All parameters monitored by the Quality Management System at Istanbul Hospital were prepared based on the Ministry of Health’s Indicator Management Guide. Indicators are determined at the end of each year by department managers and department quality managers. Indicators are determined in two headings. All parameters are performed by the Department Quality Officer taking into account the Department-Based Indicators, Clinic-Based Indicators, the structure of the hospital, the patient profile and priorities, and revisions are made if the Ministry publishes a new Indicator. For each Indicator data that is tracked, an individual Indicator Card is created. The sub-indicator parameter on the card indicates who are responsible, the analysis period, who are responsible. This information is defined. The data collected by the Department’s Quality Officer and reported to the Quality Management Representative are analyzed in the specified analysis format, and the necessary improvements are made if there is a deviation from the department’s target value.
PDCA – Cycle Plan – Do – Check – Act
RCA (Root – Cause-Analysis)
DÖF (Düzeltici Önleyici Faaliyet)
FMEA (Failure Mode and Effect Analysis)
Data of the department and clinical based indicators are entered into TUR-GÖS data input system of the Ministry of Health every 3-months by the Quality Representative.
The following committees meet at certain intervals throughout the year with the participation of the department quality officers: