-
AKDENZ UNIVERSITY HOSPITALAKDENZ UNIVERSITY HOSPITAL
THE IMPORTANCE OF ISO 9001 QUALITY MANAGEMENT SYSTEM APPLIED IN
THE AKDENIZ UNIVERSITY HOSPITAL
DURING TRANSITION TO
JCI- ACCREDITATION STANDARDS FOR HOSPITALS
THE IMPORTANCE OF ISO 9001 QUALITY MANAGEMENT SYSTEM APPLIED IN
THE AKDENIZ UNIVERSITY HOSPITAL
DURING TRANSITION TO
JCI- ACCREDITATION STANDARDS FOR HOSPITALS
-
AKDENZ UNIVERSITY HOSPITALAKDENZ UNIVERSITY HOSPITAL
Akdeniz University Hospital is a Health Research and Application
Centerwhich has:
Closed area 150.000 m2
Number of Staff 3000 academic and administrative staff
Outpatients 700.000 (annual average)
Inpatients 67.000 (annual average)Inpatients 67.000 (annual
average)
Operations 27.000 (annual average)
Organ transplantations 2.962 (1982/30.09.2010)
2662 Kidney Transplantation, 195 Liver Transplantation, 46
Heart
Transplantation, 57 Pancreas Transplantation, 2 Arm
Transplantation
-
QUALITY STUDIES IN AKDENIZ UNIVERSITY HOSPITALQUALITY STUDIES IN
AKDENIZ UNIVERSITY HOSPITAL
A new hospital building, equipped with new technology and
equipment, and staffed by hospital administrators who want to
establish a modern hospital management system:
-Total Quality Management studies began in 1997.
-Total Quality Management practices applied in Administrative
Departments-Total Quality Management practices applied in
Administrative Departmentsbetween 1997 and 2001.
- ISO 9001 Quality Management System (QMS) implementation
initiated in all medical and administrative parts of the hospital
in 2001.
- In 2003, the first ISO 9001 QMS Certificated hospital among
all university and public hospitals in Turkey. In 2009, the
certificate was renewed for the 3rd time.
-
IMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITALIMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITAL
DOCUMENTATION
Studies began with an assessment of the current situation, and
an analysis
of the organization.
50 members of staff sitting on 14 committees.
ISO 9001 QMS and Internal Auditor training was arranged for all
committee
members. members.
Processes are determined by senior management and committee
members.
Process-based documents prepared. (120 procedures, 374
instructions,
140 workflow diagrams, 345 job descriptions, 2,000 standard
forms)
Documentation can be viewed electronically.
-
IMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITALIMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITAL
MANAGEMENT RESPONSIBILITY
The most important advantage enjoyed by our hospital is the
active
leadership role taken by the top management in implementing
ISO 9001 QMS applications, with the following
understandings;
The mission of the leadership was determined as: To meet the
expectations of our
patients through the efforts of our specialized staff, by
following all current scientific
and technological developments in the world at the highest
level, using the highest-and technological developments in the
world at the highest level, using the highest-
quality and most effective and efficient methods.
The Head Doctor is also the Quality Management Representative of
the hospital.
Creation of a QMS organizational chart to ensure the effective
establishment and
maintenance of the system.
The addition of a Quality Management Department to the
hierarchical structure of the
organization.
The Quality Management Department is responsible for carrying
out quality studies.
-
IMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITALIMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITAL
MANAGEMENT RESPONSIBILITY
The managers of all medical and administrative departments are
identified as being
responsible for the QMS activities of their departments.
The decision by top management to take QMS certification under
objective
evaluation.
The decision by top management to require the improvement of
services and
operational processes from the committees (Hospital Advisory
Board, Management
Committee, Quality Council, etc.)
Decisions are carried out by the project teams, committees and
process owners.
Hospital management goals and Department goals are determined
annually.
Documentation of the objectives is evaluated periodically within
hospital management
committees and Management Review Meetings.
Management Review Meetings are carried out under the
chairmanship of the Rector,
and with the participation of Hospital Administrators and
Department Heads.
-
IMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITALIMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITAL
RESOURCE MANAGEMENT
Planning of human resources and staff work standards are carried
out
by experts belonging to the project team in our hospital.
Hospital staff training needs are determined, planned and
Hospital staff training needs are determined, planned and
systematically organized by the Training Department.
(Communication
training, fire safety, hospital infection and hand washing,
workplace
health and safety, hospital emergency plans, ISO 9001
quality
management system training, etc.)
-
IMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITALIMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITAL
RESOURCE MANAGEMENT
"Hospital Automation System" was established and operated in
order
to facilitate the re-entries of data and information about the
availability
of hospital services.
In our hospital, the necessary building materials and auxiliary
plant and
inventory materials are available in order to fulfill the
operation of the inventory materials are available in order to
fulfill the operation of the
processes in the most effective way.
Conditions related to the work environment are established
in
accordance with legal regulations in our hospital.
For this purpose, Workplace Health and Safety Department has
started
its activities.
-
IMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITALIMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITAL
SERVICE/PRODUCT REALIZATION
When a new service is requested, this service will be designed
and
implemented. When dealing with demands for services the
following criteria
will be taken into account;
Oral and written requests from patients and relatives of
patients,
Legal and regulatory requirements, Legal and regulatory
requirements,
Additional requirements to be determined by the hospital.
The necessary documents are prepared and updated when changes
occur
in the system.
-
IMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITALIMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITAL
SERVICE/PRODUCT REALIZATION
Hospital management is responsible for the monitoring and
continuous
availability of information about the provision of services at
the stage of
realization, as well as products, service providers and
patients.
The automated hospital data system provides the base point
through which
diagnostic and therapeutic procedures can be identified and
traced, and the
information then recorded and stored.
-
IMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITALIMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITAL
SERVICE/PRODUCT REALIZATION
Design Studies are initiated by top management as a result
of:
Customer feedback,
Department requests,
Legislative changes,
Error rate reduction,
Saving-oriented changes,
Willingness to use new technologies.
Design Studies encompass:
Outpatient Surgery Centre, Private Health Centre, Hospital
Security System,
Workplace Health and Safety, Chemotherapy Unit.
-
IMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITALIMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITAL
SERVICE/PRODUCT REALIZATION
Calibration :
In our hospital, all medical devices used for measurements are
calibrated in
the following manner;
Using 15 calibration devices available in the Calibration
Centre,
By trained and experienced technical team, By trained and
experienced technical team,
Using 16 kinds of calibration methods, (temperature, pressure,
weight,
anaesthesia equipment, patient monitors etc.)
4,000 calibration and 2,000 electrical safety tests are carried
out annually,
Devices are calibrated in place if necessary,
Calibration records are monitored by the automated
programme,
The Calibration Centre also provides services to external
organizations.
-
IMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITALIMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITAL
MEASUREMENT, ANALYSIS AND IMPROVEMENT
In our hospital, monitoring, measurement and improvements are
made in the
following ways:
Verification of purchased products,
Control of services,
Internal audits,
Customer feedback, data analysis, corrective and preventive
actions.
-
IMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITALIMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITAL
MEASUREMENT, ANALYSIS AND IMPROVEMENT
Patient Satisfaction Measurement Data provided from:
Surveys,
Satisfaction, request and complaints boxes,
Electronical petitions, transmitted from the hospital web
page,
Written petitions, Written petitions,
Data collected from personal applications.
-
IMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITALIMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITAL
MEASUREMENT, ANALYSIS AND IMPROVEMENT
To measure patient satisfaction, 26,000 surveys are carried
out
annually, and scanned with optical readers.
Surveys, other data assessment and improvements are carried
out by the Patient Satisfaction Evaluation Committee.out by the
Patient Satisfaction Evaluation Committee.
-
IMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITALIMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITAL
MEASUREMENT, ANALYSIS AND IMPROVEMENT
Internal Audit:
Planned internal audits of 60 medical and administrative
departments are
made at least once a year.
In internal audits, an auditing committee of the hospital
consisting of 150
persons are involved.persons are involved.
As a result of internal audits, 500 corrective / preventive
actions are
implemented annually and improvement studies are carried
out.
-
IMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITALIMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITAL
MEASUREMENT, ANALYSIS AND IMPROVEMENT
Apart from internal audits, 120 services and products which do
not
confirm to the required standards are identified by hospital
employees
and reported to hospital management every year and corrective
or
preventive actions are initiated.
-
IMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITALIMPLEMENTATION OF ISO 9001 QMS STANDARDS IN OUR
HOSPITAL
MEASUREMENT, ANALYSIS AND IMPROVEMENT
Improvement:
Improvement activities are carried out through the joint efforts
of Quality
Department employees and process owners, then reported to
top
management. (Reduction of the waiting period in receiving
biological
samples, Prevention of false samples sent to the Central
Laboratory etc.)
-
The examples we give above show how it is possible to create a
management model for a hospital of this size using the ISO 9001
quality management system.
Application of the ISO 9001 Quality Management System Standards
in our hospital over a period of 10 years has also given a more
detailed and specific approach to the functioning of the health
services, and there are now plans for the implementation of
JCI-Accreditation standards for hospitals.
-
WHY JCI-ACCREDITATION STANDARDS FOR HOSPITALS ?WHY
JCI-ACCREDITATION STANDARDS FOR HOSPITALS ?
In general, issues mentioned in JCI accreditation standards for
hospitals
are also given in the ISO 9001 quality management system
standards.
JCI-accreditation standards for hospitals are include
organizational
standards and as well as the patient-oriented standards.
Patient-focused standards are emphasized medical care, more
specific and Patient-focused standards are emphasized medical care,
more specific and
detailed.
Because of this feature provides ease of implementation in
hospitals.
-
CONSISTENCY OF ISO 9001 QUALITY MANAGEMENT SYSTEM STANDARDS AND
JCI-ACCREDITATION STANDARDS FOR HOSPITALS
CONSISTENCY OF ISO 9001 QUALITY MANAGEMENT SYSTEM STANDARDS AND
JCI-ACCREDITATION STANDARDS FOR HOSPITALS
Studies in accordance with ISO 9001 quality management system
standards and JCI- accreditation standards for
hospitals.
JCI-ACCREDITATION STANDARDS FOR HOSPITALS
Subject
Management of Communication and Information
ISO 9001 STANDARDS AND JCI-ACCREDITATION STANDARDS FOR
HOSPITALS
ISO 9001:2008 QUALITY MANAGEMENT SYSTEMSTANDARDS
Subject
Quality Management System
Governance, Leadership, and Direction
Management of Communication and Information
Staff Qualifications and Education
Facility Management and Safety
Access to Care and Continuity of Care
Patient and Family Rights
Assessment of Patients
Care of Patients
Patient and Family Education
Anesthesia and Surgical Care
Medication Management and Use
Quality Improvement and Patient Safety
Prevention and Control of Infections
Resource Management
Product Realization
Measurement, Analysis and Improvement
Management Responsibility
-
FACILITIES IN THE IMPLEMENTATION OF JCI-ACCREDITATION STANDARDS
FOR HOSPITALS
FACILITIES IN THE IMPLEMENTATION OF JCI-ACCREDITATION STANDARDS
FOR HOSPITALS
THE IMPORTANCE OF ISO 9001 QUALITY MANAGEMENT SYSTEM
Culture and quality consciousness of ISO 9001 quality management
system
in senior management and employees,
Employee participation and the establishment of effective
communication,
Quality organization to be ready,
System and organizational documents to be ready,
All processes and tasks to be defined,
-
FACILITIES IN THE IMPLEMENTATION OF JCI-ACCREDITATION STANDARDS
FOR HOSPITALS
FACILITIES IN THE IMPLEMENTATION OF JCI-ACCREDITATION STANDARDS
FOR HOSPITALS
THE IMPORTANCE OF ISO 9001 QUALITY MANAGEMENT SYSTEM
Elimination of non-conformities with using the quality
management system
by all employees,
The system is self-controlled and staff to be familiar with the
culture of
audit,
All departments identify goals and accomplish their work in this
direction, All departments identify goals and accomplish their work
in this direction,
Made the documentation and transition to implementetion of
JCI-
accreditation standards for hospitals easier for us,
-
FACILITIES IN THE IMPLEMENTATION OF JCI-ACCREDITATION STANDARDS
FOR HOSPITALS
FACILITIES IN THE IMPLEMENTATION OF JCI-ACCREDITATION STANDARDS
FOR HOSPITALS
Within the framework of JCI accreditation standards for
hospitals, the new
documents are produced about medical care, by the doctors and
nurses
involved in committees (International Patient Safety Procedure ,
Medical
Authorization Procedures, Doctor Order Procedure etc. ),
Documents generated with in the JCI-accreditation standards for
hospitals Documents generated with in the JCI-accreditation
standards for hospitals
and applications are integrated to the ISO 9001 quality
management
system.
-
RESULTRESULT
In our hospital, the ISO 9001 Quality Management System has been
successfully implemented since 2001. We believe that now we have
achieved this standard, our institution is an appropriate candidate
for modern and innovative standards projects or pilot
applications.
-
AKDENZ UNIVERSITY HOSPITALAKDENZ UNIVERSITY HOSPITALTHE
IMPORTANCE OF ISO 9001 QUALITY MANAGEMENT
SYSTEM APPLIED IN THE AKDENIZUNIVERSITY HOSPITAL DURING
TRANSITION TO
JCI- ACCREDITATION STANDARDS FOR HOSPITALS
THE IMPORTANCE OF ISO 9001 QUALITY MANAGEMENT SYSTEM APPLIED IN
THE AKDENIZUNIVERSITY HOSPITAL
DURING TRANSITION TO
JCI- ACCREDITATION STANDARDS FOR HOSPITALS