1. PURPOSE
The purpose is to ensure the compliance, continuity, adequacy, and effectiveness of our institution with the Healthcare Quality Standards, Quality Management System, and related regulations. This includes defining the roles and responsibilities of all personnel—from top management to department staff—in quality improvement efforts; establishing the quality management structure; planning, executing, and coordinating quality improvement activities; and ensuring continuous quality improvement.
2. SCOPE
Covers all teams and committees working under the Quality Management Unit.
3. DEFINITION
HQS: Healthcare Quality Standards
4. RESPONSIBLE PARTIES
The Center Director; Quality Management Director, Quality Management Representative, and all personnel involved in teams and committees are responsible.
5. IMPLEMENTATION
5.1. Vertical Hierarchical Structures (Dimensions)
- Corporate Services
- Patient and Employee-Oriented Services
- Healthcare Services
- Support Services
- Indicator Management
5.2. Horizontal Hierarchical Structures (Departments)
- Corporate Structure
- Quality Management
- Document Management
- Risk Management
- Adverse Event Reporting System
- Emergency and Disaster Management
- Training Management
- Social Responsibility
- Patient Experience
- Access to Services
- Healthy Working Environment
- Infection Prevention
- Sterilization Services
- Medication Management
- Patient Care
- Radiation Safety
- Prosthetic Laboratory Services
- Facility Management
- Hospitality Services
- Information Management
- Material and Equipment Management
- Medical Record and Archiving Services
- Waste Management
- Outsourced Services
- Monitoring of Indicators
- Service Quality Indicators
5.3. Duties, Authorities, and Responsibilities Regarding the Quality Management Structure:
- Corporate Services fall under the responsibility of the Center Administrative Unit, Administrative and Financial Affairs Director and Assistant, and the Quality Management Unit, and are monitored by the Quality Management Director.
Documents related to Corporate Structure, Quality Management, Document Management, Risk Management, Adverse Event Reporting, Emergency and Disaster Management, Training Management, and Social Responsibility are monitored by the Quality Management Unit in accordance with the HQS ADSH guidebook, and necessary actions are taken.
- Patient and Employee-Oriented Services are under the responsibility of Senior Management and the Patient Rights Unit, and monitored by the Quality Management Director.
Patient Experience and Access to Services, Healthy Working Environment are followed up by the Patient Rights Unit in line with the HQS ADSH guidebook, and necessary actions are taken.
- Healthcare Services are provided in seven different clinics within our center. Each clinic is primarily under the authority of the Head of the Department, under the Dean's Office in terms of education and academic services, and under the Center Directorate in terms of clinical services. Infection Prevention and Sterilization Services are monitored by the Infection Control Committee and the Sterilization Unit; Medication Management by the responsible physician and nurse; Patient Care by the clinics and inpatient ward Deputy Chief Physician; Radiation Safety by the Head of the Oral, Dental, and Maxillofacial Radiology Department; and Prosthetic Laboratory Services by the Head of the Prosthetics Lab Unit, all in accordance with the HQS ADSH guidebook.
- Support Services are under the responsibility of the Dean, Center Director, Administrative and Financial Affairs Director, Technical Service Staff, Inventory Officer, Head Nurse, IT Officer, and the Quality Management Unit, and monitored by the Quality Management Director.
Facility Management is handled by Technical Service Staff; Hospitality Services by the responsible nurse of inpatient wards; Information Management by the IT unit officer; Material and Equipment Management by the warehouse and Movable Property Registration Control Officer; Medical Record and Archive Services by the Billing Department Officer; Waste Management by the Assistant Director of Administrative and Financial Affairs and the responsible nurse; Outsourced Services by the Quality Management Unit—all followed in accordance with the HQS ADSH guidebook.
- Indicator Management is under the responsibility of the Deputy Center Director, Quality Management Representative, IT unit, relevant departments, and the Quality Management Unit, and monitored by the Quality Management Director.
Monitoring of Indicators and Quality Indicators is conducted by the Quality Management Unit in accordance with the HQS ADSH guidebook. For deficiencies identified in the HQS ADSH guidebook, a Corrective and Preventive Action (CAPA) Form is filled out, and resolution is required within a specified time. At least one self-assessment is conducted annually, and necessary improvement actions are taken for identified non-conformities.