DAY ONE
Time
Physician Patricia O'Shea
Nurse Denise Fritz
Dr. Chyntia, SpPD
Ns. Hendra
Dr. Darrel Fernando 0745 – 0800
Administrator Robert Christmas
Clinician Pongtorn Kietdumrongwong
Fitri Arman
Dr. Abdi Reza, Sp BS
Dr. Yudistira Dr. Iwan RA Dr. Aris Ramdani Siahaan Team Meeting with Survey Coordinator and Translators
0800 – 0820
Opening Conference and Agenda Review
0820 – 0915
Hospital’s Orientation to the Organization Services (1)
Leadership for Quality and Patient Safety Interview Part One(2)
Document Review
1015 – 1230
Surveyor Working Lunch
1230 – 1330
1330 – 1600
Medical Professional Education Leadership Interview (3) Auditorium Gd. A Lt.8
Undangan
Dr. Cut Nurul, SpA
(Discussion of the logistical support issues and requirements)
0915 – 1015
Clinician Mark Scott
(Surveyors will eat alone and use the time for survey planning) FMS Document Review Individual Patient – Individual Patient – Department/Service Department/Service Quality Measurement Quality Measurement R. Kuliah Lt. Tracer Tracer 2A
Dr. Natasha Supartono R. Rapat divisi Lt.7 Auditorium Gd. A Lt.8 Auditorium Gd. A Lt.8
Auditorium Gd. A Lt.8
R. Kuliah Lt.7
Dr. Hervita, Dr. Eric, Dr. Yoan
Direksi, Dekanat, Dewas, Semua Kepala Unit/ Departemen, PIC Chapter, Pemilik Proses Bisnis, Tamu Undangan Direksi, Dekanat, Dewas, Semua Kepala Unit/ Departemen, PIC Chapter, Pemilik Proses Bisnis, Tamu Undangan Direksi, Dekanat, Dewas, Dr. Hervita, KMKK, Komite Medik, Komite Etik dan Penelitian, Komite PPIRS, Komite Etik dan Hukum, Komite Keperawatan, Komite Tenaga Kesehatan, Bidang Pelayanan Medik, Bagian SDM, K3RS, Bagian Perencanaan, ULP PIC Chapter, Semua Pemilik Bisnis Proses
R. Kuliah Lt.7
PIC MPE, Bakordik, KPS, Dekanat, Direktur SDM dan Pendidikan
Individual Patient – Department/Service PIC FMS, Direktur Umum dan Operasional, Quality Bagian Teknik, Komite PPIRS, USL, Unit Measurement Tracer Fasilitas Medik, K3RS, Bagian Administrasi, IGD, Tim Proteksi Radiasi, TMRC
1600 – 1630 1630 – 1730
Meeting with Survey Coordinator (4)
Debriefing Sore
R. THT Komunitas
Dr. Hervita, Dr. Eric, Dr. Yoan Direksi, Dekanat, Semua Kepala Unit/ Departemen, PIC Chapter, Pemilik Proses Bisnis
DAY TWO Time
Physician Patricia O'Shea
0800 – 0915 0915 – 1030 1030 – 1200
1500 – 1600 1600 – 1630 1630 – 1730
Administrator Robert Christmas Daily Briefing
Clinician Pongtorn Kietdumrongwong
Clinician Mark Scott
(Surveyors share observations from the previous day. See SPG, page 54) Quality Program Interview (5) Individual Patient – Department/Service Quality Measurement Tracer
1200 – 1300
1300 – 1500
Nurse Denise Fritz
Individual Patient – Department/Service Quality Measurement Tracer
Facility Tour
Individual Patient – Department/Service Facility Tour Quality Measurement Tracer Surveyor Working Lunch
(Surveyors will eat alone and use the time for survey planning)
Medication Management System Tracer (6)
Individual Patient – Department/Service Quality Measurement Tracer
Organ and Tissue Transplant Services Interview and Tracer (7) Facility Tour
R. Kuliah Lt. 2A
Undangan
Auditorium Gd. A Lt.8
Direksi, Dekanat, Semua Kepala Unit/ Departemen, PIC Chapter, Pemilik Proses Bisnis
Auditorium Gd. A Lt.8
Direksi, KMKK, Bidang Pelayanan Medik, Sekretaris Dewas, Bagian SDM, PJ Mutu, Bidang Pelayanan Medik, Komite Medik, K3RS, Komite PPIRS, Bagian Perencanaan, Komite Etik dan Hukum, ULP, Tim CP
Individual Patient – Department/Service Quality Measurement Tracer R. Kuliah Lt.7
Human Subject Research Leadership Interview (8) Auditorium Gd. A Lt.8
Dirmed, PPRA, Satelit Instalasi Farmasi, IAL, Panitia Farmasi dan Terapi, Komite Medik, PIC MMU, Team Transplantasi Terpadu Dirut, Dirbangsar, Bagian Penelitian, CRSU, Komite Etik dan Penelitian, KMKK, Dekanat, MRU, PIC HRP
Undetermined Survey Activity Meeting with Survey Coordinator (4)
Debriefing Sore
Dr. Hervita, Dr. Eric, Dr. Yoan R. THT Komunitas
Direksi, Dekanat, Semua Kepala Unit/ Departemen, PIC Chapter, Pemilik Proses Bisnis
DAY THREE Time 0800 – 0915
0915 – 1100
1100 – 1200
Physician Patricia O'Shea
Nurse Denise Fritz
Administrator Robert Christmas
Clinician Pongtorn Kietdumrongwong
Daily Briefing (Surveyors share observations from the previous day. See SPG, page 54) Individual PatientDepartment/Service Staff and Quality Individual Patient – Medical Measurement Department/Service Professional Tracer Quality Measurement Education Individual Patient – Tracer Qualifications Department/Service (Nursing) Quality Measurement Tracer Medical Student and Trainee Interview (9)
R. Kuliah Lt. 2B
Undetermined Survey Activity
Auditorium Gd. A Lt.8
Management of Contract Research Studies Auditorium Gd. A Lt.8
Individual Patient – Department/Service Quality Measurement Tracer
R. Kuliah Lt.2 A
Surveyor Working Lunch
1200 – 1300
Clinician Mark Scott
(Surveyors will eat alone and use the time for survey planning)
1300 – 1500
Infection Prevention and Control System Tracer (10)
Individual PatientDepartment/Service Quality Measurement Tracer
Individual Patient – Department/Service Quality Measurement Tracer
Direksi, Dekanat, Semua Kepala Unit/ Departemen, PIC Chapter, Pemilik Proses Bisnis Dir SDM, Bagian SDM, Komite Keperawatan, Bidang Keperawatan, Bagian Diklat, PIC SQE Dirut, Dirbangsar, Bagian Penelitian, CRSU, Komite Etik dan Penelitian, KMKK, Dekanat, MRU, PIC HRP Dekanat, KPS, Bakordik, Dir SDM, PIC MPE
R. Kuliah Lt.7
Staff and Medical Professional Education Qualifications(Physicians) And SQE Residents R. Kuliah Lt.2 A
Undangan
Human Subject Research Process Interview(11) Auditorium Gd. A Lt.8
Dir SDM, Bagian SDM, Bidang Pelayanan Medik, KMKK, Komite Medik, Panitia Penilaian Kinerja Medik, Bagian Diklat, Komite Keperawatan, Bidang Keperawatan, Bagian Diklat, PIC SQE Dekanat, KPS, Bakordik, Dir SDM, PIC MPE Dirut, Dirbangsar, Bagian Penelitian, CRSU, Komite Etik dan Penelitian, KMKK, Dekanat,
MRU, PIC HRP
1500 – 1600 1600 – 1630 1630 – 1730
Undetermined Survey Activity
Undetermined Survey Activity
Meeting with Survey Coordinator (4) Debriefing Sore
R. THT Komunitas
Dr. Hervita, Dr. Eric, Dr. Yoan Direksi, Dekanat, Semua Kepala Unit/ Departemen, PIC Chapter, Pemilik Proses Bisnis
DAY FOUR Time 0800 – 0900
0900 – 1100
1100 – 1200 1200 – 1300 1300 – 1430
1430 – 1600 1600 – 1630 1630 – 1730
Physician Patricia O'Shea
Nurse Denise Fritz
Administrator Robert Christmas
Clinician Pongtorn Kietdumrongwong
Daily Briefing
Clinician Mark Scott Auditorium Gd. A Lt.8
(Surveyors share observations from the previous day. See SPG, page 54) Staff Medical Education Qualifications/ Other Closed Patient Medical Record Review Closed Patient Medical Record Review Health Professionals R. Kuliah Lt.6 A
Undetermined Survey Activity
Individual Patient – Department/Service Quality Measurement Tracer
R. Kuliah Lt.6 B
Undetermined Survey Activity
Auditorium Gd. A Lt.8
Undetermined Survey Activity Surveyor Working Lunch
R. Kuliah Lt.2
Undetermined Survey Activity
(Surveyors will eat alone and use the time for survey planning) 1300 – 1500 Individual PatientDepartment/Service Supply-Chain Management Quality Individual Patient – and Evidence-Based Measurement Department/Service Purchasing Interview and Tracer Tracer (12) Quality Auditorium Measurement 1500 – 1600 Gd. A Lt.8 Individual Patient – Tracer Department/Service Individual Patient – Quality Department/Service Quality Measurement Tracer Measurement Tracer Meeting with Survey Coordinator (4)
Debriefing Sore
R. Kuliah Lt.2
Undangan Direksi, Dekanat, Semua Kepala Unit/ Departemen, PIC Chapter, Pemilik Proses Bisnis Panitia Rekam Medis, Unit Rekam Medis, PIC MOI Dir SDM, Bagian SDM, Komite Tenaga Kesehatan, Bagian Keteknisian Medik, Bagian Diklat, PIC SQE, Komite Tenaga Kesehatan
Undetermined Survey Activity R. Kuliah Lt.7
Dirut, Dirum, Dir SDM, Dirmed, Individual Patient- UPL, Panitia Penerimaan Barang, Department/Service SPI, IAL, Unit Fasilitas Medik, Quality Bagian Diklat, Bagian Akuntansi, Measurement Bagian Perbendaharaan Bagian Tracer Anggaran, PIC GLD Individual Patient – Department/Service Quality Measurement Tracer R. THT Komunitas
Dr. Hervita, Dr. Eric, Dr. Yoan Direksi, Dekanat, Semua Kepala Unit/ Departemen, PIC Chapter, Pemilik Proses Bisnis
DAY FIVE Time
Physician Patricia O'Shea
10:3012:00
1200 – 1300 1300 – 1500 1500 – 1530 1530 – 1600
Administrator Robert Christmas
Clinician Pongtorn Kietdumrongwong
Clinician Mark Scott
Daily Briefing
0800 – 0900 0900 – 1030
Nurse Denise Fritz
Individual Patient– Department/Service Quality Measurement Tracer
(Surveyors share observations from the previous day. See SPG, page 54) Individual Patient– Individual Patient– Individual Patient– Department/Service Department/Service Department/Service Quality Quality Measurement Quality Measurement Tracer Measurement Tracer Tracer
Auditorium Gd. A Lt.8
Undangan Direksi, Dekanat, Semua Kepala Unit/ Departemen, PIC Chapter, Pemilik Proses Bisnis
Individual Patient– Department/Service Quality Measurement Tracer
Leadership for Quality and Patient Safety Ethical Framework and Culture of Safety System Themes
Integration of Findings and Lunch (14) (Surveyors will eat alone and use the time for report preparation) Survey Integration and Exit Report Preparation (W ill require individual Internet access and shared printer access) Leadership Exit Report (15) (Optional: Leadership group to receive detailed survey findings) Exit Findings Presentation (Leaders can decide who participates in this session; the size of the group is not limited.)
Auditorium Gd. A Lt.8
Dirut, Dir. SDM, Dewas, Dekanat, Komite Etik dan Hukum, KMKK, Komite Medik, Komite Keperawatan, Komite Etik dan Penelitian, Tim Transformasi Budaya, SPI, PIC QPS
R. Kuliah Lt.7 R. Kuliah Lt.7 R. KaDep THT Lt. 7 Auditorium Gd. A Lt.8
Direksi dan Dr. Hervita
Direksi, Dewas, Dekanat, Semua Kepala Unit/ Departemen, PIC Chapter, Pemilik Proses Bisnis, Tamu Undangan
Guide to Sessions (1) Orientation of Surveyors to the Organization Services (Organization Chart). The presentation must be 20 minutes maximum. The quality improvement process presentation will NOT be required for this session. (See 1300 – 1400 session) (2)
Leadership for Quality and Patient Safety Interview – See Survey Process Guide, 5th Edition (SPG), page 56
(3)
Medical Professional Education Leadership Interview – See Survey Process Guide, 5th Edition (SPG), page 119
(4) Meeting with Survey Coordinator – The meeting at 1600 each day with the survey coordinator is to clarify issues and to review the agenda for the following day. The team may also wish to use some time to review issues prior leaving the hospital. The survey plan is to leave the hospital no later than 1730. (5)
Quality Program Interview – Bring examples of a Data validation, Root Cause Analysis (RCA), Failure Modes and Effects Analysis (FMEA) and resulting action plans, and tools
(6) Medication Management System Tracer – The session does not require a presentation. The surveyor meets with physicians and others involved in the medication process (45 min), followed by tracer activities in inpatient and outpatient areas, review of data that pertain to any/all aspects of medication management process, including medication error data and supply chain integrity. See SPG, 5th Edition, pages 79–81. (7)
Organ and Tissue Transplant Services Interview and Tracer. See Survey Process Guide, 5th Edition (SPG), page 70
(8)
Human Subject Research Leadership Interview. See Survey Process Guide, 5th Edition (SPG), page 123
(9)
Medical Student and Trainee Interview – See Survey Process Guide, 5th Edition (SPG), page 121.
(10) The Infection Prevention and Control System Tracer – does not require a presentation. The surveyor meets with members of your Infection Control Committee responsible for infection control (45 Min). Please provide data that pertains to any/all aspects of infection control. This session will be followed by a patient tracer with a focus on isolation precautions, and finally a visit to the Central Sterilizing Department and any other area for cleaning/decontamination/sterilization of equipment e.g. endoscopy, bronchoscopy, dental etc. See SPG 5th Edition, pages 82–84. (11) Human Subject Research Process Interview – See Survey Process Guide, 5th Edition (SPG), page 125 (12) Supply-Chain Management and Evidence-Based Purchasing Interview and Tracer – See Survey Process Guide, 5th Edition (SPG), page 65 (13) Ethical Framework and Culture of Safety Interview – See Survey Process Guide, 5th Edition (SPG), page 63 (14) Integration of Findings and Lunch – NOTE: All documents/ information must be submitted for consideration by 11:30 AM to be included in the Survey. Once the surveyors begin the integration of findings and scoring the standards, no additional information will be accepted. (15) Leadership Exit Report – The surveyors can provide an optional more detailed feedback to the leadership group, discussing the systems issues that were observed during the survey. The large meeting will be briefer and cover a summarized overview of findings of the survey
