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Pg1}\par\pard\sect\sectd\sbknone\cols3\colno1\colw4846\colsr160\colno2\colw5200\col
sr160\colno3\colw1404\colsr160\ql \li1408\sb0\sl-322\slmult0 \par\pard\ql
\li1408\sb0\sl-322\slmult0 \par\pard\ql \li1408\sb0\sl-322\slmult0 \par\pard\ql
\li1408\sb0\sl-322\slmult0 \par\pard\ql \li1408\sb0\sl-322\slmult0 \par\pard\ql
\li1408\sb0\sl-322\slmult0 \par\pard\ql \li1408\sb0\sl-322\slmult0 \par\pard\ql
\li1408\sb0\sl-322\slmult0 \par\pard\ql \li1408\sb0\sl-322\slmult0 \par\pard\ql
\li1408\sb136\sl-322\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf2\f3\fs28 Efektif 1 Januari 2018\par\pard\column \ql
\li5006\sb0\sl-648\slmult0 \par\pard\ql \li5006\sb0\sl-648\slmult0 \par\pard\ql
\li5006\sb0\sl-648\slmult0 \par\pard\ql \li5006\sb0\sl-648\slmult0 \par\pard\ql
\li20\sb312\sl-648\slmult0 \up0 \expndtw0\charscalex97 \ul0\nosupersub\cf3\f4\fs72
STANDAR\par\pard\ql \li20\sb85\sl-828\slmult0 \up0 \expndtw0\charscalex97
NASIONAL\par\pard\ql \li20\ri17\sb10\sl-883\slmult0 \up0 \expndtw0\charscalex97
AKREDITASI \line \up0 \expndtw0\charscalex97 RUMAH SAKIT\par\pard\ql
\li20\sb166\sl-828\slmult0 \up0 \expndtw0\charscalex97 \ul0\nosupersub\cf4\f5\fs72
Edisi 1,\par\pard\ql \li5006\sb0\sl-299\slmult0 \par\pard\ql \li5006\sb0\sl-
299\slmult0 \par\pard\ql \li5006\sb0\sl-299\slmult0 \par\pard\ql \li5006\sb0\sl-
299\slmult0 \par\pard\ql \li5006\sb0\sl-299\slmult0 \par\pard\ql \li5006\sb0\sl-
299\slmult0 \par\pard\ql \li5006\sb0\sl-299\slmult0 \par\pard\ql \li5006\sb0\sl-
299\slmult0 \par\pard\ql \li5006\sb0\sl-299\slmult0 \par\pard\ql \li5006\sb0\sl-
299\slmult0 \par\pard\ql \li5006\sb0\sl-299\slmult0 \par\pard\ql \li5006\sb0\sl-
299\slmult0 \par\pard\ql \li5006\sb0\sl-299\slmult0 \par\pard\ql \li5006\sb0\sl-
299\slmult0 \par\pard\ql \li5006\sb0\sl-299\slmult0 \par\pard\ql \li5006\sb0\sl-
299\slmult0 \par\pard\ql \li5006\sb0\sl-299\slmult0 \par\pard\ql \li5006\sb0\sl-
299\slmult0 \par\pard\ql \li5006\sb0\sl-299\slmult0 \par\pard\ql \li5006\sb0\sl-
299\slmult0 \par\pard\ql \li5006\sb0\sl-299\slmult0 \par\pard\ql \li5006\sb0\sl-
299\slmult0 \par\pard\ql \li5006\sb0\sl-299\slmult0 \par\pard\ql \li5006\sb0\sl-
299\slmult0 \par\pard\ql \li20\sb147\sl-299\slmult0 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf5\f6\fs26 KOMISI AKREDITASI RUMAH
SAKIT\par\pard\ql \li20\sb20\sl-299\slmult0 \up0 \expndtw-3\charscalex100 AGUSTUS
2017\par\pard\column \ql \li10356\sb0\sl-253\slmult0 \par\pard\ql \li10356\sb0\sl-
253\slmult0 \par\pard\ql \li10356\sb0\sl-253\slmult0 \par\pard\ql \li10356\sb0\sl-
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253\slmult0 \par\pard\ql \li10356\sb0\sl-253\slmult0 \par\pard\ql \li10356\sb0\sl-
253\slmult0 \par\pard\ql \li10356\sb0\sl-253\slmult0 \par\pard\ql \li10356\sb0\sl-
253\slmult0 \par\pard\ql \li10356\sb0\sl-253\slmult0 \par\pard\ql \li10356\sb0\sl-
253\slmult0 \par\pard\ql \li10356\sb0\sl-253\slmult0 \par\pard\ql \li10356\sb0\sl-
253\slmult0 \par\pard\ql \li10356\sb0\sl-253\slmult0 \par\pard\ql \li10356\sb0\sl-
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253\slmult0 \par\pard\ql \li10356\sb0\sl-253\slmult0 \par\pard\ql \li10356\sb0\sl-
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253\slmult0 \par\pard\ql \li10356\sb0\sl-253\slmult0 \par\pard\ql \li10356\sb0\sl-
253\slmult0 \par\pard\ql \li10356\sb0\sl-253\slmult0 \par\pard\ql \li10356\sb0\sl-
253\slmult0 \par\pard\ql \li10356\sb0\sl-253\slmult0 \par\pard\ql \li10356\sb0\sl-
253\slmult0 \par\pard\ql \li10356\sb0\sl-253\slmult0 \par\pard\ql \li10356\sb0\sl-
253\slmult0 \par\pard\ql \li10356\sb0\sl-253\slmult0 \par\pard\ql \li10356\sb0\sl-
253\slmult0 \par\pard\ql \li10356\sb0\sl-253\slmult0 \par\pard\ql \li10356\sb0\sl-
253\slmult0 \par\pard\ql \li20\sb131\sl-253\slmult0 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf1\f2\fs22 1
\par\pard\sect\sectd\fs24\paperw11900\paperh16820\pard\sb0\sl-240{\bkmkstart Pg2}
{\bkmkend Pg2}\par\pard\ql \li5433\sb0\sl-276\slmult0 \par\pard\ql\li5433\sb0\sl-
276\slmult0 \par\pard\ql\li5433\sb0\sl-276\slmult0 \par\pard\ql\li5433\sb0\sl-
276\slmult0 \par\pard\ql\li5433\sb0\sl-276\slmult0 \par\pard\ql\li5433\sb0\sl-
276\slmult0 \par\pard\ql\li5433\sb156\sl-276\slmult0 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 SAMBUTAN \par\pard\ql \li2726\sb44\sl-
276\slmult0 \up0 \expndtw-3\charscalex100 KETUA EKSEKUTIF KOMISI AKREDITASI RUMAH
SAKIT \par\pard\ql \li4763\sb44\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Dr.
dr. Sutoto, M.Kes \par\pard\ql \li10355\sb0\sl-253\slmult0
\par\pard\ql\li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb0\sl-253\slmult0
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\par\pard\ql\li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb0\sl-253\slmult0
\par\pard\ql\li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb0\sl-253\slmult0
\par\pard\ql\li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb0\sl-253\slmult0
\par\pard\ql\li10355\sb206\sl-253\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf1\f2\fs22 2

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\li1900\sb44\sl-276\slmult0 \up0 \expndtw-2\charscalex100 3. dr. Pranawa,
Sp.PD,KGH \par\pard\ql \li1900\sb44\sl-276\slmult0 \up0 \expndtw-3\charscalex100 4.
Prof. Dr. dr. Bambang Supriyatno, Sp.A(K) \par\pard\ql \li1900\sb24\sl-
276\slmult0 \up0 \expndtw-2\charscalex100 5. dr. Kuntjoro Adi Purjanto, M.Kes
\par\pard\ql \li1900\sb44\sl-276\slmult0 \up0 \expndtw-2\charscalex100 6.
Suarhatini Hadad \par\pard\ql \li1900\sb44\sl-276\slmult0 \up0 \expndtw-
2\charscalex100 7. Prof. Dr. drg. Tri Erri Astoeti,M.Kes \par\pard\ql
\li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb88\sl-276\slmult0 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 TIM PELAKSANA \par\pard\ql
\li1900\sb0\sl-276\slmult0 \par\pard\ql\li1900\sb88\sl-276\slmult0 \up0 \expndtw-
2\charscalex100 \ul0\nosupersub\cf7\f8\fs24 1. Dr. dr. Sutoto, M.Kes
\par\pard\ql \li1900\sb24\sl-276\slmult0 \up0 \expndtw-2\charscalex100 2. dr.
Djoti Atmodjo, Sp.A, MARS \par\pard\ql \li1900\sb44\sl-276\slmult0 \up0 \expndtw-
2\charscalex100 3. Dra. M. Amatyah S, M.Kes \par\pard\ql \li1900\sb44\sl-
276\slmult0 \up0 \expndtw-3\charscalex100 4. dr. Nico A. Lumenta, K.Nefro, MM,
MH.Kes \par\pard\ql \li1900\sb44\sl-276\slmult0 \up0 \expndtw-2\charscalex100 5.
dr. Luwiharsih, M.Sc \par\pard\ql \li1900\sb44\sl-276\slmult0 \up0 \expndtw-
2\charscalex100 6. dr. Djoni Darmadjaja, Sp.B, MARS \par\pard\ql \li1900\sb44\sl-
276\slmult0 \up0 \expndtw-2\charscalex100 7. Dr. dr. Hanny Ronosulistyo, Sp.OG, MM
\par\pard\ql \li1900\sb44\sl-276\slmult0 \up0 \expndtw-3\charscalex100 8. dr.
Achmad Hardiman, Sp.KJ, MARS \par\pard\ql \li1900\sb44\sl-276\slmult0 \up0
\expndtw-2\charscalex100 9. dr. Nina Sekartina, MHA \par\pard\ql \li1900\sb24\sl-
276\slmult0 \up0 \expndtw-2\charscalex100 10.Dr. dr. Meliana Zailani, MARS
\par\pard\ql \li1900\sb44\sl-276\slmult0 \up0 \expndtw-3\charscalex100 11.dr. Henry
Boyke Sitompul, Sp.B, FICS \par\pard\ql \li1900\sb44\sl-276\slmult0 \up0 \expndtw-
2\charscalex100 12.Dra. Pipih Karniasih, S.Kp, M.Kep \par\pard\ql \li1900\sb44\sl-
276\slmult0 \up0 \expndtw-2\charscalex100 13.dr. Nurul Ainy Sidik, MARS
\par\pard\ql \li1900\sb44\sl-276\slmult0 \up0 \expndtw-3\charscalex100 14.Dr. dr.
Ina Rosalina, Sp.AK, M.Kes, MH.Kes \par\pard\ql \li1900\sb44\sl-276\slmult0 \up0
\expndtw-2\charscalex100 15.Saida Simanjuntak, S.Kp, MARS \par\pard\ql
\li1900\sb44\sl-276\slmult0 \up0 \expndtw-2\charscalex100 16.dr. Sri Rachmani,
M.Kes, MH.Kes \par\pard\ql \li1900\sb44\sl-276\slmult0 \up0 \expndtw-
2\charscalex100 17.dr. Wasista Budiwaluyo, MHA \par\pard\ql \li1900\sb24\sl-
276\slmult0 \up0 \expndtw-2\charscalex100 18.dr. Dahsriati, Sp.KJ \par\pard\ql
\li1900\sb44\sl-276\slmult0 \up0 \expndtw-2\charscalex100 19.dr. Yawestri Pudjiati
G, MARS \par\pard\ql \li1900\sb44\sl-276\slmult0 \up0 \expndtw-2\charscalex100
20.dr. Tedjo W. Putranto, MM \par\pard\ql \li1900\sb44\sl-276\slmult0 \up0
\expndtw-2\charscalex100 21.Poniwati Yacub, SKM \par\pard\ql \li1900\sb44\sl-
276\slmult0 \up0 \expndtw-2\charscalex100 22.Didin Syaefudin, S.Kp, MARS
\par\pard\ql \li1900\sb44\sl-276\slmult0 \up0 \expndtw-2\charscalex100 23.Dr.
Widaningsih SKp, M.Kep \par\pard\ql \li1900\sb44\sl-276\slmult0 \up0 \expndtw-
2\charscalex100 24.dr. Mary S. Maryam, MHA, PhD \par\pard\ql \li1900\sb44\sl-
276\slmult0 \up0 \expndtw-2\charscalex100 25.Susihar, SKM, MKep \par\pard\ql
\li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb0\sl-253\slmult0
\par\pard\ql\li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb0\sl-253\slmult0
\par\pard\ql\li10355\sb151\sl-253\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf1\f2\fs22 3
\par\pard\sect\sectd\fs24\paperw11900\paperh16820\pard\sb0\sl-240{\bkmkstart Pg4}
{\bkmkend Pg4}\par\pard\ql \li4766\sb0\sl-276\slmult0 \par\pard\ql\li4766\sb0\sl-
276\slmult0 \par\pard\ql\li4766\sb0\sl-276\slmult0 \par\pard\ql\li4766\sb0\sl-
276\slmult0 \par\pard\ql\li4766\sb88\sl-276\slmult0 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 DAFTAR ISI \par\pard\li1548\sb0\sl-
276\slmult0\par\pard\li1548\sb86\sl-276\slmult0\fi0\tx10569 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 PENDAHULUAN\tab \up0 \expndtw-
3\charscalex100 6\par\pard\li1548\sb139\sl-276\slmult0\fi0\tx10569 \up0 \expndtw-
3\charscalex100 KEBIJAKAN UMUM AKREDITASI RUMAH SAKIT\tab \up0 \expndtw-
3\charscalex100 13\par\pard\li1548\sb137\sl-276\slmult0\fi0\tx10569 \up0 \expndtw-
3\charscalex100 KEBIJAKAN PRA SURVEI AKREDITASI\tab \up0 \expndtw-3\charscalex100
19\par\pard\li1548\sb139\sl-276\slmult0\fi0\tx10569 \up0 \expndtw-3\charscalex100
KEBIJAKAN SURVEI AKREDITASI RUMAH SAKIT\tab \up0 \expndtw-3\charscalex100
22\par\pard\li1548\sb137\sl-276\slmult0\fi0\tx10569 \up0 \expndtw-3\charscalex100
KEBIJAKAN PEMBERIAN SKOR\tab \up0 \expndtw-3\charscalex100
30\par\pard\li1548\sb139\sl-276\slmult0\fi0\tx10569 \up0 \expndtw-3\charscalex100
KEBIJAKAN PENENTUAN KELULUSAN\tab \up0 \expndtw-3\charscalex100
36\par\pard\li1548\sb137\sl-276\slmult0\fi0\tx10569 \up0 \expndtw-3\charscalex100
KEBIJAKAN PENUNDAAN PENETAPAN STATUS AKREDITASI\tab \up0 \expndtw-3\charscalex100
38\par\pard\li1548\sb139\sl-276\slmult0\fi0\tx10569 \up0 \expndtw-3\charscalex100
KEBIJAKAN PASCA SURVEI\tab \up0 \expndtw-3\charscalex100
39\par\pard\li1548\sb137\sl-276\slmult0\fi0\tx10569 \up0 \expndtw-3\charscalex100
PERPANJANGAN STATUS AKREDITASI\tab \up0 \expndtw-3\charscalex100
42\par\pard\li1548\sb139\sl-276\slmult0\fi0\tx10569 \up0 \expndtw-3\charscalex100
KEBIJAKAN REMEDIAL\tab \up0 \expndtw-3\charscalex100 42\par\pard\li1548\sb137\sl-
276\slmult0\fi0\tx10569 \up0 \expndtw-3\charscalex100 KEBIJAKAN SURVEI
VERIFIKASI\tab \up0 \expndtw-3\charscalex100 43\par\pard\li1548\sb139\sl-
276\slmult0\fi0\tx10569 \up0 \expndtw-3\charscalex100 KEBIJAKAN SURVEI TERFOKUS\tab
\up0 \expndtw-3\charscalex100 43\par\pard\li1548\sb134\sl-
276\slmult0\fi0\tx10569 \up0 \expndtw-3\charscalex100 KEBIJAKAN
BANDING\ul0\nosupersub\cf8\f9\fs24 (APPEAL)\tab \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf7\f8\fs24 43\par\pard\li1548\sb142\sl-276\slmult0\fi0\tx10569
\up0 \expndtw-3\charscalex100 PENGUNGKAPAN KEPADA PUBLIK DAN KERAHASIAAN\tab
\up0 \expndtw-3\charscalex100 44\par\pard\li1548\sb137\sl-
276\slmult0\fi0\tx10569 \up0 \expndtw-3\charscalex100 KEBIJAKAN PROMOSI
AKREDITASI\tab \up0 \expndtw-3\charscalex100 44\par\pard\li1548\sb139\sl-
276\slmult0\fi107\tx2147\tx10569 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf6\f7\fs24 I.\tab \up0 \expndtw-3\charscalex100 SASARAN
KESELAMATAN PASIEN\tab \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf7\f8\fs24
45\par\pard\li1548\sb137\sl-276\slmult0\fi628\tx10569 \up0 \expndtw-3\charscalex100
SASARAN 1 : MENGIDENTIFIKASI PASIEN DENGAN BENAR\tab \up0 \expndtw-3\charscalex100
45\par\pard\li1548\sb139\sl-276\slmult0\fi628\tx10569 \up0 \expndtw-3\charscalex100
SASARAN 2 : MENINGKATKAN KOMUNIKASI YANG EFEKTIF\tab \up0 \expndtw-3\charscalex100
46\par\pard\li1548\sb137\sl-276\slmult0\fi628\tx10569 \up0 \expndtw-3\charscalex100
SASARAN 3 : MENINGKATKAN KEAMANAN OBAT-OBAT YANG HARUS\tab \up0 \expndtw-
3\charscalex100 49\par\pard\ql \li3710\sb134\sl-276\slmult0 \up0 \expndtw-
3\charscalex100 DIWASPADAI\ul0\nosupersub\cf8\f9\fs24 (HIGH ALERT MEDICATIONS)
\par\pard\li2176\sb142\sl-276\slmult0\fi0\tx10569 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf7\f8\fs24 SASARAN 4 : MEMASTIKAN LOKASI PEMBEDAHAN YANG
BENAR,\tab \up0 \expndtw-3\charscalex100 51\par\pard\qj \li3710\ri1517\sb8\sl-
420\slmult0 \up0 \expndtw-3\charscalex100 PROSEDUR YANG BENAR, PEMBEDAHAN PADA
PASIEN \up0 \expndtw-3\charscalex100 YANG BENAR \par\pard\ql \li2176\sb119\sl-
276\slmult0\tx10569 \up0 \expndtw-3\charscalex100 SASARAN 5 : MENGURANGI RISIKO
INFEKSI TERKAIT PELAYANAN \tab \up0 \expndtw-3\charscalex100 53 \par\pard\ql
\li3710\sb124\sl-276\slmult0 \up0 \expndtw-3\charscalex100 KESEHATAN
\par\pard\li2176\sb153\sl-276\slmult0\fi0\tx10569 \up0 \expndtw-3\charscalex100
SASARAN 6 : MENGURANGI RISIKO CEDERA PASIEN AKIBAT\tab \up0 \expndtw-
3\charscalex100 54\par\pard\li1588\sb137\sl-276\slmult0\fi2121 \up0 \expndtw-
3\charscalex100 TERJATUH\par\pard\li1588\sb139\sl-276\slmult0\fi0\tx2147\tx10569
\up0 \expndtw-3\charscalex100 II.\tab \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf6\f7\fs24 STANDAR PELAYANAN BERFOKUS PASIEN\tab \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 57\par\pard\li1588\sb137\sl-
276\slmult0\fi561\tx10569 \up0 \expndtw-3\charscalex100 BAB 1. AKSES KE RUMAH SAKIT
DAN KONTINUITAS PELAYANAN (ARK)\tab \up0 \expndtw-3\charscalex100
57\par\pard\li1588\sb139\sl-276\slmult0\fi561\tx10569 \up0 \expndtw-3\charscalex100
BAB 2. HAK PASIEN DAN KELUARGA (HPK)\tab \up0 \expndtw-3\charscalex100
78\par\pard\li1588\sb137\sl-276\slmult0\fi561\tx10569 \up0 \expndtw-3\charscalex100
BAB 3. ASESMEN PASIEN (AP)\tab \up0 \expndtw-3\charscalex100
99\par\pard\li1588\sb139\sl-276\slmult0\fi561\tx10569 \up0 \expndtw-3\charscalex100
BAB 4. PELAYANAN DAN ASUHAN PASIEN (PAP)\tab \up0 \expndtw-3\charscalex100
135\par\pard\ql \li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb137\sl-
253\slmult0
\up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf1\f2\fs22 4
\par\pard\sect\sectd\fs24\paperw11900\paperh16820\pard\sb0\sl-240{\bkmkstart Pg5}
{\bkmkend Pg5}\par\pard\li1495\sb0\sl-276\slmult0\par\pard\li1495\sb0\sl-
276\slmult0\par\pard\li1495\sb0\sl-276\slmult0\par\pard\li1495\sb0\sl-
276\slmult0\par\pard\li1495\sb92\sl-276\slmult0\fi655\tx10569 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 BAB 5. PELAYANAN ANESTESI DAN BEDAH
(PAB)\tab \up0 \expndtw-3\charscalex100 153\par\pard\li1495\sb137\sl-
276\slmult0\fi655\tx10569 \up0 \expndtw-3\charscalex100 BAB 6. PELAYANAN
KEFARMASIAN DAN PENGGUNAAN OBAT (PKPO)\tab \up0 \expndtw-3\charscalex100
171\par\pard\li1495\sb139\sl-276\slmult0\fi655\tx10569 \up0 \expndtw-
3\charscalex100 BAB 7. MANAJEMEN KOMUNIKASI DAN EDUKASI (MKE)\tab \up0 \expndtw-
3\charscalex100 187\par\pard\li1495\sb137\sl-276\slmult0\fi26\tx2147\tx10569
\up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 III.\tab \up0 \expndtw-
3\charscalex100 STANDAR MANAJEMEN RUMAH SAKIT\tab \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf7\f8\fs24 198\par\pard\li1495\sb139\sl-
276\slmult0\fi655\tx10569 \up0 \expndtw-3\charscalex100 BAB 1. PENINGKATAN MUTU DAN
KESELAMATAN PASIEN (PMKP)\tab \up0 \expndtw-3\charscalex100
198\par\pard\li1495\sb137\sl-276\slmult0\fi655\tx10569 \up0 \expndtw-
3\charscalex100 BAB 2. PENCEGAHAN DAN PENGENDALIAN INFEKSI (PPI)\tab \up0 \expndtw-
3\charscalex100 226\par\pard\li1495\sb139\sl-276\slmult0\fi655\tx10569 \up0
\expndtw-3\charscalex100 BAB 3. TATA KELOLA RUMAH SAKIT (TKRS)\tab \up0 \expndtw-
3\charscalex100 249\par\pard\li1495\sb137\sl-276\slmult0\fi655\tx10569 \up0
\expndtw-3\charscalex100 BAB 4. MANAJEMEN FASILITAS DAN KESELAMATAN (MFK)\tab
\up0 \expndtw-3\charscalex100 293\par\pard\li1495\sb139\sl-
276\slmult0\fi655\tx10569 \up0 \expndtw-3\charscalex100 BAB 5. KOMPETENSI DAN
KEWENANGAN STAF (KKS)\tab \up0 \expndtw-3\charscalex100
326\par\pard\li1495\sb137\sl-276\slmult0\fi655\tx10569 \up0 \expndtw-
3\charscalex100 BAB 6. MANAJEMEN INFORMASI DAN REKAM MEDIS (MIRM)\tab \up0
\expndtw-3\charscalex100 353\par\pard\li1495\sb139\sl-276\slmult0\fi0\tx2147
\up0 \expndtw-3\charscalex100 IV.\tab \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf6\f7\fs24 PROGRAM NASIONAL\par\pard\li1495\sb137\sl-
276\slmult0\fi655\tx10569 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf7\f8\fs24
SASARAN I PENURUNAN ANGKA KEMATIAN IBU DAN BAYI DAN\tab \up0 \expndtw-
3\charscalex100 369\par\pard\li1548\sb139\sl-276\slmult0\fi2135 \up0 \expndtw-
4\charscalex100 PENINGKATAN KESEHATAN IBU DAN BAYI\par\pard\li1548\sb137\sl-
276\slmult0\fi602\tx10569 \up0 \expndtw-4\charscalex100 SASARAN II PENURUNAN
ANGKA KESAKITAN HIV/AIDS\tab \up0 \expndtw-4\charscalex100
372\par\pard\li1548\sb139\sl-276\slmult0\fi602\tx10569 \up0 \expndtw-
4\charscalex100 SASARAN III PENURUNAN ANGKA KESAKITAN TUBERKULOSIS\tab \up0
\expndtw-4\charscalex100 373\par\pard\li1548\sb137\sl-276\slmult0\fi602\tx10569
\up0 \expndtw-4\charscalex100 SASARAN IV PENGENDALIAN RESISTENSI
ANTIMIKROBA\tab \up0 \expndtw-4\charscalex100 376\par\pard\li1548\sb139\sl-
276\slmult0\fi602\tx10569 \up0 \expndtw-4\charscalex100 SASARAN V PELAYANAN
GERIATRI\tab \up0 \expndtw-4\charscalex100 379\par\pard\li1548\sb137\sl-
276\slmult0\fi14\tx2147\tx10569 \up0 \expndtw-4\charscalex100 V.\tab \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 INTEGRASI PENDIDIKAN KESEHATAN DALAM
PELAYANAN RUMAH\tab \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf7\f8\fs24
381\par\pard\li1548\sb139\sl-276\slmult0\fi599 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf6\f7\fs24 SAKIT (IPKP)\par\pard\li1548\sb137\sl-
276\slmult0\fi0\tx10569 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf7\f8\fs24
DAFTAR SINGKATAN DAN ISTILAH (GLOSSARY)\tab \up0 \expndtw-4\charscalex100
389\par\pard\li1548\sb139\sl-276\slmult0\fi0\tx10569 \up0 \expndtw-4\charscalex100
DAFTAR PUSTAKA\tab \up0 \expndtw-4\charscalex100 405\par\pard\ql \li10355\sb0\sl-
253\slmult0 \par\pard\ql\li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb0\sl-
253\slmult0 \par\pard\ql\li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb0\sl-
253\slmult0 \par\pard\ql\li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb0\sl-
253\slmult0 \par\pard\ql\li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb0\sl-
253\slmult0 \par\pard\ql\li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb0\sl-
253\slmult0 \par\pard\ql\li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb0\sl-
253\slmult0 \par\pard\ql\li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb0\sl-
253\slmult0 \par\pard\ql\li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb0\sl-
253\slmult0 \par\pard\ql\li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb0\sl-
253\slmult0 \par\pard\ql\li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb0\sl-
253\slmult0 \par\pard\ql\li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb13\sl-
253\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf1\f2\fs22 5
\par\pard\sect\sectd\fs24\paperw11900\paperh16820\pard\sb0\sl-240{\bkmkstart Pg6}
{\bkmkend Pg6}\par\pard\ql \li5025\sb0\sl-276\slmult0 \par\pard\ql\li5025\sb0\sl-
276\slmult0 \par\pard\ql\li5025\sb0\sl-276\slmult0 \par\pard\ql\li5025\sb0\sl-
276\slmult0 \par\pard\ql\li5025\sb88\sl-276\slmult0 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 PENDAHULUAN \par\pard\qj
\li1440\ri1183\sb311\sl-317\slmult0 \up0 \expndtw0\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Akreditasi Rumah Sakit di Indonesia dilaksanakan untuk
menilai kepatuhan rumah \line \up0 \expndtw0\charscalex103 sakit terhadap standa
akreditasi. Akreditasi rumah sakit yang sudah mulai \line \up0 \expndtw-
1\charscalex100 dilaksanakan sejak tahun 1995 di Indonesia, selama ini
menggunakan standar \line \up0 \expndtw0\charscalex103 akreditasi berdasarkan
tahun berapa standar tersebut mulai dipergunakan untuk \line \up0 \expndtw-
3\charscalex100 penilaian, sehingga selama ini belum pernah ada Standar Nasional
Akreditasi Rumah \line \up0 \expndtw-2\charscalex100 Sakit di Indonesia, sedangkan
status akreditasi saat ini ada status akreditasi nasional \line \up0
\expndtw0\charscalex100 dan status akreditasi internasional, maka di Indonesia
perlu ada Standar\ul0\nosupersub\cf6\f7\fs24 Nasional \line \up0
\expndtw0\charscalex103 \ul0\nosupersub\cf7\f8\fs24 Akreditasi Rumah Sakit.
Berdasarkan hal tersebut maka standar akreditasi untuk \line \up0
\expndtw0\charscalex104 rumah sakit yang mulai diberlakukan pada Januari 2018 ini
diberi nama Standar \line \up0 \expndtw-2\charscalex100 Nasional Akreditasi Rumah
Sakit Edisi 1 dan disingkat menjadi SNARS Edisi 1. \par\pard\qj \li1440\sb0\sl-
320\slmult0 \par\pard\qj\li1440\ri1233\sb1\sl-320\slmult0 \up0 \expndtw-
2\charscalex100 Standar Nasional Akreditasi Rumah Sakit Edisi 1, merupakan standar
akreditasi baru \up0 \expndtw-1\charscalex100 yang bersifat nasional dan
diberlakukan secara nasional di Indonesia. Disebut \up0
\expndtw0\charscalex102 dengan edisi 1, karena di Indonesia baru pertama kali
ditetapkan standar nasional \up0 \expndtw-3\charscalex100 untuk akreditasi rumah
sakit. \par\pard\qj \li1440\ri1243\sb0\sl-320\slmult0 \up0 \expndtw0\charscalex100
Standar Nasional Akreditasi Rumah Sakit edisi 1 berisi 16 bab. Dalam
Standar \up0 \expndtw0\charscalex102 Nasional Akreditasi Rumah Sakit Edisi 1 yang
selanjutnya disebut SNARS Edisi 1 \up0 \expndtw0\charscalex100 ini juga dijelaskan
bagaimana proses penyusunan, penambahan bab penting pada \up0 \expndtw-
2\charscalex100 SNARS Edisi 1 ini, referensi dari setiap bab dan juga glosarium
istilah-istilah penting, \up0 \expndtw-3\charscalex100 termasuk juga kebijakan
pelaksanaan akreditasi rumah sakit. \par\pard\ql \li1996\sb0\sl-276\slmult0
\par\pard\ql\li1996\sb0\sl-276\slmult0 \par\pard\ql\li1996\sb105\sl-276\slmult0
\up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Proses Penyusunan Standar
Nasional Akreditasi Rumah Sakit Edisi 1 \par\pard\qj \li1440\ri1243\sb308\sl-
320\slmult0 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Pada tahap
awal Komisi Akreditasi Rumah Sakit (KARS) membentuk Tim penyusun \line \up0
\expndtw0\charscalex104 yang terdiri dari 25 orang, Tim tersebut dibagi menjadi
sub tim-sub tim, masing-\line \up0 \expndtw0\charscalex100 masing sub tim mereview
3 - 4 bab dari standar akreditasi versi 2012. Mengingat di \line \up0 \expndtw-
2\charscalex100 tingkat internasional ada panduan prinsip-prinsip standar
akreditasi yang dikeluarkan \line \up0 \expndtw0\charscalex100 oleh ISQua (The
International Society for Quality in Health Care) yaitu badan \line \up0
\expndtw0\charscalex103 akreditasi yang melakukan akreditasi standar akreditasi
yang dipergunakan oleh \line \up0 \expndtw-3\charscalex100 badan akreditasi.
\par\pard\ql \li1440\ri1235\sb0\sl-320\slmult0 \up0 \expndtw0\charscalex104 Langkah
awal yang dilakukan KARS adalah mengundang pakar akreditasi untuk \up0
\expndtw0\charscalex103 menjelaskan bagaimana prinsip-prinsip standar akreditasi
dari ISQua yang harus \up0 \expndtw-3\charscalex100 diperhatikan oleh KARS dalam
menyusun standar akreditasi di Indonesia. \line \up0 \expndtw-1\charscalex100
Berdasarkan hal tersebut maka Standar Nasional Akreditasi Rumah Sakit Edisi 1
ini, \up0 \expndtw-2\charscalex100 disusun dengan menggunakan acuan acuan sebagai
berikut: \par\pard\ql \li1646\sb17\sl-276\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24 Prinsip-prinsip
standar akreditasi dari ISQua \par\pard\ql \li1646\ri1186\sb28\sl-
320\slmult0\tx2006\tx2006 \up0 \expndtw-2\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24 Peraturan dan
perundangan-undangan termasuk pedoman dan panduan di \line\tab \up0 \expndtw-
2\charscalex100 tingkat Nasional baik dari pemerintah maupun profesi yang wajib
dipatuhi dan \line \tab \up0 \expndtw-4\charscalex100 dilaksanakan oleh rumah
sakit di Indonesia \par\pard\ql \li1646\sb57\sl-276\slmult0
\up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3913?\ul0\nosupersub\cf7\f8\fs24 Standar akreditasi JCI edisi 4 dan edisi 5
\par\pard\ql \li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb230\sl-
253\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf1\f2\fs22 6

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{\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn
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}}\par\pard\sect\sectd\fs24\paperw11900\paperh16820\pard\sb0\sl-240{\bkmkstart Pg7}
{\bkmkend Pg7}\par\pard\ql \li1646\sb0\sl-276\slmult0 \par\pard\ql\li1646\sb0\sl-
276\slmult0 \par\pard\ql\li1646\sb0\sl-276\slmult0 \par\pard\ql\li1646\sb0\sl-
276\slmult0 \par\pard\ql\li1646\sb88\sl-276\slmult0 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24
Standar akreditasi rumah sakit KARS versi 2012 \par\pard\qj \li1646\ri1204\sb28\sl-
320\slmult0\tx2006 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3913?\ul0\nosupersub\cf7\f8\fs24 Hasil kajian hasil survei dari standar dan
elemen yang sulit dipenuhi oleh rumah \line\tab \up0 \expndtw-3\charscalex100 sakit
di Indonesia \par\pard\qj \li1440\sb0\sl-317\slmult0
\par\pard\qj\li1440\ri1184\sb6\sl-317\slmult0 \up0 \expndtw0\charscalex100 Setelah
draft standar nasional akreditasi rumah sakit selesai disusun oleh masing-\line
\up0 \expndtw-4\charscalex100 masing sub tim, KARS mengadakan pertemuan tim
penyusun untuk membahas setiap \line \up0 \expndtw0\charscalex102 bab yang ada di
dalam standar akreditasi tersebut. Masukan dari anggota sub tim \line \up0
\expndtw-1\charscalex100 lainnya, dipergunakan oleh sub tim untuk memperbaiki
standar, selanjutnya masing-\line \up0 \expndtw0\charscalex102 masing sub tim
membahas dengan pemangku kepentingan\ul0\nosupersub\cf8\f9\fs24
(stakeholder)\ul0\nosupersub\cf7\f8\fs24 terkait. \line \up0
\expndtw0\charscalex100 Sebagai contoh untuk bab Pencegahan dan Pengendalian
Infeksi, dibahas dengan \line \up0 \expndtw-2\charscalex100 mengundang Kementerian
Kesehatan, Perhimpunan Rumah Sakit Seluruh Indonesia \line \up0 \expndtw-
3\charscalex100 (PERSI), Persatuan Perawat Nasional Indonesia \up0 \expndtw-
3\charscalex100 (PPNI), Himpunan Perawat \par\pard\qj \li1440\ri1245\sb7\sl-
313\slmult0 \up0 \expndtw-1\charscalex100 Pencegahan dan Pengendalian Infeksi
(HIPPI), Persatuan Pengendalian Infeksi \up0 \expndtw0\charscalex104 (Perdalin)
dan lain-lain. Pembahasan dilakukan untuk setiap bab yang dilakukan \up0 \expndtw-
2\charscalex100 secara intens, sehingga terjadi diskusi dua arah dan masukan-
masukan yang sangat \up0 \expndtw-3\charscalex100 bermanfaat. \par\pard\qj
\li1440\ri1243\sb2\sl-320\slmult0 \up0 \expndtw0\charscalex100 Berdasarkan masukan
dari pemangku kepentingan\ul0\nosupersub\cf8\f9\fs24
(stakeholder)\ul0\nosupersub\cf7\f8\fs24 tersebut, sub tim \line \up0
\expndtw0\charscalex100 melakukan perbaikan draft standar tersebut. Setelah
perbaikan selesai dilakukan di \line \up0 \expndtw-2\charscalex100 masing-masing
sub tim, Komisi Akreditasi Rumah Sakit (KARS) mengundang semua \line \up0 \expndtw-
3\charscalex100 pemangku kepentingan \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf8\f9\fs24 (stakeholder)\ul0\nosupersub\cf7\f8\fs24 dan
beberapa rumah sakit yang akan \par\pard\qj \li1440\ri1184\sb4\sl-
316\slmult0 \up0 \expndtw0\charscalex103 dipergunakan uji coba untuk membahas
standar tersebut secara pleno. Masukan \line \up0 \expndtw0\charscalex103 pada
rapat pleno tersebut oleh masing-masing sub tim dipergunakan untuk \line
\up0 \expndtw-1\charscalex100 memperbaiki draft standar tersebut. Hasil
perbaikan draft standar tersebut diuji \line \up0 \expndtw-1\charscalex100
cobakan ke rumah sakit berdasarkan kelas dan jenis rumah sakit. Rumah sakit yang
\line \up0 \expndtw-4\charscalex100 dipilih sebagai tempat uji coba, dikirimi
terlebih dahulu draft standar akreditasi tersebut \line \up0 \expndtw-
4\charscalex100 dan diminta secara aktif untuk membahas standar akreditasi tersebut
di internal rumah \line \up0 \expndtw0\charscalex103 sakit, baik dari segi tata
bahasa maupun bisa tidaknya standar tersebut di \line \up0 \expndtw-
3\charscalex100 implementasikan. Setelah itu KARS menugaskan tim penyusun melakukan
kunjungan \line \up0 \expndtw0\charscalex106 ke rumah sakit untuk melakukan diskusi
dengan tim akreditasi rumah sakit dan \line \up0 \expndtw0\charscalex104 pimpinan
di rumah sakit. Rumah sakit diminta membuat masukan tertulis terkait \line \up0
\expndtw-2\charscalex100 dengan standar dan elemen yang perlu diperbaiki,
dihilangkan atau ditambah. \par\pard\qj \li1440\sb0\sl-320\slmult0
\par\pard\qj\li1440\ri1248\sb1\sl-320\slmult0 \up0 \expndtw-1\charscalex100 Tim
penyusun memperbaiki draft standar kembali dengan memperhatikan masukan \up0
\expndtw0\charscalex100 dari rumah sakit dan selanjutnya dibahas secara
internal di Rapat KARS dan \up0 \expndtw0\charscalex103 kemudian diunggah
di\ul0\nosupersub\cf8\f9\fs24 website\ul0\nosupersub\cf7\f8\fs24 www.kars.or.id,
dengan harapan dapat mendapat \up0 \expndtw-3\charscalex100 masukan dari rumah
sakit lainnya dan masyarakat. \par\pard\qj \li1440\ri1184\sb300\sl-320\slmult0 \up0
\expndtw0\charscalex100 Setelah tim melakukan perbaikan berdasarkan masukan
dari rumah sakit dan \up0 \expndtw-4\charscalex100 unggahan
di\ul0\nosupersub\cf8\f9\fs24 website\ul0\nosupersub\cf7\f8\fs24 maka Komisi
Akreditasi Rumah Sakit mempresentasikan standar \up0 \expndtw-2\charscalex100
tersebut dihadapan para pejabat Kementerian Kesehatan dan Badan Pembina KARS
\up0 \expndtw-1\charscalex100 serta mengajukan penetapan Standar Nasional
Akreditasi Rumah Sakit Edisi 1 yang \up0 \expndtw-2\charscalex100 efektif akan
diberlakukan di bulan Januari 2018. \par\pard\ql \li10355\sb0\sl-253\slmult0
\par\pard\ql\li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb0\sl-253\slmult0
\par\pard\ql\li10355\sb57\sl-253\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf1\f2\fs22 7
\par\pard\sect\sectd\fs24\paperw11900\paperh16820\pard\sb0\sl-240{\bkmkstart Pg8}
{\bkmkend Pg8}\par\pard\ql \li2215\sb0\sl-276\slmult0 \par\pard\ql\li2215\sb0\sl-
276\slmult0 \par\pard\ql\li2215\sb0\sl-276\slmult0 \par\pard\ql\li2215\sb0\sl-
276\slmult0 \par\pard\ql\li2215\sb88\sl-276\slmult0 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Pengelompokan Standar Nasional
Akreditasi Rumah Sakit Edisi 1 \par\pard\qj \li1440\ri1241\sb308\sl-320\slmult0
\up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Standar dikelompokkan
menurut fungsi-fungsi penting yang umum dalam organisasi \up0
\expndtw0\charscalex103 perumahsakitan. Pengelompokan berdasarkan fungsi, saat
ini paling banyak \up0 \expndtw-3\charscalex100 digunakan di seluruh dunia.
\par\pard\qj \li1440\ri1191\sb3\sl-317\slmult0 \up0 \expndtw0\charscalex100 Standar
dikelompokkan menurut fungsi-fungsi yang terkait dengan penyediaan \line \up0
\expndtw-2\charscalex100 pelayanan bagi pasien; juga dengan upaya menciptakan
organisasi rumah sakit yang \line \up0 \expndtw-1\charscalex100 aman, efektif, dan
terkelola dengan baik. Fungsi-fungsi tersebut tidak hanya berlaku \line \up0
\expndtw0\charscalex102 untuk rumah sakit secara keseluruhan tetapi juga untuk
setiap unit, departemen, \line \up0 \expndtw0\charscalex100 atau layanan yang ada
dalam organisasi rumah sakit tersebut. Lewat proses survei \line \up0 \expndtw-
2\charscalex100 dikumpulkan informasi sejauh mana seluruh organisasi mentaati
pedoman yang \line \up0 \expndtw-3\charscalex100 ditentukan oleh standar.
Keputusan pemberian akreditasinya didasarkan pada tingkat \line \up0 \expndtw-
2\charscalex100 kepatuhan terhadap standar di seluruh organisasi rumah sakit yang
bersangkutan. \line \up0 \expndtw-2\charscalex100 Pengelompokan Standar Nasional
Akreditasi Rumah Sakit Edisi 1 (SNARS Edisi \up0 \expndtw-3\charscalex100 1)
\par\pard\ql \li1440\sb37\sl-276\slmult0 \up0 \expndtw-3\charscalex100 sebagai
berikut: \par\pard\ql \li1655\sb0\sl-276\slmult0 \par\pard\ql\li1655\sb88\sl-
276\slmult0\tx2147 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 I.
\tab \up0 \expndtw-3\charscalex100 SASARAN KESELAMATAN PASIEN \par\pard\qj
\li2147\ri3575\sb44\sl-640\slmult0 \up0 \expndtw-6\charscalex100
\ul0\nosupersub\cf7\f8\fs24 SASARAN 1 : Mengidentifikasi pasien dengan
benar \line \up0 \expndtw-6\charscalex100 SASARAN 2 : Meningkatkan
komunikasi yang efektif \par\pard\ql \li2147\sb0\sl-276\slmult0
\par\pard\ql\li2147\sb25\sl-276\slmult0 \up0 \expndtw-5\charscalex100 SASARAN 3
: Meningkatkan keamanan obat-obatan yang harus \par\pard\ql \li4017\sb44\sl-
276\slmult0 \up0 \expndtw-3\charscalex100 diwaspadai (High Alert Medications)
\par\pard\ql \li2147\sb0\sl-276\slmult0 \par\pard\ql\li2147\sb68\sl-276\slmult0
\up0 \expndtw-6\charscalex100 SASARAN 4 : Memastikan lokasi pembedahan yang
benar, \par\pard\qj \li4017\ri2567\sb8\sl-320\slmult0 \up0 \expndtw-3\charscalex100
prosedur yang benar, pembedahan pada pasien \up0 \expndtw-3\charscalex100 yang
benar. \par\pard\ql \li2147\sb0\sl-276\slmult0 \par\pard\ql\li2147\sb81\sl-
276\slmult0 \up0 \expndtw-7\charscalex100 SASARAN 5 : Mengurangi risiko
infeksi terkait \par\pard\ql \li4017\sb44\sl-276\slmult0 \up0 \expndtw-
3\charscalex100 pelayanan kesehatan \par\pard\ql \li2147\sb0\sl-276\slmult0
\par\pard\ql\li2147\sb88\sl-276\slmult0 \up0 \expndtw-6\charscalex100 SASARAN 6
: Mengurangi risiko cedera pasien akibat terjatuh \par\pard\ql \li1588\sb0\sl-
276\slmult0 \par\pard\ql\li1588\sb68\sl-276\slmult0\tx2147 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 II. \tab \up0 \expndtw-3\charscalex100
STANDAR PELAYANAN BERFOKUS PASIEN \par\pard\ql \li2147\sb44\sl-276\slmult0 \up0
\expndtw-3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 1. Akses ke Rumah Sakit dan
Kontinuitas Pelayanan (ARK) \par\pard\ql \li2147\sb44\sl-276\slmult0 \up0 \expndtw-
2\charscalex100 2. Hak Pasien dan Keluarga (HPK) \par\pard\ql \li2147\sb44\sl-
276\slmult0 \up0 \expndtw-2\charscalex100 3. Asesmen Pasien (AP) \par\pard\ql
\li2147\sb44\sl-276\slmult0 \up0 \expndtw-2\charscalex100 4. Pelayanan dan Asuhan
Pasien (PAP) \par\pard\ql \li2147\sb44\sl-276\slmult0 \up0 \expndtw-3\charscalex100
5. Pelayanan Anestesi dan Bedah (PAB) \par\pard\ql \li2147\sb44\sl-276\slmult0
\up0 \expndtw-3\charscalex100 6. Pelayanan Kefarmasian dan Penggunaan Obat
(PKPO) \par\pard\ql \li2147\sb24\sl-276\slmult0 \up0 \expndtw-2\charscalex100 7.
Manajemen Komunikasi dan Edukasi (MKE) \par\pard\ql \li1521\sb0\sl-276\slmult0
\par\pard\ql\li1521\sb88\sl-276\slmult0\tx2147 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf6\f7\fs24 III. \tab \up0 \expndtw-3\charscalex100 STANDAR
MANAJEMEN RUMAH SAKIT \par\pard\ql \li10355\sb223\sl-253\slmult0 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf1\f2\fs22 8

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}}\par\pard\sect\sectd\fs24\paperw11900\paperh16820\pard\sb0\sl-240{\bkmkstart Pg9}
{\bkmkend Pg9}\par\pard\ql \li2147\sb0\sl-276\slmult0 \par\pard\ql\li2147\sb0\sl-
276\slmult0 \par\pard\ql\li2147\sb0\sl-276\slmult0 \par\pard\ql\li2147\sb0\sl-
276\slmult0 \par\pard\ql\li2147\sb88\sl-276\slmult0 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 1. Peningkatan Mutu dan Keselamatan
Pasien (PMKP) \par\pard\ql \li2147\sb44\sl-276\slmult0 \up0 \expndtw-
3\charscalex100 2. Pencegahan dan Pengendalian Infeksi (PPI) \par\pard\ql
\li2147\sb24\sl-276\slmult0 \up0 \expndtw-2\charscalex100 3. Tata Kelola Rumah
Sakit (TKRS) \par\pard\ql \li2147\sb44\sl-276\slmult0 \up0 \expndtw-3\charscalex100
4. Manajemen Fasilitas dan Keselamatan (MFK) \par\pard\ql \li2147\sb44\sl-
276\slmult0 \up0 \expndtw-3\charscalex100 5. Kompetensi dan Kewenangan Staf
(KKS) \par\pard\ql \li2147\sb44\sl-276\slmult0 \up0 \expndtw-3\charscalex100 6.
Manajemen Informasi dan Rekam Medis (MIRM) \par\pard\li1495\sb0\sl-
276\slmult0\par\pard\li1495\sb95\sl-276\slmult0\fi0\tx2147 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 IV.\tab \up0 \expndtw-3\charscalex100
PROGRAM NASIONAL\par\pard\ql \li2147\sb37\sl-276\slmult0 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 1. Menurunkan Angka Kematian Ibu dan
Bayi. \par\pard\ql \li2147\sb44\sl-276\slmult0 \up0 \expndtw-2\charscalex100 2.
Menurukan Angka Kesakitan HIV/AIDS. \par\pard\ql \li2147\sb24\sl-276\slmult0
\up0 \expndtw-2\charscalex100 3. Menurukan Angka Kesakitan TB \par\pard\ql
\li2147\sb44\sl-276\slmult0 \up0 \expndtw-3\charscalex100 4. Pengendalian
Resistensi Antimikroba (PPRA) \par\pard\ql \li2147\sb44\sl-276\slmult0 \up0
\expndtw-2\charscalex100 5. Pelayanan Geriatri \par\pard\qj \li1562\sb0\sl-
320\slmult0 \par\pard\qj\li1562\ri1244\sb8\sl-320\slmult0\tx2147 \up0
\expndtw0\charscalex100 \ul0\nosupersub\cf6\f7\fs24 V. INTEGRASI PENDIDIKAN
KESEHATAN DALAM PELAYANAN DI RUMAH \line\tab \up0 \expndtw-3\charscalex100 SAKIT
\par\pard\ql \li1636\sb0\sl-276\slmult0 \par\pard\ql\li1636\sb0\sl-276\slmult0
\par\pard\ql\li1636\sb105\sl-276\slmult0 \up0 \expndtw-2\charscalex100 Yang Perlu
Diketahui Pada Standar Nasional Akreditasi Rumah Sakit edisi 1 \par\pard\qj
\li1440\ri1238\sb8\sl-320\slmult0 \up0 \expndtw0\charscalex103
\ul0\nosupersub\cf7\f8\fs24 Standar Nasional Akreditasi Rumah Sakit Edisi 1
merupakan standar pelayanan \up0 \expndtw0\charscalex102 berfokus pada pasien untuk
meningkatkan mutu dan keselamatan pasien dengan \up0 \expndtw-3\charscalex100
pendekatan manajemen risiko di Rumah Sakit. \par\pard\ql \li1440\sb37\sl-
276\slmult0 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Setiap elemen
penilaian dilengkapi dengan (R) atau (D), atau (W) atau (O) atau \par\pard\ql
\li1440\sb44\sl-276\slmult0 \up0 \expndtw-3\charscalex100 (S), atau kombinasinya
yang berarti sebagai berikut : \par\pard\ql \li1540\ri1223\sb14\sl-
313\slmult0\tx2147\tx2147\tx2147 \up0 \expndtw0\charscalex100
\ul0\nosupersub\cf7\f8\fs24 (R) =Regulasi, yang dimaksud dengan regulasi adalah
dokumen pengaturan yang \line\tab \up0 \expndtw-2\charscalex100 disusun oleh
rumah sakit yang dapat berupa kebijakan, prosedur (SPO), \line \tab \up0
\expndtw-2\charscalex100 pedoman, panduan, peraturan Direktur rumah sakit,
keputusan Direktur rumah \line \tab \up0 \expndtw-3\charscalex100 sakit dan atau
program. \par\pard\ql \li1540\ri1209\sb2\sl-320\slmult0\tx2147\tx2147\tx2147
\up0 \expndtw-2\charscalex100 (D) = Dokumen, yang dimaksud dengan dokumen adalah
bukti proses kegiatan atau \line\tab \up0 \expndtw-1\charscalex100 pelayanan yang
dapat berbentuk berkas rekam medis, laporan dan atau \line \tab \up0
\expndtw0\charscalex100 notulen rapat dan atau hasil audit dan atau ijazah
dan bukti dokumen \line \tab \up0 \expndtw-3\charscalex100 pelaksanaan kegiatan
lainnya. \par\pard\ql \li1540\ri1246\sb9\sl-310\slmult0\tx2147\tx2147 \up0
\expndtw-1\charscalex100 (O) =Observasi, yang dimaksud dengan observasi
adalah bukti kegiatan yang \line\tab \up0 \expndtw0\charscalex100 didapatkan
berdasarkan hasil penglihatan/observasi yang dilakukan oleh \line \tab \up0
\expndtw-3\charscalex100 surveior. \par\pard\qj \li1540\ri1243\sb2\sl-
320\slmult0\tx2147 \up0 \expndtw0\charscalex102 (S) =Simulasi, yang dimaksud dengan
simulasi adalah peragaaan kegiatan yang \line\tab \up0 \expndtw-3\charscalex100
dilakukan oleh staf rumah sakit yang diminta oleh surveior. \par\pard\ql
\li1540\ri1244\sb5\sl-315\slmult0\tx2147\tx2147\tx2147\tx2147 \up0 \expndtw-
1\charscalex100 (W) =Wawancara, yang dimaksud dengan wawancara adalah kegiatan
tanya jawab \line\tab \up0 \expndtw0\charscalex100 yang dilakukan oleh surveior
yang ditujukan kepada pemilik/representasi \line \tab \up0
\expndtw0\charscalex100 pemilik, direktur rumah sakit, pimpinan rumah sakit,
profesional pemberi \line \tab \up0 \expndtw-2\charscalex100 asuhan (PPA), staf
klinis, staf non klinis, pasien, keluarga, tenaga kontrak dan \line \tab \up0
\expndtw-3\charscalex100 lain-lain. \par\pard\ql \li10355\sb0\sl-253\slmult0
\par\pard\ql\li10355\sb0\sl-253\slmult0 \par\pard\ql\li10355\sb0\sl-253\slmult0
\par\pard\ql\li10355\sb98\sl-253\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf1\f2\fs22 9

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}}\par\pard\sect\sectd\fs24\paperw11900\paperh16820\pard\sb0\sl-240{\bkmkstart
Pg10}{\bkmkend Pg10}\par\pard\ql \li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb132\sl-276\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf6\f7\fs24 Ada beberapa perubahan nama bab yaitu: \par\pard\qj
\li1507\ri1196\sb8\sl-320\slmult0\tx1867 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3928?\ul0\nosupersub\cf7\f8\fs24 Akses Pelayanan
dan Kontinuitas (APK) berubah nama menjadi Akses ke Rumah \line\tab \up0 \expndtw-
4\charscalex100 Sakit dan Kontinuitas Pelayanan (ARK) \par\pard\qj
\li1507\ri1251\sb20\sl-320\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3928?\ul0\nosupersub\cf7\f8\fs24 Pelayanan Pasien
(PP) berubah nama menjadi Pelayanan Asuhan Pasien (PAP) \line \up0 \expndtw-
5\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3928?\ul0\nosupersub\cf7\f8\fs24
Manajemen Penggunaan Obat \up0 \expndtw-5\charscalex100 (MPO) berubah nama
menjadi Pelayanan \par\pard\ql \li1867\sb37\sl-276\slmult0 \up0 \expndtw-
3\charscalex100 Kefarmasian dan Penggunaan Obat (PKPO) \par\pard\ql
\li1507\ri1244\sb28\sl-320\slmult0\tx1867\tx1867 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3928?\ul0\nosupersub\cf7\f8\fs24 Pendidikan
Pasien dan Keluarga (PPK) berubah nama menjadi Manajemen \line\tab \up0
\expndtw-4\charscalex100 Komunikasi dan Edukasi (MKE), dimana beberapa
standar dari Manajemen \line \tab \up0 \expndtw-5\charscalex100 Komunikasi dan
Informasi \up0 \expndtw-5\charscalex100 (MKI) standar versi \up0 \expndtw-
5\charscalex100 2012 yang terkait dengan \par\pard\ql \li1867\sb37\sl-
276\slmult0 \up0 \expndtw-3\charscalex100 komunikasi, dijadikan satu di Manajemen
Komunikasi dan Edukasi ini. \par\pard\qj \li1507\ri1247\sb8\sl-
320\slmult0\tx1867 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3928?\ul0\nosupersub\cf7\f8\fs24 Tata Kelola, Kepemimpinan dan Pengarahan (TKP)
berubah nama menjadi Tata \line\tab \up0 \expndtw-4\charscalex100 Kelola Rumah
Sakit (TKRS) \par\pard\qj \li1507\ri1248\sb20\sl-320\slmult0\tx1867 \up0
\expndtw0\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3928?\ul0\nosupersub\cf7\f8\fs24 Kualifikasi dan Pendidikan Staf (KPS) berubah
nama menjadi Kompetensi dan \line\tab \up0 \expndtw-5\charscalex100 Kewenangan Staf
(KKS) \par\pard\qj \li1507\ri1250\sb0\sl-320\slmult0\tx1867 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3928?\ul0\nosupersub\cf7\f8\fs24
Manajemen Komunikasi dan Informasi (MKI) berubah nama menjadi Manajemen
\line\tab \up0 \expndtw-4\charscalex100 Informasi dan Rekam Medis (MIRM)
\par\pard\qj \li1507\ri1191\sb20\sl-320\slmult0\tx1867 \up0 \expndtw-
2\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3928?\ul0\nosupersub\cf7\f8\fs24
Sasaran Milenium Development Goals (SMDGs) berubah nama menjadi Program
\line\tab \up0 \expndtw-5\charscalex100 Nasional dimana terdiri dari:
\par\pard\qj \li1955\ri1252\sb0\sl-320\slmult0\tx2315 \up0 \expndtw0\charscalex100
1. menurunkan angka kematian ibu dan bayi serta meningkatkan angka
\line\tab \up0 \expndtw-3\charscalex100 kesehatan ibu dan bayi \par\pard\ql
\li1955\sb17\sl-276\slmult0 \up0 \expndtw-4\charscalex100 2. menurunkan angka
kesakitan HIV/AIDS \par\pard\ql \li1955\sb44\sl-276\slmult0 \up0 \expndtw-
4\charscalex100 3. menurunkan angka kesakitan tuberkulosis \par\pard\ql
\li1955\sb44\sl-276\slmult0 \up0 \expndtw-4\charscalex100 4. pengendalian
resistensi antimikroba \par\pard\ql \li1955\sb44\sl-276\slmult0 \up0 \expndtw-
4\charscalex100 5. pelayanan geriatri \par\pard\qj \li1440\sb0\sl-320\slmult0
\par\pard\qj\li1440\ri1241\sb8\sl-320\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf6\f7\fs24 Ada penambahan standar pada Standar Nasional Akreditasi
Rumah Sakit Edisi \up0 \expndtw-4\charscalex100 1 ini yaitu: \par\pard\ql
\li1507\sb37\sl-276\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3928?\ul0\nosupersub\cf6\f7\fs24 Pengendalian
Reistensi Antimikroba (PRA) \par\pard\qj \li1867\ri1183\sb8\sl-320\slmult0 \up0
\expndtw-4\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Pengendalian Resistensi
Antimikroba (PRA) merupakan upaya pengendalian \line \up0 \expndtw-
1\charscalex100 resistensi antimikroba secara terpadu dan paripurna di
fasilitas pelayanan \line \up0 \expndtw-3\charscalex100 kesehatan termasuk rumah
sakit dan merupakan standar baru di dalam Standar \line \up0 \expndtw-
3\charscalex100 Nasional Akreditasi Rumah Sakit Edisi 1 ini. Standar ini dianggap
perlu mengingat \line \up0 \expndtw-4\charscalex100 Resistensi mikroba terhadap
antimikroba \up0 \expndtw-4\charscalex100 (disingkat: resistensi antimikroba,
\par\pard\qj \li1867\ri1189\sb0\sl-320\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf8\f9\fs24 antimicrobial resistance,\ul0\nosupersub\cf7\f8\fs24
AMR) telah menjadi masalah kesehatan yang mendunia, \line \up0
\expndtw0\charscalex103 dengan berbagai dampak merugikan yang dapat
menurunkan mutu dan \line \up0 \expndtw0\charscalex103 meningkatkan risiko
pelayanan kesehatan khususnya biaya dan keselamatan \line \up0 \expndtw-
3\charscalex100 pasien. \par\pard\ql \li1507\sb237\sl-276\slmult0 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3928?\ul0\nosupersub\cf6\f7\fs24
Integrasi Pendidikan Kesehatan dalam Pelayanan Rumah Sakit (IPKP) \par\pard\qj
\li1867\ri1242\sb16\sl-310\slmult0 \up0 \expndtw0\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Standar Integrasi Pelayanan dalam Pendidikan Klinis di
Rumah Sakit (IPKP) \line \up0 \expndtw0\charscalex100 merupakan standar baru di
Standar Nasional Akreditasi Rumah Sakit Edisi 1. \line \up0 \expndtw-
4\charscalex100 Standar IPKP ini hanya diberlakukan untuk rumah sakit yang
menyelenggarakan \par\pard\ql \li10243\sb0\sl-253\slmult0
\par\pard\ql\li10243\sb245\sl-253\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf1\f2\fs22 10
\par\pard\sect\sectd\fs24\paperw11900\paperh16820\pard\sb0\sl-240{\bkmkstart Pg11}
{\bkmkend Pg11}\par\pard\qj \li1867\sb0\sl-317\slmult0 \par\pard\qj\li1867\sb0\sl-
317\slmult0 \par\pard\qj\li1867\sb0\sl-317\slmult0
\par\pard\qj\li1867\ri1207\sb208\sl-317\slmult0 \up0 \expndtw-2\charscalex100
\ul0\nosupersub\cf7\f8\fs24 proses pendidikan tenaga kesehatan sesuai
peraturan perundang-undangan. \line \up0 \expndtw-2\charscalex100 Standar ini juga
menunjukkan suatu kerangka untuk mencakup pendidikan medis \line \up0
\expndtw0\charscalex100 dan pendidikan staf klinis lainnya dengan memperhatikan
mutu pelayanan dan \line \up0 \expndtw0\charscalex100 keselamatan pasien di rumah
sakit tersebut. Kegiatan pendidikan harus masuk \line \up0 \expndtw-1\charscalex100
dalam kerangka peningkatan mutu dan keselamatan pasien rumah sakit, karena \line
\up0 \expndtw-1\charscalex100 itu rumah sakit wajib mempunyai sistem
pengawasan mutu pelayanan dan \line \up0 \expndtw-2\charscalex100 keselamatan
pasien terhadap aktivitas pendidikan yang dilaksanakan di rumah \line \up0
\expndtw-3\charscalex100 sakit. \par\pard\ql \li1507\sb37\sl-276\slmult0 \up0
\expndtw-4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3928?\ul0\nosupersub\cf6\f7\fs24 Penyelenggaraan Pelayanan Geriatri
\par\pard\qj \li1867\ri1185\sb11\sl-317\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Pasien geriatri adalah pasien lanjut usia dengan multi
penyakit/gangguan akibat \line \up0 \expndtw0\charscalex100 penurunan fungsi
organ, psikologi, sosial, ekonomi dan lingkungan yang \line \up0
\expndtw0\charscalex100 membutuhkan pelayanan kesehatan secara tepadu dengan
pendekatan multi \line \up0 \expndtw0\charscalex100 disiplin yang bekerja sama
secara interdisiplin. Dengan meningkatnya sosial \line \up0 \expndtw-
3\charscalex100 ekonomi dan pelayanan kesehatan maka usia harapan hidup semakin
meningkat, \line \up0 \expndtw-3\charscalex100 sehingga secara demografi terjadi
peningkatan populasi lanjut usia. Oleh karena \line \up0 \expndtw-3\charscalex100
itu rumah sakit perlu menyelenggarakan pelayanan geriatri sesuai dengan tingkat
\line \up0 \expndtw-4\charscalex100 jenis pelayanan geriatri. \par\pard\ql
\li3717\sb0\sl-276\slmult0 \par\pard\ql\li3717\sb0\sl-276\slmult0
\par\pard\ql\li3717\sb85\sl-276\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf6\f7\fs24 Seberapa sering standar diperbaharui? \par\pard\qj
\li1440\ri1240\sb8\sl-320\slmult0 \up0 \expndtw0\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Secara terus-menerus akan dikumpulkan berbagai
informasi dan pengalaman yang \up0 \expndtw-2\charscalex100 terkait dengan
standar. Bila standar tidak lagi mencerminkan praktik pelayanan \up0
\expndtw0\charscalex100 kesehatan mutakhir, teknologi yang umum ada, praktik
manajemen mutu, dan \up0 \expndtw0\charscalex100 sebagainya, maka standar akan
direvisi atau dihapus. Setiap 3 (tiga) tahun standar \up0 \expndtw-3\charscalex100
akan direview. \par\pard\ql \li2488\sb0\sl-276\slmult0 \par\pard\ql\li2488\sb61\sl-
276\slmult0 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Arti
tanggal \u8216?berlaku\u8217? pada sampul Standar Nasional Edisi 1 \par\pard\ql
\li1440\sb44\sl-276\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Tanggal \u8216?berlaku\u8217? yang tercetak pada sampul
berarti: \par\pard\qj \li1440\ri1238\sb212\sl-315\slmult0 \up0 \expndtw-
1\charscalex100 Bagi rumah sakit yang telah terakreditasi menurut standar versi
2012, bila akreditasi \up0 \expndtw0\charscalex100 ulang dilaksanakan tahun 2018
akan menggunakan Standar Nasional Akreditasi \up0 \expndtw0\charscalex100 Rumah
Sakit edisi 1 ini. Standar ini dipublikasikan 5 (lima) bulan sebelum tanggal \up0
\expndtw-1\charscalex100 berlaku, sehingga memberikan
waktu bagi rumah sakit untuk mempelajari dan \up0 \expndtw-3\charscalex100
mempersiapkan pelaksanaan SNARS Edisi 1. \par\pard\qj \li1440\ri1185\sb201\sl-
320\slmult0 \up0 \expndtw-3\charscalex100 Bagi rumah sakit yang baru pertama kali
akreditasi di tahun 2018, akan menggunakan \up0 \expndtw0\charscalex102 SNARS Edisi
1. Standar akreditasi versi 2012 akan berlaku sampai dengan 31 \up0 \expndtw-
3\charscalex100 Desember 2017. \par\pard\ql \li3844\sb0\sl-276\slmult0
\par\pard\ql\li3844\sb0\sl-276\slmult0 \par\pard\ql\li3844\sb5\sl-276\slmult0
\up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Cara menggunakan buku
standar ini. \par\pard\ql \li1440\sb44\sl-276\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Buku standar ini dapat digunakan sebagai:
\par\pard\ql \li1507\sb44\sl-276\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24 Pedoman untuk
mengelola organisasi rumah sakit agar efisien dan efektif; \par\pard\qj
\li1507\ri1183\sb28\sl-320\slmult0\tx1867 \up0 \expndtw0\charscalex102
\ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24 Pedoman bagi
pengelolaan dan pemberian pelayanan dan asuhan pasien; \line\tab \up0 \expndtw-
3\charscalex100 juga pedoman bagi upaya memperbaiki kualitas dan efisiensi
pelayanan tersebut; \par\pard\ql \li10243\sb236\sl-253\slmult0 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf1\f2\fs22 11

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Pg12}{\bkmkend Pg12}\par\pard\ql \li1507\sb0\sl-330\slmult0
\par\pard\ql\li1507\sb0\sl-330\slmult0 \par\pard\ql\li1507\sb0\sl-330\slmult0
\par\pard\ql\li1507\ri1183\sb158\sl-330\slmult0\tx1867 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24
Sarana untuk menilai fungsi-fungsi penting dalam suatu organisasi rumah sakit; \up0
\expndtw0\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3913?\ul0\nosupersub\cf7\f8\fs24 Sarana untuk memahami apa saja standar
yang harus dipenuhi seluruh \line\tab \up0 \expndtw-5\charscalex100 organisasi
rumah sakit dalam proses akreditasi oleh KARS; \par\pard\qj \li1507\ri1243\sb19\sl-
320\slmult0\tx1867 \up0 \expndtw0\charscalex103 \ul0\nosupersub\cf9\f10\fs24 \u-
3913?\ul0\nosupersub\cf7\f8\fs24 Sarana untuk menilai seberapa jauh suatu
organisasi belum atau telah \line\tab \up0 \expndtw-4\charscalex100 memenuhi
standar; \par\pard\qj \li1507\ri1244\sb0\sl-320\slmult0\tx1867 \up0 \expndtw-
2\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24
Sarana untuk mengetahui kebijakan-kebijakan akreditasi, bagaimana prosedur
\line\tab \up0 \expndtw-4\charscalex100 serta prosesnya; dan \par\pard\ql
\li1507\sb57\sl-276\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24 Mengenal
terminologi yang digunakan dalam buku standar. \par\pard\ql \li3974\sb0\sl-
276\slmult0 \par\pard\ql\li3974\sb88\sl-276\slmult0 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Kategori-kategori Ketentuan KARS
\par\pard\ql \li1440\ri4424\sb0\sl-340\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Ketentuan KARS dijelaskan dalam kategori berikut
ini : \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3913?\ul0\nosupersub\cf7\f8\fs24 Ketentuan Mengikuti Akreditasi Rumah Sakit
\line \up0 \expndtw-5\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3913?\ul0\nosupersub\cf7\f8\fs24 Standar \par\pard\ql \li1507\sb5\sl-276\slmult0
\up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3913?\ul0\nosupersub\cf7\f8\fs24 Maksud dan Tujuan \par\pard\ql \li1507\sb64\sl-
276\slmult0 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3913?\ul0\nosupersub\cf7\f8\fs24 Elemen Penilaian (EP) \par\pard\ql
\li3381\sb0\sl-276\slmult0 \par\pard\ql\li3381\sb88\sl-276\slmult0 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Ketentuan Mengikuti Akreditasi Rumah
Sakit \par\pard\qj \li1440\ri1182\sb11\sl-317\slmult0 \up0
\expndtw0\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Bagian Ketentuan Mengikuti
Akreditasi Rumah Sakit, merupakan regulasi baru di \line \up0 \expndtw-
2\charscalex100 KARS, Ketentuan ini meliputi Ketentuan spesifik untuk mengikuti
proses akreditasi \line \up0 \expndtw0\charscalex100 dan untuk mempertahankan
status akreditasi. Rumah sakit harus mematuhi \line \up0
\expndtw0\charscalex100 Ketentuan dalam bagian ini sepanjang waktu dalam proses
akreditasi. Walaupun \line \up0 \expndtw-2\charscalex100 demikian, Ketentuan ini
tidak diberi nilai seperti standar lain dalam survei di tempat. \line \up0
\expndtw-2\charscalex100 Rumah sakit akan dinilai antara memenuhi atau tidak
memenuhi Ketentuan ini. Jika \line \up0 \expndtw-3\charscalex100 rumah sakit tidak
memenuhi Ketentuan tertentu, maka rumah sakit akan diminta untuk \line \up0
\expndtw-4\charscalex100 segera memenuhinya atau terancam tidak mendapatkan
akreditasi. \par\pard\ql \li5503\sb0\sl-276\slmult0 \par\pard\ql\li5503\sb81\sl-
276\slmult0 \up0 \expndtw-5\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Standar
\par\pard\qj \li1440\ri1183\sb0\sl-320\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Standar KARS mencakup harapan kinerja, struktur, atau
fungsi yang harus diterapkan \up0 \expndtw-2\charscalex100 agar suatu rumah sakit
dapat terakreditasi oleh KARS. Sasaran Keselamatan \up0
\expndtw0\charscalex102 Pasien dianggap sebagai standar dan dimonitoring sama
seperti standar lainnya \up0 \expndtw-3\charscalex100 dalam survei di tempat.
\par\pard\ql \li4833\sb0\sl-276\slmult0 \par\pard\ql\li4833\sb69\sl-276\slmult0
\up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Maksud dan Tujuan
\par\pard\qj \li1440\ri1179\sb11\sl-316\slmult0 \up0 \expndtw0\charscalex103
\ul0\nosupersub\cf7\f8\fs24 Maksud dan tujuan dari suatu standar akan
membantu menjelaskan makna \line \up0 \expndtw0\charscalex102 sepenuhnya dari
standar tersebut. Maksud dan tujuan akan mendeskripsikan \line \up0 \expndtw-
1\charscalex100 tujuan dan rasionalisasi dari standar, memberikan penjelasan
bagaimana standar \line \up0 \expndtw-1\charscalex100 tersebut selaras dengan
program secara keseluruhan, menentukan parameter untuk \line \up0 \expndtw-
3\charscalex100 Ketentuan-Ketentuannya, atau memberikan \u8220?gambaran tentang
Ketentuan dan tujuan-\line \up0 \expndtw-4\charscalex100 tujuannya. \par\pard\ql
\li4696\sb0\sl-276\slmult0 \par\pard\ql\li4696\sb82\sl-276\slmult0 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Elemen Penilaian (EP) \par\pard\qj
\li1440\ri1243\sb8\sl-320\slmult0 \up0 \expndtw0\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Elemen Penilaian (EP) dari suatu standar akan menuntun
rumah sakit dan surveior \line \up0 \expndtw-1\charscalex100 terhadap apa yang akan
ditinjau dan dinilai selama proses survei. EP untuk setiap \par\pard\ql
\li10243\sb0\sl-253\slmult0 \par\pard\ql\li10243\sb123\sl-253\slmult0 \up0
\expndtw-2\charscalex100 \ul0\nosupersub\cf1\f2\fs22 12

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\par\pard\qj\li1440\sb0\sl-315\slmult0 \par\pard\qj\li1440\sb0\sl-315\slmult0
\par\pard\qj\li1440\ri1182\sb215\sl-315\slmult0 \up0 \expndtw0\charscalex100
\ul0\nosupersub\cf7\f8\fs24 standar menunjukkan ketentuan untuk kepatuhan
terhadap standar tersebut. EP \up0 \expndtw-4\charscalex100 ditujukan untuk
memberikan kejelasan pada standar dan membantu rumah sakit untuk \up0
\expndtw0\charscalex104 memenuhi sepenuhnya ketentuan yang ada, untuk
membantu mengedukasi \up0 \expndtw-1\charscalex100 pimpinan dan tenaga kesehatan
mengenai standar yang ada serta untuk memandu \up0 \expndtw-2\charscalex100 rumah
sakit dalam persiapan proses akreditasi. \par\pard\ql \li3203\sb0\sl-276\slmult0
\par\pard\ql\li3203\sb82\sl-276\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf6\f7\fs24 KEBIJAKAN UMUM AKREDITASI RUMAH SAKIT \par\pard\ql
\li2951\sb0\sl-276\slmult0 \par\pard\ql\li2951\sb88\sl-276\slmult0 \up0 \expndtw-
3\charscalex100 PERSYARATAN AKREDITASI RUMAH SAKIT (PARS) \par\pard\ql
\li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb68\sl-276\slmult0 \up0 \expndtw-
3\charscalex100 Gambaran Umum \par\pard\qj \li1440\ri1246\sb11\sl-316\slmult0
\up0 \expndtw0\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Bagian ini merupakan
hal baru dalam pelaksanaan akreditasi rumah sakit di \line \up0
\expndtw0\charscalex104 Indonesia, di akreditasi sebelumnya tidak ada persyaratan
yang ditetapkan oleh \line \up0 \expndtw0\charscalex103 KARS untuk mengikuti
akreditasi rumah sakit. Persyaratan ini bukan berarti \line \up0
\expndtw0\charscalex100 menghambat rumah sakit untuk mengikuti akreditasi, tetapi
mendorong rumah sakit \line \up0 \expndtw0\charscalex100 untuk mengikuti
peraturan dan perundang-undangan, sehingga akreditasi yang \line \up0
\expndtw0\charscalex100 dilaksanakan dalam rangka peningkatan mutu dan
keselamatan pasien dapat \line \up0 \expndtw-1\charscalex100 dicapai.
\par\pard\qj \li1440\sb0\sl-320\slmult0 \par\pard\qj\li1440\ri1236\sb1\sl-
320\slmult0 \up0 \expndtw0\charscalex104 Untuk rumah sakit yang akan melakukan
akreditasi pertama kalinya, kesesuaian \line \up0 \expndtw-1\charscalex100 dengan
seluruh persyaratan akreditasi rumah sakit dinilai selama survei awal. Untuk
\line \up0 \expndtw-2\charscalex100 rumah sakit yang sudah terakreditasi,
kesesuaian dengan persyaratan akreditasi \line \up0 \expndtw-2\charscalex100
rumah sakit dinilai sepanjang siklus akreditasi, melalui survei lokasi langsung.
\par\pard\ql \li3156\sb0\sl-276\slmult0 \par\pard\ql\li3156\sb0\sl-276\slmult0
\par\pard\ql\li3156\sb5\sl-276\slmult0 \up0 \expndtw0\charscalex104
\ul0\nosupersub\cf6\f7\fs24 Persyaratan, Maksud dan Tujuan, Monitoring,
\par\pard\ql \li4432\sb24\sl-276\slmult0 \up0 \expndtw0\charscalex106 Dampak
ketidakpatuhan \par\pard\ql \li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb0\sl-
276\slmult0 \par\pard\ql\li1440\sb132\sl-276\slmult0 \up0 \expndtw-4\charscalex100
Persyaratan Pertama : PARS.1 \par\pard\qj \li1440\ri1244\sb8\sl-320\slmult0 \up0
\expndtw-1\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Rumah sakit memenuhi semua
persyaratan informasi dan data kepada Komisi \up0 \expndtw-3\charscalex100
Akreditasi Rumah Sakit (KARS). \par\pard\ql \li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb81\sl-276\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf6\f7\fs24 Maksud dan tujuan untuk PARS.1 \par\pard\qj
\li1440\ri1245\sb0\sl-320\slmult0 \up0 \expndtw0\charscalex106
\ul0\nosupersub\cf7\f8\fs24 Pada waktu mengajukan permohonan survei
akreditasi, rumah sakit perlu \line \up0 \expndtw0\charscalex100 memberikan
data dan dan informasi yang dibutuhkan untuk proses akreditasi. \line
\up0 \expndtw0\charscalex103 Misalnya : mengisi aplikasi survei secara lengkap,
data direktur rumah sakit, data \line \up0 \expndtw0\charscalex100 kelengkapan
surat tanda registrasi dan surat izin praktik para staf medis serta data \line \up0
\expndtw0\charscalex100 perizinan-perizinan lainnya, termasuk bila ada
perubahan direktur rumah sakit, \line \up0 \expndtw0\charscalex100 kepemilikan,
peningkatan kelas, pembangunan/renovasi yang cukup luas, dan lain \line \up0
\expndtw0\charscalex100 sebagainya serta bila ingin mengajukan banding keputusan
akreditasi. \par\pard\qj \li1440\ri1265\sb288\sl-320\slmult0 \up0
\expndtw0\charscalex104 Rumah sakit wajib memberikan data dan informasi kepada
KARS, data tersebut \line \up0 \expndtw0\charscalex100 dimulai pada waktu
pengajuan survei dan selama siklus survei akreditasi tiga \par\pard\ql
\li10243\sb0\sl-253\slmult0 \par\pard\ql\li10243\sb83\sl-253\slmult0 \up0 \expndtw-
2\charscalex100 \ul0\nosupersub\cf1\f2\fs22 13

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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn
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{\sp{\sn pVerticies}{\sv 8;4;(0,315);(9079,315);(9079,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv
14996726}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}
{\sv 1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
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{\shp
{\*\shpinst\shpleft1411\shptop11777\shpright10490\shpbottom12092\shpfhdr0\shpbxpage
\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz6940\shplid7
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn
geoRight}{\sv 9079}}{\sp{\sn geoBottom}{\sv 315}}
{\sp{\sn pVerticies}{\sv 8;4;(0,315);(9079,315);(9079,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv
16181725}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}
{\sv 1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw11900\paperh16820\pard\sb0\sl-240{\bkmkstart
Pg14}{\bkmkend Pg14}\par\pard\qj \li1440\sb0\sl-320\slmult0
\par\pard\qj\li1440\sb0\sl-320\slmult0 \par\pard\qj\li1440\sb0\sl-320\slmult0
\par\pard\qj\li1440\ri1266\sb196\sl-320\slmult0 \up0 \expndtw0\charscalex103
\ul0\nosupersub\cf7\f8\fs24 tahunan. Penyampaian data sesuai yang diminta KARS,
harus disampaikan oleh \up0 \expndtw-1\charscalex100 rumah sakit ke KARS.
\par\pard\ql \li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb61\sl-276\slmult0
\up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Monitoring PARS.1
\par\pard\qj \li1440\ri1236\sb8\sl-320\slmult0 \up0 \expndtw0\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Monitoring dilaksanakan terus-menerus selama siklus
akreditasi terkait dengan \up0 \expndtw-3\charscalex100 pengajuan yang
diperlukan. \par\pard\ql \li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb81\sl-
276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Dampak
Ketidakpatuhan terhadap PARS.1 \par\pard\qj \li1440\ri1183\sb11\sl-317\slmult0 \up0
\expndtw-2\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Jika rumah sakit gagal
memenuhi persyaratan informasi dan data hingga waktu yang \line \up0
\expndtw0\charscalex100 ditentukan kepada KARS, rumah sakit akan dianggap berisiko
gagal akreditasi atau \line \up0 \expndtw0\charscalex102 penetapak akreditasi
tertunda sampai semua persyaratan akreditasi dipenuhi dan \line \up0 \expndtw-
1\charscalex100 dilakukan survei terfokus. Sebagai contoh, jika informasi pada
aplikasi survei rumah \line \up0 \expndtw0\charscalex102 sakit tidak tepat /tidak
sesuai selama pelaksanaan survei maka dibutuhkan survei \line \up0
\expndtw0\charscalex100 terfokus dan rumah sakit diminta menanggung biaya
dari pelaksanaan survei \line \up0 \expndtw-3\charscalex100 terfokus. Sebagai
tambahan, jika terdapat bukti bahwa rumah sakit telah memalsukan \line \up0
\expndtw0\charscalex102 atau menahan informasi atau bermaksud menghilangkan
informasi yang diajukan \line \up0 \expndtw-3\charscalex100 kepada KARS,
persyaratan dan konsekuensi pada PARS.2 akan berlaku. \par\pard\ql \li1440\sb0\sl-
276\slmult0 \par\pard\ql\li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb105\sl-
276\slmult0 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Persyaratan
Kedua: PARS.2 \par\pard\qj \li1440\ri1243\sb8\sl-320\slmult0 \up0 \expndtw-
1\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Rumah sakit menyediakan informasi yang
lengkap dan akurat kepada KARS selama \up0 \expndtw-2\charscalex100 keseluruhan
fase dari proses akreditasi. \par\pard\ql \li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb81\sl-276\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf6\f7\fs24 Maksud dan tujuan untuk PARS.2 \par\pard\qj
\li1440\ri1243\sb14\sl-313\slmult0 \up0 \expndtw0\charscalex104
\ul0\nosupersub\cf7\f8\fs24 KARS menginginkan setiap rumah sakit yang mengajukan
akreditasi atau sudah \up0 \expndtw0\charscalex102 terakreditasi untuk melaksanakan
proses akreditasi secara jujur, berintegritas dan \up0 \expndtw0\charscalex100
transparan. Hal ini dibuktikan dengan menyediakan informasi yang lengkap
dan \up0 \expndtw0\charscalex100 akurat selama proses akreditasi dan pasca
akreditasi . \par\pard\qj \li1440\ri3957\sb0\sl-340\slmult0 \up0 \expndtw-
3\charscalex100 KARS mendapatkan informasi tentang rumah sakit melalui: \up0
\expndtw-3\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3928?\ul0\nosupersub\cf7\f8\fs24 informasi dari rumah sakit dan karyawan
\par\pard\ql \li1507\sb18\sl-276\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3928?\ul0\nosupersub\cf7\f8\fs24 informasi dari
masyarakat \par\pard\ql \li1507\sb64\sl-276\slmult0 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3928?\ul0\nosupersub\cf7\f8\fs24
informasi dari pemerintah \par\pard\qj \li1507\ri5041\sb28\sl-320\slmult0 \up0
\expndtw-4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3928?\ul0\nosupersub\cf7\f8\fs24 informasi dari media massa dan media sosial \up0
\expndtw-4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3928?\ul0\nosupersub\cf7\f8\fs24 komunikasi secara lisan \par\pard\qj
\li1507\ri1238\sb20\sl-320\slmult0\tx1867 \up0 \expndtw0\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3928?\ul0\nosupersub\cf7\f8\fs24 Observasi
langsung dengan atau melalui wawancara atau komunikasi lainnya \line\tab \up0
\expndtw-3\charscalex100 kepada pegawai KARS \par\pard\qj \li1507\ri1234\sb0\sl-
340\slmult0\tx1867 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3928?\ul0\nosupersub\cf7\f8\fs24 Dokumen elektronik
atau\ul0\nosupersub\cf8\f9\fs24 hard-copy\ul0\nosupersub\cf7\f8\fs24 melalui
pihak ketiga, seperti media massa \line\tab \up0 \expndtw-2\charscalex100 atau
laporan pemerintahan \par\pard\qj \li1440\ri1183\sb281\sl-320\slmult0 \up0
\expndtw0\charscalex100 Untuk Persyaratan ini, pemalsuan informasi
didefinisikan sebagai pemalsuan \line \up0 \expndtw0\charscalex102 (fabrikasi),
secara keseluruhan atau sebagian dari informasi yang diberikan oleh \line \up0
\expndtw-3\charscalex100 pihak yang mengajukan atau rumah sakit yang diakreditasi
kepada KARS. Pemalsuan \line \up0 \expndtw-3\charscalex100 bisa meliputi perubahan
draft, perubahan format, atau menghilangkan isi dokumen \par\pard\ql
\li10243\sb0\sl-253\slmult0 \par\pard\ql\li10243\sb163\sl-253\slmult0 \up0
\expndtw-2\charscalex100 \ul0\nosupersub\cf1\f2\fs22 14

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{\sp{\sn pVerticies}{\sv 8;4;(0,314);(9079,314);(9079,0);(0,0)}}
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16181725}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}
{\sv 1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}

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}}

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{\sp{\sn pVerticies}{\sv 8;4;(0,315);(9079,315);(9079,0);(0,0)}}
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{\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn
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{\sp{\sn pVerticies}{\sv 8;4;(0,317);(9079,317);(9079,0);(0,0)}}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv
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}}\par\pard\sect\sectd\fs24\paperw11900\paperh16820\pard\sb0\sl-240{\bkmkstart
Pg15}{\bkmkend Pg15}\par\pard\ql \li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb88\sl-276\slmult0 \up0
\expndtw-3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 atau mengirimkan informasi,
laporan, data dan materi palsu lainnya. \par\pard\ql \li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb112\sl-276\slmult0
\up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Monitoring PARS.2
\par\pard\qj \li1440\ri1223\sb8\sl-320\slmult0 \up0 \expndtw-2\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Monitoring dari PARS ini dimulai sejak proses
pendaftaran dan terus berlanjut hingga \up0 \expndtw-2\charscalex100 rumah sakit
tersebut terakreditasi oleh atau mencari akreditasi dari KARS \par\pard\ql
\li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb81\sl-276\slmult0 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Dampak Ketidakpatuhan terhadap
PARS.2 \par\pard\qj \li1440\ri1183\sb12\sl-315\slmult0 \up0 \expndtw0\charscalex102
\ul0\nosupersub\cf7\f8\fs24 Jika KARS meyakini bahwa rumah sakit memasukkan
informasi yang tidak akurat \up0 \expndtw-3\charscalex100 atau palsu atau
mempresentasikan informasi yang tidak akurat atau palsu ke surveior, \up0
\expndtw0\charscalex100 maka rumah sakit akan dianggap Berisiko Gagal Akreditasi
dan kemungkinan perlu \up0 \expndtw-3\charscalex100 menjalani survei terfokus.
Kegagalan mengatasi masalah ini tepat waktu atau pada \up0 \expndtw-
4\charscalex100 saat survei terfokus dapat berakibat Kegagalan Akreditasi.
\par\pard\ql \li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb82\sl-276\slmult0
\up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Persyaratan Ketiga:
PARS.3 \par\pard\qj \li1440\ri1223\sb16\sl-310\slmult0 \up0 \expndtw-
1\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Rumah sakit melaporkan bila ada
perubahan dari profil rumah sakit (data elektronik) \up0 \expndtw-1\charscalex100
atau informasi yang diberikan kepada KARS saat mengajukan aplikasi survei dalam
\up0 \expndtw-3\charscalex100 jangka waktu maksimal 10 hari sebelum waktu
survei. \par\pard\ql \li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb83\sl-
276\slmult0 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Maksud dan
tujuan untuk PARS.3 \par\pard\qj \li1440\ri1229\sb8\sl-320\slmult0 \up0
\expndtw0\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Untuk memahami kepemilikan,
perizinan, cakupan dan volume pelayanan pasien, \up0 \expndtw0\charscalex100 dan
jenis fasilitas pelayanan pasien, serta faktor lainnya, KARS memerlukan profil
\up0 \expndtw-1\charscalex100 rumah sakit melalui aplikasi survei. KARS memerlukan
data profil rumah sakit terkini \up0 \expndtw0\charscalex100 untuk mempertimbangkan
proses pelaksanaan survei. Data-data tersebut termasuk \up0 \expndtw-
3\charscalex100 tapi tidak hanya terbatas pada informasi di bawah ini: \par\pard\ql
\li1507\sb37\sl-276\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24 Perubahan nama
rumah sakit \par\pard\ql \li1507\sb64\sl-276\slmult0 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24
Perubahan kepemilikan rumah sakit \par\pard\qj \li1507\ri5025\sb28\sl-
320\slmult0 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3913?\ul0\nosupersub\cf7\f8\fs24 Perubahan bentuk badan hukum rumah sakit
\up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3913?\ul0\nosupersub\cf7\f8\fs24 Perubahan kategori rumah sakit \par\pard\ql
\li1507\sb57\sl-276\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24 Perubahan kelas
rumah sakit \par\pard\ql \li1507\ri1243\sb34\sl-313\slmult0\tx1867\tx1867\tx1867
\up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3913?\ul0\nosupersub\cf7\f8\fs24 Pencabutan atau pembatasan izin operasional,
keterbatasan atau penutupan \line\tab \up0 \expndtw-3\charscalex100 layanan
pasien, sanksi staf klinis atau staf lainnya, atau tuntutan terkait masalah
\line \tab \up0 \expndtw-2\charscalex100 peraturan dan hukum oleh pihak
Kementerian Kesehatan dan atau Dinas \line \tab \up0 \expndtw-3\charscalex100
Kesehatan \par\pard\qj \li1507\ri1226\sb22\sl-320\slmult0\tx1867 \up0
\expndtw0\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3913?\ul0\nosupersub\cf7\f8\fs24 Penambahan atau penghapusan, satu atau lebih
jenis pelayanan kesehatan, \line\tab \up0 \expndtw-3\charscalex100 misalnya
penambahan unit dialisis atau penutupan perawatan trauma. \par\pard\ql
\li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb81\sl-276\slmult0 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Monitoring PARS.3 \par\pard\qj
\li1440\ri1236\sb0\sl-320\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Monitoring dari PARS.3 ini dilaksanakan saat
pengajuan aplikasi survei secara \up0 \expndtw-2\charscalex100 elektronik atau
saat berlangsungnya proses survei. Apabila ditemukan adanya \up0 \expndtw-
1\charscalex100 perubahan profil rumah sakit yang tidak dilaporkan
dapat mengakibatkan \up0 \expndtw-3\charscalex100 dilaksanakannya survei terfokus
dalam waktu yang berbeda. \par\pard\ql \li10243\sb0\sl-253\slmult0
\par\pard\ql\li10243\sb0\sl-253\slmult0 \par\pard\ql\li10243\sb218\sl-
253\slmult0 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf1\f2\fs22 15

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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn
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{\sp{\sn pVerticies}{\sv 8;4;(0,314);(9079,314);(9079,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv
16181725}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}
{\sv 1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}

{\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn
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{\sp{\sn pVerticies}{\sv 8;4;(0,315);(9079,315);(9079,0);(0,0)}}
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn
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\par\pard\ql\li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb88\sl-276\slmult0 \up0
\expndtw-4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Dampak Ketidakpatuhan terhadap
PARS.3 \par\pard\qj \li1440\ri1238\sb14\sl-313\slmult0 \up0 \expndtw-
1\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Apabila rumah sakit pada saat pengajuan
aplikasi survei secara elektronik atau saat \up0 \expndtw0\charscalex103
berlangsungnya proses survei tidak menyampaikan perubahan profil rumah sakit
\up0 \expndtw0\charscalex106 dapat berakibat tidak dilaksanakan survei
akreditasi, gagal akreditasi atau \up0 \expndtw-3\charscalex100 dilaksanakan
survei terfokus dalam waktu yang berbeda. \par\pard\ql \li1440\sb0\sl-
276\slmult0 \par\pard\ql\li1440\sb82\sl-276\slmult0 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Persyaratan Keempat: PARS. 4
\par\pard\qj \li1440\ri1231\sb8\sl-320\slmult0 \up0 \expndtw0\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Rumah sakit mengizinkan memberikan akses kepada
KARS untuk melakukan \up0 \expndtw0\charscalex104 monitoring terhadap
kepatuhan standar, melakukan verifikasi mutu dan \up0 \expndtw-
3\charscalex100 keselamatan atau terhadap laporan dari pihak yang berwenang.
\par\pard\ql \li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb61\sl-276\slmult0
\up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Maksud dan tujuan untuk
PARS.4 \par\pard\qj \li1440\ri1242\sb8\sl-320\slmult0 \up0
\expndtw0\charscalex104 \ul0\nosupersub\cf7\f8\fs24 Atas hasil akreditasi yang
dicapai rumah sakit memiliki arti rumah sakit memiliki \line \up0
\expndtw0\charscalex102 komitmen terhadap pemangku kepentingan seperti,
masyarakat, Kementerian \line \up0 \expndtw-1\charscalex100 Kesehatan, badan
pemerintahan pusat/propinsi/kabupaten/kota, sumber pendanaan \line \up0 \expndtw-
2\charscalex100 (asuransi kesehatan), dan pihak lainnya bahwa rumah sakit
akan menjaga untuk \line \up0 \expndtw-3\charscalex100 memenuhi standarnasional
akreditasi rumah sakit edisi 1 \up0 \expndtw-3\charscalex100 termasuk
kebijakan \par\pard\qj \li1440\ri1182\sb0\sl-320\slmult0 \up0
\expndtw0\charscalex100 akreditasi oleh KARS. Dengan demikian, perlu dipahami
bahwa KARS memiliki \up0 \expndtw-4\charscalex100 kewenangan untuk melakukan
telusur dan investigasi terhadap pelaksanaan mutu dan \up0 \expndtw0\charscalex100
keselamatan pasien ke seluruh atau sebagian rumah sakit, dengan pemberitahuan
\up0 \expndtw-2\charscalex100 atau tanpa pemberitahuan, untuk memastikan rumah
sakit tetap memenuhi dan \up0 \expndtw-2\charscalex100 mematuhi standar.
Surveior selalu menggunakan tanda pengenal resmi sebagai \up0
\expndtw0\charscalex100 identitas dan surat tugas dari KARS ketika
melakukan kunjungan tanpa \up0 \expndtw-3\charscalex100 pemberitahuan kepada
rumah sakit sebelumnya. \par\pard\ql \li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb41\sl-276\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf6\f7\fs24 Monitoring PARS.4 \par\pard\qj \li1440\ri1246\sb8\sl-
320\slmult0 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Monitoring
dari persyaratan ini dilaksanakan selama fase siklus akreditasi tiga
\up0 \expndtw-3\charscalex100 tahunan. \par\pard\ql \li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb81\sl-276\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf6\f7\fs24 Dampak Ketidakpatuhan terhadap PARS.4 \par\pard\qj
\li1440\ri1240\sb8\sl-320\slmult0 \up0 \expndtw0\charscalex104
\ul0\nosupersub\cf7\f8\fs24 KARS akan menarik status akreditasi dari rumah
sakit yang menolak atau \up0 \expndtw0\charscalex100 membatasi akses terhadap
surveior KARS yang ditugaskan untuk melaksanakan \up0 \expndtw-3\charscalex100
telusur dan investigasi langsung. \par\pard\ql \li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb61\sl-276\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf6\f7\fs24 Persyaratan Kelima : PARS.5 \par\pard\qj
\li1440\ri1238\sb8\sl-320\slmult0 \up0 \expndtw0\charscalex102
\ul0\nosupersub\cf7\f8\fs24 Rumah sakit bersedia menyerahkan data hasil
monitoring dari Kementerian \up0 \expndtw0\charscalex100 Kesehatan/Dinas
Kesehatan Propinsi/Kabupaten/Kota berupa berkas asli atau \up0 \expndtw-
3\charscalex100 fotokopi legalisir kepada KARS. \par\pard\ql \li1440\sb0\sl-
276\slmult0 \par\pard\ql\li1440\sb81\sl-276\slmult0 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Maksud dan tujuan untuk PARS.5
\par\pard\ql \li1440\sb44\sl-276\slmult0 \up0 \expndtw0\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Dalam pelaksanaan survei akreditasi yang
menyeluruh, surveior KARS dapat \par\pard\li1440\sb41\sl-
276\slmult0\fi0\tx4209\tx5102 \up0 \expndtw0\charscalex103 meminta informasi\tab
\up0 \expndtw0\charscalex103 dari\tab \up0 \expndtw0\charscalex103 Kementerian
Kesehatan/Dinas Kesehatan\par\pard\qj \li1440\ri1245\sb0\sl-320\slmult0 \up0
\expndtw0\charscalex103 Provinsi/Kabupaten/Kota berbagai aspek operasional rumah
sakit dan lembaga \line \up0 \expndtw0\charscalex100 lainnya yang juga melakukan
penilaian terhadap area yang berhubungan dengan \par\pard\ql \li10243\sb207\sl-
253\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf1\f2\fs22 16

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Pg17}{\bkmkend Pg17}\par\pard\qj \li1440\sb0\sl-313\slmult0
\par\pard\qj\li1440\sb0\sl-313\slmult0 \par\pard\qj\li1440\sb0\sl-313\slmult0
\par\pard\qj\li1440\ri1219\sb223\sl-313\slmult0 \up0 \expndtw0\charscalex100
\ul0\nosupersub\cf7\f8\fs24 mutu dan keselamatan, sebagai contoh pemeriksaan
keselamatan kebakaran, \line \up0 \expndtw0\charscalex104 pemeriksaan sanitasi
rumah sakit dan lain sebagainya. Dalam hal ini termasuk \line \up0 \expndtw-
1\charscalex100 kepatuhan terhadap peraturan perundang-undangan dan monitoring
dari mutu dan \line \up0 \expndtw-2\charscalex100 keselamatan berupa
insiden/kejadian yang dilaporkan ke pihak berwenang. \par\pard\ql
\li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb82\sl-276\slmult0 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Monitoring PARS.5 \par\pard\qj
\li1440\ri1239\sb11\sl-316\slmult0 \up0 \expndtw-1\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Apabila diperlukan, rumah sakit bersedia memberikan
semua catatan resmi, laporan \line \up0 \expndtw0\charscalex100 dan rekomendasi
dari lembaga lain seperti lembaga yang membidangi perizinan, \line \up0
\expndtw0\charscalex102 pemeriksaan, peninjauan ulang, pemerintahan dan
perencanaan. KARS juga bisa \line \up0 \expndtw-1\charscalex100 meminta laporan
secara langsung dari lembaga lain tersebut. Laporan tersebut bisa \line \up0
\expndtw-2\charscalex100 diminta selama berlangsungnya fase siklus akreditasi tiga
tahunan, termasuk selama \line \up0 \expndtw-1\charscalex100 survei akreditasi atau
sebagai bagian dari monitoring yang menyangkut insiden atau \line \up0 \expndtw-
4\charscalex100 mutu. \par\pard\ql \li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb82\sl-276\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf6\f7\fs24 Dampak Ketidakpatuhan terhadap PARS.5 \par\pard\qj
\li1440\ri1196\sb16\sl-310\slmult0 \up0 \expndtw0\charscalex103
\ul0\nosupersub\cf7\f8\fs24 Apabila rumah sakit tidak bersedia menyediakan
laporan resmi ketika diminta \up0 \expndtw0\charscalex100 pada saat survei
berlangsung, dapat berakibat dilaksanakannya survei terfokus \up0 \expndtw-
4\charscalex100 untuk mengkaji kembali laporan dan standar yang berhubungan.
\par\pard\ql \li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb83\sl-276\slmult0
\up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Persyaratan Keenam :
PARS.6 \par\pard\qj \li1440\ri1219\sb8\sl-320\slmult0 \up0
\expndtw0\charscalex102 \ul0\nosupersub\cf7\f8\fs24 Rumah sakit mengizinkan
pejabat KARS atau surveior senior yang ditugaskan \up0 \expndtw0\charscalex102
oleh KARS untuk mengamati proses survei secara langsung. Pejabat KARS atau \up0
\expndtw0\charscalex100 surveior senior yang ditugaskan wajib menggunakan tanda
pengenal resmi sebagai \up0 \expndtw0\charscalex102 identitas dan surat tugas dari
KARS, termasuk ketika melakukan kunjungan tanpa \up0 \expndtw-3\charscalex100
pemberitahuan kepada rumah sakit sebelumnya. \par\pard\ql \li1440\sb0\sl-
276\slmult0 \par\pard\ql\li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb105\sl-
276\slmult0 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Maksud dan
tujuan untuk PARS.6 \par\pard\qj \li1440\ri1236\sb8\sl-320\slmult0 \up0
\expndtw0\charscalex108 \ul0\nosupersub\cf7\f8\fs24 Pejabat KARS atau surveior
senior dapat ditugaskan oleh Ketua Eksekutif \line \up0
\expndtw0\charscalex104 KARS untuk mengawasi surveior baru, melakukan evaluasi
standar baru dan \line \up0 \expndtw-2\charscalex100 melaksanakan evaluasi terhadap
adanya perubahan tersebut selain aktivitas lainnya. \par\pard\ql \li1440\sb0\sl-
276\slmult0 \par\pard\ql\li1440\sb81\sl-276\slmult0 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Monitoring PARS.6 \par\pard\qj
\li1440\ri1239\sb0\sl-320\slmult0 \up0 \expndtw-1\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Evaluasi bisa dilaksanakan pada semua fase proses
akreditasi, termasuk saat \up0 \expndtw-3\charscalex100 pelaksanaan survei
verifikasi dan survei terfokus. \par\pard\ql \li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb69\sl-276\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf6\f7\fs24 Dampak Ketidakpatuhan terhadap PARS.6 \par\pard\qj
\li1440\ri1240\sb8\sl-320\slmult0 \up0 \expndtw0\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Apabila rumah sakit tidak bersedia dilaksanakan
evaluasi pada semua fase proses \up0 \expndtw0\charscalex103 akreditasi, termasuk
saat pelaksanaan survei verifikasi dan survei terfokus dapat \up0 \expndtw-
3\charscalex100 berakibat kegagalan akreditasi. \par\pard\ql \li1440\sb0\sl-
276\slmult0 \par\pard\ql\li1440\sb61\sl-276\slmult0 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Persyaratan Ketujuh : PARS.7
\par\pard\qj \li1440\ri1245\sb8\sl-320\slmult0 \up0 \expndtw0\charscalex102
\ul0\nosupersub\cf7\f8\fs24 Rumah sakit bersedia bergabung dalam sistem
penilaian perkembangan mutu \line \up0 \expndtw0\charscalex102 dengan memberikan
hasil pengukuran indikator mutu. Dengan demikian direktur \par\pard\ql
\li10243\sb216\sl-253\slmult0 \up0 \expndtw-2\charscalex100
\ul0\nosupersub\cf1\f2\fs22 17

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\par\pard\qj\li1440\sb0\sl-320\slmult0 \par\pard\qj\li1440\sb0\sl-320\slmult0
\par\pard\qj\li1440\ri1248\sb196\sl-320\slmult0 \up0 \expndtw0\charscalex100
\ul0\nosupersub\cf7\f8\fs24 rumah sakit dapat membandingkan capaian indikator area
klinis, area manajemen \line \up0 \expndtw0\charscalex100 dan sasaran keselamatan
pasien dengan rumah sakit lain melalui Sismadak KARS. \par\pard\ql \li1440\sb0\sl-
276\slmult0 \par\pard\ql\li1440\sb61\sl-276\slmult0 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Maksud dan tujuan untuk PARS.7
\par\pard\qj \li1440\ri1183\sb8\sl-320\slmult0 \up0 \expndtw-1\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Kumpulan indikator KARS memberikan keseragaman,
ketepatan spesifikasi dan \up0 \expndtw-3\charscalex100 standarisasi data yang
dikumpulkan sehingga dapat dilakukan perbandingan di dalam \up0 \expndtw-
4\charscalex100 rumah sakit dan antar rumah sakit. \par\pard\qj
\li1440\ri1191\sb5\sl-315\slmult0 \up0 \expndtw0\charscalex100 Pengumpulan,
analisis dan penggunaan data merupakan inti dari proses akreditasi \line \up0
\expndtw-1\charscalex100 KARS. Data dapat menunjang perbaikan yang berkesinambungan
bagi rumah sakit. \line \up0 \expndtw-3\charscalex100 Data juga bisa
menyediakan arus informasi yang berkesinambungan bagi KARS \line \up0 \expndtw-
1\charscalex100 dalam mendukung kelangsungan perbaikan mutu dan keselamatan
pasien rumah \line \up0 \expndtw-2\charscalex100 sakit. \par\pard\qj
\li1440\sb0\sl-320\slmult0 \par\pard\qj\li1440\ri1182\sb1\sl-320\slmult0 \up0
\expndtw-2\charscalex100 Pemilihan dan penggunaan kumpulan indikator
diintegrasikan ke dalam prioritas \up0 \expndtw-3\charscalex100 parameter rumah
sakit, seperti yang dijabarkan dalam standar TKRS.5, TKRS.11, dan \up0 \expndtw-
4\charscalex100 TKRS.11.1. \par\pard\ql \li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb61\sl-276\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf6\f7\fs24 Monitoring PARS.7 \par\pard\qj \li1440\ri1182\sb8\sl-
320\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Indikator
wajib dan indikator yang dipilih dievaluasi secara menyeluruh selama proses \up0
\expndtw-3\charscalex100 akreditasi berlangsung. Pengisian kedua indikator tersebut
dilakukan sebelum proses \up0 \expndtw0\charscalex103 survei. Evaluasi dilaksanakan
pada semua fase proses akreditasi, termasuk saat \up0 \expndtw-3\charscalex100
pelaksanaan survei verifikasi dan survei terfokus. \par\pard\ql \li1440\sb0\sl-
276\slmult0 \par\pard\ql\li1440\sb81\sl-276\slmult0 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Dampak Ketidakpatuhan terhadap
PARS.7 \par\pard\qj \li1440\ri1208\sb308\sl-320\slmult0 \up0 \expndtw-
2\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Apabila rumah sakit tidak bersedia
bergabung dalam sistem penilaian perkembangan \up0 \expndtw0\charscalex102 mutu
dengan memberikan hasil pengukuran indikator mutu dan dapat berakibat \up0
\expndtw-3\charscalex100 pada hasil akreditasi. \par\pard\ql \li1440\sb0\sl-
276\slmult0 \par\pard\ql\li1440\sb81\sl-276\slmult0 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Persyaratan Kedelapan: PARS.8
\par\pard\qj \li1440\ri1242\sb8\sl-320\slmult0 \up0 \expndtw0\charscalex102
\ul0\nosupersub\cf7\f8\fs24 Rumah sakit wajib menampilkan status akreditasi
dengan tepat, program dan \up0 \expndtw0\charscalex103 pelayanan sesuai dengan
tingkatan status akreditasi yang diberikan oleh KARS \up0 \expndtw-3\charscalex100
melalui website atau promosi lainnya. \par\pard\ql \li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb61\sl-276\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf6\f7\fs24 Maksud dan tujuan untuk PARS.8 \par\pard\qj
\li1440\ri1231\sb8\sl-320\slmult0 \up0 \expndtw0\charscalex104
\ul0\nosupersub\cf7\f8\fs24 Situs, iklan dan promosi rumah sakit serta
informasi lain yang dibuat oleh \up0 \expndtw0\charscalex104 rumah sakit kepada
masyarakat harus secara tepat menggambarkan capaian \up0 \expndtw-
1\charscalex100 tingkatan status akreditasi yang diberikan oleh KARS, program dan
pelayanan yang \up0 \expndtw-3\charscalex100 diakreditasi oleh KARS.
\par\pard\ql \li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb81\sl-276\slmult0
\up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Monitoring PARS.8
\par\pard\qj \li1440\ri1187\sb0\sl-320\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Evaluasi terhadap persyaratan ini dilaksanakan pada
seluruh fase akreditasi, termasuk \up0 \expndtw-5\charscalex100 siklus akreditasi
tiga tahunan. \par\pard\ql \li10243\sb0\sl-253\slmult0 \par\pard\ql\li10243\sb0\sl-
253\slmult0 \par\pard\ql\li10243\sb18\sl-253\slmult0 \up0 \expndtw-
2\charscalex100 \ul0\nosupersub\cf1\f2\fs22 18

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}}\par\pard\sect\sectd\fs24\paperw11900\paperh16820\pard\sb0\sl-240{\bkmkstart
Pg19}{\bkmkend Pg19}\par\pard\ql \li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb88\sl-276\slmult0 \up0
\expndtw-4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Dampak Ketidakpatuhan terhadap
PARS.8 \par\pard\qj \li1440\ri1222\sb308\sl-320\slmult0 \up0
\expndtw0\charscalex103 \ul0\nosupersub\cf7\f8\fs24 Apabila informasi tentang
capaian tingkatan status akreditasi yang diberikan oleh \up0 \expndtw-
3\charscalex100 KARS tidak sesuai, dapat berakibat pada hasil akreditasi.
\par\pard\ql \li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb125\sl-276\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf6\f7\fs24 Persyaratan kesembilan: PARS.9 \par\pard\qj
\li1440\ri1236\sb8\sl-320\slmult0 \up0 \expndtw-1\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Rumah sakit menyelenggarakan pelayanan pasien dalam
lingkungan yang tidak \up0 \expndtw-1\charscalex100 memiliki risiko atau
mengancam keselamatan pasien, kesehatan masyarakat atau \up0 \expndtw-
3\charscalex100 keselamatan staf. \par\pard\ql \li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb61\sl-276\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf6\f7\fs24 Maksud dan tujuan untuk PARS.9 \par\pard\qj
\li1440\ri1237\sb8\sl-320\slmult0 \up0 \expndtw0\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Rumah sakit yang dipercaya pasien, staf dan
masyarakat, dinyatakan berisiko \up0 \expndtw0\charscalex100 rendah dan
merupakan tempat yang aman. Oleh karena itu, rumah sakit menjaga \up0
\expndtw0\charscalex100 kepercayaan dengan melakukan peninjauan dan pengawasan
terhadap praktik \up0 \expndtw-3\charscalex100 keselamatan. \par\pard\ql
\li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb61\sl-276\slmult0 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Monitoring PARS.9 \par\pard\qj
\li1440\ri1243\sb8\sl-320\slmult0 \up0 \expndtw0\charscalex103
\ul0\nosupersub\cf7\f8\fs24 Evaluasi dilaksanakan terutama selama proses
survei berlangsung termasuk \line \up0 \expndtw0\charscalex103 melalui laporan
atau pengaduan dari masyarakat atau sanksi dari pihak yang \line \up0
\expndtw-2\charscalex100 berwenang pada seluruh fase akreditasi, termasuk siklus
akreditasi tiga tahunan. \par\pard\ql \li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb81\sl-276\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf6\f7\fs24 Dampak Ketidakpatuhan terhadap PARS.9 \par\pard\qj
\li1440\ri1184\sb16\sl-310\slmult0 \up0 \expndtw-2\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Risiko keamanan yang membahayakan pasien, pengunjung
dan staf yang ditemukan \up0 \expndtw-3\charscalex100 pada saat survei dapat
berakibat pada hasil akreditasi sampai masalah tersebut dapat \up0 \expndtw-
4\charscalex100 diatasi dengan baik. \par\pard\ql \li3717\sb0\sl-276\slmult0
\par\pard\ql\li3717\sb0\sl-276\slmult0 \par\pard\ql\li3717\sb127\sl-276\slmult0
\up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 KEBIJAKAN PRA SURVEI
AKREDITASI \par\pard\ql \li4262\sb0\sl-276\slmult0 \par\pard\ql\li4262\sb8\sl-
276\slmult0 \up0 \expndtw-3\charscalex100 Persyaratan kelayakan umum
\par\pard\qj \li1440\ri1223\sb8\sl-320\slmult0 \up0 \expndtw-2\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Setiap rumah sakit dapat mengajukan survei
akreditasi kepada Komisi Akreditasi \up0 \expndtw-3\charscalex100 Rumah Sakit
(KARS) bila memenuhi semua kriteria sebagai berikut: \par\pard\ql \li1800\sb37\sl-
276\slmult0 \up0 \expndtw-5\charscalex100 1. Rumah sakit berlokasi di wilayah
Indonesia \par\pard\qj \li1800\ri1247\sb0\sl-320\slmult0\tx2160 \up0
\expndtw0\charscalex102 2. Rumah sakit umum maupun rumah sakit khusus untuk semua
kelas rumah \line\tab \up0 \expndtw-3\charscalex100 sakit \par\pard\ql
\li1800\sb25\sl-276\slmult0 \up0 \expndtw-2\charscalex100 3. Izin operasional
rumah sakit masih berlaku \par\pard\ql \li1800\ri1192\sb11\sl-
316\slmult0\tx2160\tx2160\tx2160\tx2160\tx2160\tx2160 \up0 \expndtw0\charscalex100
4. Bila izin rumah sakit sudah habis masa berlakunya, pengajuan permohonan
\line\tab \up0 \expndtw-2\charscalex100 survei bisa dilakukan, bila Dinas Kesehatan
meminta syarat perpanjangan izin \line \tab \up0 \expndtw0\charscalex104
operasional harus sudah terakreditasi. Untuk itu rumah sakit mengirimkan \line \tab
\up0 \expndtw0\charscalex100 surat/ persyaratan dari Dinas Kesehatan tersebut ke
KARS dan survei dapat \line \tab \up0 \expndtw-1\charscalex100 dilaksanakan. Hasil
survei yang diberikan berupa surat keterangan hasil \line \tab \up0 \expndtw-
3\charscalex100 akreditasi yang dapat dipergunakan untuk mengurus izin
operasional. Bila izin \line \tab \up0 \expndtw-3\charscalex100 operasional sudah
terbit, rumah sakit mengirimkan dokumen izin tersebut ke \par\pard\ql
\li10243\sb0\sl-253\slmult0 \par\pard\ql\li10243\sb44\sl-253\slmult0 \up0 \expndtw-
2\charscalex100 \ul0\nosupersub\cf1\f2\fs22 19

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Pg20}{\bkmkend Pg20}\par\pard\qj \li2160\sb0\sl-320\slmult0
\par\pard\qj\li2160\sb0\sl-320\slmult0 \par\pard\qj\li2160\sb0\sl-320\slmult0
\par\pard\qj\li2160\ri1190\sb196\sl-320\slmult0 \up0 \expndtw0\charscalex100
\ul0\nosupersub\cf10\f11\fs24 survei@kars.or.id\ul0\nosupersub\cf7\f8\fs24 dan
Komisi Akreditasi Rumah Sakit akan memberikan \up0 \expndtw-4\charscalex100
sertifikat akreditasi kepada rumah sakit tersebut. \par\pard\ql \li1800\sb17\sl-
276\slmult0 \up0 \expndtw-3\charscalex100 5. Direktur/Kepala rumah Sakit adalah
tenaga medis (dokter atau dokter gigi) \par\pard\ql \li1800\ri1184\sb8\sl-
320\slmult0\tx2160\tx2160 \up0 \expndtw-3\charscalex100 6. Rumah sakit beroperasi
penuh\ul0\nosupersub\cf8\f9\fs24 (full operation)\ul0\nosupersub\cf7\f8\fs24
dengan menyediakan pelayanan \line\tab \up0 \expndtw0\charscalex102 rawat inap,
rawat jalan, dan gawat darurat secara paripurna selama 24 jam \line \tab \up0
\expndtw-3\charscalex100 sehari dan 7 hari seminggu. \par\pard\qj
\li1800\ri1248\sb0\sl-320\slmult0\tx2160 \up0 \expndtw-1\charscalex100 7. Rumah
sakit mempunyai izin Instalasi Pengelolaaan Limbah Cair (IPLC) yang \line\tab
\up0 \expndtw-2\charscalex100 masih berlaku. \par\pard\ql \li1800\ri1219\sb6\sl-
313\slmult0\tx2160\tx2160\tx2160 \up0 \expndtw0\charscalex100 8. Rumah sakit
mempunyai izin pengelolaan limbah bahan berbahaya dan \line\tab \up0
\expndtw0\charscalex100 beracun yang masih berlaku atau kerjasama dengan
pihak ketiga yang \line \tab \up0 \expndtw-2\charscalex100 mempunyai izin sebagai
pengolah limbah bahan beracun dan berbahaya yang \line \tab \up0 \expndtw-
3\charscalex100 masih berlaku dan atau izin sebagai transporter yang masih berlaku.
\par\pard\qj \li1800\ri1248\sb2\sl-320\slmult0\tx2160 \up0 \expndtw0\charscalex100
9. Semua tenaga medis pemberi asuhan di rumah sakit telah mempunyai Surat
\line\tab \up0 \expndtw-3\charscalex100 Tanda Registrasi (STR) dan Surat Izin
Praktik (SIP) \par\pard\qj \li1800\ri1244\sb0\sl-320\slmult0\tx2160 \up0
\expndtw0\charscalex102 10.Rumah sakit melaksanakan atau bersedia melaksanakan
kewajiban dalam \line\tab \up0 \expndtw-2\charscalex100 meningkatkan mutu asuhan
dan keselamatan pasien. \par\pard\ql \li1440\sb0\sl-276\slmult0
\par\pard\ql\li1440\sb61\sl-276\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf6\f7\fs24 Catatan\ul0\nosupersub\cf7\f8\fs24 : \par\pard\qj
\li1440\ri1223\sb8\sl-320\slmult0 \up0 \expndtw0\charscalex100 Bila dalam kajian
persyaratan yang disampaikan tidak memenuhi kriteria 1. sampai \up0 \expndtw-
2\charscalex100 dengan 10. maka KARS dapat memutuskan bahwa tidak dilaksanakan
survei sampai \up0 \expndtw-3\charscalex100 dengan persyaratan dipenuhi.
\par\pard\ql \li2087\sb0\sl-276\slmult0 \par\pard\ql\li2087\sb81\sl-276\slmult0
\up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Tata cara pengajuan
survei akreditasi pertama kali dan survei ulang \par\pard\ql \li1440\sb0\sl-
276\slmult0 \par\pard\ql\li1440\sb88\sl-276\slmult0\tx2006 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 1. \tab \up0 \expndtw0\charscalex102
Rumah sakit mengajukan permohonan survei akreditasi yang dikirim melalui
\par\pard\qj \li2006\ri1249\sb0\sl-320\slmult0 \up0 \expndtw-1\charscalex100 email
ke\ul0\nosupersub\cf10\f11\fs24 survei@kars.or.id\ul0\nosupersub\cf7\f8\fs24 atau
secara online melalui website :\ul0\nosupersub\cf10\f11\fs24 www.kars.or.id
\up0 \expndtw0\charscalex100 \ul0\nosupersub\cf7\f8\fs24 paling lambat 1 (satu)
bulan sebelum tanggal pelaksanaan yang diajukan oleh \up0 \expndtw-3\charscalex100
rumah sakit. \par\pard\li1440\sb36\sl-276\slmult0\fi0\tx2006 \up0 \expndtw-
1\charscalex100 2.\tab \up0 \expndtw0\charscalex100 Surat permohonan survei
dilampiri dengan kelengkapan sebagai berikut :\par\pard\li1440\sb41\sl-
276\slmult0\fi633 \up0 \expndtw0\charscalex100 a. Aplikasi survei yang sudah diisi
dan ditandatangani oleh Direktur/Kepala\par\pard\li1440\sb41\sl-
276\slmult0\fi993 \up0 \expndtw-1\charscalex100 rumah sakit.\par\pard\ql
\li2073\sb39\sl-276\slmult0 \up0 \expndtw-3\charscalex100 b. Hasil self asessment
terakhir, dengan skor minimal 80 % \par\pard\ql \li2073\sb44\sl-276\slmult0 \up0
\expndtw-2\charscalex100 c. Izin operasional yang masih berlaku \par\pard\ql
\li2073\sb24\sl-276\slmult0 \up0 \expndtw-3\charscalex100 d. Ijazah dokter atau
dokter gigi dari Direktur/Kepala rumah sakit. \par\pard\ql \li2073\sb44\sl-
276\slmult0 \up0 \expndtw-5\charscalex100 e. Surat pernyataan Direktur/Kepala
rumah sakit yang berisi: \par\pard\ql \li2431\sb64\sl-276\slmult0 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24
Tidak keberatan memberikan akses rekam medis kepada surveior \par\pard\qj
\li2431\ri1593\sb0\sl-340\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24 Tidak
meninggalkan rumah sakit selama kegiatan survei berlangsung \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24
Semua tenaga medis sudah mempunyai STR dan SIP. \par\pard\qj \li2073\ri1251\sb0\sl-
320\slmult0\tx2433 \up0 \expndtw-3\charscalex100 f. Daftar tenaga medis yang
dilengkapi dengan nomer Surat Tanda Registrasi \line\tab \up0 \expndtw-
4\charscalex100 (STR) dan Surat Izin Praktik (SIP) dan masa berlakunya \par\pard\ql
\li2073\sb26\sl-276\slmult0 \up0 \expndtw-5\charscalex100 g. Surat izin
pengelolaan air limbah (IPLC) yang masih berlaku \par\pard\ql \li10243\sb0\sl-
253\slmult0 \par\pard\ql\li10243\sb0\sl-253\slmult0 \par\pard\ql\li10243\sb0\sl-
253\slmult0 \par\pard\ql\li10243\sb0\sl-253\slmult0 \par\pard\ql\li10243\sb111\sl-
253\slmult0 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf1\f2\fs22 20

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\par\pard\ql\li2073\sb0\sl-310\slmult0 \par\pard\ql\li2073\sb0\sl-310\slmult0
\par\pard\ql\li2073\ri1184\sb234\sl-310\slmult0\tx2433\tx2433 \up0 \expndtw-
1\charscalex100 \ul0\nosupersub\cf7\f8\fs24 h. Surat izin pengelolaan limbah
B-3 yang masih berlaku atau perjanjian \line\tab \up0 \expndtw-4\charscalex100
kerjasama dengan pihak ke 3 yang mempunyai izin pengolah limbah B-3 dan \line
\tab \up0 \expndtw-5\charscalex100 tranporter yang masih berlaku. \par\pard\ql
\li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb83\sl-276\slmult0\tx2006 \up0
\expndtw-3\charscalex100 3. \tab \up0 \expndtw-3\charscalex100 Berdasarkan
pengajuan permohonan survei akreditasi pada poin 2. maka KARS \par\pard\ql
\li2006\sb44\sl-276\slmult0 \up0 \expndtw-3\charscalex100 akan melakukan evaluasi
permohonan dan menetapkan: \par\pard\qj \li2073\ri1251\sb28\sl-
320\slmult0\tx2433 \up0 \expndtw0\charscalex103 \ul0\nosupersub\cf9\f10\fs24 \u-
3928?\ul0\nosupersub\cf7\f8\fs24 Bila rumah sakit telah memenuhi
persayaratan maka KARS akan \line\tab \up0 \expndtw-5\charscalex100 melanjutkan
proses akreditasi \par\pard\ql \li2073\ri1241\sb0\sl-
320\slmult0\tx2433\tx2433\tx2433 \up0 \expndtw0\charscalex103
\ul0\nosupersub\cf9\f10\fs24 \u-3928?\ul0\nosupersub\cf7\f8\fs24 Bila rumah
sakit belum memenuhi persyaratan maka KARS akan \line\tab \up0
\expndtw0\charscalex100 memberitahukan ke Rumah Sakit agar melengkapi
persyaratan dan \line \tab \up0 \expndtw-1\charscalex100 pelaksanaan akreditasi
ditunda sampai dengan kekurangan persyaratan \line \tab \up0 \expndtw-
3\charscalex100 dipenuhi oleh rumah sakit. \par\pard\ql \li1440\sb0\sl-
276\slmult0 \par\pard\ql\li1440\sb81\sl-276\slmult0\tx2006 \up0 \expndtw-
5\charscalex100 4. \tab \up0 \expndtw-5\charscalex100 Permohonan survei akreditasi
diterima, maka: \par\pard\qj \li2073\ri1248\sb0\sl-330\slmult0\tx2433 \up0
\expndtw-4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3928?\ul0\nosupersub\cf7\f8\fs24 KARS menjadwalkan survei akreditasi dan
memberi tahu jadwal survei \line\tab \up0 \expndtw-5\charscalex100 kepada rumah
sakit dengan tembusan kepada Dinas Kesehatan Provinsi \line \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3928?\ul0\nosupersub\cf7\f8\fs24
Rumah sakit melakukan kontrak komitmen dengan Komisi Akreditasi
\par\pard\ql \li2433\sb35\sl-276\slmult0 \up0 \expndtw-4\charscalex100 Rumah Sakit
yang antara lain berisi tentang: \par\pard\ql \li2433\ri1184\sb8\sl-
320\slmult0\tx2858\tx2858\tx2858\tx2858\tx2858\tx2858\tx2858\tx2858 \up0
\expndtw0\charscalex80 \ul0\nosupersub\cf9\f10\fs24 \u-3913? \tab \up0
\expndtw0\charscalex101 \ul0\nosupersub\cf7\f8\fs24 Kesediaan rumah sakit dilakukan
evaluasi terus menerus mulai dari \line\tab \up0 \expndtw0\charscalex100 permohonan
survei yang diajukan, pada waktu survei akreditasi \line \tab \up0 \expndtw-
2\charscalex100 dilaksanakan dan selama siklus akreditasi 3 tahunan. Evaluasi pasca
\line \tab \up0 \expndtw0\charscalex105 akreditasi ini dapat dilakukan setiap
saat dengan atau tanpa \line \tab \up0 \expndtw-3\charscalex100 pemberitahuan
terlebih dahulu, yang dilaksanakan oleh pejabat KARS \line \tab \up0 \expndtw-
4\charscalex100 atau surveior senior yang ditugaskan dengan menggunakan
tanda \line \tab \up0 \expndtw-4\charscalex100 pengenal dari KARS. Bila rumah sakit
menolak dilakukan evaluasi dapat \line \tab \up0 \expndtw-4\charscalex100 berisiko
sertifikat akreditasi ditarik kembali oleh KARS \par\pard\ql \li2433\ri1187\sb0\sl-
320\slmult0\tx2858\tx2858\tx2858\tx2858\tx2858 \up0 \expndtw0\charscalex80
\ul0\nosupersub\cf9\f10\fs24 \u-3913? \tab \up0 \expndtw0\charscalex101
\ul0\nosupersub\cf7\f8\fs24 Kesediaan Rumah Sakit dilakukan survei verifikasi tepat
waktu atau \line\tab \up0 \expndtw-3\charscalex100 sesuai dengan jadwal sebanyak
dua kali yaitu satu tahun setelah survei \line \tab \up0 \expndtw0\charscalex102
dan dua tahun setelah survei. Bila Rumah Sakit menolak dilakukan \line \tab \up0
\expndtw-1\charscalex100 survei verifikasi maka berisiko sertifikat akreditasi
ditarik kembali oleh \line \tab \up0 \expndtw-5\charscalex100 KARS. \par\pard\ql
\li2433\ri1185\sb0\sl-320\slmult0\tx2858\tx2858\tx2858\tx2858\tx2858 \up0
\expndtw0\charscalex80 \ul0\nosupersub\cf9\f10\fs24 \u-3913? \tab \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Kesediaan rumah sakit memberikan
data dan informasi yang akurat \line\tab \up0 \expndtw-3\charscalex100 dan tidak
palsu kepada KARS dan surveior. Bila terbukti data dan \line \tab \up0
\expndtw-3\charscalex100 informasi tidak akurat atau dipalsukan maka rumah sakit
siap menerima \line \tab \up0 \expndtw-4\charscalex100 risiko gagal akreditasi dan
rumah sakit mengajukan ulang permohonan \line \tab \up0 \expndtw-4\charscalex100
untuk dilakukan survei oleh KARS. \par\pard\ql \li2433\ri1183\sb0\sl-
320\slmult0\tx2858\tx2858\tx2858\tx2858 \up0 \expndtw0\charscalex80
\ul0\nosupersub\cf9\f10\fs24 \u-3913? \tab \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Kesediaan Rumah Sakit melaporkan perubahan data di
aplikasi survei \line\tab \up0 \expndtw0\charscalex102 (kepemilikan, Direktur
Rumah Sakit, perizinan, pelayanan, \line \tab \up0 \expndtw-
4\charscalex100 gedung/bangunan dan fasilitas dll) selambat-lambatnya 10 hari
sebelum \line \tab \up0 \expndtw-4\charscalex100 survei dilakukan \par\pard\ql
\li2433\ri1185\sb20\sl-320\slmult0\tx2858\tx2858\tx2858 \up0 \expndtw0\charscalex80
\ul0\nosupersub\cf9\f10\fs24 \u-3913? \tab \up0 \expndtw0\charscalex101
\ul0\nosupersub\cf7\f8\fs24 Kesediaan Rumah Sakit melaporkan bila ada
kejadian sentinel, \line\tab \up0 \expndtw-4\charscalex100 perubahan kelas rumah
sakit, perubahan jenis atau kategori rumah sakit, \line \tab \up0 \expndtw-
5\charscalex100 penambahan pelayanan baik spesialistik atau sub
spesialistik, \par\pard\ql \li10243\sb0\sl-253\slmult0
\par\pard\ql\li10243\sb123\sl-253\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf1\f2\fs22 21
\par\pard\sect\sectd\fs24\paperw11900\paperh16820\pard\sb0\sl-240{\bkmkstart Pg22}
{\bkmkend Pg22}\par\pard\qj \li2858\sb0\sl-310\slmult0 \par\pard\qj\li2858\sb0\sl-
310\slmult0 \par\pard\qj\li2858\sb0\sl-310\slmult0
\par\pard\qj\li2858\ri1189\sb234\sl-310\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf7\f8\fs24 perubahan bangunan yang lebih dari 25 % dari bangunan
saat sekarang \up0 \expndtw-2\charscalex100 selama siklus akreditasi 3 tahun dan
bersedia dilakukan survei terfokus \up0 \expndtw-3\charscalex100 sesuai
kebutuhan. \par\pard\qj \li2433\ri1252\sb22\sl-320\slmult0\tx2858 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24
Kesediaan Rumah Sakit melengkapi perizinan yang terkait dengan \line\tab
\up0 \expndtw-5\charscalex100 tenaga dan sarana-prasarana (fasilitas)
\par\pard\ql \li2433\ri1186\sb25\sl-315\slmult0\tx2858\tx2858\tx2858\tx2858 \up0
\expndtw-3\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3913?\ul0\nosupersub\cf7\f8\fs24 Kesediaan Rumah Sakit mengizinkan pejabat KARS
atau surveior senior \line\tab \up0 \expndtw-5\charscalex100 yang ditugaskan
dengan menggunakan tanda pengenal dari KARS \line \tab \up0 \expndtw-
2\charscalex100 untuk melakukan evaluasi pada saat berlangsungnya survei.
Evaluasi \line \tab \up0 \expndtw0\charscalex100 bisa dilaksanakan pada seluruh
fase akreditasi, termasuk siklus \line \tab \up0 \expndtw-3\charscalex100
akreditasi tiga tahunan. \par\pard\ql \li2433\ri1247\sb21\sl-
320\slmult0\tx2858\tx2858 \up0 \expndtw0\charscalex101 \ul0\nosupersub\cf9\f10\fs24
\u-3913?\ul0\nosupersub\cf7\f8\fs24 Kesediaan Rumah Sakit menyediakan fasilitas
dan lingkungan yang \line\tab \up0 \expndtw0\charscalex102 aman bagi pasien,
keluarga dan staf sesuai dengan peraturan \line \tab \up0 \expndtw-
5\charscalex100 perundang-undangan. \par\pard\qj \li2433\ri1249\sb0\sl-
320\slmult0\tx2858 \up0 \expndtw-5\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3913?\ul0\nosupersub\cf7\f8\fs24 Kesediaan Rumah Sakit melakukan pembayaran
survei paling lambat 7 \line\tab \up0 \expndtw-5\charscalex100 hari sebelum
pelaksanaan survei \par\pard\ql \li2073\ri1243\sb20\sl-320\slmult0\tx2433\tx2433
\up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3928?\ul0\nosupersub\cf7\f8\fs24 KARS mengirimkan nama-nama surveior dan rumah
sakit dapat menolak \line\tab \up0 \expndtw-2\charscalex100 nama tersebut bila ada
conflict of interest antara surveior dan rumah sakit, \line \tab \up0 \expndtw-
5\charscalex100 antara lain sebagai berikut : \par\pard\qj \li2433\ri1252\sb0\sl-
320\slmult0\tx2858 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3913?\ul0\nosupersub\cf7\f8\fs24 Surveior pernah bekerja dan atau pernah sebagai
pejabat di Rumah \line\tab \up0 \expndtw-3\charscalex100 Sakit tersebut.
\par\pard\qj \li2433\ri1185\sb12\sl-330\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24 Surveior
mempunyai hubungan saudara dengan Direksi Rumah Sakit \line \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24
Surveior bekerja di Rumah Sakit pesaing dari Rumah Sakit yang disurvei \line
\up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3913?\ul0\nosupersub\cf7\f8\fs24 Surveior bekerja di Rumah Sakit yang
sedang ada konflik dengan \par\pard\ql \li2858\sb35\sl-276\slmult0 \up0
\expndtw-3\charscalex100 Rumah Sakit yang disurvei \par\pard\ql
\li1440\ri1186\sb28\sl-320\slmult0\fi993\tx2433\tx2006\tx2006\tx2006\tx2006 \up0
\expndtw-4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3913?\ul0\nosupersub\cf7\f8\fs24 Surveior pernah melakukan survei akreditasi
pada
siklus sebelumnya. \line\tab \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24 Pernah terjadi
konflik antara surveior dengan Rumah Sakit. \line \up0 \expndtw-5\charscalex100 5.
\up0 \expndtw-1\charscalex100 KARS memberitahu jadwal kedatangan surveior dan
jadwal acara survei \line\tab \up0 \expndtw-3\charscalex100 akreditasi dan
dokumen-dokumen yang harus disampaikan kepada surveior. \line \up0 \expndtw-
5\charscalex100 6. \up0 \expndtw-3\charscalex100 Selama proses pengajuan survei
sampai dilaksanakan survei akreditasi, Rumah \line\tab \up0 \expndtw-
4\charscalex100 Sakit dapat melakukan komunikasi dengan sekretariat KARS, melalui
no telpun \line \tab \up0 \expndtw-1\charscalex100 (021) 29941553 atau (021)
29941552 atau melalui email ke survei@kars.or.id \line \tab \up0 \expndtw-
2\charscalex100 atau info@kars.or.id \par\pard\ql \li3131\sb0\sl-276\slmult0
\par\pard\ql\li3131\sb0\sl-276\slmult0 \par\pard\ql\li3131\sb105\sl-276\slmult0
\up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 KEBIJAKAN SURVEI
AKREDITASI RUMAH SAKIT \par\pard\ql \li4627\sb0\sl-264\slmult0
\par\pard\ql\li4627\sb110\sl-264\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf11\f12\fs23 Dasar Proses Akreditasi \par\pard\qj
\li1440\ri1228\sb16\sl-313\slmult0 \up0 \expndtw-2\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Proses akreditasi didasarkan pada hasil evaluasi
kepatuhan Rumah Sakit terhadap \up0 \expndtw-4\charscalex100 Standar Nasional
Akreditasi Rumah Sakit edisi 1 . Setelah terakreditasi, rumah sakit \up0 \expndtw-
2\charscalex100 diharapkan untuk menunjukkan kepatuhan terus menerus terhadap
standar di setiap \up0 \expndtw-3\charscalex100 siklus akreditasi. Standar
akreditasi diperbarui setiap tiga tahun. \par\pard\ql \li5191\sb0\sl-264\slmult0
\par\pard\ql\li5191\sb104\sl-264\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf11\f12\fs23 Tujuan Survei \par\pard\ql \li10243\sb0\sl-
253\slmult0 \par\pard\ql\li10243\sb113\sl-253\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf1\f2\fs22 22

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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn
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{\sp{\sn pVerticies}{\sv 8;4;(0,314);(9079,314);(9079,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv
13431551}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}
{\sv 1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}

{\shp
{\*\shpinst\shpleft1411\shptop13025\shpright10490\shpbottom13340\shpfhdr0\shpbxpage
\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz1713\shplid1
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn
geoRight}{\sv 9079}}{\sp{\sn geoBottom}{\sv 315}}
{\sp{\sn pVerticies}{\sv 8;4;(0,315);(9079,315);(9079,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv
13952251}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}
{\sv 1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}

{\shp
{\*\shpinst\shpleft1411\shptop14928\shpright10490\shpbottom15243\shpfhdr0\shpbxpage
\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz3939\shplid2
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn
geoRight}{\sv 9079}}{\sp{\sn geoBottom}{\sv 315}}
{\sp{\sn pVerticies}{\sv 8;4;(0,315);(9079,315);(9079,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv
13952251}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}
{\sv 1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw11900\paperh16820\pard\sb0\sl-240{\bkmkstart
Pg23}{\bkmkend Pg23}\par\pard\qj \li1440\sb0\sl-320\slmult0
\par\pard\qj\li1440\sb0\sl-320\slmult0 \par\pard\qj\li1440\sb0\sl-320\slmult0
\par\pard\qj\li1440\ri1202\sb196\sl-320\slmult0 \up0 \expndtw-2\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Survei akreditasi dilaksanakan dengan menilai
kesesuaian rumah sakit terhadap \up0 \expndtw-3\charscalex100 standar nasional
akreditasi rumah sakit edisi 1 melalui proses: \par\pard\li1440\sb49\sl-
276\slmult0\fi0\tx2006 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3913?\tab \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf7\f8\fs24 wawancara dengan staf dan pasien serta informasi lisan
lainnya;\par\pard\li1440\sb60\sl-276\slmult0\fi0\tx2006 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3913?\tab \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf7\f8\fs24 pengamatan proses penanganan pasien
secara langsung;\par\pard\li1440\sb67\sl-276\slmult0\fi0\tx2006 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3913?\tab \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 tinjauan terhadap kebijakan,
prosedur, panduan praktik klinis, rekam medis\par\pard\li1440\sb44\sl-
276\slmult0\fi566 \up0 \expndtw-3\charscalex100 pasien, catatan personel,
kepatuhan terhadap peraturan perundang-undangan,\par\pard\li1440\sb41\sl-
276\slmult0\fi566 \up0 \expndtw-4\charscalex100 dan dokumen lain yang diminta dari
rumah sakit;\par\pard\li1440\sb55\sl-276\slmult0\fi0\tx2006 \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3913?\tab \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 tinjauan data peningkatan mutu dan
keselamatan pasien, penilaian kinerja dan\par\pard\li1440\sb43\sl-276\slmult0\fi566
\up0 \expndtw-4\charscalex100 hasil;\par\pard\ql \li1440\sb46\sl-
276\slmult0\tx2006\tx8260 \up0 \expndtw0\charscalex80
\ul0\nosupersub\cf9\f10\fs24 \u-3913? \tab \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf7\f8\fs24 pelaksanaan aktivitas telusur pasien secara
individual \tab \up0 \expndtw-5\charscalex100 (yaitu mengevaluasi \par\pard\ql
\li1440\ri1183\sb8\sl-320\slmult0\fi566\tx2006\tx2006\tx2006 \up0 \expndtw-
2\charscalex100 pengalaman perawatan pasien melalui proses perawatan di rumah
sakit); dan \up0 \expndtw0\charscalex80 \ul0\nosupersub\cf9\f10\fs24 \u-3913?
\up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf7\f8\fs24 pelaksanaan aktivitas
telusur terfokus terhadap sistem atau proses di seluruh \line\tab \up0
\expndtw0\charscalex100 organisasi (misalnya, manajemen obat, pengendalian
infeksi, limbah dan \line \tab \up0 \expndtw-1\charscalex100 bahan berbahaya,
atau sistem dan proses rawan masalah, berisiko tinggi, \line \tab \up0 \expndtw-
3\charscalex100 bervolume tinggi/rendah lainnya.) \par\pard\ql \li5186\sb0\sl-
264\slmult0 \par\pard\ql\li5186\sb103\sl-264\slmult0 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf11\f12\fs23 Proses Survei \par\pard\qj
\li1440\ri1183\sb13\sl-317\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Metode aktivitas telusur merupakan proses survei
oleh surveior KARS langsung di \up0 \expndtw-3\charscalex100 lokasi. Dalam
metode aktivitas telusur, surveior memilih pasien dari populasi pasien \up0
\expndtw-3\charscalex100 di rumah sakit dan melakukan telusur terhadap asuhan yang
diberikan kepada pasien \up0 \expndtw0\charscalex100 oleh rumah sakit dan juga
akanmelakukan aktivitas telusur terhadap sistem dan \up0 \expndtw0\charscalex100
proses penting dalam pelayanan klinis dan manajerial. Dalam aktivitas ini
surveior \up0 \expndtw-2\charscalex100 dapat menemukan bukti masalah ketidakpatuhan
terhadap standar dalam satu atau \up0 \expndtw0\charscalex100 beberapa langkah
proses pelayanan dan asuhan pasien serta proses manajemen \up0 \expndtw-
3\charscalex100 atau pada saat acara pertemuan diantara proses-proses tersebut.
\par\pard\ql \li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb81\sl-276\slmult0
\up0 \expndtw-4\charscalex100 Dalam proses survei, surveior dapat melakukan:
\par\pard\qj \li1507\ri2837\sb0\sl-340\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24 wawancara
kepada staf secara individual atau di dalam kelompok \up0 \expndtw-
4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24
mengamati perawatan pasien \par\pard\qj \li1507\ri4865\sb9\sl-320\slmult0 \up0
\expndtw-4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3913?\ul0\nosupersub\cf7\f8\fs24 wawancara kepada pasien dan keluarganya
\up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3913?\ul0\nosupersub\cf7\f8\fs24 meninjau rekam medis pasien \par\pard\ql
\li1507\sb57\sl-276\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24 meninjau
catatan personel/file pegawai \par\pard\ql \li1507\sb64\sl-276\slmult0 \up0
\expndtw-4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3913?\ul0\nosupersub\cf7\f8\fs24 meninjau kebijakan dan prosedur dan dokumen
lainnya. \par\pard\qj \li1440\ri1242\sb308\sl-320\slmult0 \up0 \expndtw-
1\charscalex100 Setelah rumah sakit menandatangani kontrak survei, rumah sakit
harus mempelajari \line \up0 \expndtw-2\charscalex100 Panduan Proses Survei
Rumah Sakit \up0 \expndtw-2\charscalex100 (\ul0\nosupersub\cf8\f9\fs24 Hospital
Survey Process Guide\ul0\nosupersub\cf7\f8\fs24 ) yang \par\pard\qj
\li1440\ri1208\sb0\sl-320\slmult0 \up0 \expndtw-2\charscalex100 ditetapkan oleh
KARS untuk mengetahui penjelasan rinci tentang proses yang terjadi \up0 \expndtw-
1\charscalex100 selama survei awal atau survei ulang, termasuk penjelasan rinci
mengenai seluruh \up0 \expndtw-2\charscalex100 aktivitas survei, dokumentasi yang
dibutuhkan, dan sumber daya lainnya. \par\pard\qj \li1440\sb0\sl-310\slmult0
\par\pard\qj\li1440\ri1196\sb19\sl-310\slmult0 \up0 \expndtw-3\charscalex100 Sejak
hari kedua survei, pada pagi hari surveior melakukan klarifikasi kepada direktur
\line \up0 \expndtw-1\charscalex100 rumah sakit dan pimpinan lainnya pada pertemuan
kepemimpinan. Pada pertemuan \line \up0 \expndtw-1\charscalex100 ini, surveior
memberikan informasi mengenai temuan mereka. Penting untuk dicatat \par\pard\ql
\li10243\sb0\sl-253\slmult0 \par\pard\ql\li10243\sb85\sl-253\slmult0 \up0 \expndtw-
2\charscalex100 \ul0\nosupersub\cf1\f2\fs22 23

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hpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz7796\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn
geoRight}{\sv 9079}}{\sp{\sn geoBottom}{\sv 317}}
{\sp{\sn pVerticies}{\sv 8;4;(0,317);(9079,317);(9079,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv
13952251}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}
{\sv 1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw11900\paperh16820\pard\sb0\sl-240{\bkmkstart
Pg24}{\bkmkend Pg24}\par\pard\qj \li1440\sb0\sl-320\slmult0
\par\pard\qj\li1440\sb0\sl-320\slmult0 \par\pard\qj\li1440\sb0\sl-320\slmult0
\par\pard\qj\li1440\ri1242\sb196\sl-320\slmult0 \up0 \expndtw0\charscalex103
\ul0\nosupersub\cf7\f8\fs24 bahwa informasi awal apapun bukanlah merupakan
keputusan akhir sampai \up0 \expndtw-3\charscalex100 pemeriksaan laporan survei
di KARS selesai. \par\pard\qj \li1440\ri1237\sb300\sl-320\slmult0 \up0
\expndtw0\charscalex100 Jika selama proses survei surveior menemukan kondisi
yang dapat berakibat \line \up0 \expndtw-2\charscalex100 ancaman serius bagi
keselamatan publik atau pasien, mereka akan melaporkan \line \up0
\expndtw0\charscalex100 kepada KARS. Dalam situasi demikian, KARS dapat
memutuskan untuk \line \up0 \expndtw-1\charscalex100 menghentikan survei dan
mempertimbangkan untuk melaporkan kepada institusi \line \up0 \expndtw-
3\charscalex100 terkait. \par\pard\qj \li1440\sb0\sl-313\slmult0
\par\pard\qj\li1440\ri1182\sb13\sl-313\slmult0 \up0 \expndtw-3\charscalex100 KARS
menetapkan tanggal berlakunya standar nasional akreditasi rumah sakit edisi 1 \line
\up0 \expndtw0\charscalex103 pada tanggal 1 Januari 2018. Dengan demikian setelah
tanggal tersebut, KARS \line \up0 \expndtw0\charscalex102 melakukan semua
kegiatan survei akreditasi dengan menggunakan standar \line \up0 \expndtw-
3\charscalex100 tersebut. \par\pard\ql \li4223\sb0\sl-276\slmult0
\par\pard\ql\li4223\sb82\sl-276\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf6\f7\fs24 Survei Akreditasi Rumah Sakit \par\pard\ql
\li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb88\sl-276\slmult0 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf11\f12\fs23 Jenis-
jenis\ul0\nosupersub\cf6\f7\fs24 Survei \par\pard\qj \li1440\ri1244\sb0\sl-
320\slmult0 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Survei
dilaksanakan sesuai dengan menilai semua standar nasional akreditasi
\line \up0 \expndtw-1\charscalex100 rumah sakit edisi 1 di seluruh rumah sakit.
Bentuk survei meliputi survei awal, survei \line \up0 \expndtw0\charscalex104
ulang, survei verifikasi dan survei terfokus. Definisi setiap survei adalah sebagai
\line \up0 \expndtw-3\charscalex100 berikut: \par\pard\ql \li1507\sb0\sl-
276\slmult0 \par\pard\ql\li1507\sb69\sl-276\slmult0 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf12\f13\fs24 \u-3978?\ul0\nosupersub\cf6\f7\fs24
Survei Awal\u8212?Survei langsung penuh pertama pada rumah sakit \par\pard\qj
\li1440\ri1221\sb16\sl-310\slmult0 \up0 \expndtw-2\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Survei Remedial\u8212?Evaluasi langsung yang
dijadwalkan paling lambat 6 bulan setelah \line \up0 \expndtw-1\charscalex100
survei awal untuk mengevaluasi elemen penilaian (EP) yang mendapatkan nilai
\line \up0 \expndtw-2\charscalex100 \u8220?tidak terpenuhi\u8221? \up0 \expndtw-
2\charscalex100 (\u8220?\ul0\nosupersub\cf8\f9\fs24 not
met\ul0\nosupersub\cf7\f8\fs24 \u8221?) atau \up0 \expndtw-2\charscalex100 \u8220?
terpenuhi sebagian\u8221? \up0 \expndtw-2\charscalex100
(\u8220?\ul0\nosupersub\cf8\f9\fs24 partially met\ul0\nosupersub\cf7\f8\fs24
\u8221?) yang \par\pard\ql \li1440\sb39\sl-276\slmult0 \up0 \expndtw-
2\charscalex100 mengakibatkan rumah sakit gagal untuk memenuhi persyaratan
kelulusan akreditasi. \par\pard\ql \li1507\sb0\sl-276\slmult0
\par\pard\ql\li1507\sb88\sl-276\slmult0 \up0 \expndtw-2\charscalex100
\ul0\nosupersub\cf12\f13\fs24 \u-3978?\ul0\nosupersub\cf6\f7\fs24 Survei
Ulang\u8212?Survei rumah sakit setelah siklus akreditasi tiga tahun \par\pard\qj
\li1440\ri1190\sb8\sl-320\slmult0 \up0 \expndtw-2\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Survei Remedial\u8212?Evaluasi langsung yang
dijadwalkan paling lambat 6 bulan setelah \up0 \expndtw-3\charscalex100 survei awal
untuk mengevaluasi elemen penilaian (EP) yang mendapatkan nilai \u8220?tidak
\up0 \expndtw-2\charscalex100 terpenuhi\u8221? (\u8220?not met\u8221?) atau \u8220?
terpenuhi sebagian\u8221? (\u8220?partially met\u8221?) yang mengakibatkan \up0
\expndtw-3\charscalex100 rumah sakit gagal untuk memenuhi persyaratan kelulusan
akreditasi. \par\pard\ql \li1507\sb0\sl-276\slmult0 \par\pard\ql\li1507\sb61\sl-
276\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf12\f13\fs24 \u-
3978?\ul0\nosupersub\cf6\f7\fs24 Survei Verifikasi \par\pard\qj
\li1440\ri1187\sb8\sl-320\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Survei verifikasi dilaksanakan satu tahun dan dua tahun
setelah survei akreditasi awal \up0 \expndtw0\charscalex100 atau survei ulang
untuk melakukan verifikasi terhadap perencanaan perbaikan \up0 \expndtw-
3\charscalex100 strategis (PPS). \par\pard\ql \li1507\sb0\sl-276\slmult0
\par\pard\ql\li1507\sb81\sl-276\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf12\f13\fs24 \u-3978?\ul0\nosupersub\cf6\f7\fs24 Survei Terfokus
\par\pard\qj \li1440\ri1183\sb14\sl-313\slmult0 \up0 \expndtw0\charscalex103
\ul0\nosupersub\cf7\f8\fs24 Survei terfokus adalah survei langsung yang terbatas
dalam lingkup, konten, dan \up0 \expndtw-1\charscalex100 lamanya, dan dirancang
untuk mengumpulkan informasi tentang suatu masalah, \up0 \expndtw-
3\charscalex100 standar, atau elemen penilaian secara spesifik. KARS melakukan
jenis survei terfokus \up0 \expndtw-4\charscalex100 sebagai berikut:
\par\pard\ql \li10243\sb217\sl-253\slmult0 \up0 \expndtw-2\charscalex100
\ul0\nosupersub\cf1\f2\fs22 24

{\shp
{\*\shpinst\shpleft1411\shptop5863\shpright10490\shpbottom6180\shpfhdr0\shpbxpage\s
hpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz3743\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn
geoRight}{\sv 9079}}{\sp{\sn geoBottom}{\sv 317}}
{\sp{\sn pVerticies}{\sv 8;4;(0,317);(9079,317);(9079,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv
13952251}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}
{\sv 1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}

{\shp
{\*\shpinst\shpleft1411\shptop6499\shpright10490\shpbottom6814\shpfhdr0\shpbxpage\s
hpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz3800\shplid1
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn
geoRight}{\sv 9079}}{\sp{\sn geoBottom}{\sv 315}}
{\sp{\sn pVerticies}{\sv 8;4;(0,315);(9079,315);(9079,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv
14217186}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}
{\sv 1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}

{\shp
{\*\shpinst\shpleft1478\shptop8403\shpright10490\shpbottom8717\shpfhdr0\shpbxpage\s
hpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz5276\shplid2
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn
geoRight}{\sv 9012}}{\sp{\sn geoBottom}{\sv 314}}
{\sp{\sn pVerticies}{\sv 8;4;(0,314);(9012,314);(9012,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv
16181725}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}
{\sv 1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}

{\shp
{\*\shpinst\shpleft1478\shptop10308\shpright10490\shpbottom10623\shpfhdr0\shpbxpage
\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz8150\shplid3
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn
geoRight}{\sv 9012}}{\sp{\sn geoBottom}{\sv 315}}
{\sp{\sn pVerticies}{\sv 8;4;(0,315);(9012,315);(9012,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv
16181725}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}
{\sv 1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}

{\shp
{\*\shpinst\shpleft1478\shptop12212\shpright10490\shpbottom12526\shpfhdr0\shpbxpage
\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz8390\shplid4
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn
geoRight}{\sv 9012}}{\sp{\sn geoBottom}{\sv 314}}
{\sp{\sn pVerticies}{\sv 8;4;(0,314);(9012,314);(9012,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv
16181725}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}
{\sv 1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}

{\shp
{\*\shpinst\shpleft1478\shptop13798\shpright10490\shpbottom14115\shpfhdr0\shpbxpage
\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz8726\shplid5
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn
geoRight}{\sv 9012}}{\sp{\sn geoBottom}{\sv 317}}
{\sp{\sn pVerticies}{\sv 8;4;(0,317);(9012,317);(9012,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv
16181725}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}
{\sv 1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw11900\paperh16820\pard\sb0\sl-240{\bkmkstart
Pg25}{\bkmkend Pg25}\par\pard\ql \li1581\sb0\sl-320\slmult0
\par\pard\ql\li1581\sb0\sl-320\slmult0 \par\pard\ql\li1581\sb0\sl-320\slmult0
\par\pard\ql\li1581\ri1215\sb196\sl-
320\slmult0\tx2006\tx2006\tx2006\tx2006\tx2006 \up0 \expndtw-6\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3928? \tab \up0 \expndtw-2\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Bila KARS menemukan adanya ketidakpatuhan yang serius
terhadap standar, \line\tab \up0 \expndtw0\charscalex100 masalah perawatan atau
keselamatan pasien yang serius, masalah regulasi \line \tab \up0 \expndtw-
2\charscalex100 atau sanksi, atau masalah serius lainnya dalam suatu rumah
sakit yang \line \tab \up0 \expndtw0\charscalex100 terakreditasi atau program
bersertifikat, yang mungkin menempatkan rumah \line \tab \up0 \expndtw-
3\charscalex100 sakit pada status Berisiko Untuk Penolakan Akreditasi. \par\pard\ql
\li1581\ri1195\sb20\sl-320\slmult0\tx2006\tx2006\tx2073 \up0 \expndtw-
6\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3928? \tab \up0 \expndtw-
2\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Bila rumah sakit memberitahu kepada
KARS adanya perubahan dalam waktu \line\tab \up0 \expndtw-5\charscalex100 15 hari,
termasuk namun tidak terbatas pada sebagai berikut: \line \tab \up0 \expndtw-
5\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24
Perubahan kepemilikan dan/atau nama rumah sakit \par\pard\ql \li2073\ri1254\sb0\sl-
320\slmult0\tx2433\tx2433\tx2433 \up0 \expndtw0\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24 Pencabutan atau
pembatasan izin operasional, setiap pembatasan atau \line\tab \up0 \expndtw-
4\charscalex100 penutupan layanan perawatan pasien, sanksi profesi atau sanksi
untuk staf \line \tab \up0 \expndtw-2\charscalex100 lain, atau tindakan lain
menurut hukum dan peraturan yang diberikan oleh \line \tab \up0 \expndtw-
3\charscalex100 otoritas kesehatan terkait \par\pard\ql \li2073\ri1190\sb24\sl-
316\slmult0\tx2433\tx2433\tx2433\tx2433\tx2433\tx2433 \up0 \expndtw-1\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24 Peralihan atau
perubahan penggunaan bangunan perawatan pasien, \line\tab \up0 \expndtw-
4\charscalex100 pembangunan baru atau perluasan bangunan perawatan pasien,
atau \line \tab \up0 \expndtw-3\charscalex100 kepemilikan bangunan di lokasi baru
di masyarakat, memperluas jenis dan \line \tab \up0 \expndtw-4\charscalex100 volume
pelayanan perawatan pasien 25 persen atau lebih dari yang telah \line \tab
\up0 \expndtw-4\charscalex100 dilaporkan di dalam profil rumah sakit,
atau tidak dilaporkan sebagai \line \tab \up0 \expndtw0\charscalex100 lokasi
perawatan pasien, atau tidak termasuk dalam ruang lingkup survei \line \tab \up0
\expndtw-4\charscalex100 akreditasi sebelumnya \par\pard\ql \li2073\ri1188\sb1\sl-
320\slmult0\tx2433\tx2433\tx2433 \up0 \expndtw-7\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24 Perluasan
kapasitas rumah sakit yang memang dimaksudkan untuk \line\tab
\up0 \expndtw-2\charscalex100 memberikan pelayanan tanpa adanya fasilitas baru,
telah direnovasi, atau \line \tab \up0 \expndtw0\charscalex100 telah diperluas
sebesar 25 persen atau lebih, yang dinilai melalui volume \line \tab \up0 \expndtw-
3\charscalex100 pasien, cakupan layanan, atau penilaian lain yang relevan
\par\pard\qj \li2073\ri1195\sb20\sl-320\slmult0\tx2433 \up0 \expndtw-
7\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-3913?\ul0\nosupersub\cf7\f8\fs24
Penambahan satu atau lebih jenis layanan kesehatan,
seperti \line\tab \up0 \expndtw-8\charscalex100 penambahan unit dialisis atau
penghentian layanan pasien trauma \par\pard\ql \li4147\sb0\sl-276\slmult0
\par\pard\ql\li4147\sb0\sl-276\slmult0 \par\pard\ql\li4147\sb0\sl-276\slmult0
\par\pard\ql\li4147\sb149\sl-276\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf6\f7\fs24 Standar Akreditasi Rumah Sakit \par\pard\qj
\li1440\sb0\sl-320\slmult0 \par\pard\qj\li1440\ri1190\sb8\sl-320\slmult0 \up0
\expndtw-3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Standar akreditasi yang
dipergunakan mulai 1 Januari 2018 adalah\ul0\nosupersub\cf6\f7\fs24
STANDAR \line \up0 \expndtw-3\charscalex100 NASIONAL AKREDITASI RUMAH SAKIT EDISI
1\ul0\nosupersub\cf7\f8\fs24 yang terdiri dari 16 bab yaitu : \par\pard\ql
\li1800\sb0\sl-276\slmult0 \par\pard\ql\li1800\sb81\sl-276\slmult0 \up0 \expndtw-
4\charscalex100 1. Sasaran Keselamatan Pasien (SKP) \par\pard\ql \li1800\sb24\sl-
276\slmult0 \up0 \expndtw-5\charscalex100 2. Akses ke Rumah Sakit dan Kontinuitas
(ARK) \par\pard\ql \li1800\sb44\sl-276\slmult0 \up0 \expndtw-4\charscalex100 3.
Hak Pasien dan Keluarga (HPK) \par\pard\ql \li1800\sb44\sl-276\slmult0 \up0
\expndtw-4\charscalex100 4. Asesmen Pasien (AP) \par\pard\ql \li1800\sb44\sl-
276\slmult0 \up0 \expndtw-4\charscalex100 5. Pelayanan Asuhan Pasien (PAP)
\par\pard\ql \li1800\sb44\sl-276\slmult0 \up0 \expndtw-4\charscalex100 6.
Pelayanan Anestesi dan Bedah (PAB) \par\pard\ql \li1800\sb44\sl-276\slmult0 \up0
\expndtw-5\charscalex100 7. Pelayanan Kefarmasian dan Penggunaan Obat (PKPO)
\par\pard\ql \li1800\sb44\sl-276\slmult0 \up0 \expndtw-5\charscalex100 8.
Manajemen Komunikasi dan Edukasi (MKE) \par\pard\ql \li1800\sb44\sl-276\slmult0
\up0 \expndtw-5\charscalex100 9. Peningkatan Mutu dan Keselamatan Pasien (PMKP)
\par\pard\ql \li1800\sb24\sl-276\slmult0 \up0 \expndtw-5\charscalex100
10.Pencegahan dan Pengendalian Infeksi (PPI) \par\pard\ql \li10243\sb0\sl-
253\slmult0 \par\pard\ql\li10243\sb190\sl-253\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf1\f2\fs22 25

{\shp
{\*\shpinst\shpleft1411\shptop10412\shpright10490\shpbottom10726\shpfhdr0\shpbxpage
\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz5276\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn
geoRight}{\sv 9079}}{\sp{\sn geoBottom}{\sv 314}}
{\sp{\sn pVerticies}{\sv 8;4;(0,314);(9079,314);(9079,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv
13952251}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}
{\sv 1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw11900\paperh16820\pard\sb0\sl-240{\bkmkstart
Pg26}{\bkmkend Pg26}\par\pard\ql \li1800\sb0\sl-276\slmult0
\par\pard\ql\li1800\sb0\sl-276\slmult0 \par\pard\ql\li1800\sb0\sl-276\slmult0
\par\pard\ql\li1800\sb0\sl-276\slmult0 \par\pard\ql\li1800\sb88\sl-276\slmult0 \up0
\expndtw-2\charscalex100 \ul0\nosupersub\cf7\f8\fs24 11.Tata Kelola Rumah Sakit
(TKRS) \par\pard\ql \li1800\sb44\sl-276\slmult0 \up0 \expndtw-3\charscalex100
12.Manajemen Fasilitas dan Keselamatan (MFK) \par\pard\ql \li1800\sb24\sl-
276\slmult0 \up0 \expndtw-4\charscalex100 13.Kompetensi & Kewenangan Staf
(KKS) \par\pard\ql \li1800\sb44\sl-276\slmult0 \up0 \expndtw-3\charscalex100
14.Manajemen Informasi dan Rekam Medis (MIRM) \par\pard\ql \li1800\sb44\sl-
276\slmult0\tx4442 \up0 \expndtw0\charscalex102 15.Program Nasional \tab \up0
\expndtw0\charscalex106 (menurunkan angka kematian ibu dan bayi serta
\par\pard\qj \li2160\ri1244\sb8\sl-320\slmult0 \up0 \expndtw0\charscalex101
meningkatkan angka kesehatan ibu dan bayi, menurunkan angka kesakitan \up0
\expndtw-2\charscalex100 HIV/AIDS, menurunkan angka kesakitan tuberkulosis,
pengendalian resistensi \up0 \expndtw-3\charscalex100 antimikroba dan pelayanan
geriatri) \par\pard\ql \li1800\sb37\sl-276\slmult0 \up0 \expndtw-3\charscalex100
16.Integrasi Pendidikan Kesehatan dalam Pelayanan Rumah Sakit (IPKP)
\par\pard\qj \li1440\ri1245\sb308\sl-320\slmult0 \up0 \expndtw0\charscalex103
Ketentuan penggunaan Standar Nasional Akreditasi Rumah Sakit Edisi I sebagai
\up0 \expndtw-3\charscalex100 berikut: \par\pard\li1440\sb64\sl-
276\slmult0\fi0\tx5025 \up0 \expndtw-2\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3928?\ul0\nosupersub\cf7\f8\fs24 Rumah Sakit
Pendidikan\tab \up0 \expndtw-2\charscalex100 : 16 bab\par\pard\ql \li1440\sb57\sl-
276\slmult0 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3928?\ul0\nosupersub\cf7\f8\fs24 Rumah Sakit non Pendidikan : 15 bab
\par\pard\ql \li3748\sb0\sl-276\slmult0 \par\pard\ql\li3748\sb268\sl-276\slmult0
\up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Jenis Surveior Akreditasi
Rumah Sakit \par\pard\ql \li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\sb88\sl-
276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Surveior
akreditasi terdiri dari : \par\pard\qj \li1516\ri2675\sb28\sl-320\slmult0 \up0
\expndtw-5\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3928?\ul0\nosupersub\cf7\f8\fs24 Surveior Manajemen yaitu tenaga medis yang ahli
perumah sakitan \up0 \expndtw-5\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3928?\ul0\nosupersub\cf7\f8\fs24 Surveior Medis yaitu para dokter spesialis
\par\pard\ql \li1516\sb57\sl-276\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf9\f10\fs24 \u-3928?\ul0\nosupersub\cf7\f8\fs24 Surveior
Keperawatan yaitu para perawat. \par\pard\ql \li1516\sb64\sl-276\slmult0\tx3849
\up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf9\f10\fs24 \u-
3928?\ul0\nosupersub\cf7\f8\fs24 Surveior lainnya \tab \up0 \expndtw-
2\charscalex100 : ahli rekam medis, apoteker, dan lain sebagainya akan
\par\pard\ql \li1876\sb44\sl-276\slmult0 \up0 \expndtw-3\charscalex100 ditugaskan
bila ada survei terfokus yang memerlukan keahliannya. \par\pard\ql \li3151\sb0\sl-
276\slmult0 \par\pard\ql\li3151\sb0\sl-276\slmult0 \par\pard\ql\li3151\sb0\sl-
276\slmult0 \par\pard\ql\li3151\sb36\sl-276\slmult0 \up0 \expndtw-
3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Pembagian tugas surveior akreditasi
rumah sakit \par\pard\qj \li1440\sb0\sl-320\slmult0
\par\pard\qj\li1440\ri1195\sb8\sl-320\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf7\f8\fs24 Pembagian tugas surveior pada pelaksanaan survei
akreditasi dengan menggunakan \up0 \expndtw-5\charscalex100 Standar Nasional
Akreditasi Rumah Sakit Edisi 1 sebagai berikut : \par\pard\ql \li5812\sb0\sl-
276\slmult0 \par\pard\ql\li5812\sb0\sl-276\slmult0 \par\pard\ql\li5812\sb125\sl-
276\slmult0 \up0 \expndtw-5\charscalex100 \ul0\nosupersub\cf6\f7\fs24
SURVEIOR\par\pard\sect\sectd\sbknone\cols2\colno1\colw5172\colsr160\colno2\colw6428
\colsr160\ql \li2781\sb260\sl-276\slmult0 \up0 \expndtw-3\charscalex100
MANAJEMEN\par\pard\ql \li2212\sb252\sl-276\slmult0 \up0 \expndtw-1\charscalex100
\ul0\nosupersub\cf7\f8\fs24 1. Pelayanan\par\pard\ql \li2572\sb41\sl-
276\slmult0\tx4435 \up0 \expndtw-3\charscalex100 Kefarmasian\tab \up0 \expndtw-
3\charscalex100 dan\par\pard\ql \li2572\sb43\sl-276\slmult0 \up0 \expndtw-
6\charscalex100 Penggunaan Obat\par\pard\ql \li2212\ri243\sb18\sl-
317\slmult0\tx2572\tx2572 \up0 \expndtw0\charscalex103 2. Peningkatan Mutu
\line\tab \up0 \expndtw0\charscalex103 dan Keselamatan \line \tab \up0
\expndtw-3\charscalex100 Pasien\par\pard\column \ql \li870\sb260\sl-
276\slmult0\tx3532 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24
MEDIS\tab \up0 \expndtw-3\charscalex100 PERAWAT\par\pard\ql \li20\sb252\sl-
276\slmult0\tx2862 \up0 \expndtw0\charscalex105 \ul0\nosupersub\cf7\f8\fs24 1.
Akses ke RS dan\tab \up0 \expndtw0\charscalex106 1. Hak pasien
dan\par\pard\ql \li380\sb41\sl-276\slmult0\tx3222 \up0 \expndtw-3\charscalex100
Kontinuitas\tab \up0 \expndtw-3\charscalex100 Keluarga\par\pard\ql \li5332\sb0\sl-
276\slmult0 \par\pard\ql \li20\sb94\sl-276\slmult0\tx2862 \up0 \expndtw-
2\charscalex100 2. Asesmen Pasien\tab \up0 \expndtw-1\charscalex100 2.
Manajemen\par\pard\ql \li3217\sb40\sl-276\slmult0\tx5076 \up0 \expndtw-
3\charscalex100 komunikasi\tab \up0 \expndtw-3\charscalex100 dan\par\pard\ql
\li3217\sb44\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Edukasi
\par\pard\sect\sectd\sbknone \ql \li10243\sb0\sl-253\slmult0
\par\pard\ql\li10243\sb0\sl-253\slmult0 \par\pard\ql\li10243\sb0\sl-253\slmult0
\par\pard\ql\li10243\sb101\sl-253\slmult0 \up0 \expndtw-4\charscalex100
\ul0\nosupersub\cf1\f2\fs22 26

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{\shp
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{\sp{\sn pVerticies}{\sv 8;4;(0,7);(7,7);(7,0);(0,0)}}
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}}\par\pard\sect\sectd\fs24\paperw11900\paperh16820\pard\sb0\sl-240{\bkmkstart
Pg27}{\bkmkend Pg27}\par\pard\li2212\sb0\sl-276\slmult0\par\pard\li2212\sb0\sl-
276\slmult0\par\pard\li2212\sb0\sl-276\slmult0\par\pard\li2212\sb0\sl-
276\slmult0\par\pard\li2212\sb102\sl-276\slmult0\fi0\tx5332\tx8169\tx10382 \up0
\expndtw-2\charscalex100 \ul0\nosupersub\cf7\f8\fs24 3. Tata Kelola Rumah\tab
\up0 \expndtw-2\charscalex100 3. Pelayanan Asuhan\tab \up0 \expndtw-
2\charscalex100 3. Pencegahan\tab \up0 \expndtw-2\charscalex100
dan\par\pard\li2212\sb41\sl-276\slmult0\fi360\tx5692\tx8529 \up0 \expndtw-
2\charscalex100 Sakit\tab \up0 \expndtw-2\charscalex100 Pasien.\tab \up0 \expndtw-
2\charscalex100 Pengendalian infeksi\par\pard\li2212\sb52\sl-
276\slmult0\fi0\tx5332\tx8169 \up0 \expndtw-2\charscalex100 4. Manajemen
Fasilitas\tab \up0 \expndtw-2\charscalex100 4. Pelayanan Anestesi\tab \up0
\expndtw-2\charscalex100 4. Sasaran\par\pard\li2212\sb41\sl-
276\slmult0\fi360\tx5692\tx8529 \up0 \expndtw-2\charscalex100 dan
Keselamatan\tab \up0 \expndtw-2\charscalex100 dan Bedah\tab \up0 \expndtw-
2\charscalex100 Keselamatan Pasien\par\pard\li2212\sb51\sl-
276\slmult0\fi0\tx4440\tx5332\tx8169 \up0 \expndtw-2\charscalex100 5.
Kompetensi\tab \up0 \expndtw-2\charscalex100 dan\tab \up0 \expndtw-2\charscalex100
5. Menurunkan Angka\tab \up0 \expndtw-2\charscalex100 5.
Manajemen\par\pard\li2212\sb43\sl-276\slmult0\fi360\tx5692\tx8529 \up0 \expndtw-
2\charscalex100 Kewenangan Staf.\tab \up0 \expndtw-2\charscalex100 Kematian Ibu
dan\tab \up0 \expndtw-2\charscalex100 Informasi dan Rekam\par\pard\li5692\sb41\sl-
276\slmult0\fi0\tx6675\tx8529 \up0 \expndtw-3\charscalex100 Bayi,\tab \up0
\expndtw-3\charscalex100 Menurunan\tab \up0 \expndtw-3\charscalex100
Medis\par\pard\qj \li5692\ri3819\sb0\sl-320\slmult0 \up0 \expndtw0\charscalex103
Angka Kesakitan \up0 \expndtw-3\charscalex100 HIV/AIDS, \par\pard\ql
\li5692\sb26\sl-276\slmult0 \up0 \expndtw0\charscalex102 Menurunan Angka
\par\pard\li5692\sb52\sl-276\slmult0\fi0\tx7515 \up0 \expndtw-3\charscalex100
Kesakitan\tab \up0 \expndtw-3\charscalex100 TB,\par\pard\qj \li5692\ri4548\sb0\sl-
320\slmult0 \up0 \expndtw-3\charscalex100 Pengendalian \line \up0 \expndtw-
3\charscalex100 Resistensi \par\pard\li5692\sb38\sl-276\slmult0\fi0\tx7490 \up0
\expndtw-3\charscalex100 Antimikroba\tab \up0 \expndtw-3\charscalex100
dan\par\pard\ql \li5692\sb23\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Pelayanan
Geriatri \par\pard\ql \li5332\ri3818\sb34\sl-313\slmult0\tx5692\tx5692\tx5692
\up0 \expndtw-1\charscalex100 6. Integrasi Pendidikan \line\tab \up0
\expndtw0\charscalex103 Kesehatan dalam \line \tab \up0 \expndtw0\charscalex101
Pelayanan Rumah \line \tab \up0 \expndtw-3\charscalex100 Sakit (IPKP)
\par\pard\qj \li1440\sb0\sl-315\slmult0 \par\pard\qj\li1440\sb0\sl-315\slmult0
\par\pard\qj\li1440\sb0\sl-315\slmult0 \par\pard\qj\li1440\ri1187\sb121\sl-
315\slmult0 \up0 \expndtw0\charscalex103 Yang perlu diperhatikan adalah setiap
surveior harus memahami dan menguasai \up0 \expndtw-3\charscalex100 semua standar
dan elemen penilaian (EP) di setiap standar akreditasi yang terdiri dari \up0
\expndtw0\charscalex102 16 bab tersebut. Pembagian tugas lebih diperuntukkan untuk
penanggung jawab \up0 \expndtw0\charscalex100 penetapan skor dan nilai. Surveior
dapat saling memberikan masukan hasil temuan \up0 \expndtw-3\charscalex100 kepada
masing-masing penanggung jawab bab. \par\pard\qj \li1440\ri1244\sb1\sl-
320\slmult0 \up0 \expndtw0\charscalex102 Jenis surveior lainnya, akan ditugaskan
bila ada survei terfokus yang memerlukan \up0 \expndtw-3\charscalex100 keahliannya.
\par\pard\ql \li3098\sb0\sl-276\slmult0 \par\pard\ql\li3098\sb81\sl-276\slmult0
\up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Ketentuan Jumlah surveior
dan jumlah hari survei \par\pard\qj \li1440\sb0\sl-313\slmult0
\par\pard\qj\li1440\ri1244\sb21\sl-313\slmult0 \up0 \expndtw0\charscalex103
\ul0\nosupersub\cf7\f8\fs24 Mengingat rumah sakit di Indonesia sangat bervariasi,
maka jumlah surveior dan \up0 \expndtw-1\charscalex100 jumlah hari survei
tergantung besar kecil dan kompleksitas rumah sakit serta rumah \up0
\expndtw0\charscalex100 sakit pendidikan atau rumah sakit non pendidikan.
Ketentuan jumlah surveior dan \up0 \expndtw-3\charscalex100 jumlah hari survei
sebagai berikut : \par\pard\li2111\sb0\sl-276\slmult0\par\pard\li2111\sb0\sl-
276\slmult0\par\pard\li2111\sb144\sl-276\slmult0\fi381\tx4099\tx5632\tx8040 \up0
\expndtw-2\charscalex100 \ul0\nosupersub\cf6\f7\fs24 JUMLAH\tab \up0 \expndtw-
2\charscalex100 RSNP/\tab \up0 \expndtw-2\charscalex100 JUMLAH\tab \up0 \expndtw-
2\charscalex100 JENIS SURVEIOR\par\pard\li2111\sb41\sl-
276\slmult0\fi391\tx4099\tx5258\tx6268\tx8215\tx8812\tx9969 \up0 \expndtw-
2\charscalex100 TEMPAT\tab \up0 \expndtw-2\charscalex100 RSP*\tab \dn2 \expndtw-
2\charscalex100 HARI\tab \dn2 \expndtw-2\charscalex100 SURVEI\tab \dn2 \expndtw-
2\charscalex100 M\tab \dn2 \expndtw-2\charscalex100 MD*\tab \dn2 \expndtw-
2\charscalex100 PW*\par\pard\li2111\sb40\sl-
276\slmult0\fi515\tx5104\tx6535\tx7766 \up0 \expndtw-2\charscalex100 TIDUR\tab \dn2
\expndtw-2\charscalex100 SURVEI\tab \dn2 \expndtw-2\charscalex100 OR\tab \dn2
\expndtw-2\charscalex100 J*\par\pard\li2111\sb63\sl-
276\slmult0\fi0\tx4099\tx5078\tx6280\tx7814\tx8978\tx10142 \up0 \expndtw-
2\charscalex100 Kurang dari\tab \up0 \expndtw-2\charscalex100 RSNP\tab \up0
\expndtw-2\charscalex100 4 hari\tab \up0 \expndtw-2\charscalex100 3 orang\tab
\up0 \expndtw-2\charscalex100 1\tab \up0 \expndtw-2\charscalex100 1\tab \up0
\expndtw-2\charscalex100 1\par\pard\ql \li2111\sb34\sl-276\slmult0 \up0 \expndtw-
3\charscalex100 100 \par\pard\ql \li10243\sb0\sl-253\slmult0
\par\pard\ql\li10243\sb110\sl-253\slmult0 \up0 \expndtw-2\charscalex100
\ul0\nosupersub\cf1\f2\fs22 27

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RSK\tab \up0 \expndtw-6\charscalex100 5\tab \up0 \expndtw-2\charscalex100
hari\tab \up0 \expndtw-6\charscalex100 7\tab \up0 \expndtw-2\charscalex100
orang\tab \up0 \expndtw-2\charscalex100 2\tab \up0 \expndtw-2\charscalex100
3\tab \up0 \expndtw-2\charscalex100 2\par\pard\li1800\sb0\sl-
276\slmult0\par\pard\li1800\sb103\sl-
276\slmult0\fi311\tx4099\tx5078\tx5280\tx6280\tx6482\tx7814\tx8978\tx10142 \up0
\expndtw-2\charscalex100 Kelas A\tab \up0 \expndtw-2\charscalex100 RSP\tab \up0
\expndtw-6\charscalex100 4\tab \up0 \expndtw-2\charscalex100 hari\tab \up0
\expndtw-6\charscalex100 6\tab \up0 \expndtw-2\charscalex100 orang\tab \up0
\expndtw-2\charscalex100 2\tab \up0 \expndtw-2\charscalex100 2\tab \up0 \expndtw-
2\charscalex100 2\par\pard\li1800\sb41\sl-276\slmult0\fi311 \up0 \expndtw-
2\charscalex100 Khusus\par\pard\li1800\sb0\sl-276\slmult0\par\pard\li1800\sb94\sl-
276\slmult0\fi242 \up0 \expndtw-2\charscalex100
Penjelasan*)\par\pard\li1800\sb40\sl-276\slmult0\fi0 \up0 \expndtw-
2\charscalex100 \ul0\nosupersub\cf7\f8\fs24 1. RSNP = Rumah Sakit Non
Pendidikan\par\pard\li1800\sb41\sl-276\slmult0\fi0\tx2854 \up0 \expndtw-
2\charscalex100 2. RSP\tab \up0 \expndtw-2\charscalex100 = Rumah Sakit
Pendidikan (utama, afiliasi dan satelit)\par\pard\li1800\sb43\sl-
276\slmult0\fi0\tx2854 \up0 \expndtw-2\charscalex100 3. RSK\tab \up0 \expndtw-
2\charscalex100 = Rumah Sakit Khusus.\par\pard\li1800\sb41\sl-
276\slmult0\fi0\tx2814 \up0 \expndtw-2\charscalex100 4. MJ\tab \up0 \expndtw-
2\charscalex100 = Surveior Manajemen\par\pard\li1800\sb41\sl-
276\slmult0\fi0\tx2799 \up0 \expndtw-2\charscalex100 5. MD\tab \up0 \expndtw-
2\charscalex100 = Surveior Medis\par\pard\li1800\sb41\sl-
276\slmult0\fi0\tx2814 \up0 \expndtw-2\charscalex100 6. PW\tab \up0 \expndtw-
2\charscalex100 = Surveior Perawat\par\pard\ql \li4871\sb0\sl-264\slmult0
\par\pard\ql\li4871\sb96\sl-264\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf11\f12\fs23 Penjadwalan Survei \par\pard\qj \li1440\sb0\sl-
320\slmult0 \par\pard\qj\li1440\ri1260\sb10\sl-320\slmult0 \up0 \expndtw-
2\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Penetapan waktu pelaksanaan survei
didasarkan pada kesepakan KARS dan rumah \up0 \expndtw-3\charscalex100 sakit.
\par\pard\ql \li4732\sb0\sl-264\slmult0 \par\pard\ql\li4732\sb83\sl-264\slmult0
\up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf11\f12\fs23 Ruang Lingkup Survei
\par\pard\qj \li1440\sb0\sl-320\slmult0 \par\pard\qj\li1440\ri1233\sb10\sl-
320\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Ruang
lingkup survei KARS ditentukan berdasarkan informasi di dalam aplikasi
\line \up0 \expndtw-2\charscalex100 survei dari rumah sakit. Setiap bangunan
serta area pelayanan dan asuhan pasien \line \up0 \expndtw-2\charscalex100 yang
tercantum dalam aplikasi survei akan tercakup dalam pelaksanaan survei.
\par\pard\ql \li10243\sb0\sl-253\slmult0 \par\pard\ql\li10243\sb203\sl-
253\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf1\f2\fs22 28

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