MOCK SURVEY AGENDA FOR RSUP Dr.

HASAN SADIKIN BANDUNG

CONDUCTED BY RSUP Dr. KARIADI SEMARANG, 12-14 SEPTEMBER 2018

DAY ONE (WEDNESDAY, 12-09-2018)

Sri Yuniarti Rahayu
Agoes Oerip Purwoko Sri Widayati Eko Sadono Nunung RD Kusumawati
TIME Administrator
Physician Surveyour Nurse Surveyour Administrator Surveyour Physician Surveyour
Surveyour
08:00-08:30 Opening Conference and Agenda Review

Participants:
Direksi, Dewas, Dekan, Ka. SPI/Komite Ka. KSM/Dep., Ka. Instalasi, Ka. Bag/Bid., Koord. Pokja

Venue:
R. Sidang RSHS

Note Taker:
1. Ina Teja Resmi, S.Kep., Ners (082321533846)
2. Shanty WUlandari, S.Kep.,Ners (082214655124)
08:30-09:15 Orientation to the Organization’s Services
Participants:
Direksi, Dewas, Dekan, Ka. SPI/Komite Ka. KSM/Dep., Ka. Instalasi, Ka. Bag/Bid., Koord. Pokja

Venue:
R. Sidang RSHS

PIC
1. Dr. Iwan Abdul Rachman, Sp.An., KNA M.Kes.
2. Dr. Dian Tjahyadi, SpOG(K).,MMRS
3. Drs. Iman Sudradjat, MKM

Note Taker:
1. Alia Rahmi Harlasgunawan, S.Kep.,Ners (082142105616)
 2. Henny Febriyanti S., A.Md.Kep (082295450001)
09:15-10:15
Leadership for Quality and Patient Safety – and Culture of Safety and Ethical Framework Interview

Participants:
1. Direktur Utama
2. Para Direktur (Direktur Medik dan Keperawatan, Direktur SDM dan Pendidikan, Direktur Umum dan Operasional)
3. Dewan Pengawas
4. Para Ketua Komite ( Etik dan Hukum, Medik, Mutu dan KP, Etik Penelitian, Komkordik, Keperawatan, PPI, Tenaga Kes. Lain)
5. Kepala Bagian Pendidikan dan Penelitian
6. Kepala Bidang Medik
7. Kepala Bidang Keperawatan
8. Kepala KSM/Dep. Bedah, Penyakit Dalam, Obgin dan Anak

Venue:
Ruang Sidang

PIC
1. Dr. dr.Tono Djuwantono,Sp.OG(K)
2. Dr. Dian Tjahyadi, SpOG(K).,MMRS
3. Dr. dr. Hadi Susiarno, Sp.OG(K)., MH.Kes
4. Fatrisia Madina, S.Kp., MM
5. dr.Bambang AmAm Setya Sulthana, Sp.B-KBD

Note Taker
1. Ina Teja Resmi, S.Kep., Ners (082321533846)
2. Shanty Wulandari, S.Kep.,Ners (082214655124)
10:15-12:00 Document Review
COP, ACC, HRP PFE, PFR, PCI FMS, MOI, IPSG AOP, ASC, MMU GLD, QPS, SQE
PIC: PIC: PIC: PIC: PIC:
1. Dr. dr. Emmy H. P., 1. dr. Dominica 1. Susi S. Puspitorini, 1. dr. Raden Yohana, 1. Siti Mahmudah,
SpPD-KP, KIC dan Herlijana, SpM dan SKM, MKM dan SpB(K)-Onk dan SH..MH.Kes dan
anggota anggota anggota anggota anggota
 2. dr. Doddy Tavianto, 2. Dr. dr. Hadi S., 2. dr. Amaylia O, SpPD- 2. dr. Indriasari, Sp An, 2. Dr. Iwan A. Rachman,
Sp.An, KAKV dan Sp.OG(K)., MH.Kes KHOM dan anggota MKes dan anggota Sp.An., KNA M.Kes.
anggota dan anggota 3. Dr. Zulvayanti, 3. Cherry Rahayu, Ssi, dan anggota
3. Dr. dr. Djatnika S, 3. dr. Riyadi, SpA(K), SpOG(K), M.Kes dan Apt dan anggota 3. Dr. dr. Ahmad R.,
SpA(K), MCTM dan M.Kes dan anggota anggota Venue: SpOTK, MKM dan
anggota Venue: Venue: R. Komut dan KP 2 anggota
R. Komut dan KP 1 R. Komut dan KP 1
Venue: Note Taker: Venue:
R. Sidang Note Taker: Note Taker: 1. Alia Rahmi R. Komut dan KP 2
1. Neneng Yaneu, 1. Rani Mardiani, SST Harlasgunawan,
Note Taker: S.Kep.,Ners (089656655889) S.Kep.,Ners Note Taker:
1. Ina Teja Resmi, (082132404976) 2. Lina Marlina, AMKeb (082142105616) 1. Dian Herdiana,
S.Kep., Ners 2. Indriyani Lestari, (08122135138) 2. Henny Febriyanti S., S.Kep.,Ners
(082321533846) AMK A.Md.Kep (082116847643)
2. Shanty Wulandari, (081322161642) (082295450001) 2. Dian Raditeyanni,
S.Kep.,Ners AMK (08122375180)
(082214655124)
12:00-13:00 Surveyor Working Lunch (private lunch for debriefing and survey planning)
13:00-14:00 Medical Prof. Education Document Review
Leadership Interview (continued as above)

Participants:
1. Direktur Medik dan
Keperawatan
2. Direktur SDM dan
Pendidikan
3. Dekan FKUP, FKGUP,
FIK, FF
4. Ka. Komkordik
5. Ka. Komite
Keperawatan
6. Ka. Bag. Diklit
7. Ka. Bag. SDM
 8. Ka. Bid. Keperawatan
9. Para KPS

Venue:
R. Sidang

PIC
1. Dr. dr. Ruswana
Anwar, Sp.OG-KFER.,
M.Kes
2. Dr. dr. Ria Bandiara,
SpPD-KGH
3. Ka. Bag. Diklit

Note Taker:
1. Ina Teja Resmi,
S.Kep., Ners
(082321533846)
2. Shanty Wulandari,
S.Kep.,Ners
(082214655124)
14:00-16:00 Individual Patient Individual Patient Facility Tour Individual Patient Tracer Medication
Tracer Activity Tracer Activity Activity Management System
Tracer Including
Units to be traced: Units to be traced: Units to be traced: Units to be traced: Medication Supply
.................................... .................................... .................................... ....................................
Participants:
Escorts: Escorts: Escorts: Escorts: 1. dr. Rudi W., SpPD-
KPTI, PhD.
1. Dr. dr. Emmy H. P., 1. dr. Dominica 1. Susi S. Puspitorini, 1. dr. Raden Yohana, 2. Dr. dr. Delita P, SpPK,
SpPD-KP, KIC Herlijana, SpM SKM, MKM SpB(K)-Onk MKes
2. dr. Doddy Tavianto, 2. Dr. dr. Hadi S., 2. dr. Amaylia O, SpPD- 2. dr. Indriasari, Sp An, 3. Cherry Rahayu, Ssi,
Sp.An, KAKV Sp.OG(K)., MH.Kes KHOM MKes Apt.
3. Dr. dr. Djatnika S, 3. dr. Riyadi, SpA(K), 3. Dr. Zulvayanti, 3. Cherry Rahayu, Ssi, 4. dr. Riyadi, SpA(K),
SpA(K), MCTM M.Kes SpOG(K), M.Kes Apt M.Kes.
4. Kurniawan Arif M, 5. Dra. Dewi Mardiah,
Note Taker: Note Taker: SKM, MM Note Taker: MSi, Apt.
1. Ina Teja Resmi, 1. Neneng Yaneu, 5. Enny Baniasih, ST 1. Alia Rahmi 6. Dra. Eni Margayani,
S.Kep., Ners S.Kep.,Ners 6. Agung Suroyo, SKM Harlasgunawan, MSi, Apt.
(082321533846) (082132404976) S.Kep.,Ners 7. Titin M., SKep, Ners,
2. Shanty Wulandari, 2. Indriyani Lestari, Note Taker: (082142105616) M.Kep.
S.Kep.,Ners AMK 1. Rani Mardiani, SST 2. Henny Febriyanti S., 8. Lia Yuliani, SST, M.Gz,
(082214655124) (081322161642) (089656655889) A.Md.Kep RD
2. Lina Marlina, AMKeb (082295450001) 9. Maudy Dirgahayu,
(08122135138) SKM., MKM
10.Dra. Mimin Lasmini,
Apt.
11.dr. H. Uun Sumardi,
Sp.PD-KPTI.,KIC.
12.Ilman Silanas, Apt
13.Dra. Siti Susiani,
MSi.,Apt
14.Jauharul Ardi,
S.Si.,Apt

Venue:
R. Komite Mutu & KP 1

PIC
1. dr. Rudi W., SpPD-
KPTI, PhD.
2. Dra. Dewi Mardiah,
MSi, Apt.
 Note Taker:
1. Dian Herdiana,
S.Kep.,Ners
(082116847643)
2. Dian Raditeyanni,
AMK (08122375180)
16:00-16:30 Meeting with Survey Coordinator (as needed, to identify needs for the following day)
 DAY TWO (THURSDAY, 13-09-2018)
Sri Yuniarti Rahayu
Agoes Oerip Purwoko Sri Widayati Eko Sadono Nunung RD Kusumawati
TIME Administrator
Physician Surveyour Nurse Surveyour Administrator Surveyour Physician Surveyour
Surveyour
08:00-09:00 Daily Briefing

Participants:
Direksi, Ka. SPI/Komite Ka. KSM/Dep., Ka. Instalasi, Ka. Bag/Bid., Koord. Pokja, unit terkait yang ditelusur satu hari sebelumnya

Venue:
Ruang Sidang

Note Taker
1. Neneng Yaneu, S.Kep.,Ners (082132404976)
2. Indriyani Lestari, AMK (081322161642)
09:00-12:00 09:00-11:00 09:00-11:00 Facility Tour Individual Tracer Activity 09:00-11:00
Individual Patient Nursing Staff Education Quality Program
Tracer Activity Qualifications Session Units to be traced: Units to be traced: Interview – Hospital
.................................... .................................... Operations
Units to be traced: Participants
.................................... 1. Ka. Bag. SDM dan Escorts: Escorts: Partcipants:
Diklit 1. Susi S. Puspitorini, 1. Hafsa, SKep, Ners, 1. Ka. Kom. Mutu & KP
Escorts: 2. Ka. Kom. SKM, MKM MKep 2. Ka. Kom. Medik
1. dr. Lilik Sukesi, SpPD- Keperawatan 2. dr. Sayu Wulan S.D., 2. dr. Nurita Dian K, 3. Ka. IBS dan TKPRS
KGH, KIC 3. Ka. Bid. MH.Kes. SpAn, KIC 4. Ka. Inst. Farmasi
2. R. Meitha RM, Skp, Keperawatan 3. dr. Artha F. Putri S., 3. Dra. Dewi Mardiah, 5. Ka. Inst. Gizi
MKep 4. Ka. Subbag Diklat SpOG MSi, Apt. 6. Para Ka. Sub KMKP
3. Dr. dr. Djatnika S, Keperawatan 4. Kurniawan Arif M, 7. Ka. KSM Bedah/
SpA(K), MCTM 5. Ka. Subkomite SKM, MM Note Taker: Obgin/Anestesi/Beda
Kredensial 5. Maudy Dirgahayu, 1. Alia Rahmi h Lainnya
Note Taker: Keperawatan SKM., MKM Harlasgunawan, 8. Ka. CSSD
1. Ina Teja Resmi, S.Kep., 6. Kukuh B.I., ST, MSi S.Kep.,Ners
Ners (082321533846) (082142105616)
2. Shanty Wulandari, Venue: Note Taker: 2. Henny Febriyanti S., Venue:
S.Kep.,Ners R. Komite Mutu & KP 2 1. Rani Mardiani, SST A.Md.Kep R. Komite Mutu & KP 1
(082214655124) (089656655889) (082295450001)
PIC 2. Lina Marlina, AMKeb PIC
1. Airiyani, S.Kp. MM (08122135138) 1. Dr. Kiki
2. Fatrisia Madina, 2. Dian H. U, SKep,
S.Kp., MM Ners, MKep
3. Ani Maryani, 3. Dra. Eni M., S.Si., Apt
S.Kp.,M.Kep.,Sp.KM 4. Dr. dr. Ferry, SpU(K)
B
Note Taker
Note Taker: 1. Dian Herdiana,
1. Neneng Yaneu, S.Kep.,Ners
S.Kep.,Ners (082116847643)
(082132404976) 2. Dian Raditeyanni,
2. Indriyani Lestari, AMK (08122375180)
AMK
(081322161642)
11:00-12:00 11:00-12:00 Continued as above Continued as above 11:00-12:00
Medical Student and Individual Patient Individual Tracer
Trainee Interview Tracer Activity Activity

Partcipants: Units to be traced: Units to be traced:

1. PSPD dan PPDS dari .................................... ....................................
2. Bedah
3. Penyakit Dalam Escorts: Escorts:
4. Obgin 1. Siti Nurlaelah, SKep, 1. Siti Mahmudah, SH,
5. Anak Ners, MKep. MH.Kes
6. Neurologi 2. Drs. Achmad Gozali, 2. Henti Sugesti, SKp.,
7. Anestesiologi Apt, MH.Kes M.Kep
8. Radiologi 3. Ria Eviyantini 3. Ir. Budi Utomo, MKM
9. Patologi Klinik Sitorus,
 Venue: S.Kp.,M.Kep.,Sp.KM Note Taker:
R. Sidang B 1. Dian Herdiana,
S.Kep.,Ners
PIC Note Taker: (082116847643)
1. Dr. dr. Ruswana 1. Neneng Yaneu, 2. Dian Raditeyanni,
Anwar, Sp.OG-KFER., S.Kep.,Ners AMK (08122375180)
M.Kes (082132404976)
2. Dr. dr.Ria Bandiara, 2. Indriyani Lestari,
SpPd-KGH AMK
(081322161642)
Only attended by
students/trainees and
surveyors
12:00-13:00 Surveyor Working Lunch (private lunch for debriefing and survey planning)
13:00-14:00 Medical Staff Education Infection Prevention Supply Chain Individual Patient Tracer Individual Patient Tracer
Qualifications Session and Control System Management and Activity Activity
Tracer Evidence-Based
Purchasing Interview Units to be traced: Units to be traced:
Participants: Participatns: and Tracer .................................... ....................................
1. Dir. Medik & 1. Dir. Umum &
Keperawatan Operasional Participatns: Escorts: Escorts:
2. Ka. Komite Medik 2. Ka. Komite PPI 1. Hafsa, SKep, Ners, 1. Siti Mahmudah, SH,
3. Ka. Komkordik 3. Waka Komite PPI Venue: MKep MH.Kes
4. Ka. Bag. SDM 4. Ka. IPSRS, CSSD, R. Komite Mutu & KP 2 2. dr. M. Naseh S. B. 2. Henti Sugesti, SKp.,
5. Ka. Bag. Diklit Binatu, Kesling, Gizi Irawan, Sp.OT M.Kep
5. dr. Leonardus W, PIC 3. Dra. Dewi Mardiah, 3. Ir. Budi Utomo, MKM
Venue: SpMK 1. Dra. Dewi Mardiah, MSi, Apt.
R. Sidang 6. Dra. Tutik P, Apt. MSi, Apt.
7. dr. H. Uun Sumardi, 2. Irfan Sofian, SSi,Apt,
PIC: SpPD-KPTI, KIC MM, Note Taker: Note Taker:
1. Dr. dr. Ahmad R., 3. Drs. Iman Sudradjat, 1. Alia Rahmi 1. Dian Herdiana,
SpOTK, MKM Venue: MKM Harlasgunawan, S.Kep.,Ners
R. Komite Mutu & KP 1 (082116847643)
 2. Dr. dr. Tono D, PIC Note Taker: S.Kep.,Ners 2. Dian Raditeyanni,
SpOG(K), MKes 1. dr. Riyadi, Sp.A(K), 1. Rani Mardiani, SST (082142105616) AMK (08122375180)
3. Dr. dr. Ruswana A, M.Kes (089656655889) 2. Henny Febriyanti S.,
SpOG(K), M.Kes 2. Ria Eviyantini 2. Lina Marlina, AMKeb A.Md.Kep
Sitorus, (08122135138) (082295450001)
Note Taker: S.Kp.,M.Kep.,Sp.KM
1. Ina Teja Resmi, B
S.Kep., Ners
(082321533846) Note Taker:
2. Shanty Wulandari, 1. Neneng Yaneu,
S.Kep.,Ners S.Kep.,Ners
(082214655124) (082132404976)
2. Indriyani Lestari,
AMK
(081322161642)
14:00-16:00 Closed Patient Medical Record Review Facility Management and 10 rekam medis pasien yang dipilih oleh surveior
Safety Document Review dari daftar rekam medis pasien yang pulang dalam
5-10 rekam medis pasien yang dipilih oleh surveior and Facility Tour satu tahun ke belakang
dari daftar rekam medis pasien yang pulang dalam
satu tahun ke belakang Participants: Venue:
1. Pokja FMS Ruang Komite Mutu 2
Venue: 2. Komite PPI
Ruang Komite Mutu 1 3. Ka. Inst. IPSRS PIC
4. Ka. Inst. K3RS 1. dr. Amaylia Oehadian, SpPD-KHOM
PIC 5. Ka. Inst. Kesling 2. Tim CMMR
1. dr. Amaylia Oehadian, SpPD-KHOM 6. Ka. Inst. Fasmed.
2. Tim CMMR 7. Ka. Inst. CSSD
Note Taker: 8. Ka. Inst. Binatu Note Taker:
1. Neneng Yaneu, S.Kep.,Ners 9. Anggota Pokja FMS 1. Dian Herdiana, S.Kep.,Ners (082116847643)
(082132404976) 10.Ka. Inst. Farmasi 2. Dian Raditeyanni, AMK (08122375180)
2. Indriyani Lestari, AMK (081322161642)
Venue:
Ruang Sidang
 PIC
1. Susi S. Puspitorini,
SKM, MKM
2. Kurniawan Arif M,
SKM, MM

Note Taker:
1. Rani Mardiani, SST
(089656655889)
2. Lina Marlina, AMKeb
(08122135138)

Dilanjutkan Facility Toor

Escort:
1. Susi S. Puspitorini,
SKM, MKM
2. Kurniawan Arif M,
SKM, MM
3. Enny Baniasih, ST
16:00-16:30 Meeting with Survey Coordinator (as needed, identify needs for the following day)
 DAY THREE (FRIDAY, 14-09-2018)
Sri Yuniarti Rahayu
Agoes Oerip Purwoko Sri Widayati Eko Sadono Nunung RD Kusumawati
TIME Administrator
Physician Surveyour Nurse Surveyour Administrator Surveyour Physician Surveyour
Surveyour
08:00-09:00 Daily Briefing

Participants:
Direksi, Ka. SPI/Komite Ka. KSM/Dep., Ka. Instalasi, Ka. Bag/Bid., Koord. Pokja, unit terkait yang ditelusur satu hari sebelumnya

Venue:
Ruang Sidang

Note Taker
1. Rani Mardiani, SST (089656655889)
2. Lina Marlina, AMKeb (08122135138)
09:00-12:00 Individual Patient Individual Patient 09:00-10:30 09:00-10:30 09:00-10:30
Tracer Activity Tracer Activity Other Clinical Staff Human Subjects Quality Program
Education Qualifications Research Leadership and Interview – Clinical
Units to be traced: Units to be traced: Session Process Interview Measures
.................................... ....................................
Participants: Participants: Participants:
1. Dr. dr. Emmy H. P., 1. dr. Dominica 1. Ka. Kom. Nakes Lain 1. Dir. Medik & 1. Dir. Utama
SpPD-KP, KIC Herlijana, SpM (KTKL) Keperawatan 2. Dir. Med & Wat
2. dr. Doddy Tavianto, 2. Dr. dr. Hadi S., 2. Sekretaris dan Ka. Sub 2. Dir. SDM & 3. Direktur Um & Op
Sp.An, KAKV Sp.OG(K)., MH.Kes KTKL Pendidikan 4. Ka. Komut & KP
3. Dr. dr. Djatnika S, 3. dr. Riyadi, SpA(K), 3. Ka. Bag. SDM 3. Ka. Kom. Etik 5. Ka. Komite Medik
SpA(K), MCTM M.Kes 4. Ka. Bag. Diklit Penelitian 6. Ka. Komite PPI
5. Ka. Subag. SDM 4. Ka. Kom. 7. Para Ka. Sub KMKP.
Venue: Venue: 6. Ka. Subbag Diklat Keperawatan 8. Ka. TKPRS
R. Sidang R. Komut dan KP 1 Keperawatan & 5. Ka. Kom. Mutu dan KP 9. Ka. KSM Bdh, Anak,
Paramedis 6. Ka. Bid. Keperawatan Obgin, P. Dlm &
7. Ka. Bag. Diklit & SDM Neuro
 Note Taker: Note Taker: 7. Ka. Subkomite 8. Ka. Inst. Farmasi & Venue:
1. Ina Teja Resmi, 1. Neneng Yaneu, Kredensial Tenaga IPSRS Ruang Sidang
S.Kep., Ners S.Kep.,Ners Kesehatan Lain 9. Ka. KSM Bedah,
(082321533846) (082132404976) Obgin, Peny. Dlm dan PIC
2. Shanty Wulandari, 2. Indriyani Lestari, Venue: Anak 1. Henti S., S.Kp., M.Kep
S.Kep.,Ners AMK R. Komite Mutu & KP 1 2. Hani H. S.Kep., Ners.
(082214655124) (081322161642) Venue: 3. Singgih P, Ners.,
PIC R. Komite Mutu & KP 2 M.Kep.
1. Dra. Gusti Yantin,
Apt.,M.Kes PIC Note Taker:
2. Asep Ahmad Dr. dr. Djatnika S, Sp.A(K), 1. Dian Herdiana,
Munawar, SKM.,MKM MCTM S.Kep.,Ners
3. Budi Utomo, MKM (082116847643)
Note Taker: 2. Dian Raditeyanni,
Note Taker: 1. Alia Rahmi AMK (08122375180)
1. Rani Mardiani, SST Harlasgunawan,
(089656655889) S.Kep.,Ners
2. Lina Marlina, AMKeb (082142105616)
(08122135138) 2. Henny Febriyanti S.,
A.Md.Kep
(082295450001)
Continued as above Continued as above 10:30-12:00 10:30-12:00 10:30-12:00
Facility Tour Human Subjects Tracer Tracer activity

Units to be traced Units to be traced Units to be traced:

......................... ......................... ....................................

Escort: Escort: Escorts:

1. Susi S. Puspitorini, 1. Ka. Kom. Etik 1. Usnadi, S.Sos, MAP
SKM, MKM Penelitian 2. Hani Handriani, SKp
2. Taufik Herdiansyah, 2. Ka. Kom. 3. Ir. Budi Utomo, MKM
SKM, MM Keperawatan
3. Kukuh B.I., ST, MSi 3. Ka. Bid. Keperawatan
 4. Agung Suroyo, SKM 4. Ka. Bag. Diklit Note Taker:
5. Ka. Bag. SDM 1. Dian Herdiana,
Note Taker: 6. Ka. Inst. Farmasi & S.Kep.,Ners
1. Rani Mardiani, SST IPSRS (082116847643)
(089656655889) 2. Dian Raditeyanni,
2. Lina Marlina, AMKeb Note Taker: AMK (08122375180)
(08122135138) 1. Alia Rahmi
Harlasgunawan,
S.Kep.,Ners
(082142105616)
2. Henny Febriyanti S.,
A.Md.Kep
(082295450001)
12:00-13:00 Surveyor Working Lunch (private lunch for debriefing and survey planning)
13:00-14:30 Survey Integration and Report Preparation
14:30-15:00 Meeting with Hospital Leadership to Review Exit Report Findings

Participants:
Direksi, Dewan Pengawas, SPI dan Para Ketua Komita

Venue:
Ruang Sidang

Note Taker:
1. Neneng Yaneu, S.Kep.,Ners (082132404976)
2. Indriyani Lestari, AMK (081322161642)
15:00-15:30 Meeting with Hospital Staff to Review Exit Report Finding

Participants:
Direksi, Dewas, Dekan, Ka. SPI/Komite Ka. KSM/Dep., Ka. Instalasi, Ka. Bag/Bid., Koord. Pokja

Venue:
Ruang Sidang
 Note Taker:
1. Ina Teja Resmi, S.Kep., Ners (082321533846)
2. Shanty Wulandari, S.Kep.,Ners (082214655124)