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Tuesday, February 27, 2018

COMMON TERMINOLOGIES USED IN NATIONAL ACCREDITATION BOARD FOR HOSPITALS & HEALTHCARE PROVIDERS (NABH) STANDARDS.

Accreditation Assessment:
The evaluation process for assessing the compliance of an organisation with the applicable standards for determining its accreditation status.

Adverse Event:
An injury related to medical management, in contrast to complications of disease. Medical management includes all aclinicspects of care, including diagnosis and treatment, failure to diagnose or treat, and the systems and equipment used to deliver care. Adverse events may be preventable or non-preventable.(WHO Draft Guidelines for Adverse Event Reporting and Learning Systems).

Ambulance:
A patient carrying vehicle having facilities to provide unless otherwise indicated at least basic life support during the process of transportation of patient. There are various types of ambulances that provide special services viz. coronary care ambulance, trauma ambulance, air ambulance, etc.

Assessment:
All activities including history taking, physical examination, laboratory investigations that contribute towards determining the prevailing treatment status of the patient.

Breakdown Maintenance:
Activities which are associated with the repair and servicing of site infrastructure, buildings, plant or equipment within the site’s agreed building capacity allocation which have become inoperable or unusable because of the failure of component parts.

Bylaws:
A rule governing the internal management of an organisation. It can supplement or complement the government law but cannot countermand it, e.g. municipal bylaws for construction of hospitals/nursing homes, for disposal of hazardous and/or infectious waste.

Care Plan:
A plan that identifies patient care needs, lists the strategy to meet those needs, documents treatment goals and objectives, outlines the criteria for ending interventions, and documents the individual’s progress in meeting specified goals and objectives. The format of the plan may be guided by specific policies and procedures, protocols, practice guidelines or a combination of these. It includes preventive, promotive, curative and rehabilitative aspects of care.

Clinical Audit:
A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. (Principles for Best Practice in Clinical Audit 2002, NICE/CHI).

Competence:
Demonstrated ability to apply knowledge and skills (para 3.9.2 of ISO 9000: 2000). Knowledge is the understanding of facts and procedures. Skill is the ability to perform specific action. For example, a competent gynecologist knows about the patho-physiology of the female genitalia and can conduct both normal as well as abnormal deliveries.

Confidentiality:
Restricted access to information to individuals who have a need, a reason and permission for such access. It also includes an individual’s right to personal privacy as well as privacy of information related to his/her healthcare records.

Consent:
1. Willingness of a party to undergo examination/procedure/ treatment by a healthcare provider. It may be implied (e.g. patient registering in OPD), expressed which may be written or verbal. Informed consent is a type of consent in which the healthcare provider has a duty to inform his/her patient about the procedure, its potential risk and benefits, alternative procedure with their risk and benefits so as to enable the patient to take an informed decision of his/her health care.
2. In law, it means active acquiescence or silent compliance by a person legally capable of consenting. In India, legal age of consent is 18 years. It may be evidenced by words or acts or by silence when silence implies concurrence. Actual or implied consent is necessarily an element in every contract and every agreement.

Credentialing:
The process of obtaining, verifying and assessing the qualification of a healthcare provider.

Treatment Record:
A document which contains the chronological sequence of events that a patient undergoes during his stay in the healthcare organisation. It includes demographic data of the patient, assessment findings, diagnosis, consultations, procedures undergone, progress notes and discharge summary. (Death certificate, where required).

Patient Satisfaction:
Patient satisfaction is a measure of the extent to which a patient is content with the health care which they received from their health care provider. Patient satisfaction is thus a proxy but a very effective indicator to measure the success of Health care providers.

Data:
Facts or information used usually to calculate analyse or plan something.

Discharge Summary:
A part of a patient record that summarises the reasons for admission, significant treatment findings, procedures performed, treatment rendered, patient’s condition on discharge and any specific instructions given to the patient or family (for example follow-up medications).

Disciplinary Proceedings:
Sequence of activities to be carried out when staff does not conform to the laid-down norms, rules and regulations of the healthcare organisation.

Effective Communication:
A two way information sharing process which involves the communicator, communicating a message that is easily understood by the recipient. Good medical care depends upon effective communication between patients and providers. Effective communication with persons who have limited language proficiency or understanding of the subject due to lack of familiarity, often requires interpreters, special efforts or other services.

Employees:
All members of the healthcare organisation who are employed full time and are paid suitable remuneration for their services as per the laid-down policy.

Ethics:
A moral principle that govern a person’s or group’s behavior.

Family:
The person(s) with a significant role in the patient’s life. It mainly includes spouse, children and parents. It may also include a person not legally related to the patient but can make healthcare decisions for a patient if the patient loses decision-making ability.

Goal:
A broad statement describing a desired future condition or achievement without being specific about how much and when. (ASQ) The term “goals” refers to a future condition or performance level that one intends to attain. Goals can be both short- and longer-term. Goals are ends that guide actions.

Grievance-handling Procedures:
Sequence of activities carried out to address the grievances of patients, visitors, relatives and staff.

Healthcare-Associated Infection:
Healthcare-associated infections (HAIs) are infections caused by a wide variety of common and unusual bacteria, fungi, and viruses during the course of receiving medical care. (CDC) This was earlier referred to as Nosocomial/hospital-acquired/ hospital associated infection(s).

Healthcare Organisation:
Generic term is used to describe the various types of organisation that provide healthcare services. This includes ambulatory care centres, hospitals, laboratories etc.

Incident Reporting:
It is defined as written or verbal reporting of any event in the process of patient care, which is inconsistent with the deserved patient outcome or routine operations of the healthcare facility.

In Service Education/Training:
Organised education/training usually provided in the workplace for enhancing the skills of staff members or for teaching them new skills relevant to their jobs/tasks.

Indicator:
A statistical measure of the performance of functions, systems or processes overtime. For example, hospital acquired infection rate, mortality rate, caesarean section rate, absence rate, etc.

Information:
Processed data which lends meaning to the raw data.

Intent:
A brief explanation of the rational, meaning and significance of the standards laid down in a particular chapter.

Inventory Control:
The method of supervising the intake, use and disposal of various goods in hands. It relates to supervision of the supply, storage and accessibility of items in order to ensure adequate supply without stock-outs/excessive storage. It is also the process of balancing ordering costs against carrying costs of the inventory so as to minimise total costs.

Job Description:
1. It entails an explanation pertaining to duties, responsibilities and conditions required to perform a job.

2. A summary of the most important features of a job, including the general nature of the work performed (duties and responsibilities) and level (i.e., skill, effort, responsibility and working conditions) of the work performed. It typically includes job specifications that include employee characteristics required for competent performance of the job. A job description should describe and focus on the job itself and not on any specific individual who might fill the job.

Job Specification:
1. The qualifications/physical requirements, experience and skills required to perform a particular job/task.

2. A statement of the minimum acceptable qualifications that an incumbent must possess to perform a given job successfully.

Laws:
Legal document setting forth the rules of governing a particular kind of activity, e.g. organ transplantation act, which governs the rules for undertaking organ transplantation.

Maintenance:
The combination of all technical and administrative actions, including supervision actions, intended to retain an item in, or restore it to, a state in which it can perform a required function. (British Standard 3811:1993).

Medical Equipment:
Any fixed or portable non-drug item or apparatus used for diagnosis, treatment, monitoring and direct care of patient.

Mission:
An organisation's purpose. This refers to the overall function of an organisation. The mission answers the question, “What is this organisation attempting to accomplish?” The mission might define patients, stakeholders, or markets served, distinctive or core competencies, or technologies used.

Monitoring:
The performance and analysis of routine measurements aimed at identifying and detecting changes in the health status or the environment, e.g. monitoring of growth and nutritional status, air quality in operation theatre. It requires careful planning and use of standardised procedures and methods of data collection.

Multi-Disciplinary:
A generic term which includes representatives from various disciplines, professions or service areas.

Near-miss:
This is used synonymously with near miss. However, some authors draw a distinction between these two phrases. A near-miss is defined when an error is realised just in the nick of time and abortive action is instituted to cut short its translation. In no harm scenario, the error is not recognised and the deed is done but fortunately for the healthcare professional, the expected adverse event does not occur. The distinction between the two is important and is best exemplified by reactions to administered drugs in allergic patients. A prophylactic injection of cephalosporin may be stopped in time because it suddenly transpires that the patient is known to be allergic to penicillin (near-miss). If this vital piece of information is overlooked and the cephalosporin administered, the patient may fortunately not develop an anaphylactic reaction (no harm event).

Objective:
A specific statement of a desired short-term condition or achievement includes measurable end-results to be accomplished by specific teams or individuals within time limits. (ASQ)

Objective Element:
It is that component of standard which can be measured objectively on a rating scale. The acceptable compliance with the measureable elements will determine the overall compliance with the standard
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Occupational health hazard:
The hazards to which an individual is exposed during the course of performance of his job. These include physical, chemical, biological, mechanical and psychosocial hazards.

Operational Plan:
Operational plan is the part of your strategic plan. It defines how you will operate in practice to implement your action and monitoring plans—what your capacity needs are, how you will engage resources, how you will deal with risks, and how you will ensure sustainability of the organisation’s achievements.

Organogram:
A graphic representation of reporting relationship in an organisation.

Outsourcing:
Hiring of services and facilities from other organisation based upon one’s own requirement in areas where such facilities are either not available or else are not cost-effective.
For example, outsourcing of House-Keeping, Security, Laboratory/Certain Special Diagnostic Facilities with other institutions after drawing a memorandum of understanding that clearly lays down the obligations of both Organisations: the one which is outsourcing and the one which is providing the outsourced facility. It also addresses the quality-related aspects.

Performance Appraisal:
It is the process of evaluating the performance of employees during a defined period of time with the aim of ascertaining their suitability for the job, potential for growth as well as determining training needs.

Policies:
They are the guidelines for decision-making, e.g. admission, discharge policies, antibiotic policy,etc.

Prescription:
A prescription is a document given by a physician or other healthcare practitioner in the form of instructions that govern the care plan for an individual patient. Legally, it is a written directive, for compounding or dispensing and administration of drugs, or for other service to a particular patient. (Reference: Miller Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition, Saunders).

Privileging:
It is the process for authorising all medical professionals to admit and treat patients and provide other treatment services commensurate with their qualifications and skills.

Procedure:
1. A specified way to carry out an activity or a process (Para 3.4.5 of ISO 9000:2000).
2. A series of activities for carrying out work which when observed by all help to ensure the maximum use of resources and efforts to achieve the desired output.

Process:
A set of interrelated or interacting activities which transforms inputs into outputs (Para 3.4.1 of ISO 9000: 2000).

Programme:
A sequence of activities designed to implement policies and accomplish objectives.

Protocol:
A plan or a set of steps to be followed in a study, an investigation or an intervention.

Quality:
1. Degree to which a set of inherent characteristics fulfill requirements (Para 3.1.1 of ISO 9000: 2000). Characteristics imply a distinguishing feature (Para 3.5.1 of ISO 9000: 2000). Requirements are a need or expectation that is stated, generally implied or obligatory (Para 3.1.2 of ISO 9000:2000).

2. Degree of adherence to pre-established criteria or standards.

Quality assurance:
Part of quality management focused on providing confidence that quality requirements will be fulfilled (Para 3.2.11 of ISO 9000:2000).

Quality Improvement:
Ongoing response to quality assessment data about a service in ways that improve the process by which services are provided to consumers/patient.

Radiation Safety:
Radiation safety refers to safety issues and protection from radiation hazards arising from the handling of radioactive materials or chemicals and exposure to Ionizing & Non-Ionizing Radiation. This is implemented by taking steps to ensure that people will not receive excessive doses of radiation and by monitoring all sources of radiation to which they may be exposed.
In a Healthcare setting, this commonly refers to X-ray machines, CT/ PET CT Scans, Electron microscopes, Particle accelerators, Cyclotrone etc. Radioactive substances &radioactive waste are also potential Hazards. Imaging Safety includes safety measures to be taken while performing an MRI, Radiological interventions, Sedation, Anaesthesia, Transfer of patient, Monitoring patient during imaging procedure etc.

Re-assessment:
It implies continuous and ongoing assessment of the patient which is recorded in the medical records as progress notes.

Resources:
It implies all inputs in terms of men, material, money, machines, minutes (time), methods, metres (space), skills, knowledge and information that are needed for efficient and effective functioning of an organisation.

Safety:
The degree to which the risk of an intervention/procedure, in the care environment is reduced for a patient, visitors and healthcare providers.

Safety Programme:
A programme focused on patient, staff and visitor safety.

Scope of services:
Range of treatment and supportive activities that are provided by a healthcare organisation.

Security:
Protection from loss, destruction, tampering, and unauthorised access or use.

Sentinel Events:
A relatively infrequent, unexpected incident, related to system or process deficiencies, which leads to death or major and enduring loss of function for a recipient of healthcare services. Major and enduring loss of function refers to sensory, motor, physiological, or psychological impairment not present at the time services were sought or begun. The impairment lasts for a minimum period of two weeks and is not related to an underlying condition.

Social Responsibility:
A balanced approach for organisation to address economic, social and environmental issues in a way that aims to benefit people, communities and society, e.g. adoption of villages for providing health care, holding of medical camps and proper disposal of hospital wastes.

Special Educational needs of the Patient:
In addition to routine carried by the healthcare professionals, patient and family have special educational needs depending on the situation.

Example: A post surgical patient who has to take care of his wound, NG tube feeding, patient on tracheotomy getting discharged who has to be taken care by the family etc. The special educational needs are also greatly influenced by the literacy, educational level, language, emotional barriers and physical and cognitive limitations. Hence it is important for the staff to determine the special educational needs and the challenges influencing the effective education

Staff:
All personnel working in the organisation including employees, “fee-forservice” medical professionals, part-time workers, contractual personnel and volunteers.

Standard Precautions:
1. A method of infection control in which all human blood and other bodily fluids are considered infectious for HIV, HBV and other blood-borne pathogens, regardless of patient history. It encompasses a variety of practices to prevent occupational exposure, such as the use of personal protective equipment (PPE), disposal of sharps and safe housekeeping.

2. A set of guidelines protecting first aiders or healthcare professionals from pathogens. The main message is: "Don't touch or use anything that has the victim's body fluid on it without a barrier." It also assumes that all body fluid of a patient is infectious, and must be treated accordingly. Standard Precautions apply to blood, all body fluids, secretions, and excretions (except sweat) regardless of whether or not they contain visible blood, non-intact skin and mucous membranes.

Standards:
A statement of expectation that defines the structures and process that must be substantially in place in an organisation to enhance the quality of care.

Strategic Plan:
Strategic planning is an organisation’s process of defining its strategy or direction and making decisions on allocating its resources to pursue this strategy, including its capital and people. Various business analysis techniques can be used in strategic planning; including SWOT analysis (Strengths, Weaknesses, Opportunities and Threats) e.g. Organisation can have a strategic plan to become market leader in provision of cardiothoracic and vascular services. The resource allocation will have to follow the pattern to achieve the target. The process by which an organisation envisions its future and develops strategies, goals, objectives and action plans to achieve that future.

Surveillance:
The continuous scrutiny of factors that determines the occurrence and distribution of diseases and other conditions of ill health. It implies watching over with great attention, authority and often with suspicion. It requires professional analysis and sophisticated interpretation of data leading to recommendations for control activities.

Validation:
1. Confirmation through the provision of objective evidence that the requirements for a specific intended use or application have been fulfilled. Objective Evidence – Data supporting the existence or variety of something.

2. The checking of data for correction or for compliance with applicable standards, rules or conventions. These are the tests to determine whether an implemented system fulfills its requirements. It also refers to what extent does a test accurately measure what it purports to measure.

Values:
The fundamental beliefs that drive organisational behavior and decision-making. This refers to the guiding principles and behaviours that embody how an organisation and its people are expected to operate. Values reflect and reinforce the desired culture of an organisation.

Vision:
An overarching statement of the way an organisation wants to be, an ideal state of being at a future point. This refers to the desired future state of an organisation. The vision describes where the organisation is headed, what it intends to be, or how it wishes to be perceived in the future.

Vulnerable Patient:
Those patients who are prone to injury and disease by virtue of their age, sex, physical, mental and immunological status, e.g. infants, elderly, physically & mentally-challenged, semiconscious/ unconscious, those on immunosuppressive and/or chemotherapeutic agents.




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