Tool that is used for identifying and organizing possible causes of a problem in a structured format. It is sometimes called a fishbone diagram because it looks like the skeleton of a fish.

Measurable items that reflect the quality of care provided and demonstrate the degree to which desired clinical outcomes are accomplished; clinical indicators help identify the goals of quality improvement.

Standardized sets of valid, reliable, and evidence-based quality measures used by The Joint Commission to integrate performance measures into the accreditation process and overall quality improvement processes.

Individual or group who relies on an organization to provide a product or service to meet some need or expectation. It is these customer needs and expectations that determine quality.

A systematic process for identifying potential design and process failures before they occur, with the intent to eliminate them or minimize the risk associated with them.

Picture of the sequence of steps in a process. Different steps or actions are represented by boxes or other symbols. A top-down flowchart shows the sequence of steps in a job or process. It can have different levels of detail. A deployment flowchart shows the detailed steps in a process and the people or departments that are involved in each step.

(Hospital-acquired condition) A term used to indicate an unintended and typically adverse patient-acquired condition occurring as a result of being cared for in a hospital.

National Academy of Sciences Institute of Medicine; a nonprofit organization with a mission of advancing and disseminating scientific knowledge to improve human health. The institute provides objective, timely, authoritative information and advice concerning health and science policy to the government, the corporate sector, the professions, and the public.

Institute for Safe Medication Practices; a nonprofit organization that is well known as an education resource for the prevention of medication errors.

A national agency that conducts surveys of inpatient and ambulatory facilities and certifies their compliance with established quality standards.

An integrated system of principles, practices, tools, and techniques focused on reducing waste, synchronizing workflows, and managing variability in production flows. Originally developed by Toyota and other Japanese companies and now adopted by the health care sector.

National Committee for Quality Assurance; an accreditation body that has become the primary group that accredits health plans.

Serious adverse events during an inpatient stay that should never occur or are reasonably preventable through adherence to evidence-based guidelines. The Centers for Medicare and Medicaid Services, through revisions in coverage and payment policies, provide hospitals with financial incentives to reduce the occurrence of never events.

A graphic tool that helps break down a big problem into its parts and then identifies which parts are the most important.

Series of linked steps necessary to accomplish work. A process turns inputs, such as information or raw materials, into outputs, such as products, services, and reports. Clinical processes are a series of linked steps necessary for the provision of patient care. It is through the improvement of processes that an organization improves its work and sustains itself.

The differences in how the steps in a work process might be accomplished and/or the variables that may affect each step in the process. Variation results from the lack of perfect uniformity in the performance of any process. Understanding variation in a process is necessary to determine the direction that improvement efforts must take.

Philosophic framework for managing organizations that recognizes quality is determined by customer needs and expectations. Attention is paid to how the work is done, with an emphasis on involving the people who best understand the detail of the work processes with which they are involved. Health care QM is specifically related to the quality of health care services provided.

Defined by TJC (2011) as a process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. A root cause analysis focuses primarily on systems and processes, not individual performance.

Graph of data in time order that help identify any changes that occur over time; also called a time plot. A run chart that has a centerline and statistical control limits added is known as a control chart. Control limits help detect specific types of change in a process.

Defined by TJC (2011) as an unexpected occurrence involving patient death or serious physical or psychological injury or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called sentinel because they signal the need for immediate investigation and response.

A concept for company-wide quality improvement that was first introduced by Motorola Corporation in 1987 and is characterized by its customer-driven approach, emphasis on decision making based on careful analysis of quantitative data, and a priority on cost reduction.

Approach to process improvement that involves developing and adhering to best-known methods and repeating key tasks in the same way, time and time again, until a better way is found, thereby creating exceptional service with maximal efficiency.