MHRS
Ministry of Health of Turkey

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
In Turkey, before the Central Doctor Appointment System (MHRS in Turkish; CDAS) citizens had various difficulties in reaching the doctor. The CDAS Project is a national-scale project that provides people to make use of the health services easily and contributes to the ascent of the indicators of the country’s health services in a positive way which is started in 2003 by the Ministry of Health taking place in the scope of the transformation programme in health and aiming all of the citizens’ access to quality health services in equity as of individuals who own equal rights in the country. Some of the hospitals that were attached to the Ministry of Health used to have their own appointment systems but there was not a certain standard. Therefore, patients used to encounter different operations in different hospitals. The queues in the hospitals that were formed with the hope of getting examined before sunrise were one of the leading dissatisfactions. The patients used to wait for hours in the queue to get a sequence number and then to get examined. Some of them used to restart the same process the next day from the beginning because they could not reach the doctor although they had waited for a long time in the hospital. From this situation the groups like the old, the disabled, the pregnant etc. used to be affected more. In the hospitals where the citizens came without knowing by which doctor they would be examined, there used to be disorders in the procedures before examination and there could be some hassles among the citizens. As for the health care workers who started their day without knowing the number of patients they would examine, they used to give service over their capacities especially in certain time zones. This situation used to cause the decline in the quality of health services, the lack of motivation and violence and spat incidents between the health care worker and the patient. In the face of these situations there was a need for an outpatient appointment system that would give 365 days 7/24 service and would be accessible all the time. This system would; • make away the citizens’ waiting in the queue off, • actualize the examination of the patient in the examination time, • give patient the freedom of choosing the doctor, • give doctors a chance to serve to patients until their capacities, • draw the service quality and general complacence to a higher level. In regard to this need, The CDAS project plan was prepared and the system was fractionally engaged.

B. Strategic Approach

 2. What was the solution?
CDAS was started by the predecessor Minister of Health Prof. Dr. Recep Akdağ and now it is being sustained by the current Minister Dr. Mehmet Müezzinoğlu. A project team has been formed in the undersecretariat coordination and within the scope of Head of IT Department for improving the project. The Head of IT Department was structured as General Directorate of Health Information Systems in 2012 so as to manage the health informatics substructure across the country. All constituent parts of the CDAS (education center, call centers, software and central substructure, equipments and licences) have been outsourced. Main objectives of the CDAS are; • to minimize the waiting durations before the examination in the hospitals, • to manage the human traffic in the hospitals, • to provide the effective usage of the doctors’ workforce in hospitals, • to increase the efficiency and quality of the health service, • to provide the decision support for improving the health policies. CDAS has united getting appointments from hospitals that are attached to Ministry of Health in a single center. An opportunity for citizens in which they can reach for 365 days and 7/24 and they can get appointments from hospitals and doctors they want has been provided. The long spans of waiting in hospitals to get through to doctor before CDAS have been abolished and at the moment it is enough for patients to be in the hospital at the appointment time that is given to them. CDAS has created an equality of opportunity to all sections in terms of reaching the doctor and it has eased the access to health service. The ways to get an appointment are these; • 182 CDAS Call Center Line, • Web application (https://mhrs.gov.tr ), • CDAS Mobile App, • Front desk at the hospitals, • Kiosk at the hospitals, • Family Practice Data Systems. According to the question of “Are you pleased with the CDAS service of the Ministry of Health?” in the computation of CDAS public service, citizen complacency is of 92.5%. Hospitals manage 30% of their daily examination capacities by themselves off CDAS, and 70% of capacity is managed by the CDAS. Habit of planned work has improved in doctors and correspondingly employee satisfaction and productivity have raised.

 3. How did the initiative solve the problem and improve people’s lives?
In the 90s, in some of the hospitals the appointment system was tried to be applied by telephone. By means of taking advantage of opportunities that the growing technology had ensured, by using different ways of getting appointment and starting out by the idea of building a central appointment system, project plans were prepared. Engineers who developed the CDAS made the appointment system accessible both to the conventional call centers and to the internet and mobile devices that were considered innovative while focusing on the importance of time management. CDAS has the specialty of being the biggest call center across the country with its 3.250 call center personnel. Experience obtained here is shared with other participants with a social responsibility awareness. CDAS Mobile Application is amongst the most common mobile applications in the field of public service. CDAS web application is the most visited page after the famous news portals in our country.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
CDAS project is begun to be argued in 2005. In 2007, software analysis studies were completed. In the midst of 2008, CDAS software began its phase of being improved and it was made ready to use while gaining its all functionality in August, 2009. In September 2009, CDAS Call Center service protocol was signed between the Ministry of Health and Türk Telekom. Pursuant to the protocol, a Call Center was established in which 144 operators would serve by detecting two pilot provinces and for the purpose of forming appointments to the hospitals in these provinces. In October 2009, the first CDAS Integration Workshop was held with Hospital Data Administration System (HDAS) soft wares and CDAS software. Our hospitals in Kayseri and Erzurum that were chosen as pilot provinces were included in CDAS. By year of January 7, 2009 call center began to serve. CDAS ranked among the preferential 11 e-State projects that were published by the Prime Ministry in 2010. By depending on the pilot studies’ processing successfully, the process of dissemination of the project gradually through the country has been started by ending the pilot practice with a decision which was taken by the Ministry of Health in June 1, 2010. For recovering the processes of CDAS during the transition period, in certain terms technical and administration educations were given to HDAS developers and CDAS managers in the Provincial Directorates of Health. CDAS that enabled service to the citizens with just 182 Call Center Line until July 2011, became to be able to give appointments also with CDAS web application (https://mhrs.gov.tr) after that date. The pilot practice that contained 2 provinces in 2010 was put into practice in all provinces except Istanbul in two years. Istanbul was included in the extent in March 26, 2012 and the system became a public service that was presented to whole country. In January 1, 2013, another alternative way that would ease to get appointments was presented to the citizens by presenting CDAS Mobile Application. In June 1, 2013, CDAS expanded its scope and not only the doctors in the hospitals but also the family doctors in the Family Health Centers were included in the appointment system. As of today, the CDAS project presents an appointment service to people live in the country via 182 Call Center Line and to people who are somewhere in the world and want to be treated in Turkey via web and mobile applications. System gives service with 3.250 Call Center workers in 5 different call centers, 32.621 specialist physicians in 822 hospitals in 81 provinces and 21.062 family doctors in 947 Family Health Centers. In the “2011 Top Ranking Performance” contest that was held by Contact Center World in 2011, AssisTT Çağrı Merkezi ve Rehberlik A.Ş. owned a silver medal came in second with the CDAS Project in the category of “Best Outsourcing Partnership”. It is aimed to perform 100% appointed examinations in all health facilities in 2023 which is the 100th anniversary of establishment of the State of the Republic of Turkey.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
CDAS project is a project that is put into practice by the Ministry of Health. Consequently, its greatest and most important shareholders are individuals who take health service and its employees who give health service. With the experience they get, 182 Call Center Line workers regularly and continuously contribute to the development of the system. The most important contribution is the support of Honorable Minister, counselor and other senior executives in the development and maintenance of the system. System’s project management leader and team have been the same people from the beginning of the project and are still working with the same job enthusiasm and sense of responsibility. When job rules are being formed in CDAS, opinions and suggestions from hospital head doctors, specialist physcians, family doctors, provincial directorates of health and advisor doctors who are attached to the Ministry of Health are taken into considreation. With respect to the opinions and suggestions, CDAS applications processes are continuously being recovered. To provide the data unity throughout the country, various integration studies are being made with the other units within the Ministry of Health. With the HDAS and Family Practice Data System (FPDS) company employees who play an active role in developing the software, workshops are being held periodically. Also, the individuals who use the CDAS state their opinions and suggestions about the system via mail address of mhrs@saglik.gov.tr and the appropriate ones are actualized by being evaluated.
 6. How was the strategy implemented and what resources were mobilized?
All products and services are financed by Ministry of Health’s own sources of circulating capital except the call receiving service that was presented by Türk Telekom with one year duration and 144 call center employees in the beginning of the project. From the beginning of the project, tenders have been lodged 6 times. Total tender price is 500 million Turkish Liras. Payment that is made until now is 200 million Turkish Liras. 85% of this payment has been used for personnel expenses. Call centers have been established in provinces that are privileged in progress and with high rate of unemployment. 97% of the over 3.500 personnel who work in the operational side of the system are giving service in these provinces.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
It is provided for patients and doctors to manage the time they spare for the examination more efficiently and planned. It has presented the opportunity to plan the doctor workforce to hospital managers. It has provided a decision support intended to improve health policies to ministry managers. It has brought dynamism in the software industry. Separate appointment applications have been singularized and a more economic appointment service has been provided. Contributions have been made to the economies of the provinces where call centers are established and to the development of human resources. Everyone has been presented with a 100% right to choose the doctor and reach. It has contributed to the uplifting of the time that doctors spare for their patients from approximately 2.5 minutes to 12 minutes. This data is the sign of getting closer to the examination duration standards that are determined by the World Health Organization in a short time. The satisfaction level of the citizens who use the CDAS is positively in the 92% rating. While in 2004, the average of the number of applying to doctor per person was around 3.5 in a year, according to the results of 2014’s first ten months, this number is around 10. CDAS’s contribution to this increasement is great in terms of providing an ease to reach the doctor. One of the proofs of CDAS’s success is the increasing graphic of call day after day. First 9 months of 2014, the number of calls received by 182 Call Center Line have been 64.092.295. Though in the first 9 months of 2011,this number was only 6.399.209. According to these numbers, it is seen that in three years the number of received calls has shown an increase at the rate of 901,57%. This increase is one of the most important signs of the righteousness of the investment that was made. While the CDAS project enters into its 5th year, average of 350.000 appointments are formed in daily basis. According to this number, every 40 patient from 100 are still get examined by getting appointment. The aim of 2023 is 100% examination with appointment.

 8. What were the most successful outputs and why was the initiative effective?
The process needs to be controlled, evaluated and improved continuously because CDAS project always needs to be up and running to serve properly. CDAS Help Desk team is established in February 22 2011 and consists of 20 people. Help desk gives 7/ 24 support both to hospitals and software firms and to citizens. Complaints and requests about the system coming from various channels are resulted in the very same day and a come-back is made. At the same time, there are 25 engineers in the contractor company for the CDAS project’s software, system maintenance and support works. Relevant contractor company analyzes the system 7/24 thanks to the monitoring programme and interferes in the situation immediately for not to suspend the receiving of appointments in a potential alarm situation. Besides this, while the intensity control on the servers are made manually, the intensity on the network is managed automatically via the Layer7 Firewall device. For the control of active users (session) in the database, various programmes are being used. Virtual robots established in call centers can generate alarms against the problems that can occur by simulating all of the operations that a call operator makes immediately. CDAS Call Centers Tracking Desk Team that serves with its team of 11 people, can watch the sudden and retroactive activities via the tracking programme. Also, CDAS Call Center Quality Team with its team of 21, measures the service quality of every call center worker. With the aim of supporting the quality team, systemic speech analysis programme’s pilot application studies have been started. CDAS Hospital Tracking Team with a team of 5 also provides the regular tracking of the coordination between hospitals and CDAS, doctors’ transferring the appointment plans to the system regularly and the tracking of the hospitals’ operations. Lastly, The Communication and Social Media Unit that will provide to control of the high capacity public project on all stations, has been established. This unit has been charged to analyze all kinds of content that citizens indicate in social media environment about CDAS. Project management are given briefings by comparing the problems and claims that reflect to social media and results from reporting units. Information about the operation is accessed by evaluating the daily, weekly and monthly reports that are regulated by our CDAS reporting teams and CDAS’s conduct is decided by looking at these feedbacks.

 9. What were the main obstacles encountered and how were they overcome?
We can gather the problems that we encountered in CDAS application under three main headlines; Technical substructure: The main source of the problems occur in technical substructure is that of it has to improve and grow continuously. There is a need for new features and new modules depending upon the proliferation of CDAS usage. Technical conditions are being organized convenient to the rising demand and thus problems can be held in minimum level. Hospital Operation: HDAS-CDAS integration problems and doctor working scales’ recording deficitly are the main two problems. First problem as the project’s technical step is tried to be overcome in constant meetings held with HDAS developers. For the other problem to be lowered to a minimum level, there published a CDAS legislation by the Ministry of Health and in this legislation doctors’ juridical responsibilities about the system has been determined. Call Center Operation: The main source of the burdens that are encountered in the operation of Call Center results from having a big scaled call center organization. To minimize the problems occur during the processes of over 3200 employees’ routine recruitment, excitation, education, planning etc. Call Center Tracking Desk and Quality Team have been established. On the other hand, another problem at the Call Centers is about the information security and sharing information. Previously, sharing patient history information by the operators is forbidden due to ensure the confidentiality of personal health data and to make standard information security. CDAS Project Management has harmonized the system software to remove the hassles that happened by the people, that is managing ISO 27001 right now. Employee trainings are put in order in this way too.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Urbanization and increasing population in the urban areas during the late 90s led to unbalanced distribution of population across the country; the increased population in the urban areas made the malfunctions of the health system clear. To remove those malfunctions and to serve a faster, more effective, more qualified and more economical medical service, the health transformation programme was put into action. One of the most important parts of this programme is CDAS Project. One of the most important elements that have led to the increase of trust of people in the Ministry of Health and its hospitals is CDAS Project. If we consider the imponderable values, the concrete benefits are the work power saving by decreasing the length of waiting in the hospitals, the saving done by using the doctor power effectively, the saving done by operating a central paging system rather than operating a separate paging system, the comfort served by developing alternative paging channels, the comfort done with the flexibility of arranging appointments with the desired hospital, branch and doctor, the social justice in reaching to the service of health sector, the contribution in the economy and the human resources of the cities where the call centers have been built, the increase in the participation of women in the work force (%60 of the workers in the overall system is composed of women), the contribution of easy management of health system. The patients and the health workers have started to appreciate time management by using appointment system. Time, which is an abstract concept, and management of it have been made measurable with the investments in the technological infrastructure. CDAS has been designed in a way which made it possible to develope or narrow it to effectively use the resources. Namely, workforce and human resource extravagency in the public services have been prevented. CDAS Project Management, that wants time management to be a habit for citizens, recently started a work to put into use the reminding appointment, cancelling and confirmation processes by making outbound calls.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The sustainability of CDAS application is the basis according to the strategic plans and goals of the Ministry of Health. To realize the sustainability and satisfaction, Project processes have been conducted with detailed and rigorous plannings in terms of financial, social, economic, cultural, environmental, institutional and executive fields and they are still being conducted. Sustainability of the application depends on the sustainability of satisfaction of both the citizens and the doctors. In this sense, arrangements of appointments and improvements in the processes and system are done regularly according to needs. The whole of the system continues its function in a redundant structure and it has prepared a precaution and work program at the highest level in case of a disaster and system interrupt. Thus, CDAS Project doesn’t lose its function under any circumstances. The system’s accessibility success is %99ç56. In case of the project’s import to other countries, the system can be applied to these countries demanded that some systematical revisions be done according to that country’s social and economic structure.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
After CDAS application is in action, the appointment culture in the presentation of service has developed. Appointment system has been adopted in some other public services. CDAS has developed technology usage, bureaucratic processes have been removed and the individuals have been given the chance of managing their own appointment processes. While the success of the Project at the beginning was suspected, today, this kind of suspect has been changed in a positive way. As a result of the evaluations, it has been seen that CDAS doesn’t mean arranging appointments for service and it has made it possible to give service to people on the highest level. Thus, health promotion has been predicted. CDAS Project, which has begun with the health transformation struggles, has brought a system for treatment processes and the resources have started to be used effectively. One of the key factors fort he success of CDAS is the fact that the standards have been applied.

Contact Information

Institution Name:   Ministry of Health of Turkey
Institution Type:   Government Agency  
Contact Person:   Hayati Tartan
Title:   Coordinator  
Telephone/ Fax:   +9031258519000
Institution's / Project's Website:  
E-mail:   hayati.tartan@saglik.gov.tr  
Address:   Mithatpasa Cd. No:3 B Blok Kat:1
Postal Code:   06434
City:   Ankara
State/Province:   N/A
Country:  

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