PERUBAHAN PARADIGMA PELAYANAN DLM AKRED BARU UNTUK

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Transcript of PERUBAHAN PARADIGMA PELAYANAN DLM AKRED BARU UNTUK

In The Making

PERUBAHAN PARADIGMA PADASTANDAR AKREDITASI VERSI 2012

Dr. dr. Sutoto, M.Kes1

DR. dr. SUTOTO, M.KesKetua Eksekutif Komisi Akreditasi Rumah Sakit 2Fakultas Kedokteran Univ Diponegoro (S1)Magister Manajemen RS Univ. Gajahmada (S2) Manajemen Pendidikan Univ Negeri Jakarta (S3) (Cumlaude)

PENDIDIKAN

3Ketua KARS tahun 2014-2018Ketua umum PERSI ( tahun 2009-2012 & tahun 2012-2015)Dewan Pembina MKEK IDI Pusat

Dewan Pembina AIPNI (Asosiasi Institusi Pendidikan Ners Indonesia)Anggota Komite Keselamatan Pasien Rumah Sakit Kementerian Kesehatan R.IDewan Penyantun RS Mata Cicendo, Pusat Mata Nasional

JABATAN SAAT INI4Sesditjen Binyanmed / Plt Dirjen BinYanmed Kemkes R.I. ( Feb- Juli 2010) Surveyor Komisi Akreditasi Rumah Sakit (KARS):Direktur Utama RS Kanker Dharmais Jakarta 2005-2010PENGALAMAN KERJA

Direktur Utama RSUP Fatmawati Jakarta 2001 2005Direktur RSUD Banyumas Jawa Tengah 1992-2001

5PENGALAMAN ORGANISASI

Ketua :IRSPI (Ikatan RS Pendidikan Ind) Th 2005-2008 Ketua :ARSPI (Asosiasi RS Pendidikan Indo-nesia) (2008-2010)Ketua IRSJAM (Ikatan RS Jakarta Metropolitan) 2008-2010

Email : sutotocokro@gmail.comHP : 081381134839

LONDON PHILHARMONIC ORCHESTRA

sutoto-KARS

MAURICE MURPHYLondon Symphony Orchestra selama 30 tahun, ia bermain di soundtrack untuk sekitar 450 film, termasuk Star Wars, Raiders Of The Lost Ark, Superman dan Harry Potter. MENINGGAL DI ROYAL FREE HOSPITAL KARENA DOKTER SALAH MEMASUKKAN NGT

8THE GENESIS OF HARMPERUBAHAN PARADIGMA RUMAH SAKITSTANDAR AKREDITASI BARUTujuan utama Peningkatan mutu dan keselamatan pasienStandar Akreditasi harus dinamisPeran direktur sangat sentralPelayanan berfokus pada pasien Keselamatan Pasien harus diutamakanKesinambungan pelayananPerbaikan terus menerusKepatuhan terhadap SPO

AKREDITASI MEMINTA BUKTI PENERAPAN STANDAR

PENERAPAN STANDAR MENDATANGKAN MANFAAT BAGI PASIEN, RUMAH SAKIT DAN KARYAWANRISIKO MENJADI DREKTUR

MUNGKINKAH SEORANG DOKTER GIGI YANG TAK BISA MELAKUKAN RESUSITASI DITUNTUT PASIEN ??

BRAINDAMAGESebuah keluarga di Hawaii menggugat dokter gigi setelah kunjungan untuk prosedur saluran akar, otak kiri anak tiga tahun mereka mati. Menurut ibu Ashley Boyle, dia hanya memiliki beberapa hari untuk hidup.

Pada 3 Desember, Boyle membawa putrinya Finley ke Pulau Gigi di Kailua untuk menjalani empat saluran akar dari Dr. Lilly Geyer. Sebelum prosedur berlangsung, Finley diberi campuran penenang , termasuk Demerol, analgesik opioid bertindak cepat. Dua puluh enam menit kemudian, gadis muda pergi ke serangan jantung.

Orang tua Finley mengatakan bahwa putri mereka tidak menerima CPR segera .pedoman American Academy of Pediatric Dentistry, tanda-tanda vital harus dipantau dan didokumentasikan setidaknya setiap lima menit untuk pasien di bawah sedasi.

16Standar KPS 8.1. Staf rumah sakit yang memberikan asuhan pasien dilatih dan dapat mendemontrasikan kemampuan dalam teknik resusitasi.

KARS

AKREDITASI RUMAH SAKITDAPATKAH SORANG PETUGAS YANG TIDAK PATUH TERHADAP SPO MEMBUNUH PASIEN ?SASARAN III : PENINGKATAN KEAMANAN OBAT YANG PERLU DIWASPADAI (HIGH-ALERT)

Rumah sakit mengembangkan suatu pendekatan untuk memperbaiki keamanan obat-obat yang perlu diwaspadai (high-alert)Sutoto.KARS19Obat high alert (yang harus diwaspadai): obat yang dapat menimbulkan KTD atau kejadian sentinel bisa salah digunakanKARS

Paralytic agent vs antacidKARS

Uvo Ologboride, the nurse named in the lawsuit, had given Smith pancuronium.The drug, which is typically used during intubations, acts as a muscle relaxant and paralytic.In higher doses, pancuronium is used to administer lethal injections.Thirty minutes later, Smith was found unresponsive.Although doctors were able to revive Richard Smith, he was brain dead.He remained in a vegetative state until he died a month later.The Smith family lawyer, Andrew Yaffa, told ABCNews.com, "This is the worst case of medical neglect I have ever seen."Yaffa, who said he's handled hundreds of hospital death cases in his 22 years as a lawyer, added, "The hospital just seems to be thumbing their nose to this family."The nurse who administered the incorrect medication "is still working there in the exact same unit where the medical error occurred," Yaffa said.Ologboride, who could not be reached by ABCNews.com, has been retrained, and fined, according to ABC News Miami affiliate WPLG.In addition, the hospital has since removed pancuronium from all nursing areas except for the operation room, where the medication will only be handled by anesthesiologists.But that's little consolation for Marc Smith, an EMT, who says, "if we administer the wrong medication and someone dies, that's negligence. That's murder."The stress has taken its toll on his mother, he said, who was married to Richard Smith for 55 years."For the most part, she's making it," he said.The elderly couple had recently taken in two children, a 2 year old and a 10 year old whose parents had died.Ever since Marc Smith was a boy, "My mother and father had taken in a countless number of children who were in bad situations at home or didn't have place to stay," he said."They did it on a teacher's salary, but we never wanted for anything growing up."A report from the Florida Agency for Health Care Administration demonstrated that with all the safeguards in place to prevent a patient from receiving the wrong medication, the nurse would have had to ignore nearly all of the protocol in place for administering drugs.Specifically, the nurse "failed to look and read what medication he was taking failed to scan to determine the right count for the medication, failed to match the patient's ID with the scanned medication."In addition, the report says, the pharmacy wasn't able to show any justification for storing pancuronium in that particular area of the hospital.

21Pancuronium (Pavulon) vs PantoprazoleKARS

Paralytic agent vs antacidBRAIN DAMAGE

APAKAH MUNGKIN SEORANG PETUGAS RS YANG TIDAK MENCUCI TANGAN SEBELUM MEMEGANG PASIEN MENCELAKAKAN PASIEN ?

25

Luka Operasi Terinfeksi MRSA

SETIAP STAF KLINIS HARUS MENCUCI TANGAN SESUAI STANDAR WHO, DAN MENERAPKAN FIVE MOMENT FOR HAND HYGINE

PERMUKAAN YG BIASA TERKONTAMINASI MRSAMARI KITA BENAHI ..STANDAR AKREDITASI NASIONAL VERSI 2012

Akreditasi Dalam UU no 44 tentang RS PASAL 401) Dalam upaya peningkatan mutu pelayanan Rumah Sakit wajib dilakukan akreditasi secara berkala minimal 3 (tiga) tahun sekali 2) Akreditasi Rumah Sakit 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.International Principles for Healthcare Standards, A Framework of requirement for standards, 3rd Edition December 2007, International Society for Quality in Health Care / ISQuaJoint Commission International Accreditation Standards for Hospitals 4 rd Edition, 2011Instrumen Akreditasi Rumah Sakit, edisi 2007, Komisi Akreditasi Rumah Sakit / KARSStandar-standar spesifik lainnya.Sumber Acuan Akreditasi RS Baru32Procedures were laid down for documenting hospitalisation for other illnesses whether cardiac or non-cardiac, and for events requiring the stopping of trial medication. Procedures were also defined for cases of worsening heart failure or renal function. For the former, sequential options included increasing the dose of diuretics, decreasing or discontinuing calcium channel blockers, adjustment of the digoxin dose, increasing the dose of other non-ACE inhibitor vasodilators and increasing the background lisinopril dose from 2.5 to 5 mg. For the latter, decreasing or discontinuing diuretics or calcium channel blockers or non-ACE inhibitor vasodilators was considered together with a decrease in background lisinopril therapy.Detailed procedures also existed for the starting and stopping of trial medication following an acute myocardial infarction. A listing of allowed and disallowed concomitant medication was provided and the procedure for recording serious adverse events was detailed.Kelompok Standar Pelayanan Berfokus pada Pasien

Standar: 161Elemen: 436IStandar Akreditasi RS yang BaruIIIIII VKelompok Standar Manajemen RS

Standar: 153Elemen: 569Sasaran Keselamatan Pasien RS

Standar: 6Elemen: 24Sasaran Milenium Develop-mental Goal

Standar: 3Elemen: 19TOTAL STANDAR : 323 ELEMEN PENILAIAN : 1043

KARS MEMPEROLEH AKREDITASI ISQUA

KOMISI AKREDITASI RUMAH SAKIT SATU-SATU NYA BADAN AKREDITASI YANG MENGAKREDITASI BADAN AKREDITASI PELAYANAN KESEHATAN DI SELURUH DUNIA SEBAGAI INTERNATIONAL ACCREDITATION BODY

BEBERAPA BADAN AKREDITASI DUNIA YANG TELAH MEMPEROLEH PENGAKUAN DARI ISQua

DAN KINI SAATNYA.INDONESIAMAJU KE PANGGUNG INTERNASIONAL

KOMISI AKREDITASI RUMAH SAKITSEBAGAI BADAN AKREDITASI RUMAH SAKIT INTERNASIONAL

HASIL PENILAIAN SURVEIAKREDITASI REGULER4 BAB8 BAB12 BAB15 BAB39HASIL PENILAIAN SURVEIAKREDITASI REGULER4 BAB8 BAB12 BAB15 BABPERDANA

40HASIL PENILAIAN SURVEI AKREDITASI REGULER4 BAB8 BAB12 BAB15 BABPERDANA

INTERNATIONALACCREDITATIONBY KARS41Standar Akreditasi RS yang BaruI. Kelompok Standar Pelayanan Berfokus pada PasienBab 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 SakitBab 1. Peningkatan Mutu dan