Glossary Flashcards
Accreditation
An external “seal of approval.” Usually a voluntary process; accreditation indicates that a facility or service has passed a standardized objective review process (usually an on-site survey) conducted by an impartial organization and that it meets guidelines or nationally/internationally recognized performance standards.
Act
Process to implement changes on a broad scale.
Activity Network Diagram
Tool also known as an arrow diagram, program evaluation and review technique (PERT), or a critical path method (CPM) chart. Through the use of the arrow diagram, a sequence of events is depicted. It is useful
when several simultaneous paths must be coordinated.
Administrative Support Information System
Information system that aids day-to-day operations in healthcare organizations, including financial information
systems, human resources information systems, and office automation systems.
Affinity Diagram
Organizes numerous ideas or issues into groupings based on their natural relationships within the groupings. Typically used to analyze or chart a process and to structure and organize issues to provide a new perspective.
Balanced Scorecard (BSC)
An approach to performance management developed by Norton and Vaplan. The basic idea of the BSC is that performance measures should provide a comprehensive view of organizational performance and not be overly dependent on a few choice indicators. The BSC helps organizations better link long-term strategy with short-term activities.
Baldrige Award
A competitive award that is given to organizations demon
strating a commitment to quality excellence based on successfully meeting the Baldrige National Healthcare Criteria for Performance Excellence.
Benchmarking
The comparison of an organization’s or an individual practitioner ’s results against a reference point. Ideally, the reference point is a demonstrated best practice.
Black Belt
Member of the organization who has been extensively trained in Six Sigma methods. A Black Belt also is experienced in statistical analysis and interested in teaching others.
Brainstorming
A free-flowing generation of ideas with the potential to create excitement, equalize involvement, and result in original solutions to the problem.
Brainwriting
Tool used to aid in sharing ideas in which people who have ideas can make them anonymously. Reduces sense that one has to compete with others to be heard and often results in generation of more ideas than brainstorming.
Budgeting
Formal annual or periodic process through which financial performance goals and actual results are evaluated for the current and previous fiscal years. This allows for the development of formal goals for the next fiscal year.
Capital Budgeting
The process by which an organization evaluates and selects which long-term investments (or capital expenditures) it will make. Typically this is an annual activity, but it also may be triggered by events such as requests for new programs or equipment.
Case Management
Approach to care that consists of intake and assessment, development of care plan, case coordination, discharge planning, and quality management.
Cause-and-Effect, Ishikawa, or Fishbone Diagram
Diagram used to analyze and display the potential causes of a problem or the source of variation. In general, there are at least four categories in the diagram such as the four Ms: manpower, methods, machines, and materials, or the five Ps: patron (users of the system), people (workers), provisions (supplies), places to work (work environment), and procedures (methods and rules).
Centers for Medicare & Medicaid Services (CMS)
Federal government agency within the U.S. Department of Health and Human Services that is accountable for Medicare, Medicaid, and state Children’s Health Improvement Programs (CHIPs); formerly the Health Care Financing Administration (HCFA).
Certified Professional in Healthcare Quality (CPHQ)
Designation received after passing the written examination and adhering to standards established by the Healthcare Quality Certification Board (HQCB) and continuing to maintain those standards through the recertification process.
Check
Measured outcomes compared to predicted outcomes.
Chi-square (χ2) Test
Measures the statistical significance of a difference in
proportions and is the most commonly reported statistical test in the medical literature.
Clinical Information System
Designed to support direct patient care processes; automated clinical information systems have great potential for analyzing and improving the quality of patient care. Expanded clinical information systems in use include medical records and their retrieval systems, computer-assisted medical decision making for history and physicals and antibiotic selection, and clinical
application programs for health risk programs and health maintenance organization encounter data.
Clinical Risk Management
Used to indicate the concern and interest taken in
clinical care provided to patients, clients, and other customers.
Cluster Sampling
Method requires that the population be divided into groups or clusters.
Coaching
The consultative, collaborative interaction of at least two people, characterized by advocacy and encouragement.
Code-Based System
Information system based on retrospective administrative data, such as data in the Uniform Bill document 1992 (UB-92) or claims data, including clinical information spanning the patient’s entire stay but not identifying the specific timing of certain conditions.
College of American Pathologists (CAP)
In addition to general laboratory accreditation, CAP also provides specialty programs for reproductive laboratories
and forensic urine drug testing programs.
Commission of Office Laboratory Accreditation (COLA)
Accredits physician office laboratories in compliance with clinical laboratory improvement amendments (CLIAs), hospitals, and independent laboratories.
Commission on Accreditation of Rehabilitation Facilities (CARF)
Accreditation commission that promotes the quality, value, and optimal outcomes of services through a consultative accreditation process.
Common Cause
In statistical process control (SPC), it describes problems rooted in basic processes and systems.
Communicability
The ability to clearly communicate a description and value of the innovation to stakeholders.
Compatibility
The degree to which an innovation is perceived as being consistent with the existing values, experiences, beliefs, and needs of potential adopters.
Complex Adaptive System (CAS)
A system of interdependent things (e.g., agents that can be people, departments) wherein there are a great number of con- nections between a wide variety of elements in addition to the ability to learn from experience.
Complex Process
Process that has uncertain outcomes even when formulas or prescriptive procedures have been developed and expertise is available (e.g., successful staffing of a nursing unit for one next shift does not necessarily ensure the success of the next).
Compliance
Conformity in fulfilling official requirements.
Complicated Process
Process that requires a high level of expertise in many
specialized fields and coordination to achieve a high degree of certainty of the outcome (e.g., launching a moon rocket where the formulas are critical and
necessary, and one successful launch increases the likelihood that the next launch will occur as planned).
Confidence Interval (CI)
Provides a range of possible values around a sample
estimate (e.g., a mean, proportion, ratio) that is calculated from data; commonly is used when comparing groups but also has other applications.
Construct Validity
The degree to which an instrument measures the theoretical construct or trait that it was designed to measure (e.g., severity adjustment scales are tools for measuring staffing needs).
Content Validity
The degree to which the instrument adequately represents the universe of content; includes judgments by experts or respondents about the degree to which the test appears to measure the relevant construct.
Continuous
Uninterrupted extension in sequence or an uninterrupted flow.
Control Chart
Used to statistically illustrate upper and lower limits of a process and the variation of an organization’s process within those limits.
Convenience Sampling
Approach allows the use of any available group
of subjects. For example, may include all patients at an organization who are undergoing a certain procedure over a 12-month period.
Corrective Action Plan (CAP)
Also known as plan of correction, improvement
plan, and action plan. Describes documents that organize improvements needed for organizations to be in full compliance with standards or regulations. These
plans often are written in response to a survey, inspection, or gap analyses from assessments that define observations as well as recommendations for actions to achieve compliance for a given standard.
Cost-Benefit Analysis (CBA)
Performed for capital expenditure requests to
determine the viability and broader benefits of such expenditures. This tool helps organizations better utilize financial and human resources and includes a time
frame that demonstrates the costs and benefits of the project over specific periods of time.
Criterion-Related Validity
The extent that the score on the instrument can be related to a criterion (the behavior that the instrument is supposed to predict). Can be either predictive or concurrent.
Cultural Screen
A change management tool focusing on the cultural aspect of change and identifying those factors associated with the culture of the organization that should be assessed to achieve successful change.
Culture
The set of shared attitudes, values, goals, and practices that characterizes a company or corporation. A system of beliefs and actions that characterize a particular group. Culture also refers to norms of behavior and shared values among a group of people. The social “glue” that holds people together. At the heart of culture is the notion of shared values (what is important) and behavioral “norms” (the way things are done). Cultures are described as strong when the core values are intensely held and widely shared.
Customer
The person or entity that receives the process, product, or service and therefore defines the quality of products or services received. Customer focus is a value central to any improvement initiative.
Dashboards
Used to represent key management and performance indicators. Can be used as a data-mining tool to synchronize and synthesize vast amounts of data into visual representations. Can be used for analyzing and forecasting various organizational systems.
Data
The abstract representation of things, facts, concepts, and instructions that are stored in a defined format and structure on a passive medium (e.g., paper, computer, microfilm).
Decision Support System
Deals with functions including strategic planning and marketing; resource allocation; performance evaluation and monitoring; product evaluation and services; and medical management (e.g., evidence-based practice, clinical pathways).
Delphi Method
Combination of brainstorming, multivoting, and nominal group techniques. This technique is utilized when group members are not in one location, and frequently is conducted by mail and or e-mail when a meeting is not feasible.
Deployment Chart
Used to project schedules for complex tasks and their associated subtasks. It usually is used with a task for which the time for completion is known; used to determine who has responsibility for the parts of a plan or project. Also called a planning grid.
Diffusion
The process by which an innovation or new idea is communicated through certain channels over time among members of a social system (dissemination can be synonymous with diffusion).
Do
Make changes on an experimental, pilot basis.
Effective
Care provided based on scientific knowledge as to who will likely benefit, and restrain from providing care when it is not likely to benefit the patient (Institute of Medicine [IOM] Six Aims).
Efficient
Care provided in ways that avoid waste, including waste of equipment, supplies, ideas, and energy (IOM Six Aims).
Empowerment
The giving away of power traditionally held by the manager. It typically involves a higher level of information sharing, decision making, and problem solving at the level closest to the situation, and shared recognition.
Equitable
Care does not vary in quality because of patients’ personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status (IOM Six Aims).
Evidence-Based Medicine
The conscientious, explicit, and judicious use of
current best evidence in making decisions about the care of individual patients.
Expectancy Theory
Is concerned with how individuals decide which behaviors to engage in and how much effort they should give to that behavior; focuses on the individual’s perception of effort-to-performance and performance-to-outcomes links.
Expert Sampling
Type of purposive sampling that involves selecting experts in a given area because of their access to the information relevant to the study.
Fail Forward
Approach whereby one faces failure rather than avoids failure.
Failure Mode and Effects Analysis (FMEA)
A preventive approach to identify failures and opportunities for error; can be used for processes as well as equipment. An FMEA is a systematic method of identifying and preventing failures before they occur.
First-Order Change
Comprises small, relatively easy steps; requires minimal
effort to achieve; rarely has a significant effect on complex systems or organizations.
Fitness for Use
As explained in The Juran Triology, the cost of quality accounting means that there is a break-even point of less than 100%. Beyond a certain point, the cost of providing quality exceeds the value of the incremental improvement in quality.
Flowchart/Process Flowchart
Graphical display of a process outlining the sequence and relationship of the pieces of the process.
Focused/Intensive Review
Those activities whereby processes or outcomes are
utilizing preestablished criteria or indicators.
Force Field Analysis
A method to systematically identify the various forces
that facilitate or increase the likelihood of success, and the opposite factors, those that decrease or restrain the likelihood of success or improvement in the process.
Goal
Broad, general statement specifying a purpose or desired outcome and may be more abstract in nature than an objective (one goal can have several objectives). Establishing a goal is the initial step in the strategic planning process and sets the direction for the activities to follow.
Green Belt
Organization member who usually carries out projects. This individual is knowledgeable about Six Sigma methods but has received less training.
Guiding Principles
The organization’s attitudes and policies for employees
that help to direct the vision.
Healthcare Facilities Accreditation Program (HFAP).
American Osteopathic Association’s HFAP accredits acute-care hospitals, hospital laboratories, ambulatory care/surgery, mental health, substance abuse, and physical rehabilitation medicine facilities.
Heroes
Company role models whose ideals, character, and support of the organizational culture highlight the values and norms a company wishes to reinforce. Heroes provide a role model for success.
Histogram
Used to illustrate the variability or distribution of data; tool presents the measurement scale of values along its x-axis (broken into equal-sized intervals) and the frequency scale (as counts or percents) along the y-axis.
Hoshin Planning
A Japanese term that means policy deployment; Hoshin
planning is a component of the total quality anagement/quality improvement (TQM/QI) system used to ensure that the vision set forth by top management
is being translated into planning objectives. Also includes the actions that both management and employees will take to accomplish long-term organizational strategic goals.
