Dokumen TKP

TATA KELOLA

TATA KELOLA

DAN

DAN

KEPEMIMPINAN

KEPEMIMPINAN

Dr. Dr. Luwiharsih,MSc Luwiharsih,MSc

luwi-15 maret 2014

luwi-15 maret 2014 22

DOKUMEN

DOKUMEN

AKREDIT

AKREDIT

ASI

ASI

RS

RS

REGULASI SBG

REGULASI SBG

DASAR

DASAR

PELAKSANAAN

PELAKSANAAN

KEGIATAN

KEGIATAN

DOKUMEN

DOKUMEN

BUKTI/PELAKSANAA

BUKTI/PELAKSANAA

N KEGIATAN

N KEGIATAN

3

3

KOMISI AKREDITASI RUMAH SAKIT KOMISI AKREDITASI RUMAH SAKIT

202 202

slide dr djoti

NASIONAL NASIONAL PERATURAN PERUNDANG! PERATURAN PERUNDANG! UNDANGAN UNDANGAN •

• UU "# $$ %ahu" 200&UU "# $$ %ahu" 200&

• • P'ra%ura" (P'ra%ura" ( )'ru"*a"+a" )'ruah )'ru"*a"+a" )'ruah sa-i%a" sa-i%a" RUMAH SAKIT RUMAH SAKIT REGULASI REGULASI • • HBLHBL • • R'"s%raR'"s%ra • • RKA/RBARKA/RBA •

• K'ia-a" P'a1a"a" RSK'ia-a" P'a1a"a" RS • • Pa"*ua"Pa"*ua" P'a1a"a"/SPO P'a1a"a"/SPO UNIT KERA UNIT KERA KETENTUAN TERTULIS KETENTUAN TERTULIS •

• K'ia-a" P'a1a"a"K'ia-a" P'a1a"a"

U"i% K'ra U"i% K'ra • • P'*#a"P'*#a" P'"+#r+a"isasia" P'"+#r+a"isasia" •

• P'*#a" P'a1a"a"P'*#a" P'a1a"a" • • SPOSPO Pr#+ra PMKP Pr#+ra PMKP slide dr djoti slide dr djoti 44

REGULASI

REGULASI

REGULASI

slide dr Djoti 5

ISTILAH

PENGERTIAN

KEBIAK 

AN

Ra"+-aia" -#"s') ( asas 1+ '"a*i

+rs 'sar ( *asar r'"ca"a *

)'a-sa"aa" sua%u )'-'raa",

-')'i)i"a" *a" cara 'r%i"*a- 

PEDOMA

N

Ku)ua" -'%'"%ua" *asar 1+

''ri arah +" s'sua%u harus

*ia-u-a"3 ha )#-#- 1a"+ '"a*i

*asar 4)'+a"+a", )'%u"u-, *s5

u"%u- '"'"%u-a" a%au

REGULASI

slide dr djoti 6

ISTILAH

PENGERTIAN

PANDUAN

4u-u5 )'%u"u- 

STANDAR

PROSEDUR

OPERASION

AL

Sua%u )'ra"+-a% i"s%ru-si/ a"+-ah!2 1a"+ *ia-u-a" u"%u- '"1''sai-a" )r#s's -'ra ru%i" %'r%'"%u.

SPO ''ri-a" a"+-ah 1a"+ '"ar *a" %'rai- 'r*asar-a" -#"s'"sus 'rsaa u"%u- 'a-sa"a-a" 'ra+ai -'+ia%a" *a" 6u"+si )'a1a"a" 1a"+ *iua% #'h sara"a )'a1a"a" -'s'ha%a" 'r*asar-a" s%a"*ar )r#6'si

PIMPINAN

RS

M'"ai" -')a%uha" s%a6 %'rha*a) r'+uasi 1+ *i%'%a)-a" #'h )i)i"a" Pa%uh %'rha*a) )'ra%ura" ( )'ru"*a"+a" RS Sis%' #"'7 %'rha*a) r'+uasi 1+ *i%'%a)-a" )i) luwi-tkp-2062013 M'"'%a)-a" r'+uasi *i RS

luwi-tkp-2062013 Na a sTD P.P 1+ 'r a-u 49/T 5  i-a 9a Naa P.P Ri"+-asa" P.P  Ba+aia"a -ai%a""1a *'"+a" s%a"*ar A)a-ah isi P.P L'ih -'%a% *ari S%a"*ar 4 1a/%i*a- 5 A)a-ah a*a a*a" R'+ua%#r 1a"+ 'a-u-a " i"s)'-si #"!si%' u"%u-'"iai -')a%uha " 'a-sa" a -a" P.P

AKSES KE PELA9ANAN DAN KONTINUITAS PELA9ANAN 4APK5

APK.:.;.

luwi-tkp-2062013 Naa I"s%a"si P''ri"%a h, Ba*a" R'+ua%#r, a%au E7aua%#r 1a"+ 'a-u-a" I"s)'-si/a u*i% s'%')a% 4#"!si%'5  %+  Au *i% S' %' ! Pa % A)a-  ah a*a R'-# '"* asi  9a/Ti *a-   i-a 1a, D')ar%''" a"a 1a"+ %'ri*'"%i<-asi *aa a)#ra" 4=#"%#h, Da)ur, >arasi, Kaar , O)'rasi, La#ra%#riu5 B'ra)a aa *iu%uh-a " '"ca)ai s%a"*ar 4c#"%#h, & hari, ? ua"5 Ka)a" s%a"*ar *ica)ai @ A)a-ah au*i%#r harus -'ai u"%u-7ai*asi *a%a  9a/Ti*a- 

LEMBAR REKOMENDASI BADAN AUDIT EKSTERNAL (EXTERNAL AUDITING BODY)

Komisi Akreditasi Rumah akit E''" P'"iaia" TKP .. TELUSUR SKO R DOKUMEN AARA! "A#$R% . M'r'-a 1a"+ 'r%a"++u"+  awa a%as %a%a

-'#a,

''ri-a"

)'rs'%uua" a%as isi ruah sa-i%

 &impi'a' R • %mpleme'tasi pem(eria' persetujua' misi rumah sakit 0 5 10 Re)ulasi * Kete'tua' di +ospital (,laws - .a') me',etujui /isi da' misi rumah sakit - .a') melakuka' re/iew (erkala - .a') me')umumka' /isi  misi ke pu(lik -Dokume'tasi *  K "isi rumah sakit  Dokume' re/iew (erkala 2. M'r'-a 1a"+ 'r%a"++u"+  awa a%as %a%a

-'#a, '"ai" a*a"1a r'7i'w 'r-aa %'rha*a) isi ruah sa-i%

• &elaksa'aa' re/iew (erkala terhadap misi rumah sakit 0 5 10 :. M'r'-a 1a"+ 'r%a"++u"+  awa a%as %a%a

-'#a,

'"+uu-a" isi ruah sa-i%

• &elaksa'aa'

me')umumka'

misi R ke pu(lik 0 5 10

HOSPITAL B9LAS

•

=#r)#ra%' 1aws

•

M'*ica s%a6 1aws

=ORPORATE B9LAS

•

K'w'"a"+a" )'ii- *a" Dir'-%ur u%aa RS

a+ar *i)'r'as

•

Bia *i aara" )'ii- a*a *'wa" )'"+awas

4RS BLU/BLUD5 a%au P'i"a, )'"+urus,

)'"+awas 49a1asa"5 a%au D'wa" -#isaris

( Dir'-si 4PT5, harus *iurai-a" *'"+a" 'as

a)a -'w'"a"+a""1a.

•

U"%u- 'iha% -'w'"a"+a" a)a 1a"+ )'ru

*ia%ur a-a iha% TKP . s* TKP .;

Komisi Akreditasi Rumah akit

TKP . s* .;

Komisi Akreditasi Rumah akit

STANDAR PEMILI K  DIRUT RS KET E''" P'"iaia" TKP ..

. M'r'-a 1a"+ 'r%a"++u"+  awa a%as %a%a -'#a, ''ri-a" )'rs'%uua" a%as isi ruah sa-i%



2. M'r'-a 1a"+ 'r%a"++u"+  awa a%as %a%a -'#a, '"ai" a*a"1a r'7i'w

'r-aa %'rha*a) isi

ruah sa-i%

 

:. M'r'-a 1a"+ 'r%a"++u"+  awa a%as %a%a -'#a,

'"+uu-a" isi

ruah sa-i% -' )ui-.

TKP . s* .;

Komisi Akreditasi Rumah akit

STANDAR PEMIL IK  DIRU T RS KE T E''" P'"iaia" TKP .2.

. M'r'-a 1a"+ 'r%a"++u"+ awa

a%as %a%a -'#a, ''ri-a"

)'rs'%uua" a%as r'"ca"a s%ra%'i-*a" r'"ca"a a"a''" ruah sa-i%, au)u" -'ia-a" *a" )r#s'*ur #)'rasi#"a

 

2. Bia -'w'"a"+a" u"%u- ''ri-a" )'rs'%uua" *i*''+asi-a", a-a ha i"i *iaar-a" *aa -'ia-a" *a" )r#s'*ur %'"%a"+ %a%a -'#a

Ke(ijaka' 

pe'dele)asia' kewe'a')a' :. M'r'-a 1a"+ 'r%a"++u"+ awa

a%as %a%a -'#a, ''ri-a"

)'rs'%uua" a%as s%ra%'+i ruah sa-i% *a" )r#+ra 1a"+ %'r-ai% *'"+a"

TKP . s* .;

Komisi Akreditasi Rumah akit

STANDAR PEMIL IK  DIRUT RS KET E''" P'"iaia" TKP .:.

. M'r'-a 1a"+ 'r%a"++u"+ awa

a%as %a%a -'#a, ''ri-a"

)'rs'%uua" a%as #*a 4ca)i%a5 *a" a"++ara" #)'rasi#"a ruah sa-i%



2. M'r'-a 1a"+ 'r%a"++u"+ awa a%as %a%a -'#a, '"+a#-asi-a" su'r *a1a 1a"+ *iu%uh-a" u"%u- '"ca)ai isi ruah sa-i%

TKP . s* .;

Komisi Akreditasi Rumah akit

STANDAR PEMI LIK  DIRUT RS KET E''" P'"iaia" TKP .$.

. M'r'-a 1a"+ 'r%a"++u"+

 awa a%as %a%a -'#a,

'"'%a)-a" a"a'r s'"i#r ruah sa-i%



2. M'r'-a 1a"+ 'r%a"++u"+

 awa a%as %a%a -'#a,

'a-u-a" '7auasi -i"'ra *ari a"a'r s'"i#r ruah sa-i%



:. E7auasi %'rha*a) a"a'r

s'"i#r *ia-sa"a-a" )ai"+ s'*i-i% s'%ahu" s'-ai

TKP . s* .;

Komisi Akreditasi Rumah akit

STANDAR PEMIL IK  DIRUT RS KET E''" P'"iaia" TKP .;.

. M'r'-a 1a"+ 'r%a"++u"+ awa a%as %a%a -'#a, ''ri-a" )'rs'%uua" a%as r'"ca"a ruah

sa-i% u"%u- u%u *a"

-'s'aa%a" )asi'". 4iha% u+a PMKP., Ma-su* *a" Tuua"5



. M'r'-a 1a"+ 'r%a"++u"+ awa a%as %a%a -'#a, s'cara %'ra%ur '"'ria *a" '"i"*a-a"u%i a)#ra" %'"%a"+ )r#+ra u%u *a" -'s'aa%a" )asi'". 4iha%  u+a PMKP..$, EP 25

PIMPINAN DEPARTEMEN /

UNIT ( PELA9ANAN

D$&AR#$"$!!%#%!#AA

%

etiap departeme'u'it kerja i'stalasi

a)ar me',usu' dokume' s(( *

1 Ke(ijaka' &ela,a'a'

2 &edoma' pe')or)a'isasia'

3 &edoma' pela,a'a'

4 &a'dua' pela,a'a'



 &

5 &ro)ram &"K&

PEDOMAN

PENGORGANISASIAN

I. P'"*ahuua"

II. Gaara" uu RS

III. isi, Misi, >asa6ah, Niai ( Tuua" RS

I. S%ru-%ur #r+a"isasi RS

. S%ru-%ur #r+a"isasi u"i% -'ra

I. Uraia" aa%a"



 )'rs1ara%a" aa%a"

II.Ta%a huu"+a" -'ra

III.P#a -'%'"a+aa" *a" -uai<-asi )'rs#"i

IC. K'+ia%a" #ri'"%asi

C. P'r%'ua"/ra)a%

CI. P'a)#ra"

PEDOMAN PELA9ANAN UNIT KERA

I. P'"*ahuua"

. La%ar 'a-a"+ 2. Tuua" P'*#a"

:. Rua"+ Li"+-u) P'a1a"a" $. Ba%asa" O)'rasi#"a

;. La"*asa" hu-u II. S%a"*ar K'%'"a+aa"

. Kuai<-asi SDM

2. Dis%riusi K'%'"a+aa" :. P'"+a%ura" a+a

III. S%a"*ar 6asii%as . D'"ah rua"+a" 2. S%a"*ar 6asii%as

PEDOMAN PELA9ANAN UNIT KERA

I.Ta%a a-sa"a )'a1a"a"

.L#+is%i- 

I.K's'aa%a" Pasi'"

II.K's'aa%a" K'ra

III.P'"+'"*aia" Mu%u

IC.P'"u%u)

luwi-tkp-2062013

PANDUAN PELA9ANAN

•

% D$%!%%

•

%% RA!8 %!8K&

•

%%% #A#A AKA!A

•

% DK"$!#A%

luwi-tkp-2062013

INSTALASI/DEPARTEMEN/U

NIT

Komisi Akreditasi Rumah akit

STANDAR PEDOM AN PENGOR GA NISASIA N PEDOM AN PELA9A NAN PANDUA N PELA9A NAN/ SPO LAIN !2 S%a"*ar TKP.;.

Sa%u a%au 'ih i"*i7i*u 1a"+ -#)'%'" '"+a%ur %ia) *')ar%''" / u"i% a%au )'a1a"a" *i ruah sa-i%

E''" P'"iaia" TKP.;.

. S'%ia) *')ar%''"/u"i% a%au )'a1a"a" *i ruah sa-i% *i)i)i" #'h s'#ra"+ *'"+a" )'a%iha", )'"*i*i-a", *a" )'"+aaa" 1a"+ s'%ara *'"+a" )'a1a"a" 1a"+ *i'ri-a". 4iha% u+a AP.;., EP3 AP.?., EP 3 *a" MPO.., EP 5

9

2. Bia 'ih *ari sa%u #ra"+ ''ri-a" araha"/)'%u"u-, a-a %a"++u"+ awa asi"+!asi"+ *iaar-a" s'cara %'r%uis.

INSTALASI/DEPARTEMEN/U

NIT

Komisi Akreditasi Rumah akit

STANDAR PEDOM AN PENGOR GA NISASIA N PEDOMA N PELA9AN AN PANDUA N PELA9AN AN/ SPO LAIN! 2 S%a"*ar TKP.;..

Pi)i"a" *ari s'%ia) *')ar%''" -i"is 'a-u-a" i*'"%i<-asi s'cara %'r%uis %'"%a"+ )'a1a"a" 1a"+ *i'ri-a" #'h *')ar%''""1a.

E''" P'"iaia" TKP.;.. . Pi)i"a" *')ar%''"

a%au )'a1a"a" 'iih *a" '"++u"a-a" 6#ra% *a" isi 1a"+ s'ra+a

& pere':a'

INSTALASI/DEPARTEMEN/UNIT

Komisi Akreditasi Rumah akit

STANDAR PEDOMA N ORG PEDOMAN PELA9ANA N PANDUAN  9AN/ SPO LAIN!2 S%a"*ar TKP.;.. E''" P'"iaia" TKP.;..

2. D#-u'" *')ar%''" a%au )'a1a"a" '"+urai-a" %'"%a"+ )'a1a"a" saa% i"i *a" 1a"+ *ir'"ca"a-a" 1a"+ *i'ri-a" #'h s'%ia) *')ar%''" a%au )'a1a"a"

9 9

:. K'ia-a" *a" )r#s'*ur *ari s'%ia) *')ar%''" a%au )'a1a"a" '"+arah-a" )''ria" )'a1a"a" 1a"+ *i%'%a)-a"

9 9

$. K'ia-a" *a" )r#s'*ur *ari s'%ia) *')ar%''" a%au )'a1a"a" '"+a%ur )'"+'%ahua" *a" -'%'ra)ia" s%a6 1a"+ *i)'ru-a" u"%u- 'a-u-a"

INSTALASI/DEPARTEMEN/U

NIT

Komisi Akreditasi Rumah akit

STANDAR PEDOMA N PENGOR GA NISASIA N PEDOMA N PELA9AN AN PANDUA N PELA9AN AN/ SPO LAIN!2 S%a"*ar TKP.;.2. Pi)i"a" 'r'-#'"*asi-a" rua"+a", )'raa%a", s%a6, *a" su'r *a1a ai" 1a"+ *iu%uh-a" #'h *')ar%''" a%au )'a1a"a"

E''" P'"iaia" TKP.;.2. . Pi)i"a"

'r'-#'"*asi-a" rua"+a" 1a"+ *iu%uh-a" u"%u-''ri-a" )'a1a"a"

9

2. Pi)i"a"

'r'-#'"*asi-a"

-'u%uha" )'raa%a" 1a"+ *iu%uh-a"

INSTALASI/DEPARTEMEN/U

NIT

Komisi Akreditasi Rumah akit

STANDAR PEDOMA N PENGOR GA NISASIA N PEDOMAN PELA9ANA N PANDUAN PELA9AN AN/ SPO LAIN!2 S%a"*ar TKP.;.2. Pi)i"a" 'r'-#'"*asi-a" rua"+a", )'raa%a", s%a6, *a" su'r *a1a ai" 1a"+ *iu%uh-a" #'h *')ar%''" a%au )'a1a"a"

E''" P'"iaia" TKP.;.2.

2. Pi)i"a" 'r'-#'"*asi-a"  uah *a" -uai<-asi s%a6 1a"+ *iu%uh-a" u"%u-''ri-a" )'a1a"a" 4iha%  u+a AP.?.:, EP ;5

9

$. Pi)i"a" 'r'-#'"*asi-a" su'r *a1a -husus ai""1a 1a"+ *iu%uh-a"

INSTALASI/DEPARTEMEN/U

NIT

Komisi Akreditasi Rumah akit

STANDAR PEDOMAN PENGORG A NISASIAN PEDOMAN PELA9ANAN PANDUAN PELA9ANA N/ SPO LAIN!2 S%a"*ar TKP.;.:. Pi)i"a" 'r'-#'"*asi-a" -ri%'ria u"%u- '"s''-si s%a6 )r#6'si#"a *i *')ar%''" a%au )'a1a"a" *a" 'iih a%au 'r'-#'"*asi-a" #ra"+!#ra"+ 1a"+ ''"uhi -ri%'ria %'rs'u%. E''" P'"iaia" TKP.;.:.

. Pi)i"a" '"+'a"+-a" -ri%'ria 1a"+ %'r-ai% *'"+a" )'"*i*i-a", -'%'ra)ia", )'"+'%ahua" *a" )'"+aaa" 1a"+ *iu%uh-a" s%a6 )r#6'si#"a *i *')ar%''"

9 9

2. Pi)i"a" '"++u"a-a" -ri%'ria %'rs'u% )a*a wa-%u 'a-u-a" s''-si s%a6 a%au 'r'-#'"*asi-a" s%a6 )r#6'si#"a

INSTALASI/DEPARTEMEN/U

NIT

Komisi Akreditasi Rumah akit

STANDAR PEDOMA N PENGOR GA NISASIA N PEDOMA N PELA9AN AN PANDUA N PELA9AN AN/ SPO LAIN! 2 S%a"*ar TKP.;.$ Pi)i"a" ''ri-a" #ri'"%asi *a" )'a%iha" a+i s'ua s%a6 1a"+ 'r%u+as *a" 'r%a"++u"+ awa *i *')ar%''" a%au *i )'a1a"a" *ia"a 'r'-a *i%u+as-a".

E''" P'"iaia" TKP.;.$.

. Pi)i"a" '"'%a)-a" )r#+ra #ri'"%asi a+i s%a6 *i *')ar%''" 1a"+ *i*#-u'"%asi-a". 4iha%  u+a KPS.3 AP.;., EP ;, *a"

AP.?.2, EP ?5

INSTALASI/DEPARTEMEN/U

NIT

Komisi Akreditasi Rumah akit

STANDAR PEDOMA N PENGOR GA NISASIA N PEDOMAN PELA9AN AN PANDUA N PELA9AN AN/ SPO LAIN!2 S%a"*ar TKP.;.;.

Pi)i"a" 'a-u-a" '7auasi -i"'ra *')ar%''" a%au )'a1a"a" *a" -i"'ra s%a6"1a. E''" P'"iaia" TKP.;.;.

. Pi)i"a" 'a-sa"a-a" )'"+u-ura" u%u 4Fuai%1 'asur's5 1a"+ '"+a%ur )'a1a"a" 1a"+ *i'ri-a" *aa *')ar%''" a%au )'a1a"a" %'rasu- -ri%'ria a5 sa)ai *5 *i Ma-su* *a" Tuua" 1a"+ s'suai *'"+a" *')ar%''" )'a1a"a" %'rs'u%

INSTALASI/DEPARTEMEN/U

NIT

Komisi Akreditasi Rumah akit

STANDAR PEDOMA N PENGOR GA NISASIA N PEDOMAN PELA9AN AN PANDUA N PELA9AN AN/ SPO LAIN!2 S%a"*ar TKP.;.;.

Pi)i"a" 'a-u-a" '7auasi -i"'ra *')ar%''" a%au )'a1a"a" *a" -i"'ra s%a6"1a. E''" P'"iaia" TKP.;.;.

:. Pi)i"a" 'a-sa"a-a" )r#+ra )'"+'"*aia" u%u a)aia *iu%uh-a"

9

$. Pi)i"a" *')ar%''" a%au )'a1a"a" *i'ri-a" *a%a *a" i"6#rasi 1a"+ *iu%uh-a" u"%u- '"+'#a *a" '"i"+-a%-a" asuha" *a" )'a1a"a"

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• &a'dua'& ko'trak  #K& 331

• etiap departeme'u'it kerja i'stalasi a)ar me',usu' dokume'

s(( >#K& 5 sd 55? * 1 Ke(ijaka' &ela,a'a' 2 &edoma' pe')or)a'isasia' 3 &edoma' pela,a'a' 4 &a'dua' pela,a'a'& 5 &ro)ram &"K&

•. "a'ajeme' etik >#K& 6 sd 62?