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Key words for Exam 3 Shaw Chapters: 4, 5, 13, 15, 21

Absolute Frequency

The number of times a score or value occurs in a data set

Bar Graph

A graphic data display tool used to show discrete categories of information

Check Sheet

A data collection tool used to identify patterns in sample observations

Continuous Data

Data that may have an infinite number of possible values in measurements that can be expressed in decimal values

Control Chart

A data display tool used to show variation in key processes over time

Discrete or Count Data

Numerical values that represent whole numbers; can be displayed in bar graphs; i.e. the number of children in a family or the number of unbillable patient accounts


A bar graph used to display data proportionally

Likert Scale

A measure that records level of agreement or disagreement along a progression of categories

Line Chart

A data display tool used to plot information on the progress of a process over time

Mean (M)

The average value in a range of values, calculated by summing the values and dividing the total by the number of values in the range


A measure of central tendency that shows the midpoint of a frequency distribution when the observations have been arranged in order from lowest to highest

Nominal Data

Values assigned to name-specific categories; also called categorical data

Ordinal Data

Values assigned to rank the comparative characteristic of something according to a given set of criteria; also known as ranked data

Pareto Chart

A bar graph used to determine priorities in problem solving

Pie Chart

A data display tool used to show the relationship of individual parts to the whole

Pivot Table

A Microsoft Excel tool used to summarize data according to categories; provide flexibility for the end user or analyst to organize and filter data in various ways before finalizing the analysis

Relative Frequency

The percentage of times a characteristic appears in a data set


The recording of a smaller subset of observations of the characteristic or parameter, making certain, however, that a sufficient number of observations have been made to predict the overall configuration of the data

Standard Deviation (SD)

A statistic used to show how the values in a range are distributed around the mean


A graphic display tool used to communicate the details of performance improvement activities


The act of relaying the performance improvement (PI) process in a structured manner to support learning and organization-wide PI

Clinical Privileges

The accordance of permission by a healthcare organization to a licensed independent practitioner (physician, nurse-practitioner, or another professional) to practice in a specific area of specialty within that organization

Credentialing Process

The examination of an independent healthcare practitioner's licenses, specialty credentials, and professional performance upon which a healthcare organization bases its decision to confer or withhold permission to practice (privileges) in the organization


A formal agreement granting an individual permission to practice in a profession, usually conferred by a national professional organization dedicated to a specific area of healthcare practice; or the accordance of permission by a healthcare organization to a licensed independent practitioner (physician, nurse-practitioner, or other professional) to practice in a specific area of specialty within that organization; this agreement usually requires an applicant to pass an examination to obtain the credential initially and then to participate in continuing education activities to maintain the credential thereafter

Due Process

The right of individuals to fair treatment under the law

Healthcare Integrity and Protection Data Bank (HIPDB)

A national database that maintains reports on civil judgements and criminal convictions issues against licensed healthcare providers

Licensed Independent Practitioner (LIP)

Any individual permitted by law to provide healthcare services without direction or supervision, within the scope of the individual's license as conferred by state regulatory agencies and consistent with individually granted clinical privileges


The legal authorization granted by a state to an entity that allows the entity to provide healthcare services within a specific scope of services and geographical location; states license both individual healthcare professionals and healthcare facilities; usually requires an applicant to pass an examination to obtain the license initially and then to participate in continuing education activities to maintain the license thereafter

National Practitioner Data Bank (NPDB)

A federally sponsored national database that maintains reports on medical malpractice settlements, clinical privileges actions, and professional society membership actions against licensed healthcare providers


The act of granting approval to a healthcare organization on the basis of whether the organization has met a set of voluntary standards developed by an accreditation agency

Accreditation Standards

An accrediting agency's published rules, which serve as the basis for comparative assessment during the review or survey process


The act of granting approval for a healthcare organization to provide services to a specific group of beneficiaries; also, the act of granting a healthcare professional approval to practice


The process of meeting a prescribed set of standards or regulations to maintain active accreditation, licensure, or certification status

Compulsory Reviews

The examinations of a healthcare facility and its processes and infrastructures as required by state laws and regulations

Conditions of Participation

A set of regulations published by CMS to outline requirements of approved programs providing healthcare services to beneficiaries of Medicare and Medicaid programs

Deemed Status

The term used for the assumption by CMS that an organization meets the Medicare and Medicaid Conditions of Participation as a result or prior accreditation by the Accreditation Association for Ambulatory Health Care (AAAHC), the American Osteopathic Association (AOA), the Commission on Accreditation of Rehabilitation Facilities (CARF), or the Joint Commission

Document Review

An in-depth study performed by accreditation surveyors of an organization's policies and procedures, administrative records, human resources records, performance improvement documentation, and other similar documents, as well as a review of closed patient records

Exit Conference

A meeting that closes a site visit during which the surveyors representing an accrediting organization summarize their findings and explain any deficiencies that have been identified; the leadership of the organization is allowed an opportunity to discuss the surveyors' perspectives or provide additional information related to any deficiencies the surveyors intend to cite in their final reports


The process of granting a healthcare organization or an individual healthcare practitioner a license to practice

Opening Conference

A meeting conducted at the beginning of the accreditation site visit during which the surveys outline the schedule of activities and list any individuals whom they would like to review

Quality Improvement Organizations (QIOs)

Private or public agencies contracted by CMS to undertake examination and evaluation of the quality of healthcare rendered to beneficiaries of federal healthcare programs

Site Visit

An in-person review conducted by an accreditation survey team; the visit involves document reviews, staff interviews, an examination of the organization's physical plant, and other activities

Survey Team

A group of individuals sent by an accrediting agency to review a healthcare organization for accreditation purposes

Tracer Methodology

A process (Joint Commission) surveyors use during the on-site survey to analyze an organization's systems, with particular attention to identified priority focus areas, by following individual patients through the organization's healthcare process in the sequence experienced by the patients; depending on the setting, this process may require surveyors to visit multiple care programs and services within an organization or within a single program or service to "trace" the care rendered

Voluntary Reviews

Examinations of an organization's structures and processes conducted at the request of a healthcare facility seeking accreditation from a reviewing agency

Breach of Duty

In a malpractice action, the issue is whether a physician exercised a standard of care that is reasonably prudent physician would have exercised under those circumstances; failure to exercise due care is a breach of duty


In a malpractice action, there must be a connection between the breach of duty and the damage - evidence that the failure to exercise due care, or breach, caused the damage


In malpractice terms, the patient must show that actual harm, or damage, occurred


Information that is not shielded and can be introduced at trail to support a patient's malpractice action against a physician or hospital

Duty to Use Due Care

A relationship must have been established between the parties in which one party has an obligation to act as a reasonably prudent person would act toward the other under a given set of circumstances; this duty exists in a physician's relationship with his or her patients

Elements of Negligence

Four basic elements that must be proved in a malpractice case: duty to use due care, breach of duty, damages, and causation

Generalizable Knowledge

In the context of research, this term means that the results of the activity may be applied to populations outside the population being studied; participants in a research project may or may not benefit directly from the study, but a larger group may benefit from the knowledge obtained in the study; the investigator conducting the research usually intends to publish the results in a scientific journal


A legal principle that applies to discussions and correspondence between persons with a certain type of relationship that has been recognized as needing confidentiality; examples of such relationships include those between a lawyer and a client, priest and penitent, husband and wife, and doctor and patient; in each of these cases, the person seeking some type of counsel holds the privilege (whether a client, penitent, spouse, or patient); the privileged information is not admissible at trail unless the holder waives the privilege


Peer review protection means that the discussions, deliberations, records, and proceedings of medical staff committees having responsibility for the evaluation and improvement of quality are kept confidential and are not subject to disclosure outside the medical staff process; this confidentiality protection generally applies to peer review and performance improvement information regarding any member of or applicant to the medical staff, meetings of the medical staff, and meetings of standing and ad hoc committees created by the medical staff; the significance of this protection is that information from peer review proceedings, whether oral or written, generally is not discoverable


The systematic investigation, including development, testing and/or evaluation, designed to develop or contribute to generalized knowledge; the results of the activity may be applied to populations outside the population being studied; participants in the activity may or may not benefit directly from it, but a larger group may benefit from the knowledge obtained from the study; the investigator conducting the study usually intends to publish the results in a scientific journal

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