A Self-Assessment Guide for Health Care Organizations - IFC

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Appendix III: Glossary accreditation 1. The process in which an independent external “accrediting” organization (usually non-governmental) assesses a health care organization to determine if it meets a formal set of standards designed to improve the quality of care. 2. The positive formal decision by an accrediting organization that a health care organization meets an applicable set of standards. adverse event An unanticipated, undesirable, or potentially dangerous occurrence in a health care organization. Also see sentinel event. client A recipient of health care regardless of the state of health. Clients may, for example, include people receiving screening or preventative services. Patients’ families may also be considered as clients. Clients are sometimes classified as being “internal” and “external”; “internal” clients/customers are people who work inside the organization (e.g. physicians, staff, management) and “external” are those that use the services of the organization (e.g. patients, families, insurers, vendors). clinical governance The means by which organizations ensure the provision of quality clinical care by making individuals accountable for setting maintaining and monitoring performance standards. 54 clinical pathway An agreed-upon treatment regime that includes all elements of care. (There are several terms used for clinical pathway - such as “care pathway” or “care map”). clinical practice guidelines Statements that help practitioners and patients choose appropriate health care for specific clinical conditions (for example, recommendations on the case management of diarrhea in children under the age of five years). The practitioner is guided through all steps of consultation (questions to ask, physical signs to look for, lab exams to prescribe, assessment of the situation, and treatment to prescribe). clinician A health professional, such as a physician, psychiatrist, psychologist, or nurse, involved in clinical practice (as distinguished from one specializing in research). confidentiality 1. The restricted access to data and information to individuals who have a need, a reason, and permission for such access. 2. An individual’s right to personal and informational privacy, including for his or her health care records. continuum of care Matching the individual’s ongoing needs with the appropriate level and type of care, treatment, and service within an organization or across multiple organizations. continuity of care The degree to which the care of individuals is coordinated among practitioners, among organizations, and over time. contracted services Services provided through a written agreement with another organization, agency, or individual. The agreement specifies the services or personnel to be provided on behalf of the applicant organization and the fees to provide these services or personnel. credentialing The process of obtaining, verifying, and assessing the qualifications of a health care practitioner to provide patient care services in or for a health care organization. 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. Also see competence; credentialing. data Facts, clinical observations, or measurements collected during an assessment activity. Data before they are analyzed are called “raw data.” disaster See emergency discharge The point at which an individual’s active involvement with an organization or program is terminated and the organization or program no longer maintains active responsibility for the care of the individual. competence A determination of an individual’s skills, knowledge, and capability to meet defined expectations, as frequently described in a job description. 54 Pietroni, Advancing Clinical Governance (1998). Available at: www.clinicalgovernance.scot.nhs.uk/documents/Clinical_Governance_Definitions.pdf 94 IFC Self-Assessment Guide for Health Care Organizations
emergency 1. An unanticipated or sudden occasion, as in emergency surgery needed to prevent death or serious disability. 2. A natural or man-made event that significantly disrupts the environment of care (for example, damage to the organization’s building(s) and grounds due to severe winds, storms, or earthquakes); that significantly disrupts care and treatment (for example, loss of utilities such as power, water, or telephones due to floods, civil disturbances, accidents, or emergencies in the organization or its community); or that results in sudden, significantly changed or increased demands for the organization’s services (for example, bioterrorist attack, building collapse, or plane crash in the organization’s community). Some severe emergencies are called “disasters”. ethical Conforming to accepted standards of moral, social or professional behavior. governance The individual(s), group, or agency that has ultimate authority and responsibility for establishing policy, maintaining quality of care, and providing for organization management and planning. Other names for this group include “board,” “board of trustees,” “board of governors,” “board of commissioners,” and “governing body.” harvesting, of organs Removal of an organ for means of transplantation. hazardous materials and waste Materials whose handling, use, and storage are guided or defined by local, regional, or national regulation, hazardous vapors, and hazardous energy sources. Although JCI considers infectious waste as falling into this category of materials, not all laws and regulations define infectious or medical waste as hazardous waste. health care–associated infection(s) (HAI) Also known as nosocomial infections. Any infection(s) acquired by an individual while receiving care or services in a health care organization. Common HAIs are urinary infections, surgical wound infections, pneumonia, and blood stream infections. health care professional Any person who has completed a course of study and is skilled in a field of health. This includes a physician, dentist, nurse, or allied health professional. Health care professionals are often licensed by a government agency or certified by a professional organization. IDA The International Development Association is the part of the World Bank that helps the world’s poorest countries. Established in 1960, IDA aims to reduce poverty by providing interest-free credits and grants for programs that boost economic growth, reduce inequalities and improve people’s living conditions. indicator A measure used to determine, over time, an organization’s performance of functions, processes, and outcomes. infectious waste See hazardous materials and waste informed consent Agreement or permission accompanied by full information on the nature, risks, and alternatives of a medical procedure or treatment before the physician or other health care professional begins the procedure or treatment. After receiving this information, the patient then either consents to or refuses such a procedure or treatment. in-service education Organized education, usually provided in the workplace, designed to enhance the skills of staff members or teach them new skills relevant to their jobs and disciplines. inpatient Generally, persons who are admitted to and housed in a health care organization at least overnight. intent statement A brief explanation of a standard’s rationale, meaning, and significance, noted in this manual under the heading Intent. Intent statements may contain detailed expectations of the standard that are evaluated in the on-site survey process. invasive procedure A procedure involving puncture or incision of the skin, or insertion of an instrument or foreign material into the body. job description Explanation of an employment position including duties, responsibilities, and conditions required to perform the job. IFC Self-Assessment Guide for Health Care Organizations 95
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PROMOTING STANDARDS IN THE PRIVATE
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Contents Foreword 2 Acknowledgement
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Acknowledgements This Guide was dev
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introduction IFC Self-Assessment Gu
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Why are Standards Important Why sho
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Leadership Systems Data Where to Be
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Preparing for the self-assessment I
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Facility Safety and Emergency Manag
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The self -assessment template IFC S
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Clinical Governance and Leadership
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Measurable Element Look for Score O
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Standard CGL.6 [Staff recruitment,
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Standard EPR.2 [Patient and family
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Standard EPR.3 [Informed consent] P
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Standard EPR.4 [Ethical management]
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Standard EPR.5 [Organ and tissue do
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Standard EPR.6 [Reproductive health
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Standard EPR.7 [Termination of preg
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Quality Measurement and Improvement
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Standard QMI.2 [Leaders’ collabor
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Page 73 and 74: Standard FSE.6 [Utilities managemen
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Page 77 and 78: After the self-assessment Next Step
Page 79 and 80: Baseline Score Score Score Clinical
Page 81 and 82: EPR.6 Reproductive health policies
Page 83 and 84: QMI.4 Medications use 1 Medication
Page 85 and 86: Baseline Score Score Score Facility
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Page 91 and 92: Appendices IFC Self-Assessment Guid
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Page 99 and 100: privileging The process whereby a s
Page 102: Contact Information Health and Educ
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