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Banjarbana 25 Februari 2017
n/NY
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Kepada Yth:
Peribal : LAPORAN YISIT BESAR
dM REKOMENDASI KHUSUS Direktur RS Daerah ldaman
Kota Banjarbaru
Lampiran, ...!....H#?.... -...
di-
Banjarbaru

Dengan Hormat
Assalaamu' alaikum Warahmatullahi Wabarakatu
Salam Akreditasi
Nabi
Segala puja puji senantiasa kita panjatkan kehadirat Allah SWT shalawat untuk
besar Muhammad SAW.

Bersama ini, kami tim akreditasi menyampaikan

LAPORAN VISIT BESAR dan
yang sudah kita ratcukan bersama pada
REKOMENDASI KHUSUS, dari kegiatan visit besar
hari kamis 23 Februari 2017lalu'
oleh 10 ketua
Kita ketahui bahwa dalam visite besar tadi telah dilalcukan asses
Instalasi Gawat Darurat (hanya satu instalasi saja
dari sekian
BAB/POKJAR terhadap
dari kepalaruang IGD'
banyak instruksi atau unit di Rumah Sakit ini), sertapemaparan

Permasalahan yang ditemukan, secara umum mengenai

:

maupun kualifikasi : Petugas admin

1. Petugas yang belum memadai, baik dari kuantitas
BTCLS, dll.
HPK, Manager on Duty, Case Manager, Sertifikasi ATLS,
Loker pasien' Name Tag petugas'
2. Sarana dan prasarana : Trolley Emergensi, X Banner,
kartu visitor, dll.
3. SOP, Alur Pelayanan Pasien: Triage, Labelling High
Alert
'dll'
kunjungan pasien' sensus harian
4. Dokumen-dokumen pencatatan, pelaporan : Laporan
respon time all.
Blue,
Pembentukan Tim-Tim : PONEK, Tim nyeri, Tim Code
d11'
5.
KHUSUS
untuk permasalahan tersebut maka telah disusun suatu REKOMENDASI
mana saja sebagai
(terlampir) dimana didalamnya berisi Unit Terkait serta Bidang
Bagi upaya terealisasi/terwujudnya
Penanggung Jawab dari poin-poin rekomendasi tersebut.
solusi dari masalah-masalah tersebut, tentu menjadi sangat
vital adalah upayalketerlibatan
langsung dari Kabid Pelayanan, Kabid Keperawatan, Kabid Penunjang dan KTU' serta KASI
UmKapnya dalam pelaksanaan serta evaluasinya'
seluruh dokumen
Untuk selanjutnya, padatanggal 25 Februari ini, kita mentargetkan
kelengkapan akreditasi sudah dapat diselesaikan dan
terkumpul. Dua minggu kedepan (14
mana hasil rekomendasi khusus
Maret z0l7) kita akan melaksanakan suatu evaluasi sejauh
ini dilaksanakan.
 h rk dTil rendorong terus pemahaman bahwa keberhasilan penilaian
iH s*fu ini sngat dipengaruhi oleh willing dari para manager Rumah sakit

Sein fit' dapat kami sampaikan disini, tim akreditasi akan melakukan
rapat
sdrci Yisit besar, rapat evaluasi akhir bulan serta rapat untuk menentukan BAB/POKJAR
ry sqia y'ang masih memerlukan studi banding ke Rumah Sakit Brigjen Hasan Basri
Krudagan.

Demikian laporan ini kami sampaikan atas perhatian,

dukungan dari Ibu Direktur
kami ucapkan terimakasih. Wassalamu' alaikum
Warahmatullatri Wabarakatu.

Ketua Akreditasi

NIP. 19700331 200212 1 010

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