Dr.dr.Sutoto.,M.

Kes
SUTOTO-KARS
 Curiculum Vitae: Dr.dr.Sutoto,MKes
TEMPAT/TGL LAHIR :PURWOKERTO, 21 JULI 1952

JABATAN SEKARANG:
1. Ketua KARS
2. Ketua umum PERSI
3. Dewan Pembina MKEK IDI Pusat
4. Dewan Pembina AIPNI (Asosiasi Institusi Pendidikan Ners Indonesia)
5. Anggota Komite Keselamatan Pasien Rumah Sakit Kementerian Kesehatan R.I
6. Dewan Penyantun RS Mata Cicendo,Pusat Mata Nasional

PENGALAMAN KERJA
1. Direktur Utama RSUP Fatmawati Jakarta 2001 - 2005
2. Direktur Utama RS Kanker Dharmais Jakarta 2005-2010
3. Sesditjen Binyanmed /Plt Dirjen BinYanmed Kemkes R.I. ( Feb- Juli 2010)
4. Direktur RSUD Banyumas Jawa Tengah 1992-2001

PENGALAMAN ORGANISASI

1. Ketua :IRSPI (Ikatan RS Pendidikan Ind) Th 2005-2008

2. Ketua :ARSPI (Asosiasi RS Pendidikan Ind) Th 2008-2010
3. Ketua IRSJAM (Ikatan RS Jakarta Metropolitan) 2008-2010

PENDIDIKAN:
1. SI dan Dokter Fakultas Kedokteran Univ Diponegoro
2. SII Magister Manajemen RS Univ. Gajahmada
SUTOTO-KARS
3. S III Manajemen Pendidikan Universitas Negeri Jakarta (Cumlaude)
 POKOK BAHASAN
1. SEJARAH AKREDITASI
2. MENGAPA AKREDITASI INTERNASIONAL
3. ISQua
4. MUNGKINKAN AKREDITASI INTERNASIONAL
OLEH KARS

SUTOTO-KARS
 Sejarah & Perkembangan
Akreditasi RS

1910 Flexner Report : Kualitas pelayanan RS rendah

Ernest Codman MD : End result system of hospital
standardization : Dokumentasi penatalaksanaan
setiap pasien, untuk peningkatan mutu pelayanan (Ernest Codman)

1913 American College of Surgeons (ACS) didirikan atas

upaya Franklin Martin MD. Sistem end result menjadi
tujuan ACS

1917 ACS menyusun Standar Minimal RS

(Franklin Martin)

4
1918 Akreditasi pertama RS : ACS mengadakan inspeksi
pada 692 RS hanya 89 yang memenuhi standar
minimal (ACS office
Chicago, 1920)
Standar Minimal :
Organisasi Staff Medis
Anggota profesional medis
Peer review untuk evaluasi mutu
1950 Mutu makin meningkat, lebih dari 3200 RS
memenuhi standar
1951 JCAH (Joint Commission on Accreditation of (JCAHO office
Chicago, 1990)
Hospitals) dibentuk oleh ACS, American College
Physicians, American Hospital Association,
American Medical Association, Canadian Medical
Association. 1987 JCAHO (J.C.A. of Healthcare Org)
5
1985 Didirikan ISQua = Intenational Society for Quality in
Health Care. 1995 Sekretariat di Australia
1954 ISQua menyelenggarakan Simposium Akreditasi dalam
International Conference of ISQua :
1994 di Treviso Italia, 1995 Canada, 1996 Jerusalem,
1997 Chicago,1998 Budapest,
1999 Melbourne : dibentuk ISQua ACCREDITATION
FEDERATION ALPHA Council

6
 ISQua
ISQuas International Accreditation
Programme (IAP) is the leading International
Health Care external evaluation programme of
its kind.
 ISQua ACCREDITATION

It 'Accredits the Accreditors' through three unique

programmes:
1. Accreditation of external evaluation
organisations and
2. Accreditation of health care standards
3. Accreditation of surveyor training
programmes

SUTOTO-KARS
 ISQua
Accreditation Federation
ALPHA Council
Standar internasional Survei Akreditasi,
1. Badan akreditasi Sertifikat Akreditasi
2. Standar
3. Training program
Badan Akreditasi Nasional
Independen
Self Assessment,
Survei Akreditasi, Sertifikat
Akreditasi

Rumah Sakit
/Sarana Yan Kes 9
International Standards for Healthcare Accreditation Bodies
Standard 1
Corporate Governance and
Strategic Directions
(Tata kelola organisasi &
Pengarahan )
1.1 Mission, Values and
Vision
1.2 Strategic Planning
1.3 Operational Planning
1.4 Leadership
1.5 Effective governance
1.6 External Relations
Standard 2
Organization and
Management performance
(Kinerja Organisasi &
Manajemen)
2.1 Interface of Governance
10
with Management 3.5 Staff Health and Safety
2.2 Quality Improvement
System Standard 4
2.3 Statutory Requirements Surveyor Selection,
2.4 Contracts and Supplies Development and
2.5 Client Relationships Deployment
2.6 Marketing (Seleksi, Pengembangan dan
Penyebaran Surveior)
4.1 Surveyor
Standard 3
Requirements
Human Resource
Management 4.2 Selection
(Manajemen SDM) 4.3 Orientation Training
3.1 Human Resource 4.4 Training, Support and
Planning Development
3.2 Recruitment, Selection 4.5 Performance Feedback
and Appointment 4.6 Credentialing and
Scope of Competence
3.3 Staff Development
3.4 Employee Relations 4.7 Surveyor Well-being
and Satisfaction
Standard 5 7.2 Planning for Survey 11

Financial and Resource 7.3 Survey Implementation

Management 7.4 Post-Survey
(Manajemen Keuangan & 7.5 Evaluation
Sumber Daya)
5.1 Financial Planning and Standard 8
Management
Accreditation Process (Proses
Akreditasi)
Standard 6 8.1 Scope of Accreditation
Information Management Program
(Manajemen Informasi)
8.2 Responsibilities for
6.1 Information Planning
Accreditation
6.2 Information
8.3 Maintenance of
Management
Accreditation
6.3 Information Resources
8.4 Accreditation
Documentation
Standard 7
8.5 Records
Survey Management
(Manajemen Survei)
7.1 Entry into the
Accreditation Program
 PRINSIP INDEPENDENSI SURVEIOR
DALAM ISQua
Batas-batas tanggung jawab dalam
organisasinya ditetapkan dengan jelas
diberitahukan kepada staf
memastikan bahwa staf dan surveior bebas
dari pengaruh pihak-pihak yang memiliki
kepentingan langsung dalam pelayanan dan
keputusan tentang akreditasi/ sertifikasi
 PRINSIP ETIKA DALAM ISQua
Semua pengambilan keputusan
dan perilaku dipandu oleh
seperangkat prinsip etika yang
tegas atau tata-perilaku termasuk
hal-hal berikut:
1. kerahasiaan informasi
tentang klien dan personalia
2. menghindari benturan
kepentingan
3. proses penanganan keluhan
4. independensi dan objektivitas
5. mendorong staf
memperhatikan etika.
Buktinya dapat meliputi:
informasi yang diperoleh selama
proses penilaian eksternal diamankan
pada semua tingkatan di organisasi,
termasuk komite-komite dan pihak
lain yang bertindak atas nama
organisasi tersebut
informasi tentang organisasi peserta
tertentu tidak diungkapkan kepada
pihak ketiga mana pun tanpa ijin
tertulis organisasi tersebut kecuali
kalau hukum mewajibkan pengung-
kapannya. Dalam hal ini organisasi
tersebut akan diberitahukan
 MENGAPA AKREDITASI
INTERNASIONAL ?
In some parts of the world, accessing healthcare can be very
expensive, even prohibitively so. While some countries have
elected to provide comprehensive healthcare services for all of
their populations, others appear to be satisfied with leaving
portions of their population without access to healthcare.
When it comes to who pays the bills for healthcare, it may be the
government or it may be the individual (sometimes either by
direct payment, and sometimes through employer-run schemes,
insurance companies etc.), or a combination of both.
However, healthcare can never be truly free someone
somewhere will always have to pay, and the payer will always
want the best value for money possible. "Affordability" of
healthcare can be the insurmountable hurdle for some human
beings. Value for money is hence another factor in assessing the
true quality of healthcare.

SUTOTO-KARS
 SURVEIOR KARS
5 Angkatan
Update 31 Agustus 2015

Surveior Jumlah
Manajemen 105
Medis 79
Keperawatan 54
Total 238

20
Sebaran Surveior Di Seluruh
Indonesia
Sebaran Rumah Sakit Terakreditasi
Di Seluruh Indonesia
Kantor KARS
Komisi Akreditasi Rumah Sakit
Epicentrum Walk - Unit 536, 716
Jl. HR Rasuna Said, Jakarta 12940
Telp: 56100008, 56100009, Fax: 29941317
Email: kars.akreditasi@kars.or.id
Ruangan Tamu
Ruangan Kerja Staf
Ruangan Kerja Staf
 LIST OF INTERNATIONAL HEALTHCARE
ACCREDITATION ORGANIZATIONS
USA: Joint Commission International
United Kingdom: QHA Trent Accreditation
Australia: Australian Council on Healthcare Standards
International (ACHSI)
New Zealand: Quality Health New Zealand (QHNZ)
Canada: Accreditation Canada
France: HAS (Haute Autorit de Sant)
Malaysia: Malaysian Society for Quality i n Healthcare
Indonesia: KARS (Komisi akreditasi Rumah
sakit/Indonesian Commission on
Accreditation of Hospital)SUTOTO-KARS
 Web based
Determination Accreditation Award Process

Surveyors Survey
Web
MJ, MD, PW Reports Upload Councilor process :
- Offline / Online
- Review reports
Secretariate - Submit
Input Web: Councilor Coordinator :
Councilors Name - Review
- Verify
- Approve

Councilor MJ
Secretariate
Exec Accreditation Counc
Councilor MD
Chairman Surveyor Email Status Coord
Coordinator Councilor PW
 Status Criteria Chapter
1. Access to Care and Continuity of Care
Paripurna 15 Ch @ (APK)
Excellence > 80% 2. Patient and Family Rights (HPK)
3. Assessment of Patients (AP)
4. Care of Patients (PP)
Utama 12 Ch @ 3 Ch 5. Anesthesia and Surgical Care (PAB)
Advance > 80% @ > 20% 6. Medication Management and Use (MPO)
7. Patient and Family Education (PPK)
8. Quality Improvement and Patient Safety
Madya 8 Ch @ 7 Ch (PMKP)
Intermediate > 80% @ > 20% 9. Prevention and Control of Infections (PPI)
10. Governance, Leadership, and Direction
(TKP)
11. Manajemen Fasilitas dan Keselamatan
11 Ch (MFK)
Dasar 4 Ch @ 12. Staff Qualifications and Education (KPS)
@ > 20%
Basic > 80% 13. Manajemen Komunikasi dan Informasi
(MKI)
14. Patient Safety Goals (SKP)
15. Millenium Development Goals (MDGs)
1. Patient and Family Rights (HPK)
Perdana 2. Prevention and Control of Infections (PPI)
4 Ch @ > 80%
Beginner 3. Staff Qualifications and Education (KPS)
4. Patient Safety Goals (SKP)
30
AKREDITASI INTERNASIONAL OLEH
KARS
MUNGKINKAH ?

SUTOTO-KARS
SUTOTO-KARS
PERMENKES NOMER 428 TAHUN 2012
 Rencana Logo
Sertifikat Akreditasi International oleh:
KARS
TERIMA KASIH

SUTOTO-KARS