Standards Glossary
The act of granting recognition to an organization that maintains a nationally standardized criteria demonstrating their commitment to a comprehensive scope of services, providing quality care consistent with industry best practices, focused patient and workforce safety, human resource onboarding and oversight, and excellent clinical outcomes.
Physician assistant (PA) or nurse practitioner (NP) who practices medicine under the supervision of a physician in accordance with state regulations. This person may work in the setting of a hospital emergency department or in an acute care center.
Licensed medical clinicians including MD’s, DO’s, PA’s, and NP’s; including employees, contractors, and those supplied through agency/lease agreement.
Staff (see Staff) engaged in direct patient care.
See Credentialing
A step-by-step approach of evaluating workforce ongoing ability to perform a job-related task by providing them with information about the task, a demonstration of its performance, an opportunity to imitate the demonstration and obtain subsequent feedback.
Organizations participating in Medicare, Medicaid, or other government funded payment programs are to establish a compliance program as a condition of enrollment. The compliance program establishes governance, internal policies and processes focusing on regulatory compliance. The plan typically covers items such as billing, coding, gifts, anti-kickback regulations, overpayments, fraud, and abuse. The plan is typically separate from other operational policies and procedures, although many interrelate (e.g., billing policies). The plan strives to ensure ethical and professional standards on how it will conduct business. The Office of the Inspector General, U.S. Department of Health & Human Services has established the seven core requirements of an effective compliance program to include: 1) Written Policies, Procedures and Standards of Conduct; 2) Compliance Officer, Compliance Committee and High-Level Oversight; 3) Effective Training and Education; 4) Effective Lines of Communication; 5) Well-Publicized Disciplinary Standards; 6) Effective System for Routine Monitoring, Auditing and Identification of Compliance Risks; and 7) Procedures and System for Prompt Response to Compliance Issues.
Attestation of qualification, competence, or authority issued to an individual by a third party with a relevant or de facto authority.
An organization that gathers data and verifies the credentials of clinicians. A CVO typically provides credentialing support to organizations providing health care services to patients. Organizations base their hiring decisions on information received from a CVO must be confident in the completeness and accuracy of the information provided.
The processes of establishing the qualifications of licensed clinicians, organizational members or organizations and assessing their background and legitimacy to provide patient care within an organization.
An organization’s written statement detailing procedures to be followed during an emergency.
The point at which an interaction between patients and professionals takes place; it is the point at which decisions about diagnosis and treatment are made, and during which care takes place including in person, telemedicine, and telephone contact.
A map, typically a floor plan, identifying the placement location and the closest evacuation route in the event of an emergency. Other exits and often fire extinguishers are also noted in the event the closest route is compromised. Evacuation maps are typically for the benefit of patients, family and visitors but may also protect workforce in an emergency.
A list of pharmaceuticals typically selected by the medical team to be maintained as part of the organization’s onsite inventory for patient care purposes or dispensing, as appropriate.
A group of individuals charged with the responsibility of establishing policies and continuously monitoring the proper implementation of the policies by the workforce of an organization. The act of Governance includes the mechanisms required to balance the powers of the workforce (with associated accountability), along with the primary duty of enhancing the organization.
Pertaining to medical procedures, informed consent is a process for getting written permission before conducting a procedure. Excluding emergencies, informed consent must be obtained prior to performing a procedure. Examples are laceration repairs, I&D’s, removal of foreign body, nail avulsion, placing restraints, etc.
An organization’s written statement detailing procedures to be taken.
A medication having a drug name that looks similar in print or sound to another drug or drugs. Such agents carry a significant safety risk of being administered improperly.
A Hazardous Waste Manifest is a shipping document that tracks hazardous waste from the point of generation to ultimate disposal. The manifest is not the receipt the driver leaves at time of pick up.
A team-based healthcare delivery system led by a healthcare clinician designed to drive primary care excellence.
A complete listing, with evidence of verification/reconciliation by the clinician, of all current medications (prescription and over the counter)
An opportunity for an organization to engage the workforce in preparation for the Accreditation processes by reviewing the systems in place to verify compliance with the UCA Standards.
Errors, typically medication-related, corrected via some form of intervention before administration to the patient. They did not cause harm but had the potential to cause harm. Near-misses may also relate to any other action which had the potential to do harm to a patient but was identified before the potential to cause harm occurred. Near-misses often reveal opportunities for process improvement and are therefore an important component of quality programs.
A program designed to validate the technical skills, knowledge, and ability of a new member to perform their specific job responsibilities according to an organization-established policy, procedure, and job description. A timeframe is generally established for an orientation period (e.g., 90 days).
Information offered by a clinician in the same professional discipline as an applicant, demonstrating their insight into the applicant’s clinical practice, ability to work as a team and ethical behavior. This should be obtained in writing and be used for the purpose of evaluating competence.
The written assessment and review of a staff member’s job performance conducted in a constructive manner to inform and guide the individual on how they are performing their required duties as per their job description. The written assessment is reviewed by management with the staff member and is signed by both the manager and the staff member. Common elements of a performance evaluation include assessment of technical skills, quality of work, and interpersonal skills, along with needs for areas of improvement and goals for upcoming year(s).
A course or principle of action adopted by the organization. Policies are formal, written, and often a reflection of the organization’s mission, vision, and values. They tend to prevail over time. In contrast, procedures are tactical methodologies to achieve a policy. They are more fluid and should be dynamic as new information, technologies, resources, or regulatory changes occur. Procedures represent a realization of the overarching policies.
In academic discipline, a primary source (also called original source or evidence) is a document that was created by the organization that originally issued the document of credential. Examples include medical schools, nursing schools, state medical boards, graduate programs, federal and state licensing boards.
The authority granted to a clinician by a health care organization’s governing board to provide patient care within the organization. Clinical privileges are limited to the individual’s license, experience and competence and should be specific to the healthcare organization’s defined scope of services provided.
The processes by which a licensed clinician is authorized by a health care organization to provide specified medical or other patient care services within the scope of services specific to that organization.
A series of actions or steps taken to achieve a particular end. Processes are typically formalized to enhance safety and quality, create consistency based on best practice and mitigate risk. Examples may include audits, expected actions or activities, logging items, checklists, documentation, work, and communication flow.
A detailed set of criteria or instructions providing guidance to workforce in the care of a patient or to assist in the performance of an organization-identified procedure.
A process that consists of systematic and continuous actions that leads to measurable improvement in health care services.
A detailed written document (or several documents) specifying quality standards, practices, resources, specifications, and the sequence of activities relevant to a particular organization. A quality plan 1) defines the quality goals; 2) includes acceptable performance metrics, frequency of measurements; 3) is realistic about where deficiencies come from; 4) selects appropriate detection and prevention methods; 5) is ongoing; and 6) is aimed at improving an organization’s outcomes.
A method or technique that has consistently shown results superior to those achieved with other means and that is used as a benchmark. These are typically evidence-based and acknowledged by most professionals within the field as exemplary.
A document designed to provide both workers and emergency personnel with the proper procedures for handling or working with a particular substance. SDS include information such as physical data, toxicity, health effects, first aid, reactivity, storage, disposal, protective equipment, spill/leak procedures and more. The manufacturer, distributor or importer of the chemical is responsible for providing the SDS to consumers.
The range of services/activities performed by governance, management, clinicians, clinical or support staff.
A source of information that was created by someone who did not experience first-hand or participate in the events or conditions being researched. Examples of secondary sources are American Medical Association (AMA), American Osteopathic Association (AOA), American Board of Medical Specialties (ABMS) and The Educational Commission for Foreign Medical Graduates (ECFMG).
All employees, excluding clinicians, including contractors and those supplied through agency/lease agreements.
A level of quality or attainment OR an idea or thing used as a measure, norm, or model in comparative evaluations. The following areas are included in the Accreditation Standards Manual: Governance, Human Resources, Health Record Management, Patient Care Processes, Patient Privacy, Rights and Responsibilities, Physical Environment and Quality Improvement.
An order written and authorized by a clinical leader or clinical leadership team based on best practices and standards of care. The order is to be carried out by members of the workforce without the requirement of obtaining an additional order from an onsite prescribing clinician. Standing Orders are carried out for patients who meet a specific set of criteria or presentation. An example is staff performing a urine dip on a patient presenting with symptoms associated with a urinary tract infection based on an order authorized by the organization’s Medical Director.
A suggestion of how to demonstrate evidence of an accomplishment of an aim or purpose. (In our case, accomplishment of the standard.)
The formal or official examination of Accreditation Standards for an Urgent Care center.
A healthcare professional who evaluates an organization’s compliance with the UCA Accreditation Standards as they apply to Scope, Quality, and Safety. Surveyors may be clincians, administrators, consultants, registered nurses, APC’s, and medical technologists with experience in the industry.
A remote diagnosis and treatment of patients by means of telecommunications technology, typically accomplished via two-way real-time interactive communication between the patient and the medical clinicians. Sometimes used synonymously with telehealth. According to Centers for Medicare & Medicaid Services (CMS) and Medicaid.gov, “Asynchronous” or “Store and Forward”: Transfer of data from one site to another using a camera or similar device that records (stores) an image that is sent (forwarded) via telecommunication to another site for consultation. Asynchronous or “store and forward” applications would not be considered telemedicine but may be utilized to deliver services.
Organized activity aimed at imparting information and/or instructions to improve the recipient’s performance or to help them attain a required level of knowledge or skill.
Prior to treating a patient or performing a procedure, including administration of medication, laceration repair, X-ray, obtaining specimens and phlebotomy, workforce must verify that services are being performed on the correct patient. Confirmation occurs using two identifiers selected by the organization to confirm that the correct patient. Workforce then confirms information provided by the patient to the patient’s chart information. Identifiers are often the patient’s first and last name and date of birth. Patient identifiers are an important component of an organization’s safety or risk mitigation program.
An order not yet entered into the medical record but voiced by a clinician to an individual on staff to carry out. If permitted, verbal orders are typically restricted to use only in the event of an emergency due to the potential for miscommunication and elevated risk of a medication or other error resulting in an adverse event.
The organization’s clinicians and staff, regardless of status (FT, PT, PRN), include employees, contractors, and those supplied through agency/lease agreement.