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
.
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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