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QUALITY

ORGANIZATION OF COMMITTEES:

COMMITTEE ON PATIENT SAFETY
COMMITTEE ON EMPLOYEE HEALTH AND SAFETY
COMMITTEE ON OCCUPATIONAL HEALTH SAFETY
COMMITTEE ON EDUCATION
COMMITTEE ON FACILITY SECURITY
COMMITTEE ON INFECTION CONTROL
COMMITTEE ON TRANSFUSION
HEALTH EXECUTIVE COMMITTEE
JOINT EXECUTIVE COMMITTEE
CLAIM EXAMINATION BOARD
COMMITTEE ON SOCIAL AND CULTURAL ACTIVITIES
COMMITTEE ON PATIENT SAFETY

Duties, Authorities and Responsibilities:

Proper identification of patients
Ensuring effective communication between employees
Ensuring drug safety
Ensuring transfusion safety
Ensuring radiation safety
Reducing the risks of falling
Ensuring safe surgical practices
Ensuring medical device safety
Ensuring patient confidentiality
Safe transfer of patients
Safe transfer of patient information and records between health professionals
Provision of information security
Prevention of infections
Providing patient safety in the laboratory

Committee Members:

Chief Physician
Chief Nurse
Director of Administrative Affairs
Surgical Specialist
Anaesthetist
Internist
Employees of Quality Management Unit
Pharmacist
Information Systems Manager

Frequency of Meetings:

The Committee on Patient Safety holds meetings four times a year and, in case of need.

COMMITTEE ON OCCUPATIONAL HEALTH AND SAFETY  

Duties, Authorities and Responsibilities:

Reducing the risk of harm for employees. Conducting studies and inspections in the fields of work environment, risk assessment, occupational accidents, emergency management, occupational health and safety and legal legislation related to environment.

Taking necessary precautions for employees in hazardous areas. Preparing an internal regulation draft that is in line with the nature of the workplace, submitting it to the approval of the employer or the employer's representative and monitoring the implementation of the internal regulation. Determining the measures to be taken after creating a report out of it and proposing it for the agenda of the committee.

Reducing the risks caused by physical abuse

Preparing a health-screening program. Evaluating the risks and measures related to occupational health and safety at the workplace, determining the measures, informing the employer or employer's representative,

Conducting necessary studies and inspections in case of every hazardous incident or occupational disease occurring in the workplace or in case of a danger related to occupational health and safety, determining the precautions to be taken with a report and giving it to the employer or employer's representative,

Planning the education and training of occupational health and safety at the workplace, preparing the programs for these subjects and rules, submitting them to the approval of the employer or employer's representative and monitoring the implementation of these programs,

Planning the necessary safety measures for the maintenance and repair works to be carried out in the facilities and monitoring the implementations of these measures,

Observing the adequacy of the measures related to fire, natural disasters, sabotage and the like in the workplace and the work of the teams,

Preparing an annual report on the health and safety status of the workplace, evaluating the actions of that year, determining the points and agenda to be included in the work program of the following year according to experience, making an offer to the employer, ensuring the conduction of the planned agenda and evaluating its implementation,

Having an urgent meeting and making decisions in the case of the occurrence of the requests stated in Article 83 of the Labour Law No. 4857.

Reducing the risks of sharp object injuries and contamination of blood and body fluids. Review, interpretation and advise on relevant programs and action plans, such as health screening that is carried out during recruitment and at intervals in order to get protected from infections, treating injured staff members wounded by infected materials, preventing the occurrence of similar incidents, and training employees on the prevention of infection.

Collaborating with other committees and departments about the prevention of infection and injuries.

Make suggestions on the evaluation of working environments that may negatively affect the health of employees such as radiology, chemotherapy and sterilization in some cases.

Developing methods for a more relaxed atmosphere for employees working in a noisy environment and offering suggestions to the relevant departments.

Play the leading role in the placement of first aid training in a specific program.

Taking into account the status of the workplace and the opportunities of the employer while making proposals, suggestion and decisions.

The Committee also carries out activities to reduce important environmental dimensions related to the activities carried out within the scope of the activity of the establishment and to raise awareness of the employees on the issue.

Committee Members:

The General Director appoints the Occupational Health and Safety Committee within the framework of laws and regulations and notifies all employees every year in January.

Committee Members;

General Director
Chief Physician
Occupational Physician
Occupational health and safety specialist
Director of Administrative Affairs
Chief Nurse

Infection Control Nurse
Radiology Technician
Laboratory Technician
Anaesthetic Technician
Employees of Quality Management Unit

Frequency of Meetings:

The Committee on occupational health and safety have a meeting once a month and meet after emergency calls for occupational accidents, etc.

COMMITTEE ON EDUCATION

Duties, Authorities and Responsibilities:

Planning and organizing training programs on a yearly basis to ensure continuous professional development of all employees working in the institution.

Keeping up with the training programs, seminars and conferences organized outside the institution and making necessary announcements in the institution.

Ensuring that training programs that are planned on a yearly basis are carried out properly and increasing the implementation of the annual training calendar by moving the dates of training programs that were not organized to other dates.

Organizing training programs that are required for employees other than the programs in the annual training calendar.

Reviewing the participation and the evaluation of participants in compulsory training programs, which are training programs for quality standards on health services, compliance training programs and all in-service training programs.

Making sure that general compliance and department adaptation training programs are carried out regularly. Determining individuals responsible for general compliance training and for each occupational section, and preparing the relevant guidelines,

Monitoring the activity and content of the training programs for patients,  sharing ideas to improve these training programs

Committee Members:

Chief Physician
Chief Nurse
Director of Administrative Affairs
Human Resources Manager
Employees of Quality Management Unit

Frequency of Meetings:

The Committee on Education holds meetings four times a year and, in case of need.

COMMITTEE ON FACILITY SECURITY

Duties, Authorities and Responsibilities:

Evaluating the data obtained from building tours,
Ensuring the infrastructure safety of the hospital,
Ensuring the safety of life and property in the institution,
Studies on emergency and disaster management,
Studies on waste management,
Maintaining, repairing, measuring and calibrating medical devices and making calibration plans,
Management of hazardous substances,

Committee Members:

Director of Administrative Affairs

Employees of Quality Management Unit

Chief Nurse

Director of Technical Services

Biomedical

Occupational Health and Safety Specialist

Frequency of Meetings:

The Committee on Infection Control holds meetings four times a year and, in case of need.

COMMITTEE ON INFECTION CONTROL

Duties, Authorities and Responsibilities:

-Establishing policies and procedures within the scope of the following subjects to reduce the risk of endemic and epidemic nosocomial infections for patients and hospital staff, ensuring that they are implemented everywhere, identifying the malfunctions and fixing theproblems by planning corrective actions.
-Operating rooms, nursing and treatment rooms, intensive care units
-Sanitation, disinfection, sterilization, isolation rooms
-Rooms for the dirty, waste storage
- Infection control of anaesthesia devices
- Health screening of hospital staff
- Disposing infected materials
- Creating surveillance data for medical case reports and demographically significant nosocomial infections.
- Publishing information on infections throughout the hospital.
- Regulating the infection control process in such a way as to improve the speed and trends of epidemiologically significant infections that will reduce the risk of important infections.
- Ensuring that the infection control process is adequate to prevent epidemiologically significant infections from spreading among patients and employees.
- Planning and carrying out training programs on the use and provision of protective equipment for the possible dripping and splashing of blood and body fluids.
- Preparing and offering training programs on hand hygiene for all employees.
- Determining the continuous measurement and improvement mechanisms of policies and contributing to its implementation.
- Preparing documents that determine the rules for cleaning, disinfection and sterilization procedures in all areas of the hospital and evaluating them in terms of scientific competence and compliance with hospital conditions.
- Cooperating with other committees on the subjects covered within the scope.
- Reviewing and commenting on the required indicator data and contributing to accomplish goals.
- Controlling the actions of the antibiotic control team.
- Making regulations that carry out the monitoring activities Monitoring regular checks and audits to provide a safe environment for the general and environmental cleanliness of employees and patients.

Committee Members:

General Director

Infection Control Physician

Infection Control Nurse

Chief Nurse

Pharmacist

Surgical Specialist

Internist

Physician Responsible for Intensive Care Units

Surgical Nurse

Employees of Quality Management Unit

Pediatrist

Frequency of Meetings:

The Committee on Infection Control holds meetings four times a year and, in case of need.

ANTIBIOTIC CONTROL TEAM (AKE)

Duties, Authorities and Responsibilities:

- Determining policies for the use of antibiotics and revising these policies when needed as they keep up with the recent scientific developments

- Preparing the "Guidelines for the Control of Antibiotic Usage and Antibiotic Prophylaxis" and determining policies related to the use of antibiotics for surgical prophylaxis,
- Presenting opinions and suggestions on the types and quantities of antibiotics to be purchased for the hospital by contacting the purchasing department.

- The Specialist for Infectious Diseases (EHU) ensures the recognition of antibiotics that require approval and determines the rules to be followed for the prescription of these medicines.
- Monitoring the proper implementation of policies for antibiotic use in clinics and surgical prophylaxis according to the indicator "proper use rates in surgical prophylaxis" indicator, presenting the results in EKK meetings and sharing them with the director of medical services.

Antibiotic Control Team (AKE)

Specialist for Clinical Microbiology and Infectious Diseases

Surgical Specialist

Pharmacist

Pediatrist

TEAM FOR DISINFECTION, ANTISEPSIS AND STERILIZATION (DAS)

Duties, Authorities and Responsibilities:

- Providing consultancy services for antisepsis, disinfection and sterilization to all units of the hospital.
- Determining the standards for disinfection, antisepsis and sterilization to be applied in the hospital.
- Monitoring the implementation of disinfection, antisepsis and sterilization.
- Deciding on the products to be used for disinfection, antisepsis and sterilization.
- Presenting the decisions and recommendations regarding DAS as an agenda item to the Committee on Infection Control.

DAS Team

Anaesthetist

Surgery Specialist

Head of Operating Room

TEAM FOR RATIONAL DRUG USE

Duties, Authorities and Responsibilities:

- Determining the hospital policy, planning activities and implementing them within the framework of the principles for rational drug use.
- Conducting pre-assessment surveys to assess the level of awareness of rational drug use of health personnel (physicians, dentists, pharmacists, nurses, and other allied health personnel), inpatients and outpatients.
-Preparing activities about rational drug use for health personnel and patients and preparing reports by creating timetables according to the tasks and distribution of roles along with the reasons for the planned activities.
- Starting the studies aimed at raising awareness with physicians, dentists, pharmacists, nurses and other allied health personnel and determining the duties and responsibilities of all the health personnel in the arrangements made for raising awareness in the patients
- Making arrangements to raise the awareness of patients about rational drug use
- Informing patients of the use of drugs
- Making arrangements such as brochures, posters and video footages for rational drug use in areas frequently used by patients
- Monitoring the briefing for rational drug use in training programs for inpatients.
-Planning activities to inform patients about drug use and ensuring that all health personnel is included in the program
- Ensuring that the healthcare personnel inform patients and patient relatives about the purpose and side effects of the treatment and medication to be used and the important points related to the treatment
- Preparing brief notes about the frequently prescribed medication and the points to be taken into consideration when using them and sharing them with patients or their relatives
- Offering training programs on the importance of smart drug use, activities to be carried out in the hospital and the program to be carried out with the help of all health personnel and disseminating brief notes on these topics. Taking proposals into consideration and  including them in the programs,
- Carrying out evaluation surveys on a regular basis in order to measure the effectiveness of the program
- Assessing the current situation in meetings held every three months and sharing completed and planned activities. Writing a report with the reasons for not being able to go according to the schedule and solution proposals.

Preparing a report on the activities that are carried out every 6 months, plans and assessment of the current situation. (Samples or photos of information materials included). Conveying the report signed by the team leader or his assistant to the Provincial Directorate of Health.

Members of the Team for Rational Drug Use:

The team carries out its duties with at least eight members. People who are thought to contribute to the team when needed can also be included in the team. The manager of the Team for Rational Drug Use is the Director of Medical Services, and his assistant is a pharmacist.

Chief Physician
Pharmacist
Internist

Frequency of Meetings:

The team holds a meeting once every three months or more when needed. It organizes meetings with at least eight people and takes decisions with absolute majority.

COMMITTEE ON TRANSFUSION                                                                                              

Duties, Authorities and Responsibilities:                                                                                      

- The committee has been examining  the use of blood and blood products available in the hospital since its establishment and determines its strategies and priority initiatives according to the data,
- Developing standards for the monitoring of transfusion practice,

-Reviewing and analysing the statistical reports of the blood centre,
-In order to ensure safe transfusion;
- Blood grouping, cross-match, methods used in studies on anti-core screening and identification,
- The methods used in the tests for preventing transfusion infections,
- Preparing policies by examining the preparation techniques of blood and blood components and their usage rates in the hospital.
- Taking precautions by evaluating the transfusion reactions observed in the hospital,
- Evaluating the use of blood and blood products, making changes to improve the quality of patient care,
- Evaluating the personnel and equipment in order to ensure that the blood centre functions smoothly in the areas of blood supply, collection, preparation and processing, and carrying out studies to eliminate deficiencies,
- Monitoring transfusion services regularly to make sure whether transactions are performed according to the standards,
- Reviewing the problematic issues  and monitoring the developments.
- Training the hospital personnel on the practice of transfusion and ensuring continuous monitoring of in-service training,
- Making recommendations about quality assurance to the other committees in the hospital, when needed.

Committee Members:                                                                                                                       Chief Physician/Deputy Chief Physician
Physician Responsible for Transfusion Centre
Chief Nurse
Employees of Quality Management Unit
Internist
Surgical Specialist
Anaesthetist
Pediatrist
Obstetrician and Gynaecologist
Orthopaedist
Head Nurse
KVC Specialist
Blood Centre Laboratory Staff
Head of Archive

Frequency of Meetings:

The committee holds meetings as often as necessary, but at least four times a year.

HEALTH SERVICE EXECUTIVE COMMITTEE:

1. AIM: The aim of the committee is to carrying out health activities, to improve the quality of health care, to establish a formal relation between hospital management and health personnel, and to establishing a method for conducting counselling services in health services.

2. SCOPE: It consists of all units attached to the Office of the Head Physician of Private Eskişehir Anadolu University.

3. PEOPLE IN CHARGE: President of the Health Service Executive Committee, Member Doctors, Head Nurse.

4. PRACTICES:

4.1-Establisment of Health Service Executive Committee:
Head Physician (Committee President)
Doctors (Member)
Head Nurse (Member and Secretary)

4.2-Duties of Health Service Executive Committee:

- Evaluating the decisions taken on health by the committees.
- Developing policies for health personnel.
- Monitoring the quality of health services and developing policies on this topic.
- Providing solutions for problems of units by evaluating them.
- Solving issues by assuming the role of an arbitrator when disputes occur between clinics.
- Providing solution for the dialogue that will be developed between health personnel within the scope of medical deontology.

4.3-Duties of Member Doctors:
-Determining the proposals and requests that disciplines want to propose as agenda items.

- Observing the hands-on training on health services that were decided to be implemented by the committee for employees according to their disciplines and counselling them throughout the training.
- Monitoring the decisions, which were taken by the committee and communicated to the Joint Meeting and Executive Committee.

5-MANNER OF WORK AND MEETING OF HEALTH SERVICES EXECUTIVE COMMITTEE:             -The head nurse is the secretary of the committee. The secretary meets with all members and determines the agenda items. The doctors are invited to the meeting in writing along with the place, date, time and agenda of the meeting at least two days prior to the meeting.
- The chief physician is the president of the Health Services Executive Committee. When the chief physician cannot attend the meetings, the deputy chief physician acts as the president.
- The Health Services Executive Committee convenes with the absolute majority of the total number of members and the decisions to be taken are taken by the majority of votes. If the votes are tied, the decision, which the president is siding with, is accepted.
-Committee decisions are written in the minute book and the doctors who attended the meeting sign the book. Those who object to the decision sign it by writing down the reason for the opposition in writing (by adding an annotation).
- The president of the committee and the doctors who are the members of the Joint Meeting and Executive Committee convey the decisions taken by the Health Services Executive Committee to the Joint Meeting and Executive Committee.
- The committee holds a meeting on the first Friday of each month.

 JOINT MEETING AND EXECUTIVE COMMITTEE                                          

1.AIM: The aim of the committee is to establish formal relations among the Executive Board, hospital managers and doctors, to regulate their relations and to determine a method in order to coordinate them.

 2. SCOPE: It consists of all units of Private Eskişehir Anadolu Hospital.

 3. PEOPLE IN CHARGE: The committee president of Joint Meeting and Executive Committee, hospital managers and member physicians are responsible for the committee.

4. ORGANIZATION:

Executive Board:................

Hospital Managers:.................

Physicians:......................

5-PRACTICES:

Duties:                                                                                                                                        

1. Solving the problems arising between the clinics and executive board.

2. Mediating between the physicians and executive board in changing the policies and opinions of the physicians and executive board and seeking a settlement between both parties.
3. Coordinating the connection, relationship, order and harmony between activities in order to achieve the common goal set by the hospital executive board, hospital managers and health personnel.
4. Thinking about the areas of change and growth that can occur in the organization of the hospital.
5. Evaluate the decisions taken by the Health Services Executive Committee and deciding on the implementation method.
6. Monitoring the decisions that are put into practice.

6 ORGANIZATION:

1. The committee holds a meeting on the second week of each month. Members who could not attend the meeting should notify the chairman of the committee of his absence along with the reason in writing. New members are accepted in place of members who did not attend the meetings three times in a year.

2. The secretary meets with all members and determines the agenda items. All members are notified of the meeting in writing along with the place and date three days prior to the meeting.

3. The executive assistant acts as the secretary.
4. Committee decisions are signed by all members after they are written in the minute book. Those who object to the decision sign it by writing down the reason for the opposition in writing (by adding an annotation).

 

COMMITTEE ON SOCIAL AND CULTURAL ACTIVITIES                                              

1. AIM: The aim of the committee is to determine the procedures and principles of activities to be organized in the fields of social, cultural and sports in order to improve trust and responsibility among the staff members of the institution and to make them get closer to each other.   

 2. SCOPE: It consists of all employees of Private Eskişehir Anadolu Hospital.

 3. PEOPLE IN CHARGE: The head of the Committee on Social and Cultural Activities and all members are responsible.                                    

 ----General director or deputy general director (President of the Committee)

-----Chief Physician/Deputy Chief Physician  (Deputy President of the Committee)

-----Representative from the Quality Management Unit (Secretary of the Committee)

-----Head nurse or deputy head nurse (member)

-----A doctor representing the Surgery Unit (member)

-----A doctor representing the Internal Medicine Unit (member)

-----A representative of non-health technical elements (member)

-----A representative of health technicians (member)

-----A representative of secretaries (member)

-----A representative of helpers (member)

5. ACTIVITY TABLE:

Duties:

1. Setting the goals of strengthening close ties and the spirit of unity among the members of the institute and establishing friendship as the goals of the activities.
2. Planning activities such as domestic and foreign trips, picnics, entertainment programs and sports activities for the employees.
3. Providing venues for the required activities.
4. Fulfilling the material and moral needs of the selected personnel, when needed.
5. Choosing the employee of the month and year among the employees and rewarding that employee.
6. Covering the expenses of the committee from the activities to be held and the donations to be accepted.

Organization:

1- The committee holds a meeting once every three months, which is 4 times in total. Members who could not attend the meeting should notify the chairman of the committee of his absence along with the reason in writing. New members are accepted in place of members who did not attend the meetings three times in a year.
2- The secretary meets with all members and determines the agenda items. All members are notified of the meeting in writing along with the place and date three days prior to the meeting.
3-Committee decisions are signed by all members after they are written in the minute book. Those who object to the decision sign it by writing down the reason for the opposition in writing (by adding an annotation).
4- The secretary is in charge of the money. He records the incomes and expenses and every member has the authority to get information on the accounts and review the records.