KEPUTUSAN DIREKTUR RUMAH SAKIT UMUM DAERAH BENGKALIS NOMOR /KPTS/I/2017 TENTANG PEMBERLAKUAN PEDOMAN PENGORGANISASIAN KOMITE MEDIK, PEDOMAN KOMITE MEDIK DAN PROGRAM KERJA KOMITE MEDIK DI RUMAH SAKIT UMUM DAERAH BENGKALIS
DIREKTUR RUMAH SAKIT UMUM DAERAH BENGKALIS, Men Menimb imban
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a" ba#$a #$a %a&a %a&am m 'an 'an(a )e )enin( in(a* a*a an m+* m+*+ )e&a )e&a anan nan %i R+ma R+ma# # Sa(i* Sa(i* Um+m Um+m Dae'a Dae'a# # Ben( Ben(a&i a&i- %i)e'& %i)e'&+(a +(an n )ene )ene&en &ena a'a 'an n K.mi*e Me%i( an *e'.'ani-a-i %enan bai( -e-+ai -*an%a' K.mi*e Me%i( '+ma# -a(i* b" ba#$ ba#$a a aa' aa' " ba#$a ba#$a be'%a-a'(a be'%a-a'(an n (.n%i-i (.n%i-i (e)ea$a (e)ea$aian ian %an )embaia )embaian n *+aan %i&a(+(an, -*'+(*+' .'ani-a-i K.mi*e PMKP be'%a-a'(an Ke)+* Ke)+*+-a +-an n Di'e(* Di'e(*+' +' R+ma# R+ma# Sa(i* Sa(i* Um+m Um+m Dae'a Dae'a# # Ben( Ben(a&i a&iN.m. N.m.'' 7/ 7/KP KPTS TS/I /I3/ 3/20 201 1 *en* *en*an an Pemb Pemben en*+ *+(a (an n K.mi K.mi*e *e Penin( Penin(a*an a*an M+*+ %an Ke-e&am Ke-e&ama*an a*an Pa-ien %i R+ma# R+ma# Sa(i* Sa(i* Um+m Dae'a# Ben(a&i- )e'&+ %i+ba# %" ba#$ ba#$a a be'% be'%aa-a' a'(a (an n )e'* )e'*im imba ban nan an -eba -ebaa aim iman ana a %ima %ima((-+% +% %a&am #+'+4 a, b %an , )e'&+ %i*e*a)(an %enan Ke)+*+-an Di'e(*+' R+ma# Sa(i* Um+m Dae'a# Ben(a&i-"
Menina*
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1" Un%an5Un%an N.m.' Ke%.(*e'an
2 Ta#+n 2006 *en*an P'a(*i(
2" Un%an5Un%an Un%an5Un%an N.m.' Ta# Ta#+n +n 200 200 *en*an *en*an Ke-e#a*an Ke-e#a*an " Un%an5Un%an Un%an5Un%an N.m.' N.m.' 66 Ta#+n a#+n 200 *en*an R+ma# Sa(i* Sa(i* 6" Un%an n%an5 5Un Un%a %an n N.m. N.m.'' Ta#+n #+n 2016 2016 *en* *en*an an Tenaa naa Ke-e#a*an 8" Pe'a* Pe'a*+'a +'an n Men*e Men*e'i 'i Ke-e# Ke-e#a*a a*an n N.m.' N.m.' 8 Ta#+n 2016 *en*an *en*an K&a-i4i(a-i %an Pe'i9inan R+ma# Sa(i* " Ke)+*+Ke)+*+-an an Men*e'i Men*e'i Ke-e#a* Ke-e#a*an an N.m.' 772/Men(e 772/Men(e-/SK -/SK/:I/ /:I/2002 2002 *en*an Pe%.man Pe'a*+'an In*e'na& R+ma# Sa(i* ; Hospital By Laws< Laws< 7" Ke)+*+Ke)+*+-an an Men*e'i Men*e'i Ke-e#a* Ke-e#a*an an N.m.' 1/Men(e 1/Men(e-/SK -/SK/I:/ /I:/2008 2008 *en*an Pe%.man Pe'a*+'an In*e'na& S*a4 Me%i- ; Medical Staff Bylaws< Bylaws< %i R+ma# Sa(i* =" Ke)+ Ke)+*+ *+-a -an n Men* Men*e' e'ii Ke-e Ke-e#a #a*a *an n Re)+ Re)+b& b&i( i( In%. In%.ne ne-i -ia a N.m. N.m.' ' 12/Men 12/Men(e-/ (e-/Pe'/ Pe'/III/2 III/200= 00= *en*an *en*an S*an%a' S*an%a' Pe&aan Pe&aanan an Minima& Minima&
R+ma# Sa(i* " Pe'a*+'an Dae'a# Kab+)a*en Ben(a&i- N.m.' 02 Ta#+n 2012 *en*an O'ani-a-i %an Ta*a Ke'>a In-)e(*.'a*, Ba%an Pe'enanaan Pemban+nan Dae'a# %an Lembaa Te(niDae'a# Kab+)a*en Ben(a&i- 10"Pe'a*+'an B+)a*i Ben(a&i- N.m.' 28 Ta#+n 2016 *en*an S*an%a' Pe&aanan Minima& R+ma# Sa(i* Um+m Dae'a# Ben(a&i-" MEMUTUSKAN Mene*a)(a n
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KEPUTUSAN DIREKTUR RUMAH SAKIT UMUM DAERAH BENGKALIS TENTANG KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN DI RUMAH SAKIT UMUM DAERAH BENGKALIS"
KESATU
!
Memben*+( K.mi*e Penin(a*an M+*+ %an Ke-e&ama*an Pa-ien %i R+ma# Sa(i* Um+m Dae'a# Ben(a&i- %enan -+-+nan -ebaaimana *e'&am)i' %a&am (e)+*+-an ini"
KEDUA
!
T+a-, $e$enan %an *an+n >a$ab K.mi*e Penin(a*an M+*+ %an Ke-e&ama*an Pa-ien R+ma# Sa(i* Um+m Dae'a# Ben(a&i%i+'ai(an %a&am &am)i'an (e)+*+-an ini"
KETIGA
!
Pa%a -aa* be'&a(+na (e)+*+-an ini, ma(a Ke)+*+-an Di'e(*+' RSUD Ben(a&i- N.m.' 7/KPTS/I3/201 *en*an Pemben*+(an K.mi*e Penin(a*an M+*+ %an Ke-e&ama*an Pa-ien %iab+* %an %ina*a(an *i%a( be'&a(+"
KEEMPAT
!
Sea&a biaa an *imb+& +n*+( )e&a(-anaan an %ima(-+% %a&am Di(*+m (e-a*+ %an (e%+a (e)+*+-an ini %ibeban(an )a%a Ana'an Pen%a)a*an %an Be&an>a Dae'a# R+ma# Sa(i* Um+m Dae'a# Ben(a&i- -e'*a -+mbe' )embiaaan R+ma# Sa(i* &ainna -e-+ai (e*en*+an"
KELIMA
!
Ke)+*+-an ini be'&a(+ -e>a( *ana& %i*e*a)(anna, %an a)abi&a %i (em+%ian #a'i *e'na*a *e'%a)a* (e(e&i'+an %a&am )ene*a)an ini a(an %ia%a(an )e'bai(an -ebaaimana me-*ina"
Di*e*a)(an %i Ben(a&i)a%a *ana& O(*.be' 201 P&*" DIREKTUR RUMAH SAKIT UMUM DAERAH BENGKALIS
H" SUHEIR? @EIN, SE Pembina U*ama M+%a NIP" 160106 1201 1 001
LAMPIRAN I
! KEPUTUSAN DIREKTUR RSUD BENGKALIS NOMOR ! / KPTS /X/!"# TANGGAL ! O(*.be' 201
STRUKTUR ORGANISASI KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN RUMAH SAKIT UMUM DAERAH BENGKALIS
DIREKTUR
Ketua Komite PMKP Wakil Ketua
Sekretaris
Ketua Subkomite Peningkatan Ketua Mutu Subkomite Manajemen Risiko dan Keselamatan
Koordinator Mutu Manajemen
Koordinator Manajemen Risiko
Koordinator Mutu Klinik
Koordinator Keselamatan Pasien
Koordinator Mutu Unit Kerja
Koordinator Pendidikan dan Pelatihan
P&*" DIREKTUR RUMAH SAKIT UMUM DAERAH BENGKALIS
H" SUHEIR? @EIN, SE Pembina U*ama M+%a NIP" 160106 1201 1 001
LAMPIRAN II !
KEPUTUSAN DIREKTUR RSUD BENGKALIS NOMOR ! / KPTS /X/!"# TANGGAL ! O(*.be' 201
SUSUNAN ANGGOTA KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN RUMAH SAKIT UMUM DAERAH BENGKALIS
Ke*+a a(i& Ke*+a Se('e*a'i-
! %'" Ri*a A-*'iani N.ia*i, M"KM, MH"Ke! %'" H>" Rima B+%ia'*i ! S'i a#+ni, AMK
Ke*+a S+b(.mi*e Penin(a*an M+*+
! %'" Ce'nan%., S)"A, MPH, M"Ke-
1" K..'%ina*.' M+*+ Mana>emen An.*a
! In%a S+a'-i, SKM ! D+ma Sa'i L+bi-, M"Keb" ! De-i Mi-ma&eni, SKM
2" K..'%ina*.' M+*+ K&ini( An.*a
! %'" An%a'i Maa-a'i ! %'" Cemm)+*'i A%em+(#&i! N+'9ana, AMK ! Si&ia An'aini, AMKG
" K..'%ina*.' M+*+ Uni* Ke'>a An.*a
! N-" Mai'ina AS, S"Ke) ! Li-e i%a, AMK ! De$i A)nima&ia, AMK
Ke*+a S+b(.mi*e Mana>emen Ri-i(. %an Ke-e&ama*an Pa-ien! %'" Neni Ha'*a*i, S)OG 1" K..'%ina*.' Mana>emen Ri-i(. An.*a
! %'" Ra%#i*a De$i'ia-*+*i, S)PD ! %'" S'i An'aini ! N-" N+'#i%aa*i, S"Ke)
2" K..'%ina*.' Ke-e&ama*an Pa-ien An.*a
! N-" S+na'ia#, S"Ke) ! N-" Di-ma$a*i, S"Ke) ! Ha%i S+'.n., SKM
" K..'%ina*.' Pen%i%i(an %an Pe&a*i#an An.*a
! N-" Me& A4'i9a, S"Ke) ! Lia Anina, Am%"Keb
P&*" DIREKTUR RUMAH SAKIT UMUM DAERAH BENGKALIS
H" SUHEIR? @EIN, SE Pembina U*ama M+%a NIP" 160106 1201 1 001
LAMPIRAN III ! KEPUTUSAN DIREKTUR RSUD BENGKALIS NOMOR ! / KPTS /X/!"# TANGGAL ! O(*.be' 201
URAIAN TUGAS KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN RUMAH SAKIT UMUM DAERAH BENGKALIS I.KETUA KOMITE PMKP Uraian Tugas 1" Membe'i(an )e'*imbanan (e)a%a Di'e(*+' %a&am #a& )enin(a*an m+*+ %an (e-e&ama*an )a-ien" 2" Memb+a* 'ananan (ebi>a(an " 6" 8" "
%an
-*an%a'
)'.-e%+'
.)e'a-i.na&
)enin(a*an m+*+ %an (e-e&ama*an )a-ien '+ma# -a(i*" Men+-+n )e%.man )enin(a*an m+*+ %an (e-e&ama*an )a-ien" Men+-+n )'.'am )enin(a*an m+*+ %an (e-e&ama*an )a-ien" Men+-+n )'.'am mana>emen 'i-i(." Me&a(-ana(an -.-ia&i-a-i (ebi>a(an, )an%+an, )'.'am %an -*an%a'
)'.-e%+' .)e'a-i.na& )enin(a*an m+*+ %an (e-e&ama*an )a-ien" 7" Be')a'*i-i)a-i %a&am )'.-e- )emi&i#an in%i(a*.' an %i&a(-ana(an .&e# Di'e(*+'" =" Menea&+a-i )e&a(-anaan 8 ;&ima< a'ea )'i.'i*a- an -+%a# %i*e*a)(an .&e# Di'e(*+' %enan 4.(+- +*ama )a%a )en+naan PPK %an clinical pathway. " Me&a(+(an (..'%ina-i %an in*e'a-i (eia*an )en+(+'an in%i(a*.' m+*+ %i -e&+'+# '+ma# -a(i*" 10" Me&a(+(an (..'%ina-i %a&am -i-*em )e&a).'an (e>a%ian (e-e&ama*an )a-ien %an )en+(+'an b+%aa (e-e&ama*an )a-ien +n*+( mem4a-i&i*a-i -.&+-i %an )e'bai(an an *e'in*e'a-i" 11" Me&a(+(an bimbinan/)embinaan %an (..'%ina-i %enan +ni*5+ni* (e'>a %a&am #a& )enin(a*an m+*+ %an (e-e&ama*an )a-ien" 12"Mem.ni*.', menea&+a-i, %an memb+a* &a).'an )e&a(-anaan
)'.'am
)enin(a*an m+*+ %an (e-e&ama*an )a-ien 1" Me&a(-ana(an %i-emina-i in4.'ma-i menenai m+*+ %an (e-e&ama*an )a-ien, be(e'>a-ama %enan +ni* (e'>a *e'(ai*" 16"Men(..'%ini' 'a)a* (..'%ina-i %enan +ni* (e'>a *e'(ai*" 18"Men+-+n (eb+*+#an )e&a*i#an5)e&a*i#an an *e'(ai* %enan )enin(a*an m+*+ %an (e-e&ama*an )a-ien" 1"Me&a(-ana(an (..'%ina-i %enan +ni*5+ni* *e'(ai* %a&am #a& )enin(a*an m+*+ %an (e-e&ama*an )a-ien"
II.
WAKIL KETUA KOMITE PMKP Uraian Tugas Memban*+ Ke*+a K.mi*e Penin(a*an M+*+ %an Ke-e&ama*an Pa-ien %a&am!
1" Memb+a* 2" " 6" 8"
'ananan
(ebi>a(an
%an
-*an%a'
)'.-e%+'
.)e'a-i.na&
)enin(a*an m+*+ %an (e-e&ama*an )a-ien '+ma# -a(i*" Men+-+n )e%.man )enin(a*an m+*+ %an (e-e&ama*an )a-ien" Men+-+n )'.'am )enin(a*an m+*+ %an (e-e&ama*an )a-ien" Men+-+n )'.'am mana>emen 'i-i(." Me&a(-ana(an -.-ia&i-a-i (ebi>a(an, )an%+an, )'.'am %an -*an%a'
)'.-e%+' .)e'a-i.na& )enin(a*an m+*+ %an (e-e&ama*an )a-ien" " Be')a'*i-i)a-i %a&am )'.-e- )emi&i#an in%i(a*.' an %i&a(-ana(an .&e# )im)inan '+ma# -a(i*" 7" Me&a(+(an (..'%ina-i %an in*e'a-i (eia*an )en+(+'an in%i(a*.' m+*+ %i -e&+'+# '+ma# -a(i*" =" Me&a(+(an (..'%ina-i %a&am -i-*em )e&a).'an (e>a%ian (e-e&ama*an )a-ien %an )en+(+'an b+%aa (e-e&ama*an )a-ien +n*+( mem4a-i&i*a-i -.&+-i %an )e'bai(an an *e'in*e'a-i" " Me&a(+(an bimbinan/)embinaan %an (..'%ina-i %enan +ni*5+ni* (e'>a %a&am #a& )enin(a*an m+*+ %an (e-e&ama*an )a-ien" 10"Mem.ni*.', menea&+a-i, %an memb+a* &a).'an )e&a(-anaan
)'.'am
)enin(a*an m+*+ %an (e-e&ama*an )a-ien" 11" Me&a(-ana(an %i-emina-i in4.'ma-i menenai m+*+ %an (e-e&ama*an )a-ien, be(e'>a-ama %enan +ni* (e'>a *e'(ai*" 12"Men(..'%ini' 'a)a* (..'%ina-i %enan +ni* (e'>a *e'(ai*" 1"Men+-+n (eb+*+#an )e&a*i#an5)e&a*i#an an *e'(ai* %enan )enin(a*an m+*+ %an (e-e&ama*an )a-ien" 16"Me&a(-ana(an (..'%ina-i %enan +ni*5+ni* *e'(ai* %a&am #a& )enin(a*an m+*+ %an (e-e&ama*an )a-ien" III.
SEKRETARIS KOMITE PMKP Uraian Tugas 1" Me'e(a)i*+&a-i -e&+'+# Keia*an K.mi*e PMKP 2" Mem4a-i&i*a-i -e&+'+# (eia*an K.mi*e PMKP " Mena*+' 'a)a* %an >a%$a& 'a)a* K.mi*e PMKP 6" Menia)(an '+an 'a)a* %an )e'&en(a)an an %i)e'&+(an 8" Men>a%i n.*+&en %i -e*ia) (eia*an )e'*em+an K.mi*e PMKP " Memban*+ memin*a &a).'an in%i(a*.' (e)a%a +ni* (e'>a *e'(ai* 7" Men%.(+men*a-i(an #a-i& )ena)aian in%i(a*.' a'ea (&ini-, mana>e'ia& %an in%i(a*.' -a-a'an (e-e&ama*an )a-ien =" Menana&i-i- %a*a PMKP be'-ama (e*+a %an an.*a K.mi*e PMKP " Memb+a* )e'enanaan ana'an (eia*an 10" Me'e(a)i*+&a-i La).'an Ta#+nan 11" Mene'ima, meninen*a'i-i' %an menin4.'ma-i(an -+'a* ma-+( (e)a%a Ke*+a K.mi*e Penin(a*an M+*+ %an Ke-e&ama*an Pa-ien" 12"Mena'-i)(an -+'a* ma-+(, mena*a* -+'a* (e&+a' %enan *e'*ib %an *e'a*+'"
1"Mene*i( -+'a* %an -e&+'+# (eia*an an %i)e'&+(an K.mi*e M+*+ %an Ke-e&ama*an Pa-ien" 16" Memb+a* )e'enanaan )ema(aian ATK -e*ia) *a#+n" 18"Memb+a* %a4*a' inen*a'i- ba'an" IV.
KETUA SUBKOMITE PENINGKATAN MUTU Uraian Tugas 1" Men+-+n 'ananan )'.'am )enin(a*an m+*+ RSUD Ben(a&i- ;*in(a* '+ma# -a(i*/corporate<" 2" Men+-+n )an%+an in%i(a*.' m+*+ " Memban*+ +ni*5+ni* (e'>a %a&am men+-+n )'.'am )enin(a*an m+*+ %i +ni* (e'>ana ma-in5ma-in" 6" Memb+a* me*.%e )eman*a+an in%i(a*.' m+*+ 8" Menia)(an ba#an +n*+( )enen*+an in%i(a*.'5in%i(a*.' m+*+" " Men+-+n )an%+an )e&a(-anaan a&i%a-i %a*a in*e'na& (#+-+- in%i(a*.' m+*+ 7" Mem4a-i&i*a-i
)en+m)+&
%an
a&i%a*.'
%a*a
%i
+ni*
(e'>a
%a&am
)en+m)+&an %an a&i%a-i %a*a m+*+" =" Mene&ena'a(an (eia*an a&i%a-i #a-i& )ena)aian in%i(a*.' m+*+ be'(..'%ina-i %enan +ni* *e'(ai* " Memb+a* &a).'an #a-i& a&i%a-i in*e'na& (#+-+- in%i(a*.' m+*+ 10"Be'(..'%ina-i %enan +ni* *e'(ai* %a&am )ene&ena'aan )eman*a+an in%i(a*.' m+*+ %an )e&a(-anaan clinical pathway 11" Me&a(-ana(an (.m+ni(a-i -ea'a in*e'na& %an
e(-*e'na&
*en*an
)ena)aian m+*+ %an )e&a(-anaan clinical pathway (e)a%a +ni* (e'>a %i &in(+nan %an )i#a( &+a' me&a&+i -+'a* *e'*+&i-, emai& %an *e&e).n 12"Memban*+ me&a(+(an )e'bai(an m+*+ me&a&+i me*.%a PDSA" 1"Me&a(+(an m.ni*.'in %an ea&+a-i )e&a(-anaan )'.'am )enin(a*an m+*+" 16"Me&a(+(an )e'ban%inan #a-i& )eman*a+an in%i(a*.' m+*+ -ea'a )e'i.%i( %enan -*an%a' na-i.na& -e'*a '+ma# -a(i* &ain an -e>eni18" Men+-+n &a).'an *a#+nan/&a).'an )e&a(-anaan )'.'am )enin(a*an m+*+" 1"Me'anan )e&a*i#an5)e&a*i#an an *e'(ai* %enan )enin(a*an m+*+ 17"Be'(..'%ina-i %enan +ni* *e'(ai* %a&am mem)+b&i(a-i(an #a-i& )ena)aian in%i(a*.' m+*+ an *e&a# %ina*a(an a&i% %an %i'e(.men%a-i .&e# Di'e(*+' 1="Me&a(+(an benchmarking %enan men+na(an #a-i& )ena)aian in%i(a*.' m+*+ an *e&a# %ia&i%a-i %an %i'e(.men%a-i .&e# Di'e(*+' V.
KETUA SUBKOMITE MANAJEMEN RISIKO DAN KESELAMATAN PASIEN Uraian Tugas 1" Men+-+n 'ananan )'.'am mana>emen 'i-i(. %an (e-e&ama*an )a-ien RSUD Ben(a&i- ;*in(a* '+ma# -a(i*/ corporate< 2" Membe'i ma-+(an )a%a Di'e(*+' )en+-+nan Kebi>a(an Ke-e&ama*an Pa-ien RS -e-+ai %enan -*an%a' a('e%i*a-i " Men+-+n in%i(a*.' (e-e&ama*an )a-ien RS
6" Memban*+ +ni*5+ni* (e'>a %a&am men+-+n )'.'am mana>emen 'i-i(. %an (e-e&ama*an )a-ien %i +ni* (e'>ana ma-in5ma-in 8" Memban*+ +ni*5+ni* (e'>a %a&am me&a(+(an mana>emen 'i-i(. me&a&+i &an(a#5&an(a#! 1< i%en*i4i(a-i 'i-i(. 2< mene*a)(an )'i.'i*a- 'i-i(. < )e&a).'an *en*an 'i-i(. 6< )ene&.&aan 'i-i(. 8< ine-*ia-i KTD %an < mana>emen (&aim5(&aim an *e'(ai* " Menin*e'a-i(an -i-*em )e&a).'an
(e>a%ian,
)en+(+'an
b+%aa
(e-e&ama*an ;safety culture measures< %an &ainna +n*+( mem+%a#(an -.&+-i %an )e'bai(an an *e'in*e'a-i" 7" Menana&i-a #a-i& )ena)aian in%i(a*.' (e-e&ama*an )a-ien =" Men(..'%ina-i(an )en%.(+men*a-ian, ea&+a-i %an +)aa *in%a( &an>+* a*a- Ke>a%ian Na'i- e%e'a ;KN< / Ke>a%ian Ti%a( Di#a'a)(an ;KTD< %an Ke>a%ian Sen*ine& " Me&a(-ana(an (..'%ina-i an*a' +ni* bi&a *e'>a%i KTD %an KN 10" Me&a(+(an (..'%ina-i *en*an )'.'am Patient Safety %an mana>emen 'e-i(. %enan +ni* *e'(ai* %a&am )emb+a*an RA %an CMEA 11" Men+-+n &a).'an *a#+nan/&a).'an )e&a(-anaan )'.'am mana>emen 'i-i(. %an (e-e&ama*an )a-ien" 12"I(+* -e'*a me&a(+(an i%en*i4i(a-i %an ana&i-i- (e>a%ian5(e>a%ian an *e'(ai* %enan (e-e&ama*an )a-ien" 1"Me'anan )e&a*i#an5)e&a*i#an an *e'(ai* %enan mana>emen 'i-i(. %an (e-e&ama*an )a-ien" VI.
KOORDINATOR Uraian Tugas Memban*+ ma-in5ma-in Ke*+a S+b(.mi*e %a&am me&a(-ana(an *+a-na"
P&*" DIREKTUR RUMAH SAKIT UMUM DAERAH BENGKALIS
H" SUHEIR? @EIN, SE Pembina U*ama M+%a NIP" 160106 1201 1 001