UPDATE PERSIAPAN AKREDITASI TRIENNIAL JCI

“Joint Commision Internasional which has evaluated

this Academic Medical Center Hospital and found it
to meet
The international health care quality standards for patient care

Medical education and human subject research

Organization management

EFFECTIVE 12 AUGUST 2016 THROUGH 11 AUGUST 2019

 RENCANA PELAKSANAAN SURVEI
•Tanggal 26 – 30 Agustus 2019
•Survey Type: Triennial_AMC Hospital

Surveyor:
1. Enrico Baldantoni, MD (Physician, Team Leader)
2. Denise Fritz, RN, BSN, MS (Nurse)
3. Frank Dawood, MBBS, MPH (Administrator)
4. Diane M. Sanders, MN, RN, NEA-BC (Clinician, Administrator)
5. Pauline Tan, MPA, MSc, BN, RN (Nurse)
6. Charles Welborn, MD (Physician)
Enrico Baldantoni, MD
Surveyor, Joint Commission International
Skills for Healthcare Organizations
• Quality Improvement
• Risk Management
• Patient Safety
• Technology Assessment

Education
• Doctor of Medicine, University of Padova School of Medicine
• Post Graduate Specialties in Cardiology, Science of Nutrition, and Public
Health, University of Padova-Italy Medical School
• Post Graduate Specialties in Hospital Administration, Legal and Insurance
Medicine, University of Ferrara-Italy Medical School
• Master in Health Economics, University of Tor Vergata Rome-Italy
• Master in Bioethics, University of Padova-Italy
• Master in Health Care Management, University of Trento-Italy

Professional Affiliations
• President of the Veneto Region, Italian Society for Quality in Health Care
• Member of the International Society for Quality in Health Care
Denise Fritz, RN, BSN, MS
Surveyor, Joint Commission International
Skills for Healthcare Organizations
• Survey Process Preparation
• Performance Improvement Assistance
• Leadership Education and Skill Building
• Team Building and Facilitation
• Patient Satisfaction coaching

Education
• Master of Science in Management (MS), Indiana Wesleyan University,
Indianapolis, Indiana
• Bachelor of Science in Nursing (BSN), East Tennessee State University,
Johnson City, Tennessee
• Associate of Applied Science in Nursing, Social Services, Corrections,
Saint Louis Community College, Saint Louis, Missouri
• Bachelor of Arts in Psychology, Webster University, Webster Groves,
Missouri

Professional Affiliations
• American Cancer Association- Board Member
• American Organization of Nurse
• American College of Health Care Executives
Frank Dawood, MBBS, MPH
Surveyor, Joint Commission International
Skills for Healthcare Organizations
• Hospital Planning and Design
• Hospital Strategic and Operational Planning
• Program and Project Management
• Leadership of Transition Programs
• Management of Strategic Initiatives
• New Service Development
• Change Management
• Team Leadership and Management
• Team Building and Motivational Skills
• Certified Professional in Healthcare Quality

Education
• Master of Public Health – Monash University – Melbourne, Australia
• Prince-2 Project Management – Department of Health - Melbourne,
Australia
• Disaster Management – Department of Defence - Melbourne, Australia
• Emergency Management – Oxfam - Melbourne, Australia
Diane M. Sanders, MN, RN-BC, NEA-BC
Surveyor, Joint Commission International
Skills for Healthcare Organizations
• Healthcare Regulations
• Healthcare Business Operations
• Program Development
• Quality Improvement and Patient Safety
• Patient Care and Patient Experience Redesign
• Leadership Development
• Nursing Practice Regulation

Education
• University of Washington, Masters in Nursing
• Montana State University, Bachelors of Science in Nursing
• Indiana University, Associate of Arts in Nursing

Professional Affiliations
• American Nurses Association, Nurse Executive Advanced Certification
• American Nurses Association, High-Risk Perinatal Nurse Certification
• Sigma Theta Tau, Nursing Honorary Society
• National Association for Healthcare Quality
Pauline Tan, MPS, MSc, BN, RN
Surveyor, Joint Commission International
Skills for Healthcare Organizations
• Regulation and Policy Making
• Work and Process Redesign
• Managerial leadership

Education
• Master of Public Administration (MPA){
• Master of Science in Asia Pacific Human Resource
Management (MSc)
• Bachelor of Nursing (BSN) and Graduate Diploma in
Advanced Nursing (Administration)
• Registered Nurse (RN)
Charles Welborn, MD (Physician)

First and Last name and credentials

Surveyor, Joint Commission International
Professional Affiliations and Credentials
• Fellow, American Academy of Pediatrics
• Fellow, American College of Emergency Physicians
• American Society of Tropical Medicine and Hygiene

Education
• Bachelor of Science in Biology/Philosophy, Spring Hill College, Mobile, Alabama, USA
• Doctor of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
• Master of Public Health and Tropical Medicine, Tulane University School of Public Health and
Tropical Medicine, New Orleans, Louisiana, USA
• Master of Science in Health Policy and Management, New York University, New York, New
York, USA

Skills for Healthcare Organizations

• Policy, procedure, and guideline development and implementation
• Quality assurance initiatives
• Medical staff recruitment and credentialing
• Pre-hospital care and disaster management
• Educational programs for multidisciplinary teams
 ROAD MAP TO JCI
RSUP
SANGLAH
LULUS JCI
AGT 2019
EDISI 6
JULI 2019 TRIENNIAL SURVEY
SURVEI JCI
JUNI 2019 VERIFIKASI II
MOCK SURVEI II KARS
DARI RSCM
MEI 2019
JAKARTA?????
BULAN IMPLEMENTASI JCI

MARET 2019
MOCK SURVEI I
DARI RSDK
SEMARANG
 TIME TABLE KEGIATAN
TH 2018 TH 2019
KEGIATAN
DES JAN FEB MAR APR MEI JUN JUL AGT
Finalisasi Regulasi
Telusur Lapangan oleh Asesor Internal
Telusur Dokumen dan Self Asessmen
Rapat Pleno Hasil Telusur
Mock Survei Standar JCI edisi 6 dari
Kementerian Kesehatan RI
Survei Verifikasi KARS II
Resurvei Akreditasi JCI edisi 6
 MOCK SURVEI I
• Tanggal 19 – 21 Maret 2019
• Tim RSUP Dr. Kariadi Semarang

Masih butuh Perhatian

• Fasilitas/ bangungan dan izin
• Dokumen untuk evaluasi dewas
• Keterlibatan peserta didik dalam pemantauan mutu, program mutu RS, regulasi RS, alur pelaporan
insiden keselamatan pasien
• Kelengkapan file pegawai (pelatihan wajib, verifikasi sumber primer)
• PEMERIKSAAN KESEHATAN KARYAWAN
• Verifikasi DPJP
• Kelengkapan RM dan penggunaan singkatan
• Update Buku Daftar Singkatan
 MOCK SURVEI I

• Kesesuaian Discharge Palnning dan Informed Consent

• Notulen rapat Dewas dan Direksi
• Kelengkapan dan update regulasi
• Alur keluar pasien dari ruang isolasi IGD ke ruang isolasi definitive
• Identifikasi pasien ( labeling obat , identitas cetak pada setiap lembar RM )
• Kalibrasi alat
• Pelaporan hasil kritis
 FOLLOW UP MOCK SURVEI I

• Pembentukan Tim Monitoring Mutu dan Keselamatan Pasien dari PPDS

• Ronde K3RS dan Ronde Manajemen
• Bulan JCI pada Mei 2019
• Pembuatan buku ( hand book ) buat staf
AGENDA SURVEY AKREDITASI JCI TAHUN 2019
AGENDA SURVEY AKREDITASI JCI TAHUN 2019
AGENDA SURVEY AKREDITASI JCI TAHUN 2019
AGENDA SURVEY AKREDITASI JCI TAHUN 2019
AGENDA SURVEY AKREDITASI JCI TAHUN 2019
Kebutuhan ruangan
No Ruangan Peruntukan Jumlah Usulan pilihan

1 Ruangan pertemuan Pembukaan, presentasi Dirut 1 1. Aula poli

dan briefing harian 2. Aula wing
3. Aula Obsgyn
2 Ruang Pertemuan Leadership interview 1 1. Ruangan sebelah aula poli
2. Ruangan Ka Instalasi dan Ka UPP wing
2 Ruangan untuk setiap Masing masing surveior 6 1. Ruang direksi , ruang Ka Bid Perawatan , Ka Bid Penunjang
sesi surveior disiapkan 1 ruangan untuk , Ka Bid Pelayanan
semua kebutuhan pertemuan 2. Ruang perawatan pasien di wing lantai 2 ( sandat room )
sesuai agenda masing masing
3 Ruangan dokumen Penyiapan dokumen inti 1 1. Aula vip
review 2. Ruang perawatan Wing lantai 2 ( Jepum Room )
4 Ruang pertemuan Basecamp 1 1. Aula vip
surveior dan private 2. Ruang perawatan Wing lantai 2 ( Jepum Room )
lunch
5 Ruangan translator Ruangan untuk 6 orang tran 1 1. Ruang pertemuan SPI
slator dan makan siang 2. Ruang perawatan Wing lantai 2 ( Jepum Room )
6 Ruangan untuk Ruangan untuk observer dan 1 1. ULP
observer makan siang 2. Ruang perawatan pasien di wing lantai 2 ( sandat room )
Total kebutuhan ruangan 12 Ruangan
TERIMA KASIH

Design & Layout: Lydia Okva Anjelia, S.I.Kom