Activity

Specific steps in the implementation of targets.

Analysis

A process of examining, explaining and interpreting findings from assessment; this is the peer review stage of quality improvement.

Approaches

Means or methods of attaining an objective or target

Assessment

The process of objectively examining an aspect of service and a known or potential problem, to determine whether intervention through action is indicated. Synonym: evaluation.

Audit

1. Thorough examination and evaluation of a problem. Synonym: Study.
2. Criteria-based assessment of the process and/or outcome of patient care using a specialized evaluation format.

Benchmark (BMK)

A standard by which an item (process, procedure, practice, product, or equipment) can be measured or judged.

Benchmarking (BMKG)

A systematic way to identify, understand, and creatively evolve superior products, services, designs, equipment, processes, and practices to improve organization’s real performance.

Certification

1. The procedure and action by which an authorized organization evaluates and certifies that an individual, institution, or program meets requirements, such as standards. Certification differs from accreditation in that certification can also be applied to individuals.
2. The process by which a non-governmental agency or association certifies that an individual has met predetermined qualifications specified by that agency or association.

Competence

Job knowledge and skills. Knowledge is the understanding of facts and procedures. Skill is the ability to perform specific actions. Behaviors, such as the ability to work in teams, are frequently considered as a part of competence.

Credentialing

The process of obtaining, verifying, and assessing the qualifications of a health care practitioner. The process determines if an individual can provide patient care services in or for a health car organization or network. The process of periodically checking staff qualifications is called recredentialing.

Credentials

Evidence of competence, current and relevant licensure, education, training, and experience. Other criteria may be added by a health care organization.

Criterion

A standard by which something is judged, and may be technical or social.

Data

The collection of material or facts on which a discussion or an inference is based.

Epidemiology

The study of the relationships of the various factors determining the frequency and distribution of diseases in a human community.

Evaluation

Systematic assessment of the relevance, adequacy, progress, efficiency, effectiveness, and impact of the program.

Function

Located within systems composed of interrelated series of processes.

Goals

Objective, measurable expectations set to measure progress toward desired results.

Indicators

Variables that help to measure changes directly or indirectly and to assess the extent to which the objectives and targets of a program are being achieved.

Job description

Explanation of an employment position including duties, responsibilities, and conditions required to perform the Job.

KPI

Key Performance Indicators (KPI) are quantifiable measurements, agreed to beforehand, that reflect the critical success factors (of the company, department, project.).

Management

The sum of the measures taken to plan, organize, operate, and evaluate all the many interrelated elements of the system.

Medical Technology

Any discrete and identifiable regimen or modality used to diagnose and treat illness, prevent disease, maintain patient well being, or facilitate the provision of health services.

Monitoring

The continuous follow-up of activities to ensure that they are proceeding according to plan.

Objective

The end result a program seeks to achieve.

Performance improvement

The continuous study and adaptation of functions and processes of a health care organization to increase the probability of achieving desired outcomes and to better meet the needs of patients and other users of services; the third segment of a performance measurement, assessment and improvement system.

Plan of Action

A broad inter-sectoral master plan for implementing the strategy in order to attain the set goals.

Policy

A set of decisions to pursue courses of action aimed at achieving defined goals.

Priority

Precedence in position of importance.

Problem

A question raised for inquiry, consideration or solution; a variation between what should be and what actually is.

Problem analysis

The procedure used to analyze performance gaps discovered through an audit and/or other activities to determine whether a problem exists, the most probable causes, who is responsible and why the responsibilities are not being met.

Process

A goal-directed, interrelated series of actions, events, mechanisms or steps.

Program

An organized aggregate of activities directed towards the attainment of defined objectives and targets.

Program budgeting

The process of making resources available to attain the objectives of programs. Emphasis is on the results to be achieved rather than on uncounted budgeting items.

Protocol

A plan or set of steps, to be followed in a study, an investigation, or an intervention. Synonyms: practice guidelines, algorithm, clinical criteria, guideline, parameter, practice parameter, review criteria.

Quality assessment

The measurement of the technical and interpersonal aspects of health care and services and the outcomes of the care and services. QA provides information that may be used in quality improvement activities.

Quality control

Periodic monitoring of aspects of precision or accuracy as they relate to the successful performance of equipment, techniques or tests rather than clinical decision-making.

Quality improvement

An approach to the continuous study and improvement of the processes of providing health care services to meet the needs of patients and others.

Quality Improvement Plan

A written document describing the goals, objectives, responsibilities, organizational structures and implementation strategies of the Quality Improvement Program.

Quality of care

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

Referral

The sending of an individual from one clinician to another clinician or specialist, from one setting or service to another, or other resource, either for consultation or care that the referring source is not prepared or qualified to provide.

Resource management

The efficient and effective management of resources. The aim is the most rational use of manpower, knowledge, facilities, and funds to achieve the intended purposes with the greatest effect for the least outlay.

Review

The method of assessing a document to ensure that the information contained therein is relevant, accurate and up-to-date.

Revision

The amending of a document by deletion, addition or alteration of information, in order to keep them relevant, accurate and up-to-date.

Risk management

Clinical and administrative activities to identify, evaluate, and reduce the risk of injury. This risk could apply to patients, staff, visitors, and the organization itself.

Service

Used to indicate the delivery of care.

Standard

1. A set of expectations predetermined by a competent authority. A standard describes the acceptable level of performance of an organization or individual. It relates to structures in place, conduct of a process, or measurable outcome achieved.
2. An expected level of performance that, if attained, would lead to the highest levels of quality in a system.

Strategy

The broad lines of action required in all sectors concerned to give effect to the comprehensive health policy and indicate the problems and ways of dealing with them. Or

A plan you develop to help you achieve your vision. It requires an evaluation of your organization internally, but also of the external and environmental factors, especially competitors, that can impact you.

Tactics

Specific actions, sequences of actions, and schedules you use to fulfill your strategy. If you have more than one strategy you will have different tactics for each.

Target

An intermediate result towards the objective that a program seeks to achieve

Trend

The repetition of a specific number of occurrences, which indicates that a problem or potential problem may exist in patient care or professional performance.

Utilization Management

The planning, organizing, directing and controlling of the health care product to ensure cost-effective, high quality care while contributing to the overall goals of the institution. This is accomplished through the judicious use of resources to control inappropriate in-patient admissions, lengths of stay and use of ancillary services.

Vision

The over-riding principle that guides the organization. It defines what you want the organization to be. The vision is often the dream of the founder or leader.

SOURCE

1. Glossary of Terms used in the “Health for all” Series No. 1-8, WHO, Geneva, 1984.

2. Joint Commission International Accreditation; Glossary of Key Terms.