Quality Management Committee Duties, Authorities and Responsibilities

JOB DESCRIPTION

Purpose

At Dr. Alp Aslan Surgical Medical Center, the purpose of this committee is to identify, plan, and ensure the implementation of activities related to patient safety, employee health and safety, education management, infection prevention, and facility safety within the institution.

COMMITTEE MEMBERS

The committee shall include the Medical Director, Administrative and Financial Affairs Director, Quality Management Officer, Healthcare Services Officer, Occupational Health and Safety (OHS) Specialist, Operating Room and Hair Transplant Unit Quality Officers, and the Education Nurse.

When necessary, additional experts or employees related to the agenda may be invited to the committee as guest participants.

DUTIES, AUTHORITIES, AND RESPONSIBILITIES

Ensure correct patient identification and necessary arrangements.
Ensure effective communication among employees.
Ensure medication safety.
Minimize risks arising from patient falls.
Ensure medical device safety.
Ensure patient privacy and confidentiality.
Ensure safe transfer of patients.
Ensure secure handover of patient information and medical records among healthcare professionals.
Ensure information security.
Ensure infection prevention and control.
Ensure patient safety in laboratory settings.
Identify and organize training programs related to patient safety.
Conduct preventive and corrective activities regarding patient safety.
Review and evaluate Adverse Event Reports.
Ensure the implementation and follow-up of arrangements addressing the health needs of employees with special conditions (e.g., pregnant, breastfeeding, disabled, or chronically ill staff).
Evaluate employee feedback (such as suggestions or complaints).
Monitor and follow up on employee risk assessment activities.
Monitor improvement actions addressing risks identified under employee safety.
Prepare and follow up on the occupational health surveillance program.
Within education management, plan, monitor, and evaluate:
- Health quality standards training,
- In-service training,
- General department and orientation training,
- Training programs for patients and their relatives.
Within facility safety, coordinate and ensure:
- Evaluation of data from building rounds,
- Safety of the medical center’s infrastructure,
- Protection of life and property within the institution,
- Coordination of emergency and disaster management activities,
- Waste management,
- Maintenance, adjustment, and calibration plans for medical devices,
- Management of hazardous materials.

GENERAL RULES

The committee convenes at least four (4) times per year at predetermined intervals. In extraordinary circumstances, meetings may be held outside the scheduled periods.
Meetings are planned in advance, and at least two (2) days prior, a formal meeting announcement form specifying the meeting leader, participants, agenda, duration, location, and time is distributed to all participants.
All decisions taken during meetings are recorded in the Committee Decision Form and signed by the participants.
Based on these decisions, the Quality Unit is responsible for initiating, finalizing, and reporting improvement actions within the committee’s scope of work.
The committee identifies necessary training activities related to its field of responsibility.
When required, the committee collaborates and integrates with other boards or teams.

ROLE DESCRIPTIONS

Medical Director

Responsible for ensuring the medical appropriateness and implementation of the committee’s agenda and decisions.
Accountable for executing medical decisions and providing feedback to the committee.
Authorized to make procedural changes, assignments, and arrangements in line with the decisions made.

Administrative and Financial Affairs Director

Responsible for ensuring the administrative appropriateness and implementation of the committee’s agenda and decisions.
Accountable for executing administrative decisions and reporting back to the committee.
Authorized to make operational adjustments, assignments, and procedural changes based on committee decisions.

Healthcare Services Officer

Responsible for ensuring that the committee’s agenda and decisions are appropriate and applicable from the perspective of healthcare services.
Accountable for implementing relevant healthcare-related decisions and providing feedback to the committee.
Authorized to make necessary arrangements based on the committee’s resolutions.

Quality Management Officer

Responsible for organizing the committee and ensuring that its agenda and decisions align with quality standards.
Accountable for managing the implementation of all decisions, maintaining process continuity, and standardizing workflows in accordance with committee resolutions.
Authorized to make necessary arrangements to ensure compliance and monitoring.

Clinical Services Nurse

Responsible for providing professional opinions on the committee’s agenda and decisions relevant to the nursing field.
Shares professional observations and insights with the committee.
Authority level is determined by the committee based on the agenda and decisions.

Education Nurse

Responsible for the practical applicability and implementation of the committee’s agenda and decisions.
Ensures the execution of relevant actions and provides feedback to the committee.
Authority is defined by the committee in accordance with the agenda and resolutions.

Department Quality Officer

Responsible for presenting department-specific opinions regarding the committee’s agenda and decisions.
Shares observations about departmental operations with the committee.
Authority is defined by the committee based on the agenda and resolutions.

Occupational Health and Safety (OHS) Specialist

Responsible for evaluating committee topics in terms of occupational safety, providing expert opinions, and managing workplace safety processes related to the facility.