QUALITY MANAGEMENT SYSTEM

In the Committee Board Team's Handbook prepared in line with the Ministry of Health Service's Quality Standards, each committee's job description, functioning and frequency of meetings are specified as stated.By giving the agenda, place, and time information to all committee members by the Quality Management Director. board meetings are held. These committee meetings aim to measure, analyze, and improve Health Service's Quality Standards, and initiate corrective/preventive activities that ensure the continuation of improvement.

Corporate Services

  • Institutional Structure
  • Quality management
  • Document management
  • Risk management
  • Security Reporting System
  • Emergency and disaster management
  • Training management
  • Social responsibility

Patient and Employee Focused Services

  • Patient experience
  • Access to the service
  • End of life services
  • Healthy Workplace environment

Health Service

  • Patient care
  • Pharmaceutical management
  • Prevention of infections
  • Sterilization services
  • Transfusion services
  • Radiation safety
  • Emergency service
  • Operating room
  • Intensive Care Unit
  • Neonatal Intensive Care Unit
  • Birth Services
  • Biochemistry laboratory
  • Endoscopy

Support Services

  • Facility management
  • Hospitality services
  • Information management system
  • Material and devices management
  • Medical records and archive services
  • Waste management
  • Outsourcing

Sign Management

  • Monitoring indicators
  • Department based indicators
  • Clinical based indicators

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. All parameters are made by the Department Quality Officer while taking into account Department Based Indicators, Clinical Based Indicators, the structure of the hospital, patient's profile and priorities, and the revisions made when the Ministry issues a new Indicator. An indicator card is created separately for each Indicator's data tracked such as sub indicator parameters on the card, responsibilities, analysis period, who is responsible. This information is defined and collected by the Department Quality Officer who reports to the Quality Management Representative. The Quality Management Representative analyze the information via the determined analysis format, and in case of deviation from the department target value, necessary improvements are made. 

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.

Our Committees

The following committees meet at certain intervals throughout the year with the participation of the department quality officers:

  • 1-Quality Council (Management Review)
  • 2-Committees
    • 2.1-Patient Safety Committee
    • 2.2-Training Committee
    • 2.3-Facility Security Committee
    • 2.4-Infection Control Committee
    • 2.5-Transfusion Committee
    • 2.6-Radiation Safety Committee
    • 2.7-Pharmaceutical Management Committee
    • 2.8-Patient Rights and Satisfaction Committee
    • 2.9-Evaluation and Maintenance Committee
  • 3-Assemblies
    • 3.1-Medical and Ethics Committee
    • 3.2-Occupational Health and Safety Board 
    • 3.3-Disciplinary Board
    • 3.4-Hospital Executive (Senior Management) Board 
    • 3.5-Academic Board
    • 3.6-Organ Tissue Transplant Coordination Board 
    • 3.7-Brain Death Board 
  • 4-Responsible Teams
    • 4.1-Rational Medicine Team 
    • 4.2-Palliative Care Team 
    • 4.3-Medical Device and Equipment Team 
    • 4.4-Building Tour Team 
    • 4.5-Emergency and Disaster Management Team 
    • 4.6-Nutrition Support Team 
    • 4.7-Lab Team 
    • 4.8-Clinical Quality Improvement Team
    • 4.9-Medical Record and Documentation Team 
    • 4.10-Baby Friendly Hospital Team 

Security Reporting System

In our hospital;

  • To ensure the reporting of unwanted events that may threaten the safety of patients and employees.
  • According to the Security Reporting Procedure, all Security Reporting System (Event Notification) Forms made by the hospital staff are delivered to Quality Management.

  • All the notifications made are open to improvement by the Quality Management Representative and the Department Quality Officer. All notifications are evaluated by the related committees, and the Quality Management Representative checks with the Ministry of Health GRS notification System.

  • As a result of the notifications, a Security Reporting System has been established to ensure that the necessary measures are taken for these events.

Physical Field Management

In our hospital; Building tours are organized at regular intervals to create a permanent, safe, and easily accessible hospital for patients, patient relatives, and employees.

The team formed by the hospital management has been defined in a way to ensure the effectiveness, continuity and systematic of the work carried out in the hospital, taking into account the size of the hospital and the variety of services.

Within the scope of the Annual Facility Maintenance Plan and Quality Management Annual Work Plan, a Building tour is held with the Building Tour Team every 3 months. Corrective / Preventive action is initiated for all detected nonconformity. Elimination of nonconformity and the execution of work within the scope of patient and employee safety are ensured with the participation of senior management.

Weekly field inspections are carried out by the Chief Physician and Nursing Services, Hotel Support Services, Patient Services, Technical Services, Quality Management Representative. Urgent nonconformity are resolved immediately, other detected nonconformity are improved by placing deadlines.

Infection Control Nurse makes daily hospital visits. Improvement is planned according to the determinations.

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

  • Self-assessment team; It consists of General Manager, Medical Director, Human Resources Manager, Financial and Administrative Affairs Manager, Nursing Services Manager, Infectious Diseases & Education & Quality Responsible Nurses, Quality Director and Hospitality Services Officer.
  • Self-assessment (internal audit) is conducted twice a year, in June and December.
  • The self-assessment plan is prepared in a way to cover all sections within the Health Quality Standards.
  • All departments are informed via e-mail about the audit schedule and plan prior to the self-assessment (internal audit).

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

 

Quality Management Unit

Patient Safety Goals