SISTIMATIKA PAPARAN

 INTRODUKSI FMEA

 DELAPAN LANGKAH FMEA

 KESIMPULAN

HERKUTANTO 3
HERKUTANTO 4
KUALITAS PELAYANAN
(Donabedian)

HERKUTANTO 5
HERKUTANTO 6
SUMBER

HERKUTANTO 7
 Apakah itu FMEA ?
 metode perbaikan proses kinerja dgn
mengidentifikasi dan mencegah potensi
kegagalan sebelum terjadi.
 proses proaktif, dimana kesalahan dicegah &
diprediksi sebelum terjadi.

 BEDAKAN DENGAN RCA: proses reaktif setelah

kecelakaan terjadi pada suatu KTD

HERKUTANTO 8
 FMEA Terminology
 Process FMEA - Conduct an FMEA on a
process that is already in place

 Design FMEA – Conduct an FMEA before

a process is put into place
 Implementing an electronic medical records or
other automated systems
 Purchasing new equipment
 Redesigning Emergency Room, Operating
Room, Floor, etc.
HERKUTANTO 9
 FAILURE MODE AND EFFECTS ANALYSIS

FAILURE (F) : When a system or part of a system

performs in a way that is not
intended or desirable
MODE (M) : The way or manner in which
something such as a failure can
happen. Failure mode is the
manner in which something can
fail.
EFFECTS (E) : The results or consequences of a
failure mode
Analysis (A) : The detailed examination of the
elements or structure of a process
HERKUTANTO 10
HERKUTANTO 11
 LANGKAH-LANGKAH
ANALISIS MODUS KEGAGALAN & DAMPAKNYA
(JCI )

1. Tetapkan Topik FMEA dan Bentuk Tim

2. Gambarkan Alur Proses
3. Identifikas Modus Kegagalan & Dampaknya (Hazard Analysis)
4. Identifikas Prioritas Modus Kegagalan
5. Identifikasi Akar Penyebab Modus Kegagalan
6. Disain ulang Proses
7. Analisis dan Test Proses Baru
8. Implementasi dan Monitor Proses Baru
HERKUTANTO 12
 Output setiap langkah
LANGKAH OUTPUT
1 Tetapkan Topik FMEA dan Bentuk Tim Topik dan Tim
2 Gambarkan Alur Proses Alur Proses tergambar
3 Identifikasi Modus Kegagalan & Modus Kegagalan &
Dampaknya Dampaknya

4 Tetapkan Prioritas Modus Kegagalan Daftar Prioritas Modus

Kegagalan
5 Identifikasi Akar Penyebab Modus Akar Penyebab
Kegagalan Modus Kegagalan

6 Disain ulang Proses Proses Baru

7 Analisis dan Uji Coba Proses Baru Hasil Uji COba
8 Implementasi dan Monitor Proses Baru Penerapan Proses Baru
HERKUTANTO 13
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus

1 Kegagalan &
Dampaknya
4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang
Proses
7 Analisis dan Uji
Coba Proses
Baru
8 Implementasi dan
HERKUTANTO Monitor Proses
14

Baru
 TUJUAN & HASIL

 Terpilihnya Topik FMEA

 Terpilihnya TIM Pelaksana untuk topik
tersebut
 Daftar Tim

HERKUTANTO 15
 PEMILIHAN TOPIK FMEA
 Proses spesifik di rumah sakit:
 Highrisk
 Highvolume
 highcost

 Didasarkan pada data incident report

keselamatan pasien
 Data rutin keselamatan pasien
 Sentinel event

HERKUTANTO 16
 TUJUAN PEMILIHAN TOPIK
 Fokus pada proses spesifik yang
dianggap prioritas (hospital specific)
 Melakukan tindakan korektif pada proses
melalui redesign proses
 Contoh:
 Proses pelayanan Transfusi darah
 Proses pemberian obat kepada pasien

HERKUTANTO 17
 Characteristic of a high risk process
 Variable team
 Complex
 Non standardized
 Tightly coupled
 Heavily dependent on human intervention
 Hierarchical vs team
 Tight time constraints
 Loose time constraints

HERKUTANTO 18
 LANGKAH 1 : PILIH PROSES YANG BERISIKO TINGGI

Pilih Proses berisiko tinggi yang akan dianalisa.

Judul Proses :
__________________________________________________________________________
_________________________________________________________
_________________________________________________________
LANGKAH 2 : BENTUK TIM

Ketua :
____________________________________________________________

Anggota 1. _______________ 4.
________________________________________
2. _______________ 5.
________________________________________
3. _______________ 6.
________________________________________

Notulen? _________________________________________
Apakah semua Unit yang terkait dalam Proses sudah terwakili ? YA / TIDAK
Tanggal dimulai ____________________ Tanggal selesai ___________________

HERKUTANTO 19
 TIME LINE AND TEAM ACTIVITIES

Premeeting Identify Topic and notivy the team (Step 1 & 2)

1st team meeting Diagram the process, identify subprocess, verify the scope
2rd team meeting Visit the worksite to observe the process, verify that all process &
subprocess steps are correct (Step 3)
3 rd team meeting Brainstorming failure modes, assign individual team members to
consult with process users (Step 3)
4rd team meeting Identify failure modes causes, assign individual team members to
consult with process users for additional input (Step 3)
5th team meeting Transfer FM & Causes to the HFMEA Worksheet (Step3). Begin the
hazard analysis (Step 4)
Identify corrective actios and assign follow up responsibilities (Step 5)
6th,7th , 8th….η team Assign team members to follow up individual charged with taking
meeting plus 1 corrective action
η team meeting plus 2 Refine corrective actions based on feedback
η team meeting plus 3 Test the proposed changes
η team meeting plus 4 Meet with Top Management to obtain approval for all actions
Postteam meeting The advisor or his/ her designee follow up until all actions are
completed
HERKUTANTO 20
1. Tetapkan topik: Transfusi Darah
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus

2 Kegagalan &
Dampaknya
4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang
Proses
7 Analisis dan Uji
Coba Proses
Baru
8 Implementasi dan
HERKUTANTO Monitor Proses
22

Baru
 TUJUAN & HASIL
 Tergambarnya alur / langkah2 PROSES
dan SUBPROSES pelayanan yang dipilih
dalam suatu bagan yang jelas
 LEMBAR ALUR
PROSES dan SUBPROSES PELAYANAN

HERKUTANTO 23
HERKUTANTO 24
HERKUTANTO 25
HERKUTANTO 26
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim

2 Gambarkan Alur
Proses
3 Identifikasi Modus

3
Kegagalan &
Dampaknya

4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan

6 Disain ulang Proses

7 Analisis dan Uji

Coba Proses Baru

8 Implementasi dan
HERKUTANTO
Monitor Proses27Baru
27
 TUJUAN & HASIL
1. Teridentifikasinya MODUS KEGAGALAN
pada setiap langkah proses pelayanan

2. Teridentifikasinya DAMPAK KEGAGALAN

pada setiap langkah proses pelayanan

HERKUTANTO 28
 HAZARD vs RISK vs.
COMPLICATIONS
1. A hazard is something that can cause harm, e.g. electricity, chemicals,
working up a ladder, noise, a keyboard, a bully at work, stress, etc. [...
tindakan medik ...??]
2. Complications are things that happen as a result of a disease or a
treatment that you prefer didn't happen [stroke from hypertension, or
bleeding following surgery]
 A complication may be described as an adverse event caused by pre-
existing factors that were outside the doctor’s control. Patients are not the
same in health, habits, immunity or healing power, and have varying susceptibility
to complications
3. A risk is the chance, high or low, that any hazard will actually cause
somebody harm.
 Risk factors are things that make it more likely that you will develop a
disease or condition. They may be things you can't do anything about, like
gender, family history, or race, or things you can control, like smoking and
diet. HERKUTANTO 29
DIFFERENCES BETWEEN RISKS vs COMPLICATIONS

RISKS COMPLICATIONS
 Allergy  Anaphylactic Rx

 Leucocytosis  Sepsis

 Bleeding  Hypovolemic shock

 Fragile tissues  Tissue damage

 Naucea / vomit  Hyponatraemia

HERKUTANTO 30
 Hazard analysis: What is it?

Hazard: Potentially dangerous condition,

which is triggered by an event,
called the cause of the hazard.

Risk: hazard that is associated with a

severity and a probability of
occurrence.
HERKUTANTO 31
Hazard, Barrier, Target Analysis

Hazard Barrier Target

High
Dog Fence Child

HERKUTANTO 32
HERKUTANTO 33
HERKUTANTO 34
HERKUTANTO 35
HERKUTANTO 36
HERKUTANTO 37
Hazard, Barrier, Target Analysis

Hazard Barrier Target

Medical Policies
Procedures Patient
Mishaps

HERKUTANTO 38
 PENERAPAN HBA PADA FMEA
 Prinsip: the DEVILS are in the DETAILS

 Cari modus / cara suatu langkah dalam

suatu subproses dapat gagal

HERKUTANTO 39
 DIAGRAM THE PROCESS

PROCESS STEPS :
Describe the process graphically, according to your policy & procedure for the activity and number each one
If the process is complex you may want to select one process step or sub process to work on

1 2 3 4 5

Prescribing, Preparing
Selection & Storage
Ordering, &
Procurement Administration
Trancribing Dispensin
g

Failure Mode Failure Mode Failure Mode Failure Mode Failure Mode

Pemesanan obat Penyimpanan Penulisan obat Peracikan obat Wrong drug

Berlebihan (tdk vaksin tdk dlm R/ tdk jls tdk sesuai dosis
Sesuai kebthn) sesuai suhunya
Wrong dosage

Penulisan Obat R/
tdk R/
Dlm formularium Wrong frequence

Wrong route
administration

HERKUTANTO 40
 Hazard analysis: What is it?

Hazard analysis: Identify all possible

hazards potentially created by a
product, process or application.

Risk assessment: It is the next step

after the collection of potential hazards.
Risk in this context is the probability and
severity of the hazard becoming reality .
HERKUTANTO 41
 Hazard analysis: What is it?

General risk assessment

protocol : E s t a b li s h A n a l y s i s P a r a m e t e r s

I d e n t ify H a z a r d s

A s s e s s R is k s

D e riv e R is k R a tin g

R e d u c e R is k s

V e r i f y E f f e c t iv e n e s s

HERKUTANTO 42
D o c u m e n t R e s u lts
 Hazard analysis: What is it?

E s t a b li s h A n a l y s i s P a r a m e t e r s

Id e n tify H a z a r d s These parameters can

be limits of the
A s s e s s R is k s
machine or design,
D e riv e R is k R a tin g limits on uses, limits
R e d u c e R is k s
on the scope of the
analysis, or other
V e r i f y E f f e c t iv e n e s s
limits.
D o c u m e n t R e s u lts HERKUTANTO 43
 Hazard analysis: What is it?

E s t a b li s h A n a l y s i s P a r a m e t e r s

I d e n t ify H a z a r d s The nature of this

step lends itself to a
A s s e s s R is k s
team approach such
D e riv e R is k R a tin g as brainstorming.
R e d u c e R is k s

V e r if y E f f e c t iv e n e s s

D o c u m e n t R e s u lts HERKUTANTO 44
 Hazard analysis: What is it?

E s t a b li s h A n a l y s i s P a r a m e t e r s

Id e n t ify H a z a r d s
Two risk factors are used:
A s s e s s R is k s
• severity of injury
D e riv e R is k R a tin g
• probability of occurrence
R e d u c e R is k s

V e r i f y E f f e c t iv e n e s s

D o c u m e n t R e s u lts HERKUTANTO 45
 Hazard analysis: What is it?

E s t a b li s h A n a l y s i s P a r a m e t e r s
Risk matrix:
I d e n t ify H a z a r d s Severity Category
Probability Level Catastrophic Critical Marginal Negligible
A s s e s s R is k s Frequent High High Serious Serious
Probable High High Serious Low
D e riv e R is k R a tin g Occasional High Serious Low Low
Remote Serious Low Low Low
R e d u c e R is k s Improbable Serious Low Low Low

If the risk is determined to not be acceptable, it

V e r i f y E f f e c t iv e n e s s
is necessary to reduce that risk by
implementing protective measures.
D o c u m e n t R e s u lts HERKUTANTO 46
 Hazard analysis: What is it?

E s t a b li s h A n a l y s i s P a r a m e t e r s
I d e n t ify H a z a r d s
A s s e s s R is k s
D e riv e R is k R a tin g
R e d u c e R is k s
V e r if y E f f e c t iv e n e s s
Remedy actions are taken to
reduce risks following the
hazard hierarchy:
• Eliminate hazards through the design
 Protect
 Warn the user
 Train the user(s)
 Personal protective equipment

D o c u m e n t R e s u lts HERKUTANTO 47
 Hazard analysis: What is it?

E s t a b li s h A n a l y s i s P a r a m e t e r s

I d e n t ify H a z a r d s This assessment

verifies that the
A s s e s s R is k s
remedy actions have
D e riv e R is k R a tin g reduced the risks to an
R e d u c e R is k s
acceptable level.

V e r if y E f f e c t iv e n e s s

D o c u m e n t R e s u lts HERKUTANTO 48
 Hazard analysis: What is it?

E s t a b li s h A n a l y s i s P a r a m e t e r s

I d e n t ify H a z a r d s

A s s e s s R is k s

D e riv e R is k R a tin g

R e d u c e R is k s The documentation can be added to a

technical file for future use.

V e r if y E f f e c t iv e n e s s

D o c u m e n t R e s u lts HERKUTANTO 49
 Full Hazard Analysis
Proactive Controls Reactive Controls

Recovery People
Threat Barrier Barrier Measures

Recovery Asset
Threat Barrier Barrier Measures Damage
Hazard Top Event
(Incident)
Recovery Environment
Threat Barrier Barrier Measures

Recovery
Measures Reputation
Escalation
controls

HERKUTANTO 50
 Completed Hazards & Effects Register

HAZARDS & EFFECTS REGISTER

Risk
Hazard ThreatsBarriers Top Recovery Consequences Rating Initial Final Remedial
Event Measures Risk Risk Action
P A E R Required

C5
X X X X X X X X X X D4,5 X
E3,4,5

X X X X X X X X

C5
X X X X X X X X X X D4,5
E3,4,5

X X X X X X X X X
HERKUTANTO 51
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim

2 Gambarkan Alur
Proses

3 Identifikasi Modus

4
Kegagalan &
Dampaknya

4 Tetapkan Prioritas
Modus Kegagalan

5 Identifikasi Akar
Penyebab Modus
Kegagalan

6 Disain ulang Proses

7 Analisis dan Uji

Coba Proses Baru

8 Implementasi dan
Monitor Proses Baru
HERKUTANTO 52
 TUJUAN & HASIL
 Tersedianya urutan prioritas
 DAFTAR PRIORITAS MODUS
KEGAGALAN

HERKUTANTO 53
HERKUTANTO 54
 ANALISIS HAZARD “LEVEL DAMPAK”
DAMPA MINOR MODERAT MAYOR KATASTROPIK
K 1 2 3 4
Kegagalan yang tidak Kegagalan dapat Kegagalan Kegagalan menyebabkan
mengganggu Proses mempengaruhi menyebabkan kerugian kerugian besar
pelayanan kepada proses dan berat
Pasien menimbulkan
kerugian ringan

Pasien Tidak ada cedera, Cedera ringan Cedera luas / berat  Kematian
Tidak ada Ada Perpanjangan Perpanjangan hari  Kehilangan fungsi tubuh
perpanjangan hari rawat rawat secara permanent (sensorik,
hari rawat lebih lama (+> 1 bln) motorik, psikologik atau
Berkurangnya fungsi intelektual) mis :
permanen organ tubuh  Operasi pada bagian atau
(sensorik / motorik / pada pasien yang salah,
psikcologik /  Tertukarnya bayi
intelektual)

Pengunj Tidak ada cedera  Cedera ringan  Cedera luas / berat Kematian
ung Tidak ada  Ada Penanganan  Perlu dirawat Terjadi pada > 6 orang
penanganan ringan  Terjadi pada 4 -6 pengunjung
Terjadi pada 1-2 org  Terjadi pada 2 -4 orang
pengunjung pengunjung pengunjung

Staf: Tidak ada cedera Cedera ringan Cedera luas / berat Kematian
Tidak ada  Ada Penanganan /  Perlu dirawat Perawatan > 6 staf
penanganan Tindakan Kehilangan waktu /
HERKUTANTO 55
Terjadi pada 1-2 staf  Kehilangan kecelakaan kerja pada
Tidak ada kerugian waktu / kec kerja : 4-6 staf
 ANALISIS HAZARD ”LEVEL PROBABILITAS”

LEVEL DESKRIPSI CONTOH

4 Sering (Frequent) Hampir sering muncul dalam waktu yang
relative singkat (mungkin terjadi
beberapa kali dalam 1 tahun)

3 Kadang-kadang Kemungkinan akan muncul

(Occasional) (dapat terjadi bebearapa kali dalam 1
sampai 2 tahun)

2 Jarang (Uncommon) Kemungkinan akan muncul

(dapat terjadi dalam >2 sampai 5 tahun)

1 Hampir Tidak Pernah Jarang sekali terjadi (dapat terjadi dalam

(Remote) > 5 sampai 30 tahun)

HERKUTANTO 56
 HAZARD SCORE
TINGKAT BAHAYA
KATASTROPIK MAYOR MODERAT MINOR
4 3 2 1

SERING 16 12 8 4
4

KADANG 12 9 6 3
3

JARANG 8 6 4 2
2

HAMPIR TIDAK 4 3 2 1
PERNAH
1

HERKUTANTO 57
HERKUTANTO 58
HERKUTANTO 59
Laboratory Test Ordering Process

HERKUTANTO 60
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus

5 Kegagalan &
Dampaknya
4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang
Proses
7 Analisis dan Uji
Coba Proses
Baru
8 Implementasi dan
HERKUTANTO Monitor Proses
61

Baru
 TUJUAN & HASIL
 Teridentifikasinya AKAR PENYEBAB
modus kegagalan yang telah
teridentifikasi
 Lembar AKAR PENYEBAB

HERKUTANTO 62
 Possible Characteristics of Root
Causes

 Root causes are systemic.

 Root causes appear far from the origin of

the failure.

 The origins of root causes lie in common-

cause variation of organization systems
HERKUTANTO 63
 many of the failure modes
had the same root causes
 Omission errors secondary to automatic stop order
 Suboptimal patient involvement in medication histories
 Suboptimal medication reconciliation by clinicians
 Confusing epidural and patient-controlled analgesia
order sets
 Lack of electronic medication administration record
 Lack of computerized order entry

HERKUTANTO 64
 PROBING
to uncover root causes and their relationships

 What could happen? (the failure mode)

 Why could this happen?
 That is, what are the most proximate causes? These
typically involve special-cause variations.

 Why could these proximate causes happen?

 That is, what systems and processes underlie those
proximate causes?
 Common-cause variation here may lead to special-
cause variation in dependent processes.
HERKUTANTO 65
What could happen? - FACTORS
 Human factors
 failure to follow policieson precaution orders or failure
to conduct appropriate staff education/training

 Assessment process factors

 faulty initial assessment process

 Equipment factors
 nonfunctional paging system that delays
communication with the individual’s physician
HERKUTANTO 66
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus

6 Kegagalan &
Dampaknya
4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang
Proses
7 Analisis dan Uji
Coba Proses
Baru
8 Implementasi dan
HERKUTANTO Monitor Proses
67

Baru
 TUJUAN & HASIL
 Teridentifikasinya PROSES BARU yang
bebas dari modus kegagalan
 Lembar langkah2 PROSES BARU

HERKUTANTO 68
 Decision Tree
Gunakan Decision Tree utk menentukan apakah modus perlu tindakan lanjut di“Proceed”.

Does this hazard involve a

sufficient likelihood of
occurrence and severity to NO
warrant that it be controlled?
(Hazard score of 8 or
higher)
Is this a single point weakness in
NO
YES the process? (Criticality – failure
results in a system failure?)
CRITICALITY
YES
Does an effective control measure already exist YES
for the identified hazard? STOP
CONTROL THE HAZARD (=BARRIER) Do not proceed
NO to find potential
causes for this
Is this hazard so obvious and readily failure mode
apparent that a control measure is not YES
warranted?
DETECTABILITY NO
(FORESEEABILITY)
Proceed to Potential
HERKUTANTO
Causes for this 69
failure mode
 PREPARING TO REDESIGN

 Conduct a literature search to gather

relevant information from the professional
literature. Do not reinvent the wheel
 Network with colleagues
 Recommit to out of the box thinking

HERKUTANTO 70
 REDESIGN STRATEGIES
 Prevent the failure from happening
(decrease likelihood of occurrence )
 Prevent the failure from reaching the
individual (increase detectability)
 Protect individuals if a failure occurs
(decrease the severty of the efects)

HERKUTANTO 71
 PROSES METODE
RISIKO TINGGI REDESIGN
 Variable input
 Decreasing variability
 Complex  Simplify
 Nonstandarized  Standardizing
 Tightly Coupled  Loosen coupling of process
 Dependent on  Use technology
human intervention  Optimise Redundancy
 Built in fail safe
 Time constraints
mechanism
 Hierarchical culture  Documentation
 Establishing a culture of
teamwork

HERKUTANTO 72
 REDESIGN PROCESS
Process Failure Potential Potential Redesign PIC Target New Outcome
Mode Effect Causes Recommend Completi Process Measure /
ations on Implementa Monitoring
date tion mechanism
for test date &
Actions

1 2 3 4 5 6 7 8 9

HERKUTANTO 73
 Proses
Redesign

Bandingkan :

Analisis & Ranking Analisis & Ranking

Failure Failure
Effect Causes Effect Causes
Mode Mode

Proses Lama Proses Baru

HERKUTANTO 74
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus

7 Kegagalan &
Dampaknya
4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang
Proses
7 Analisis dan Uji
Coba Proses
Baru
8 Implementasi dan
HERKUTANTO Monitor Proses
75

Baru
 TUJUAN & HASIL
 Terujinya PROSES BARU dilapangan
 Le

HERKUTANTO 76
SIKLUS PDSA

HERKUTANTO 77
SIKLUS PDSA

HERKUTANTO 78
 LEMBAR KERJA
UJI COBA

HERKUTANTO
79
 LEMBAR KERJA
UJI COBA

HERKUTANTO
80
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus

8 Kegagalan &
Dampaknya
4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang
Proses
7 Analisis dan Uji
Coba Proses
Baru
8 Implementasi
HERKUTANTO dan Monitor 81
Proses Baru
 TUJUAN & HASIL
 PENERAPAN PROSES BARU
 Manajemen Perubahan

 Lembar MONITORING PROSES BARU

HERKUTANTO 82
 Strategies for Creating and Managing
the Change Process
 Establish a sense of urgency
 Create a guiding coalition
 Develop a vision and strategy
 Communicate the changed vision
 Empower broad-based action
 Generate short-term wins
 Consolidate gains and produce more change
 Anchor new approaches in the culture
HERKUTANTO 83
LEMBAR MONITOR PROSES BARU

HERKUTANTO 84
LEMBAR MONITOR PROSES BARU

HERKUTANTO 85
 KESIMPULAN
 PROSES BARU YANG LEBIH AMAN

 KEBIJAKAN & SOP LEBIH BAIK

 RUMAH SAKIT YANG AMAN

HERKUTANTO 86
HERKUTANTO 87
HERKUTANTO 88