Our hospital has established a Quality Management Unit in accordance with the Quality Standards in Health published by the Directorate General of Health Services of the Ministry of Health. The unit conducts its activities within the framework of the Health Quality Standards.
QUALITY UNIT
The unit ensures the effective, efficient, and fair provision of health services and aims to increase patient safety and satisfaction, as well as employee satisfaction, in line with the “Regulation on the Improvement and Evaluation of Quality in Health” and SKS standards published by the Directorate General of Health Services of the Ministry of Health. All activities are carried out in coordination with the Quality Management Director and the Quality Unit Staff.
QUALITY MANAGEMENT DIRECTOR
Responsible for preparing, implementing, and regularly auditing the hospital’s Quality Management System in accordance with SKS compliance, carrying out corrective activities, and implementing developments in the Quality Management System.
DUTIES OF THE QUALITY MANAGEMENT UNIT
- Coordinate the activities carried out within the framework of SKS,
- Monitor activities related to corporate goals and objectives,
- Manage self-assessments,
- Manage processes related to the Unwanted Incident Notification System,
- Manage processes related to risk management,
- Manage activities related to measuring patient and employee satisfaction (such as survey applications, evaluation of survey results, improvement activities based on survey results, receiving patient and employee feedback, etc.),
- Manage document management within the framework of SKS,
- Manage processes related to quality indicators,
- Participate as a member in committees determined within the framework of SKS.
- All departments within the scope of Health Quality Standards have designated departmental quality responsible persons, and activities are carried out accordingly.
DUTIES OF DEPARTMENTAL QUALITY RESPONSIBLE PERSONS
- Implement SKS for their departments, inform the Quality Management Unit about the implementations,
- Ensure that SKS written regulations sent to their departments reach all department employees,
- Ensure that written regulations are stored in suitable environments (electronic environment or files, folders, etc.) accessible to department employees,
- Together with top management and department managers, determine department goals within the scope of SKS,
- Analyze department goals and report to the Quality Management Unit,
- Monitor corrective-preventive activities carried out in departments,
- Inform department employees about SKS activities,
- Personally inspect patient and employee safety practices in their departments,
- Ensure that reporting and notifications within the scope of SKS (Unwanted Incident Notification System, Falls, Medication Lines, Lab. Errors, Emergency Codes, Exposure to Blood and Body Fluids, and Cutting/Piercing Tool Injuries) are regularly made,
- Act jointly with the Quality Management Unit in SKS Self-Assessments,
- Responsible for coordinating patient satisfaction surveys and employee satisfaction surveys.
- Responsible for tracking the use of documents and externally sourced documents in their departments.
- Participate in evaluation meetings where goals and self-assessment results will be discussed with hospital management. Each departmental quality responsible person keeps regular records of their activities and sends a copy of the evaluation reports to the Quality Management Unit.
COMMITTEES AND TEAMS FORMED WITHIN THE SCOPE OF SKS
COMMITTEES
- RADIATION SAFETY COMMITTEE
- DRUG SAFETY COMMITTEE
- PATIENT SAFETY COMMITTEE
- EMPLOYEE HEALTH AND SAFETY COMMITTEE
- EDUCATION COMMITTEE
- FACILITY SAFETY COMMITTEE
- TRANSFUSION COMMITTEE
TEAMS
- PINK CODE TEAM
- WHITE CODE TEAM
- BLUE CODE TEAM
- BUILDING TOUR TEAM
- RISK ASSESSMENT TEAM
- RED CODE TEAM
- EMERGENCY AND DISASTER MANAGEMENT TEAM
QUALITY UNIT ACTIVITIES
- Continuation of Work on Health Quality Standards Version 6.1.
- Evaluation of Health Quality Standards Version 6.1 Indicators, Preparation of Indicator Cards, and Ongoing Work.
- Planning and Conducting Self-Assessment Processes of Applied Standards at the Hospital.
- Revision of the Document Management System.
- Management and Analysis of Patient and Employee Satisfaction Surveys.
- Planning of Drills to be Conducted within the Scope of SKS