Roles
and Responsibilities

1. JOB DESCRIPTION
At Private Cosmedica Medical Center, the Quality Management Unit is responsible for identifying risks related to patient safety, employee health and safety, training management, and facility security, and for developing a comprehensive Patient and Employee Safety Program covering all systems.

2. COMMITTEE MEMBERS
Responsible Manager, Administrative Manager, Nursing Services Manager, Quality Management Officer, IT Officer, Clinical Services Officer, Occupational Health & Safety (OHS) Specialist, Department Quality Officers.
Experts or staff may be invited as additional participants to the committee as needed, depending on the agenda.

3. DUTIES, AUTHORITIES, AND RESPONSIBILITIES

Ensure correct patient identification and necessary arrangements.

Foster effective communication among employees.

Ensure medication safety.

Ensure transfusion safety.

Ensure radiation safety.

Reduce risks related to patient falls.

Ensure safe surgical practices according to current criteria and support their improvement.

Ensure medical device safety.

Ensure patient privacy.

Ensure safe patient transfers.

Ensure secure transfer of patient information and records among healthcare staff.

Ensure information security.

Ensure infection prevention.

Ensure patient safety in the laboratory.

Determine and organize training related to patient safety.

Conduct preventive and corrective actions regarding patient safety.

Review Incident Reports.

Ensure and monitor adjustments for personnel with special conditions (pregnant, breastfeeding, disabled, chronic illnesses, etc.).

Evaluate employee feedback (suggestions, complaints, etc.).

Monitor risk assessments related to employees.

Track corrective actions for risks identified under employee safety.

Prepare and monitor the Health Surveillance Program.

Plan, monitor, and evaluate training within the scope of quality in healthcare, in-service training, general department and orientation training, and training provided to patients and their relatives.

Under facility safety: assess data from building tours, ensure infrastructure safety, protect life and property within the institution, coordinate emergency and disaster management, manage waste, maintain and calibrate medical devices, and plan and coordinate hazardous material management.

4. GENERAL RULES

The committee meets at least 4 times per year according to the Quality Unit Annual Work Plan, and may convene outside scheduled periods for extraordinary situations.

Meetings are planned in advance; at least 2 days prior, participants are informed by the HR department regarding meeting agenda, duration, time, and location.

All decisions made during meetings are recorded and signed in the committee log.

The Quality Unit is responsible for initiating, completing, and reporting improvements based on committee decisions.

The committee determines necessary training activities related to its scope.

The committee may collaborate with other boards and teams as needed.

5. ROLE DESCRIPTIONS

Responsible Manager: Ensures the medical appropriateness and implementation of the committee’s agenda and decisions; responsible for applying medical decisions and reporting back to the committee. Authorized to make operational adjustments and assignments as needed.

Administrative Manager: Ensures administrative appropriateness and implementation of the committee’s agenda and decisions; responsible for applying administrative decisions and reporting back to the committee. Authorized to make operational adjustments and assignments as needed.

Nursing Services Manager: Ensures the appropriateness and implementation of the committee’s agenda and decisions regarding nursing services; responsible for applying nursing-related decisions and reporting back to the committee. Authorized to make adjustments as needed.

Quality Management Officer: Responsible for the organization of the committee and ensuring the agenda and decisions meet quality standards; oversees the implementation of all decisions and ensures standardized operations and necessary follow-up.

Clinical Nurse: Provides opinions related to the agenda and decisions concerning their professional group; shares observations with the committee. Authority is determined by the agenda and decisions.

IT Officer: Responsible for the resolution and development of agenda items and decisions in the Hospital Information Management System (HBYS); ensures decisions are adapted to HBYS and informs users; authorized to make system changes.

Training Nurse: Ensures the agenda and decisions are practically applicable; responsible for implementation and reporting to the committee. Authority is defined according to the agenda and decisions.

Department Quality Officer: Provides opinions on agenda items and decisions related to departmental operations; shares observations about department performance with the committee. Authority is determined by the agenda and decisions.

Technical Service Officer: Provides technical opinions on agenda items and decisions related to their profession and department; responsible for implementing decisions regarding technical services and medical devices and reporting back to the committee. Authorized to make necessary adjustments.

Occupational Health & Safety (OHS) Specialist: Evaluates and provides opinions on committee matters from a workplace safety perspective; responsible for executing facility-related safety processes.