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[ Recorded presentation ] Recorded presentation

Role of self-assessment, peer review and benchmarking for quality improvement

Hediye Seval Akgun, Professor1, Coskun Bakar, MD, specialist2, Memnune Kavasoglu, Quality analyst3, and Gamze Gunes, Quality Analyst3. (1) Chief Quality Officer, Baskent University Hospitals Network, School of Medicine, 12. sokak no:7/8 Bahcelievler Cankaya, Ankara, 06490, Turkey, 9003122120434, sevala@baskent-ank.edu.tr, (2) Public Health Department, Baskent University, 12. sokak no:7/8 Bahcelievler Cankaya, Ankara, 06490, Turkey, (3) Baskent University, Baskent University Hospitals Network, 12. sokak no:7/8 Bahcelievler Cankaya, Ankara, 06490, Turkey

To achieve of real improvements in quality depends on understanding and revising the processes based on relevant data. In keeping with its mission, Baskent University Hospitals Network has developed a performance management system that is aimed at ensuring continuous planning, measurement, assessment, and improvement of processes, systems, and outcomes. This scientific approach to scan quality achievement is focused on the following activities: Problem identification, criteria setting, documentation, monitoring and evaluation, action for change, and re-evaluation. Within the program, the first step was to identify and set up teams at 8 different hospitals. These teams were then after trained trough a series of training sessions, workshops and brain storming activities on performance improvement tools and techniques. An indicator-based system was established and the analysis process has been standardized through a computer system. In addition to the indicator-based system, we identified several other elements that needed to be included in the measurement and assessment phase. First hospital physicians and other staff also have valuable input regarding the performance of an organization and opportunities for improvement. So we established recommendation systems to obtain information from this group, and used this as an integral component of our performance improvement program. Second, we felt that a continuous “bottom-up” assessment of the quality of care was needed. This was met by an internal audit of ongoing processes at each of our institutes. We are also assessing the success of our program with respect to whether goals have been met, and whether planned start-up activities have been initiated or put into gear every year as well as benchmarking our results with the other health institutes in the country.

Learning Objectives:

Keywords: Performance Measurement, Quality Improvement

Presenting author's disclosure statement:

Any relevant financial relationships? No

[ Recorded presentation ] Recorded presentation

Performance Measurement, Reporting, and Standards in Hospital Care

The 134th Annual Meeting & Exposition (November 4-8, 2006) of APHA