# Policy Implementation Map

## Source basis

- Incident Occurrence Reporting Program: `SMC-GP-LD-017` (revision 1 April 2025).
- Occurrence / Variance Report: `Form-LD-017-A`.
- Incident Reporting Cycle OVR flowchart.

The application uses the Al Wattan Medical Group name and supports multiple configurable medical-complex branches. Legacy source labels such as SMC, QI/RM, and QM are represented as branch management and Quality & Patient Safety (QPS) roles.

## Workflow mapping

| Policy / form requirement | Application behavior |
| --- | --- |
| Report at occurrence/discovery, same shift or within 24 hours | Submission page displays the deadline; submission timestamp is auditable. |
| Confidential and non-punitive culture | Confidential banners, protected storage, scoped ACL, and anonymous display masking. |
| Known facts and immediate action | Required factual description and separate immediate-action field. |
| Patient, staff, visitor, or other involved | Full person-involved section, patient MRN, position, badge/mobile, and department. |
| Complete incident categories | All policy/form categories and detailed items are selectable. |
| Incident, reportable event, sentinel event, near miss, unsafe condition | Required report-type classification. |
| Patient events also documented in medical record | Manager must explicitly record whether medical-file documentation was completed. |
| Manager initial investigation | Dedicated manager gate with action/treatment, sentinel screening, causes, and contributing factors. |
| Top three contributing factors | Interface and server validation enforce a maximum of three. |
| Risk matrix and grading | Consequence x likelihood produces a 1-25 score and Low/Moderate/High/Extreme grade. |
| Gray/Green/Yellow/Red investigation | Grade drives policy due date and risk badge. |
| Yellow and Red added to risk register | High and Extreme reports are automatically flagged as risk-register items. |
| Sentinel event immediate RCA | QPS escalation routes to the RCA gate before final review. |
| Further action decision | QPS can close-route directly or assign corrective/preventive department action. |
| CAP and recommendations | RCA and action modules record root causes, CAP recommendations, owners, and evidence. |
| QPS final closure | Closure is restricted to authorized QPS users and requires feedback and rationale. |
| Red closure/down-grade approval | Extreme-risk closure requires confirmation of QPS Coordinator/Committee approval. |
| Feedback to reporter and unit manager | Closure generates notifications for the reporter and assigned manager. |
| Quarterly QPS/EOC review | Authorized quarterly dashboard and CSV export by year/quarter. |
| Strict confidentiality for printouts | Every generated OVR PDF is marked CONFIDENTIAL and access is audited. |

## Deadline mapping

| Risk grade | Investigation target |
| --- | ---: |
| Gray / Low | 5 working days |
| Green / Moderate | 10 working days |
| Yellow / High | 14 working days |
| Red / Extreme | 14 working days; action plan target 30 working days |
| QPS closure after completed review | 4 working days |

Weekends are excluded; Saudi public holidays are not automatically excluded in version 1.0. Add an approved holiday calendar before relying on exact regulatory working-day computation.

## Resolved source inconsistency

The legacy form prints `4-6` for Moderate and `15-25` for Extreme, leaving scores 7, 13, and 14 undefined. Appendix D of the policy provides complete bands: `1-3 Low`, `4-7 Moderate`, `8-12 High`, and `13-25 Extreme`. The application uses the complete Appendix D bands.

## Items requiring local governance confirmation

- Named QPS Coordinator and committee approval workflow at each branch.
- External Saudi regulatory reporting triggers and responsible owner.
- Data retention and secure deletion period.
- Whether reporter identity should ever be hidden from QPS itself.
- Branch-specific Infection Prevention, Pharmacy, Finance, HR, and treating-clinician notification rules.
- Approved public-holiday calendar for working-day calculations.