We had a pleasant interview with NPISTANBUL Hospital Quality and Human Resources Director Serdar Karagöz about being a conscious patient and the perception of quality in health.
Can you tell us about NPISTANBUL Hospital's "Quality Health Service" Approach?
Health service is much different from other services. Because there is a very intense information asymmetry between the service receiver and the service provider. For example, when you buy a product, you have information about the product you are buying. Or when you go to a restaurant for a meal, you know more or less what kind of food you will eat and how you will be served. However, in healthcare, patients unfortunately do not have detailed information about the service they will receive. As such, the quality process in healthcare is much more important than quality processes in all other products and services. We need to put ourselves in the patients' shoes. There are many international studies in this field. Patients now decide in the first 10 seconds whether a hospital is of high quality or not. Patients also concentrate their satisfaction more on hospitality services. In addition, maximum treatment possibilities are used for the best interest of our patients. By paying attention to issues such as "Was the reception at the reception desk friendly, how was the parking service, how was the approach at the call center, or was the toilet in the lobby clean?", they decide whether the hospital is of good quality or not.
Is the information obtained before coming to the hospital effective in these judgments?
Maybe... However, you go to get service with an idea about that health institution beforehand. If the person greeting you has a sour face, the dialog is not good, or you came to the doctor you thought was very good, but you were not taken to your appointment on time and you were kept waiting for a long time, then with great dissatisfaction; "maybe I will come for this disease, but I will not come again" may occur.
Also, when you make an appointment and start treatment, you do not know exactly what kind of service you will receive. This is where the basic point of quality starts. In other words, when you go to a supermarket, no one looks at you and says 'you need tomatoes, eggplants, cheese'. However, this is not the case with physicians. You go to a physician with a complaint, a problem. For example, you go to the physician with a stomach ache, and the physician tells you what other services you need to purchase, such as tests and X-rays, which are needed for accurate diagnosis. In this case, there is a need for a control mechanism between the person who purchases the health service and the provider of this service. This is where the "quality standard" comes into play. Because health services are consumed as soon as they are produced. For example, you will undergo an operation and you need anesthesia. The specialist produces the service needed for anesthesia at that moment, taking into account your weight, age and blood pressure. In other words, healthcare is a service area that is consumed as soon as it is produced. At this point, we healthcare professionals work to ensure the standards of the service before it is produced.
Can you tell us about the work in this process?
We are building the system. If there will be an operation, we apply an evaluation procedure before going into surgery. We have a "Pre-Operative Evaluation" form, and we put this into practice. For example, the anesthesiologist evaluates the patient by looking at details such as age, height, weight, films taken, previous illnesses, etc. and writes the operation note and the amount of medication to be used on this form. We attach importance to this issue for the following reason; when this procedure is not applied, this decision may have to be made during the operation, but with an incomplete evaluation at that moment, the patient may die from an anesthesia reaction. Or the patient may not wake up due to the wrong dose. In order to prevent such risks, we have created the "Pre-Operative Evaluation" form and have put into operation the reporting of the use of the entire operation team.
We also apply these quality assurance procedures for nursing services. Nurses have to ask and fill in certain questions such as "Does the patient have food allergies before the operation?" to register in the system. When the patient is taken to the operating room by the floor nurse, the label with this information is taken to the operating room with the patient and handed to the operating room nurse. If we had not set up this system, perhaps this information would not have been asked or the label would have been forgotten while the patient was being transported to the operating room. As a result, there could have been a risk of an allergic drug being used during surgery and the patient could have been left in an undesirable situation. It is precisely against these risks that we, as a hospital, have created the "Safe Surgery Guideline System". The quality service of hospitals is actually hidden in details such as these.
So basically, we deal more with the part before the service is provided. Of course, we have an instant control system, but the preparation beforehand is much more important.
What other examples can you give on this subject?
For example, we have an ambulatory control system that is also applied during surgery. Let me give some details: Before entering the operation, all the materials to be used are counted, and after the operation, they are counted again. These counts are made against the risk of being forgotten on the patient and the patient is taken out. We introduced the system of checking the underfoot of the team in charge after the last count in surgeries, despite the risk that the gauze swabs, which we call the Spanner used during the operation, may be thrown on the floor after being used in the operation and may stick under the feet of the physician or nurse by stepping on their feet. Because when the Spanner was not found underfoot, when the previous count and the next count did not match, the patient was opened and checked again with the thought that "the Spanner was forgotten in the patient", and the operation time was prolonged. If there is no consistency in the number of materials used, the patient has to stay in the operating room until that material is found.
We also have a patient identity verification system that we implement within the scope of the JCI accreditation system. The name needs to be verified both when giving medication to the patient on the floor and during surgery. For example, during the operation, the patient is prepared for surgery, but despite all procedures, there may still be a risk of confusion between the patient and the operation site, so before starting the operation, our entire operation team says the patient's name and the type of operation out loud, and final approval is obtained. After the approval of the question "Is it suitable for everyone?" is obtained and the identity verification is completed by the entire operation team, the operation starts.
As I mentioned in other examples, the quality approach in healthcare is based on systems that include such fine details.
For example, when you apply to a hospital with an ailment, there are complaints that the tests and examinations requested are excessive, unnecessary, or requested to make extra profit, especially since it is a private hospital? How do you evaluate this?
The issues you mentioned are actually a process of quality standards. JCI, to which we are accredited, has clinical road maps that are used separately for each diagnosis. In the world, JCI standards are also used at Harvard and John Hopkins Hospital. These treatment maps are written in terms of both nurses and physicians, which tests should be performed in relation to the patient's condition. The reason for this is to prevent anything missing in the patient's screening and to ensure that the correct diagnosis can be made. Therefore, these tests are necessary. Also, in a single document, all units should have access to all the work done so that a multidisciplinary evaluation can be made. Because physicians and nurses may not always be in communication. In this document, the evaluation of different disciplines such as nurses and psychologists can be seen, which provides a multidisciplinary approach and the patient can be diagnosed correctly. We actually think for the patients and design them to receive quality healthcare services. In other words, all the tests and analyzes are both necessary for accurate diagnosis and are the result of world standards. While we receive JCI accreditation and undergo audits every year, all these studies are monitored. In addition, even if an analysis is performed in another center, the same tests are requested again for a different evaluation. The reason for this is again for the correct diagnosis within the framework of these quality standards. Sometimes the images may not be good, sometimes there may be a wrong test, sometimes there may be deficiencies due to problems caused by the device in the place where the test is performed. For this reason, we take all safety precautions by thinking on behalf of patients and clients.
For example, we do a lot of tests here. As a hospital, we have undertaken a cost and joined the external quality control system established by American organizations. Many laboratories in the world are included in this pool system. We are audited and trained to ensure that all our tests are performed with the correct method. We receive confirmation of the accuracy of the test methods performed in our laboratories. Our understanding of quality here is the measures we take to ensure that everything goes right before these tests are run.
For example, we use the TDM (therapeutic drug monitoring) drug monitoring system, which is used by 2% in the world. In other words, we have a system that we follow digitally so that there is no disruption in the medications taken especially by inpatients. This is especially important for inpatient psychiatric patients.
As NPISTANBUL Hospital, we use a smart building concept in security. We offer services with a smart building concept for patients and their relatives with card access system, fire detection modules, unbreakable mirrors, glasses, accessories and soft-walled rooms specially designed with the idea of security in all clinics.
We create our understanding of quality within the framework of the security measures we take. Even if everything goes under control, there is still the possibility of margin of error. For this reason, it is also necessary to constantly conduct drills. For example, in the event of a patient having a heart attack during surgery, a Code Blue drill is very important. It is necessary to apply drills by scenarizing situations such as who will be in the code blue area in how many seconds and who will bring the necessary device. Since health and human beings are involved, there is always room for error. It is also very important to identify and improve these mistakes. Mistakes should not be ignored. If you are dealing with health, you should reveal the mistakes transparently so that you can improve yourself. Therefore, even if the patient is discharged, we always question the patient's opinion and satisfaction level afterwards. If there is a problem, we investigate the cause, do due diligence and take the necessary measures.
What is the "Concept of Being a Good Hospital" according to you?
In fact, being a good hospital is a whole. For example, you cannot take comfort out of this concept... A good hospital is a hospital that has taken patient safety at the highest level from the facility to clinical processes, from managerial processes to technical processes, has integrated accepted medical standards into all clinical procedures, monitors whether these are indeed well managed with performance and clinical indicators, continuously improves them if there are places that are not going well, disseminates the good points to other employees with exemplary practices, informs its patients about all these and offers the necessary health comfort.
The World Health Organization's definition in this context is as follows: "The institution providing health services should ensure physical, mental and social well-being. What is meant by social well-being is 'feeling good', that is, does the patient feel good when he/she enters that institution, this is very important."
Being a good hospital includes everything from medical technology to the security measures taken, from staff training to qualification, from the quality of the medical supplies used to the water flowing from the tap. In addition to these, the approach of the leader manager in this context is very important and valuable.
So, do you think communication in health is important?
Yes, it is very important. Communication is also defined in JCI standards that we have adopted. Communication is divided into written and verbal. One of the main topics is communication. In other words, from a medical point of view, there is a 24-hour basis in the hospital. There is a process that runs until the patient's treatment is over. But since the same staff, nurse and doctor cannot work 24 hours a day, they have to take shifts with each other. During this handover, all information must be transferred verbally and in writing. This is how the integrity of treatment is ensured. In our hospital, all patients other than psychiatric patients are handed over at the bedside. Since psychiatric patients have different sensitive conditions, the process works differently. It is also important that physicians follow patient information. On the other hand, the communication of the staff working in the call center and the staff working in support services is very important. On the other hand, it is also very important to know the points where communication should or should not be established. We have a very important rule: The staff in our call center are prohibited from answering the question "which department should I apply to" that they encounter during patient calls. Because there is a risk that very simple complaints may be directed to completely different departments.
Let's say the patient complained about the staff, for example, he/she was not satisfied with the receptionist's sullenness or the nurse's service and behavior... What is your approach in such cases?
The main element here is patient orientation. The parties may act in defense or denial, especially if there is a psychiatric illness... Rather than an approach like "If the patient said it, it is true", the medical committee is first convened and the patient's condition is examined. We look at the past approach of the nurse or the relevant staff. We also conduct one-to-one interviews in this process. If the situation is due to the patient's pathological condition, this is also a result for us. It is a finding related to the treatment, it is meaningful for the physician to study this situation. If the person in charge has caused a situation that jeopardizes patient safety, his/her employment contract is terminated immediately.
Why is JCI Important? Why did we choose this accreditation?
Because JCI is the world's largest health accreditor. It is an independent organization that has the most comprehensive health standard in the world and receives accreditation for itself in every standard. It has very experienced auditors. As institutions, JCI is the most experienced in its field.
Is there an upper limit for hospitals to develop quality standards?
No, there is a limit in quality. Because as mistakes can happen anywhere, mistakes happen in medicine as well, there is no zero error anywhere. This is exactly why we are constantly trying to improve ourselves. We received the first JCI accreditation in 2012, but we are audited in the same way every year. There is no situation where you say, "I got this accreditation, it's done." Every year we try to improve the missing parts with the audit experiences we gained from the previous year. We undergo this accreditation audit every year in order to continuously improve ourselves, to continuously progress towards becoming better. If a good quality system is established, there will be mistakes. For example, if there is an error or deficiency in a staff member, we examine that staff member and ensure that they receive the training they need. This shows that you are collecting information, catching these mistakes and presenting them transparently to the auditor, and that you can identify areas where you can improve yourself.
So, which questions should a patient ask when choosing a hospital and according to what?
If you had asked this question before, I would have said that patients are not as interested in quality as they are today. But nowadays, quality is very important. Therefore, people who will receive health services should definitely receive health services from an accredited institution. Because hospitals improve themselves with the audits they receive from reliable accredited organizations.
For detailed information about our approach to health: You can visit our Corporate Ethical Approach and We are Here for Your Health pages.