Clinical Reporting & Quality Measures Expansion — User Guide

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Overview

This guide covers the Phase 2 and Phase 3 expansion of CL-15: Clinical Reporting & Quality Measures. It builds on the Phase 1 base (report definitions, report runs, AZDHS incident reporting, compliance dashboards) and adds:

• Dual-track incident deadlines — align incident reporting timelines with AZDHS licensing and/or AHCCCS Policy 961.
• Clinical audit report — a single report that aggregates compliance signals across several CL modules.
• Quality measure reports (HEDIS / CARF) — lightweight automated aggregation from CL-10 outcomes.
• Patient-portal quality measures — a read-only view of a patient’s measure status and follow-up deadlines.
• CARF survey readiness — a pre-survey checklist and readiness score sourced from Governance (GR-08).

Some items in this expansion are shipped today and some are pending; each section below states its status so you know what to expect in the UI.

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Incident reporting deadline tracks

CL-15 supports a configurable incident deadline track (cl_module_settings.incident_deadline_track) so each facility can follow the regulator that governs its contract. How deadlines are calculated (dual example): for a serious_injury incident discovered Friday 4 pm, a dual-track org computes both an AZDHS deadline (e.g. 6 hours → Friday 10 pm) and an AHCCCS deadline (next business day → Monday), and alerts you against each. Operational notes:

• The track is configured by an org admin at CL Settings → Incident reporting (/cl/settings). See the admin guide for the configuration and legal-verification steps.
• Switching tracks is not retroactive — only incidents created after the change use the new track.
• Business-day handling currently supports weekday-only exclusion; holiday calendars are deferred.

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Clinical audit report

The clinical_audit report type aggregates compliance signals across CL modules into one report for survey preparation and ongoing monitoring.

• Dimensions: break-glass access (CL-01), accounting of disclosures (CL-11), documentation timeliness (CL-04), consent status, and risk screening (CL-07).
• Selecting dimensions: choose the dimensions per definition via checkboxes in the Report Definition dialog; selections are stored on the report definition (cl_report_definitions.filters).
• Running it: trigger a run from CL → Report History; summary counts per dimension are written to cl_report_runs.result_summary.

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Quality measure reports (HEDIS / CARF)

• hedis and carf report types compute a lightweight aggregate from cl_outcome_measures (CL-10) over the trailing 12 months on each run.
• The aggregate exposes fields such as denominator, significant_change_count, by_instrument, and by_severity in result_summary.

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Patient portal — quality measures

Portal users can see a read-only summary of their own quality-measure status and upcoming follow-up deadlines.

• The view is scoped to the current patient and shows latest scores, trend direction, and upcoming follow-up dates — not raw clinical data.
• Example: a patient with PHQ-9 and GAD-7 scores in CL-10 and a follow-up appointment sees their latest values, trend, and the next follow-up date.
• SUD privacy: measures derived from 42 CFR Part 2 (SUD) data are gated by the patient’s consent status; without the required consent, those measures are withheld.
• When no measure data exists, the page shows an empty state rather than an error.

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CARF survey readiness

• Route: /cl/carf-readiness (permission cl.report_definitions.view).
• Data source: Governance (GR-08), consumed through the read-only @/platform/governance contract — the Clinical core does not read Governance tables directly.
• Empty state: “No CARF accreditation data. Add accreditations in Governance.”

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Permissions