SKS Audit Prep with Training Records: Plan, Orientation, Assessment

As an assessment against SKS, Turkey's Health Quality Standards, approaches, a familiar rush begins in the training unit: sign-in sheets in binders are scanned, Excel files are merged, and someone tries to answer "Who took this training again?" Yet SKS expectations for training are clear, and records kept in order throughout the year can turn audit week into an ordinary week.

In this article, we summarize what the "Training Management" section of the SKS Hospital set requires, then offer a practical checklist for planning, orientation, attendance and assessment records.

The framework first

Under the Regulation on Improving and Assessing Quality in Healthcare, institutions carry out self-assessments, record the results in the Ministry's electronic system and prepare a quality improvement action plan for standards found "partially met" or "not met". Institutions scoring 95 or above are announced. The regulation provides for no fine; the main consequence is the quality score and the action plan obligation.

The Ministry of Health's versions page lists SKS Hospital Version 6.1 as the most current hospital set. The standard codes below belong to this version.

What does the SKS Training Management section require?

The last column contains our suggestions based on good practice, not the SKS text. This article focuses on staff training; patient education under KEY06 is a separate topic.

1. Annual training plan

SKS requires training plans to define at least the following (KEY02.01):

• Aims and objectives of the training
• When, by whom and to whom it will be delivered
• Training method
• Stages, if any (basic, advanced, theoretical, practical)
• Location and duration
• General headings for the content
• Materials needed
• Method for evaluating effectiveness

Keeping the plan alive

When an unplanned training is held or the content or method changes, the plan should be revised, and the revision should be traceable (KEY02.02, KEY02.03). In practice, this means keeping the plan as dated versions rather than as the latest state of a single file. When the auditor asks, "Why did the March hand hygiene training move to April?", the answer should be in the revision record.

From needs analysis to plan

Showing that the plan is based on the needs analysis in KEY01 is strong evidence. Incident reports, findings of the infection control committee, patient complaints, the previous year's exam results and new devices or protocol changes are natural sources for the needs analysis.

2. Orientation records

Every new employee should receive general and department orientation; topics are set taking into account the hospital's type, service areas and professional differences (KEY03.01). Leads for general orientation should be assigned, an orientation guide prepared for each profession, and the training delivered kept in the personnel file (KEY03.02–KEY03.04).

The most common gap is contracted service staff. Orientation records for cleaning, security and catering staff often stay with the contractor. Making these records accessible at the hospital as well saves time at audit.

3. In-service training and attendance records

In-service training leads should be assigned; topics should be categorized by hierarchical level, professional group, department-specific and general, and training should be delivered as planned (KEY04.01–KEY04.03). Staff should receive training covering the SKS processes of their unit, and the relevant employees should have access to training materials (KEY04.04, KEY04.06).

A good attendance record includes:

1. The employee's name, title and department
2. The training's name, date, duration and method (face to face, online, blended)
3. The person who delivered the training
4. Its link to the plan (plan code or line)
5. Exam result and completion status, if any

For OHS (occupational health and safety) training delivered online, the requirements of the OHS training regulation of April 2, 2026 also apply: log-ins and log-outs, completion rates and assessment results are recorded, monitored and reported. OHS induction training, by contrast, is recorded in minutes and kept in the personnel file.

4. Assessment and effectiveness records

KEY05 requires evaluating the effectiveness and efficacy of orientation and in-service training. As examples of usable methods, the SKS text lists pre-test/post-test, self-assessment, observation, interviews, evaluation with department heads, surveys and methods that measure training-related behavior change.

In practice, at least one assessment method should be defined in the plan for each training, and its result should be recorded. The difference between the pre-test and post-test shows the training's effect on knowledge; a short retest a few months later, or observation on the floor, helps show whether it carried over into behavior. Feeding the results into the next year's needs analysis closes the loop.

5. The personnel file test

KEY03.04 and KEY04.05 require training records to be accessible from the personnel file. Before the audit, you can run a simple internal test: pick a few employees at random from different departments and professional groups and, for each one, try to find their orientation training, their in-service training over the past year and their exam results in their file. This test lets you see gaps in your record system before the auditor does.

Typical gaps to watch for

1. Disconnect between plan and delivery: Unplanned training was never added to the plan; some planned training dropped off without a trace.
2. Signatures but no assessment: Attendance is documented, but there is no data on the training's effect.
3. Night and weekend teams: Because sessions are held during the day, shift workers' training is incomplete.
4. Scattered records: OHS training in the OHS unit, infection training at the committee, orientation records in human resources; none of them match the personnel file.
5. Outdated materials: The protocol was updated, but the training slides and questions are still on the old version.

Pre-audit checklist

Plan and needs analysis

• This year's training needs analysis is done, and the underlying data is on file.
• The annual training plan includes the minimum headings in KEY02.01.
• Plan revisions are dated and traceable.

Orientation

• Every employee who started in the past year has a general and department orientation record.
• Orientation guides for each profession are up to date.
• Orientation records for contracted service staff are accessible at the hospital.

In-service training

• The delivery status of planned training can be reported by department.
• There is a make-up plan for employees who didn't attend.
• Employees can access training materials.

Assessment and records

• An assessment method is defined for each training, and the results are recorded.
• Training records can be found in randomly selected personnel files.
• For online OHS training, log-in/log-out, completion and exam records can be reported.

Sources

• SKS Hospital Version 6.1 (Ministry of Health, Training Management section KEY01–KEY06)
• SKS Hospital versions (General Directorate of Health Services)
• Amendment to the Regulation on Improving and Assessing Quality in Healthcare (Official Gazette, RG 26.05.2023, No. 32202)
• Regulation on the Procedures and Principles of Employees' Occupational Health and Safety Training (RG 02.04.2026, No. 33212)

Audit-ready training records with ATP MedAI

ATP MedAI's mandatory training catalog is aligned with SKS topics. The annual training plan is defined in the platform, training is assigned automatically by role and department, and reminders go out automatically. For each employee, log-in time, active time and exam score are recorded; the attendance certificate is e-signed. The manager dashboard shows completion rates by department and the teams falling behind, and audit-ready reports can be exported as PDF or Excel. The competency map also helps track new staff through orientation.

This article is for general information only and is not legal advice; check official sources for current amounts and provisions.

ATP MedAI Editorial Team
This article was prepared for general information. If you spot an error or omission, let us know and we'll correct it.