Code of Maine Rules › 95 - INDEPENDENT AGENCIES › 629 - DIRIGO HEALTH AGENCY › Chapter 3 - AWARDING THE MAINE QUALITY FORUM SAFETY STAR › Section 629-3-2 - Definitions

Current through 2024-29, July 17, 2024
1.
Applicant.
"Applicant" means the hospital
				  submitting a completed Safety Star Application Form to MQF.
2.
Application.
"Application" means the process
				  whereby a hospital requests consideration for the Safety Star award by
				  submitting a completed Safety Star Application Form to MQF.
3.
Best Practice.
"Best practice" means a
				  suggestion of medical treatment and/or medical care process that experts have
				  agreed upon and accepted for particular circumstances.
4.
Hospital.
"Hospital" is any acute care
				  institution required to be licensed pursuant to 22 M.R.S.A., chapter
				  405.
5.
MQF.
"MQF" means Maine Quality Forum, an
				  independent division of the Dirigo Health Agency tasked with improving the
				  quality of health care in Maine.
6.
M.R.S.A.
"M.R.S.A." means Maine Revised
				  Statutes Annotated.
7.
NQF.
"NQF" means National Quality Forum, a
				  private, not-for-profit organization created to develop and implement a
				  national strategy for healthcare quality measurement and reporting.
8.
Policy Review.
A "policy review" is a review
				  of written policy, along with observation and interviews to determine if a
				  policy reflects recognized best practice, and is commonly acknowledged,
				  understood and practiced across all organizational levels.
9.
Public Display.
"Public display" means placing
				  information in a medium in such a way as to attract attention to the
				  information.
10.
Reapplication.
"Reapplication" means the
				  process whereby an applicant that does not meet three or fewer safe practice
				  thresholds makes changes to improve upon those practices and have just those
				  missed practices validated for the Safety Star.
11.
Reconsideration.
"Reconsideration" means the
				  re-review process for a Safety Star award decision whereby an applicant who
				  does not receive the Safety Star award requests a reexamination of that
				  decision.
12.
Record Review.
"Record review" means a review
				  of patient charts and other hospital records.
13.
Safe Practice.
High priority practices that
				  demonstrate evidence of efficacy, are generalizable, are usable, and when
				  implemented fully will improve significantly the safety of patients. A safe
				  practice is a process, technique, method or protocol that has been demonstrated
				  to improve patient safety when appropriately implemented.
14.
Safety Star Manual.
"Safety Star Manual"
				  refers to the most recent version of the MQF published Safety Star Manual,
				  which outlines the Safety Star practices, thresholds, and application
				  processes. The Safety Star Manual contains application and reapplication
				  forms.
15.
Site Visit.
A "site visit" is the process of
				  a Site Visit Team going to an applicant's facility to conduct policy reviews
				  and record reviews to validate that the applicant has met or exceeded the
				  threshold for each Safety Star safe practice.
16.
Site Visit Report.
The "Site Visit Report" is
				  the document the Site Visit Team completes after a site visit and submits to
				  the MQF Director. The Validation Manual contains the Site Visit Report
				  form.
17.
Site Visit Team (SVT).
"Site Visit Team" or
				  "SVT" means a group of members from the Validation Team who conduct a site
				  visit to validate a Safety Star application.
18.
Standards.
"Standards" are the criteria upon
				  which hospitals will be assessed. Standards are built upon the NQF Safe
				  Practices and micro-specified via established thresholds for
				  achievement.
19.
Threshold.
"Threshold" is the minimum
				  requirement (established by MQF) for achieving recognition of adequate
				  implementation of a Safety Star safe practice.
20.
Validation.
"Validation" is a process for
				  confirming the representations of the applicant.
21.
Validation Criteria.
"Validation criteria"
				  are the guidelines for the information SVT members look for during site visits
				  to validate that applicants meet the thresholds for all Safety Star safe
				  practices.
22.
Validation Forms.
"Validation forms" are
				  completed by the SVT during site visits as part of the Site Visit
				  Report.
23.
Validation Manual.
"Validation Manual" refers
				  to the most recent version of the MQF published Validation Manual, which
				  describes the Safety Star validation process, validation criteria, and the
				  roles of the Validation Team and Site Visit Teams. The Validation Manual also
				  contains the forms needed to complete the validation process.
24.
Validation Team (VT).
"Validation Team" means
				  the group of quality improvement healthcare professionals who volunteer to
				  assist with the development and refinement of Safety Star validation criteria
				  as well as comprise the Site Visit Teams.