Quality Management Directorate


Our hospital quality management unit quality director Ecz. Arif ÖZDEMİR and the quality management team ensure the coordination of the work carried out within the framework of SKS.






  • It provides the follow-up of the works for corporate goals and objectives.
  • Manages self-assessments.
  • Manages the processes related to the security reporting system.
  • Manages processes related to risk management.
  • It manages studies for measuring patient and employee experiences (such as survey applications, evaluation of survey results, improvement studies for survey results, receiving patient and employee feedback).
  • It provides management of documents within the framework of SKS.
  • Manages processes for quality indicators.
  • He attends the committees determined within the framework of SKS as a member.



Corporate Objectives and Targets:

The process of achieving the goals and targets determined annually is followed every 6 months and the results are evaluated at the end of the year. The results of the analysis of the goals and objectives regarding the realization situations are reported to the employees of the institution.

Self Evaluation Activities:

In our hospital, a self-assessment plan is created with the quality management unit and self-assessment team, including all SKS standards, once a year. The team that will perform the self-assessment in the plan and their dates are determined and announced to all departments.

Corrective and preventive actions are initiated for nonconformities detected as a result of self-evaluation and the process of eliminating nonconformity is followed by the quality unit. The results of CEF are evaluated according to the deadline determined. If the problem is solved, it is closed, if not, root cause analysis is performed and the date of CEF is extended.

Self-evaluation results are reported to the management.


Security Reporting System:

In our hospital; It is used to ensure the reporting of unwanted events that may threaten the safety of patients and employees, when they are about to happen, not to happen (at the last moment) or to occur, to monitor these events, and to take necessary measures for the events as a result of notifications. The main goals are to ensure Patient Safety and to present a Healthy Work Life environment.

Risk management:

In order to prevent or minimize risks related to all services offered in our hospital and hospital, within the scope of patient, patient relatives, visitors, employees, and facility and environmental safety, we aim to ensure patient safety and to ensure a healthy and effective working life.

Hastane yöneticisi, iş sağlığı ve güvenliği birim sorumlusu ve iş sağlığı ve  güvenliği uzmanlarının değerlendirmesi ile riskler belirlenip planlamaya uygun takip süreci yürütülmektedir.


Measuring Patient and Employee Experiences:

Patient experience surveys are conducted every month, including emergency, outpatient and inpatient patients. A survey is conducted once a year for the employees. All data are analyzed by the Quality Management Unit and these data are brought to the agenda in the relevant committee and team meetings. Annual survey results are reported to the entire hospital.

In addition to the survey application, the notifications made to wishes, suggestions and complaints boxes within the hospital, applications to the patient rights unit, suggestions and complaints of patients and employees made through the hospital website and hastahaklari.saglik.gov.tr address are evaluated on a monthly basis.


Managing Documents in the SKS Framework:

The document management system procedure of our hospital has accepted the SKS Document Management System Guide published by the Ministry of Health, General Directorate of Health Services, Department of Quality and Accreditation in Health. And all the documents used in our hospital are prepared in the light of this guide. The Quality Management Unit is responsible for the control of the documents. All employees can access the documents through our hospital intranet system through a common network.

Documents Used in Our Hospital:

It consists of procedure, instruction, guide, form, plan, consent document, list, auxiliary documents.

All other documents hanging in the hospital are hanged within a certain control and order.

Quality Indicators:

Department based and clinic based indicators are collected by means of data collection according to the Ministry of Health indicator management guide and SKS standards and sent to the relevant institution. The indicators to be notified in the indicator notification area on the Corporate Quality System web page are entered into the relevant fields with the data collected quarterly. The whole process is coordinated by the Quality Unit and the responsible for the indicator. To analyze and interpret the results obtained, the result value is compared with the target value. If the results of the analysis show a negative deviation from the target value, root cause analysis is performed to reveal the situations causing the deviation. Whether the result is positive or negative, critical points in achieving this result are evaluated.


Committees determined within the framework of SKS:

The committees that are required by SKS standards in our hospital are as follows:

  • Patient Safety Committee
  • Employee Health And Safety Committee
  • Education Committee
  • Facility Security Committee
  • Infection Control Committee

Patient Safety Committee: It operates in order to determine the possible risks that will ensure the effectiveness, continuity and systematicity of the studies carried out in the hospital, to determine the appropriate methods and techniques for eliminating these risks, and to ensure the safe service delivery and the sustainability of the safe working environment. The Committee convenes at regular intervals at least four times a year and when necessary.

Quality Management Team: The team conducts an evaluation of the quality activities by organizing meetings with the department quality managers, hospital management and quality management unit. The team evaluates quality activities such as institutional goals and objectives, indicator data, corrective preventive actions, tracking of self-assessment non-compliance.