B NEW! B Hospital Survey Findings Report

Joint Commission
International Accreditation
FINAL ACCREDITATION SURVEY FINDINGS

REPORT
RSUP Dr. Hasan Sadikin Bandung

Bandung, Indonesia
International Health Care Organization (IHCO) Identification Number: 60001633
Survey Dates: 18 March 2019 - 22 March 2019

Program: Academic Medical Center Hospital
Survey Type: Triennial

Surveyor Team: David S. Loose, MSN, RN, Nurse, Team Leader
Antonio Silva Perez, MS, Administrator
Pongtorn Kietdumrongwong, MD, Physician
Deborah Vellasamy, MA, MBA, RN, Nurse
Patricia M. O'Shea, MBA, MPH, MD, Physician
Academic Medical Center Hospital
IHCO ID: 60001633
Date Generated: 26 March 2019
OUTCOME:
Based on the findings of the Triennial Academic Medical Center Hospital survey of 18 March 20 19 to 22 March
2019 and the Decision Rules of Joint Commission International (JCI), RSUP Dr. Hasan Sadikin Bandung has been
granted the status of ACCREDITED.
Upon confirmation from the JCR Finance Department indicating that all survey related fees have be en paid, you
will receive the JCI Academic Medical Center Hospital certificates and, if necessary, your organization’s entry on the
JCI website will be updated. You will also have access to The JCI Gold Seal of Approval™, the JCI Accreditation
Gold Seal of Approval ™ Guidelines, and the JCI Accreditation Publicity Guide under the “Resources” tab in JCI
Direct Connect.
The Joint Commission International Academic Medical Center Hospital Standards are intended to stimulate
continuous, systematic and organization-wide improvement in daily performance and in the outcomes of patient
care. It is our expectation that all of the issues identified in the following survey report will have been satisfactorily
resolved and full compliance with each identified standard will be demonstrated at the time of your next
accreditation survey. Therefore, RSUP Dr. Hasan Sadikin Bandung is encouraged to immediately place
organization-wide focus on the standards with measurable elements scored as “Not Met” and “Partially Met” and to
implement the actions necessary to achieve full compliance.
Between surveys, RSUP Dr. Hasan Sadikin Bandung will be expected to demonstrate compliance with the most
current edition of the JCI standards at the time, which includes the JCI accreditation policies and procedures
published on the JCI website.
JCI will continue to monitor RSUP Dr. Hasan Sadikin Bandung for compliance with all of the JCI Academic
Medical Center Hospital standards on an ongoing basis throughout the three year accreditation cycle . The
compliance monitoring activities may include but not be limited to document and record reviews, the review of data
monitoring reports, leadership interviews and staff interviews. The monitoring activities may take place on-site or
off-site. JCI also reserves the right to conduct an unannounced, onsite evaluation of standards compliance at its
discretion.
REQUIRED FOLLOW-UP:
Some of findings identified in this report suggest that if not attended to in a timely manner can evolve into a
generalized threat to patient and/or staff health and safety and may over time result in a sentinel event. These health
and safety risks would be counter to the improvement efforts your critical care program has accomplished to date,
and counter to the spirit of continual improvement in quality and continual reduction of risk that are considered
part of the accreditation process. This is of concern to us and we believe should be a priority concern for your
organization. For this reason, a Strategic Improvement Plan (SIP) describing the sustainable measures that will be
implemented to achieve full compliance is required for the following standard(s) and measurable element(s):
This report contains confidential and/or privileged material. Any review or dissemination or other use of, or taking of any action in reliance
upon, this information by persons or entities other than the intended recipient is prohibited.
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 COP.2.1, ME #3
 COP.2.2, ME #4
 SQE.9.2, ME #2
The SIP must be submitted to JCI within the next 45 days or by 10 May 2019 for review and acceptance. Details
regarding access to the SIP system will be sent to you by way of a separate notification.
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REPORT OF SURVEY FINDINGS:

Note: The Accreditation Committee may request follow-up for any or all of the standards after the accreditation
decision.
International Patient Safety Goals

IPSG.1 The hospital develops and implements a process to improve accuracy of patient
identifications.
Measurable Element #1
Patients are identified using two patient identifiers, not including the use of the patient's room
number and location in the hospital. (Also see MMU.5.2, ME 4 and MOI.9, ME 2)
Partially Met
In the In Vitro Fertilization Clinic, the embryo was identified with father's and mother's first
name and date of birth; however, the full name was not used as required by hospital policy and
procedure "IPSG 1: International Patient Safety Goal for Patient Identification"
(HK.02.03/X.4.1.3/13755/2018).
Assessment of Patients
AOP.1.1 Each patient's initial assessment includes a physical examination and health history as
well as an evaluation of psychological, spiritual/cultural (as appropriate), social, and
economic factors.
All inpatients and outpatients have an initial assessment that includes a health history and physical
examination consistent with the requirements defined in hospital policy. (Also see MMU.4, ME
5)
Partially Met
The hospital policy and procedure "Assessment of Patients" (HK. 0203 /X.4.1.3/ 15009 / 2018)
required all inpatient and outpatient medical assessments to have a complete history and physical
examination. A complete history and physical examination were documented in 11 of 17 (65%
compliance) of open and closed records reviewed.
AOP.1.4 Patients are screened for nutritional status, functional needs, and other special needs and
are referred for further assessment and treatment when necessary.
Patients in need of a functional assessment are referred for such an assessment.
Partially Met
Patients in need of a functional assessment were inconsistently referred for such an assessment.
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Although the hospital had screening criteria that resulted in a score, the score did not lead to an
additional assessment.
AOP.1.5 All inpatients and outpatients are screened for pain and assessed when pain is present.
The assessment is recorded in a way that facilitates regular reassessment and follow -up according
to criteria developed by the hospital and the patient's needs.
Partially Met
After the patient received a medication for pain the reassessment and follow-up of pain was
performed in 11 of 21 (52% compliance) open and closed medical records reviewed.
AOP.5.10.1 The hospital identifies measures for monitoring the quality of the services to be provided
by the reference/contract laboratory.
The frequency and type of performance expectation data from reference/contract laboratories
are determined by the hospital. (Also see GLD.6.1, ME 1)
Partially Met
The hospital had determined the frequency of reporting of performance expectation data.
Although they identified two types of performance expectation data from reference/contract
laboratories, the data was inconsistently monitored.
An annual report of the data from reference/contract laboratories is provided to hospital
leadership to facilitate management of contracts and contract renewals. (Also see GLD.6.1, ME
2)
Partially Met
An annual report of the data from reference/contract laboratories was provided to hospital
leadership; however, the data was not reported in a manner that would consistently facilitate the
management of contracts and contract renewals.
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AOP.5.11 A qualified individual is responsible for blood bank and/or transfusion services and
ensures that services adhere to laws and regulations and recognized standards of practice.
The blood bank has established, implemented, and documented processes for a) through f) of the
intent. (Also see COP.3.3, ME 2)
Partially Met
The following were observed in the Blood Bank:
1. The logbooks used to document the temperature of the refrigerators had readings out of
range 33% of the time.
2. The cool boxes used to transport blood were not properly labeled and did not have biohazard
warning signs.
AOP.6.3 Radiation safety guidelines for staff and patients are in place, followed, and documented;
and compliance with the facility management and infection control programs is
maintained.
A comprehensive radiation safety program for patients and staff is in place and addresses
potential safety risks and hazards encountered within or outside the department. (Also see FMS.4,
ME 1)
Partially Met
The radiation safety program was implemented; however, the following was not in compliance:
1. There was no alarm or monitor available when staff prepared radioactive substances.
2. The waste bin was not radiation proof.
3. The program did not link the activation protocol to the hospital wide disaster preparedness
plan.
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Care of Patients
COP.1 Uniform care of all patients is provided and follows applicable laws and regulations.
Uniform care is provided that meets requirements a) through e) in the intent.
Partially Met
Patients who were admitted with an ST-elevation myocardial infarction during weekdays were
treated with primary percutaneous coronary intervention. Patients that were admitted on nights
or weekends, with the same medical problem, were treated with Streptokinase due to the lack of
availability of Cardiac Catheterization Laboratory staff. Consequently, treatment was delayed due
to the waiting for the arrival of the cardiology staff.
COP.2.1 An individualized plan of care is developed and documented for each patient.
The plan of care is individualized based on the patient's initial assessment data and identified
needs. (Also see ASC.7.3, ME 3)
Partially Met
The plan of care was not consistently individualized based on the patient's initial assessment data
and identified needs. For example, this included no modification of the plan of care when
patients were placed in isolation or when "bundles" were used to decrease infection rates.
The plan of care is updated or revised and reviewed by the multidisciplinary team based on the
reassessment of the patient by the health care practitioners.
Not Met
The plan of care was updated or revised and reviewed by the multidisciplinary team based on the
reassessment of the patient by the health care practitioners in zero of 14 (0% compliance) open
and closed medical records reviewed.
COP.2.2 The hospital develops and implements a uniform process for prescribing patient orders.
Orders are found in a uniform location in medical records. (Also see MMU.4.3, ME 3 and
MOI.9, ME 3)
Not Met
Orders were found in various locations in the medical records. Examples of this included orders
in the following:
1. ICU flow chart.
2. Inpatient medication card.
3. Special form used for Intensive Care and High Care patients.
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4. Integrated development record for outpatients.

5. Medication record for Emergency Room patients.
6. Narcotics special prescription sheet.
7. Spinal orthosis prescription sheet in the Rehabilitation Unit.
8. Anesthesia medical record.
9. Hemodialysis integrated patient care form.
COP.3.2 Resuscitation services are available throughout the hospital.
Medical equipment for resuscitation and medications for basic and advanced life support are
standardized and available for use based on the needs of the population served. (Also see ASC.3,
ME 3)
Partially Met
Medical equipment for resuscitation for basic and advanced life support were not consistently
standardized. Examples of this included:
1. The locks on the Pediatric Unit emergency carts were checked every shift. The locks on a red
bag containing similar emergency equipment when the cart was not available was checked
weekly.
2. The Pediatric Unit and the Pediatric Intensive Care Unit used a different weight-based dosage
calculation sheet for pediatric emergency medications
3. The medications in the emergency carts were not standardized. For example, some contained
Ephedrine and Epinephrine and other carts did not.
4. The medications for advanced life support did not include Glucose, Magnesium, Calcium,
and Bicarbonate as recommended by current professional guidelines such as the American
Heart Association or the European Society of Cardiology.
5. The cardiac pacing wire was not available in the General Intensive Care Unit. In addition, the
cardiac pacing mode was not tested as required by the manufacturer.
6. The emergency cart in the High Care Burn Unit did not contain Naloxone although the cart
label stated Naloxone was to be stored in the cart. Naloxone was present on emergency carts
in other areas where procedural sedation was performed.
7. Pediatric patients were present in the High Care Burn Unit; however, the emergency cart did
not include a weight-based dosage calculation sheet that was available in other areas where
pediatric patients were treated.
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COP.3.3 Clinical guidelines and procedures are established and implemented for the handling,
use, and administration of blood and blood products.
Clinical guidelines and procedures are established and implemented for the handling, use, and
administration of blood and blood products. (Also see AOP.5.11, ME 2)
Partially Met
Clinical guidelines and procedures were established for the handling, use, and administration of
blood and blood products in the hospital policy and procedure, "Administration and Monitoring
of Blood Transfusions" (X/1/12/05/0208). The policy was not fully implemented as evidenced
by the following:
1. Two nurses were to verify and document the information before starting administration of
blood. This was documented in eight of 11 (72% compliance) closed medical records
reviewed.
2. Vital signs were to be recorded before the transfusion and at the completion of the
transfusion. This was documented in zero of 11 closed (0% compliance) medical records
reviewed.
Medication Management and Use

MMU.3 Medications are properly and safely stored.
Medications are protected from loss or theft throughout the hospital. (Also see FMS.4.1, ME 3)
Partially Met
The organization had implemented an inventory control system using medication cards. In the
Operating Theatre, a mismatch was noted between the actual number and inventory number of
Propofol and inhalation agents. The staff also reported this discrepancy when the inventory was
performed. An inventory control system was not implemented in the Specialist Clinic Dental
Unit.
MMU.3.3 The hospital has a medication recall system.
There is a medication recall system in place.
Partially Met
The hospital used lot numbers to track medications when recalls occurred. This tracking was not
possible in the Outpatient Pharmacy when medications were removed from their original
packages.
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MMU.4 Prescribing, ordering, and transcribing are guided by policies and procedures.
The hospital establishes and implements a process for the safe prescribing, ordering, and
transcribing of medications in the hospital. (Also see IPSG.2 and COP.2.2)
Partially Met
The hospital policy and procedure "Confirmation of Physician Orders" (X/1/1.3.10/07/3003)
required physicians to write their medication orders in three places: the multidisciplinary medical
record, a prescription form that went to the pharmacy, and on the nursing medication
administration record. This process had the potential for transcription and omission errors.
Examples included:
1. IV fluid of 2000 cc per day was ordered in the multidisciplinary medical record and was
transcribed as 3000 cc in the pharmacy dispensing prescription form.
2. IV Cimetidine 1 ampoule was ordered twice a day in the multidisciplinary record to
commence on 13 March. The medication was administered five days later.
MMU.4.1 The hospital defines the elements of a complete order or prescription.
The required elements of complete medication orders or prescriptions include at least a) through
g) identified in the intent as appropriate to the order.
Partially Met
The required elements of complete medication orders or prescriptions included at least a)
through g) as appropriate to the order; however, zero of seven medical records reviewed had f)
rate of administration when intravenous infusion are ordered.
The hospital develops and implements a process to manage medication orders that are
incomplete, illegible, or unclear. (Also see MOI.12, ME 3)
Partially Met
The hospital had developed a process; however, they had not fully implemented it to manage
medication orders that were incomplete, illegible, or unclear. Examples noted in open and closed
medical records included:
 10:5 solution for Neostigmine and Atropine.
 X used for time.
 Morphine infusion with no dose.
 No documentation of time.
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MMU.6.1 Medication administration includes a process to verify the medication is correct based on
the medication prescription or order.
Medications are administered as prescribed and noted in the patient's medical record. (Also see
COP.2.3, ME 1)
Partially Met
Medications were administered as prescribed and noted in the patient's medical record; however,
the following had no record of administration:
1. Intravenous infusion Aminoglobulin 1000 mls. /24 hours and Intravenous Albumin 20% 100
cc daily for five days prescribed by the physician for severe malnutrition.
2. 200 mls.of high caloric milk feeds prescribed by the nutritionist for severe malnutrition.
3. IV Sodium Chloride 0.9 % 500 cc ordered to hydrate two cancer patients.
Quality Improvement and Patient Safety

QPS.4.1 Individuals with appropriate experience, knowledge, and skills systematically aggregate
and analyze data in the hospital.
Data are aggregated, analyzed, and transformed into useful information to identify opportunities
for improvement. (Also see PCI.6, ME 2)
Partially Met
Data was not consistently aggregated, analyzed, and transformed into useful information to
identify opportunities for improvement. Examples of this included International Patient Safety
Goals One, International Patient Safety Goal Two, and blood transfusion data.
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Prevention and Control of Infections

PCI.5 The hospital designs and implements a comprehensive infection control program that
identifies the procedures and processes associated with the risk of infection and
implements strategies to reduce infection risk.
The hospital has identified those processes associated with infection risk. (Also see AOP.5.3, ME
2; AOP.5.3.1, MEs 1 and 3; MMU.5, MEs 1 and 3)
Partially Met
The hospital had identified those processes associated with infection risk; however, the following
was observed:
1. Dust was observed in the following areas: Atop the cabinets in the sterile supply room and
medical equipment room in the Operating Theater; at the bottom of the distilled water
container used in the Dental Unit; in the medication room storage shelves, medication
preparation table, spill kits and cooler boxes in the Female Oncology Ward.
2. The temperature in the Dental Clinic sterile storage was monitored every day except holidays
and weekend.
3. Carpets were used in a prayer room in the semi-sterile area of the Operating Theater. The
staff did not change their gowns when leaving the prayer room.
4. Staff in the Dental Clinic refilled water from filtered water container to distilled water
container connected to the dental chair without gloves and disinfecting the container lid.
5. Sterile supplies were stored on the second floor Pediatric Unit and the Labor and Delivery
Unit with no monitoring of the temperature and humidity.
6. During the reprocessing of endoscopes, it was noted that the leak test was performed once a
week, rather than after each cleaning as required by the manufacturer. Cidex OPA MEC was
not tested prior to each use as required by the manufacturer recommendations.
7. The drying cabinet for a colonoscope was of inadequate height and consequently the end of
the colonoscope was coiled and rested on the cabinet floor.
8. Hinged instruments noted in the High Care Unit isolation unit were sterilized in the closed
position.
PCI.7.1 The hospital identifies and implements a process for managing the reuse of single -use
devices consistent with regional and local laws and regulations.
The hospital identifies single-use devices and materials that may be reused.
Partially Met
The hospital had identified 10 single-use devices that could be reused. During tracer activities,
three additional single-use devices were being reused that were not on the list of the 10 items that
could be reused.
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PCI.7.3 The hospital implements practices for safe handling and disposal of sharps and needles.
Sharps and needles are collected in dedicated, closable, puncture-proof, leakproof containers that
are not reused.
Partially Met
Sharps and needles were collected in dedicated, closable, puncture-proof, leakproof containers
that were not reused; however, the following was observed:
1. In the Operating Theater, unsecured sharpboxes were located on the floor.
2. In the Hot Lab, paper sharpboxes were used. The lower half of these boxes were wet.
3. Injection needles were disposed into the general waste bins instead of the appropriate
containers in the Female Oncology Ward.
PCI.7.4 The hospital reduces the risk of infections associated with the operations of food services.
The hospital stores food and nutrition products using sanitation, temperature, light, moisture,
ventilation, and security in a manner that reduces the risk of infection.
Partially Met
The head of the kitchen stated that the temperature range for refrigerated food needed to be
between 17 and 23 centigrade on arrival. According to the Ministry of Health Regulation #78,
2013, "Nutrition Services Guideline" the required temperatures was to be between -5 to 0
centigrade.
The hospital prepares food and nutrition products using proper sanitation and temperature.
Partially Met
The hospital prepared food and nutrition products using proper sanitation and temperature;
however, water temperature was not monitored at the sink where utensils were sanitized.
PCI.7.5 The hospital reduces the risk of infection in the facility associated with mechanical and
engineering controls and during demolition, construction, and renovation.
Engineering controls are implemented to minimize infection risk in the hospital.
Partially Met
Engineering controls were implemented to minimize infection risk in the hospital; however, the
hospital was not in compliance for the following:
1. Air pressure was monitored in the Operating Theater; however, in February the pressure
could not be maintained in two operating rooms for more than 15 days. There was no
documentation of action taken.
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2. In the Hot Lab, the temperature was monitored every day except on weekends.
3. In the Embryology Lab, the temperature was monitored but not recorded.
PCI.8 The hospital provides barrier precautions and isolation procedures that protect patients,
visitors, and staff from communicable diseases and protects immunosuppressed patients
from acquiring infections to which they are uniquely prone.
Negative-pressure rooms are monitored routinely and available for infectious patients who
require isolation for airborne infections.
Partially Met
The organization had 13 negative pressure rooms. The Pascals were being monitored. There was
no evidence that the hospital was monitoring the 12 air changes per hour required by the
Infection Control Committee.
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Facility Management and Safety

FMS.4 The hospital plans and implements a program to provide a safe physical facility through
inspection and planning to reduce risks.
The hospital has a program to provide a safe physical facility. (Also see AOP.5.3, ME 1 and
SOP.6.3, ME 1)
Partially Met
The hospital had a program to provide a safe physical facility; however, the following was not in
compliance:
1. The second floor Pediatric Unit had Chlorhexadine in the hazardous material locker.
According to the MSDS sheet, eyes were to be rinsed for 15 minutes if this chemical came in
contact with the eyes. The unit had no eye wash provisions.
2. In the medical gas area, the following deficiencies were found: There were no explosion proof
light fixtures to prevent an explosion in the area; 32 medical gas cylinders were found
unsecured; the lighting in the area was very poor.
3. Windows located in the VIP suites could be opened, posing a risk for patients and visitors.
4. The call bell in the patient toilet in Room 5 of the General Medical Ward at the Fresis
building was broken for about a year and was not repaired.
5. No call bells were in the patient bathrooms in the Emergency Room and in the Dialysis
Clinic.
6. The corridor on COT building had windows at the floor level. The width of window was
wide enough for children to slip through. There was no measure to prevent access and fall.
7. There was no evacuation plan for the embryos stored in the In Vitro Fertilization Clinic.
FMS.4.1 The hospital plans and implements a program to provide a secure environment for
patients, families, staff, and visitors.
The hospital has a program to provide a secure environment, including monitoring and securing
areas identified as security risks. (Also see AOP.5.3 and AOP.6.3)
Partially Met
The hospital had a program to provide a secure environment, including monitoring and securing
areas identified as security risks; however, the west evacuation door on the first floor of the
Pediatric Unit, and the south evacuation door on the second floor of the Pediatric Unit were
unsecured.
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FMS.5 The hospital has a program for the inventory, handling, storage, and use of hazardous
materials and waste.
The program establishes and implements the proper protective equipment and procedures
required during use. (Also see AOP.5.3, ME 3 and AOP.6.3, ME 4)
Partially Met
The program established and implemented the proper protective equipment (PPE) and
procedures required during use; however, the following was observed:
1. The Emergency Generator and the Medical Gas area had signs specifying the type of PPE
required to enter these areas. Equipment required were goggles, face shields, boots, gloves,
aprons and respirator. None of this PPE were available.
2. The Central Sterilization Supply Department had an Ethylene Oxide Sterilizer. The masks
used to protect staff in case of a leak used organic vapor cartridges. Staff were not aware of
how to maintain these cartridges.
The program establishes and implements proper labeling of hazardous materials and waste. (Also
see AOP.5.6, ME 5; AOP.6.6, ME 4; MMU.3; and MMU.3.1, ME 2)
Partially Met
The program established and implemented proper labeling of hazardous materials and waste;
however, the following was observed:
1. The bottles with Formaldehyde used to store and transport biopsies did not contain any label
to identify the content as hazardous materials.
2. The following did not have hazardous material labels: Anesthesia inhalation agent, Alcohol
spray for skin preparation in the Operating Theatre, Carbon dioxide gas cylinder in the
Operating Theater, chemicals used in the Embryology Lab.
3. In the Burn Unit, the housekeeper cleaning supplies included a bottle of purple liquid labeled
with a hazardous warning label (an exclamation point), but no labels regarding the contents of
the bottle. No MSDS sheets were available to indicate the nature of the hazard or
appropriate management in the event of exposure.
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FMS.7 The hospital establishes and implements a program for the prevention, early detection,
suppression, abatement, and safe exit from the facility in response to fires and nonfire
emergencies.
The hospital establishes and implements a program to ensure that all occupants of the hospital's
facilities are safe from fire, smoke, or other nonfire emergencies.
Partially Met
The hospital established and implemented a program to ensure that all occupants of the hospital's
facilities are safe from fire, smoke, or other non-fire emergencies; however, the exhaust ducts
located in the kitchen had not been cleaned. As the ducts were not routinely cleaned, the
accumulation of grease could increase the risk of fire.
The program includes the abatement of fire and containment of smoke.
Partially Met
The program included the abatement of fire and containment of smoke; however, the following
was observed:
1. The medical record archive had a large amount of flammable material (medical records) and
insufficient means to abate fire (two, six kilograms fire extinguishers).
2. The Magnetic Resonance Imaging (MRI) did not have a compatible fire extinguisher in the
area.
3. The male and female Psychiatric wards had only one fire extinguisher to abate fire.
4. The IT server did not have a means to extinguish fire during weekends or when the staff were
not present in the area.
The program includes the safe exit from the facility when fire and nonfire emergencies occur.
Partially Met
The program included the safe exit from the facility when fire and non-fire emergencies occurred;
however, the following were observed:
1. Two fire exit doors on the second floor of the Pediatric Unit were locked.
2. The public corridors and hallways located in restricted areas had exit signs that could not be
seen.
3. The exit door located in the Medical Record Archive opened to the inside.
4. In the Hot Lab, a bolted bench obstructed the emergency exit.
5. In the Pharmacy storage room, there were dead end areas without emergency exit.
6. The emergency exit in the Outpatient Pharmacy was locked. The key was not readily
available.
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FMS.8 The hospital establishes and implements a program for inspecting, testing, and
maintaining medical equipment and documenting the results.
Medical equipment is inspected and tested when new and according to age, use, and
manufacturers' recommendations thereafter. (Also see AOP.6.5, MEs 4 and 5)
Partially Met
The medical equipment was inspected and tested; however, the following was observed:
1. One of two tourniquet machines in the Operating Theatre had preventive maintenance
performed.
2. The endosurgery machine in the Operating Theatre was last calibrated in 2016. There was no
preventive maintenance performed since then.
3. The laparoscopy machine in the Operating Theatre preventive maintenance was performed in
2016. There was no preventive maintenance performed since then.
4. The scale used in the Parahyangan Unit measure weights for chemotherapy and
investigational medication weight-based doses was last calibrated in 2016. Regulations
required yearly calibration of scales.
Staff Qualifications and Education

SQE.1.1 Each staff member's responsibilities are defined in a current job description.
Those individuals identified in a) through d) in the intent, when present in the hospital, hav e job
descriptions appropriate to their activities and responsibilities or have been privileged if noted as
an alternative. (Also see AOP.3, ME 1; PCI.1, ME 3; and SQE.5, ME 3)
Partially Met
The head of each clinical department had a job description; however, the job descriptions were
not specific to their responsibilities.
SQE.9.2 There is a uniform, transparent decision process for the initial appointment of medical
staff members.
Appointments are not made until at least licensure/registration has been verified from the
primary source, and the medical staff member then provides patient care services under
supervision until all credentials required by laws and regulations have been verified from the
original source, up to a maximum of 90 days. (Also see SQE.3)
Not Met
Appointments were made for the medical staff; however, the hospital did not verify their licenses
before hiring.
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Management of Information
MOI.2 Information privacy, confidentiality, and security—including data integrity—are
maintained.
The hospital has a written process that protects the confidentiality, security, and integrity of data
and information. (Also see COP.2.2, ME 6, SQE.5, ME 1; and MOI.3, MEs 2 and 3)
Partially Met
The hospital had not implemented a process to maintain the privacy, confidentiality, and security
of the images taken during the care of dermatology, plastic, and burn patients. Consent was not
obtained from patients, and images were stored in the personal mobile phones of the physicians
and in the camera of the training department photographer.
MOI.4 The hospital uses standardized diagnosis and procedure codes and ensures the
standardized use of approved symbols and abbreviations across the hospital.
The hospital implements the uniform use of approved symbols, and those not to be used are
identified.
Partially Met
The hospital implemented the uniform use of approved symbols, and those not to be used were
identified; however, the following was noted in open and closed medical record review:
 -/- for negative
 - in circle for negative
 Big S for cross-out
If the hospital allows abbreviations, the hospital implements the uniform use of approved
abbreviations and each abbreviation has only one meaning.
Partially Met
The hospital implemented the uniform use of approved abbreviations; however, the following
was noted in open and closed medical record review:
 CA for conjunctival anemia
 SI for scleral icteric
 Dg for with
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Medical Professional Education

MPE.1 The hospital's governing body and leadership of the hospital approve and monitor the
participation of the hospital in providing medical education.
The review includes the satisfaction of patients and staff with the clinical care provided under the
program.
Partially Met
The hospital included the satisfaction of patients but did not include staff in the review of the
education program.
MPE.4 The hospital understands and provides the required frequency and intensity of medical
supervision for each type and level of medical student and trainee.
The hospital has established uniform expectations for all staff providing supervision t o ensure
that the process results in uniform medical student and trainee experiences.
Partially Met
The hospital had established uniform expectations for all staff providing supervision to ensure
that the process results in uniform medical student experiences. This did not result in uniform
trainee experiences.
MPE.5 Medical education provided in the hospital is coordinated and managed through a
defined operational mechanism and management structure.
For each medical student and trainee, there is documentation of at least a) through g) of the
intent.
Partially Met
For each medical student and trainee, there was documentation in a personal folder of a) through
g); however, the following was not in compliance; e) identification of medical student and trainee
competencies.
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B NEW! B Hospital Survey Findings Report

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Joint Commission

FINAL ACCREDITATION SURVEY FINDINGS

RSUP Dr. Hasan Sadikin Bandung

Survey Dates: 18 March 2019 - 22 March 2019

Survey Type: Triennial

REPORT OF SURVEY FINDINGS:

International Patient Safety Goals

4. Integrated development record for outpatients.

COP.3.2 Resuscitation services are available throughout the hospital.

Medication Management and Use

MMU.3.3 The hospital has a medication recall system.

MMU.4.1 The hospital defines the elements of a complete order or prescription.

Quality Improvement and Patient Safety

Prevention and Control of Infections

Facility Management and Safety

Staff Qualifications and Education

Medical Professional Education

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