CURRICULUM VITAE

DATA PRIBADI
Nama : dr.ADIB ABDULLAH YAHYA,MARS
Pangkat : Brigjen TNI (Purn)
Tempat/tanggal lahir : Magelang,16 Februari 1949
Jabatan : DIREKTUR UTAMA RUMAH SAKIT MMC
Agama : Islam
ALAMAT : Jl. Punai H-24,Kel.Tengah,Jakarta Timur – 13540
Telp : (021)8404580
Fax : (021) 8408047
HP : 08161803497
E-MAIL : adibabdullahyahya@yahoo.com
PENDIDIKAN UMUM
SMA Negeri Magelang 1966
S1 : Fakultas Kedokteran Universitas Gajah Mada (UGM),
Yogyakarta, 1973
S2 : Fakultas Kesehatan Masyarakat, Universitas Indonesia (UI), Jakarta,
Program Kajian Administrasi Rumah Sakit ( KARS )

PENDIDIKAN MILITER
Sekolah Staf dan Komando TNI Angkatan Darat (SESKOAD), 1987/1988

PENGHARGAAN :

1. TNI : SATYA LENCANA KESETIAAN 24 TAHUN

SATYA LENCANA DWIJA SISTHA
2. FK UGM : ALUMNUS BERPRESTASI (TAHUN 2000 dan 2013)
3. PERSI : PARAMAKARYA SATYA HUSADA (TAHUN 2012)
4. MARKPLUS : JABODETABEK MARKETING CHAMPION SECTOR HOSPITAL TAHUN 2017
5. KARS : INOVATOR & MOTIVATOR PATIENT SAFETY DI INDONESIA (TAHUN 2018)

1
PENGALAMAN JABATAN
Komandan Detasemen Kesehatan Pasukan Pengamanan Presiden (Paspampres), 1987-1991
Kepala Rumah Sakit “Muhammad Ridwan Meuraksa”, Jakarta, 1992
Kepala Kesehatan Daerah Militer (Kakesdam) Jaya, Jakarta, 1993
Komandan Pusat Pendidikan Kesehatan TNI – AD,1995 – 1999
Wakil Kepala Pusat Kesehatan TNI, 1999 – 2000
Kepala RSPAD Gatot Soebroto, 2000 – 2002
Dekan Fakultas Kedokteran UPN, Jakarta, 2000 – 2002
Wakil Ketua Tim Dokter Kepresidenan RI, 2000 – 2002
Direktur Kesehatan TNI Angkatan Darat (Dirkesad), 2002-2004
Wakil Ketua Tim Pemeriksaan kesehatan untuk calon Presiden dan calon Wakil Presiden RI Th.2004
DOSEN Pasca Sarjana FKM UI, Kajian Administrasi Rumah Sakit (KARS)
DOSEN Pasca Sarjana ,Prodi Biomedical Engineering, UI
DIREKTUR UTAMA RUMAH SAKIT MMC

ORGANISASI
Ketua Ikatan Rumah Sakit Jakarta Metropolitan (IRSJAM), 2000-2003
Ketua Umum Perhimpunan Rumah Sakit Seluruh Indonesia ( PERSI), 2003-2009
PRESIDENT OF ASIAN HOSPITAL FEDERATION ( AHF ) 2009 – 2011
Anggota Komnas FBPI.
Surveyor KARS
Ketua Umum PERMAPKIN
Ketua Komtap Bidang Kebijakan Kesehatan KADIN Indonesia
Angggota TNP2K.
Dewan Pakar Perhimpunan Rumah Sakit Seluruh Indonesia ( PERSI)
Dewan Pakar IDI
Anggota Majelis Kehormatan Etik Kedokteran (MKEK) IDI Pusat
Tim Konsultan Institut Manajemen Risiko Klinis ( IMRK )
Anggota KNKPRS
Koordinator Bidang 1 : KAJIAN KESELAMATAN PASIEN, IKPRS- PERSI
Instruktur HOPE ( Hospital Preparedness for Emergencies and Disasters} 2
 1

MANAJEMEN FASILITAS
DAN KESELAMATAN ( SAFETY )

Dr. ADIB A YAHYA, MARS

29 SEPT 2018
 PENGERTIAN

Fasilitas adalah segala sesuatu hal yang menyangkut

Sarana, Prasarana maupun Alat (baik alat medik
maupun alat non medik) yang dibutuhkan oleh rumah
sakit dalam memberikan pelayanan yang sebaik-baiknya
bagi pasien
Sarana : segala sesuatu benda fisik yang dapat tervisualisasi oleh
mata maupun teraba panca indera dan dengan mudah dapat
dikenali oleh pasien dan umumnya merupakan bagian dari suatu
bangunan gedung ( pintu, lantai, dinding, tiang kolong gedung,
jendela) ataupun bangunan itu sendiri.

Prasarana adalah seluruh jaringan/instalasi yang membuat suatu

sarana bisa berfungsi sesuai dengan tujuan yang diharapkan,
anatara lain, instalasi air bersih dan air kotor, instalasi listrik, gas
medis, komunikasi, pengkondisian udara dll
Keselamatan : Suatu tingkatan keadaan tertentu dimana
gedung, halaman/ground dan peralatan rumah sakit
tidak menimbulkan bahaya atau risiko bagi pasien, staf
dan pengunjung.

Keamanan : Proteksi dari kehilangan, pengrusakan dan

kerusakan, atau akses serta penggunaan oleh mereka
yang tidak berwenang.
 Hospital
Hospitals are historically unsafe places to work.
Experience indicates that the injury rate at medical care facilities is
higher than the rate at many industries.
Most of the injuries result from slips, trips, and falls or from using
incorrect lifting techniques, especially when lifting patients.
Therefore, hospital staff must exercise great care in protecting
themselves and ensuring a safe environment for
the patients as well as those who enter the hospital.
The staff must be alert and identify any hazards in order to
provide an environment free from unsafe acts or unsafe conditions.
To accomplish this goal, all levels of the hospital staff,
functional managers, supervisors, and
employees must be vigilant in the performance of their
jobs to eliminate practices or conditions that could result in
injury to patients, visitors, or employee’s damage/loss to property.
 8
Historically hospitals were
not the safest places

William Penn – first US hospital in 1713.

 How dangerous is health care?
Less than one death per 100 000 encounters
- Nuclear power
- European railroads
- Scheduled airlines
One death in less than 100 000 but more than 1000 encounters
- Driving
- Chemical manufacturing
More than one death per 1000 encounters
- Bungee jumping
- Mountain climbing
- Health care
 How Hazardous Is Health Care?

DANGEROUS REGULATED ULTRA-SAFE

(>1/1000) (<1/100K)
100,000
HealthCare Driving
Total lives lost per year

10,000

1,000
Scheduled
Airlines
100
Mountain Chemical European
Climbing Manufacturing Railroads
10
Bungee Chartered Nuclear
Jumping Flights Power
1
1 10 100 1,000 10,000 100,000 1,000,000 10,000,000

Number of encounters for each fatality

Death associated with medication error
Source: Leape
Hospital Facility Management
and Safety
 introduction
The hospital infrastructure has thousands of
pieces of equipment and system parts,
ranging from massive boilers, switch-gear,
and uninterruptible power supplies (UPS), to
sensors that go virtually unnoticed.

So how can ensure the hospital building is

safe and has the ability to offer uninterrupted
care for the long term?
Critical equipment failure brings
unexpected costs and the possible loss
of revenue-generating services.
It can significantly impact patient
care/satisfaction and employee safety,
while increasing exposure to litigation
and negative public relations
Environment of Care standards require
hospitals to maintain their buildings and
understand the health of their utility
systems.
Another concern is during times of climatic
disasters, people often make it a point to
head to local hospitals in the hopes of
finding safety from the storm.
These problems are made worse if the
natural disaster shuts down the electricity
in the region and issues with generators
have raised some questions in regards to
hospital safety problems during times of
natural disaster.
Another safety challenges during disaster
for hospitals are the loss of services
Other issues include the loss of infrastructure,
such as electronic records, a shortage of
workforce due to transportation loss, or injury, or
illness, as well as a drastic increase in the
number of patients with severe illnesses or
injuries.

Even a relocation of care to an alternate location

is not enough to help, as it will not be well
equipped enough for the influx of patients.
 Facility Management and Safety

Nine topics :

(1) Leadership and Planning,

(2) Safety and Security,
(3) Hazardous Materials,
(4) Disaster Preparedness,
(5) Fire Safety,
(6) Medical Technology,
(7) Utility Systems,
(8) Facility Management Program Monitoring, and
(9) Staff Education.
 (1)
Leadership and Planning:
Local authorities’ laws, regulations, and inspections determine in large
part how a facility is designed, used, and maintained.

All hospitals, regardless of size and resources, must comply with

these requirements as part of their responsibilities to their patients,
families, staff, and visitors.

Hospitals begin by complying with laws and regulations.

Hospital leadership, including governance and senior management, are

responsible for knowing what national and local laws, regulations, and
other requirements apply to the hospital’s facilities; implementing the
applicable requirements or approved alternative requirements; and
planning and budgeting for the necessary upgrading or replacement as
identified by monitoring data or to meet applicable requirements and
providing evidence of progress toward implementing the improvements.
Hospital leadership takes responsibility for planning for and
meeting the requirements in the prescribed time frame.

To manage the risks within the environment in which

patients are treated and staff work requires planning.

When the hospital has non-hospital entities within the

patient care facilities to be surveyed (such as an
independently owned coffee shop or gift shop), the hospital
has an obligation to ensure that these independent entities
comply with the facility management and safety programs.

Hospitals work to provide safe, functional, and supportive

facilities for patients, families, staff, and visitors.
The hospital develops one master program or individual programs
that include :

a) Safety and Security.

Safety—the degree to which the hospital’s buildings, grounds, and
equipment do not pose a hazard or risk to patients, staff, and visitors
Security—Protection from loss, destruction, tampering, or
unauthorized access or use;
b) Hazardous materials—Handling, storage, and use of radioactive
and other materials are controlled, and hazardous waste is safely
disposed; 
c) Emergencies—Response to epidemics, disasters, and emergencies
is planned and effective;
d) Fire safety—Property and occupants are protected from fire and
smoke;
e) Medical technology—Technology is selected, maintained, and used
in a manner to reduce risks;
f) Utility systems—Electrical, water, and other utility systems are
maintained to minimize the risks of operating failures.
Hospitals need to develop a facility/environment risk
management program that addresses managing
environmental risk through the development of facility
management plans and the provision of space, technology,
and resources.

One or more individuals provide oversight to the program. In

a small hospital, one individual may be assigned part-time. In
a larger hospital, several engineers or other specially trained
individuals may be assigned.
Program oversight includes:
a) planning all aspects of the program, such as
development of plans and providing recommendations for space,
technology, and resources;
b) implementing the program;
c) educating staff;
d) testing and monitoring the program;
e) periodically reviewing and revising the program;
and
f) providing annual reports to the governing body on the
effectiveness of the program.

Depending on the hospital’s size and complexity, a

facility/environment risk committee may be formed and given
responsibility for overseeing the program and program continuity
Actions :

1.     The hospital complies with relevant laws, regulations, and

facility inspection requirements.
2.     The hospital develops and maintains a written program(s)
describing the processes to manage risks to patients, families,
visitors, and staff.
3.     One or more qualified individuals oversee the planning
and implementation of the facility management program to reduce
and control risks in the care environment.
 (2)
Safety and Security:
Safety refers to ensuring that the building, property, medical and
information technology, equipment, and systems do not pose a physical
risk to patients, families, staff, and visitors.

Security, on the other hand, refers to protecting the organization’s

property and the patients, families, visitors, and staff from harm.

Prevention and planning are essential to creating a safe and supportive

patient care facility.

Effective planning requires the hospital to be aware of all the risks

present in the facility.

The goal is to prevent accidents and injuries; to maintain safe and secure
conditions for patients, families, staff, and visitors; and to reduce and to
control hazards and risks.
As part of the safety program, the hospital develops and implements a
comprehensive, proactive risk assessment to identify areas
in which the potential for injury exist.

Examples of safety risks that pose a potential for injury or harm include
sharp and broken furniture, linen chutes that do not close properly,
broken windows, water leaks in the ceiling, and locations where there is
no escape from fire.

In addition to the safety program, the hospital must have a security

program to ensure that everyone in the hospital is protected from
personal harm and from loss or damage to property.
This is also important during periods of construction or
renovation.

Construction and renovation pose additional risks to the safety of

patients, families, visitors, and staff, and include risk related to infection
control, ventilation, traffic flow, garbage/refuse, and other risks.

A pre-construction risk assessment is helpful in identifying these

potential risks, as well as the impact of the construction project on
services provided.

The risk assessment should be performed during all phases of

construction
Restricted areas such as the newborn nursery and the
operating theatre must be secure and monitored.

Children, elderly adults, and other vulnerable patients unable

to protect themselves or signal for help must be protected from
harm.

In addition, remote or isolated areas of the facility and

grounds may require the use of security cameras.
Actions :

1.     The hospital plans and implements a program to provide a safe

physical facility through inspection and planning to reduce risks.

2.     The hospital plans and implements a program to provide a

secure environment for patients, families, staff, and visitors

3.     The hospital plans and budgets for upgrading or replacing

key systems, buildings, or components based on the facility
inspection and in keeping with laws and regulations
 (3)
Hazardous Materials
A hazardous materials program is in place that includes identifying and
safely controlling hazardous materials and waste throughout the facility.

World Health Organization (WHO) identifies hazardous

materials and waste by the following categories:
(a) Infectious waste;
(b) Pathological and anatomical waste;
(c) Hazardous pharmaceutical waste;
(d) Hazardous chemical waste;
(e) Waste with a high content of heavy metals;
(f) Pressurized containers;
(g) Sharps;
(h) Highly infectious waste;
(i) Genotoxic/cytotoxic waste; and
(j) Radioactive waste.
The hazardous materials program includes processes for the inventory
of hazardous materials and waste that includes :

- the material, the quantity, and the location;

- handling, storage, and use of hazardous materials;
- proper protective equipment and procedures during use, spill, or
exposure;
- proper labeling of hazardous materials and waste;
- reporting and investigation of spills, exposures, and other incidents;
- proper disposal of hazardous waste; and
- documentation, including any permits, licenses, or other regulatory
requirements.
Information regarding procedures for handling or working with
hazardous materials in a safe manner must be immediately
available at all times and includes information about
- the physical data of the material (such as its boiling point, flash
point, and the like),
- its toxicity,
- what effects using the hazardous material may have on health,
- identification of proper storage and disposal after use,
- the type of protective equipment required during use, and
- spill-handling procedures, which include the required first aid for
any type of exposure.

Many manufacturers provide this information in the form of

Material Safety Data Sheets (MSDS).
Actions :

1. The hospital has a program for the inventory,

handling, storage, and use of hazardous materials.
2.  The hospital has a program for the control and
disposal of hazardous materials and waste.
 (4)
Disaster Preparedness
Community emergencies, epidemics, and disasters may directly involve the
hospital, such as damage to patient care areas as a result of an earthquake,
or a flu epidemic that keeps staff from coming to work.

The development of the program should begin by identifying the types

of disasters that are likely to occur in the hospital’s region and what the
impact of these disasters would have on the hospital.

It is just as important to identify the effects of a disaster as it is to

identify the types of disasters.

This helps in planning the strategies that are needed in the event that a
disaster occurs.

In addition, hospitals need to identify their role within the community.

To respond effectively, the hospital develops a program to manage such
emergencies.
The program provides processes for :

a) determining the type, likelihood, and consequences of hazards, threats,

and events;
b) determining the hospital’s role in such events;
c) communication strategies for events;
d) the managing of resources during events, including alternative sources;
e) the managing of clinical activities during an event, including alternative
care sites;
f) the identification and assignment of staff roles and responsibilities during
an event; and
g) the process to manage emergencies when personal responsibilities of
staff conflict with the hospital’s responsibility for providing patient care.
 The disaster preparedness program is tested by an annual test of
the full program internally or as part of a communitywide test; or
testing of critical elements c) through g) of the program during the
year.

If the hospital experiences an actual disaster, activates its program,

and debriefs properly afterward, this situation represents the
equivalent to an annual test.

Actions :

1. The hospital develops, maintains, and tests an emergency

management program to respond to emergencies, epidemics, and
natural or other disasters that have the potential of occurring within
their community.
 (5)
Fire Safety

Fire is an ever-present risk in a hospital.

Every hospital needs to plan how it will keep its occupants safe in case of
fire or smoke.
A hospital establishes a program in particular for the prevention of fires
through
- the reduction of risks, such as safe storage and handling of potentially
flammable materials, including flammable medical gases such as oxygen;
- hazards related to any construction in or adjacent to the patient-
occupied buildings;
- safe and unobstructed means of exit in the event of a fire;
- early warning, early detection systems, such as smoke detectors, fire
alarms, and fire patrols; and
- suppression mechanisms, such as water hoses, chemical suppressants,
or sprinkler systems.
These actions, when combined, give patients, families, staff, and visitors’
adequate time to safely exit the facility in the event of a fire or smoke.
The hospital’s fire safety program identifies

- the frequency of inspecting, testing, and maintaining fire protection

and safety systems, consistent with requirements;
- the program for safely evacuating the facility in the event of a fire
or smoke;
- the process for testing all portions of the program during each 12-
month period;
- the necessary education of staff to effectively protect and to
evacuate patients when an emergency occurs; and
- the participation of staff members in at least one fire safety test per
year.
Actions :

1. The hospital establishes and implements a program for the

prevention, early detection, suppression, abatement, and safe exit
from the facility in response to fires and non-fire emergencies.

2.  The hospital regularly tests its fire and smoke safety program,
including any devices related to early detection and suppression,
and documents the results.

3.   The fire safety program includes limiting smoking by staff and

patients to designated non–patient care areas of the facility.
 (6)
Medical Technology

To ensure that medical technology is available for use and functioning

properly, the hospital performs and documents an inventory of medical
technology; regular inspections of medical technology; testing of medical
technology according to its use and manufacturers’ requirements; and
performance of preventive maintenance.

Qualified individuals provide these services. Medical technology is

inspected and tested when new and then on an ongoing basis, according
to the technology’s age, use, and manufacturers’ instructions.
Inspections, testing results, and any maintenance are documented.

The hospital has a system in place for monitoring and acting on medical
technology hazard notices, recalls, reportable incidents, problems, and
failures sent by the manufacturer, supplier, or regulatory agency.
Actions :

1. The hospital establishes and implements a program for

inspecting, testing, and maintaining medical technology and
documenting the results.

2.  The hospital has a system in place for monitoring and acting on

medical technology hazard notices, recalls, reportable incidents,
problems, and failures.
 (7)
Utility Systems

Utilities can be defined as the systems and equipment that support

essential services that provide for safe health care.

Such systems include

- electrical distribution,
- water,
- ventilation and airflow,
- medical gases,
- plumbing,
- heating,
- waste, and
- communication and data systems.
The safe, effective, and efficient operation of utility and other key
systems in the hospital is essential for patient, family, staff, and
visitor safety and for meeting patient care needs

Hospitals should have a complete inventory of all utility systems

components and identify which components have the greatest
impact on life support, infection control, environmental support, and
communication.

The utility management program includes strategies for utility

maintenance that ensure that these key systems components, such
as electric, water, waste, ventilation, and medical gas, are regularly
inspected, maintained, and, when necessary, improved.
Patient care, both routine and urgent, is provided on a 24-hour basis,
every day of the week in a hospital.

However, an uninterrupted source of clean water and electrical power is

essential to meet patient care needs.

Regardless of the type of system and level of its resources, a hospital

needs to protect patients and staff in emergencies, such as system
failure, interruption, or contamination.
To prepare for such emergencies, the hospital

- identifies the equipment, systems, and locations that pose the highest
risk to patients and staff (for example, it identifies where there is a need
for illumination, refrigeration, life support, and clean water for cleaning and
sterilization of supplies);
- assesses and minimizes the risks of utility system failures in these
areas; 
- plans emergency power and clean water sources for these areas and
needs;
- tests the availability and reliability of emergency sources of power and
water;
- documents the results of tests; and
- ensures that the testing of alternative sources of water and electricity
occurs at least quarterly or more frequently if required by local laws,
regulations, manufacturers’ recommendations, or conditions of the
sources for power and water.
Conditions of the sources of power and water that may increase the
frequency of testing include

- repeated repair of the water system;

- frequent contamination of the water source;
- unreliable electrical grids; and
- recurrent, unpredictable power outages.
Actions :

1.     The hospital establishes and implements a program to ensure

that all utility systems operate effectively and efficiently.
2.     Utility systems are inspected, maintained, and improved.
3.     The hospital utility systems program ensures that potable water
and electrical power are available at all times and establishes and
implements alternative sources of water and power during system
disruption, contamination, or failure.
4.     The hospital tests its emergency water and electrical systems
and documents the results.
5.     Designated individuals or authorities monitor water quality
regularly.
 (8)
Facility Management Program Monitoring

Monitoring each of the facility management programs through data

collection and analysis provides information that helps the hospital
prevent problems, reduce risks, make decisions on system
improvements, and plan for upgrading or replacing medical technology,
equipment, and utility systems.

The monitoring requirements for the facility management programs are

coordinated with the requirements.

Monitoring data are documented and quarterly reports are provided to

hospital leadership.
Actions :

1. The hospital collects and analyzes data from each of

the facility management programs to support planning
for replacing or upgrading medical technology,
equipment, and systems, and reducing risks in the
environment.
 (9)
Staff Education
Staff are the hospital’s primary source of contact with patients, families,
and visitors.
Thus, they need to be educated and trained to carry out their roles in
identifying and reducing risks, protecting others and themselves, and
creating a safe and secure facility.
The program can include group instruction, printed educational
materials, a component of new staff orientation, or some other
mechanism that meets the hospital’s needs.
The program includes instruction on the processes for reporting
potential risks, reporting incidents and injuries, and handling hazardous
and other materials that pose risks to themselves and others.
Staff responsible for operating or maintaining medical technology
receive special training.
The training can be from the hospital, the manufacturer of the
technology, or some other knowledgeable source
Actions :

1.     The hospital educates, trains, and tests all staff

about their roles in providing a safe and effective patient
care facility.
2.     Staff members are trained and knowledgeable
about their roles in the hospital’s programs for fire safety,
security, hazardous materials, and emergencies.
3.     Staff are trained to operate and to maintain medical
technology and utility systems
 Safe Hospital Environment

The needs of patients change.

Models of care change.
Ways of working change.
The benefits of technology change.
Hospitals must change to keep pace, to remain fit for
purpose.
Hospitals are not buildings; they are systems through
which a wide range of healthcare services are delivered.
Hospitals are assets; they should be planned, designed,
operated, utilized and maintained in a way that befits their
importance as a vehicle for the delivery of safe patient
care and as a key contributor to the quality of the patient
experience.
The safety goals included reducing the number of errors, falls
and infections at the facility and improving patient outcomes,
patient and family satisfaction and the hospital’s financial
performance.
A safe environment “results in better clinical outcomes,
reduced cost and higher satisfaction”.
The safe facility is a zero-threshold building, with every
transition between rooms flush so as not to impede shoes,
wheelchairs, walkers or any other form of hospital transport.
A handrail with a built-in nightlight leads from the patient bed
to the bathroom.
Hand-washing sinks are distributed throughout the facility, in
places like corridors and caregiver team areas, in addition to
patient rooms.
A hand-wash monitoring system that uses radio-frequency
identification technology is in use at the hospital
The patient rooms are equipped with nurse servers, as well as bedside
charting and medication scanning technology.
Safety features of the same-handed rooms include ventilation with 100
percent fresh air; a hands-free, hand-washing sink and soap
dispenser; a nurse server for storing patient supplies (with a locked
area for medications); a computer for bedside charting; and a family
zone with overnight accommodations.
The flooring, curtains and upholstery have antibacterial properties.
A handrail leads from the patient bed to the bathroom, which is
located three feet from the head of the bed; the bathroom door slides
for ease of operation and the handrail features a low, recessed, wall-
mounted, night-light fixture.
The patient beds can be lowered to 16 inches off the floor to reduce
the impact of possible falls and have built-in scales, pressure-relieving
mattresses and a system for contacting nurses directly if high-risk
patients attempt to get up without assistance.
The new design, along with staff training and improved technology
and equipment, has resulted in lower rates of risk
Thank you