JCI. proses evaluasi independen yang dilakukan oleh Joint Commission International (JCI) untuk menilai dan meningkatkan kualitas serta keselamatan layanan kesehatan di berbagai institusi di seluruh dunia

proses evaluasi independen yang dilakukan oleh Joint Commission International (JCI) untuk menilai dan meningkatkan kualitas serta keselamatan layanan kesehatan di berbagai institusi di seluruh dunia

1. Biodata
Nama : Achmad Hardiman
Pekerjaan : Direktur IMRS Persi dan Konsultan Manajemen RS
Email addres : [email protected] Tilp : 0811135913
Fax : 021 - 86902958
Pendidikan : - Dokter ,FKUI Lulus tahun 1971
- Dokter Spesialis Kedokteran Jiwa ,FKUI,Lulus tahun 1976
- Magister Administrasi Rumah Sakit,FKM UI,Lulus th 1996
Organisasi : - Ketua Institut Manajemen Rumah Sakit,PERSI
- Anggauta Dewan Pengawas RSUP Dr. M.Djamil Padang
- Anggauta Pengurus BKKMK,Intakindo
Training : - Hospital Reform and Restructuring,World Bank Institute,
The National University of Singapore, 2003
- Pengembangan Konsultan PPMK.,UGM ,2001
- Pengembangan Konsultan BLUD ,PPMK UGM,ARSADA Pusat
dan Depdagri,2008
- Self Assessment Total Quality Management Malcolm Baldrige,
Lembayung Center,2008
- Lead Auditor ISO 9001:2000 ,SGS Indonesia,2008
- Lead Auditor OHSAS 18000 :2007,SGS Indonesia2009

2. Pengalaman Mengajar
1. Kajian Administrasi Rumah Sakit,FKM UI : 1997 – 2002.
2. Kebijakan Kesehatan , MMR UGM , 2003 – 2004.
Pengalaman Pekerjaan
1.Direktur RSJ Palembang : 1976 – 1985, RSJ Semarang : 1985 -1996
3.Direktur Kesehatan Jiwa : 1996 – 1999
4.Sekretaris Direktorat Jenderal Pelayanan Medik : 1999 – 2000 & 2004
5.Direktur Pelayanan Medik Spesialistik : 2000 – 2003
6.Kepala Pusat Kesehatan Kerja : 2005
7.Direktur Pengendalian Penyakit Tidak Menular : 2006 – 2007
8. Direktur RSU Menteng Mitra Afia : 2008 – 2009
Pengalaman Konsultan
1. Studi kelayakan Wing Internasional RSUP Karyadi,Semarang
2. Pendampingan SPM RSUP Moh Husin,Palembang
3. Pendampingan RBS dan RBA ,RSSN Bukitinggi
4. Pendampingan Business Plan RS Dr Radjiman.S ,Malang

 

3. Akreditasi Internasional dalam
Konsep Joint Commission Internatonal
Achmad Hardiman
Direktur IMRS PERSI
Fax : 62 – 21- 45857833
Email : [email protected]
Pelatihan Manajemen Rekam
Medis & Informasi Kesehatan
Jakarta 01 /11 - 2010

4. Sektor – sektor yg masuk dalam
perdagangan global
1.Bussiness
2.Communication
3.Construction and
engineering
4.Distribution
5.Education
6.Enviromen
7.Financial
8.Health
9.Tourism and travel
10.Recreation, cultural,
and sporting
11.Transport
12.“Other”
Sektor yang termasuk :

5. Latar Belakang
Globalisasi : GATS : Mode III
- Investasi asing RS tersier di Ibukota
Propinsi dengan 400 tt (2010 : Saham asing 60 %)
- Telah ada Parkway Group ( Singapura)
Siloam Hospital Groups Jakarta,Surabaya & Medan
Ramsay HC (Australia): Mitra Internasional.
- Masyarakat Indonesia ke
RS RS Singapura : 200.000 per tahun : 754 /hari
Malaysia : 38.325 per tahun : 105/hari
- Devisa yang keluar : Rp5.520.000.000.000/tahun
( 600 juta USD dgn kurs 1 USD = Rp 9200 )

6. Performance Gap &
Competitiveness Impact
Gov. Agencies
+ Contributors
Performance
Hospitals
Performance
Quality
Expectations
of
Customers
1. Private Owned 1. Ministries
Competitor
Enterprises
Competitive
ness
Total Competitiveness
2. State Owned 2. Contributors
Perform
Gap

7. •Amerika Serikat,Kanada dan Australia
mempunyai sistem Akreditasi tertua
•Eropa,Jerman,Perancis,Irlandia dan Spanyol
mempunyai sistem akreditasi yang baru
•Jepang,Korea, Malaysia, Thailand dan
Indonesia mempunyai sistem akreditasi baru
dengan dibatu peran pemerintah
•WHO, World Bank dan pengembangan bank
mengembangkan model akreditasi
Akreditasi - Kecenderungan di
Dunia

8. The Major Quality Awards
International Quality Award
The Malcolm Baldrige (MBQA)
USA
Japan
The Deming PrizeThe European
Quality Award
Europe
Singapore Quality
Award
Indonesian Hospital Acreditation Award
JCI
ISO 9001 : 2000 ( MUTU )
OSHAS 18001:1999 ( K3)

9. Pendahuluan
• Joint Commission International (JCI) adalah
kepanjangan tangan internasional dari The Joint
Commission (TJC).
• Berdiri sejak tahun 1997
• TJC and JCI are independen, nirlaba(non-
profit), bukan badan pemerintah (non-
governmental agencies)

10. Mission of
Joint Commission International
To improve the safety and quality of care
in the international community through the
provision of education, publications,
consultation, evaluation, and accreditation
services
SHANGRI-LA HOSPITAL
El Dorado, Republic of Freedonia
SHANGRI-LA HOSPITAL
El Dorado, Republic of Freedonia

11. Struktur Internasional JCI
•International Board of Directors (of JCR)
•International Accreditation Committee
•International Standards Committee
•Regional Advisory Councils
•Four International Offices

12. •Usually a voluntary process by which
a government or non-government
agency grants recognition to health
care institutions which meet certain
standards that require continuous
improvement in structures,
processes, and outcomes.
Accreditation – A Definition
–Usually a voluntary process–Usually a voluntary process by which
a government or non-government
agency grants recognition to health
care institutions
Usually a voluntary process by which
a government or non-government
agency grants recognition to health
care institutions which meet certain
standards
SHANGRI-LA HOSPITAL
El Dorado, Republic of Freedonia
SHANGRI-LA HOSPITAL
El Dorado, Republic of Freedonia

13. Apakah Standar ?
•Suatu statemen tentang keselamatan
dan mutu yang diharapkan

14. Types of Expectations in
Standars
•Inputs (Structures) : Sumber daya
•Processes : Aktifitas - aktifitas
•Outcomes : Hasil - hasil

17. Joint Commission
International Standards
•Menetapkan harapan – harapan yang
optimal dan tercapai (Set optimum,
achievable expectations)
•Focus on the patient
•Didisain untuk dapat
diinterprestasikan/disuvai dengan budaya
lokal dan kerangka hukum (Designed to
be interpreted/surveyed within the local
culture and legal framework)
•Menstimulasi perbaikan yang
berkelanjutan (Stimulates continuous
improvement)

18. The JCI Evaluation Process
•Meliputi seluruh unit organisasi dan semua
sistem pelayanan dan manajemen (Covers all
portions of an organization and all systems of
care and management)
•Fokuskah semua kejadian terhadap pasien-
pasien – metode pengusutan digunakan (Is
focused on what happens to patients – patient
tracers used )
•Proaktifkah – evaluasi mutu dan keselamatan
pelayanan pasien dimasa mendatang (Is
proactive – evaluates the likely quality and safety
of patient care in the future)

19. Client name/ Presentation Name/ 12pt - 19
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Patient Tracer
–Follows the care and needs of the
patient

20. Client name/ Presentation Name/ 12pt - 20
©

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The Accreditation Journey:
The Basics
Evaluate the commitment of leadership
(Board, CEO, and clinical leaders) to a
never ending journey.
Assess the purity of purpose: to be a
safe, high quality organization.
Set a clear understanding that the
process will require significant leader
time. Assigning accreditation only to the
quality department will not work.

24. Standards Component
Manajemen komunikasi dan Informasi (MCI)
•Pelayanan pasien sangat kompleks dan sangat
tergantung pada komunikasi informasi.
•Komunikasi kepada dan dengan masyarakat,pasien
dan keluarganya dan kepada tenaga profesional
kesehatan lain.
•Kegagalan komunikasi adalah salah satu penyebab
utama dari insiden keselamatan pasien.

25. Standards MCI
MCI.1 The Organization communicates with its community to
facilitate acces to care and acces information about its patient
care services
MCI.2 The Organization informs patients and families about its
care and services and how to acces those swervices
MCI.3 Patients and family communication and education are
provided in an understandable format and language
MCI.4 Communication is effective throughout the organization
MCI.5 The leaders ensure that there is effective communication
and coordination amongs those individuals and department
responsible for providing clinical services
....... MCI.20

26. Measurable Elements of MCI.1
1.The organization has identified its communities
and populations of interest
2.The organization has implemented a
communication strategy with these populations
3.The organization provides information on its
services,hours of operation,and the process to
obtain care
4.The organization provides information on the
qualities of its services

29. Bermuda
Brazil
Mexico
Barbados
Chile
Costa Rica
Pakistan
India
Thailand
Singapore
Philippines
China
Hong Kong
Taiwan
S. Korea
Bangladesh
Indonesia
Malaysia
Turkey
Egypt
Ethiopia
Saudi
Arabia
Qatar
UAE
Jordan
Lebanon
Spain
Ireland
Demark
Germany
Cz. R.
Aus
Italy
Swz.
JCI Headquarters
Chicago, USA
JCI European Office
Ferney-Voltaire, France
JCI Middle East Office
Dubai, UAE
JCI Asia-Pacific Office
Singapore
JCI Accredited Organizations
To date, 249 organizations in 34 countries

30. JCI Accredited Organizations
in Asia-Pacific Region
22
11
33
11
22
1515
55
44
66
Correct as at 5 Jul 09
11

31. Applying for Accreditation
•Survey Application
–Submit application in electronic or
written format to JCI Office
–Must inform JCI if changes to
information in application after
submission
•Application is used to
–determine length of survey &
number of surveyors
–prepare preliminary agenda &
contract for survey
•Survey Scheduled within 180 days

32. The Accreditation Survey
Once your application is completed, a
surveyor team will be assigned and dates
confirmed.
A survey team leader will be in contact to
coordinate an agenda and plans for the
survey.
Support staff in doing the work they routinely
do so the survey does not cause undue
anxiety and fear.

33. After the Survey
Celebrate your success!
If there are areas for improvement, you may need
to submit documentation or a follow-up progress
report to JCI.
Maintain the momentum from your preparation and
survey. Establish a system and process for ongoing
standards compliance and survey readiness.
Continue education.

34. Biaya :
50.000 US
untuk registrasi
50.000 US
Untuk survey
50.000 US
Untuk perbaikan
Di RS Siloam

35. Reported Returns on Accreditation
•Improved care – fewer complications
•Better reputation -- increased number of
new patients
•More satisfied staff – better retention and
lower recruitment and training costs
•More efficient, cost effective work
processes

36. Reported Returns on Accreditation
•Better preventive maintenance program –
longer life of biomedical equipment
•Special recognition from payment sources
and insurance companies
•Greater clarity to leadership structure and
quality oversight
•Better safety management, and risk
reduction – reduced liability
exposure

37. Needlestick Injuries – Needlestick Injuries –
Changi General Hospital, SingaporeChangi General Hospital, Singapore
No. of Needlestick Injury per 1000 CGH Healthcare Workers
0.53
2.80
1.72
0.59
0.001.20
1.17
2.92
2.88
1.74
2.29
2.85
2.36
5.93
1.192.98
2.39
2.99
2.36
2.45
3.45
4.80
2.97
5.96
4.29
6.13
6.25
2.48
1.871.88
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2
4
6
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(CGH) No. of needlestick injury per 1000 CGH healthcare workers
The rate of needlestick injuries per 1000 healthcare workers was
reduced from 7.91 in 2003 to 3.48 in 1
st
6 months of 2005, an
improvement of 127%

38. Standar Standar AkreditasiAkreditasi
dalam UU 44/2009 ttg RSdalam UU 44/2009 ttg RS
•Pasal 40 Akreditasi
(1) Dalam upaya peningkatan mutu pelayanan RS wajib dilakukan
akreditasi secara berkala menimal 3 (tiga) tahun sekali.
(2) Akreditasi RS sebagaimana dimaksud pada ayat (1) dilakukan
oleh suatu lembaga independen baik dari dalam maupun dari luar
negeri berdasarkan standar akreditasi yang berlaku.
(3) Lembaga independen sebagaimana dimaksud pada ayat (2)
ditetapkan oleh Menteri.
(4) Ketentuan lebih lanjut mengenai akreditasi RS sebagaimana
dimaksud pada ayat (1), & ayat (2) diatur dengan Peraturan Menteri.

39. Standar Akreditasi Rumah Sakit KARS
( Indonesia ) yang disempurnakan
Disusun dengan acuan :
1.International Principles for Healthcare Standards,
A Framework of requirement for standards, 3rd Edition December 2007,
International Society for Quality in Health Care / ISQua
2.Joint Commission International Accreditation Standards for Hospitals 3 rd
Edition, 2008
3.Instrumen Akreditasi Rumah Sakit, edisi 2007, Komisi Akreditasi Rumah
Sakit / KARS
4.Standar-standar spesifik lainnya.
2012 Sistem Akreditasi Baru
2012-2014 Lama-Baru Paralel

40. Kerangka Standar Akreditasi Rumah Sakit
I. Kelompok Standar Pelayanan Berfokus pada Pasien
Bab 1. Akses ke Pelayanan dan Kontinuitas Pelayanan (APK)
Bab 2. Hak Pasien dan Keluarga (HPK)
Bab 3. Asesmen Pasien (AP)
Bab 4. Pelayanan Pasien (PP)
Bab 5. Pelayanan Anestesi dan Bedah (PAB)
Bab 6. Manajemen dan Penggunaan Obat (MPO)
Bab 7. Pendidikan Pasien dan Keluarga (PPK)
II. Kelompok Standar Manajemen Rumah Sakit 
Bab 1. Peningkatan Mutu dan Keselamatan Pasien (PMKP)
Bab 2. Pencegahan dan Pengendalian Infeksi (PPI)
Bab 3. Tata Kelola, Kepemimpinan, dan Pengarahan (TKP)
Bab 4. Manajemen Fasilitas dan Keselamatan (MFK)
Bab 5. Kualifikasi dan Pendidikan Staf (KPS)
Bab 6. Manajemen Komunikasi dan Informasi (MKI)
III. Sasaran Keselamatan Pasien Rumah Sakit
Sasaran I : Identifikasi pasien dengan tepat
Sasaran II : Tingkatkan komunikasi yang efektif
Sasaran III : Tingkatkan keamanan obat yang perlu diwaspadai (high-alert)
Sasaran lV : Pastikan tepat-lokasi, tepat-prosedur, tepat-pasien operasi
Sasaran V : Kurangi risiko infeksi terkait pelayanan kesehatan
Sasaran VI : Kurangi risiko pasien jatuh
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41. KESIMPULAN
•Akreditasi JCI merupakan salah satu akreditasi RS
yang bersifat internasional
•Ekpektansi standar meliputi Input,proses dan
outcome
•Lebih dari 300 standar dan lebih dari 1000 kriteria
untuk pengukurannya
•KARS Indonesia dalam proses penyesuaian standar
akreditasi yang mengacu pada a.l standar JCI yang
kan diberlakukan tahun 2012
•Baru 1 RS di Indonesia yang telah lulus akreditasi
JCI pada tahun 2007

42. GARUDA achieve IOSA (Operational Safety Audit )
IOSA is the first global standard to include 8 major aspects of an
airline’s ability to deliver a safe operation,comprise more than 900
standards that an airline is audited to, and in order to achieve
IOSA Registration,