The purpose of quality-related activities and results is to determine whether they comply with planned regulations, to provide impartial and objective evidence regarding the effectiveness of these regulations and their suitability for the objectives, and to ensure that any nonconformities are corrected and prevented from recurring.
The purpose of self-assessment activities is to:
-Verify that the hospital and all blocks are operating in accordance with written procedures,
-Evaluate the adequacy of existing documentation,
- Requesting corrective action for non-compliant situations,
- Ensuring employee participation in improvement and development efforts,
- Continuously improving the effectiveness of the quality system in accordance with the Ministry of Health's Quality Standards in Healthcare and patient safety objectives,
- Providing information to block management and senior management regarding the results of implementation related to all processes.
Selection of Evaluators
Self-assessment evaluators consist of personnel determined by the quality director in agreement with the relevant department managers/supervisors. It is essential that evaluators are informed in advance about the Ministry of Health's Quality Standards in Health and the self-assessment processes.
When determining the departments to be evaluated, evaluators must be from independent departments; it is not appropriate for them to evaluate their own departments.
Documents Used
The following are taken into consideration in the evaluations: standards that constitute the quality documentation system (Ministry of Health Quality Standards in Health), written plans, procedures, instructions, supporting documents, forms, externally sourced documents, data tracked by the automation system, manuals, duties-authorities-responsibilities, organizational charts, regulations, and legal requirements.
Self-assessment Stages
1. Planning
2. Preparation
3. Conducting the self-assessment
4. Reporting
5. Follow-up
1. Planning
At the beginning of each year, the “Quality and Productivity Management Plan” sets the self-assessment schedule, which will be conducted twice a year. According to the plan, the Quality Director prepares a “Self-Assessment Plan” indicating which departments will be assessed in which blocks and by whom, and submits it to senior management for approval. After approval, the Quality and Productivity Unit announces this plan to all block management teams.
After the self-assessment plan is announced, the assessment team is informed prior to the assessment with the “Self-Assessment Evaluator List” and the “Self-Assessment Plan.” The responsible evaluator or the person they authorize contacts the other evaluators in their team and the department manager they will evaluate according to the plan, determines the day and time they will visit that department during the evaluation week in advance, and reports the date they have determined to the Quality and Productivity Unit.
The responsible evaluator gathers the evaluation team prior to the evaluation to plan the process, discussing matters such as sharing documents if a document review is to be conducted for the department, in order to organize the process for an efficient evaluation.
When planning, evaluators consider the status, importance, and previous evaluation results of the departments to be evaluated.
In addition, processes that perform poorly in evaluations may be subject to unscheduled evaluations within the same period, based on the assessment of the Quality and Efficiency Unit and the relevant block management. Furthermore, evaluations not included in the “Self-Evaluation Plan” may be conducted in response to patient/patient relative complaints, problems arising in service delivery, or at the request of senior management.
2. Preparation
A list of questions specific to the section to be evaluated is prepared. Standard questions relevant to all personnel and a self-assessment questionnaire list specific to the section, based on the Ministry of Health's Quality Standards in Healthcare, are prepared for each section. The questionnaire lists are shared with the evaluators by the quality and efficiency unit.
The assessment teams read all documents (procedures, instructions) of the section to be assessed as indicated in the plan and obtain information about the section's operations. Assessors may ask questions other than those on the self-assessment questionnaire and record their findings through observation. The unit to be self-evaluated is notified of the date and time of the self-evaluation at least one day in advance using the “Self-Evaluation Relevant Unit Notification Form.”
3. Conducting the Self-Assessment
The assessment begins with a preliminary meeting/opening meeting at the agreed-upon date and time, where the assessment team visits the relevant department and is joined by the person responsible for the department being assessed and other personnel accompanying the assessment. During this meeting, the scope of the assessment, how it will be conducted, which areas will be visited, and, if known, who will be interviewed, are explained by the assessment manager, and the suitability of the plan for both parties is ensured. The opening meeting is led by the assessment team and is limited to 10-15 minutes.
Assessment:
During the assessment, a self-assessment questionnaire specific to the department is used. For each question marked as “Not Compliant” or “Partially Compliant” in the questionnaire, corrective/preventive action is requested. Non-conformities observed during the audit but not included in the questionnaire are additionally noted in the blank spaces of the questionnaire, and a DÖF is opened.
Issues for which sufficient answers cannot be obtained, situations that cannot be verified and whose existence cannot be concretely proven are not considered non-conformities and are indicated as opinions in the “Self-Assessment Results Report.”
The evaluator directs questions to the person performing the work and/or the responsible employee to determine:
- Whether the personnel fully understand their job deions, duties, authorities, and responsibilities,
- Whether procedures and instructions are being applied appropriately and effectively,
- Whether the latest revisions of relevant standards, procedures, and instructions are being used and are easily accessible,
- Whether records are kept completely and accurately and their effectiveness.
A closing meeting is held at the end of the assessment. The responsible assessor manages the meeting. At this meeting, the relevant department manager is informed of the results and identified nonconformities, and agreement is reached on the nonconformities.
The evaluator must assess the effectiveness of the application; they must prove the nonconformities they identify with objective data and must not create nonconformities based on probability and subjective judgments or observations.
After the assessment, the assessors gather in the area designated by the lead assessor and record the assessment nonconformities. Corrective/preventive actions are initiated for the identified nonconformities, if necessary. Once the nonconformities have been documented, the “Self-Assessment Results Report” is completed.
4. Reporting
After the nonconformities have been documented, a “Self-Assessment Results Report” is completed for each assessment performed. The nonconformities/deficiencies identified in relation to the assessed section are specified in the report.
When completing the Self-Assessment Report, the names and surnames of all persons participating in the audit are written in the section “Those participating in the assessment.”
Documents used in the assessment, such as relevant procedures, instructions, supporting documents, etc., are written in the “Documents Used in the Assessment” section.
Observations made during the audit, the department's activity in the assessment, attitudes, etc. should be noted in the “Results and Assessment” section. Finally, it should be noted whether a reassessment is necessary, and if so, a new assessment date should be set and noted. It should be signed by the assessors and the person responsible for the department being assessed and submitted to the Quality and Efficiency Unit.
5. Follow-up
After evaluation, the Self-Assessment Report is forwarded to the quality and efficiency unit. The process of forwarding, recording, and closing DÖFIs to the department is followed according to the “Corrective/Preventive Actions Procedure.” The CAP action plan should be determined in a way that ensures the effective elimination of nonconformities and prevents their recurrence, and should be appropriate to the scope of the nonconformities and proportional to the impact they have. Completion times should be realistic. Nonconformities and deficiencies indicated as CAP and observations should be eliminated within the completion times.
Preparation of the Self-Assessment Report by the Quality and Efficiency Unit
As a result of the self-assessment, scoring is performed on the SKS Self-Assessment Table, taking into account all standards for which non-compliance was determined based on the Ministry of Health's Quality Standards in Health. The number of points obtained according to the Ministry of Health's Quality Standards in Health is calculated. An explanation is written next to the standards that could not be met. The self-assessment report is submitted to management. The findings obtained as a result of the self-assessment are presented within the hospital; general opinions about the current state of the system and non-conformities identified in all departments are presented to block management and senior management to ensure that the necessary improvement efforts are initiated.
Retention of Records
All records related to self-assessment are stored in a folder named “SELF-ASSESSMENT.”
The originals of all forms and reports mentioned in this procedure are kept by the quality and efficiency unit in the relevant file for 5 years. Records whose retention period has expired are destroyed by shredding. The IT unit is responsible for backing up records kept in electronic format.