Poa RSGS

RSPAD Gatot Soeboto Ditkesad Hospital
ACTION PLANNING REPORT
FINDINGS and RECOMMENDATIONS
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
International Patient Safety Goals IPSGs!"
May 26-31, 2013 Page 1

FINDINGS and RECOMMENDATIONS Patient Identifi#ation Many policies to describe the process so that need to read all to understand what is expected Staff inconsistent is using two identifiers of name and medical record number as often say name and date of birth. Not all medical record forms have patient name and medical record number, so that confirmation of the two identifiers is not possible. Practice in Psychiatry to use name and face recognition with photograph not included in policies. Re#o$$endation: Should integrate policies for one overall policy with all requirements and variations, such as Psychiatry. Staff should be retrained in primary identification elements to be consistently used. ll medical record documents should have patient full name and medical record number written for identification. Suggest initiating patient tracers to reinforce staff !nowledge " consistent performance.
May 26-31, 2013 Page 2
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
IPSG %
#r. $eguh %uncoro, Sp.P
No. &

FINDINGS and RECOMMENDATIONS Effe#ti&e Co$$'ni#ation Some staff not !nowledgeable of the 'write( down,) 'read(bac!,) and 'verify) process to confirm the accuracy of verbal and telephone orders or test results. *erbal and telephone orders are not documented. Re#o$$endations" +ducate and train staff on the policy. $racers and clinical audits to monitor the implementation of the policy.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
IPSG (
&. +ducation ,. $raining staff -. Monitor audit
#r. $eguh.%, Sp.P
No.&
May 26-31, 2013 Page 3

FINDINGS and RECOMMENDATIONS )i*+,alert Medi#ations $he policies on high(alert medications are not implemented throughout the organi.ation. /ac! of appropriate par level of concentrated electrolytes in crash cart. Staff not !nowledgeable on the policy and procedure. Re#o$$endations" 0larify the policy for storage of both refrigerated and non(refrigerated high alert medications. Provide the list of high(alert medications to the units with a process of expiration list. 1mplement the policy at all locations. Monitor the implementation through regular supervision by the pharmacy staff.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
IPSG -
&. 1mplementasi !ebi2a!an penyimpanan dan labeling ,. #aftar ttg obat high alert disimpan dan dicantum!an expired -. Monitor pela!sanaannya
#rs. Syarifudin, pt
No.&
May 26-31, 2013 Page 4

FINDINGS and RECOMMENDATIONS Ens're Corre#t,Site. Corre#t,Pro#ed're. Corre#t,Patient S'r*ery No preoperative chec!ing process Site verification is inconsistently documented as defined by policy. $ime out not rigorously performed or not performed in all cases where required, and sometimes documented prior to performance. Re#o$$endations" #evelop procedure that will support uniform process to ensure the correct site mar!ing and revise forms in the chec!(in area to 34. Modify the preoperative verification form to include relevant documents are available. +ducate and train staff on the policy. Monitor performance to ensure correct implementation and provide feedbac! to staff. )and )y*iene #uring patient traces and building tours, hand hygiene practice was not observed to be practiced by staff. Re#o$$endation: Should continue focus on improving practice through real time observations of 7 moments of 8and 8ygiene. 9eedbac! should be provided to staff so they
May 26-31, 2013 Page 5
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
IPSG /
&. Membaut formulir baru dan menerap!annya ,. +du!asi staf -. Monitor " audit
#r. 4. 5ebet, SP.6
No.&
IPSG 0
&. Monitor pela!sanaan hand hygiene dg : lang!ah ,. Memberi!an umpan bali! !epada staf 3. nalisis data yg sudah di!umpul!an departemen yg !urang patuh focus untu!
Mayor /aurentia
No.&

FINDINGS and RECOMMENDATIONS can understand the improvements needed. #ata should be further analy.ed to identify practice gaps not only by discipline but also by unit;department. $his information should be shared with staff. Red'#in* )ar$ fro$ Falls 9all ris! monitoring does not include consideration of unintended consequences from ris! reduction interventions. 4eassessment of fall ris! inconsistently performed and documented. No fall ris! assessment in 3utpatient 0linics, #ialysis, +ndoscopy, and +mergency #epartment <+#=. Re#o$$endation" 9alls data monitoring and analysis should include evaluation of unintended consequences from interventions, such as use of restraints or fluid restrictions. 9all ris! assessment must be performed for 3ut Patient 0linics, #ialysis, +ndoscopy and +#. Suggested ris! assessment tool for outpatients could be '>et(6p( nd(>o) which is quic! and easy to perform. 1nterventions for fall ris! should include basic
May 26-31, 2013 Page 6
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
pelatihan
IPSG 1
1. Peng!a2ian risi!o 2atuh di unit rawat 2alan, endos!opi, 8# dan 1># dengan formulir !husus dan 2. Penerapan metode >et 6p " >o untu! pasien rawat 2alan strategi untu! pasien risi!o 2atuh sedang dan tinggi < literature a!an diberi!an untu! dimasu!!an dalam form peng!a2ian risi!o 2atuh di rawat 2alan =, perhati!an ling!ungan dan beri!an informasi untu! tet 3. nalisis risi!o 2atuh, membuat laporan, pasien dg tinda!an pengi!atan !a2i s!in
/t!. Nurfadilah
No.&

FINDINGS and RECOMMENDATIONS safety practices regardless of fall ris! level and defined interventions for moderate and high ris!. Plan of care should include safety for fall ris!. 1nterventions for 3utpatients should include safety strategies in the outpatient environments and education for reducing fall ris! and safety actions in the home.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
ris! 4. Pasien dengan risi!o 2atuh sedang dan tinggi rencana tinda! lan2ut
May 26-31, 2013 Page 7

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
A##ess to Care and Contin'ity of Care ACC!" Pre,ad$ission tests $here is no policy addressing specific screening tests or procedures that must be completed prior to admission or a policy addressing that there are no requirements prior to admission Re#o$$endation" 1f there are no requirements, this should be stated in a policy 1f there are requirements: Specialty medical departments should identify if there are any tests or procedures that should be completed prior to admission, such as +%>, chest x(rays or blood screening for cardiology patients with scheduled admission. $his should be identified in policy ACC2% %ebi2a!an tentang tida! ada persyaratan pasien < s!rining = untu! masu! rawat inap, masu! melalui poli!lini! dan 1># %ainstal 1># no.,
May 26-31, 2013 Page 8

FINDINGS and RECOMMENDATIONS Ad$ission3Re*istration Pro#ed'res $here were no standard processes defined in policy or procedure for the admission process to the hospital, registration for out patients, or admitting to the +#, or admission to observation beds. Re#o$$endations" 4egistration;admission leaders need to develop, standardi.e, and place in writing specific procedures for admission; registration for the patients identified. Staff should be trained in procedures.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
ACC2%2%
%ebi2a!an tentang registrasi ; admisi untu! pasien rawat inap di ? area : - 4awat 2alan proses registrasi - 1># proses registrasi - 4awat inap proses admisi - Status observasi untu! pasien di ruang observasi 1>#, do!ter belum memutus!an untu! dipulang!an atau masu! rawat inap diobservasi dulu di 1>#
%ainstal 1>#
No.&
May 26-31, 2013 Page 9

FINDINGS and RECOMMENDATIONS Tria*e Staff does not !now the reference for which the triage process is based. $riage evaluation may be conducted but it is inconsistently written in the +# record. Re#o$$endations" +# clinical leaders should clearly identify the evidence( based reference for the triage process. Staff should be trained in the criteria, the scientific reference, and how to apply, and what must be documented. Monitoring of +# records should be used to reinforce correct process with feedbac! to staff about their performance.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
ACC2%2%2%
Program triase proses dan criteria sudah ada, bu!ti do!umentasi belum ada edu!asi pd staf
%ainstal 1>#
No.,
May 26-31, 2013 Page 10

FINDINGS and RECOMMENDATIONS Delays in #are Policy does not define what constitutes a 'delay) in care@ thus, it is not clear when a delay occurs. Policy does to clearly state who should communicate the delay to the patient or with in what time frame. Re#o$$endation" 0linical leaders need to define when a delay of care occurs. '#elays) should be defined as significant time delay in obtaining appointment or scheduling surgery or procedures. #elays that do not need to be communicated are the 'delay) when physician is behind in the appointments for today. Policy should clearly define who should communicate the delay to the patient or family and include information about possible alternatives to the wait. Policy should identify when <time frame= this delay should be communicated to the patient;family. Policy should define what must be documented in the patient record.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
ACC2%2%2-
1. %ebi2a!an tentang %ainstal 1># definisi !eterlambatan pelayanan berbeda untu! pasien !ritis di 1># !eterlambatan lebih !ecil, pasien yang sudah ter2adwal, !eterlambatan bisa lebih lama, siapa yang harus menginformasi!an tentang !eterlambatan pelayanan, batas wa!tu, bagaimana dan !apan informasi hrs disampai!an !epada !eluarga, alternative pelayanan yang ditawar!an !epada !eluarga untu! mengatasi !eterlambatan pelayanan tsb ,. +du!asi staf ttg !ebi2a!an tsb
No.&
May 26-31, 2013 Page 11

FINDINGS and RECOMMENDATIONS Ad$ission3Dis#+ar*e #riteria for ICU Policy does not include measurable physiological criteria for admission and discharge from the 106s. 0urrently the criteria are vague without much definition. Re#o$$endation" 4evise admission;discharge criteria to be physiologically based +ducation physicians, nurses, +# staff, and admission staff in the criteria. 4evised policy to include the criteria and publish for staff reference.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
ACC2 %2/
%ebi2a!an tentang criteria %ainstal pasien masu! dan !eluar 106 nestesi : 4eanimasi - criteria pasien masu! secara fisiologis dan bisa diu!ur, siapapun do!ter yg menulis permintaan masu! 106 dapat diterap!an sesuai criteria - !apan dan !ondisi apa pasien bisa di!eluar!an atau tida! boleh lagi di 106 - criteria yang berbeda ut! tipe 106 yang berbeda, distandarisasi untu! 106 yang dimili!i
No.&
May 26-31, 2013 Page 12

FINDINGS and RECOMMENDATIONS Transfer #riteria Policy does not address the standard criteria for transferring patients from one provider to another. 1n practice, process is unclear as there is no process defined or standardi.ed.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
ACC2(
%ebi2a!an $ransfer pasien #r. srofi , !apan pasien a!an Sp.5P dipindah!an dari & lo!asi !e lo!asi lain, dan bagaimana bisa diputus!an apa!ah pasien laya! atau tida! untu! dipindah!an, apabila ada pengalihan tanggung 2awab dari & do!ter !e do!ter lain bagaimana proses transfernya
No. &
Internal Transfer of Patients Policy does not specifically address the process to be used for transfer of patients within the organi.ation, such as from +# to the inpatient setting, surgical to non( surgical settings. Re#o$$endations" 0linical leaders need to define the process of transfer of the patients from one setting or service to another, including the referral and the acceptance of the patient by the medical providers. #ocumentation of the process should be defined. Policy should be revised accordingly.
ACC2(2%
May 26-31, 2013 Page 13

FINDINGS and RECOMMENDATIONS Patients on 4ass Policy does not address all the required care processes to support the patient on pass. $he policy does not address the provision of scheduled medications, or treatments while on pass or what the patient or family should do if there is an emergency. Re#o$$endation" $he policy should be developed addressing how the process to support the patientAs care needs will be met while on pass, such as: Medications $reatments 1nstructions on what to do in case of an emergency or the patientsA condition changes.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
ACC2-
%ebi2a!an tentang pasien cuti #r. asrofi, obat, yg hrs dima!an Sp.5P pasien, bagaimana perawatan medis selama pasien cuti diberi!an, 2i!a ter2adi !e2adian gawat darurat pada pasien yg sedang cuti sebut!an instru!si, yang 2elas pada do!ter dan perawat, proses untu! farmasi dan profesi lain
No.&
May 26-31, 2013 Page 14

FINDINGS and RECOMMENDATIONS S'$$ary list $here is no process or policy addressing the implementation of the summary list for outpatients receiving 'continuing care) in the organi.ation. Re#o$$endation" $he policy and procedure needs to be developed doing addressing the follow: #efinition of 'continuing care patient) Bhen will it be started Bho will initiate Bho will update Bhen will it be updated
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
ACC2-2-
May 26-31, 2013 Page 15
%ebi2a!an tentang #efinisi /t!. Nurfadillah pasien yg a!an mendapat!an pelayanan ber!elan2utan dan pasien ber!elan2utan : pasien yg a!an mendapat!an perawatan mayor di 4S, harus teru!ur, implementasi!an summary list, terdiri dari : - Prosedur bedah yg pasien pernah dapat!an - 4iwayat penya!it dahulu dan saat ini - 4iwayat alergi - 4iwayat dirawat sebelumnya 9ormulir dibuat tetap!an !apan mulai diimplementasi!an, diperbaharui, siapa yg harus bertanggung 2awab untu! memperbai!i Summary list snapshot untu! melihat !ondisi pasien dengan cepat, lebih detail dapat dilihat di status, berla!u untu! semua poli!lini!, dalam & formulir
No.&

May 26-31, 2013 Page 16

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
Patient and Fa$ily Ri*+ts PFR!" Pri&a#y $he consultants observed the following privacy breeches during tracers. $reatment ta!es place in the 106 with no screening. No privacy in the psychiatry unit Re#o$$endations" +stablish privacy process in the clinical areas and monitor the process with audits. Patient ri*+ts infor$ation Patient rights and responsibility is not provided in writing to inpatients, +#, and outpatients. Re#o$$endation" +stablish procedure for giving written copy of rights information to each admitted patient. 3r if rights are read to inpatients, this should be stated in policy. 3ffer each outpatient;+# a copy of rights information at time of registration. #escribe process in policy. PFR2%2( &. 0ara menerap!an system men2aga privasi pasien diseluruh area 4S ,. Monitoring %ainstal 4awat 1nap No.,
PFR20
&. Prosedur pemberian 1nformasi tentang ha!, pasien !eti!a dirawat di 4S ,. Monitor pela!sanaannya
%ainstal 4awat 1nap
No.,
May 26-31, 2013 Page 17

FINDINGS and RECOMMENDATIONS Re5'est for additional infor$ation $here is no clear process defined in policy as how additional information about a provider is handled and communicated to patients. Re#o$$endation" /eaders should define the process and can be done through website. Staff should be educated about the process and how to advise patients. Infor$ed #onsent 5lood consent form is not filled out. $he physicians inconsistently sign informed consents. Re#o$$endation" Medical leadership should wor! with surgery and anesthesia departments for full compliance with the completion of consents as per hospital policy.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
PFR212%
&. %ebi2a!an tentang proses pemberian informasi pada pasien yang membutuh!an informasi tambahan tentang perawatan pasien, ,. Monitor audit
%ainstal 4awat 1nap
No.,
PFR212/
&. $entu!an indicator !epatuhan pengisian informed consent ,. Monitor audit
%abagdo!
No.&
May 26-31, 2013 Page 18

FINDINGS and RECOMMENDATIONS Clini#al Resear#+, Patient Infor$ation Patients are not informed about: +xpected benefits Potential ris!s lternatives ssurance their refusal or withdraw will not compromise their care 4eview for research protocols and organi.ation process for benefits and ris!s Re#o$$endation" Process for patient information on the issues outlined above should be incorporated into the policy and procedure. Process should be monitored for compliance with audits. Resear#+, O&ersi*+t $he organi.ation does not have a committee or mechanism to oversee all research within the organi.ation. Re#o$$endation" $here should be a committee with a process to oversee the pro2ects. $here should be an evaluation process of the committee or process on a scheduled basis.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
PFR26 PFR262%
&. %ebia2a!an tentang 1nformasi pada pasien tentang penelitian yg dila!u!an melibat!an pasien dan bagaimana pasien !eluar dari penelitian ,. Monitor pela!sanaannya
#r. Made stina
No.,
PFR27
Prosedur pengawasan penelitian &. $etap!an proses pengawasaan penelitian ,. 3torisasi pada badan pengawas penelitian
#r. Made stina
No.,
May 26-31, 2013 Page 19

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
Assess$ent of Patient AOP!" Assess$ent , $ini$'$ #ontent Minimum content for medical assessment and nursing assessment is defined by policy. 8owever, the policy is confusing. Some of the items defined for medical assessment are included in Nursing 9orm. Policy does not clearly provide criteria for ris! screening for nutrition and functional ris!. Policy states physician does the assessment, but no evidence in medical records. Medical assessment for outpatients is S3 P without defining content. S3 P is a methodology for organi.ing information. Minimum content for initial assessment not defined by policy for rehabilitation staff, dieticians, and psychologist. 0ompletion of inpatient medical assessment started in +# and verified by inpatient
May 26-31, 2013 Page 20
AOP2% AOP2%2%
&. %larifi!asi pada %ebi2a!an tentang isi minimal dalam re!am medic : mulai dari peng!a2ian awal ,. 5uat formulir yang sesuai -. Melatih staf ?. Memantau !onsistensi implementasinya diseluruh area 4S
#r. #onny /dian, Sp.M Ns. #esnita 9itri, S%ep
No.&

FINDINGS and RECOMMENDATIONS physician varies greatly. Policy does not define what constitutes verification of inpatient physician of the medical assessment started in +#. Re#o$$endation" Minimum content for initial medical assessments should be defined; clarified for inpatients and outpatient clinics for all disciplines, e.g., physicians, rehabilitation therapists, dietitians. 9or medical assessment confirmation by inpatient physician, the elements of review and what is to be documented should be clarified. Specialty specific medical assessment elements may be defined for inclusion in addition to the minimum content. 1f chec!s are used to indicate answers, policy should specify what 'complete) means, such as chec!ing all categories or chec!ing if it applies instead of describing what should be included in the minimum content. fter defining minimum content of assessment, clinical leaders should train staff and emphasi.e completion of initial assessment information is an important
May 26-31, 2013 Page 21
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS

FINDINGS and RECOMMENDATIONS patient safety factor. 4evise policy for clarity accordingly. 0ompletion of initial assessments should be monitored for compliance with feedbac! provided to clinical staff. Initial assess$ent #o$4leted in (/,+o'rs of ad$ission 1nitial medical and nursing assessments not consistently completed within ,? hours as many elements left blan!. Some medical assessments are missing completely. Assess$ents #o$4leted 8it+in ti$e fra$e $ime period for nutrition, rehabilitation therapist, psychologist to respond to a referral;consultation is not specified in policy. Nutrition reported they see all psychiatric patients within ,? hours of admission. 8owever, they are not assessed during wee!ends or holidays so they do not meet their time. Re#o$$endation" 4esponse time to referral should be defined in policy that is realistic practice including wee!ends and holidays. 9or Psychology and Nutrition often patient
May 26-31, 2013 Page 22
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
AOP2%2/2%
1. %ebi2a!an pengisian #r. #onny /dian, Sp.M re!am medic dengan sempurna Ns. #esnita Memonitoring pra!ti! 9itri, S%ep !lini!
No.&
AOP2%2/
&. $entu!an time frame dari mulai dipanggil sampai mela!u!an peng!a2ian ,. 5erapa lama respon wa!tu -. Monitoring
No.&

FINDINGS and RECOMMENDATIONS populations or specific diagnoses are determined priorities with specific response times. Ris9 Assess$ent for n'trition ris9 Nutrition ris! assessment is inconsistently documented by nursing, although it is part of the initial nursing assessment. 1t is also defined to be part of the medical assessment. #ocumentation in medical record of referrals to other health professional staff for further assessment is not performed. S#reenin* for f'n#tional ris9 9unctional ris! screening criteria is not defined, performed, or evident in medical record. Re#o$$endation" Physicians, nursing and rehabilitation leaders should collaboratively define the screening criteria to be used to trigger a further assessment of functional ris!. Policy should further define when referral is made to which specialty rehab staff, such as physical therapy, speech therapy. Screening for functional ris! assessment should be consistently performed for all inpatients and documented. $hose outpatient clinics where
May 26-31, 2013 Page 23
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
AOP2%21
AOP2%21
1. S!rining nutrisi !ebi2a!an : tentau!an siapa yang mela!u!an do!ter atau perawat ,. Peng!a2ian dila!u!an minimal ,? 2am setelah masu! 4S -. 1mplementasi dan monitoring &. %ebi2a!an S!rining risi!o fungsional 2. 5entu! $im : 4ehab medi!, do!ter, perawat pasien yg a!an diru2u! !e rehab medic criteria, buat form s!rining dila!u!an oleh perawat, lapor pada do!ter tinda! lan2ut -. 5uat formulir ?. Pelatihan staf 7. Monitoring
No.&
No.&

FINDINGS and RECOMMENDATIONS nutrition;functional ris! is a disease factor, such as diabetes, cardiac, 2oint replacement, should also have criteria established. $he criteria should be used to trigger the referral. Pain s#reenin* and assess$ent Pain screening inconsistently performed and documented. Bhen pain is present, comprehensive assessment of characteristics of pain is not consistently performed or documented. lthough assessment of pain characteristics is defined in policy, either the physician or nurse inconsistently documents it in medical record when pain is present. Re#o$$endation" Policy should define that when pain is assessed 'as present), the further assessment of the pain characteristics should be performed and documented by either the physician or nurse to determined that pain was present. Staff should be re(educated in the revised process. Medical assessment forms should be modified to include a place for such documentation. Modified assess$ent for s4e#ial 4o4'lations
May 26-31, 2013 Page 24
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
AOP2%26
&. $entu!an definisi s!ala #r. #onny untu! S!rining nyeri /dian, Sp.M dan pasien tipa apa ,. S!ala nyeri pada Ns. #esnita status pasien 9itri, S%ep -. S!ala nyeri untu! neonates 4. %olom untu! staf menulis asesmen nyeri untu! menulis rencana lan2ut 2i!a ada nyeri 7. S!rining nyeri di rawat 2alan :. 1mplementasi dan monitoring !epatuhan
No.&
AOP2%2:
< lihat re!omendasi
#r. #onny
No. &

FINDINGS and RECOMMENDATIONS Modified assessments have been identified. 8owever, the modified assessment for pediatrics patients does not include relevant questions for development needs of physiological functions, including speech. Policy defines modified assessments according to those identified in standards. 8owever, no evidence in medical record reviews of some modified assessments for geriatric;elderly, terminally ill <end of life assessment not defined or evidence in medial record.= Psychiatrist states alcohol and drug abuse cases are infrequent. $hey did not identify a modified assessment for these types of patients. Policy on abuse and violence did not address modified assessments. Re#o$$endation" 3rgani.ation should consider what special patient populations listed in the intent statement and determine which patient populations need a modified assessment from the defined adult assessments. Modified assessment forms should be revised accordingly. 9or example, information for frail elderly is already included in the basic nursing assessment and does not need further Assess$ent of dyin* 4atient
May 26-31, 2013 Page 25
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
consultant 2ci untu! dicantum!an dalam !ebi2a!an 4S = &. 4eview !ebi2a!an ,. Modifi!asi dari formulir yang ada -. Pelatihan staf ?. Monitoring
/dian, Sp.M Ns. #esnita 9itri, S%ep
AOP2%27
1. %ebi2a!an tenang
#r. #onny
No.&

FINDINGS and RECOMMENDATIONS No policy or form to support the special assessments for 'end stage of life) patients. No process defined that would trigger this type of assessment. Should be physician assessment and order that would initiate the special assessment. No policy to support the assessment, except general statement that is restatement of the standards.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
,. -. ?. 5.
Reassess$ent No policy or practice that defines when reassessment by nutrition, rehabilitation staff should occur. Most often, the reassessment policy and practice states that reassessment is determined according to patient needs and as defined in Plan of 0are.
AOP2(
1.
peng!a2ian pasien terminal definisi!an proses yang a!an diimplementasi!an Membuat formulir $raining staf Monitor !epatuhan SP3 perawatan a!hir hayat mulai dari peng!a2ian lihat standar 03P ttg perawatan pasien terminal buat & !esatuan #efinisi : $entu!an fre!uensi berapa hari untu! mela!u!an asesmen pada pasien do!ter, perawat, rehab medic #o!ter harus melihat pasien setiap hari, perawat mela!u!an peng!a2ian setiap shift 2. Mengubah %ebi2a!an asesmen
/dian, Sp.M Ns. #esnita 9itri, S%ep
No.&
May 26-31, 2013 Page 26

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
P+ysi#ian daily reassess$ent Not consistently performed or documented, particularly on wee!ends. 106 physician inconsistent in documenting reassessments every shift as defined by their policy. La;oratory safety 4ro*ra$ $he laboratory safety program does not report to the organi.ationAs safety management program annually or when events occur. Meas're$ent of #riti#al &al'e re4ortin* No monitoring of reporting critical test values. Point of 0are testing performed at bedside by nurses, such as blood glucose, is not reported into the /aboratory critical test results reporting.
AOP2(
-. Moniroting staf &. %ebi2a!an Peng!a2ian pasien pada hari libur untu! semua unit ,. +du!asi pada do!ter di 106 -. Moniroting !epatuhan
No. &
AOP202%
AOP202-2%
&. /aporan pd $im Mutu #r. 9+bria secara ber!ala mulai sterina, Sp.P% a!hir Culi, pelaporan mulai bln C6ni 1. Pelaporan nilai !ritis #r. 9ebria sterina, Sp.P% pengumpulan data, !esimpulan dan analisis data 2. Pelaporan pemeri!saan gula darah sewa!tu yang dila!u!an diruang perawatan harus dilapor!an di /ab
No.,
No.&
May 26-31, 2013 Page 27

FINDINGS and RECOMMENDATIONS Pro4er stora*e of rea*ents mbient room temperature for reagent storage is not monitored to ensure proper storage. Radiation safety ris9s /ac! of proper hanging of aprons as found laid or folded. /ac! of proper recording of lead aprons to support trac!ing and ta!ing out of service when required. Re#o$$endation" 4adiation safety program should ensure that all aprons within and outside the radiology department are part of the safety inspection program. prons should be traceable and those determined to be unfit, should be ta!en out of service.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
AOP2020 AOP212( &. System Penyimpanan pron
#r. 9ebria sterina, Sp.P% #r. +!o No.&
May 26-31, 2013 Page 28

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
Care of Patients COP!" Unifor$ 5'ality of #are 4ro#ess /ac! of uniform quality of care processes was observed in inconsistent processes such as pain screening, initial medical and nursing assessments@ reassessments@ informed consents@ preanesthesia assessments, and medical assessment before surgery. Re#o$$endation" Policies and practice should be implemented in the same manner throughout the organi.ation and should be followed to ensure that patients with the same health care needs receive a uniform quality of care. Bhen same services are provided by different departments, clinical leaders should wor! together to ma!e sure that one level of care is provided. Policies such as pain, restraints, should be organi.ation(wide and not redefined for each unit or department. Unifor$ lo#ation of $edi#al orders Medical orders are written in several different places. $his is a safety ris! and presents
May 26-31, 2013 Page 29
COP2%
%etida!seragaman !ualitas pelayanan berbeda, dan tida! !onsistem &. #ata tentang monitoring dan analisa, buat improvement program yg a!an dila!u!an 2. %umpul!an data analisa !epatuhan
#r. 5udiman, Sp.5P
No.,
COP2(2(
&. $entu!an dimana penulisan instru!si medis < revisi formulir =
#r. 5udiman, Sp.5P
No.&

FINDINGS and RECOMMENDATIONS obstacles for timely " effective follow(through to implement orders. Care of e$er*en#y 4atient Policy provided during document review reflected the triage process. $he policy did not address the care of patients presenting with different diseases or signs;symptoms. 1t was stated +# has departmental S3Ps that reflect care according to disease or presenting signs and symptoms that include care to be provided. Res's#itation ser&i#es No standardi.ation of equipment, supplies, testing, or security 1nconsistent testing of defibrillator and monitoring security of cart +mergency meds are used for routine purposes. 4esuscitation training for code team not defined in policy. Re#o$$endations" Policies should be integrated and revised to include standardi.ation of equipment, supplies, monitoring requirements for equipment functioning and security chec!s of
May 26-31, 2013 Page 30
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
COP2-2%
,. +du!asi staf -. Monitoring Perawatan pasien, risi!o tinggi : 1. 4evisi %ebi2a!an ttg perawatan pasien risi!o tinggi protocol, alur, setiap departemen, ex @ penanganan pasien asma, M01, fra!tur
#r. 5udiman, Sp.5P
No.,
COP2-2(
1. 4evisi %ebi2a!an #r. Sudaryadi, Sp. n tentang bagaimana proses resusitasi, alat, apa yg harus ada dlm trolley emergency, obat, standar yg hrs ada di trolley emergency, bagaimana system pengunciannya dan harus !onsisten !ode untu! resusitasi, tulis!an pada trolley emergency dosis yg diberi!an ut! pasien
No.&

FINDINGS and RECOMMENDATIONS cart. Policy should specify resuscitation training requirements for code team responders. Structured reference medication dosing guidelines for neonate and children should be available on the appropriate carts for patient safety. +mergency carts should be secured. Medications should not be used for routine treatments as this deletes the availability of required emergency drugs for an emergency.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
ana! dan neonates 2. +du!asi staf tida! boleh mengambil obat emergency untu! obat rutin 3. 3rang yg mengawasi isi trolley emergencu dan mengece! fungsi defib setiap hari do!umentasi tgl dan apa yg dila!u!an pd saat monitoring tsb COP2-21 1. #efinisi!an !ebi2a!an dan prosedur peng!a2ian awal pasien 8#, monitoring pasien selamaa 8#, cantum!an evaluasi ulang oleh perawat form untu! peng!a2ian ulang pasien yang memerlu!an 8# ,. +du!asi -. Monitoring !epatuhan #r. 2o!o Bibisono, SP.P# Ns. Made Murtini No.&
Dialysis ssessment " reassessment inconsistently documented without definition for frequency or what should be assessed. Re#o$$endation" Policy should be developed that defines the care to be provided to dialysis patients. 0are to be provided should start with assessments parameters and frequency of reassessments by medical staff and nursing. Monitoring before, during, and after dialysis should be defined and implemented consistently.
May 26-31, 2013 Page 31

FINDINGS and RECOMMENDATIONS %ey factors for plan of care should be defined along with what care should be provided. Staff should be trained in the process. Care of Patients 8it+ Restraints Policy on restraints is a general policy with S3Ps defined at the unit level. $here is no assurance that care and monitoring provided reflects a uniform process of care. Re#o$$endation" $here should be one restraint policy applicable across the organi.ation for patients that may need restraints. ny minor changes for specific populations should also be stated in the policy. Staff should be retrained in the revised policy and include monitoring and documentation requirements. 0onsistency of implementation should be monitored through medical record review. Ot+er 4oli#ies for +i*+ ris9 4atients and ser&i#es" elderly. #+ildren. a;'se Policies are generic or are unit(specific, although these patients are treated in many different units and clinics. Policy on abuse does not include signs and symptoms or the care provided while
May 26-31, 2013 Page 32
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
COP2-26
$raining lihat re!omendasi consultant C01
Ns. Made Murtini
No.,
COP2-2:
1. $entu!an definisi 5agaimana merawat pasien geriatric, ana!, neonatus ,. +du!asi staf -. Monitoring harian dan chec! list oleh perawat
Ns. /yana
No.,

FINDINGS and RECOMMENDATIONS hospitali.ed. N'trition ser&i#es 1nconsistent evidence of diet order written in medical record. Re#o$$endation" ll patients must have a die order written prior to receiving food. Pain $ana*e$ent D Screening, assessment, and reassessment practices are inconsistent with policy. D Bhen pain is present, nurses usually document a pain score. Physicians do not document a score but may document that patient has 'pain.) D 0haracteristics of pain when present were inconsistently assessed or documented. D $here is a general pain policy and unit(specific S3Ps, which does not support uniform practices. D 1nconsistent or no pain screening in some 3utpatient clinics. Re#o$$endation" $here should be one pain policy that reflects the practices across the organi.ation. Policy should address elements required in the intent statement. Nursing staff should be retrained in policy
May 26-31, 2013 Page 33
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
COP2/
Pelayanan nutrisi
/t!. 1shi!o .8
No.,
COP21
Mana2emen nyeri < !er2asama dengan 3P =
No.&

FINDINGS and RECOMMENDATIONS requirements for conducting screening and assessment, and frequency for reassessment. 4etraining should also include what is required for documentation and the frequency of documentation. 3ther clinical staff, such as medical staff and rehabilitation staff, should also be trained in the pain assessment policy and should include pain screening when providing initial assessments. Pain screening in 3utpatient 0linics and Procedure areas should be consistently performed and documented. End of Life Care No policies or processes defined to support end of life care as defined in the intent statements. Re#o$$endation" 3rgani.ation should develop a guideline or plan of care that can be individuali.ed to address the unique care needs of the dying patient and their family. $he care interventions should include all elements defined in the intent statements. Staff should be trained in the required care and how to document. Medical record review should be conducted to
May 26-31, 2013 Page 34
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
COP26 COP262%

FINDINGS and RECOMMENDATIONS support consistent practice.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
May 26-31, 2013 Page 35

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
Anest+esia and S'r*i#al Care ASC!" Sedation $here is inconsistent pre(sedation assessment in pediatric patient population. No established or performed recovery phase monitoring in pediatrics. No discharge criteria or process for post sedation care. Re#o$$endation" +ducate staff about the process and procedure that should be implemented as per policy. Monitoring with the quality department should be put in place for compliance. Ris9s. Benefits. Alternati&es $he traced surgical patientsA records were missing ris!s, benefits and alternatives related to the planned anesthesia and surgery. Re#o$$endation" 0urrent anesthesia and surgical consent forms should be completed with ris!s, benefit and alternative sections filled out and monitored for compliance.
May 26-31, 2013 Page 36
ASC2-
&. 5uat proses ,. +du!asi staf -. Monitoring oleh $im Mutu
#r. Co!o Baluyo, Sp. n Ns. 1!a %arti!a
No.&
ASC202% ASC262%
&. $ambah!an di form informed consent tentang risi!o dan !euntungan tinda!an anestesi dan pembedahan ,. +du!asi staf -. Monitoring !epatuhan
#r. gus Sutarman, Sp.5 Ns. 1!a %arti!a
No.&

FINDINGS and RECOMMENDATIONS Re#o&ery 4+ase $onitorin* rrival and discharge time not consistently documented on 4ecovery Monitoring Phase. S'r*i#al Re4ort Surgical note is missing elements from a= through f= in the intents statement. Re#o$$endation" Surgical report should be filled including all elements, especially the complications. 3nce the form is revised to include all elements for documentation, it should be monitored for compliance. Do#'$entation of Posts'r*i#al Plans Postsurgical plans were not complete in the traced patients. Postsurgical plan section is not clearly identified and physicians are using the bac!side of operative note to write their progress note with their orders. Re#o$$endation" $he postsurgical plan section should be clearly delineated with orders written in the doctorsA orders only and should include the level of care, care setting, follow(up monitoring or treatment and need for medication. $he planned care should be documented in
May 26-31, 2013 Page 37
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
ASC21 ASC262(
&. +du!asi staf ,. Monitoring !epatuhan 1. 4evisi form 5uat dua baris di form untu! !olom !omentar dan !ompli!asi ,. +du!asi staf -. Monitoring !epatuhan
#r. Priyono Sp n
No.&
#r. gus No.& Sutarman, Sp.5, %.3n! Ns. 1!a %arti!a
ASC262/
1. $empat untu! penulisan rencana pasca pembedahan definisi!an proses, tempat!an dimana ditulis pada form ,. +du!asi staf -. Monitoring !epatuhan
#r. gus No.& Sutarman, Sp.5, %.3n! Ns. 1!a %arti!a

FINDINGS and RECOMMENDATIONS the patient record. FINDINGS and RECOMMENDATIONS
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
Medi#ation Mana*e$ent and Use MMU!" Medi#ation $ana*e$ent 4lan $he organi.ation developed a new plan for ,E&-. $he process for annual evaluation of the medication management system has 2ust been started. Re#o$$endation" 3rgani.ation should implement the process for annual review of medication management system that includes relevant data and analysis of processes. Medi#ation list and 'se Medication list policy review does not include safety, efficacy and annual review. Medications are not protected from loss or theft throughout the organi.ation. Re#o$$endation" +stablish a policy and process to monitor the
May 26-31, 2013 Page 38
MMU2%
1. Peng!a2ian tahunan untu! mana2emen obat buat rencana dan proses untu! evaluasi tahunan dan pasti!an di!er2a!an ,. Monitoring !epatuhan
#rs. Syarifudin, pt
No.&
MMU2(2%
&. 4evisi daftar obat ,. %embang!an proses dan implementasinya -. +valuasi tahunan ?. Monitor !epatuhan
#rs. Syarifudin, pt
No.&

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
Medi#ation Mana*e$ent and Use MMU!" medication list and review the medication list annually for safety and efficacy. $here should be oversight for the medication use and protection from loss or theft. Medi#ation stora*e 3pened undated and unlabeled medications are found in outpatient clinics. 1nconsistent monitoring of refrigerator temperature 0ontrolled substance storage boxes were not labeled. +mergency medication cart in the pediatrics and 106 was not loc!ed 8igh lert medications not stored in a safe and secure manner that prevents inadvertent access Re#o$$endation" $he pharmacy should supervise and oversee medication storage and labeling in the hospital and ma!e sure that it is a uniform process. Pharmacy staff should perform audits on patient care areas to ensure that medications are stored as per policy. $he process should be strictly enforced for
May 26-31, 2013 Page 39
MMU2MMU2-2( GLD2-2(2%
&. ,. -. ?.
#efinisi!an strateginya Proses 1mplementasi Monitoring
#irbin2angmed #rs. Syarifudin, pt %abagwat

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
Medi#ation Mana*e$ent and Use MMU!" controlled drugs, high alert medications and concentrated electrolytes in the allocated areas of the hospital. $he emergency carts should be loc!ed at all times after the review done by the nursing staff and should only be used during emergency. $his process should be monitored to ensure compliance. Stora*e of in&esti*ational $edi#ations and n'trition 4rod'#ts Policy is missing as how appropriate nutrition products and investigational drugs are stored. Sample medication policy is missing. Re#o$$endations" Policy should be developed and implemented as how nutritional products, and investigational drugs are stored. Sample medication policy should be developed. Co$4lete $edi#ation order Medication orders were incomplete and illegible. #ouble chec!ing and signing of orders by
May 26-31, 2013 Page 40
MMU2-2%
&. ,. -. ?. 7.
5uat !ebi2a!an $entu!an proses +du!asi staf Monitoring !epatuhan %ebi2a!an tentang obat,an sampel
#rs. Syarifudin, pt /t!. 1shi!o /t!. 3de 6.5
No.&
MMU2/ MMU2/2%
&. $erap!an %ebi2a!an pemesanan obat ,. +du!asi staf -. Monitoring !epatuhan
%abagwat
No.&

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
Medi#ation Mana*e$ent and Use MMU!" nursing and pharmacy staff not consistently done. 1nitial medications ta!en prior to admission are not compared to the list of medications. P4N orders did not include indications as per policy. Prescribing, ordering, and transcribing not performed as per hospital policy. Re#o$$endation" $he hospital should develop a process to comply with complete orders and hospital policy. /eadership of medical staff, pharmacy, and nursing should review the process and implement it throughout the organi.ation. udits with notifications should be implemented when medication orders are incomplete, illegible or unclear.
May 26-31, 2013 Page 41

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
Medi#ation Mana*e$ent and Use MMU!" Pre4arin* and dis4ensin* ppropriateness review is not performed for medications. ppropriateness is not correctly applied for review of chemotherapy. 0hemotherapy preparation is not supervised. Medications are inconsistently labeled. 0ross(chec! drugs for drug;drug interactions and allergies are not performed. Re#o$$endation" Medication orders need to be reviewed for appropriateness prior to dispensing. +stablish a robust and efficient process for review at the pharmacy for all orders dispensed by the pharmacy. $he pharmacy should have a standardi.ed process for reviewing chemo orders for appropriateness. MMU202% &. $entu!an proses #ra. 4enni, pt sesuai dengan standar ,. +du!asi staf di %ainstal 4awat 9armasi pusat, satelit 1nap dan tempat meraci! obat !emoterapi -. Monitoring !epatuhan dengan audit !etat No.&
May 26-31, 2013 Page 42

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
Medi#ation Mana*e$ent and Use MMU!" Medi#ation ad$inistration No policy for patient self(administration of medications. $imely administration was not defined in policy. Medications administered in the outpatient were not documented. Re#o$$endation" policy should be developed whether self( administration of medication by the patient is permitted. 1f permitted, the method of supervision and storage of medication brought into the hospital by the patient that is to be used in self( administration should be described in the policy. Process for medication administration should be clear to staff " implemented. Monitor for compliance with stated policy. MMU212% MMU212( &. 4evisi ; leng!api !ebi2a!an ,. 1mplementasi !ebi2a!an -. +du!asi staf ?. Monitoring !epatuhan %ainstal 4awat 1nap #ra. 4enni, pt No.&
May 26-31, 2013 Page 43

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
Medi#ation Mana*e$ent and Use MMU!" Monitorin* 3rgani.ation does not have a uniform and well(defined process for adverse effects, near miss and medication errors reporting, data collection and analysis. Pharmacy collects data on medication errors and near misses from pharmacy process only. $hus, data are not yet readily used to improve the processes and outcomes. 4e#o$$endation" Process for adverse effects, near miss and medication error should be redefined. #ata collection should not be limited to pharmacy and should be performed throughout the organi.ation. Pharmacy " quality department should wor! collaboratively to analy.e " use data to improve safety of practices. FINDINGS and RECOMMENDATIONS MMU26 MMU262% 5elum ada Proses yg seragam tentang penanganan laporan %$#, near miss dan !esalahan pengobatan &. 5uat proses ,. Pengumpulan dan analisa data -. Program improvement ?. 1nformasi!an pd organisasi ttg hasilnya 7. +du!asi staf :. Monitoring !epatuhan %abagdo! %abagwat %abagdi!lat #ra. 4enny No. &
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORIT Y
STATUS
Patient and Fa$ily Ed'#ation PFE!"

May 26-31, 2013 Page 44

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
Medi#ation Mana*e$ent and Use MMU!" Ed'#ational needs assessed $he inpatient nursing assessment has a very well developed education needs assessment section. 1nitial patient educational needs are not consistently documented. Re#o$$endation" $he initial assessments should consistently include evaluation of patientAs initial education needs at time of admission and should continue throughout course of hospitali.ation. Learnin* readiness 1nitial assessment of patientAs learning readiness is inconsistently documented. No ongoing reassessment of patientAs readiness to learn when education is provided. Re#o$$endation" 1nitial assessment of patientAs learning readiness should be consistently evaluated and documented. 5arriers to learning should be reassessed each time prior to providing patient education. PFE2( &. ,. -. ?. #efinisi Perbaharui form +du!asi staf Monitoring !epatuhan Ns. Satria >obel No.&
PFE2(2%
May 26-31, 2013 Page 45

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
Medi#ation Mana*e$ent and Use MMU!" Patient ed'#ation 4ro&ided +vidence in medical record for pain management, medications and safety factors including side effects are not consistently documents when appropriate to the patientAs condition and interventions. E&al'ation of 4atients< 'nderstandin* No evidence of patient;family understanding of education provided. Re#o$$endation" Patient education form and process should be revised to include evaluation of patient;family understanding of education. Staff should be taught how to evaluate patientAs understood, such as as!ing questions, return demonstration, nodding head in agreement. PFE2/
PFE20
May 26-31, 2013 Page 46

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
Medi#ation Mana*e$ent and Use MMU!" Preferred Learnin* Met+ods No information about patientAs preferred learning method@ i.e. verbal, written, demonstration, is assessed or documented. Re#o$$endation" /earning preference method should be documented in initial assessments. +ducation provided should attempt to meet patientAs preferred learning style. PFE20
May 26-31, 2013 Page 47

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
='ality I$4ro&e$ent and Patient Safety =PS!" Pro*ra$ Fo#'s Program plan is missing relevant elements such as information flow, committee structure, methodology, how priorities are established <criteria used=, process for communicating quality and patient safety information to the >overning 5oard and approval of the nnual Plan by the 5oard of $rustees, how information is disseminated to clinical staff that are the end(users of the information. Re#o$$endation" $he program plan should be revised to include the identified elements above. $he >overning 5oard should approve the annual program plan. /eadership should discuss with the 5oard the priority monitoring results for 5oard to understand the status of quality and patient safety initiatives in the organi.ation. $he plan should include the process for regularly reporting quality and safety information to the 5oards. May 26-31, 2013
Page 48
=PS2%

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
='ality I$4ro&e$ent and Patient Safety =PS!" Co$$'ni#ation of 5'ality infor$ation to staff #issemination to staff of quality improvement and patient safety information is not forthcoming. Staff is not able to describe quality improvement and patient safety results related to their practice. Re#o$$endation" Fuality improvement and patient safety data including results of monitoring Patient Safety >oals should be provided as feedbac! to clinical staff on a regular basis to encourage improved performance. 3rgani.ation should establish several methods for communicating results of quality and patient safety data to staff. Management should be involved in reinforcing the dissemination of results. Priorities and Clini#al 4at+8ays. G'idelines. Proto#ol /eaders have established three criteria for selecting 0linical
May 26-31, 2013 Page 49
=PS2%2/
=PS2(2%

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
='ality I$4ro&e$ent and Patient Safety =PS!" pathways, >uidelines, and Protocol. 8owever, five priorities are required to be established for standardi.ation of care. $he pathways, guidelines, or protocols are not specified to the priority criteria. Re#o$$endation" 3rgani.ation is required to select five priorities annually and to identify standardi.ed practices for each priority. $he priority criteria could include patient populations or diagnosis, procedures, populations, or diseases. 3rgani.ation should reconsider priorities and align the clinical pathways, guidelines, and protocols selected according to priority. #ata should provide information on how use of standardi.ed practices has reduced variation in process and outcomes. Re5'ired #lini#al $eas'res Medication use process focuses only
May 26-31, 2013 Page 50
=PS2-2%

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
='ality I$4ro&e$ent and Patient Safety =PS!" on pharmacy process and does not include the other five processes in medication use and management. Re#o$$endation: 4evise definition of medication error to include all six processes of medication use and management. 4evise indicator profiles to include reporting and monitoring of mediation use errors beyond the pharmacy. 4eview the process for reporting of medication errors to ensure an easy and successful way to report. 3rgani.ation must also consider error reporting and intensive analysis for significant adverse drug events and significant medication errors as required in FPS.G. Monitorin* IPSG #efinition of indicators for the : 1PS> is not clearly defined. Re#o$$endation" 4evise indicator profiles to clarify definition of numerator and data.
May 26-31, 2013 Page 51
=PS2-2-

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
='ality I$4ro&e$ent and Patient Safety =PS!" 1dentify the source for the data. 1nclude observation of practices to ensure proper implementation of safety strategies. Data analysis Most of monitoring results presented as run charts. Re#o$$endation" 3rgani.ation should use other statistical presentations tools for data such as control charts according to type of data. >alidation 9ormal validation process has not been initiated. Re#o$$endation: 0onsider criteria when validation must be performed. 1nitiate validation process according to defined steps in the intent statement. *alidation is required for FPS.-.& H clinical indicators. Provide evidence of the process. Ad&erse 4atterns and trends on data
May 26-31, 2013 Page 52
=PS2/
=PS20
=PS26

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
='ality I$4ro&e$ent and Patient Safety =PS!" 3rgani.ation has not defined measurement for serious adverse errors or significant medication errors. 1ssue seems focused in incomplete definition and reporting process. Re#o$$endation" 4edefine mediation errors to include all six processes of medication use and management. +stablish and train staff in reporting mechanism. $rain staff in definition of medication errors to be reported. +stablish process and individuals that will be included in data analysis and defining and ta!ing actions for improvements. Ris9 $ana*e$ent fra$e8or9 $he organi.ation does not have a ris! management framewor! that includes all the components as defined in the intent statement. Re#o$$endation" 0onsultants provided an example framewor! to assist in integration of the
May 26-31, 2013 Page 53
=PS2%%

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
='ality I$4ro&e$ent and Patient Safety =PS!" various components necessary to manage ris!.
May 26-31, 2013 Page 54

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
='ality I$4ro&e$ent and Patient Safety =PS!" FINDINGS and RECOMMENDATIONS STANDARD ACTIONS RESPONSIBLE PERSON PRIORITY STATUS
Pre&ention and Control of Infe#tions PCI!" Pro*ra$ fo#'s Program plan is not comprehensive. 9or example, it does not address the surveillance activities, case finding and investigation of outbrea!s, process for annual ris! assessment and evaluation of program effectiveness. Plan does not reference policies developed for identified ris!s. Surveillance program does not consistently identify measureable goals. PCI20
May 26-31, 2013 Page 55

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
='ality I$4ro&e$ent and Patient Safety =PS!" Ris9,;ased 4ro*ra$ Program is not based on a ris! assessment. Re#o$$endation" 3rgani.ation should conduct a ris! assessment each year to determine priorities for focus in improvement opportunities. 0onsultants provided sample ris! assessment. PCI21
May 26-31, 2013 Page 56

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
='ality I$4ro&e$ent and Patient Safety =PS!" Poli#ies and a#tions for red'#in* ris9s Many practice gaps observed during building tour and patient tracers. 9ly and mosquito in 3perating 4oom <34=. Practice of shoe changes when staff has bare feet in sterile corridor highly questionable or science based. +ntrance to 34 not secured such that any family or visitor could wal! into area. 0oc! roach in !itchen. Sewers not covered. 1n psychiatry, open drain trough from toilets flow into drainpipe by shower. 5athrooms and showers were deep dirty with mildew and mold. 9loors including corners had ca!ed dirt. 0eiling tiles were missing about clean preparation areas. Paint was peeling or bubbling on May 26-31, 2013
Page 57
PCI26

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
='ality I$4ro&e$ent and Patient Safety =PS!" Mana*e$ent of e5'i4$ent #leanin* and sterili?ation #uring the building tour, the following infection control issues were identified in 0entral Sterili.ation Service. Fuality control chec!s of equipment not !nown. No trac!ing of devices required for soa!ing time. 1nconsistent quality controls for steam sterili.ation. +thylene 3xide sterili.er without systematic and questionable quality control. Staff did not !now requirement for daily quality control monitoring. PCI262%
May 26-31, 2013 Page 58

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
='ality I$4ro&e$ent and Patient Safety =PS!" Re4ro#essin* of sin*le 'se de&i#es $rac!ing process incomplete and question reliable. 4eprocessing of #ialyses not consistent with policy. 0riteria for evidence of wear and tear and deterioration not specified but left to end(user. Re#o$$endations" Policy and practices should be revised to resolve above identified inadequacies in practice. Monitoring of SS1 should include evaluation of use of reprocessed instruments or devices. PCI262%2%
May 26-31, 2013 Page 59

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
='ality I$4ro&e$ent and Patient Safety =PS!" Infe#tion #ontrol d'rin* re$odelin* and reno&ation Policy to support but do not have a systematic ris! assessment with interventions and monitoring according to ris! level. Re#o$$endation" 0onsultants will provide systematic process for evaluating remodeling and renovation pro2ects and determining the appropriate alternative strategies and monitoring requirements. PCI2620
May 26-31, 2013 Page 60

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
='ality I$4ro&e$ent and Patient Safety =PS!" Isolation 4ro#ed'res Staff uninformed of different isolation practices. Supplies for isolation process not available. Re#o$$endations" Staff should be retrained in types of isolation and proper procedures. 1nfection control rounding should include observation of case in or needing isolation to ensure proper implement of isolation techniques consistent with policy. Nursing and facilities should wor! together in monitoring negative pressure rooms to ensure ongoing, consistent process. ny testing when patient being placed in room should be documented as part of the unit quality control processes. PCI2:
May 26-31, 2013 Page 61

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
='ality I$4ro&e$ent and Patient Safety =PS!" Infe#tion #ontrol inte*ration 8it+ =PS /eadership of the P01 program is not included in the organi.ationAs FPS oversight mechanism. PCI2%@ ME (
May 26-31, 2013 Page 62

STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
Go&ernan#e. Leaders+i4. and Dire#tion GLD!" Go&ernan#e str'#t're $he documents provided to define the roles and responsibilities of all leaders and governance. >overnance is not identified on the organi.ational chart. $here is no documentation of an evaluation of governance or leadership. Re#o$$endation" $he organi.ationsA 'by laws) need to be amended to address: >overnance structure, including the governing body<s= 4eporting relationships 4esponsibilities and accountabilities of leadership and governance +valuation process for governance +valuation process for leaders and managers. GLD2%
May 26-31, 2013 Page 63

FINDINGS and RECOMMENDATIONS Go&ernan#e res4onsi;ilities $he processes for the oversight and review of the governing body are not clear. $he processes were not !nown or documented for the required areas. Re#o$$endation" #ocuments and processes for the roles and responsibility of the governance and leadership need to be defined to address: pproval of the strategic plan pproval of capital and operating budgets llocation of resources <financial, human and equipment= +valuation of the senior managers 4eview of reports on the quality and safety program pproval of the quality and safety plan
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
GLD2%2( A GLD2%20
May 26-31, 2013 Page 64

FINDINGS and RECOMMENDATIONS Contra#t o&ersi*+t /eaders were not aware of all the contracts in the organi.ation. Provisions of services from 8ouse!eeping contract were not met, but 2ust recently meetings were held to address the deficiencies. 8owever, no actions have been ta!en to address the deficiencies and improve the services. Re#o$$endation" senior leader should be identified that will have responsibility for oversight of contracts. 3versight responsibility include:: Provide data on performance expectations of the contract ddress deficiencies 8old contractors accountable 0hange contractor if service does not improve 1nclude measurement of services in the quality and safety program. Fa#ility Mana*e$ent and Safety FMS!"
May 26-31, 2013 Page 65
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
GLD2-2GLD2-2-2%

FINDINGS and RECOMMENDATIONS Mana*e$ent 4lans $here are no facility management plans written. Re#o$$endation" $he facility management teams need to write the :;G required management plans using the standards for each plan as a guide for the topics and contents.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
FMS2(
May 26-31, 2013 Page 66

FINDINGS and RECOMMENDATIONS O&ersi*+t of fa#ilities $ana*e$ent 1ndividuals are assigned to oversee all areas except equipment management and safety and security. #isaster preparedness is overseen by the +# services and is not integrated in the overall facility management program. 3rgani.ation responds to failures. 8owever, there is no planning process or use of data to establish priorities. Re#o$$endation" $he following needs to be implemented: 1dentify one leader or a group of leaders <one for each area= #evelop process for oversight addressing: o Planning, o Prioriti.ation o ssessment of goal achievement.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
FMS2-
May 26-31, 2013 Page 67

FINDINGS and RECOMMENDATIONS Monitorin* of in#idents related to FMS $here is no coordinated monitoring program to identify incidents or in2uries related to the facility management and safety. $here is no use of monitoring and outcome data to use to improve the facility management program. Re#o$$endation" $he individual<s= and responsible leaders need to: +stablish a monitoring process for each of the G facility safety areas <data= naly.e the data 6se the data analysis to redesign the plans.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
FMS2-2%
May 26-31, 2013 Page 68

FINDINGS and RECOMMENDATIONS Se#'rity $here is no process to identify and plan for securing areas where there are patients with security ris!s, such as the newborn and N106 nurseries and pediatric areas. Re#o$$endations" $he organi.ations leaders should: 1dentify clinical areas where ris!s to patents safety and security are a priority <such as pediatrics, new born and N106 nurseries=. #evelop a process to decrease the ris!s of harm. #rill the plan to ensure it is effective and staff is !nowledgeable.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
FMS2/
May 26-31, 2013 Page 69

FINDINGS and RECOMMENDATIONS Fa#ility ins4e#tion $here is no process for completing, documenting, and updating a current facility assessment. #ue to the lac! of facility inspection;assessment, there is no process to plan or prioriti.e maintenance and improvements to the facility. $here is no coordination process for the facility safety plans or improvement goals. Re#o$$endation" $he facility leaders should: 1mplement a process to perform and document an ongoing facility assessment <as discussed in the facility documents review session=. 0ategori.e and prioriti.e the findings the findings #evelop the plan for improvement to reduce ris!s. #eveloped a process to trac! the improvements to ensure they are complete and effective.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
FMS2/2%
May 26-31, 2013 Page 70

FINDINGS and RECOMMENDATIONS Use of data for 4lannin* and 4rioriti?in* $here is no coordinated process for planning and budgeting for hospital improvements and upgrades to improve and ensure patient safety and security. Re#o$$endation" process should be developed that uses the building assessment to identify safety issues to establish priorities for the budgeting for facility improvements.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
FMS2/2(
May 26-31, 2013 Page 71

FINDINGS and RECOMMENDATIONS )a?ardo's Materials and Baste $he following items are missing from the inventory: 0ytotoix medications 8a.ardous waste, 5io(ha.ardous materials. $he management plan does not address: Storage 8andling #isposal. $here are no plans or processes in place that address: use of appropriate personal protective equipment. air handling in the areas where gluterheldyde or other noxious chemicals are used. $here is a lac! of !nowledge by facility leaders to what is needed for staff wor!ing with all ha.ardous materials. /abeling of ha.ardous materials does not include the name of the chemical May 26-31, 2013 such as for
Page 72
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
FMS21 FMS212%

FINDINGS and RECOMMENDATIONS Fire safety $he fire safety program does not meet minimum expectations. $he following items are not present or inappropriate: 5asic !nowledge of fire safety /ighted fire exit signs in the hallways and at the doors 9unctional fire notification system. Staff !nowledge of alternative fire safety response devices;processes. Sufficient or effective fire drills Re#o$$endation" $he entire fire safety program needs to be reassessed and plans need to be developed to: Provide basic !nowledge and concepts 4eplace the fire signage 4epair the fire notification system 1mplement effective drills or other fire safety activities for all staff.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
FMS26
May 26-31, 2013 Page 73

FINDINGS and RECOMMENDATIONS Medi#al e5'i4$ent 4ro*ra$ $he following equipment management processes are not in place: 1nventory of all medical equipment Process to management the required preventative and scheduled maintenance 1dentification of all equipment in the hospital Process for staff to recogni.e when equipment has meet the maintenance requirements and is safe to use +ffective reporting;repair process and documentation for failing;bro!en equipment Re#o$$endation" n individual must be assignment to oversee the equipment management system who will address all the issues noted above.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
FMS2:
May 26-31, 2013 Page 74

FINDINGS and RECOMMENDATIONS Medi#al e5'i4$ent $ana*e$ent 4ro#ess Since there is no process to manage the medical equipment, there is no data on the completing of the management process. Re#o$$endation" medical equipment management program must be implemented and documented in a manner that will allow collection and analysis of data to use for improvement of the process.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
FMS2:2(
May 26-31, 2013 Page 75

FINDINGS and RECOMMENDATIONS Medi#al e5'i4$ent re#all $here is no coordinated recall system for the medical equipment. Re#o$$endation" n effective recall system will include the following: 1nventory of all equipment 6nique identification of all equipment for trac!ing /ocations of all equipment Process to notify departments when equipment in their area is recalled and to retrieve and isolate the equipment until repaired or released by manufacturer.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
FMS2:2(
May 26-31, 2013 Page 76

FINDINGS and RECOMMENDATIONS Medi#al *as $ana*e$ent Medical gas canisters are not secured from falling. 0anisters that are full and empty are not recogni.able for the staff with a detailed process to investigate. Re#o$$endation" Policies and procedures need to be developed and implemented: Secure and safe storage Separation of full and empty. Staff trainin* Staff training and !nowledge is not present or tested for, for their role in all seven facility safety areas. Re#o$$endation" $he organi.ation should develop training for all new employees and ongoing training annually that addresses role of staff in providing a safe environment, using the seven safety plans as the guide.
STANDARD
ACTIONS
RESPONSIBLE PERSON
PRIORITY
STATUS
FMS2%@
FMS2%% A FMS2%%2-
May 26-31, 2013 Page 77

STANDAR D
ACTIONS
RESPONSIBL E PERSON
PRIORIT Y
STAT S
Sta!! "#ali!i$ations and Ed#$ation %S"E&' (ob des$)iption Not all job descriptions fully addressed: Position requirements Activities and responsibility. Re$o**endation' Human resource managers and department heads need to review and revise all job descriptions to address the required elements.
S"E+,+,
May 26-31, 2013 Page 78

FINDINGS and RECOMMENDATIONS Res#s$itation t)ainin edical staff specialist! some nurses! and other health professional staff did not have the required resuscitation training or evidence of current training. "here was no policy that addressed which employees are required to specific type of resuscitative training. Re$o**endation' A policy should be established that clearly defines level of training for staff providing patient care. A process to provide the training and trac#ing of those trained should be established and implemented.
STANDAR D
ACTIONS
RESPONSIBL E PERSON
PRIORIT Y
STAT S
S"E+.+,
May 26-31, 2013 Page 79

FINDINGS and RECOMMENDATIONS P)i*a)/ So#)$e 0e)i!i$ation%PS0& Primary $ource %erification &P$%' of licensure is not in effect for nurses and other professionals that require licenses. P$% is not implemented for education for (other health professionals) that require special education for their jobs. *or nurses! P$% has been initiated for education but with only one attempt several months ago. Re$o**endations' P$% process should be implemented for all staff! that is nurses and other health care providers that require licensure and speciali+ed education for their job class. P$% should be attempted at least , times with documentation of attempts maintained in the personnel files.
STANDAR D
ACTIONS
RESPONSIBL E PERSON
PRIORIT Y
STAT S
S"E+,1 and S"E+,2
May 26-31, 2013 Page 80

FINDINGS and RECOMMENDATIONS P)i*a)/ So#)$e 0e)i!i$ation -urrently primary source verification is not implemented. Process for credential file review at least once every three years is not in place. Re$o**endation' .rgani+ation should define the elements that need verification &license! education! e/perience! training'. %erification of information can be done through secure web site! documented phone confirmation from the source! written confirmation! and third parties such as a designated official governmental or nongovernmental agency. As 0ndonesian medical council is planning to implement primary source of verification! organi+ation can use this process for the new recruitment process after verification that the system in place. -redential file review process in the policy should be included.
May 26-31, 2013 Page 81
STANDAR D
ACTIONS
RESPONSIBL E PERSON
PRIORIT Y
STAT S
S"E+3+,

FINDINGS and RECOMMENDATIONS Clini$al P)i4ile-es and Appoint*ent Process for privileging is in progress. 0nitial appointment and reappointment is not granted through items a-f in the intent statement. Annual performance review is not in place. Re$o**endation' 1evelop the process for privileging and include elements a-f in the intent statement for reappointment decision. 0nitiate a process to privilege all physician staff within a time frame. "he policy should be revised to have the privileges to be performed on the initial appointment and reappointment. 0n preparation of initial 2-0 survey! the organi+ation should be in full compliance with the new medical staff privileging process four months prior to scheduled survey. Annual performance review May 26-31, 2013
Page 82
STANDAR D
ACTIONS
RESPONSIBL E PERSON
PRIORIT Y
STAT S
S"E+,5

FINDINGS and RECOMMENDATIONS E4al#ation o! Medi$al Sta!! "he professional practice evaluation does not include the quality and safety of patient services provided by the medical staff member. "he annual evaluation does not consider comparative data such as benchmar#ing to literaturebased medicine. Re$o**endation' .bjective criteria for professional practice evaluation should be developed and include patient safety practices along with comparative data such as benchmar#ing to literature-based medicine.
STANDAR D
ACTIONS
RESPONSIBL E PERSON
PRIORIT Y
STAT S
S"E+,,
May 26-31, 2013 Page 83

STANDAR D
ACTIONS
RESPONSIBL E PERSON
PRIORIT Y
STAT S
Mana-e*ent o! Co**#ni$ations and In!o)*ation %MCI&' E!!e$ti4e $o**#ni$ation
-ommunication and coordination among nurses and physicians and departments responsible for providing clinical services are not effective throughout the organi+ation.
Re$o**endation:
MCI+6 MCI+2
"he leaders should support and foster effective communication between the medical! nursing and pharmacy staff in the delivery of clinical services.
S7i!t $7an-e $o**#ni$ation "he clinical elements of hand off between services and shifts are not standardi+ed. Re$o**endation' 3eaders of clinical departments should consider developing standardi+ed content of the hand off which include the essential elements vital to the patient safety for the ne/t provider. MCI+8
May 26-31, 2013 Page 84

FINDINGS and RECOMMENDATIONS Abb)e4iations 4napproved symbols and abbreviations were found in the medical records. Re$o**endation' "he organi+ational policy clearly defines a list of approved and (not to use) abbreviations. 0t should be implemented and monitored for compliance. $taff should be educated on the policy and as how to access the approved list.
STANDAR D
ACTIONS
RESPONSIBL E PERSON
PRIORIT Y
STAT S
MCI+,9
May 26-31, 2013 Page 85

FINDINGS and RECOMMENDATIONS Data Mana-e*ent
STANDAR D
ACTIONS
RESPONSIBL E PERSON
PRIORIT Y
STAT S
MCI+,:
1ata and information is not utili+ed in decision ma#ing! educate and support the participation of patients and families in care processes. Re$o**endation' 1ata management should be an integral part of decisionma#ing processes. Processes should be developed. $taff should be educated as how to access and use information as such. Cons#ltant s#--estion: 1ue to si+e! comple/ity and clinical research activities! consider initiating the process of 5lectronic edical 6ecords &5 6'.
May 26-31, 2013 Page 86

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RSPAD Gatot Soeboto Ditkesad Hospital

ACTION PLANNING REPORT

FINDINGS and RECOMMENDATIONS

International Patient Safety Goals IPSGs!"

May 26-31, 2013 Page 1

RSPAD Gatot Soeboto Ditkesad Hospital

#r. $eguh %uncoro, Sp.P

RSPAD Gatot Soeboto Ditkesad Hospital

&. +ducation ,. $raining staff -. Monitor audit

#r. $eguh.%, Sp.P

May 26-31, 2013 Page 3

RSPAD Gatot Soeboto Ditkesad Hospital

May 26-31, 2013 Page 4

RSPAD Gatot Soeboto Ditkesad Hospital

#r. 4. 5ebet, SP.6

RSPAD Gatot Soeboto Ditkesad Hospital

RSPAD Gatot Soeboto Ditkesad Hospital

May 26-31, 2013 Page 7

RSPAD Gatot Soeboto Ditkesad Hospital

FINDINGS and RECOMMENDATIONS

May 26-31, 2013 Page 8

RSPAD Gatot Soeboto Ditkesad Hospital

May 26-31, 2013 Page 9

RSPAD Gatot Soeboto Ditkesad Hospital

May 26-31, 2013 Page 10

RSPAD Gatot Soeboto Ditkesad Hospital

May 26-31, 2013 Page 11

RSPAD Gatot Soeboto Ditkesad Hospital

May 26-31, 2013 Page 12

RSPAD Gatot Soeboto Ditkesad Hospital

May 26-31, 2013 Page 13

RSPAD Gatot Soeboto Ditkesad Hospital

May 26-31, 2013 Page 14

RSPAD Gatot Soeboto Ditkesad Hospital

May 26-31, 2013 Page 15

RSPAD Gatot Soeboto Ditkesad Hospital

May 26-31, 2013 Page 16

RSPAD Gatot Soeboto Ditkesad Hospital

FINDINGS and RECOMMENDATIONS

%ainstal 4awat 1nap

May 26-31, 2013 Page 17

RSPAD Gatot Soeboto Ditkesad Hospital

%ainstal 4awat 1nap

&. $entu!an indicator !epatuhan pengisian informed consent ,. Monitor audit

May 26-31, 2013 Page 18

RSPAD Gatot Soeboto Ditkesad Hospital

#r. Made stina

#r. Made stina

May 26-31, 2013 Page 19

RSPAD Gatot Soeboto Ditkesad Hospital

FINDINGS and RECOMMENDATIONS

#r. #onny /dian, Sp.M Ns. #esnita 9itri, S%ep

RSPAD Gatot Soeboto Ditkesad Hospital

RSPAD Gatot Soeboto Ditkesad Hospital

#r. #onny /dian, Sp.M Ns. #esnita 9itri, S%ep

RSPAD Gatot Soeboto Ditkesad Hospital

#r. #onny /dian, Sp.M Ns. #esnita 9itri, S%ep

#r. #onny /dian, Sp.M Ns. #esnita 9itri, S%ep

RSPAD Gatot Soeboto Ditkesad Hospital

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/dian, Sp.M Ns. #esnita 9itri, S%ep