Document Management
Various documents are needed in order to standardize the activities carried out in our institution and to harmonize them with national and international quality standards. For this purpose, approximately 1500 documents have been created in our institution. The preparation, approval, enforcement, revision, control and current sharing of the created documents (procedure, protocol, plan, instruction, task, authority and responsibilities, form, etc.) require a separate activity. These activities are carried out by our directorate. All documents that can be accessed through the hospital information system can be printed out by users when deemed necessary.
Self-Assessment Activities
A Self-Assessment Team has been appointed to carry out internal evaluations periodically in order to ensure compliance with quality standards. The findings obtained from the audits carried out by the team are analyzed and shared with the relevant committees, and necessary improvement and training activities are decided.
Activities for Monitoring and Measuring Processes
As an important part of the concept of "Process Management", our efforts to measure, monitor and improve the effectiveness and efficiency of processes continue increasingly. Our Directorate; It guides senior management in the selection of indicators to be monitored. Our Quality Management Directorate ensures the interpretation and verification of the analyzes prepared by the relevant units and regularly reports this information to the senior management and relevant committees. Approximately 120 indicators are regularly monitored in our hospitals.
Safety Reporting System (Patient and Employee Safety Culture)
The most important aim of the quality studies carried out in our hospitals is to create a safe environment for both our employees and our patients. Our institution has guided the World Health Organization (WHO) Patient Safety Goals and the patient safety goals published by the SKS to ensure patient safety.
In order to ensure that the concept of patient safety becomes a corporate culture in our hospitals, trainings are organized to increase the sensitivity of our employees and patients to patient safety, visual materials are used and employees are encouraged to report errors.
The most important parameter of the program we carry out is to report incidents and take preventive measures by analyzing them in order to prevent the recurrence of incidents that threaten the safety of our patients and employees. There is a "Safety Reporting System" for the detection and follow-up of errors that occur in our hospitals.
Events that threaten patient safety are reported to the Quality Management Directorate by the person(s) who experienced and/or witnessed the event as soon as possible by filling in the "Safety Reporting System (GRS) Notification Form" via the Hospital Information Management System. Each notification is subject to a preliminary examination by our Directorate. During the preliminary investigation, incidents that require more detailed examination are transferred to the relevant committees, root-cause analyzes are made and the necessary measures to prevent recurrence are determined and implemented. The general analysis of the reported events is made by our Directorate and presented to the senior management at regular intervals.
Activities of Boards and Committees
Ensuring the standard information, communication and compliance required by the working groups (Committees, Self-Assessment Team, etc.) carrying out quality activities requires a planned guidance service. This service is provided by the Quality Management Directorate in our institution.
Improvement Activities
Improvements constitute one of the important topics in all quality studies. Quality Management System improvement studies are carried out on the basis of the "Corrective and Preventive Action Form" prepared by the Quality Management Directorate.
In case of detected/potential nonconformities, “Corrective and Preventive Action (CPA)” is initiated under the control of the Quality Unit. The target in the CAPA system; To ensure the systematic follow-up of the planned actions to eliminate nonconformities and to “conclude” the studies. In these studies, the primary aim is to prevent the occurrence of nonconformities (preventive approach), the secondary aim is to prevent the recurrence of nonconformities (corrective approach).
We plan improvements with "Root Cause Analysis" studies based on objectivity and analytical approach, in order to learn why, why and how problems occur when required by the quality standards we apply, and to reach real solutions.
Fishbone diagram, brainstorming, tree diagram, flowcharts, control charts etc. are some of the tools used by our directorate in root-cause analysis studies.
Educational Activities
The quality improvement and patient safety program we are conducting requires our employees to be equipped with the knowledge required by the standards. Both the updating of the current scientific knowledge and the need to remind our employees of this knowledge at regular intervals require the execution of many training programs. For this reason, various training programs are carried out by our Directorate for our newly recruited and continuing personnel in our hospitals. The training programs in question are prepared taking into account the quality standards and incoming demands. The main purpose of the created training programs; is to ensure that all employees do their work within the framework of certain standards, consciously, professionally, diligently, lovingly, confidently and with a smiling face.