QUALITY MANAGEMENT AND PATIENT SAFETY

Policy of Koç University Hospital

We, Koç University Hospital, commit to:

Pursuant to our management approach and quality and environment policy;

Uphold the requirements of Koç Holding with laws, regulations, national and international standardization and accreditations for quality and environment by taking needs, expectations and rights of patients, personnel, students, faculty members, researchers and all shareholders into consideration at every step of our services,

Prioritize continuous development and improvement through teamwork in line with occupational ethics in order to provide the healthcare services required by clinical medicine education at national and international standards.

Take necessary measures to ensure continuous improvement of patient care standards,

Pay attention for increasing satisfaction of our patients, their family members, our staff, students, researchers and faculty members,

Be a leading academic organization for scientific research and novel procedures by using up-to-date knowledge and cutting-edge medical technologies,

Provide a preferable hospital environment by facilitating improvement of competency and education of our staff and encourage participation in quality and environmental management systems,

Spend effort to raise environmental awareness in patients and their relatives, our personnel, students, researchers, faculty members, subcontractors, suppliers and the society which we interact with, Be in constant communication with our shareholders on environmental matters,

Identify, monitor and check environmental elements, prevent pollution and continuously improve our environmental performance in order to minimize negative environmental impact and environmental risks of clinical teaching and research studies as well as testing, diagnosis and treatment services,

Maintain consistency in quality of patient care while managing medical and other waste in accordance with legal requirements in order to decrease amount of waste; and protect the environment by implementing energy saving projects in order to use the natural resources efficiently,

Adopt a transparent hospital management system oriented on total quality management that focuses on the patient through continuously improved processes and performance,

Dispose the waste produced in the service delivery and clinical medical education in line with laws and regulations; prevent damage to the environment and leave a clean environment for future generations,
Legate the systems created for this purpose, our corporate culture and our dignity to future generations.

Information Security Policy
 

In order to ensure sustainability of the healthcare services that we deliver and to protect our information assets, Koç University Hospital;

• Secure confidentiality, integrity and accessibility of all assets that are subject to information security standards.

• We fulfill all provisions of laws, regulations and standards related to the information security and we continuously improve the fulfillment.

• We manage all internal/external risks that threaten our information assets in a systematic manner and we record all adverse events that may influence our information security and take measures immediately.

• We enter into confidentiality agreements with our employees and the third parties that supply goods and services.

• We ensure security of our systems with physical and technical policies that we had created.

• We organize training and educations to improve technical and behavioral competencies in order to increase the awareness of information security.

OUR QUALITY MANAGEMENT SYSTEM

Aiming to improve the quality of services continuously, Koç University Hospital adopts the continuous quality improvement management. This approach of management is evident in all fields of service in the form of a corporate philosophy.

ISO STANDARDS

Koç University Hospital is “the first” university hospital that has been awarded with ISO 9001:2015 Quality Management System and ISO 14001:2015 Environmental Management System certificates (2015 versions) that cover all service fields of the hospital. The hospital provides high service quality in terms of patient care, treatment and safety.

ISO 9001: 2015 Quality Management System

Koç University Hospital was awarded with the ISO 9001 Quality System Certificate on November 23^rd-24^th-25^th, 2016. The fact that ISO 9001 Quality System Certificate covers all medical and administrative departments of the hospital regarding the scope of services is important to implement the quality management system in the entire hospital. It is “the first” hospital that is certified with the 2015 version of ISO 9001 in Turkish healthcare sector. Many quality improvement studies are conducted to improve the quality continuously and take a step forward through periodical reviews.

ISO 14011:2015 Environmental Management System

Attaching importance not only to patients’ health but also to the environmental health, the Koç University Hospital started working for ISO 14001: Environmental Management Standards and became “the first” hospital that was awarded with this certificate on November 23^rd-24^th-25^th, 2016.

Our hospital maintains energy saving activities by ensuring effective use of natural resources, sorting all wastes in the hospital through the principle of sorting the waste in the source, preventing pollution of nature and environment through waste minimization and management, eliminating hazardous wastes before they damage the nature and putting the recyclable wastes into use through the transfer of them to recycling firms in accordance with local and international laws, regulations, guidelines and Koç Holding Environmental Management System requirements. We intend to leave a sustainable life for the future generations in all waste management processes at the hospital by complying with the “Zero Waste Project of the Ministry of Environment and Urbanization” and assessing the activities within the scope of the project.
Sustainability is achieved through panel studies, brochures, notifications, trainings and visits that increase awareness on environmental issues for patients, family members, employees, students, academicians, researchers and contractors.
 

REVIEW OF HEALTH QUALITY STANDARDS (SKS), MINISTRY OF HEALTH

Our hospital renders services in accordance with the Health Quality Standards (SKS) of the Ministry of Health. To assess requirements of the standard, self-assessment studies are conducted annually in the institution. Moreover, the hospital is regularly visited by inspectors of the Ministry of Health.

BABY-FRIENDLY HOSPITAL

World Health Organization and UNICEF advise to avoid any supplementary foods, including water, for the first six months and breastfeed the baby along with the supplementary foods up to 24 months. Breast milk is essential for babies at 0 to 6 months of age. Breastfeeding is crucial until 2 years of age. Babies are quite vulnerable to infections in the age range of 0 to 2 years. Breast milk is the main nutrient that boosts the immunity. Breastfeeding protects the mother from diseases such as breast cancer and uterine cancer.
“Promotion of Breast Milk and Baby-Friendly Hospitals” program has been conducted by Turkish Ministry of Health in cooperation with UNICEF since 19991.
Within the scope of Baby-Friendly Hospital certification, Baby-Friendly Hospitals Program has been started to promote breastfeeding, provide the mothers with information regarding the lactation, have them adopt accurate breastfeeding habits and to make breastfeeding a successful and well-established practice at the hospitals. The title of “Baby Friendly Hospital” is granted to hospitals that offer delivery services, inform candidate mothers about breast milk and lactation as of the conception, promote mothers to breastfeed their infants immediately after the birth and have healthcare professionals that are specifically trained for this subject to instruct mothers on how they can breastfeed their babies.
 
Our hospital was granted the title of “Baby-Friendly Hospital” by the Ministry of Health on September 26^th 2019. The Ministry of Health presented the plaque to our hospital on November 26^th 2019. Koç University Hospital continues the service delivery with the title of “Baby-Friendly Hospital”.

BABY FRIENDLY HOSPITAL LACTATON POLICY
 

In this institution, “Baby Friendly Hospital and Accurate Lactation Practices” are adopted and it is aimed to ensure that all newborn infants are healthy.

For this purpose;

• A breastfeeding policy, in writing, has been issued, and the policy is submitted to all healthcare professionals at regular intervals.
• All employees have been trained in accordance with this policy.
• All pregnant women are informed about breast milk and benefits and methods of breastfeeding.
• Unless medically necessary, it is recommended to feed the newborn infants only with breast milk for the first 6 months. Families are informed that the lactation should be maintained until 2 years of age and beyond in addition to supplementary foods later on.
• The mothers are educated for starting the breastfeeding within the first 30 minutes after the delivery.
• Mothers are trained about breast feeding techniques and how they can continue to produce milk if they are not with their babies. They are instructed about pumping and storing the breast milk and how they can give the breast milk to their babies.
• It is ensured that the mother and the baby stay in the same room for 24 hours after the delivery. They are not allowed to stay in separate rooms, unless it is required for health problems.
• Mothers are informed about benefits of breast milk to encourage breastfeeding and thus, it is ensured that mothers breastfeed their babies gladly.
• Mothers are encouraged to breastfeed their babies whenever the babies want.
• Baby bottle and pacifiers are not accepted to our hospital and mothers and other family members are told not to give them to babies.
• Mothers are informed about healthcare facilities to consult after the discharge, regarding continued breastfeeding, solving the problems they face, and self-examination and routine follow-ups of the baby.
• A breastfeeding room is arranged at Pediatrics Outpatient Clinic to have the mothers breastfeed their babies comfortably.
• International code of formula (WHO Code) regulating the marketing and sale of formulas is adopted and applied at all fields of our hospital.

Department Quality Representatives

• Managing the standardization and accreditation works that are planned in compliance with the strategic goals of the hospital,
• Ensuring validity of ISO 9001:2015 Quality Management System and ISO 14001: 2015 Environmental Management System certifications through tracking and inspecting,
• Conducting investigations and certification works in accordance with the demands notified by the departments within the scope of department-specific accreditation,
• Determining the areas that require improvement through self-assessment in cooperation with Department Quality Representatives in accordance with the “Quality in Health” Standards and conducting improvement studies,
• Organizing training and improvement activities to boost the rate of compliance with the patient safety goals of the Joint Commission International and maintaining the works within the scope of Patient Safety Movement,
• Complying with the requirements of the standard by acting in line with and ensuring the continuity of the Joint Commission International (JCI) standards,
• Measuring and assessing the patient safety culture, Conducting educational and improvement activities to boost the safety culture, Identifying the conditions that pose risk regarding the patient safety before the patient faces them and increase the reporting regarding this issue,
• Determining the areas that require improvement through self-assessment in cooperation with Department Quality Representatives in accordance with the “Quality in Health” Standards and conducting improvement studies,
• Assessing the indicatory results of previous years, determining the performance indicators, entering the data, cooperating with the departments to improve performance results, tracking and analyzing the performance indicators in accordance with requirements of Health Quality Standards by focusing the areas that are open to improvement in cooperation with the departments
• Integrating the data to performance monitoring system of the Ministry of Health, managing the infrastructure and improvement studies regarding the cases requested to be entered into the national data system,
• Evaluating risks of the processes in cooperation with the departments and managing the improvement activities in the areas deemed high-risk as a result of the evaluation,
• Discussing the clinical pathways and protocols set in Vehbi Koç Foundation Healthcare Institutions and ensuring that they are integrated to the system and performance monitoring is done,
• Increasing the compliance with the clinical pathways and protocols, cooperating with the departments to practice the new clinical pathways and protocols,
• Ensuring that the development projects regarding the areas that are open to improvement are conducted successfully,
• Carrying out the studies to ensure that the services that are recently planned to be designed are covered by the standard,
• Empowering the Department Quality Representatives through on-job trainings and ensuring their active participation to the quality development processes
• Conducting environmental studies within the scope of Koç Holding’s environmental goals and legal requirements,
• Maintaining the success that we gained in quality and patient safety.

• Quality Management and Improvement Committee
• Patient Safety Committee
• Medical Record Committee
• Medication Management Committee
• Infection Control Committee
• Transfusion Committee
• Radiation Safety Committee
• Facility Safety and Environmental Management Committee
• Education Committee

Patient Safety and Safety Culture

OUR PATIENT SAFETY PRACTICES

Patient Safety Practices of the Koç University Hospital focus on continuous improvement of the safety for all patients, visitors, students, academicians and researchers and meeting the patient- and organization-oriented standards in line with the principle of  “First, do no harm the patients”.

Koç University Hospital renders services based on the philosophy of “Your Safety is Our Priority” Our hospital uses the International Patient Safety Goals published by the Joint Commission International to guide the practices that ensure the patient safety and to develop relevant practices.
 

• Verifying the Patient Identity

Verification of the patient identity is very crucial for patient safety. Identity verification aims to match the patient accurately with all procedures and treatments. In all cases requiring a procedure and a treatment for the patient, verification is made through at least two of the identifiers (name-surname, date of birth and protocol number) verbally and/or using the wrist band in cooperation with the patient.
 

• Correct and Efficient Communication

Timely, complete, correct, understandable and accurate communication that does not cause uncertainty reduces the errors and boosts the patient safety. Communicating patient information and responsibilities from one clinic to the other or from one healthcare staff to the other is crucial to ensure continuity of patient care and patient safety. Our patients are informed before each procedure/treatment by our healthcare personnel.

Medical information of our patients is shared between healthcare personnel accurately, safely and in accordance with relevant policy of the hospital during shift changes, in-house phone calls and patient transfers. To prevent errors originating from the communication, verbal directives or on-call directives are not allowed except for predetermined conditions. For verbal/phone directives, read-back and verification rule is applied and the critical test results are notified in a timely manner. This process is tracked with in-house inspections.
You are informed about care at home by physician/nurse and a written information text is delivered before you are discharged.
 

• Medication Safety

All medication applications are performed in accordance with the 8-C’s Principle at our hospital (Correct patient, Correct medication, Correct time, Correct dose, Correct route, Correct medication form, Correct effect, Correct record).

All medication directives are checked by the Pharmacy Department, prepared at special medication preparation areas and safely transferred to relevant departments at our hospital.

Additional control steps are taken in storage, prescription, preparation, transfer, administration and supervision stages of high-risk medicines (the drugs that have potential of frequent and serious harms for the patients due to a possible mistake) to ensure safety in the facility.
 

• Surgery/Surgical Intervention Safety

Considering surgical procedures (major and minor surgeries), it is vitally important to prevent and/or reduce the risk of performing incorrect surgery or a harmful procedure in correct or incorrect patients in terms of the patient safety.

Patients are informed verbally by our physicians in a language that they can understand regarding the necessary surgery/procedure, patient’s condition, recommended treatment, potential benefits and disadvantages, alternatives, success rates, potential problems regarding the recovery and the results of refusing the treatment and next, written consents of patients are obtained.

The surgeon marks the side or part of the body to be operated on with an indelible marker in order to perform the procedure at the correct side and the patient is also involved in this process, if possible. The marking is performed for side surgeries (e.g. right arm, left arm), surgeries performed for multiple organs (fingers, toes etc.) and the procedures that require determination of level (e.g. spinal procedures).

When all members of the surgery team are available at the operating theater/procedure room, “Time Out” procedure is conducted under the leadership of the team member, who is responsible for the process, immediately before an incision is made or the procedure is started. In the time-out, predetermined criteria are checked using an active communication (verbal feedback by focusing on the control process). After a consensus is achieved, the procedure is started.

When the surgery/procedure is completed and Sign-Out is performed, the patient is transferred outside the operating theatre.
 

• Infection Control and Prevention

Infection prevention and control program is created and implemented by Infection Control Committee to protect our patients and employees against infections. In addition, preparation plans for exceptional circumstances have been created to be prepared for a potential epidemic and/or pandemic within the scope of our quality management and patient safety standards.

All employees ensure hand hygiene by washing their hands or using hand sanitizers before and after contacting the patients and their belongings and they wear protective equipment –whenever necessary- to protect both the patients and themselves.

Patients with infection are followed up by our Infection Control Team. Isolation precautions defined in our standards are taken, when necessary.

Our patients are educated on infection prevention and control. Rooms and items are cleaned in accordance with the standards after each discharge. Trainings on infection control and prevention are organized for all employees regularly. Processes are tracked in the organization through various inspection systems.
 

• Fall Prevention

The risk of fall throughout the treatment at the hospital may be higher than the risk of fall in routine daily life for our patients. The medicines, the procedures, the disease and the care environment are principal factors that increase the risk. Our employees evaluate the risk of fall for all patients. The patient with a risk of fall and his/her family members are informed and delivered the information form and brochures that are issued specifically to address this issue. Safety measures are taken to prevent falls. A call button is available at the bed side along with bathrooms and restrooms used by our patients. Inpatients are informed about the use of nurse call buttons, if needed.  Details of use are available on the call buttons equipped in other restrooms of our hospital. Patients, family members and companions are regularly educated on the fall prevention.

Warning plates are placed on doors, files and other standardized places for the patients with a risk of fall in order to create awareness in all health professionals and the patients are worn non-slip booties according to the risk score. The devices warning the nurses that the patient is getting out of the bed are equipped in rooms of the patients who are poorly oriented and have no companion.