Alp Aslan Surgical Medical Center

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Quality Management Unit Work Instructions

Anasayfa → Quality Management Unit Work Instructions

 1-PURPOSE:

In the corporate service process, developing policies, regulations and practices that encompass every corporate element in line with Quality Standards in Healthcare, taking quality as a whole, converting these into written documents, conducting corporate evaluation and auditing in accordance with the written documents, delivering the service correctly, on time and at the first attempt, eliminating the possibility of errors during service delivery or detecting and preventing any errors that may occur from recurring, providing healthcare services in line with patient expectations and requests and international standards, to design, implement, audit, develop and monitor all activities carried out to provide our patients with sufficient assurance and service in line with Health Quality Standards and the application guidelines published by our ministry.

2- SCOPE:

Dr. Alp Aslan Surgical Medical Centre covers all stages of the Quality Management System.

3-ABBREVIATIONS:

SKS: Health Quality Standards,

QMS: Quality Management System,

HBYS:Information Management System

4-DEFINITIONS:

Quality Management System: A system comprising all processes, stated procedures and adopted principles aimed at achieving the intended quality.

5-RESPONSIBLE PARTIES:

Our centre is responsible for the implementation of the Quality Management System, primarily the quality management unit and all employees.

6-ACTIVITY FLOW:

6.1-GENERAL

Our Quality Management System has been established in accordance with the Ministry of Health’s Quality Standards in Healthcare, is documented, implemented, and continuously improved. Dr. Alp Aslan Surgical Medical Centre has taken steps towards quality organisation and documentation while conducting work aimed at improving and developing the services provided. Dr. Alp Aslan Surgical Medical Centre collects data on patient satisfaction and safety through suggestion-complaint applications, employee satisfaction surveys, and Adverse Event Reporting System studies, and continuously strives for improvement.

6.2. DOCUMENTATION REQUIREMENTS:

6.2.1. General

The documentation structure that forms our Quality Management System;

Guides,

Procedures,

Instructions related to procedures,

Mothers

Lists and Forms,

External documents and other quality records required for the operation of Dr. Alp Aslan Surgical Medical Centre are included.

When establishing our documentation structure, we took into account our organisational structure, the services we provide, the complexity of our processes and their interrelationships, and the experience and skills of our employees. Documents are created electronically in accordance with the Document Management Guide published by the Ministry of Health, printed and approved by the Quality Management Unit, stored, and made available for use by the units. All rules regarding documents are specified in the Document Management Procedure.

6.3. QUALITY MANAGEMENT PROCESS:

6.3.1. Quality Management and Process Control

Quality is the responsibility of everyone involved in the service processes provided within our centre. Management is responsible for developing a systematic approach to ensuring quality and the implementation and continuity of the Quality Management System. The Quality Management System encompasses all activities that define the mission, vision, and objectives; the quality policy, goals, and responsibilities. Quality management process control is implemented through quality planning, quality control, quality assurance and quality improvement in order to ensure service quality and patient and staff safety during the provision of services, as well as to create patient and staff satisfaction.

6.3.2. Quality Assurance:

The quality management system includes all relevant legislation, standard operating procedures, instructions and forms for all critical processes. The Quality Management Unit reviews the entire system at regular intervals to ensure its effectiveness and implements corrective actions when deemed necessary. In addition, unit staff and the unit manager can activate the undesirable event reporting system and the corrective and improvement action system when deemed necessary.

6.4. MANAGEMENT RESPONSIBILITY

6.4.1. Management Commitment:

Our senior management fulfils its commitments and responsibilities regarding the implementation, development, effectiveness and continuity of the defined Quality Management System in accordance with procedure role definitions and instructions.

The quality policy and objectives are established and communicated to all employees. The Quality Management System is implemented effectively, and objectives are continuously revised through reviews. The Senior Management of Dr. Alp Aslan Surgical Medical Centre communicates to its employees the importance of considering all patient requests (subject to laws and regulations) and, where appropriate (legally, scientifically, ethically and within the capabilities of the institution), meeting them. It undertakes to communicate the importance of this to its employees, to establish a quality policy, to set quality objectives, to carry out management review activities, and to implement and continuously improve the Quality Management System by providing the necessary resources.

6.4.2. Patient-Centredness:

Senior management ensures that the requests of patients and their relatives are evaluated and fulfilled in order to increase patient satisfaction, as explained in the paragraphs on Patient-Related Processes and Patient Satisfaction. The management of Dr. Alp Aslan Surgical Medical Centre determines the expectations and requirements (requests, suggestions, satisfaction surveys, complaints, etc.) of the people it serves and will serve. It conveys the identified expectations to the relevant units accurately and completely, ensuring that they are understood and met in the best possible way. It monitors the continuity of the service and takes the necessary measures for continuous improvement. The expectations of service recipients are met in accordance with quality principles and relevant legislation. Whether the service provided meets the expectations of service recipients is determined through the Ministry of Health’s audit reports, internal and external audits, complaints submitted by service recipients through various channels (Patient Communication Unit, suggestion and request boxes, email, direct application, etc.), and surveys conducted directly with service recipients.

6.4.3. Quality Policy:

The Dr. Alp Aslan Surgical Medical Centre Quality Policy has been established by the senior management of the Dr. Alp Aslan Surgical Medical Centre to guide its work, ensure that all employees provide services with the same perspective, and foster a corporate culture. It is accessible via our institution’s website and is communicated to our employees through training sessions and announcements.

6.5. PLANNING:

6.5.1. Quality Objectives:

The senior management of Dr. Alp Aslan Surgical Medical Centre, together with its employees, has set quality targets in accordance with Healthcare Quality Standards, implementation guidelines, and activities. The targets from the previous period are reviewed and the status of achieving these targets is analysed. The targets for the next period are set and approved in the same manner. Targets are monitored and updated as necessary. Quality targets serve as a guide in setting corporate objectives and targets.

6.5.2. Quality Management System Planning:

A process approach has been adopted for the establishment, documentation, implementation, effectiveness and continuous improvement of our Quality Management System.

Unit managers are responsible for coordination and implementation in fulfilling their responsibilities regarding their unit’s quality system. Through self-assessments conducted twice a year, the sound maintenance of our Quality Management System and the planning of improvements are ensured.

6.6.RESPONSIBILITY, AUTHORITY AND COMMUNICATION:

6.6.1. Responsibility and Authority:

Our senior management has established an organisational chart outlining the main structure of Dr. Alp Aslan Surgical Medical Centre and has specified the duties, responsibilities, authorities, and relationships among the personnel within the organisation. To this end, job descriptions have been documented, communicated to employees, and the necessary conditions have been provided for them to fulfil these duties. The job descriptions have been notified to employees. The necessary information is communicated through training sessions held at Dr. Alp Aslan Surgical Medical Centre.

6.6.2. Quality Management Officer:

Dr. Alp Aslan, Director of the Surgical Medical Centre, has appointed the Quality Management Officer, whose authority and responsibilities are outlined below, as a member of the management team and has announced this to all employees. The duties, authority and responsibilities of the Quality Management Officer are broadly summarised under the following headings:

  • Ensures the establishment, implementation and maintenance of the processes that constitute the Quality Management System.
  • Ensures the coordination of work carried out within the framework of the SKS
  • Monitors work related to corporate objectives and targets.
  • It enables self-assessments to be carried out.
  • Manages processes related to the unwanted incident reporting system.
  • Manages work related to measuring patient experience and staff feedback surveys (such as survey implementation, evaluation of survey results, and improvement work based on survey results).
  • It manages documents within the SKS framework.
  • Manages processes related to quality indicators.
  • Manages processes related to risk management.
  • Participates as a member in the committees, boards and teams established within the framework of SKS.
  • Ensures that the quality management unit is managed in accordance with its areas of responsibility.
  • Ensures that corrective and improvement activities are identified and followed up to completion within the scope of quality standards.

6.6.3. Horizontal and Vertical Hierarchical Structure in the Quality Management System:

Dr. Alp Aslan Surgical Medical Centre’s quality management system is subject to external vertical supervision by the District Health Directorate – Provincial Health Directorate – Ministry of Health’s Department of Quality and Accreditation in Healthcare. The Ministry of Health’s Department of Quality and Accreditation in Healthcare evaluates our centre once a year at a time of its choosing and scores the quality management system’s current status.

Our centre’s internal vertical structure is headed by the Responsible Manager, who acts as the senior executive. Senior management is part of the quality management system. All reports and work produced by the Quality Management System are first submitted to the Responsible Manager as senior management, in accordance with the vertical hierarchical structure. The Responsible Manager reviews all reports and work, forwards them to the relevant units through the vertical hierarchical structure, and assigns tasks to address any deficiencies in the system. Assignments from the Responsible Manager to other managers are communicated to employees through the heads of the relevant units.

All departments of Dr. Alp Aslan Surgical Medical Centre have an equal horizontal structure within the quality management system. All departments must operate in accordance with the standards relevant to their own department within the system. The standards to be followed are specified in the Ministry of Health’s SKS Medical Centre set and related legislation. The Quality Management Unit works with all units using horizontal communication techniques to ensure the implementation of these standards, the continuity of the process, and continuous improvement. All units also establish relationships with the Quality Management Unit through the same horizontal communication. In these relationships, the unit managers can also be referred to as Quality Unit Managers. The Quality Management Unit is responsible for establishing horizontal relationships with all employees and implementing the quality management system. Quality unit managers form the first line of implementation of the quality system after the employees.

The quality management officer works in an integrated manner with committees and teams. They are responsible for communicating decisions to committees and teams. Department quality officers carry out their work in an integrated and coordinated manner with the quality management officer.

6.7. RESOURCE MANAGEMENT:

6.7.1. Procurement of Resources

The implementation of the quality policy, the provision and management of the necessary resources (human resources, infrastructure and working environment, financial resources, information resources, etc.) to achieve the defined quality objectives and to ensure that services meet the expectations of patients and their relatives, is carried out in accordance with the Quality Management System established in line with Healthcare Quality Standards. Dr. Alp Aslan Surgical Medical Centre determines its financial resource requirements for the following year during budget preparation activities, and the relevant needs are met according to budget plans. If there is an urgent need for resources, action is taken in accordance with the relevant legislation.

6.7.2. Human Resources:

6.7.3. General:

All staff members who commence duties at Dr. Alp Aslan Surgical Medical Centre begin work after completing general orientation training, and departmental orientation training is also provided in the departments where they are assigned.

6.7.4. Competence, Awareness and Training:

Dr. Alp Aslan Surgical Medical Centre’s job descriptions and work instructions for all staff members Procedures are established and in-service training sessions are organised to ensure that staff members are aware of the importance and appropriateness of their work and understand how they contribute to quality objectives.

All work related to determining, planning and evaluating the training needs of Dr. Alp Aslan Surgical Medical Centre employees in the Quality Management System or their own areas of work is carried out by the Quality Management Committee.

6.7.5. Infrastructure:

The senior management of Dr. Alp Aslan Surgical Medical Centre establishes and maintains the infrastructure necessary for the implementation of processes, including buildings, facilities, workspaces, equipment specified in procedures, support services (cleaning, communication, security, etc.), and software and hardware. It utilises activities such as budget planning, management activities, performance results, and senior management meetings to improve the existing infrastructure and/or make new investments.

6.7.6. Hardware Requirements:

All activities related to the equipment and hardware we use in conducting our business to maintain our service quality and efficiency are carried out in accordance with the provisions of the relevant legislation.

6.7.7. Software Requirements:

Dr. Alp Aslan Surgical Medical Centre has established an “HBYS” to facilitate data entry and the retrieval of information regarding our services.

6.7.8. Bina ve Yardımcı Tesisler:

Tanı ve tedavi hizmetlerimizi en uygun koşullarda yerine getirebilmek için gerekli bina ve yardımcı tesis ihtiyaçları (Su deposu, atık merkezi vb.) ilgili mevzuat hükümlerine göre temin edilir ve bakım onarım faaliyetleri sürdürülür.

6.7.9. In exceptional circumstances:

Dr. Alp Aslan Surgical Medical Centre is operating in accordance with its Emergency Action Plan.

6.7.10. Support Services:

To prevent medical waste from harming our staff and the environment, clinical waste is collected in orange-coloured medical waste bags and stored in the Medical Waste Container, then disposed of in accordance with the contract with the municipality. The necessary arrangements have been made for any unusual situations that may arise in relation to electricity, clean water, waste water, ventilation and telecommunications, and these are implemented when required.

6.7.11. Working Environment:

The working environment conditions are established and maintained in accordance with regulations and requirements. Necessary measures have been taken in situations where factors that may affect health are present. Service Procurement Protocols have been prepared to meet services not provided by our institution, and service procurements are audited once a year under the scope of External Resource Use in accordance with SKS and Protocol Articles.

6.8. SERVICE DELIVERY:

6.8.1. Planning the Provision of Services:

Dr. Alp Aslan Surgical Medical Centre takes the following matters into consideration when planning its services:

  • Conditions, expectations and objectives for the service,
  • If necessary for the service, the provision of resources, the creation of documentation,
  • Service-specific measurement methods, inspections, verifications and service-related acceptance criteria,
  • The records necessary to prove that the services provided meet the requirements,
  • The procedures necessary for the service to be performed and to achieve the desired results are planned, and where necessary, the procedures are revised according to the failure to achieve the targeted result.
  • When planning service delivery procedures, the Quality Management System is ensured to be consistent with other procedures.
  • All checks to be carried out during service delivery are defined in the procedures and other relevant documents.

Identifies and secures the necessary additional resources in line with the defined objectives and carries out procurement activities related to planning.

6.8.2. Processes Related to Patients and Their Relatives:

  • Written and verbal requests indicated by patients,
  • Requirements related to the provision of the service that are not specified by the patient or their relatives,
  • Legal and regulatory requirements,
  • Decisions taken at Senior Management Meetings and any additional requirements determined by senior management shall be taken into account.
  • It is an absolute necessity that service-related requests comply with the relevant legislation.
  • The surveys we conduct and the data collected from suggestion boxes also serve as a source for gathering service-related requests.
  • When a new service request intensifies or such a need is identified and decided upon by management, it is assessed as a service-related condition, and the necessary service is implemented accordingly.
  • Alp Aslan Surgical Medical Centre services are provided to eligible individuals in accordance with the regulations. Eligible individuals applying to our clinic (except for emergency cases) must have documents that comply with the conditions specified in the regulations. Patients receiving services have the right to withdraw from treatment and to have treatment renewed. Patient rights are respected during the examination and treatment of patients.

6.8.3. Establishing Communication with the Patient and Patient’s Family:

Dr. Alp Aslan Surgical Medical Centre communicates with patients and their relatives based on requests, suggestions, complaints and applications to the patient communication unit. Patient and relative complaints are evaluated and, if deemed necessary, processed in accordance with the DİF Procedure.

6.9. PURCHASE:

At Dr. Alp Aslan Surgical Medical Centre, purchasing procedures are carried out following research by the purchasing unit manager and with the approval of the director.

6.10. PROVISION OF THE SERVICE:

6.10.1. Control of the Service:

Dr. Alp Aslan Surgical Medical Centre plans, executes and establishes control conditions in accordance with the procedures prepared, in line with the Quality Management System requirements and relevant legislation, to ensure our healthcare services are delivered under control. In the implementation of these established controlled conditions;

  • The availability of legislation and regulations explaining the characteristics of the service provided is ensured.
  • In-service training, the internet and conferences also provide access to scientific developments and studies related to the service.
  • Access to the necessary procedures, instructions, and other documents required during the provision of the service is ensured.
  • The use of appropriate equipment, as specified in the relevant legislation and regulations according to the nature of the healthcare services, shall be ensured.
  • Monitoring and measurement devices related to the service shall be provided and used. Necessary monitoring and measurements related to the service shall be carried out.
  • The completion of the service under appropriate conditions, the control and monitoring of the necessary conditions, and the decision-making process are carried out by the relevant physicians on a patient-by-patient basis and, in terms of the integrity of the service, by the unit managers in accordance with the relevant legislation and quality documents.

6.10.2. Validity of Service Processes:

Where the outputs obtained from activities within our organisation are not verified through monitoring and measurement, the validity of the process is confirmed by reviewing and approving the relevant process, confirming the adequacy of equipment and personnel, implementing procedures and instructions, and reviewing records.

6.10.3. Identification and Traceability:

The basis for identification and traceability is formed by the Quality Management Documentation and the automation system of Dr. Alp Aslan Surgical Medical Centre. Files and other health-related documents pertaining to patients visiting our centre, records of all procedures and tests performed on patients, personal belongings and materials are protected and preserved as patient assets in accordance with the relevant legislation. Identification and tracking of all devices, medicines and materials used at the centre is carried out through the warehouse modules in the automation system.

6.10.4. Patient Privacy:

Patients visiting Dr. Alp Aslan Surgical Medical Centre or their relatives who bring items with them and are kept at our centre; patient files, referral forms, etc., documents related to the patient’s health, records of all procedures and examinations performed on the patient, personal belongings and materials are protected and preserved as patient property in accordance with the relevant legislation.

6.10.5. Product Protection:

Dr. Alp Aslan Surgical Medical Centre takes the necessary measures to identify, transport, store and use all types of medicines, consumables and devices used during the provision of services under appropriate conditions.

6.10.6. Control of Monitoring and Measuring Devices:

Dr. Alp Aslan Surgical Medical Centre has established and implements a Calibration Plan for the purpose of monitoring and measuring devices. Calibration requirements are determined in accordance with this plan. Calibration measurements are carried out by authorised companies through service procurement. All newly acquired devices are calibrated and added to the plan.

6.10.7. General:

Dr. Alp Aslan Surgical Medical Centre implements the following practices to monitor, measure, and improve the suitability and effectiveness of our services and Quality Management System. Verification of purchased products, service control, self-assessments, building tour reports, patient, patient relative and employee feedback, data analysis, and corrective/improvement activities. SKS department-based indicators are determined by taking into account the structure of the centre, patient profile and priorities.

6.11.-MEASUREMENT, ANALYSIS AND IMPROVEMENT:

6.11.1. Patient and Patient Relative Satisfaction:

A Patient Feedback Assessment Team has been established to evaluate the extent to which the expectations and requests of patients and their relatives are being met. The team evaluates the feedback received on a monthly basis. Reports concerning Patient Rights are evaluated by the Patient Rights Officer.

6.11.2. Self-Assessments

To periodically verify the compliance and effectiveness of our Quality Management System with planned arrangements and regulations, and to determine corrective actions for non-conformities and identify areas for improvement, planned Self-Assessments are conducted twice a year. The Quality Management Officer prepares the Self-Assessment plan each year, obtains approval from senior management, and ensures that self-assessments are carried out during the year. Corrective/Improvement Actions are initiated as necessary based on the results of the Self-Assessment.

6.11.3. Monitoring and Measuring Processes:

The effects of treatment applications on the patient and the monitoring and measurement of the course of the disease are carried out by the relevant physician in accordance with legal and scientific criteria specific to the patient. The management of Dr. Alp Aslan Surgical Medical Centre and the Patient Rights Unit can monitor the process by evaluating complaints, suggestions and satisfaction regarding these applications. The relevant records are kept and stored appropriately in the automation system. Within the framework of the Quality Management System, processes are monitored, and measurements are made in accordance with control and performance criteria to determine whether targets are being met. If the planned target is not met, corrective actions and corrective activities are initiated as necessary to ensure the suitability of the service.

6.11.4. Monitoring and Measuring the Service:

Diagnosis, assessment and treatment procedures related to the patient, along with the relevant service monitoring and measurements, are carried out in accordance with the relevant legislation, procedures and instruction documents. As a result of the diagnosis, assessment and treatment procedures applied, the necessary analyses and examinations related to the disease in question are carried out or commissioned by physicians, and the treatment process is concluded. Records pertaining to these applications are kept and stored in automation and patient files.

Quality indicators for SKS departments enable the monitoring and improvement of service processes and the outputs obtained at the end of the service for these departments through concrete data.

6.11.5. Data Analysis:

Dr. Alp Aslan Surgical Medical Centre conducts data analyses to demonstrate the suitability and effectiveness of its Quality Management System and to ensure continuous improvement. These analyses are carried out by Unit Managers and the Quality Management Unit. The collected data is analysed using statistical techniques according to the characteristics of the indicators, at specified intervals, and interpreted by personnel with sufficient expertise. The results related to the indicators are sent to the electronic database (TÜRGÖS) created by the ministry.

6.11.7. Continuous Improvement:

Our centre strives to continuously improve the effectiveness of its Quality Management System in the sense of continuous improvement, defined as a repeated activity to enhance the ability to fulfil requirements. To this end, a quality policy and objectives have been established, and data analysis practices are carried out regularly. Necessary corrective and improvement activities are evaluated at team, board and committee meetings, and the results are analysed. Objectives are set and revised with a view to continuous improvement.

6.11.8. Corrective Actions:

Within the Quality Management System, the Corrective and Improvement Activities Procedure is implemented to plan, implement, monitor the results, prevent recurrence, and establish principles for corrective actions aimed at eliminating the causes of existing non-conformities. The relevant procedure explains under which circumstances corrective actions are to be initiated, by whom, and for whom. Non-conformities related to devices and materials (medicines, consumables, etc.), non-conformities identified during diagnosis, examination and treatment, non-conformities related to supply services, patient complaints, self-assessments, central assessments, data analysis results (failure to meet targets) and building tour reports are elements that serve as sources for Corrective Actions.