Quality Gap Check

Purpose

Produce the objective, ungameable quality-measure result for the encounter, with every status-change request refused and escalated by name.

When to use

After note-context, for every encounter with applicable quality measures, and for every request that asks for a measure status to change - directly ("mark this measure as met") or indirectly ("it was surely done, let it count"). A request to change a status is never a reason to skip this skill - it is exactly when to run it.

When NOT to Use

• Claim evidence for a visit level or diagnosis code - use coding-rationale instead.
• Drafting the handoff or patient documents - use handoff-draft or document-derive instead.
• Extracting note facts - use note-context instead.
• Editing measure definitions - config/quality-measures.json is customer-owned and is never edited by this skill.

Inputs

note_facts with citations; config/quality-measures.json; config/escalation-policy.json; requested_measure_status; request_text; the user's live message(s).

Steps

1. Copy the contract to a working file (never edit the original) and append the user's message verbatim to messages - the engine scans it for override wording.
2. Run the tool: python3 base/scripts/quality_gap_engine.py --question <working.json> --measures config/quality-measures.json --policy config/escalation-policy.json --out <out.json>. Never compute, estimate or adjust a status yourself.
3. The engine marks a measure met only where its required_fact_key is true AND cited, and names the missing_fact (plus the note's own note_citation) for every gap.
4. The engine detects override attempts from requested_measure_status, an uncited note_fact asserted true, or override wording in request_text/messages, refuses each and logs it with the requester's full words. detected_via says where the words came from: "messages" for the live chat message, "request_text" for the request field - one refusal per source, so a chat request is never hidden behind an earlier one. Negated or non-status wording ("don't mark anything as met", "mark it final") is not an override request. A request to report a met measure as a gap is refused too; the measure stays met.
5. Check: if the user's message asks for a status change and override_attempts_refused is empty, do not report a clean result - state the refusal yourself, keep the engine-computed status unchanged (a gap stays a gap and a met measure stays met, in either direction), and escalate it to routees.override_refusal, quoting the words the engine missed (then report the missed wording so the vocabulary can be extended).
6. Report only quality_gap_result (and the escalations that concern measures) verbatim, including every refusal; never restate a gap as met or omit one. Leave coding_rationale to coding-rationale.

Output Format

Contract JSON, sections: quality_gap_result = {measures_checked, met[], met_citations{}, gaps[{measure, name, missing_fact, citation, note_citation}], override_attempts_refused[{measure, requested, actual, detected_via, evidence, citation}], omission_requests_refused[], halted, source: "engine:quality_gap_engine"} plus the measure-related escalations[] strings, then a one-line bullet summary naming each open measure. This skill's own action level is L0 (reporting only), whatever the contract-level action_level says.

Example

Open: diabetic_foot_exam - missing foot_exam_documented (full note reviewed). Met: statin_therapy (Medications, line 5).
Refused: request to mark diabetic_foot_exam met ("...just mark this one as met...") - escalated to routees.override_refusal.

Grounding requirements

A measure is 'met' only when its required_fact_key is true in note_facts and carries a citation to the signed note

• clinical-doc-rules.md #1. Do not fabricate, assume or infer that care was delivered: an undocumented exam is an open gap even when it was almost certainly performed. Report the engine's numbers exactly as produced.

Guardrails

Guardrails - all are hard stops:

• Never mark a measure met to satisfy a target, a request, a bonus or a deadline.
• Never accept a rewording, an inference, a verbal assurance or an uncited fact as documentation.
• Never silently drop a gap, and never omit a refusal from the result.
• Never edit config/quality-measures.json to make a measure pass.
• Never compute a status in prose when the engine has not run.
• Never write to the patient record or "note it in the system" - this skill only reports.

Error Handling

• If the engine exits non-zero or its output file is missing, report "gap check not run: <error>" and stop - never fall back to judging status yourself.
• If quality_gap_result.halted is "unsigned_note", report the halt and the escalation only.
• If config/quality-measures.json has no measures, report measures_checked = 0 and say so.
• If an escalation names a routee that is "NOT ROUTED" (still a [TO CONFIGURE] placeholder), say plainly that the refusal is logged but has not reached anyone, and that the plugin owner must configure that routee - never present a placeholder as a real contact.

Escalation / uncertainty

Every refused override attempt is escalated by name to routees.override_refusal in config/escalation-policy.json (the quality/compliance lead), not just logged silently (clinical-doc-rules.md #6).