IMPACT RISK CATEGORY RISK CODE SOURCE OF RISK RISK CAUSE IMPACT DESCRIPTION CONTROL MITIGATION PLAN RISK

RISK RISK CAUSE IMPACT DESCRIPTION CONTROL MITIGATION PLAN RISK OWNER RELATED UNIT Key Indicators
Note : Measured impact includes : strategic impact
(related to organization's goals ), operational, finance,
regulatory compliance and reputation
Incorrect identification leads to drug
administration errors, wrong patient , Using 2 ( two ) patient identifier Increasing achievement of Medical, Nursing & Medical, Nursing, > 95 % patient have correct
Financial Loss A1 Patient Identification Patient's morbidity & mortality
wrong surgery, incorrect patient examination (name and date of birth ) correct patient identification Ancillary Managers Ancillary identification
and treatment
Establish medical guidelines for critical
Prolong result delivery due to difficulty Immediate decision for Medical, Nursing & Medical, Nursing, > 95 % patient have immediate
Reputation (Negative Publication) A2 Critical Result Patient's morbidity & mortality resut, therefore the criticaal result
contacting the clinicians medical critical result Ancillary Managers Ancillary critical result follow up
could be executed by GP
High Alert Medication ( HAM ) coordinator ( unit leaders ) compliance Increasing compliance Medical, Nursing & Medical, Nursing, No adverse event in HAM
Loss of Key persons A3 Low monitoring of HAM administration Patient's morbidity & mortality
administration monitoring monitoring Ancillary Managers Ancillary administration
Errors in patient's drug administration by Implementing drug's Unit Dose Creating Pharmacy's Unit Medical & Ancillary Medical, Nursing, 100 % patient received correct
Employement & working environment Patient's morbidity & mortality
nurse Administration by pharmacy Dose Team Managers Ancillary medication
A4 Medication Error
Errors in patient's drug administration due to All medications instructions are Enhancing the use of E-MR Medical & Ancillary Medical, Nursing, 100 % patient received correct
Employee turnover Clinical Care & Patient Safety Patient's morbidity & mortality
prescribing and transcribing electronicly prescribe by Clinicians Managers Ancillary medication
Patien's morbidity & mortality,
Only marked patients may be escorted surgical site marker by Medical & Nursing
Revocation of JCI Accreditation wrong site surgery Patient complaint due to re- Medical, Nursing No case of wrong site surgery
to the operating room specialist Managers
Wrong Side, Wrong Procedure, operation, hospital financial loss
A5
Warning or Restriction on Activities by National Wrong Patient Related to Surgery Patien's morbidity & mortality, Calculation of gauze and instrument by Increasing standard and
instrument left behind in patient's body Medical & Nursing No case of operation with left
Regulation ( including National Accreditation Patient complaint due to re- specific tools before closing the procedure compliance Medical, Nursing
cavity Managers behind instrument in body cavity
Compliance ) operation, hospital financial loss abdominal cavity monitoring

Patient's Fall, Patient's morbidity & coordinator ( unit leaders ) compliance Increasing compliance Medical & Nursing
A6 Fall Risk Low fall risk monitoring Medical, Nursing < 5% patient experience fall
mortality monitoring monitoring Managers

Human Resources & Training Staff Sufficient Education & Medical, Nursing & Medical, Nursing, Hospital with > 90% competent
Insufficient staff knowledge Patient 's morbidity & mortality
Mapping Training Ancillary Managers Ancillary staff
A7 Sentinel & Adverse Event Strong safety culture
Low incident report rate due to under Safety culture survey result monitoring Create a non blaming culture Director and All All Departments &
Organization with blaming culture organizaton ( survey result > 75
reporting ( staffs are afraid to report ) and follow up in the organization Managers Units
%)
No further complaints after leaving
Litigation Building an excellent Patient survey with very satisfied
B1 Complaint management Unresolved complaint management customer care office or at the customer Customer Care All Hospital Unit
Financial Loss complaint management team result > 30 %
VISION & MISSION care daily round
No incident of fake doctors, all
Sufficient Credentialing Medical, Medical
B2 Credentialing Fake doctors Patient's morbidity & mortality Primary Source Verification ( PSV ) Medical Manager clinicians passed the PSV and
Program Committee
credentialing system
OPPE ( On Going Professional Practice Medical, Medical
B3 Delineation of clinical privileges Insufficient doctor's skill Patient's morbidity & mortality Regular OPPE assesment Medical Manager Competent and reliable clinicians
Evaluation ) result follow up Committee
VISION
No case and incident report
Counterfeit or Imitation medication & Compliance to supply chain policy and Supply Chain Management
Patient's morbidity & mortality Medical Manager Medical, Ancillary related to counterfeit or
products procedure Monitoring
B4 Supply Chain Imitation medication & products
Leadership & Management No case and incident report
Compliance to supply chain policy and Supply Chain Management
To be an International Standard Hospital Contaminated & defective products Patient's morbidity & mortality Medical Manger Medical, Ancillary related to contaminated &
procedure Monitoring
Increasing organization safety defective
Strong products
safety culture
low quality performance hospital Creating a non blaming hospital culture Quality Manager All Department & Unit
MISSION B5 Performance Management Unsustainable safety culture organization culture organizaton ( survey result > 75
Establish Awal Bros Mail Box to increase Increasing organization safety Quality Manager, IT Increase report rate to the Awal
low quality performance unit All Department & Unit
incident report culture Manager Bros Mail Box System
Negative Publicity Human Resources & Training Staff Increasing organization Strong safety culture
Providing professional health care services B6 Reputation and Image Litigation Case Hospital Director Human Resources
Financial Loss Mapping safety culture organizaton ( survey result > 75
Sufficient Monitoring No case and report of critical
B7 Critical Supply Critical Supply Item's availability Patient's morbidity & mortality Maintaining regular inventory program Hospital Director Medical, Pharmacy
Program supply unavaiability
Denial or revocation of JCI & KARS
Sustainably achievied national
Denial or revocation of national & accreditaiton Establish quality improvement as part of Increasing organization safety
B8 National & International Accreditation Hospital Director Human Resources and international accreditation
international accreditation fully stop operation due to national each staff's job description culture
and reaccreditation
regulation incompliance

Unsafe building faclity for daily and Compliance to policy, procedure

C1 Safe facility Low Preventive Maintenance Audit Implementation Sufficient Monitoring Program GA GA
emergency management and regulations
Facility & Assets Patient's morbidity & mortality, Compliance preventive Medical, Medical Medical, Medical No patient safety incident report
C2 Safe Medical Facility Low Preventive Maintenance Audit Implementation
patient safety incident maintenance schedule Maintenance Maintenance due to preventive maintenance
Compliance all policy and
C3 Dietary & Food Service food contamination Patient's morbidity & mortality Audit Implementation Increasing policy and procedure compliance
Medical, Dietary Medical, Dietary
procedure

Fire extinguishers: APAR, Hidrant,

Hospital Director, Hospital Director, Well functioned APAR, Hydrant
Electrical system error Building loss and damage from fire sprinkler systems. Fire drill scheduled
GA Managers GA Managers and sprinkler system
periodically.

D1 Fire Safety Sufficient Monitoring Program

 Early warning, early detection systems,
such as smoke detectors, Fire alarms
and Fire patrols. Fire detection and
Patient, Family and Staff injury or Hospital Director, Hospital Director,
Staff's carelessness abatement equipment and systems are Regular fire drill training
death GA Managers GA Managers
inspected, tested, and maintained
D1 Fire Safety according Sufficient Monitoring Program
to manufacturers’ recommendations.

safe and unobstructed means of exit in Hospital Director, Hospital Director,

Malfunctioned fire detector Financial loss Free obstructions exit door
the event of a fire GA Managers GA Managers

safe storage and handling of potentially

flammable materials, including Hospital Director, Hospital Director, All staff completed fire drill
Unsafe flammable materials Fully or partially stop operation
flammable and oxidizing medical gases GA Managers GA Managers training
such as oxygen and nitric oxide.
Emergency Management
Building damage due to flood and
Establish policy, procedure and perform Increasing preparation for Hospital Director, Hospital Director, GA Completed simulation of natural
D2 Natural Disaster Flood and earth quake earthquake, patient / family /staff
simulation for natural disaster natural disaster GA Manager Manager disaster
injury or death

Infectious Disease Outbreak Establish policy, procedure and perform Increasing preparation to Medical Manager, Medical Manager, Completed simulation of
Increasing potential infection
D3 including Emerging Infectious Increasing global emerging disease cases simulation for emerging & re-emerging receive emerging & re- Nursing Manager, Nursing Manager, PPI receiving patient with emerging
spreading throughout hospital
Disease disease emerging disease patient PPI Coordinator Coordinator & re-emerging disease

Low preventive maintenance

Establish policy, procedure and perform Increasing preparation for Hospital Director, Hospital Director, GA Completed simulation of
Power Failure Loss of power supply
simulation for loss of power supply interference power supply GA Manager Manager interference power supply
D4 Insufficient power capacity

Establish policy, procedure and perform Increasing preparation for Hospital Director, Hospital Director, GA Completed simulation of
D5 Water supply interference Interference or damage water pipeline No water supply
simulation for loss of water supply interference power supply GA Manager Manager interference water supply

Low preventive maintenance Increasing preparation for

Establish policy, procedure and perform Hospital Director, Hospital Director, GA Completed simulation of
Electricity Failure Loss of electrical supply interference of electrical
simulation for loss of electrical supply GA Manager Manager interference electrical supply
D6 Damaged electricity panel supply

Complaints due to difficulty in calling No complaint for difficulty calling

E1 Access to service Insufficient operator system Monitoring complaints after system upgrading Upgrade operator system GA Manager GA, Marketing
the hospital the hospital
Very satsified patient survey
E2 Customer's satisfaction Unsatisfied patient with delivered services Patient's complaint, unloyal patientsRegular feed back and complaint monitoring
Enhancing customer relation officer team
Medical, Marketing Medical, Marketing
result > 30 %
Community Expectations
Patient didn't receive appropriate
Insufficient support system for patient All staff received training for Age Medical & Nursing No complaint relating Age
E3 Cultural & Special Needs services related to their condition, Training for Age Specific & Special Needs competency Medical, Nursing
with cultural & special needs Specific & Special Needs competency Manager Specific & Special Needs patients
patient complaint

Establish Early Warning

Medical & Nursing Decreasing numbers of code
F1 Management of deteriorating patient Insuffiicient Early Warning Sytem Patient's morbidity & mortality Implementation monitoring System & RRT poilicy and Medical, Nursing
Manager blue event in hospital ward
procedure
Establish Early Warning
Medical & Nursing Increasing numbers of RRT
F2 Activation of RRT Slow response of Rapid Response Team Patient's morbidity & mortality Implementation monitoring System & RRT poilicy and Medical, Nursing
Manager activation in hospital ward
Good Patient Outcome procedure
Enhancing Coordination of
Insufficient Discharge planning by Clinicians Patient's morbidity & mortality, Discharge monitoring Medical & Nursing Low rate of post PCI patient
F3 Patient Readmission Care Medical, Nursing
Inconsistency patient & family education at patient's complaint Manager readmission
Education monitoring at discharge Enhancing patient education
discharge
F4 Delayed treatment Doctors do not visit the patient during weekend Patient's morbidity & mortality Implementation monitoring Establish policy for cllinicians weekendMedical
visit Manager Medical Clinicians visit on weekend

Potential patient safety incident due Continuous education & Human Resources All staffs are competent to their
G1 Staff competency insufficient staff training program Implementation monitoring Human Resources
to staff's incompetency training program Manager job description

Incompetent staff due to high turn Enhance employee's Human Resources

G2 Employee's Turn Over Growing hospital business in Indonesia Employee retension program implementation monitoring Human Resources Low staff turn over rate
over rate retention program Manager
Work Force
Director, Medical &
Enhance employee's Medical, Human
G3 Loss of Key Person Growing hospital business in Indonesia Clinicians and employees hijacking
Employee retension program implementation monitoring Human Resources Loyal clinicians and employees
retention program Resources
Manager
Strong safety culture
Low incident report rate due to under Director and All All Departments &
G4 Safety Culture Organizational Organization with blaming culture Safety culture survey result monitoringCreate
and follow
a nonupblaming culture in the organization organizaton ( survey result > 75
reporting ( staffs are afraid to report ) Managers Units
%)
 Medical & Nursing
Unresolved incident or complaint Director, Medical &
H1 Litigation Patient or family filed for law suit Follow up and monitoring for patient
Establish
complaint
a strong customer relation officer team Manager, Medical No litigation case
case Nursing Manager
Committee
insufficient third party contract Good contract service
H2 Contract Management Insufficient monitoring of third party contract Audit Implementation Enhancing policy monitoring GA Manager GA
Legal evaluation evaluation
Penalty from government authority,
H3 Regulatory Compliance Insufficient monitoring of licence expiration date potential hospital safety incident ( e.x Audit Implementation Enhancing policy monitoring GA Manager GA No expired operational license
expired lift licence )

Change the numeric access No case of Personal Threat,

Personal Threat, Physical Violence,
I1 Access and Control Inconsistent regular access code changes All access using finger print access code to finger print IT Manager IT, Security Physical Violence, Child
Child Abduction, Theft
access code Abduction, Theft
No case of Personal Threat,
Personal Threat, Physical Violence,
Security I2 Identification Insufficient visitor monitoring Implementation monitoring Enhancing visitor monitoring GA Manager GA, Security Physical Violence, Child
Child Abduction, Theft
Abduction, Theft
No case of Personal Threat,
Personal Threat, Physical Violence,
I3 Surveillance & CCTV Insufficient CCTV monitoring Implementation monitoring Enhancing CCTV surveilance monitoringGA Manager GA, Security Physical Violence, Child
Child Abduction, Theft
Abduction, Theft

Good access management, data

Communication & Information
Full E-Medical Record and upgrade Building Full E-Medical
J1 Privacy & Confidentiality Unprotected patient's data Data theft and loss IT Manager IT maintained from theft
applications Record System
and loss
Full E-MR system with
Full E-Medical Record and upgrade Building Full E-Medical
J2 Informed consent Incomplete data filling Incomplete hospital legal data IT Manager IT mandatory field informed
applications Record System
consent application
Difficulty to analyze and seeing data's
Insufficient data interface IT Manager IT
trend Building Full E-Medical Sufficient IT system that meets
Full E-Medical Record System with
Electronic
J3 Information & Data Management System Difficulty to create the right and Record System with good management and operational
System does not support internal and good data interface
immediate decission based on data interface IT Manager IT needs
external management needs
hospital data / information
Prolong services due to medical Full E-Medical Record and upgrade Building Full E-Medical
J4 Records Management Insufficient medical record storage IT Manager IT Full E-MR system
record waiting time applications Record System
Always updated / valid website
J5 Release of Information Non updated website information Patient's complaint Regular website update E Bussiness Corporate Manager
Enhancing policy monitoring E Bussiness, Marketing
information
Negative reputation & image from the Social media monitoring by E-Bussiness Enhancing social media
J6 Social Media Unmonitored social media complain E Bussiness Corporate Manager
E Bussiness, Marketing Full Social Media Monitoring
viral spreading social media complaint Team monitoring
Good access management, data
Monitoring and controling data access
J7 Piracy of Hospital's Confidential informationUnprotected hospital management's data Data theft and loss Enhancing policy monitoring IT Manager IT maintained from theft
authority
and loss
Good access management, data
Monitoring and controling data access
J8 Data Integrity & Security Low access and user monitoring Data theft and loss Enhancing policy monitoring IT Manager IT maintained from theft
authority
and loss
Building a safe computer Data maintainedand from
J9 Virus & Malware Increase global malware virus spreading Data loss Using updated Linux system IT Manager IT
system by Linux malware viruses

GA Manager,
GA Manager, Infection
Unsafe and unhealthy environment Infection Control, Renovation comply to all
K1 Contractor Non Compliance Low compliance monitoring Safe and healthy renovation environment Enhancing policy monitoring Control, Health &
during renovation Health & Safety hospital standards
Safety Committee
Committee
Work Health & Safety
GA Manager,
GA Manager, Infection All staffs received specific
Unprotected staff from infection, Infection Control,
K2 Workplace health and safety Insufficient implementation Regular Medical Chek Up and Vaccination Enhancing policy monitoring Control, Health & vaccination and medical check
radiation and other spefiic risk Health & Safety
Safety Committee up
Committee

Increasing compliace to
Minimal to zero fraud incident
L1 Fraud Low internal control monitoring Financial loss Finance internal control & compliance team hospital financial standard
Finance & Accounting Manager
Finance, Accounting
report
and procedure
Direct monitoring to daily
cashier operation to give
L2 Unpaid patient Low internal control monitoring Financial loss Finance internal control & compliance team Finance & Accounting Manager
Finance, Accounting Minimal to zero unpaid patient
immediate support during
the event
Coordination with marketing
L3 AR aging Low internal AR control monitoring Insufficient cash flow Weekly monitoring with target establishment department to speed up Finance & Accounting Manager
Finance, Accounting Payment received in < 45 days
billing and payment
Coordination process
with marketing
L4 Bad-debt Low internal bad debt control monitoring Financial loss Monthly monitoring with target establishment department to speed up Finance & Accounting Manager
Finance, Accounting Payment received in < 90 days
billing and payment process
Misinterpretation on tax regulation in the Participation in seminars and tax
past (not applying cost allocation method) regulation updates held by KAP and Tax Finance & Accounting Manager
creates potential exposure Office
Monthly and annual tax Misinterpretation on tax regulation which Tax penalty and tax dispute with Tax Finance, Accounting, Comply to all government tax
L5 Establish SOP on tax reporting/filing
compliance risk may create potential tax exposure in the authority Tax payment to be executed 2 days before deadline Finance & Accounting Manager Tax regulation
future
 Monthly and annual tax Tax penalty and tax dispute with Tax Finance, Accounting, Comply to all government tax
L5 Establish SOP on tax reporting/filing
compliance risk authority Tax regulation

Late tax payment and filing of tax returns to the Tax Office
L6 Timeliness in Financial Reports
Delayed implementation of new
L7 accounting standard in the
financial and other regular reports
Finance & Accounting
(RTO). DR has no capability to cover medium
Operational Disturbance due to IT
L8
failure (server down time)
External factors (fiber optic, electricity blackout)
Potensial Financial Loss From BPJS (
L9 National Health Care Coverage )
Patient
Tax returns to be submitted before deadline Finance & Accounting Manager
Finance &
Difficulty in data analysis and Accounting On time and reliable financial
insufficient IT support system Building IT system that meets internal financial needsUpgrade IT system Finance, Accounting, IT
immediate decision making Manager IT report
Manager
Correction to the published financial Participation in seminars/invitations by
reports must be made and may result the regulator (OJK, Bapepam, BI, Tax)
Revisions on Indonesian GAAP standards
in lack of public trust to the accuracy and participate in other seminars and Finance & Accounting Manager
Finance, Accounting
often occur
of the company's financial reports training held by the public accounting
going forward offices. Increasing awareness of
Comply to all government
existing and new
Request auditor to bring awareness of financial regulation
government regulations
Lack of information in the new accounting Incompliance to the accounting any new accounting standards that will
Finance & Accounting Manager
Finance, Accounting
standard practices standard impact the company and its investee
companies
Lack of knowledge in changes or new Incompliance to the accounting Bringing auditor to do an interim audit
Finance & Accounting Manager
Finance, Accounting
regulations imposed by the regulators standard to address any major issues
Finance &
delayed services due to manual Accounting
insufficient IT support system Upgrade IT system Finance, Accounting, IT
operation Manager IT
Manager
Server Prolem :
No IT Disaster Recovery (DR) which include
Server : Data Backup only cover Finance &
recovery point (RPO) and time of recovery Impact files and systems stored in
selective systems such as Accurate and Accounting
server, such as Accurate and Cognos Finance, Accounting, IT
COGNOS with short recovery point Manager IT
failures (hardware, system) and major (financial reporting system)
(RPO = 1 week, RTO = 6 months). Manager
failures on office-wide system and network
storage
- IT provides back-up system Finance &
DR has limited capability to recover from Loss of important data which may Internet : Two internet service / procedure for file storage Accounting Hospital operations still running
Finance, Accounting, IT
minor failures (deleted or lost documents) lead to: Financial / Legal / Reputation providers (linknet and iforte), however on server Manager IT in down time period
penalties due to loss of documents if router is malfunction, internet will still - Have a back-up router Manager
and Ineffective work production be down Finance &
Limited network storage Accounting Finance, Accounting, IT
Manager IT
Finance &
Internet disturbance: Failure in computer Most of office work performed Accounting
network and system without redundancies through Internet (emails, google Finance, Accounting, IT
Use of laptop instead of PC to access Manager IT
on network router drive), internet down would
email and work data anywhere Manager
somewhat disrupt business
operations Finance &
Accounting Finance, Accounting, IT
Manager IT
Director, Medical The cost of patients during
Manager, Finance Medical, Finance & treatment and hospitalization
Clinical Pathway Monitoring Establish clinical pathway
Challenge of using effective and & Accounting Accounting, IT does not exceed the BPJS coding
Low per capita financial coverage
efficient medication & treament Manager
Finance, &
IT for diagnosis
All expenses are calculated through an Building electronic cost Effective cost control and
Accounting Finance, Accounting, IT
accurate acost accounting program accounting system increase profit margin
Manager IT

Potential patient safety incident due

Patient Hand Over
Among Hospital staff Communications Ineffective hospital communication system
Effective Communication
Read Back
Insufficient patient hand over Medical, Nursing & Medical, Nursing, No report of patient's hand over
to non effective communication, Audit implementation Enhance monitoring
communication and documentation Ancillary Managers Ancillary miscommunication
unclear patient's intrusctions
Director & All Only updated information,
All Departments &
Non updated staff's information Audit implementation Enhance monitoring Hospital Managers , policy and procudure available in
Units
QMR the unit
Potential patient safety incident due Medical, Nursing,
Medical, Nursing & All clinicians verified Read Back
Unclear patient's instruction from Clinicians to non effective communication, Audit implementation Enhance monitoring Ancillary, Medical
Ancillary Managers Instruction
unclear patient's intrusctions Committee

Ineffective communication and coordination Medical, Nursing,

Inaccurate discharge planning time GP conducing coordination of Medical, Nursing & Accurate discharge planning
Coordination of Care between clinicians, GP, Nursing and other Patient's record audit implementation Ancillary, Medical
and prolong hospitaization care and report it to clinicians Ancillary Managers time
ancillary services Committee

Staff, patient & family exposed to low GA Manager, Work

Air quality, heat, noise, lighting and GA, Work Health & Good regular exposure test
Low compliance monitoring air quality, heat, poor lighting and Regular exposure monitoring and audit Enhance surveilance monitoring Health & Safety
radiation Safety Committee result
radiation Committee

Staff, patient & family exposed to GA Manager, Work Unused hazardous substances
GA, Work Health &
Hazardous substances and dangerous good Low compliance monitoring hazardous substance and dangerous Regular exposure monitoring and audit Enhance surveilance monitoring Health & Safety and dangerous good are locked
Safety Committee
good Committee in appropriate cabinet

Environmental Staff, patient and family exposed to GA, Cleaning Service,

Waste Management Low compliance monitoring Regular exposure monitoring and audit Enhance surveilance monitoring
GA Manager, Infection Control Appropriate waste management
infectious waste, needle stick injury Infection Control
Environmental

GA Manager, GA, Cleaning Service,

Cleaning Service Low compliance monitoring Dirty environment Regular hospital cleanliness monitoring Enhance monitoring Hospital Cleanliness Rate > 80 %
Infection Control Infection Control

Staff, patient and family exposed to Infection Control, All

Infection Control Low compliance monitoring Regular monitoring and follow up HAI's surveilance
Enhance
data surveilance monitoring Infection Control Low rate of HAI Surveilance Data
oHospital Acquired Infection Department, All Units