these are new structures and it will be essential to ensure that effective dialogue between central and provincial public health agencies hospitals and hospital unions occurs to ensure that local health needs are met however there is at present no systematic adverse event reporting in place which could be an area for future consideration the focus so far has been on structural and organisational components of hospitals broadening the programme towards clinical outcomes of healthcare services seems advisable to make the model more useful for formative functions such as quality improvement initiatives within hospitals development of a reporting and learning system should be led by the department of health care quality and accreditation and the public hospital institute strengthening the involvement of all stakeholders in the standard setting process and increased transparency on the process of evaluation and scoring would also help to further increase the acceptability and impact of the programme it is troubling that at present strong disagreements exist between the profession turkish medical association nurses association midwives association and the government on mutual roles and responsibilities