THE IMPORTANCE OF ISO 9001 QUALITY … · ISO 9001 STANDARDS AND JCI-ACCREDITATION STANDARDS FOR HOSPITALS ISO 9001:2008 QUALITY MANAGEMENT SYSTEM STANDARDS Subject Quality Management

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



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.


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.


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.


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.)


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.


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.



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.



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.



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.


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.



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.



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.



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.



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.



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


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,



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,



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


THE IMPORTANCE OF ISO 9001 QUALITY MANAGEMENT SYSTEM APPLIED IN THE AKDENIZUNIVERSITY HOSPITAL

