Quality Tools
A four-stage problem-solving model used for improving a process or carrying out change.
Plan, Do, Study, Act (PDSA)
The most common expression of centering of a distribution. Calculated by totaling the observed values and dividing by the number of observations.
Average (or Mean)
An immediate pause by the entire team to confirm correct patient, procedure, and site.
Timeout
A designation given to eligible rural hospitals by CMS that is located more than 35 miles from a hospital or another.
Critical Access Hospital (CAH)
A diagram in which the numerical values of variables are represented by the height or length of rectangles of equal width.
Bar graph
Tomah Health Compliance Officer.
Shelly Egstad
The process of acknowledging the receipt of information and clarifying with the sender of the communicated message.
Closed-loop Communication
A step-by-step approach for identifying all possible failures in a process.
Failure Mode & Effects Analysis (FMEA) or proactive risk assessment.
The patterns in a Run Chart or Control Chart that feature the continued rise or fall of a series of points.
Trends
An event that results in death, permanent harm, or severe temporary harm.
Sentinel (Never) Event
A status conferred by CMS on an organization whose standards and survey process are determined by CMS to be equivalent to those of the Medicare programs or other federal laws (such as CLIA).
Deemed status
A graph in which the entire circle represents 100% of the data to be displayed.
Pie Chart
Anonymous hotline, talk to Director or any one in admin.
The process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a healthcare organization.
Credentialing
An approach used to uncover underlying reasons a problem of event occurred.
Root Cause Analysis (RCA)
The universal data under investigation from which a sample will be taken.
Population
An injury resulting from a medical intervention related to a medication.
Adverse Drug Event (ADE)
A statement that defines the performance expectations, structures, or processes that must be in place for a CAH to provide sate and high-quality care, treatment, and services.
Standard
A graph used to visually represent data over time to monitor a process to whether or not the long range average is changing.
Run Chart
A contract between two entities that speaks to maintaining PHI security and overall HIPAA compliance.
Business Associate Agreement (BAA).
An organizational accountability for the system they designed and employee accountability for the choices they make.
Just Culture
A pictorial representation showing all of the steps of a process.
Flowchart
A method that allows us to infer information about a population based on results from a subset of the population, without having to investigate every case.
Sampling methodology
The lead Federal agency charged with improving the safety and quality of healthcare for all Americans.
Agency for Healthcare Research and Quality (AHRQ)
A term used to describe an organizational culture that strives to achieve error-free performance and safety in every procedure, every time. Doing what we say we will do.
High Reliability
A run chart with statistically determined upper and lower control limits. Used to determine how much variability in a process is due to random variation and how much is due to unique events.
Control Chart
The act that protects the patient against balance billing or having unexpected costs.
No Surprises Billing Act.
Guidelines that have been scientifically developed based on recent literature review and are consensus driven.
Evidence-based Guidelines