Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Introduction to
the JCI
Standards
Overview of
PENDIDIKAN
S-1 Fakultas Kedokteran Universitas Sam Ratulangi - Manado , Lulus 1995
S-2 Fakultas Kesehatan Masyarakat, KARS Universitas Indonesia, Lulus 2005
PELATIHAN / SEMINAR
2015 : Practicum Acreditation JCI 5th edition Singapura
2011 : Practicum Acreditation JCI 4th edition Seoul
Patient Safety Course, Singapura
2010 : Safety in Healthcare, Kuala Lumpur
2009 : Hospital Management Asia, Vietnam
Course Risk Management PRMIA Jakarta
2007 : New Perspektif, Conferrence ASHRM, Chicago USA
Certified Profesional Healthcare Risk Management course, Chicago USA
Risk Management Base Training, Joint Commision Resources (JCR)
Patient Safety Up Date, Joint Commision International (JCI) Singapura
2005 : Lead Audior ISO 9001 2000, International Registered Certificated
Auditor (IRCA)
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PENGALAMAN KERJA
2016 : Konsultan JCI RS Sutomo
2015 : Konsultan JCI RS Islam Cempaka putih Jakarta, RS Advent Bandung, RS JMC Jakarta
2014 : Konsultan JCI RS MMC Jakarta, RS Kanujoso Blkppn, RS Sleman Jogja, RS Tarakan Kaltara
2013 : Konsultan JCI RS kanujoso Blkppn, RS Sleman
2012 : Konsultan JCI RSUP Fatmawati, RSUP Wahidin Sudirohusodo Makasar, RS Medistra
2011 : Konsultan JCI RSCM, Konsultan Manajemen Risiko & Keselamatan Pasien RS Tarakan Kaltim
2010 : Konsultan Manajemen risiko RSUP Fatmawati Jakarta, RS Bieuren, RS Lhoksemawe Aceh
2009 : Konsultan Manajemen risiko & Kes Pasien RS Wahidin Makasar, RS Pelni Jakarta
Konsultan RS Aini, RS Sardjito
2007 : Direktur RS Zahirah
Konsultan Manajemen risiko RS Persahabatan, RS Dharmais
2006 Konsultan Manajemen RS Asri, Konsultan Manajemen RS Medika BSD,
2004 - 2005 : Manajer Operasional Medika Plaza International Clinic
2003 : General Manajer Cempaka Medical Centre
2003 - 2004 : Direktur Operasional RS Sentra Medika
2002 - 2003 : Wakil Direktur Medik & Asist Direktur RS Sentra Medika
2000 - 2001 : Kepala Bagian Humas RS MMC
1999 - 2000 : Kepala Bagian Rehabilitasi Medik RS MMC
1999 : Asisten Konsultan WHO Umbrella Project Depkes
1996 -1999 : Kepala Puskesmas Sindang Barang Kabupaten Cianjur
ORGANISASI
2007 2012 : Ketua Bidang IV (Pelaporan Insiden) KKP RS PERSI , Sterring Committe KKP RS
2005 - Saat ini:Ketua Institut Manajemen Risiko Klinis (IMRK) / ICRMI
Member of ASQ (American Quality Society),
Member of Profesional Risk Management International Association
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Arjaty / JCI Edisi 5/2015
Patient-Centered Standards
1. International Patient Safety Goals (IPSG)
2. Access to Care and Continuity of Care
(ACC)
3. Patient and Family Rights (PFR)
4. Assessment of Patients (AOP)
5. Care of Patients (COP)
6. Anesthesia and Surgical Care (ASC)
7. Medication Management and Use (MMU)
8. Patient and Family Education (PFE)
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Accreditation
A Definition
Usually a voluntary process by which a
government or non government agency
grants recognition to health care institutions
which meet certain standards that require
continuous improvement in structures,
processes, and outcomes.
Sukarela - Penghargaan
STANDARD
(STRUKTUR, PROSES,
OUTCOME)
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ACREDITATION
CERTIFICATE
18-24 Months
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ROAD MAP
Survey
Track Record Period: the period of time prior to your survey within
which surveyors will examine compliance. (Track record period :
periode waktu sebelum survey untuk menilai kepatuhan anda)
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Feb March April Mei Juni July Aug Sept Oct Nov
Schedule your Mock Survey at least two months before the start of your
track record to give you time to fix identified issues (jadwalkan Mock survey
minimal dua bulan sebelum waktu mock survey yg diinginkan untuk
membenahi isu yg ada)
.
Feb March April Mei Juni July Aug Sept Oct Nov
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PENGORGANISASIAN
AKREDITASI
Direktur Utama
Core Team
KA PANITIA AKREDITASI
Sekretariat
Koord Dokumen
Koord sosialisasi
Koord Telusur
ASC PCI
MMU MOI
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Standards Content
What is a Standard?
A statement of the safety and quality expected
Types of Expectations in Standards
Inputs (Structures) : Resource
Processes : Activities
Outcomes : Results
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CHAPTER
STANDAR
ME
APR
12
IPSG
10 30 CHAPTER
STANDAR
ME
PFR
19 76 IPSG
6 24
AOP
38 162 ACC
23 103
COP
26 107 PFR
30 100
ASC
16 54 AOP
44 184
MMU
19 77 COP
22 74
PFE
5 17 ASC
14 51
QPS
12 53 MMU
21 84
PCI
20 72 PFE
7 28
GLD
33 184 QPS
23 89
FMS
23 91 PCI
24 83
SQE
24 99 GLD
27 98
MCI
16 63 FMS
27 92
MPE
7 30 SQE
24 99
HRP
10 42 MCI
28 109
290 1.157 320 1.218
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INTENT STATEMENT
Informed consent for care sometimes requires that people other than (or in
addition to) the patient be involved in decisions about the patients care. This is
especially true when... culture or custom requires that others make care
decisions...
MEASURABLE ELEMENTS
1. The hospital has a process for when others can grant informed consent.
( RS Proses general consent diberikan oleh selain pasien)
2. The process respects law, culture, and custom.
(Proses sesuai hukum, budaya dan adat)
3. Individuals, other than the patient, granting
consent are noted in the patients record.
(Pemberi General consent selain pasien tercatat dlm RM)
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The bulleted elements are not scored as such, but ignoring them
completely will lead surveyors to drill down and ask what else
was considered in compliance with the standard
(Elemen bullet tidak di skoring, tapi dapat
1/31/17 menjadi pertanyaan surveyor untuk menilai kepatuhan standar)
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11
abuse and neglect are shaped by the culture of the patient population. These assessments are not intended to be
proactive case-finding processes. Rather, the assessment of these patients responds to their needs and condition
in a culturally acceptable and confidential manner. The assessment process is modified to be consistent with
local laws and regulations and professional standards related to such populations and situations and to involve
the family when appropriate or necessary. (Also see AOP.1.2 and AOP.1.2.1)
Standard AOP.1.7
Dying patients and their families are assessed and reassessed according to their individualized needs.
Intent of AOP.1.7
Assessments and reassessments need to be individualized to meet patients and families needs when patients are
at the end of life. Assessments and reassessments should evaluate, as indicated by the patients condition,
a) such symptoms as nausea and respiratory distress;
b) factors that alleviate or exacerbate physical symptoms;
c) current symptom management and the patients response;
d) patient and family spiritual orientation and, as appropriate, any involvement in a religious group;
e) patient and family spiritual concerns or needs, such as despair, suffering, guilt, or forgiveness;
f) patient and family psychosocial status, such as family relationships, the adequacy of the home
environment if care is provided there, coping mechanisms, and the patients and familys reactions to
illness;
JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 5TH EDITION
g) the need for support or respite services for the patient, family, or other caregivers;
h) the need for an alternative setting or level of care; and
i) survivor risk factors, such as family coping mechanisms and the potential for pathological grief
reactions.
Measurable Elements of ACC.4.3.2
Assessment of Patients
Measurable Elements of AOP.1.7
1. 1.A discharge summary
Dying patients is prepared
and their familiesbyarea assessed
qualifiedand
individual.
reassessed for those elements in a) through i) of the
intent, according to their identified needs.
2. A copy of the discharge summary is provided to the practitioner responsible for the patients continuing
(AOP)
2.or follow-up
Assessmentcare.
findings guide the care and services provided. (Also see AOP.2, ME 2)
3. Assessment findings are documented in the patient record.
3. A copy of the discharge summary is provided to the patient in cases in which information regarding the
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practitioner responsible for theArjaty
patients continuing
/ JCI or follow-up care is unknown.
Edisi 5/2015
Standard
4. A copy of theAOP.1.8
completed discharge summary is placed in the patient's record in a time frame identified
The initial assessment includes determining the need for discharge planning.
by the hospital.
69
Standard ACC.4.4
The records of outpatients requiring complex care or with complex diagnoses contain profiles of the medical
Continuity of Care (ACC)
care and are made available to health care practitioners providing care to those patients.
Access to Care and
Intent of ACC.4.4
When the hospital provides ongoing care and treatment for outpatients with complex diagnoses and/or who
need complex care (for example, patients seen several times for multiple problems, multiple treatments, in
multiple clinics, and/or the like), there may be an accumulated number of diagnoses and medications and an
evolving clinical history and physical examination findings. It is important for any health care practitioner in all
settings providing care to that outpatient to have access to information about the care being provided.
The process for providing this information to health care professionals includes
identifying the types of patients receiving complex care and/or with complex diagnoses (such as patients
seen in the cardiac clinic with multiple comorbidities, or patients with end-stage renal failure);
identifying the information needed by the clinicians who treat those patients;
determining what process will be used to ensure that the medical information needed by the clinicians is
available in an easy-to-retrieve and easy-to-review format; and
evaluating the implementation results to verify that the information and process meet the needs of the
clinicians and improve the quality and safety of outpatient clinical services.
1. The hospital identifies the types of outpatients receiving complex care and/or with complex diagnoses
who require an outpatient profile.
2. The information to be included in the outpatient profile is identified by the clinicians who treat those
patients.
3. The hospital uses a process that will ensure the outpatient profile is available in an easy to retrieve and 12
review format.
4. The process is evaluated to see if it meets the needs of the clinicians and improves the quality and safety
of outpatient clinical visits.
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Policy Requirements
Some standards require organizations
to have a written policy or procedure
for a specific process.
(Standard RS buat Kebijakan & SPO)
DOCUMENT REVIEW
Tujuan : survei kepatuhan pada standar.
Peserta :
staf yang paham dokumen yang akan disurvei,
penerjemah yang profesional.
Tim surveyor dapat menunjuk sejumlah staf yg hadir /
(dibatasi ) dalam sesi Dokumen Review.
Sesi adalah wawancara dengan staf tentang dokumen.
Hampir semua chapter membuat Plans, Policies, and
Procedures tertulis.
Document
Review
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How to Prepare
Banyak dokumen yang diperlukan menjadi bagian dari
dokumen lain. RS tidak perlu fotokopi bagian dokumen2
ini. Sebaliknya, dokumen2 dapat diidentifikasi
menggunakan bookmark / daftar dokumen.
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1. Dokumen : 3P ?
2. Dokumen sesuai standard yg di
syaratkan?
3. Implementasi sesuai dokumen
standard ?
4. Implementasi Konsisten &
menyeluruh di semua are RS ?
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