header buttons.
- Standards-Audited LinkingAssociates each audit with the accreditation standards being assessed.
- Embedded Finding RegisterCaptures findings inline on the audit with clause, text, severity, linked CAPA and status.
CAPA Management
- Corrective & Preventive ActionsFull CAPA records capturing root cause, corrective action and preventive action narratives.
- Sequenced CAPA ReferencesAuto-numbers CAPAs with a CAPA/year/nnnn sequence on creation.
- Six-State CAPA LifecycleMoves CAPAs through Draft, In Progress, Awaiting Verification, Effectiveness Check, Closed and Escaped.
- Workflow Action ButtonsHeader buttons start, submit-for-verification, run effectiveness check, close and mark-escaped each CAPA.
- Audit & Finding TraceabilityLinks each CAPA to its originating audit and specific finding for closed-loop traceability.
- Incident Reference LinkingRecords an external incident or event reference that triggered the CAPA.
Accreditation Standards
- Accreditation Standards RegisterCatalog of standards/clauses with title, body-defined code, requirement intent and evidence required.
- Seeded Standards CatalogShips 43 preloaded accreditation standard clauses across multiple bodies.
- Nine Accrediting BodiesCovers JCI, NABH, SafeCare, COHSASA, ISQua, ISO 15189, ISO 9001, CAP and local MoH.
- Edition & Chapter TrackingRecords the standard's version/edition and chapter or section reference.
- Uniqueness EnforcementThe app guarantees each clause code is unique per accrediting body.
- Evidence Requirement DocumentationStores the evidence auditors expect for each standard clause.
Policy & Document Control
- Controlled Policy RegisterManages controlled policy and procedure documents with title, unique document number and version.
- Seeded Policy SetShips 7 preloaded controlled policy documents as a starting library.
- Seven Policy TypesClassifies policies as Clinical, Administrative, Safety, Infection Control, IT, HR or Financial.
- Five-State Document LifecycleDrives documents through Draft, In Review, Approved, In Force and Archived via workflow buttons.
- PDF AttachmentStores the actual policy file as a binary attachment with filename.
- Effective & Review-Due DatesTracks each policy's effective date and next review-due date.
Governance Committees
- Committee Meeting ManagementRecords governance committee meetings with date, chairperson, attendees, agenda and minutes.
- Ten Committee TypesCovers MEC, P&T, Infection Control, M&M, QA/PI, Credentialing, Ethics, Research/IRB, Board and Quality Board.
- Seeded Committee MeetingsShips 14 preloaded committee meeting records as reference/demo data.
- Meeting Status WorkflowMoves meetings through Scheduled, Held, Canceled and Postponed via header buttons.
- Action Item RegisterCaptures inline committee action items with description, responsible owner, due date and status.
- Action Count RollupEach meeting shows a computed count of its action items.
Security & Roles
- Three-Tier RolesProvides User, Quality Officer and Quality Manager groups with escalating implied permissions.
- Granular Access RightsUsers get read-only, Officers create/edit, and Managers full delete rights across all eight models.
- Dedicated App CategoryRegisters a Quality & Governance app category to organize the role assignment screen.
- Auto-Grant on InstallPost-install hook grants all three governance groups to administrator users so menus appear immediately.
- Full History & ActivitiesEvery record has messaging, tracking and scheduled activities.
More in this app
- Quality indicators with targetsThe quality dashboard, a KPI library with definitions and targets, and the measurements taken each period.
- Safety and quality, analysedIncidents, measurements, action plans, reviews, CAPAs, policies and meetings in pivot and graph.
- Research activityParticipants, protocols, amendments, IRB reviews and adverse events in pivot and graph.

Works with

What Quality & Accreditation works with

Quality & Accreditation shares one database with the rest of the Bridge HMS Suite and BridgeERP: these are the apps it already talks to, with nothing to buy in between.