Our Quality History
It is possible with a system approach to meet the increasing expectations of our people in the health sector and to provide quality health services.
To achieve this aim; Under the guidance of our Quality Directorate, which was established in 2007, the journey to quality has started in our hospitals in line with ISO 9001 standards. In this context, a significant part of the personnel participated in the basic quality concepts and corporate culture, process management, training of trainers, improvement techniques and contributed to the determination of the quality policy, mission, vision and values of our hospitals.
ISO 9001 (International Organization for Standardization) studies, which we consider as the most important contribution to the development of the quality culture in our institution, also have an important place in this journey. For this reason, necessary studies were carried out in both our hospitals in 2008 and ISO 9001 quality management system certificate was obtained.
With the SKS (Quality Standards in Health) Hospital Set published by the Ministry of Health in 2011, we have reached the arguments that will take our hospitals one step further in their quality journey.
The Health Quality Standards of the Ministry of Health were first completely reviewed by the employees of the Quality Unit. Afterwards, SKS departments were evaluated together with the process responsible for that department, and it was discussed whether there was a difference in terms of existing documentation and practices in our Hospitals, and whether there was a need for regulation/change. In these studies, “100% compliance with SKS” was not aimed, the legislative requirements and internal dynamics, which are quite different from public hospitals as a private hospital, were taken into consideration. Changes deemed appropriate by the process responsible were reflected in our processes.
Quality Unit; It is actively involved in the Integrated Quality Management System studies carried out within the scope of ISO 9001:2008 Quality Management System and Quality Standards in Health (SKS) models.
Our Quality Structure
In order to make the right decisions at Lokman Hekim Hospitals, a structure was organized that facilitates the participation of all employees in the decision-making mechanism. The committees shown in the Quality Management Organization Chart (below) consist of different fields of duty and different professional groups. Each process is planned with the contribution of experts in the field and is structured as planned. Whether the activities carried out in the processes planned by the committees are carried out as desired is monitored through indicators, and necessary improvement and training activities are carried out when needed.
Our Quality Management Directorate
Our Quality Directorate carries out all quality improvement and patient safety measurements carried out in our Hospitals by “Lokman Hekim Engürüsağ Health Tourism Education Services and Construction Taahhüt A.Ş.” It is the unit responsible for organizing the name of the Board of Directors. Our Directorate, which provides services in the General Directorate quality office and in the quality offices in the branches, coordinates all the activities that must be done in accordance with the quality standards, and also carries out the activities of planning and implementing the necessary quality improvement and patient safety measurements for all employees.
Our Quality Team
Sibel UĞURLUOĞLU, Quality Management Director
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Hatice Kübra ALBAYRAK, Quality Management Officer
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Gülay KARACAN, Quality Management Specialist
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Van Hospitals Quality Team
Murat DEMİR, Quality Management Director
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İrem DURAK, Quality Management Director
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Various documents are needed in order to standardize the activities carried out in our institution and to harmonize them with national and international quality standards. For this purpose, approximately 2000 documents have been created in our institution. The preparation, approval, implementation, revision, control and current sharing of the created documents (procedure, protocol, plan, instruction, task, authority and responsibilities, form, etc.) require a separate activity. These activities are also carried out by our Directorate. All documents that can be accessed through the hospital information system can be printed out as "Uncontrolled Copies" by users when deemed necessary.
A trained Self-Assessment Team has been appointed to carry out internal evaluations periodically in order to ensure compliance with quality standards. The findings obtained from the audits carried out by the team are analyzed and shared with the relevant Committees, and necessary improvement and training activities are decided.
Activities for Monitoring and Measuring Processes
As an important part of the concept of "Process Management", our efforts to measure, monitor and improve the effectiveness and efficiency of processes continue increasingly. To this end; Efforts are made to determine process-specific, measurable, achievable and realistic indicators, to define the critical ones as “targets” and to evaluate their traceability.
Our Directorate guide senior management during the selection of indicators to be monitored. Our Quality Directorate ensures the interpretation and verification of the analyzes prepared by our statistical units and regularly reports this information to the senior management and relevant committees. Approximately 293 indicators are monitored regularly in our hospitals. Rate of Staff Participation in Trainings, Violence Against Employees Rate, Sharp / Piercing Injury Rate, Staff Leaving the Institution, Completion Rate of Health Screenings of Staff, Falling Patient Rate, Medication Error Reporting Rate, Hand Hygiene Compliance Rate, Central Catheter Related Bloodstream Infection Rate , Urinary Catheter-Associated Urinary Tract Infection Rate, Ventilator-Associated Pneumonia/Ventilator-Associated Event Rate, Surgical Antibiotic Prophylaxis Eligibility Rate, Disposal Blood and Blood Component Ratio, Contrast CT Scan Ratio, Emergency Service Re-admission Rate, Appropriate Surgical Checklist Usage Rate, Pressure Wound Rate in Intensive Care Unit, Mortality Rate in Intensive Care Unit, Primary Cesarean Section Rate, Safe Birth Checklist Usage Rate, Rate of Patients Who Died Due to Complications of Chemotherapy During Chemotherapy Treatment, Rate of Rejected Samples in Biochemistry Laboratory Tests, Loss in Biochemistry Laboratory Service Process Sample Rate, Complete Patient File Rate, Waiting and Results Time for Imaging Services, Mortality Rate After By-Pass Surgery, Percentage of Patients Diagnosed with DM Receiving DM Education, Rate of Development of Glaucoma Within One Month After Cataract Operation, COPD Receiving Steroid Therapy Rate of Diagnosed Patients, Rate of Complete Blood Count in the First 24 Hours After Delivery, Rate of Patients Performed Pulmonary Function Test for the Diagnosis of Asthma, etc.
Spam Notification System
The most important aim of the quality studies carried out in our hospitals is to create a safe environment for both our employees and our patients. Our institution has guided the WHO Patient Safety Goals and the patient safety goals published by the SKS to ensure patient safety.
In order to ensure that the concept of patient safety becomes a corporate culture in our hospitals, trainings aiming to increase the sensitivity of our employees and patients to patient safety are organized, visual materials are used and employees are encouraged to report errors.
The most important parameter of the program we carry out is to report incidents and take preventive measures by analyzing them in order to prevent the recurrence of incidents that threaten the safety of our patients and employees. There is an "Unwanted Event Notification System" for the detection and follow-up of errors that occur in our hospitals.
Incidents that threaten patient safety are reported to the Quality Directorate by the person(s) who experienced and/or witnessed the incident, by making an Undesired Incident Notification via the quality management program as soon as possible. Each notification is subject to a preliminary examination by our Directorate. During the preliminary investigation, the events that require more detailed examination are transferred to the relevant committees, root-cause analyzes are carried out, and the necessary measures to prevent recurrence are determined and implemented. The general analysis of the reported events is made by our Directorate and presented to the senior management at regular intervals.
Activities of Boards and Committees
Ensuring the standard information, communication and compliance required by the working groups (Committees, Improvement Teams, Internal Evaluation Team) carrying out the quality activities requires a planned guidance service. This service is provided by the Quality Directorate in our institution.
Improvements constitute one of the important topics in all quality studies. Quality Management System improvement studies are carried out on the basis of the "Corrective and Preventive Action Procedure" prepared by the Quality Directorate.
In case of detected/potential nonconformities, “Corrective and Preventive Action (CPA)” is initiated under the control of the Quality Unit. The target in the CAPA system; to ensure the systematic follow-up of the planned actions to eliminate nonconformities and to “conclude” the studies. In these studies, the primary aim is to prevent the occurrence of nonconformities (preventive approach), the secondary aim is to prevent the recurrence of nonconformities (corrective approach).
We plan improvements with "Root Cause Analysis" studies based on objectivity and analytical approach, in order to learn why, why and how problems occur when required by the quality standards we apply, and to reach real solutions.
Fishbone diagram, brainstorming, tree diagram, flowcharts, control charts etc. are some of the tools used by our directorate in root-cause analysis studies.
The quality improvement and patient safety program we are conducting requires our employees to be equipped with the knowledge required by the standards. The need to update existing scientific information and remind our employees of this information periodically requires the execution of many training programs. For this reason, various training programs are carried out by our Directorate for our newly recruited and continuing personnel in our hospitals. The training programs in question are prepared taking into account the quality standards and incoming demands. The main purpose of the created training programs; is to ensure that all employees do their work within the framework of certain standards, consciously, professionally, with care, with love, with confidence and with a smiling face.
In the training programs planned by our Directorate, with our employees; Topics such as Infection Control, Patient Rights, Patient and Employee Safety, Patient Care, Basic and Advanced Life Support, Occupational Health and Safety, Emergency Code Systems, Medicines and Materials Management are shared.
Our Quality Committees
Committees operate in our hospitals to carry out various tasks. In the formation of the committees, the relevant legislation and the titles of Quality Standards in Health were taken into account. The fields of activity of each committee are outlined below.
Patient Safety Committee
Establishing and implementing the patient safety program of our hospitals, designing clinical and administrative processes in this direction, collecting data on processes, analyzing data, planning and implementing the necessary improvements, and maintaining the changes that result in improvement are the working areas of this committee. In this context, the Committee carries out the following activities;
- Selecting indicators for monitoring the quality of services provided in the hospital, collecting data on these indicators, analyzing the data and providing the validation of the analysis data,
- Defining a process for detecting and managing events that threaten/potentially threaten patient safety, receiving feedback through a defined process, and taking preventive measures by performing root-cause analysis for events,
- Planning and implementation of improvements with the findings obtained from the analysis,
Facility Safety Committee
Making our hospitals safe and secure for patients, their relatives, employees and visitors, effectively managing the physical facility, medical and other equipment and people, reducing and controlling dangers and risks, preventing accidents and injuries and ensuring safe conditions are among these issues. is the working area of the committee. In this context, the Committee carries out the following activities;
- Ensuring that the requirements of the current legislation regarding facility management are fulfilled,
- Creating and implementing plans for the management of risks (safety, safety, hazardous materials, emergency, fire, medical technology and technical and sanitary installations) for patients, visitors and employees,
- Ensuring that risk assessments are carried out by a trained team in order to reduce and control the risks associated with the facility,
- Establishing and implementing a security program to prevent physical injuries to the people in the institution from factors such as buildings, equipment, medical technology,
- Establishing and implementing a security program that will prevent those in the institution from attacks such as theft, extortion and harassment,
- Establishing and implementing a program for the inventory, transportation, storage and use of dangerous goods,
- Developing, maintaining and testing an emergency management program in order to respond to emergencies, epidemics and natural or other disasters,
- Developing and implementing a program for the prevention, early detection, suppression, mitigation and safe evacuation of fire and non-fire emergencies,
- Establishing and implementing a program for auditing, testing, maintaining and calibrating medical technologies and documenting results,
- Developing and implementing a program to ensure that the technical and sanitary facilities operate effectively and efficiently,
- Ensuring data collection and analysis to reduce risks related to each of the safety, security, disaster, fire, hazardous materials, medical technology, technical and sanitary programs,
- Ensuring that all employees are trained on their duties in maintaining a safe facility.
Infection Prevention/Control Committee
Evaluation of health care processes in terms of infection risk, surveillance, hand hygiene, isolation measures, rational use of antibiotics, cleaning, disinfection, sterilization, asepsis, antisepsis, occupational infection of employees, planning for extraordinary situations, laundry, morgue, waste management and ventilation systems. The prevention and control committee of infections in important fields of activity such as prevention of infections in support services has been carrying out its activities effectively and actively since the opening of our Hospitals.
Employee Health and Safety Committee (Occupational Health and Safety Board)
The main field of work of this committee is to design and implement the employee health and safety program to be carried out in our hospitals. In this context, the Committee carries out the following activities;
- Establishing and implementing an employee health and safety program,
- Identifying and implementing the necessary processes to reduce the risks of exposure to physical violence (White Code),
- Carrying out risk analyzes in order to reduce the risk of injury to employees and ensuring that the measures determined as a result of the analyzes are implemented,
- Identifying, supplying and using personal protective equipment needed in work areas,
- Ensuring that the risk of sharps injury is reduced and the process to be applied in case of exposure is designed and implemented,
- Determining the scope of health screenings that should be done at the beginning and after the job and ensuring its implementation.
- Planning, coordinating and evaluating the effectiveness of training activities for both our employees and patients and their relatives in our hospitals constitute the work area of this committee. In this context, the Committee carries out the following activities;
- Establishing, implementing, monitoring and evaluating continuous in-service training programs for each personnel who start to work, in order to maintain and develop their knowledge and skills,
- Planning and providing trainings that will support the participation of patients and their relatives in care decisions,
- Evaluating training needs and ensuring that they are recorded in the file,
- Evaluating the patient's ability to learn and willingness to learn and ensuring that they are used in the planning of education,
Considering the values and preferences of the patient and their relatives in the selection of education methods; Ensuring adequate interaction between the patient, their relatives and staff so that learning can take place.