AKREDITASI RUMAH SAKIT

VERSI 2012
Myr Kes F. Malau, MAP
 Perubahan Paradigma
Standar Akreditasi Baru

1. Tujuan akreditasi: quality improvement

2. Continuous quality improvement
3. Peran direktur/pimpinan RS: sangat sentral
4. Patient safety
5. Patient centered care
6. Compliance with Standard
7. Tracer Methodology
 TUJUAN AKREDITASI:
QUALITY IMPROVEMENT & PATIENT SAFETY

UU RS
PASAL 40
• 1) Dalam upaya peningkatan mutu pelayanan Rumah Sakit wajib
dilakukan akreditasi secara berkala minimal 3 (tiga) tahun sekali

Pasal 43
• 1) Rumah Sakit wajib menerapkan standar keselamatan pasien
• 2) Standar keselamatan pasien sebagaimana dimaksud pada ayat (1)
di laksanakan melalui pelaporan insiden , menganalisa , dan
menetapkan pemecahan masalah dalam rangka menurunkan
angka KTD
 Basic Concepts
of Hospital Accreditation

Hospital
verification

Self PDCA
Quality & Safety
assessment

Self improvement
Self
improvement
Self assessment
Learning Hospital
PDCA Process
Accreditation
Hospital PPS
Verification
Self
assessment PDCA
Self
Improvement Basic Concept
 Learning organization  learning process
 Continuous quality improvement
 Patient centered care
 Patients Safety

Sutoto.KARS 4
 PATIENT CENTERED CARE
• Harvey Picker ( 1915 – 2008)
• He was the founder of the Boston-based
Picker Institute, whose goal is to promote
patient-centered healthcare.
• He believed that the American health care
system was technologically and scientifically
outstanding, but overall was not sensitive to
patients' concerns and their comfort
• In The Year 1986, they founded the Picker
Institute, dedicated to developing a patient-
centered approach to healthcare

Sutoto.KARS 6
 THE DECISION MAKING PROCESS,A PATIENT CENTERED APPROACH:
AN ESSENTIAL PART OF A PATIENT-CENTERED APPROACH TO MEDICINE, CALLED COLLABORATION

THE PATIENT'S
FAMILY:
PATIENT’S Involved in decision-
FAMILY making

HEALTH
HEALTH CARE THE HEALTH CARE
CARE INSTRUCTIONS INSTITUTIONS
TEAM (HOSPITALS,
INSURANCE
COMPANIES, ETC.)
SETTING FACILITY
DESIGN BASED ON
REGULATIONS
HEALTH CARE TEAM (PHYSICIANS,
NURSES AND TECHNICIANS:
INTERDICIPINARY TEAM
MODEL/APPROACH
Patient Centered Care - A Conceptual Model and Review of the State of the Art
Ravishankar Jayadevappa and Sumedha Chhatre. The Open Health Services and Policy Journal, 2011, 4, 15-25
 Fig.(2) Conceptual model of patient centered care

Provider Characteristics
Physician
Hospital
Nurse

Clinical
Convenience

Patient Cost
Characteristics
Ethnicity Clinical Health resqurce
Insurance Patient Centered Care Utilization
Education Treatment Choice Minimize Direct cost
Income Indirect cost
Marietal status

Outcomes

Maximize Satisfaction
Survival With care
Health related quality of life
Functional status
Psychological wellbeing

Patient Centered Care - A Conceptual Model and Review of the State of the Art
Ravishankar Jayadevappa and Sumedha Chhatre. The Open Health Services and Policy Journal, 2011, 4, 15-25
PERAN DIREKTUR
Patuh terhadap
peraturan &
perundangan RS

PIMPINAN RS
Menetapkan
regulasi di RS

Menjamin kepatuhan staf

Sistem monev terhadap regulasi yg
terhadap regulasi yg ditetapkan oleh pimpinan
ditetapkan pimpinan

Rangkuman Bab Tata Kelola Kepemimpinan dan Pengarahan

 IMPLEMENTASI DAN KEPATUHAN TERHADAP
KEBIJAKAN DAN STANDAR MENJADI DASAR HUKUM
DAN PELAYANAN YANG BERKUALITAS

Contoh diantaranya adalah staf/staf klinis mampu memperagakan:

1. Bekerja sesuai SPO
2. Menggunakan APAR secara benar
3. Cuci tangan dengan standar WHO dan patuh terhadap five moment for hand
hygine
4. IIdentifkasi pasien dengan benar
5. Read back
6. RJP/CPR. Dll
Prosedur high risk harus sesuai/patuh terhadap Standar
• IV admixture harus sesuai standar
• Handling cytotoxic
Acknowledgement : WHO World Alliance for Patient Safety 12
Hasil Yang Dicapai
16
17
18
QUESTION ?