Healthcare quality and governance terms, explained
Plain-language explanations of healthcare quality, governance and information terms. Related product links describe the available software scope; a definition does not imply that a feature is implemented.
- Measurable element
- The smallest unit a Joint Commission International standard is assessed at. Other accreditation programmes use their own terms for the same idea.
- CAPA
- Corrective and preventive action. The tracked fix arising from any finding, whatever its source.
- RCA and RCA2
- Root cause analysis is a structured way of finding why a safety event happened. RCA2 is an updated approach that emphasises stronger corrective actions and checking whether they worked.
- FMEA
- Failure mode and effects analysis. A proactive method for examining how a process could fail and what the effects would be. Accreditation programmes such as JCI expect proactive risk assessment of high-risk processes, and FMEA is a common way to do it.
- Sentinel event
- A patient safety event that causes death, permanent harm or severe temporary harm. Definitions, investigation requirements and notification windows differ by regulator and accreditation programme, so confirm the rules that apply to your facility.
- WHO ICPS
- The WHO International Classification for Patient Safety, a framework for describing and grouping patient safety incidents. A facility chooses whether and how to code its incidents against it.
- NCC MERP
- The NCC MERP index classifies a medication error by outcome, from circumstances that could cause an error through to death. A clinical reviewer assigns the category after investigation.
- NCC MERP
- SQE
- The Staff Qualifications and Education chapter of the Joint Commission International standards. It covers how a facility checks, records and reviews staff qualifications, licences and competence. Requirements vary by edition.
- JCI SQE FL-09 Credentials and licences FL-10 HR and workforce
- FMS
- The Facility Management and Safety chapter of the Joint Commission International standards. It covers how a facility manages its premises, equipment and safety risks. Requirements vary by edition.
- JCI FMS FL-12 Assets and equipment FL-13 Facility inspections
- Tracer methodology
- A review method in which people follow a patient or a process through an organisation and compare what is written with what happens in practice. It relies on interviews, observation and record review. Software records can be source material, but the method is led by people.
- Tracer methodology FL-04 Clinical audits FL-07 Document hub FL-13 Facility inspections
- Primary source verification
- Confirming a qualification or licence directly with the body that issued it, rather than relying on a copy. Whether it is required, and how, depends on the regulator and accreditation programme.
- Privileging
- Authorising a named clinician to perform specific procedures or services after review of their qualifications and competence. It is a decision made by authorised people in the facility, and it is distinct from holding a licence.
- Three Lines Model
- The Institute of Internal Auditors’ Three Lines Model, which replaced the earlier wording three lines of defence. It describes how a governing body, management and internal audit share accountability and assurance. The organisation defines the roles and independence.
- Three Lines Model FL-03 Risk management FL-04 Clinical audits FL-06 Complaints
- Inherent vs residual risk
- Inherent risk is the level of risk before any controls are applied. Residual risk is what remains after them. Organisations compare residual risk with their own risk appetite.
- Break-glass access
- Emergency access that lets an authorised user open a record outside their usual permissions. Organisations normally require a stated reason and review each use afterwards.
- Effective dating
- Recording the date from which a price, rate or rule applies, so earlier transactions keep the value that applied when they were made.
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