QUALITY MANAGEMENT SYSTEM
- The job description, functioning and meeting frequency of each committee are carried out as stated in the Committee Board Team Handbook prepared in line with the Ministry of Health Service Quality Standards. Committee e-mail groups have been created according to the committee member lists, and the meeting announcement is made by the Quality Management Director by e-mail to all committee members by informing them of the agenda, place and time. Committee/board meetings are held to measure, analyze and improve Service Quality Standards and initiate corrective/preventive actions, aiming for continuous improvement.
CORPORATE SERVICES
*Corporate Structure
*Quality management
*Document Management
*Risk management
*UNWANTED EVENT REPORTING SYSTEM
*Emergency and Disaster Management
*Education Management
*Social responsibility
Patient and Employee Focused Services
*Patient Experience
*Access to Service
*End of Life Services
*Healthy Working Life
Health Service
*Patient care
*Medication Management
*Prevention of Infections
*Sterilization Services
*Transfusion Services
*Radiation Safety
*Emergency room
*Operating room
*Intensive Care Unit
*Newborn intensive care unit
*Birth Services
*Biochemistry Laboratory
*Endoscopy
Support Services
*Facility Management
*Hospitality Services
*Information Management System
*Material and Device Management
*Medical Record and Archive Services
*Waste Management
*Outsourcing
Indicator Management
Monitoring Indicators
Department Based Indicators
Clinical Based Indicators
All parameters followed in the Quality Management System at Private Meltem Hospital and Maternity Hospital have been prepared based on the Ministry of Health Indicator Management Guide. Indicators are determined by department managers and department quality officers at the end of each year. Indicators are determined under two headings. All parameters are made by the Department Quality Officer, taking into account Department-Based Indicators, Clinic-Based Indicators, the structure of the hospital, patient profile and priorities, and revisions are made if the Ministry publishes a new Indicator. A separate Indicator Card is created for each Indicator data followed. On the card, the sub-indicator parameter, those responsible, the analysis period, who are responsible. This information is defined. The data collected by the Department Quality Officer and reported to the Quality Management Representative is analyzed in the specified analysis format, and necessary improvements are made in case of deviation from the department target value.
PUKO – Plan – Implement – Check – Take Precautions)
CNA (Root Cause Analysis)
DÖF (Corrective Preventive Action)
FMEA (Error Modes and Effects Analysis)
Department and Clinic Based Indicator data are entered into the Ministry of Health data entry system TUR-GÖS every 3 months by the Quality Representative. At the beginning of the year, all data are collected through Quality Performance Evaluation meetings with department quality officers and planned improvements are made.
Our committees
The following committees meet periodically throughout the year with the participation of department quality officers:
1-Quality Council (Management Review)
2-Committees
2.1-Patient Safety Committee
2.2-Education Committee
2.3-Facility Security Committee
2.4-Infection Control Committee
2.5-Transfusion Committee
2.6-Radiation Safety Committee
2.7-Drug Management Committee
2.8-Patient Rights and Satisfaction Committee
2.9-Evaluation and Maintenance Committee
3-Boards
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 Transplantation 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 Material Team
4.4-Building Tour Team
4.5-Emergency and Disaster Management Team
4.6-Nutition Support Team (Nde)
4.7-Laboratory Team
4.8-Clinical Quality Improvement Team
4.9-Medical Record and Documentation Team
4.10-Baby Friendly Hospital Team
UNWANTED EVENT REPORTING SYSTEM
Adverse Event Reporting System
In our hospital;
To ensure notification of undesirable events that may threaten the safety of patients and employees, but do not occur at the last moment (near miss) or occur
According to the Adverse Event Notification Procedure, all Adverse Event Reporting System Registration Forms made by the hospital staff are completed and submitted to the Quality Management unit.
All notifications made are planned for improvement by the Quality Management Representative and the Department Quality Officer. All notifications are evaluated by the relevant committees and entered into the Ministry of Health GRS notification System by the Quality Management Representative.
As a result of the notifications, an Adverse Event Notification System has been established to ensure that the necessary precautions are taken for these events. All employees are given training on the subject as stated in the annual training plan. Feedback is given to senior management and all reporting employees about the improvements made regarding incident notification (improvements are discussed in face-to-face meetings, e-mail, telephone, committees).
Physical Area Inspections
In our hospital; Building tours are held at regular intervals in order to create permanent, safe and easily accessible hospital physical conditions and technical infrastructure for patients, their relatives and employees.
The team formed by the hospital management is defined to ensure the effectiveness, continuity and systematicity of the work carried out in the hospital, taking into account the size of the hospital and the diversity of services.
Building tours are held with the Building Tour Team every 3 months within the scope of the Annual Facility Maintenance Plan and Quality Management Annual Work Plan. Corrective / Preventive action is initiated for all detected nonconformities. Elimination of nonconformities and carrying out 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, and Quality Management Representative. Urgent nonconformities are resolved immediately, other detected nonconformities are improved by setting a deadline.
The Infection Control Nurse makes daily and monthly hospital rounds. Improvement is planned according to the findings.
Self-Assessment Process: Within the scope of Health Quality Standards (SKS), self-evaluation (internal audit) is carried out twice a year in our hospital.
Self-evaluation team; It consists of General Manager, Administrative Director, Human Resources Officer, Financial and Administrative Affairs Manager, Nursing Services Director, Infectious Diseases & Training & Quality Responsible Nurses, Quality Director and Hospitality Services Officer.
Self-evaluation (internal audit) is carried out twice a year, in June and December.
The self-evaluation plan is prepared to cover all sections within the Health Quality Standards.
Before the self-evaluation (internal audit), all departments are informed about the audit schedule and plan via e-mail.
