Quality Management System

• It identifies and proposes the elements needed for the Quality Management Unit to establish a quality policy governing all operations and to ensure its continuity, and monitors, within a programme, the established quality standards, the efforts to achieve them, and the details of the changes to be made.
• Participates in and manages self-assessments planned twice a year.
• It monitors and manages the processes relating to the Adverse Event Reporting system.
• It periodically collects and evaluates statistical data to determine the improvement stages required for faulty or incomplete work processes to comply with the previously targeted quality level.
• Ensures the coordination of work carried out within the framework of the SKS.
• Monitors work towards corporate aims and goals.
• Manages processes in line with risk management.
• Manages efforts related to the evaluation and improvement of patient and employee views and suggestions (such as improvement efforts related to feedback, and the collection of patient and employee feedback).
• Ensures the management of documents within the framework of the SKS.
• It manages processes according to quality indicators.
• Follows the current developments of our Ministry.
• Participates as a member of the committees specified within the framework of the SKS.
• The Responsible Manager carries out other duties assigned.⇒The quality management unit is not personally responsible for implementing all processes relating to the SKS. Quality work that needs to be carried out within a unit's field of activity is the responsibility of all staff working in that unit.The area of responsibility of the quality management committee has been defined.

Patient safety have been defined to cover at least the following topics.

• Correct identification of patients
• Ensuring medication safety
• Reducing risks arising from falls o Ensuring patient privacy
• Safe transfer of patients
• Ensuring information security
• Prevention of infections

Employee safety have been defined to cover at least the following matters.

• Ensuring and monitoring arrangements made for the health status and needs of staff with special circumstances (such as pregnant, breastfeeding, disabled, or those with chronic illness)
• Evaluation of employee feedback (such as suggestions and complaints)
• In accordance with the relevant legislation, in its work regarding occupational health and safety services;

⇒ Follow-up of risk assessment activities for employees ⇒ Follow-up of improvement activities for risks identified within the scope of employee safety ⇒ Preparation and follow-up of the health surveillance programme

Training management must be defined to cover at least the following topics:

• Healthcare quality standards training
• In-service training and orientation training

Facility safety have been defined to cover at least the following topics.

• Ensuring the safety of life and property in the medical centre
• Disaster and emergency management activities
• Waste management activities and the management of hazardous materials”

Every December, a "Quality Plan" is prepared by the Quality Management Unit and forwarded to the Medical Centre's Responsible Manager and Departmental Quality Officers for implementation.

At the medical centre, a "Document Management System" is in place to ensure that the processes related to applications are planned and put in writing, that applications are carried out in accordance with written rules, and that quality studies are managed effectively. Its management is ensured in accordance with the "Document Management Procedure" prepared within the scope of the Healthcare Quality Standards, and a quality software document system is in place to ensure that documents prepared/revised are known to all staff in the field. For a manageable "Document Management System" at our medical centre, the "Document Management Guide" prepared by the Ministry of Health was taken into consideration, and the system infrastructure was built upon that guide.

At our medical centre, the indicators listed in the SKS Department-Based Indicators and Clinical Indicators sections are monitored, and the "Institution-Based Indicators" determined together with department managers and department quality officers, taking into account the medical centre's structure, patient profile and priorities, are also monitored. In this process, data relating to the indicators is collected and analysed at intervals determined according to their characteristics; as a result of the analyses carried out, the necessary improvement activities are planned and implemented.

At Private Natural Clinic Medical Centre, work on obtaining and analysing the data that will form the basis of measurements compliant with the SKS Indicator Management Guide is continued with a continuous IMPROVEMENT approach to quality. In order to measure the adequacy of the services we provide and their compliance with the standards of the Republic of Turkey Ministry of Health, indicator topics and targets have been determined in line with the institution's field of activity and practices.

Indicators are measured at regular intervals and are evaluated and analysed quarterly by the indicator officers. These results are shared with senior management. In indicator management, in the event of target nonconformities identified during the quarterly period, indicator-based root cause analyses are carried out, and improvements are planned and implemented.

Employees responsible for monitoring indicators receive training once a year.

Efforts undertaken within the scope of corrective and improvement action are carried out within the framework of the rules determined by the Özel Natural Clinic Tıp Merkezi quality management unit, and improvement efforts carried out in response to nonconformities are, where necessary, addressed within the scope of corrective and improvement action. Records of the improvement efforts carried out by the quality management unit are maintained.

A "Building Tour" is conducted at least once every 3 months to identify deficiencies related to the physical condition and functioning of the facility and to make the necessary improvements. Management of this process is carried out in accordance with the "Building Tour Instruction" prepared within the scope of the Healthcare Quality Standards. In this process, a team is formed to carry out the building tours. Taking into account the diversity of services, this team is defined in such a way as to ensure the effectiveness, continuity, and systematic nature of the work carried out at the medical centre, and the team includes at least one person from the medical centre's management. Through regular Building Tours, the medical centre's physical conditions and technical infrastructure are ensured to remain continuously safe, easily accessible, and reliable for patients, their relatives, and employees.

A "Self-Assessment" activity is carried out within the institution under the responsibility of the Medical Centre's Quality Management Unit, based on the Healthcare Quality Standards (SKS). Its management is ensured in accordance with the procedure prepared under the SKS Medical Centre set. In this process, the aim is to reveal impartial and objective evidence as to whether quality-related studies and their results comply with existing regulations, the effectiveness of these regulations, and their conformity with objectives, and to ensure that any non-conformities are improved and their recurrence prevented.

Taking into account factors such as the size and structure of the medical centre, this must be carried out at a frequency and at regular intervals determined by the medical centre, at least twice within a one-year period.

Before self-assessment;

• The team(s) responsible for self-assessment are determined.
• A self-assessment schedule is prepared.
• Departments are informed in advance about the self-assessment schedule.
• Self-assessment is planned to cover all SKS sections.

Senior management is informed of any non-conformities identified as a result of the self-assessment, and the necessary improvement work is carried out.

• The Adverse Event Reporting System has been established at our medical centre, and the process is actively carried out through integration with the Ministry. When an adverse situation occurs in patient or employee safety, reports are received and resolved through root cause analysis.
• Notifications can be made under the headings of Patient Safety, Employee Safety, Medication Safety, Surgical Safety, and Laboratory Safety, and improvements are planned for the nonconformities identified.
• Following the reports made, root cause analyses are carried out, supported by frequent training sessions to improve the process and raise awareness.
• Periodic immunisation checks are carried out for all our employees, ensuring their protection against possible transmission risks.
• By minimising facility-related risks, a safe treatment environment is provided for patients, while healthy working areas are created for employees with the same level of care.

To protect the safety of life and property of patients and employees, general use areas are monitored 24/7 by our medical centre's camera system.

As the emergency code system;

• Blue Code,
• White Code,
• Code Red,
• Pink Code,

Training on emergencies is given once a year, and the process is subsequently tested through drills.

Emergency and Disaster Management;

Employees who will serve on the disaster and emergency management team, along with their backups, have been identified and their responsibilities defined. In accordance with the regulations and guidelines published by the relevant legislative authority, an emergency plan has been created for the risks identified in relation to disasters and emergencies. A facility evacuation plan for disasters and emergencies is in place. Plans are reviewed annually under the coordination of a quality management unit. Floor emergency plan sketches are located at floor entrances or lift exits.

With the participation of employees, a facility evacuation drill is conducted at least once a year. Drill objectives are set and the drill is repeated until it is carried out successfully. Any nonconformities identified during the drill are addressed with the necessary improvements by the quality unit. In line with the earthquake risk assessment carried out at our medical centre, the necessary work has been carried out regarding YORA. Taking into account the capacity of the medical centre and the effectiveness of the method to be used, an effective fire suppression system has been established, ensuring the safety of patients and employees.

Drill Procedures

An “Evacuation Plan” is in place for facility evacuation in emergencies and disasters. A “Building Evacuation Drill” is held at least once a year with employee participation.

Building Evacuation Drill; It is planned to also cover the evacuation of inpatient clinics/wards. Video recordings are kept. A report is prepared.

Employees who will take part in emergencies are given training on the emergency and disaster plan.

A risk management team has been established within the institution. Duties and responsibilities have been defined for the active implementation and reporting of risk management activities. Hazards are identified and risks determined on a department or process basis by the risk assessment team, with the participation of the relevant department managers and staff.

Improvement work determined in line with the institution's risk assessment and action plan is carried out. The corrective and improvement actions required for risks, the parties responsible for these actions and the targeted completion dates are monitored by the Quality Unit. Risk management is carried out in an integrated manner with the Quality Unit; all risks — physical, chemical, biological, ergonomic, psychosocial and those related to the services provided — are prepared by the Occupational Safety Specialist.

The Notification System is a platform developed for reporting errors encountered by healthcare facilities and professionals in medical processes. It has been established to enable the reporting of adverse events that could threaten the safety of patients and staff — whether near misses (events that almost occurred but were averted at the last moment) or events that actually occurred — to monitor these events, and to ensure that the necessary measures are taken in response to them following notification. Notifications can be made individually or institutionally. Özel Natural Clinic Tıp Merkezi operates a system based on the principle that focuses not on who made the error but on eliminating the error itself, placing patient and staff safety at its core.

The system has been designed so that employees feel safe, and if the relevant user requests confidentiality during the reporting process, the confidentiality principle is applied, particularly regarding the stages of reporting and sharing of reports.

For the efficient and effective use of the system, at least once a year, to all institutional employees;

• The purpose, importance and responsibilities of the Adverse Event Reporting System
• The system's structure, designed to help employees feel safe
• Emphasising the system's focus on learning from errors and the aim of continuous improvement
• Which events are covered by reporting within the Adverse Event Reporting System
• The manner in which notifications are made, the rules to be followed, and confidentiality
• How to fill in notification forms, through sample cases
• Training is provided on general information regarding how notifications are evaluated and analysed.

In the strategic plan, the performance targets set to achieve the strategic objectives constitute the Medical Centre's Quality Goals. All units within Private Natural Clinic Medical Centre prepare, with reference to the strategic plan, quality goals for their own units and action plans containing the planning of the activities they will carry out to achieve these goals, and forward them to the Quality Management Unit. Quality goals are also a performance indicator of the work processes related to the unit. Quality goals must, as far as possible, be measurable and expressed numerically, and must cover a specific time period (annual or multi-year).

The determination and publication of unit targets and the creation of action plans are carried out by the quality unit in coordination with the relevant unit manager.

The status of progress regarding institutional goals and action plans, together with decisions for the following year, are evaluated at the Quality Management Meeting held in January; new goals are set and revised where necessary.

The committees within the quality organisational structure meet on the dates specified by the Quality Management Unit, in accordance with the "Committee Operating Procedure", to evaluate the matters specified in their duties, authorities and responsibilities, and make their decisions.

⇒Quality officers come together at least once every three months to hold a Quality Management Meeting; they assess the processes and share the issues of the relevant periods.

Institutional Policies are reviewed at Quality Management Meetings for adequacy, suitability and currency. They are revised if a need for change is identified.

The institution's quality policy must be approved by senior management; in the event of a change in management, it is reviewed again and the commitment is renewed.