Quality Works

Quality works in our hospital is carried out in line with the Ministry of Health Quality Standards in Health-Hospital by the “Quality Unit” with the support of the management and department quality officers.

Quality officers have been assigned for each department according to the Quality Standards in Health. These sections are as follows;

1. Corporate Services

  • Corporate Structure
  • Quality management
  • Document Management
  • Risk management
  • Safety Reporting System
  • Emergency and Disaster Management
  • Training Management
  • Social Responsibility

2. Patient and Employee Oriented Services

  • Patient Experience
  • Access to Services
  • End of Life Services
  • Healthy Working Life

3. Healthcare Services

  • Patient care
  • Medication Management
  • Prevention of Infections
  • Sterilization Services
  • Transfusion Services
  • Radiation Safety
  • Emergency Room
  • Operating room
  • Intensive Care Unit
  • Newborn Intensive Care Unit
  • Birth Services
  • Biochemistry Laboratory
  • Microbiology Laboratory

4. Support Services

  • Facility Management
  • Hospitality Services
  • Information Management System
  • Material and Device Management
  • Medical Record and Archive Services
  • Waste Management
  • Outsourcing

5. Indicator Management

  • Monitoring Indicators
  • Department Based Indicators
  • Clinical Based Indicators

Our committees

The following committees meet periodically throughout the year with the participation of department quality officers:

  1. Administrative and Medical Services Board
  2. Disciplinary Board
  3. Medical Ethics Committee
  4. Employee Health and Safety Board
  5. Medication Management Committee -Rational Medicine Team
  6. Transfusion Center Committee -Hemovigilance Team
  7. Infection Control Committee
  8. Patient Safety Committee
  9. Laboratory Efficiency Team
  10. Patient Rights and Patient Satisfaction Committee
  11. Training Committee
  12. Facility Security Committee
  13. Radiation Safety Committee
  14. Medical Records and Documentation Committee
  15. Emergency and Disaster Management Team
  16. Building Tour Team
  17. Palliative Care Team
  18. Nutrition Support Team
  19. Clinical Quality Improvement Committee
  20. Emergency Code Management Team

Safety Reporting System

In our hospital, a Safety Reporting System was established;

  • To ensure that undesirable events that may threaten the safety of patients and employees, that are about to occur, or that do not occur at the last moment (near miss), are reported
  • To monitor these events
  • As a result of the notifications, to ensure that the necessary measures are taken against these incidents.

Indicator Management

Indicator Management System has been established in order to contribute to the continuous improvement of quality by developing the measurement systematic and culture in the hospital and by following the common indicators used in the international arena, creating opportunities for comparison and cooperation. In this context, all indicators, including Clinic-Based and Department-Based indicators, determined by the Ministry of Health are followed with the support of the hospital information management system. When deviations from the target threshold value are detected in the indicators followed, PUKO (Plan-Do-Check-Take Action) improvement studies are planned and implemented with the relevant department.

Physical Space Audits

In our hospital, building tours are carried out at regular intervals in order to create a continuous, safe and easily accessible hospital physical conditions and technical infrastructure for patients, their relatives and employees.

The team formed by the hospital management was defined in a way that would ensure the effectiveness, continuity and systematicity of the work carried out in the hospital, taking into account the size of the hospital and the diversity of services.

During the building tours, the physical condition and functioning of the hospital are audited and necessary improvements are made.

Self-evaluation Process Within the scope of Quality Standards in Health (SKS), self-evaluation (internal audit) is performed at least once a year in our hospital.

  • Self-evaluation team consists of department managers and department quality officers.
  • Self-evaluation (internal audit) is carried out twice a year, in June and December.
  • The self-evaluation plan is prepared to cover all parts of the Quality Standards in Health.
  • Before the self-evaluation (internal audit), all departments are informed via e-mail about the audit schedule and plan.

*While preparing the text above, the Healthcare Quality Standards-Hospital Set prepared by the Department of Quality and Accreditation in Health was used.