SONNUR ÖZKARA

DIRECTOR OF HEALTH CARE SERVICES

QUALITY MANAGEMENT DIRECTOR

QUALITY MANAGEMENT UNIT WORKING PRINCIPLES
KYB was established according to SKS in our hospital and technical equipment (computer, printer, telephone, fax, etc.) was provided.
Quality Management Director (KYD) works as the Quality Management Unit responsible. The Quality Management Unit employs experienced and trained employees.
Quality Management Director; Participates in all committees (Patient Safety Committee, Employee Safety Committee, Infection Control Committee, Facility Safety Committee and Training Committee, etc.) as members. Works in coordination of works related to Quality Standards in Health in Committees.
Coordination of all work carried out within the framework of the SPS is ensured.
Work towards corporate goals and objectives are followed. Annual targets are determined by the senior management by taking the opinion of the employees. Target action plans (HEP) are prepared for the realization of the objectives. Target planners and the times of realization of the targets are indicated in this plan. Evaluation meetings are held for at least 6 months of the year in order to realize the targets.
The current status of the departments in line with the SKS, working in coordination with the department's quality officers; goals, self-assessment results, CPF, safety reporting, statistical data, training, infection rates, hand hygiene compliance, indicator objectives, etc. Results Senior management is evaluated at least once a year with the participation of department managers, department quality managers and necessary improvement activities are initiated.
Self-assessment is carried out at least once a year according to the Self-Assessment Procedure. Non-conformities identified as a result of the self-evaluation are reported to the senior management. Necessary improvement activities and corrective preventive actions are initiated.
The processes for Safety Reporting System (GRS) are managed according to the Safety Reporting System procedure. The Security Reporting System is designed to cover all kinds of events that may threaten the safety of patients and employees (unintentional or adverse events occurring, adverse events reflected in the law); all employees can report to the quality management unit with the Safety Reporting System Notification Form. Notification forms can also be left in the Complaint and Suggestions boxes. Confidentiality is ensured if there is a request for the confidentiality of the notifications made in the Security Reporting System Notification Form. The root cause analysis (KNA) for the notifications made and the necessary corrective preventive actions are initiated.
Security Reporting System KNA for notification forms is analyzed according to quality management unit, related manager, committee, department quality responsible and Root Cause Analysis Form. The necessary improvement works and, if necessary, corrective preventive actions are initiated. Security Reporting System is followed up by Quality Management Unit with the follow-up form.
All employees are provided with trainings related to the Safety Reporting System. Security Reporting System Evaluation meetings, questionnaires, etc., for the purpose of taking opinions and suggestions of the employees about the notification system. feedbacks about the use of the system at regular intervals with activities are taken and improvement works are carried out if necessary.
Risk management processes are carried out according to the risk management procedure. Risk assessments, analysis and necessary improvement studies are carried out in accordance with the risk assessment team and regulations as determined by the Occupational Health and Safety Risk Assessment Regulation.
Patient and employee satisfaction surveys are conducted by the personnel who are trained in the application of the questionnaire according to the questionnaire application guide in the periods determined by the Ministry of Health.
Survey results are reported by the quality management unit. The results of the report are arranged in 6-month periods and evaluated with senior management at least once in each semester. The relevant department is included in the assessment process if necessary. According to the results of the survey, necessary corrective and preventive actions are initiated and necessary improvement activities are carried out.
Patient complaint management, employee complaints management team works, patient and employee complaints, suggestions and satisfaction forms and feedback are evaluated at regular intervals. Necessary activities are initiated.
The regulations written in the SPS framework shall be carried out according to the Control of Documents Procedure.
SKS The evaluation of statistical information on service provision is ensured.
According to the Indicator Management Procedure, coordination of Indicator management activities is ensured. For each indicator to be monitored, processes, data collection and analysis methods are defined. Target analysis is done according to the indicator follow-up form, evaluated with top management and indicator responsible and good if necessary