Poa Jci 2024 - Rev00

POA (Plan Of
No Rencana Kegiatan
1 Pengukuran Indikator Mutu
2 Membuat Risk Regiter
3 Menentukan Clinical Pathway
4 Kick Off - JCI Commitment
Presentasi masing-masing Standard

5
BAB
Revisi SPO dengan template JCI

4
khusus untuk yang berbahasa Inggris
5 Ronde Mutu dan Keselamatan Pasien
Tindak Lanjut Ronde dan

6
Keselamatan Pasien
Edukasi dan simulasi penggunaan alat

7
-alat emergency
Edukasi dan simulasi penggunaan alat
7
-alat emergency
Simulasi bencana yang melibatkan

9
BPPD, Damkar
10 Simulasi code Blue
11 Quis JCI
12 Telusur Internal
13 Mork survey
14
Persiapan Initial survey
15
16 JCI Survey
POA (Plan Of Action) JCI Mutu RS Murni Teguh Tuban
Bulan Januari
Langkah – Langkah PIC
Mggu 1 2 3 4
Pengukuran Indikator Prioritas RS Irma
Revisi lembar kerja pengumpulan data mutu PJ Unit
Pengukuran Indikator Prioritas unit
Penambahan Indikator Mutu Prioritas Layanan baru
(Cath lab/DSA, Aesthetic Clinic)
Menyusun presentasi semua Indikator untuk JCI
Irma
presentation
Pengukuran Indikator Keselamatan Pasien
Irma
Identifikasi risiko, analisa Risiko
Menyusun FMEA dan RCA tahun 2024
Menentukan dan Menyusun Clinical Pathway
Melakukan sosialisasi dan pengukuran dr. Arimbawa/ Irma
Melakukan evaluasi kepatuhan implementasi Clinical
Pathway
Buat daftar acara Bu Agung /Sekretariat
Persiapkan banner untuk tanda tangan semua staf RS Pak Denny / PIC
Informasi agenda dan jadwal presentasi per Standard

Sekretariat
BAB setiap hari
Monitor penyelesaian hasil diskusi per standard
Bu Agung / Irma/
Translator
Daftar dokumen Lihat sheet berikutnya
PIC Bab
Menyiapkan cheklist ronde Bu Agung / Irma
Melakukan ronde dan koordinasi terkait temuan ronde

Bu Agung
klinis
Melakukan ronde dan koordinasi terkait temuan ronde

non klinis
staf memperagakan pemasangan laringoscope,pasang

face mask dan ambubag, test alat DC Shock, membuka
dan memasang oksigen pada trolly emergency PJ Unit
PJ Unit
Edukasi dan tindak lanjut berkala
simulasi penggunaan alat-alat medis

Diklat
mengajukan permohonan ke BPPD dan Damkar
Menyiapkan fasilitas simulasi dr Rama
Menentukan lokasi code blue Bu Agung
megajukan pertanyaan kepada staf medis dan non medis

tentang standar JCI
Bu Agung
Telusur Dokumen
Dr Ngurah/ All
Telusur Unit Kerja / Management Round
Manager
Melakukan simulasi survey
Menyusun Panitia
Menujuk penanggung jawab dokumen

Dr Putri
Menunjuk pendamping dan penghubung
Mengajukan biaya dan akomodasi
Dr. Ngurah and all

Persiapan presentasi direktur
management team
Mencari penterjemah Bu Agung / Dr. Putri
ALL PIC
Murni Teguh Tuban Bali Tahun 2024
Februari Maret April Mei Juni Juli Agustus

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1
Agustus September Oktober November Desember
2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3
FINAL SURVEY
esember
4
International Patient Safety Goals (IPSG)
In
Standard Standard Text Type of Document
English
The hospital develops and implements a process to

IPSG.1 Yes Policy/procedure
improve accuracy of patient identifications.

IPSG.2 improve the effectiveness of verbal and/or telephone Yes Policy/procedure
communication among caregivers.
The hospital develops and implements a process for

IPSG.2.1 Yes Policy/procedure
reporting critical results of diagnostic tests.
The hospital develops and implements a process for

handover communication.

IPSG.3 Yes Policy/procedure
improve the safety of high-alert medications.

IPSG.3.1 improve the safety of look-alike/sound-alike Yes Policy/procedure
medications.

manage the safe use of concentrated electrolytes.
The hospital develops and implements a process for the

IPSG.4 preoperative verification and surgical/ invasive Yes Policy/procedure
procedure site marking.
The hospital develops and implements a process for the

time-out that is performed immediately prior to the start
of the surgical/invasive procedure and the sign-out that
is conducted after the procedure.
The hospital adopts and implements evidence-based

IPSG.5 hand-hygiene guidelines to reduce the risk of health Yes Policy/procedure
care–associated infections.
Hospital leaders identify care processes that need
improvement and adopt and implement evidence-based
interventions to improve patient outcomes and reduce
the risk of hospital- associated infections.

IPSG.6 reduce the risk of patient harm resulting from falls for Yes Policy/procedure
the inpatient population.

IPSG.6.1 reduce the risk of patient harm resulting from falls for Yes Policy/procedure
the outpatient population.
Medication Management and Use (MMU)

In
English
The hospital identifies and documents a current list of

medications taken by the patient at home and reviews
MMU.4 Yes Policy/procedure
the list against all new medications prescribed or
dispensed.
The hospital identifies safe prescribing, ordering, and

MMU.4.2 transcribing practices and defines the elements of a Yes Policy/procedure
complete order or prescription.
The hospital establishes and implements a process for

MMU.7.1 reporting and acting on medication errors and near Yes Policy/procedure
misses (or close calls).
Access to Care and Continuity of Care (ACC)
In
English
The hospital establishes criteria for admission to and
ACC.2.3 discharge from departments/wards providing Yes Policy/procedure
intensive or specialized services
Patient-Centered Care (PCC)
In
English
The hospital establishes a process to ensure patient

privacy and confidentiality of care and information
PCC.1.3 and allows patients the right to have access to their Yes Policy/procedure
health information within the context of existing law
and culture.
Patient informed consent is obtained through a

process defined by the hospital and carried out by
PCC.4.1 Yes Policy/procedure
trained staff in a manner and language the patient can
understand.
Care of Patients (COP)
In
English
Clinical guidelines and procedures are established

COP.3.4 and implemented for the handling, use, and Yes Policy/procedure
administration of blood and blood products.
The transplant program obtains informed consent
COP.8.5 specific to organ transplantation from the transplant Yes Policy/procedure
candidate.
Transplant programs that perform living donor

transplants use clinical and psychological selection
COP.9.2 Yes Policy/procedure
criteria to determine the suitability of potential living
donors.
Anesthesia and Surgical Care (ASC)

In
English
The administration of procedural sedation is

ASC.3 Yes Program
standardized throughout the hospital.
Quality Improvement and Patient Safety (QPS)
Standard Standard Text In English Type of Document
The hospital uses a defined process for identifying

QPS.7 Yes Policy/procedure
and managing sentinel events.
An ongoing program of risk management is used to

identify and to proactively reduce unanticipated
QPS.10 Yes Program
adverse events and other safety risks to patients
and staff.
Prevention and Control of Infections (PCI)
The hospital designs and implements a

comprehensive infection prevention and control
PCI.4 program that identifies the procedures and Yes Program
processes associated with the risk of infection and
implements strategies to reduce infection risk.
The hospital identifies and implements a process

for managing the reuse of single-use devices
PCI.6.1 consistent with regional and local laws and Yes Policy/procedure
regulations and implements a process for managing
expired supplies.
Staff Qualifications and Education (SQE)
The hospital has a standardized, objective,

evidence-based procedure to authorize medical
SQE.10 staff members to admit and to treat patients and/or Yes Policy/procedure
to provide other clinical services consistent with
their qualifications.
The hospital uses an ongoing standardized process
SQE.11 to evaluate the quality and safety of the patient care Yes Written document
provided by each medical staff member.
Governance, Leadership, and Direction (GLD)
The structure and authority of the

hospital’s governing entity are
GLD.1 Yes Policy/procedure
described in bylaws, policies and
procedures, or similar documents.
Facility Management and Safety (FMS)
The hospital develops and implements

a program to provide a secure
FMS.6 Yes Program
environment for patients, families,
staff, and visitors.
Management of Information (MOI)
Documents, including policies,

procedures, and programs, are
MOI.7 Yes Written document
managed in a consistent and uniform
manner.
Sample Hospital Survey Agenda
Note: The following agenda serves as an example. The surveyor team may revise the arrangement of each session to better accomm
Hospital Survey Agenda (3 surveyors, 5 days)

DAY ONE
Time Physician Surveyor Nurse Surveyor
0745 – 0800 Team Meeting with Survey Coordinator and Translators (to discuss logistical support issues and r
0800 – 0820 Opening Conference and Agenda Review
0820 – 0900 Orientation to the Hospital’s Services
Document Review
0900 – 1200
(one room with separate working areas for each team member)
Surveyor Working Lunch

1200 – 1300
(private surveyor lunch for debriefing and survey planning)
1300 – 1400 Leadership for Quality, Patient Safety, Ethics, and Culture of Safety Interview
Individual Patient Individual Patient

1400 – 1600
Tracer Activity Tracer Activity
Meeting with Survey Coordinator

1600 – 1630
(as needed, to identify needs for the following day)
Surveyor Meeting
1630 – 1730
(private surveyor meeting for planning agenda activities for the following day; may be held in
Note: Individual Patient Tracer Activity may include Department/Service Quality Measurement Tracers and/or other tracer activit
DAY TWO
0800 – 0900 Daily Briefing
Individual Patient Tracer Individual Patient Tracer

0900 – 1200
Activity Activity
1200 – 1300
Medication Management
1300 – 1500 System Tracer, Including
Medication Supply Chain
Individual Patient Tracer
Activity
Undetermined Survey
Activity
1500 – 1600 (time may be used to
visit the pharmacy)
1600 – 1630
(as needed, identify needs for the following day)
Surveyor Meeting
1630 – 1730

DAY THREE
Organ and Tissue

Nursing and Other Clinical
Transplant Services
0900 – 1100 Staff Education Qualifications
Interview and Tracer (if
Session
applicable)
Undetermined Survey
1100 – 1200 Activity (Medical Transport Undetermined Survey Activity
as applicable)
Undetermined Survey
1100 – 1200 Activity (Medical Transport Undetermined Survey Activity
as applicable)

1200 – 1300
Infection Prevention and

Medical Staff Education
1300 – 1500 Control
Qualifications Session System Tracer
Individual Patient Tracer

1500 – 1600 Activity (Isolation Process at
Individual Patient Tracer unit level)
Activity

1600 – 1630
1630 – 1730 Surveyor Meeting

DAY FOUR
Closed Patient Medical Record Review (a

0900 – 1100 separate work area or separate room needed for each
surveyor)
Individual Patient
1100 – 1200 Patient Group Interview
Tracer Activity

1200 – 1300
1300 – 1430
1300 – 1430
Quality Program Interview Individual Patient
—Clinical Measures Tracer Activity
Individual Patient Individual Patient

1430 – 1600
Tracer Activity Tracer Activity
1600 – 1630
Surveyor Meeting
1630 – 1730

DAY FIVE
Individual Patient Tracer Individual Patient Tracer

0900 – 1100 Activity / Undetermined Activity / Undetermined
Survey Activity Survey Activity
1100 – 1200 Survey Integration and Report Preparation

1200 – 1300 Surveyor Working Lunch (private lunch for surveyors to integrate findings)
1300 – 1430 Survey Integration and Report Preparation (continuation)
1430 – 1500 Conference with Leadership to Review Exit Report Findings
1500 – 1530 Conference with Staff to Review Exit Report Findings
ospital Survey Agenda
am may revise the arrangement of each session to better accommodate the organization.
ey Agenda (3 surveyors, 5 days)

DAY ONE
Administrator
or and Translators (to discuss logistical support issues and requirements)
ening Conference and Agenda Review
Orientation to the Hospital’s Services
Document Review
h separate working areas for each team member)
veyor lunch for debriefing and survey planning)
, and Culture of Safety Interview
Facility Management and Safety Document Review and Facility Tour
eded, to identify needs for the following day)
Surveyor Meeting
anning agenda activities for the following day; may be held in hotel)
ment/Service Quality Measurement Tracers and/or other tracer activity.

DAY TWO
Administrator Surveyor
Daily Briefing
Facility Management and Safety Document Review and Facility Tour

(continued)
Facility Management and Safety System Tracer

eeded, identify needs for the following day)
Surveyor Meeting

DAY THREE
Daily Briefing
Facility Management and Safety Document Review
Undetermined Survey Activity (Laser/ Hemodialysis as applicable)

Undetermined Survey Activity (Laser/ Hemodialysis as applicable)
Individual Patient Tracer Activity
Surveyor Meeting

DAY FOUR
Daily Briefing
0900 – 1030
Quality Program Interview—Operations
1030 – 1200
Supply Chain Management and Evidence-Based Purchasing Interview

and Tracer
Supply Chain Management and Evidence-Based Purchasing Interview
and Tracer

Surveyor Meeting

DAY FIVE
Daily Briefing
Individual Patient Tracer Activity / Undetermined Survey Activity
rvey Integration and Report Preparation

Lunch (private lunch for surveyors to integrate findings)
egration and Report Preparation (continuation)
with Leadership to Review Exit Report Findings
nce with Staff to Review Exit Report Findings

Poa Jci 2024 - Rev00

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Poa Jci 2024 - Rev00

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Format Tersedia

POA (Plan Of

1 Pengukuran Indikator Mutu

2 Membuat Risk Regiter

3 Menentukan Clinical Pathway

4 Kick Off - JCI Commitment

Presentasi masing-masing Standard

Revisi SPO dengan template JCI

5 Ronde Mutu dan Keselamatan Pasien

Tindak Lanjut Ronde dan

Edukasi dan simulasi penggunaan alat

Simulasi bencana yang melibatkan

10 Simulasi code Blue

Buat daftar acara Bu Agung /Sekretariat

Informasi agenda dan jadwal presentasi per Standard

Monitor penyelesaian hasil diskusi per standard

Menyiapkan cheklist ronde Bu Agung / Irma

Melakukan ronde dan koordinasi terkait temuan ronde

Melakukan ronde dan koordinasi terkait temuan ronde

staf memperagakan pemasangan laringoscope,pasang

Edukasi dan tindak lanjut berkala

simulasi penggunaan alat-alat medis

Menyiapkan fasilitas simulasi dr Rama

Menentukan lokasi code blue Bu Agung

megajukan pertanyaan kepada staf medis dan non medis

Melakukan simulasi survey

Menujuk penanggung jawab dokumen

Mengajukan biaya dan akomodasi

Dr. Ngurah and all

Mencari penterjemah Bu Agung / Dr. Putri

Februari Maret April Mei Juni Juli Agustus

The hospital develops and implements a process to

The hospital develops and implements a process to

The hospital develops and implements a process for

The hospital develops and implements a process for

The hospital develops and implements a process to

The hospital develops and implements a process to

The hospital develops and implements a process to

The hospital develops and implements a process for the

The hospital develops and implements a process for the

The hospital adopts and implements evidence-based

The hospital develops and implements a process to

The hospital develops and implements a process to

Medication Management and Use (MMU)

The hospital identifies and documents a current list of

The hospital identifies safe prescribing, ordering, and

The hospital establishes and implements a process for

Patient-Centered Care (PCC)

The hospital establishes a process to ensure patient

Patient informed consent is obtained through a

Care of Patients (COP)

Clinical guidelines and procedures are established

Transplant programs that perform living donor

Anesthesia and Surgical Care (ASC)

The administration of procedural sedation is

Standard Standard Text In English Type of Document

The hospital uses a defined process for identifying

An ongoing program of risk management is used to

Prevention and Control of Infections (PCI)

Standard Standard Text In English Type of Document

The hospital designs and implements a

The hospital identifies and implements a process

Staff Qualifications and Education (SQE)

Standard Standard Text In English Type of Document