Quality and Accreditation Unit

The foundations of accreditation work in Turkey were laid for the first time in 2005 with quality assessments in healthcare and service standards for assessments were established. These standards have evolved over time in numerical and structural terms and have been implemented in four different versions. As of 2013, the standards have been restructured according to four basic principles and ten objectives related to Accreditation and as of the fifth version it has taken its final form with the name Accreditation Standards in Health.

The Hospital Seti, which sheds light on the Accreditation System in Health in Turkey, is designed to be understood and interpreted in a common language by all stakeholders, including hospitals. The first part of the SAS-Hospital Set, which contains Standards, Evaluation Measures and Guidelines within the Hospital Set, sets out the basic policies and principles for Accreditation in Health, and the second part contains historical development process and general information regarding Accreditation standards. The third part contains guidelines containing Standard Requirements designed to assist in the understanding and application of standards and assessment criteria.

The SAS-Hospital Set, which includes the basic knowledge of the accreditation process and the requirements to become an Accredited Hospital, is for the benefit of hospitals and all stakeholders to improve the quality of healthcare.

The three main elements of healthcare quality management aimed at by the National Accreditation Structure and the Transition Programme in Health, which was established on the basis of the Accreditation Standards in Health, have been completed.

Quality assessments in health

Accreditation system in healthcare

Quality ratings in health:

SKS is based on the determination of the quality level based on structure, process and output in healthcare institutions. Quality assessments shall be made and reported periodically. The resulting scores can be used for various incentives and sanctions. Obligation is basic. The aim is to include all healthcare institutions in the process.

Accreditation system in health:

SAS is a system for healthcare institutions and organisations to apply on a voluntary basis and to be documented according to their success. The Accreditation System in Health is a system that hospitals can apply to if they want to go beyond the quality level achieved in healthcare with quality assessments and corporate differentiation across the country. It has been established as an incentive for domestic and foreign health tourism due to its internationally approved documentation.

This structure, presented by our Ministry of Health in the field of quality in our country, is critical for the country's health system to sit on solid foundations within the framework of a continuously improved and sustainable concept of service.

Development of Standards

The foundations of quality studies in health within the Ministry in Turkey date back to 2003, and the concepts of quality and accreditation are among the principles set out in the Transition Programme and the priorities of health policy.

In the Health Transition Programme, emphasis is placed on the planning and supervisory roles of the Ministry of Health, i.e. the structure and practice of a Ministry of Health that sets standards for services, sets rules, oversees the framework of practices and the level of implementation of these standards. The first steps towards the Accreditation System were taken with the principle of quality and accreditation for quality and effective health services, which is the sixth component of the programme.

Accreditation work, which was first publicly stated on the Turkish health agenda in 2003, is the result of a long journey. In 2005, when the first step of this journey was undertaken, for the first time work was started on establishing service standards covering healthcare, including all healthcare processes. The study was initially aimed at creating awareness among managers and employees of quality service delivery and documenting service processes in healthcare institutions by identifying them. Within this framework, 100 quality standards were established in 2005. The Quality Standards in Healthcare were upgraded to 150 in 2007, 354 in 2008 and 388 in 2009 for private hospitals and upgraded to 621 in 2011 with the latest revision and have undergone significant changes and improvements over the years in terms of both the numerical and the content and scope of the standards.

This process, which began in 2005, was carried out gradually because a large number of institutions were not familiar with the concept of quality and accreditation before. The recognition, adoption and awareness-raising of these studies by health institutions and their inevitable contribution to the development of health services has led to the spread of the studies over a period of years.

Through accreditation standards and accreditation programmes, which will apply these standards as a whole to audit processes, it prioritizes achieving some key objectives in healthcare institutions. The objectives are aimed at both the outputs (results) of the services and how those services are obtained (structure and processes). Objectives to be achieved by accreditation:

• Patient safety,
• The truth,
• Patient focus,
• Uygunluk,
• The timing,
• Continuity
• Effectiveness,
• The activity,
• The efficiency,
• A healthy work life.

In addition to achieving these objectives, some other benefits of accreditation for healthcare institutions will be listed below:

• Guarantees the quality
• It's based on constant quality improvement.
• Provides credibility to the organization
• It 's a tool for effective process management
• Supports efficient financial resource management
• Supports self-assessment
• Depends on the continuity of care
• The worker cares about his satisfaction
• Supports communication and cooperation
• Provides ethical management
• Supports professional service offerings
• Provides efficient resource management
• Supports safe drug management
• Based on patient satisfaction
• It supports safe study presentations
• Efficiency in human resource management
• Policies and procedures
• It promotes business peace
• Provides patient safety
• Supports teamwork in organizations
• Encouraging examples of good practice
• It supports security culture
• It improves the health outcomes of patients

Accreditation Standards in Health-Hospital aims primarily to establish success targets for meeting the standards in hospitals.

Objectives of Accreditation Standards in Health

Accreditation Standards in Health, WHO Patient Safety Goals, the principles of The International Society for Quality in Healthcare (ISQua), accreditation programs implemented around the world and our country's needs and priorities have been established to achieve quality objectives in order to ensure quality in hospitals.

Structure of the Hospital Set of Accreditation Standards in Health

The Health Accreditation Standards include 7 Dimensions, 34 Chapters, 59 Standards, 242 evaluation criteria. The SAS Hospital Set consists of Standards, Assessment Measures and related guidelines. The guidelines set out the objectives, objectives and standard requirements of the standards. The standard, evaluation criteria and related guidelines should be considered and applied together as a whole. The following 7 dimensions are included in the Health Accreditation Standards:

• Management and organization
• Performance Scale and Quality Improvement
• Healthy Work Environment
• The experience of the sick
• Health services
• Support services
• Emergency Management

General purpose and scope of dimensions

The dimensions contained in the Accreditation Standards in Health are defined to cover all parts of the hospital based on services provided in hospitals, management activities and persons involved in the service process.

• Management and organization

The aim is to create a management structure at the management and organizational level, ensuring continuity in the operation of the hospital and ensuring the systematic conduct of work activities, together with an effective institutional quality management structure involving senior management and all employees.

In order to achieve this goal, a hospital organizational structure must be created, basic policies and values must be established, a quality management structure must be created, document management must be provided, a safety reporting system must be established, risk management and education management must be provided, work must be done to promote and improve health, institutional communication must be provided.

• Performance Scale and Quality Improvement

Interventions aimed at improving quality and timely identification of possible problems with the provision of services, including administrative, financial and medical processes. These objectives are to be achieved through the use of institutionally defined indicators and SAS indicators.

• Healthy Work Environment

In this dimension, the aim is to ensure that employees lead a healthy working life and work in hospital organisations in order to provide quality healthcare.

To this end, a structure for managing human resources should be established, measures should be taken to address factors that threaten the health and safety of employees and requirements for improving working life should be identified.

Patient Experience The Patient Experience Dimension aims to look at services from the patient's perspective with the aim of ensuring basic patient rights, patient safety and patient satisfaction.

To this end, the services provided by the hospital must be organised in such a way as to safeguard the rights of the patient and their loved ones, ensure timely access to services and ensure patient comfort and ensure patient safety.

• Health services

The aim is to ensure that all medical services provided in the hospital are delivered within the scope of SAS objectives. To this end, work should be carried out in the areas of control and prevention of infections, sterilization services, drug administration, transfusion management, radiation safety, patient care, laboratory services, safe surgery and emergency health services.

• Support services

In the Support Services dimension, the aim is to create the necessary infrastructure to ensure the safety and continuity of medical service processes. In order to achieve this objective, work should be carried out on hospitality services, facilities management, waste management, information management and material and equipment management should be provided, activities for the use of external resources should be planned.

• Emergency Management

In this dimension, natural disasters such as earthquakes, floods, or fires, explosions, etc. The aim is to prevent the most rapid and effective intervention in the event of the risk and/or action of kidnapping and/or child abduction, respiratory or cardiac arrest and violence by employees.

Düzeltici – Önleyici Faaliyetler (DÖF)

• Opening the correction and prevention activity log
• Selection of Working Group and Officials
• Distribution of e-mail forms
• Conduct assignments related to DEF (with the WORK MODULE)
• Tracking and reporting until DEF is completed
• DIFF statistics

Uygunsuzluk Kayıtları

•  Identification of places and types of irregularities
•  Entry of records of irregularities, reporting on a periodic basis
•  Creating an OFF from inappropriateness

Tracking of quality goals

•  Defining the current quality targets
•  Record and report results of targets

Audit Records

•  Making control plans,
•  Registration and reporting of audit reports

Meetings of the Board

•  Planning of the management review meeting
•  Record and track meeting notes

Supplier Evaluation

•  Assessment of supplier service and delivery
•  Periodic evaluation reports of suppliers

Staff records

•  Missing records of staff
•  Staff organization

Job Descriptions

• Preparation, approval and publication of job descriptions

Educational records

•  Planning of training for employee compliance and other internal training courses.
•  Registration and reporting of training attendance

Educational surveys

•  Results of internal training questionnaires for staff
•  External training survey results for clients

Calibration Records

• Planning of calibration operations of measuring instruments, recording and reporting measurements

Maintenance Records

• Periodic maintenance planning of machinery and equipment
•  Preparation of maintenance reports

Design

•  Design plans and follow-up
•  Meeting notes on the design,
•  Design verification reports

According to the Accreditation Standards in Health, the current status of our hospital (goals, self-assessment results, safety reporting, committee work reports, DÖF reports, demonstration follow-up results, satisfaction reports, etc.) was established with the aim of conducting accreditation activities in health services. Quality and Accreditation Institute of Health Services of Turkey (TUSKA) It aims to be accredited by the European Commission.

• Since its inception, our hospital has adopted the concept of modern healthcare as its fundamental principle. Patient-focused, internal and external customer satisfaction-oriented certifications, providing overall quality management and standardization of processes, are considered the cornerstones of the institution's policies. In this context, he started working on the Quality Management System in our hospital in 2007 and at the end of 2009 received the certificate of TSE EN ISO 9001:2008 Quality Management System.
• In January 2012, the certification study carried out by TSE resulted in the certification of TS 18001 Occupational Health and Safety Management System and TS EN ISO 14001 Environmental Management System, in September 2013 the certification of TS EN ISO 22000 Food Safety Management System and in March 2014 the certification of TS ISO 10002 Customer Satisfaction Management System.
• Our hospital also holds an internationally valid IQNet certificate.
• Our hospital has the distinction of being the only public university hospital with five certifications in this area.

• Efficiency: It's a measure of achieving your goals.
• Efficiency: The ability to do things right.
• Efficiency: refers to the relationship between the amount of service produced and the inputs used in the production of these services.
• Healthy Working Life: Providing an ideal and safe working environment and infrastructure for healthcare workers.
• Patient Safety: Measures and remedial actions that can be taken to maintain an acceptable level of risk for all service stakeholders that may cause harm and are foreseeable.
• Fact: Services are guaranteed in all service units of the organization to have equal access to treatment and care only, without any other discrimination.
• Patient Focus: To ensure the active participation of the patient in the diagnosis, treatment and care services, taking into account the needs, needs, expectations and values of all services offered.
• Appropriateness: It is to benefit more than harm the health of the person in the medical procedures and processes decided to be carried out. Timeliness: the provision of diagnostic, treatment and care services within the most appropriate and acceptable time frame for the patient's needs.
• Continuity: ensuring the chronological, interdisciplinary and post-discharge continuity of medical services.

Quality and Accreditation Institute of Health Services of Turkey (TUSKA)

Access to:  http://www.tuseb.gov.tr/tuska/index.php

Ministry of Health Hospital Accreditation Standards in Health / v1.1.

Access to: http://tuseb.gov.tr/tuska/yuklemeler/saglikta_akreditasyon_standartlari_hastane.pdf