- Healthcare quality
- The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (IOM definition).
- IOM's six aims for quality
- Care that is Safe, Timely, Effective, Efficient, Equitable, and Patient-centered (STEEEP).
- Quality leadership
- Setting the strategic vision, culture, structure, and resources for quality and safety across an organization, integrating quality into governance and operations.
- Strategic plan
- A long-range roadmap defining an organization's mission, vision, goals, and priorities; the quality plan must align with it.
- Quality management plan
- A written document describing how an organization will measure, assess, and improve quality and safety, including structure, scope, accountability, and reporting.
- Mission vs. vision
- Mission = why the organization exists today (its purpose); vision = the aspirational future state it is working toward.
- Just culture
- A culture that balances accountability and learning: it distinguishes human error (console), at-risk behavior (coach), and reckless behavior (discipline), instead of blaming individuals for system failures.
- Culture of safety
- A shared organizational commitment in which staff feel safe to report errors and near misses without fear of blame, supporting learning and prevention.
- Governing body (board) role in quality
- Ultimate accountability for the quality and safety of care; sets the quality agenda, allocates resources, and reviews performance.
- Change management
- A structured approach to transitioning individuals and the organization from a current state to a desired future state (e.g., Lewin: Unfreeze → Change → Refreeze; Kotter's 8 steps).
- Lewin's change model
- Three stages: Unfreeze (create readiness), Change (implement the new way), Refreeze (embed and sustain the change).
- Strategic alignment of quality
- Linking quality goals and measures to the organization's strategic priorities so improvement work supports the overall mission.
- Stakeholder
- Any person or group with an interest in or affected by a process or its outcomes — patients, staff, providers, payers, regulators, community.
- Quality professional roles
- Facilitator, coach, consultant, educator, data analyst, and change agent — supporting teams rather than owning every improvement.
- SWOT analysis
- A strategic assessment of internal Strengths and Weaknesses and external Opportunities and Threats.
- Quality council / committee
- A cross-functional leadership group that prioritizes, oversees, and coordinates the organization's quality and safety initiatives.
- Performance improvement (PI)
- The continuous study and improvement of processes to better meet the needs of patients and other stakeholders.
- Resource allocation in quality
- Prioritizing time, staff, and budget toward the highest-impact quality and safety initiatives (often guided by risk and strategic priority).
- Servant leadership
- A leadership style focused on serving and developing staff first, which supports a culture of engagement and safety.
- Organizational culture
- The shared values, beliefs, and behaviors that shape how work is done; a key driver of quality and safety outcomes.
- Business case for quality
- Demonstrating the financial and value return of a quality initiative (reduced harm, lower cost, better reimbursement) to justify investment.
- Quality integration
- Embedding quality and safety into daily operations, governance, and every department rather than treating it as a separate siloed function.
- Education and training role of quality pro
- Building staff competency in QI methods, measures, and safety practices so improvement is owned at the front line.
- PDSA cycle
- Plan–Do–Study–Act: an iterative, small-scale method to test and refine a change before spreading it. The engine of the Model for Improvement.
- Model for Improvement
- The IHI framework: three questions (What are we trying to accomplish? How will we know a change is an improvement? What change can we make?) plus PDSA cycles.
- DMAIC
- The Six Sigma improvement sequence: Define, Measure, Analyze, Improve, Control.
- Six Sigma
- A data-driven methodology focused on reducing variation and defects, aiming for no more than 3.4 defects per million opportunities.
- Lean
- An improvement philosophy focused on maximizing value and eliminating waste (non-value-added steps) and improving flow.
- The 8 wastes (Lean / DOWNTIME)
- Defects, Overproduction, Waiting, Non-utilized talent, Transportation, Inventory, Motion, Excess processing.
- Lean Six Sigma
- A combined approach using Lean to remove waste and Six Sigma (DMAIC) to reduce variation.
- Value stream mapping
- A Lean tool that diagrams every step in a process to distinguish value-added from non-value-added activity and target waste.
- Root cause analysis (RCA)
- A structured, retrospective process to identify the underlying system causes of an adverse event or near miss, focusing on systems rather than individuals.
- 5 Whys
- An RCA technique that repeatedly asks 'why' (about five times) to move from a symptom to its underlying root cause.
- Fishbone (Ishikawa / cause-and-effect) diagram
- A tool that organizes possible causes of a problem into categories (e.g., People, Process, Equipment, Environment, Materials, Management) to find root causes.
- FMEA
- Failure Mode and Effects Analysis: a proactive, prospective method to identify how a process could fail, the effects, and priorities for prevention before harm occurs.
- Risk Priority Number (RPN)
- In FMEA, the Risk Priority Number (RPN) equals Severity times Occurrence times Detection. Higher-RPN failure modes are prioritized for mitigation.
- RCA vs. FMEA
- RCA is reactive/retrospective (after an event); FMEA is proactive/prospective (before an event, on a high-risk process).
- Flowchart
- A diagram showing the sequence of steps in a process as it actually occurs; used to understand and find improvement opportunities.
- Process map
- A more detailed flowchart that shows inputs, outputs, roles (swim lanes), and decision points across a process.
- Affinity diagram
- A tool that groups large numbers of ideas (e.g., from brainstorming) into natural categories to organize and prioritize them.
- Brainstorming
- A group technique for generating many ideas quickly without immediate judgment.
- Nominal group technique
- A structured brainstorming/prioritization method where members generate ideas silently, then rank them to reach group consensus.
- Multivoting
- A prioritization technique that narrows a large list of options to a few through successive rounds of voting.
- Force field analysis
- A tool that maps the driving forces for and restraining forces against a change to plan how to strengthen drivers and reduce barriers.
- Gap analysis
- Comparing current performance to a desired or benchmark state to identify the gap and plan improvement.
- Spread / scale-up
- Taking an improvement that worked in a pilot and reliably implementing it across other units or the whole organization.
- Rapid cycle improvement
- Running many small, fast PDSA tests of change in quick succession to learn and adapt rapidly.
- Standardization
- Establishing a single, agreed-upon best way to perform a process to reduce variation and error.
- Plan stage (PDSA)
- Define the objective, predict what will happen, and plan the test of change and the data to collect.
- Study stage (PDSA)
- Analyze the data from the test, compare results to the prediction, and summarize what was learned.
- Continuous quality improvement (CQI)
- An ongoing, never-ending effort to improve processes and outcomes, built on data and team involvement.
- Pareto principle
- The 80/20 rule: roughly 80% of problems come from 20% of causes — focus improvement on the vital few.
- Kaizen
- A Lean philosophy of continuous, incremental improvement involving everyone; a 'Kaizen event' is a focused rapid-improvement workshop.
- Project charter
- A document that defines an improvement project's problem, scope, goals, team, and timeline; aligns and authorizes the work.
- Population health
- The health outcomes of a group of individuals, including the distribution of outcomes within the group; managed by addressing clinical care, behaviors, and social factors.
- Population health management
- Coordinating care and resources across a defined population to improve outcomes and reduce cost, often using risk stratification and registries.
- Social determinants of health (SDOH)
- Non-medical conditions where people live, work, and age — economic stability, education, healthcare access, environment, and social context — that shape health outcomes.
- Care transitions
- The movement of a patient between settings or providers (e.g., hospital → home); high-risk points for errors and readmissions.
- Care coordination
- Deliberately organizing patient-care activities and sharing information among all participants to deliver safer, more effective care.
- Transitional care
- A set of actions designed to ensure continuity and coordination of care as patients transfer between locations or levels of care.
- Readmission
- An unplanned return to inpatient care, often within 30 days; a key outcome and value-based payment measure tied to transition quality.
- Medication reconciliation
- Comparing a patient's medication orders to all medications they are taking at each transition to prevent omissions, duplications, and interactions.
- Risk stratification
- Classifying a population by health risk so resources and interventions can be targeted to the highest-need patients.
- Patient registry
- An organized system that collects data on patients with a particular condition to track and improve their care.
- Patient-centered medical home (PCMH)
- A primary-care model providing comprehensive, coordinated, patient-centered care with enhanced access and a team approach.
- Accountable care organization (ACO)
- A group of providers who jointly accept accountability for the quality and cost of care for a defined population, sharing in savings.
- Health equity
- Everyone having a fair and just opportunity to be as healthy as possible, requiring removal of obstacles such as poverty and discrimination.
- Health disparity
- A preventable difference in health outcomes or burden of disease experienced by disadvantaged populations.
- Health literacy
- The degree to which individuals can obtain, process, and understand basic health information needed to make decisions.
- Teach-back method
- Asking patients to explain instructions in their own words to confirm understanding; a core health-literacy and safety tool.
- Discharge planning
- Arranging the services, follow-up, education, and supports a patient needs after leaving a facility to ensure a safe transition.
- Chronic care model
- A framework for proactive, planned care of chronic disease emphasizing self-management support, delivery design, decision support, and clinical information systems.
- Patient engagement
- Involving patients as active partners in their own care and in organizational improvement; associated with better outcomes.
- Preventive care
- Services (screenings, immunizations, counseling) aimed at preventing disease or detecting it early, central to population health.
- Community health needs assessment (CHNA)
- A systematic assessment of a community's health needs, required of nonprofit hospitals to guide improvement priorities.
- Handoff communication
- Standardized transfer of patient information and responsibility between caregivers (e.g., SBAR, I-PASS) to prevent transition errors.
- SBAR
- A standardized handoff/communication format: Situation, Background, Assessment, Recommendation.
- Data vs. information
- Data are raw facts/numbers; information is data that has been processed and given context so it is meaningful for decisions.
- Structure, process, outcome measures (Donabedian)
- Structure = capacity/resources; Process = what is done (e.g., aspirin given); Outcome = the result (e.g., mortality). The classic quality-measurement framework.
- Outcome measure
- Reflects the result of care on a patient's health status (e.g., mortality, readmission, infection rate).
- Process measure
- Reflects whether a recommended care step was performed (e.g., % of patients given prophylactic antibiotics on time).
- Balancing measure
- A measure that checks whether improving one part of a system causes problems elsewhere (an unintended consequence).
- Benchmarking
- Comparing performance to a reference point — internal, competitive, or best-in-class — to identify improvement opportunities.
- Run chart
- A line graph of data plotted over time with a median, used to detect trends, shifts, and patterns (non-random variation).
- Control chart
- A run chart with a center line (mean) and upper and lower control limits, used to distinguish common-cause from special-cause variation.
- Control limits
- Statistically calculated boundaries on a control chart, most commonly set at plus or minus 3 standard deviations (3 sigma) from the mean.
- Common-cause variation
- Natural, expected, random variation inherent to a stable process; points stay within control limits. Address by redesigning the process.
- Special-cause variation
- Variation from a specific, assignable cause outside the normal process (a point beyond control limits or a non-random pattern). Investigate the specific cause.
- Run chart rules
- Non-random signals include a shift (6 or more consecutive points on one side of the median), a trend (5 or more points steadily rising or falling), and too few or too many runs.
- Histogram
- A bar chart showing the frequency distribution of continuous data, revealing its shape, center, and spread.
- Pareto chart
- A bar chart ordering causes from most to least frequent, with a cumulative line, to identify the 'vital few' causes.
- Scatter diagram
- A plot of two variables used to show the strength and direction of a relationship (correlation) between them.
- Mean, median, mode
- Mean = arithmetic average; median = middle value when ordered; mode = most frequent value. Median resists outlier distortion.
- Standard deviation (σ)
- A measure of how spread out data are around the mean; larger σ means more variation.
- Nominal data
- Categorical data with no inherent order (e.g., blood type, gender).
- Ordinal data
- Categorical data with a meaningful order but unequal intervals (e.g., pain scale, satisfaction 'poor→excellent').
- Continuous (interval/ratio) data
- Numeric data measured on a scale with equal intervals (e.g., blood pressure, length of stay).
- Rate
- A ratio with a defined numerator over a denominator and time/population (e.g., falls per 1,000 patient-days).
- Risk adjustment
- Statistically accounting for differences in patient mix (severity, comorbidities) so outcomes can be fairly compared across providers.
- Reliability (data)
- The consistency of a measure — the degree to which it gives the same result on repeat measurement.
- Validity (data)
- The degree to which a measure actually captures what it is intended to measure.
- Data integrity
- The accuracy, completeness, and consistency of data throughout its lifecycle; essential for trustworthy quality reporting.
- Dashboard
- A visual display of an organization's key performance indicators at a glance to support monitoring and decisions.
- Scorecard / balanced scorecard
- A performance tool tracking measures across multiple perspectives (financial, customer, internal process, learning/growth) tied to strategy.
- Aggregate data
- Data combined or summarized across cases (e.g., a unit's average), as opposed to individual record-level data.
- Data sampling
- Collecting data from a representative subset of a population to draw conclusions efficiently when full census is impractical.
- Statistical process control (SPC)
- The use of run and control charts to monitor a process over time and detect non-random (special-cause) variation.
- Numerator and denominator
- In a measure, the numerator is the count meeting the criterion (e.g., patients who received the care); the denominator is the eligible population.
- Trend analysis
- Examining data over time to identify the direction and pattern of performance.
- Bar chart vs. histogram
- A bar chart compares categories (gaps between bars); a histogram shows the distribution of continuous data (bars touch).
- Patient safety
- The prevention of errors and harm to patients during the provision of health care; a core dimension of quality.
- Adverse event
- An injury caused by medical management (rather than the underlying disease) that results in harm to the patient.
- Near miss (close call)
- An event or error that could have caused harm but did not, by chance or timely intervention; a key learning opportunity.
- Sentinel event (Joint Commission)
- A patient-safety event (not primarily related to the natural course of illness) reaching a patient and resulting in death, permanent harm, or severe temporary harm.
- Never event
- A serious, largely preventable, and clearly identifiable adverse event (e.g., wrong-site surgery, retained foreign object); NQF's 'serious reportable events.'
- Active failure vs. latent condition
- Active failures are unsafe acts by frontline staff; latent conditions are hidden system weaknesses (design, staffing) that set the stage for failure.
- Swiss cheese model
- Reason's model: harm occurs when gaps ('holes') in multiple layers of defense line up, letting a hazard pass through to the patient.
- Human factors
- Designing systems, tasks, and devices to fit human capabilities and limitations, reducing the chance of error.
- Forcing function
- A design that makes an error impossible or very hard (e.g., incompatible connectors that prevent wrong-route administration). A strong error-proofing strategy.
- Hierarchy of error-prevention (strength)
- Strongest = forcing functions/automation; moderate = standardization, checklists, reminders; weakest = education and policies alone.
- High reliability organization (HRO)
- An organization that operates in complex, high-risk conditions yet has very few adverse events, through preoccupation with failure and a strong safety culture.
- Five principles of HROs
- Preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to expertise.
- National Patient Safety Goals (NPSGs)
- Joint Commission goals updated annually that target specific high-risk safety problems (e.g., patient ID, communication, medication safety, infection prevention).
- Two patient identifiers
- An NPSG requiring at least two identifiers (e.g., name and date of birth — never the room number) before care, medications, or procedures.
- Universal Protocol
- Joint Commission requirements to prevent wrong-site, wrong-procedure, wrong-person surgery: pre-procedure verification, site marking, and a time-out.
- Time-out
- A pause immediately before a procedure for the whole team to confirm correct patient, site, and procedure.
- High-alert medications
- Drugs that bear a heightened risk of significant harm when used in error (e.g., insulin, anticoagulants, opioids, concentrated electrolytes).
- Five rights of medication administration
- Right patient, right drug, right dose, right route, right time (often expanded with right documentation and right reason).
- Hospital-acquired condition (HAC)
- A condition a patient acquires during a hospital stay (e.g., CAUTI, CLABSI, pressure injury, falls) that is often preventable; tied to CMS payment.
- CLABSI / CAUTI
- Central line-associated bloodstream infection / catheter-associated urinary tract infection — common, largely preventable healthcare-associated infections.
- Healthcare-associated infection (HAI)
- An infection a patient acquires while receiving care for another condition; a major patient-safety focus.
- Bundle (care bundle)
- A small set of evidence-based practices that, performed together reliably, improve outcomes (e.g., a central-line insertion bundle).
- Disclosure of adverse events
- Communicating with patients/families honestly and promptly when harm occurs, including what happened, the consequences, and steps taken.
- Incident / occurrence report
- A confidential internal report documenting an error, near miss, or unsafe condition, used for learning and trending — not part of the medical record.
- Rapid response team (RRT)
- A team that responds to early signs of patient deterioration to prevent codes and deaths outside the ICU.
- Read-back / verbal order verification
- Repeating a verbal or telephone order back to the prescriber to confirm accuracy; an NPSG communication safeguard.
- Workarounds
- Informal shortcuts staff use to bypass a process barrier; they may complete a task but often defeat safety controls and signal a flawed system.
- Quality review
- The systematic evaluation of the quality and appropriateness of care against established standards and criteria.
- Peer review
- Evaluation of a practitioner's clinical performance by professional peers to assess and improve quality; typically confidential and protected.
- Utilization management (UM)
- Evaluating the medical necessity, appropriateness, and efficiency of health services against criteria, via prospective, concurrent, and retrospective review.
- Utilization review timing
- Prospective = before care (prior authorization); concurrent = during the stay; retrospective = after care is delivered.
- Credentialing
- Verifying a practitioner's qualifications — education, training, licensure, and experience — before granting them the ability to practice.
- Privileging
- Authorizing a credentialed practitioner to perform specific procedures or services based on demonstrated competence.
- Primary source verification
- Confirming a practitioner's credentials directly with the issuing source (e.g., the medical school or licensing board), required in credentialing.
- Ongoing Professional Practice Evaluation (OPPE)
- Routine, continuous monitoring of practitioner performance data used in privileging decisions.
- Focused Professional Practice Evaluation (FPPE)
- A time-limited, focused evaluation of a practitioner (new privileges or a performance concern) to confirm competence.
- Medical necessity
- Care that is reasonable and necessary to diagnose or treat a condition, judged against evidence-based criteria such as InterQual or MCG.
- Case management
- A collaborative process of assessment, planning, coordination, and advocacy to meet a patient's health needs efficiently across the continuum.
- Risk management
- Identifying, evaluating, and reducing risks of loss or harm to patients, staff, and the organization (clinical, financial, and legal).
- Enterprise risk management (ERM)
- An organization-wide approach to identifying and managing all categories of risk (clinical, operational, financial, strategic, reputational).
- Claims management
- Handling actual or potential legal claims against the organization to minimize loss and learn from events.
- Confidentiality / privilege of QI data
- Many quality, peer-review, and incident-report records are legally protected from discovery to encourage candid review (varies by state and PSO).
- Patient Safety Organization (PSO)
- An entity certified under the Patient Safety and Quality Improvement Act to collect and analyze patient-safety data with federal confidentiality protection.
- Provider profiling
- Aggregating performance data by individual provider or group to compare practice patterns and outcomes.
- Quality reporting / public reporting
- Sharing performance data with regulators, payers, or the public (e.g., Hospital Compare) to drive accountability and improvement.
- Accountability
- Holding individuals, teams, and the organization responsible for performance and outcomes, balanced with a just, learning culture.
- Mortality and morbidity (M&M) review
- A structured case review of deaths and complications to identify opportunities for improvement and learning.
- Adverse event reporting to external bodies
- Reporting certain events to required external entities (state agencies, the FDA via MedWatch, or accreditors) per regulation.
- The Joint Commission (TJC)
- A major U.S. accrediting body that surveys and accredits hospitals and other organizations against standards of quality and safety.
- Accreditation
- Voluntary review by an external body confirming an organization meets defined quality and safety standards.
- Deemed status
- Status granted when an accreditor's standards are recognized as meeting Medicare's Conditions of Participation, so the organization need not undergo a separate CMS survey.
- CMS Conditions of Participation (CoPs)
- Federal health and safety requirements that providers must meet to participate in (and be paid by) Medicare and Medicaid.
- Centers for Medicare & Medicaid Services (CMS)
- The federal agency administering Medicare and Medicaid; sets CoPs, quality measures, and value-based payment programs.
- Tracer methodology
- A Joint Commission survey technique that follows ('traces') an individual patient's care experience through the organization to evaluate compliance.
- Standards vs. regulations
- Standards (e.g., TJC) are typically voluntary best-practice requirements; regulations (e.g., CMS CoPs, OSHA) are legally mandated.
- HIPAA
- The Health Insurance Portability and Accountability Act, protecting patient health information through the Privacy and Security Rules.
- Protected health information (PHI)
- Individually identifiable health information protected under HIPAA; share only the minimum necessary.
- EMTALA
- The Emergency Medical Treatment and Labor Act, requiring Medicare hospitals to screen and stabilize emergency patients regardless of ability to pay.
- OSHA
- The Occupational Safety and Health Administration, setting and enforcing workplace safety standards (e.g., bloodborne pathogens, hazard communication).
- NCQA
- The National Committee for Quality Assurance, which accredits health plans and develops the HEDIS performance measures.
- HEDIS
- The Healthcare Effectiveness Data and Information Set — NCQA's standardized measures used to compare health-plan quality.
- Value-based purchasing (VBP)
- CMS programs that tie a portion of payment to quality and outcomes rather than volume, rewarding better performance.
- Pay-for-performance (P4P)
- Reimbursement model that financially rewards providers for meeting quality and efficiency targets.
- Hospital Readmissions Reduction Program (HRRP)
- A CMS program that reduces payments to hospitals with excess 30-day readmissions for targeted conditions.
- DNV / accrediting organizations
- Besides The Joint Commission, CMS recognizes other accreditors (e.g., DNV Healthcare, HFAP) that can confer deemed status.
- Survey readiness
- Maintaining continuous compliance with standards (not just before a survey) so the organization is always survey-ready.
- Plan of correction
- An organization's documented plan to fix deficiencies cited during an accreditation or regulatory survey, with actions and timelines.
- AHRQ
- The Agency for Healthcare Research and Quality — a federal agency producing patient-safety tools, measures, and evidence to improve care.
- Core measures
- Standardized, nationally endorsed clinical process/outcome measures hospitals report (originated with TJC/CMS aligned measure sets).
