CAQ-HM key terms

A state regulatory approval process requiring health care providers to demonstrate community need before building facilities, adding beds, or acquiring major equipment. It aims to control costs and prevent duplication of services.

A federal law requiring Medicare-participating hospitals to provide a medical screening examination and stabilizing treatment to anyone presenting with an emergency condition, regardless of insurance or ability to pay.

Federal legislation establishing national standards for protecting individually identifiable health information and governing its permitted uses and disclosures by covered entities and their business associates.

A federal criminal law prohibiting knowingly offering, paying, soliciting, or receiving remuneration to induce referrals of items or services reimbursed by federal health care programs. Violations carry severe penalties.

A federal statute barring physicians from referring Medicare patients for designated health services to entities in which they or immediate family members hold a financial interest, unless a specific exception applies.

A network of providers that voluntarily accepts shared responsibility for the cost and quality of care for an assigned population, sharing in savings when spending targets and quality benchmarks are met.

A strategic performance framework that translates mission and vision into measurable objectives across financial, customer, internal process, and learning and growth perspectives, linking strategy to daily operations.

The legal obligation of governing board members to act in the organization's best interest with loyalty, care, and obedience, including oversight of finances, quality, and compliance.

Foundational statements describing an organization's purpose, its desired future state, and the guiding principles that shape decisions, priorities, and behavior throughout the enterprise.

A documented roadmap that assesses internal and external conditions, sets priorities and goals, allocates resources, and defines measures and accountability for achieving the organization's long-term direction.

A structured assessment of an organization's internal strengths and weaknesses and external opportunities and threats, used to inform strategy, prioritization, and resource allocation decisions.

A measure reflecting the average relative resource intensity and clinical complexity of a hospital's patient population, calculated from diagnosis-related group weights and used in payment and benchmarking.

A hospital's written policy defining eligibility, discounts, and processes for providing free or reduced-cost care to patients unable to pay, as required for nonprofit tax-exempt status.

The proportion of total costs to total gross charges, used to convert billed charges into estimated costs for financial analysis, Medicare cost reports, and payer contract evaluation.

A patient classification system grouping hospital stays by clinical condition, procedures, complications, and resource use, forming the basis for prospective payment under Medicare and many commercial payers.

A reimbursement method paying a predetermined fixed amount per discharge, visit, or episode based on classification categories, shifting financial risk from payers to providers.

Payment models that adjust reimbursement based on quality, outcomes, patient experience, and cost performance rather than volume alone, rewarding providers for meeting specified performance thresholds.

A continuous improvement approach focused on eliminating waste, standardizing work, and improving flow by engaging frontline staff to identify and remove non-value-adding steps in processes.

A rapid-cycle improvement method in which a change is planned, tested on a small scale, studied for results, and acted upon through adoption, adaptation, or abandonment before broader implementation.

A structured retrospective method for investigating adverse events to identify underlying system failures and contributing factors, leading to corrective actions rather than individual blame.

A prospective risk assessment technique that maps a process step by step, identifies where it could fail, rates the severity and likelihood of each failure, and prioritizes preventive actions.

A digital longitudinal record of a patient's health information shared across care settings, supporting clinical documentation, order entry, results review, and coordination among authorized users.

The electronic sharing of patient health information among disparate organizations and systems according to agreed standards, enabling continuity of care across providers and settings.

The ability of different information systems, devices, and applications to access, exchange, integrate, and cooperatively use data in a coordinated manner across organizational boundaries.

Tools embedded in health information systems that deliver patient-specific knowledge and alerts at the point of care to support clinical decisions and promote evidence-based practice.

The process of verifying a clinician's education, licensure, training, and experience, and granting permission to perform specified procedures and provide services within an organization.

A systematic method of verifying that staff possess and maintain the knowledge, skills, and behaviors required for their roles, often through observation, testing, and documented performance review.

An organizational philosophy that distinguishes human error, at-risk behavior, and reckless conduct, encouraging reporting and learning while holding individuals accountable for conscious choices.

A deliberate process of identifying and developing internal talent to fill key leadership and critical roles over time, reducing vacancy risk and preserving institutional knowledge.

The process of disclosing a proposed treatment's risks, benefits, and alternatives, confirming patient understanding, and obtaining voluntary agreement before proceeding with care.

A serious, largely preventable patient safety incident, such as wrong-site surgery or retained surgical item, that should never occur and is often subject to mandatory reporting and nonpayment policies.

An unexpected occurrence involving death, serious physical or psychological injury, or the risk thereof, requiring immediate investigation and response, often with root cause analysis.

The shared beliefs, attitudes, and behaviors of an organization regarding safety, reflected in open reporting, psychological safety, teamwork, and leadership commitment to preventing harm.

The deliberate organization of patient care activities and information sharing among participants to facilitate appropriate, timely, and efficient delivery of services across settings and providers.

A primary care delivery model providing accessible, comprehensive, coordinated, and continuous care with the patient and family as the central focus, supported by team-based practice and health information technology.

The systematic identification and stratification of a defined population's health needs, followed by targeted interventions and resources to improve outcomes and reduce disparities across the continuum.

Nonmedical conditions in which people live, work, and age, such as income, housing, education, and food security, that influence health outcomes and access to care.