Download - Sesi III. Dr. Ayi Djembarsari, MARS
![Page 1: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/1.jpg)
Pengembangan Clinical Leadership : Pengalaman RSUPN Cipto Mangunkusumo Dalam Mencapai
Standar Akreditasi JCI
RSUPN DR.CIPTO MANGUNKUSUMOGoes to Joint Commission International Accreditation
Ayi Djembarsari
![Page 2: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/2.jpg)
KepemimpinandanDokter
• Kepemimpinanadalahbagianpentingdaripekerjaanprofesionalseorangdokter.
• Setiapindividudokterbekerjadalamsistemdandalamorganisasi.
• Merekamemilikiperandantanggungjawabuntukberkontribusidalammenjalankanorganisasidimanamerekabekerja agar mencapaimutu yang lebihbaik.
![Page 3: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/3.jpg)
What is clinical leadership?
• Clinical leadership describes both a set of tasks to lead improvements in the safety and quality of health care, and the attributes required to successfully carry them out.
![Page 4: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/4.jpg)
At a strategic level, these include:
• participating in setting the safety and quality agenda, and taking responsibility for implementing that agenda
• taking a substantial role in determining priorities for allocation of resources to support best practice
• acting as champions for improvement• attaching professional and organisational status to safety and quality activities
• taking the lead in prioritising, designing and implementing improved processes of care
• ensuring training and organisational support are available to support involvement in clinical governance activities.
![Page 5: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/5.jpg)
Clinical Leadershipdalamrangkaclinical governance
• Clinical leader berperanpentingdalammewujudkanclinical governance .
• Manajemendantenagaprofesionaldokterbertanggungjawabdalampelayananpasien, meminimalkanrisikodanuntukterusmemantaudanmeningkatkankualitaspelayanan.
![Page 6: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/6.jpg)
![Page 7: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/7.jpg)
VISI : MenjadiRumahSakitPendidikandanPusatRujukanNasionalterkemukadi Asia Pasifikpada tahun 2014.
MISI :1. Memberikan pelayanan kesehatan paripurna dan bermutu serta
terjangkau oleh semua lapisan masyarakat,2. Menjadi tempat pendidikan dan pelatihan tenaga kesehatan,3. Tempat penelitian dan pengembangan dalam rangka
meningkatkan derajat kesehatan masyarakat melalui manajemen yang mandiri
![Page 8: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/8.jpg)
• JCI is a RSCM Priority
SasaranketujuhKementerianKesehatan RI tentangkebutuhanIndonesia untukmemiliki RS berkualitasdunia
Dalam rangka mencapai excellence, standar JCI merupakan pilihan karena merupakan standar internasional yang khas untuk institusi kesehatan.
![Page 9: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/9.jpg)
STANDAR JCI
PATIENT‐CENTERED STANDARDS :
1.International Patient Safety Goals (IPSG).
2.Access to Care and Continuity of Care (ACC)
3.Patient and Family Right (PFR)
4.Assesement of Patients (AOP)
5.Care of Patients (COP)
6.Anesthesia and Surgical care (ASC)
7.Medication Management and Use (MMU)
8.Patient and Family Education (PFE)
![Page 10: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/10.jpg)
standar ...
II. HEALTH CARE ORGANIZATION MANAGEMENT STANDARDS
1.Quality Improvement and Patient Safety (QPS)
2.Prevention and Control of Infections (PCI)3.Governance, Leadership, and Direction (GLD)4.Facility Management and Safety (FMS)5.Staff Qualifications and Education (SQE)6.Management of Communication and Information (MCI)
![Page 11: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/11.jpg)
WAKTU PELAKSANAAN
• Februari 2011 sampai dengan November 2012
January 2011
‐ Team Formulation‐ Benchmark‐ Books
February 2011
‐ Action Plan‐ Submit Application ‐ Start Documentation phase
April 2011
‐ Documentation Finished
May 2011
‐ Socialization Phase‐ Baseline Audit from JCI
June ‐ November 2011
‐ Implementation Phase
November 2011
‐ FIRST INTERNAL AUDIT
Dec 2011 – Feb 2012
‐ Corrective Action
March 2012
‐MOCKUP SURVEY from JCI
April 2012
‐‐ Corrective Action‐‐ Submit Application Survey
May 2012
‐ Receive & Complete JCI Survey Contract + Travel instruction form
September 2012
‐ JCI team leader determine survey
agenda
November 2012
‐ JCI ACCREDITATION SURVEY
December 2012
‐ Receive accreditation decision
![Page 12: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/12.jpg)
KEGIATAN POKOK
Rincian Kegiatan Pokok berupa:1. Pembentukan Tim persiapan Akreditasi JCI RSCM 2. Pembentukan Tim Mutu. 3. Pembentukan Unit Manajemen Kinerja.4. Pembentukan Unit Kesehatan dan Keselamatan Kerja.5. Perbaikan sistem Teknologi Informasi.6. Konsultasi dengan JCI melalui kantor JCI Asia Pacific 7. Pengembangan Sistem Manajemen Klinik, Operasional dan Finansial 8. Revisi Standart Prosedur Operasional pelayanan Medik9. Revisi Standart Prosedur Operasional pelayanan Non – Medik10. Revisi Standart Prosedur Operasional pengelolaan Keuangan11. Pengembangan Sarana Fisik Bangunan, Alat Kedokteran dan Alat Non
Medik.
![Page 13: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/13.jpg)
Persiapan dan Kegiatan Tim
• Sosialisasi Program JCI•Penyusunan Dokumen (Kebijakan, SPO dan IK)
Tim Persiapan
•Review Dokumem•Sosialisasi Kebijakan, SPO&IK•Pengawasan saat Implementasi
Tim Mutu
•Pengumpulan data terkait indikator medik dan KPI
•Analisis data Dash Board.
Tim Manajemen
Kinerja
14 pokja sesuai dengan Standart JCI
21 Departemen Medik ( 145 Divisi )10 Unit Pelayanan Medik Terpadu2 Instalasi Medik15 Bidang / Bagian12 Unit pelayanan
![Page 14: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/14.jpg)
SASARAN
Sasaran penerapan JCI di RSCM terdiri dari :
• 21 Departemen Medik ( 145 Divisi )
• 10 Unit Pelayanan Medik Terpadu
• 2 Instalasi Medik
• 15 Bidang / Bagian
• 12 Unit pelayanan
4500 karyawan dan 1700 mahasiswa
Dalam area fasilitas RS seluas 12 hektar.
![Page 15: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/15.jpg)
![Page 16: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/16.jpg)
ROAD MAP DALAM TAHUN 2011
Penyusunan dokumen(Februari – April )
Review dan sosialisasi(Mei )
Implementasi Kebijakan, SPO dan IK ( Mei dst )
Nov : Internal Audit
![Page 17: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/17.jpg)
Program RevitalisasiBudaya• Penetapannilaibudaya• Sosialisasidaninternalisasi :
– Kepaladepartemen, kepala unit , kepalabagian– PIC unit ataudepartemen– Selanjutnyapadamasing‐masingdepartemendan unit, olehtim
unit dan TIB korporat (62 departemen, DSSG dan unit kerja). • Implementasidanpendampingan, mulaidilaksanakan. • Monitoring danevaluasidanpendampingan• Penguatan :
– Reward & consequence – Lombabudaya (culture fair), ulangtahun RSCM 19 Nopember
2011 – Penilaiankinerja– Remunerasi
![Page 18: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/18.jpg)
Menolong ……….
• Padadasarnya, seseorang yang bekerjadibidangkesehatanmempunyaikeinginanyang kuatuntukmenolongorang lain denganmemberikanpelayanan yang prima.
• Budaya RSCM :
“ Menolong, Memberikan Yang Terbaik “.
![Page 19: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/19.jpg)
Kesepakatan Landasan Ideologi & Nilai‐Nilai Budaya RSCM –6/4/2011
![Page 20: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/20.jpg)
NILAI BUDAYA & MAKNA PERILAKU UTAMA
PROFESIONALISMEKompetendanbertanggungjawabdalammenjalankanperanuntukmemberikan yang terbaik, berorientasipadakeselamatan.
1.Kompeten, BertanggungJawabdanMemberikanyang Terbaik
INTEGRITASMenjaga keselarasan antara yang dipikirkan dengan yang dikatakan dan yang dilakukan dengan selalu menjunjung tinggi moral, etika, dan kemanusiaan.
2. Jujur, Disiplin dan Konsisten3. Menjunjung Tinggi Moral, Etika dan Kemanusiaan
KEPEDULIANMelayanidenganhati, proaktif, pekadantanggapterhadapkebutuhanpelanggan.
4.Proaktif, Peka, Dan Tanggap5.Ramah Dan Bersahabat6.Saling Menghargai Dan Bekerja Sama
PENYEMPURNAAN BERKESINAMBUNGANSenantiasaberupayamelakukanperbaikandanpenyempurnaanhinggamelampauiharapanpelanggan yang didukungolehpenelitiandanpengembangan.
7.Kreatif danInovatif8.Terbuka TerhadapPerubahan
BELAJAR & MENDIDIKMelaksanakanpembelajarandanpendidikan yang berorientasipadapelayananterbaikdenganmenggunakansumberdaya yang efektifdanefisien.
9.Belajar Berkesinambungan10.Mendidik DenganSantun
Nilai-Nilai Budaya RSCM
![Page 21: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/21.jpg)
5R sebagai sarana mencapai efisiensi, produktivitas, kualitas,dan keselamatan kerja
Budaya5R
Ringkas
Rapi
ResikRawat
Rajin
![Page 22: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/22.jpg)
GOOD TO GREAT
![Page 23: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/23.jpg)
Medical Leadership Competency Framework
![Page 24: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/24.jpg)
Demonstrating Personal Qualities• Developing self awareness• Managing yourself• Continuing personal development• Acting with integrity
Working with Others• Developing networks• Building and maintaining relationships• Encouraging contribution• Working within teams
Managing Services• Planning• Managing resources• Managing people• Managing performance
Improving Services• Ensuring patient safety• Critically evaluating• Encouraging improvement and
innovation• Facilitating transformation
Setting Direction• Identifying the contexts for change• Applying knowledge and evidence• Making decisions• Evaluating impact
![Page 25: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/25.jpg)
Keyhas limited opportunities toshow competence in allelements of the domainhas greater opportunities toshow competence in allelements of the domainhas frequent opportunitiesto show competence in allelements of the domain.
Continuing Practice
Undergraduate
Postgraduate
Application
![Page 26: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/26.jpg)
Demonstrating Personal Qualities
• Developing Self Awareness
• Managing Yourself
• Continuing Personal Development
• Acting with Integrity.
![Page 27: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/27.jpg)
Working with others
• Developing Networks
• Building and Maintaining Relationships
• Encouraging Contribution
• Working within Teams.
![Page 28: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/28.jpg)
Managing Services
• Planning
• Managing Resources
• Managing People
• Managing Performance.
![Page 29: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/29.jpg)
Improving Services
• Ensuring Patient Safety
• Critically Evaluating
• Encouraging Improvement and Innovation
• Facilitating Transformation.
![Page 30: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/30.jpg)
Setting Direction
• Identifying the Contexts for Change
• Applying Knowledge and Evidence
• Making Decisions
• Evaluating Impact.
![Page 31: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/31.jpg)
Clinical Leaders:The foundation for excellence
Clinical leadership
• Integrating clinical practice, science and innovation
• Mentorship of young doctors
• External face for profession and Health Service
• Defining agenda for future practice
![Page 32: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/32.jpg)
“Leadership is the art of getting someone else to do something you want done because he
wants to do it “
Dwight Eisenhower
![Page 33: Sesi III. Dr. Ayi Djembarsari, MARS](https://reader034.vdocuments.us/reader034/viewer/2022052322/55721456497959fc0b944d00/html5/thumbnails/33.jpg)
TERIMA KASIH.