1 stage certification audit report as per sni iso 9001...

824 100 18088

1st Stage Certification Audit Report as per

SNI ISO 9001:2015

for

UNIVERSITAS MUHAMMADIYAH YOGYAKARTA

Kampus Terpadu UMY, Jl. Brawijaya, Kasihan, Bantul, 55183, D. I.

Yogyakarta, Indonesia

Stage 1 Audit Report

Client Standard(s) Certification Number(s) Audit Type


SNI ISO 9001:2015 824 100 18088 1st Stage Certification Audit

Rev. 20180910 / MS-0015679 /10

Contents

1 Audit result ......................................................................................................................... 3

2 General issues ................................................................................................................... 3

3 Scope ..................................................................................................................................... 5

3.1 Description of the organization ............................................................................................ 5

3.2 Scope of certification ............................................................................................................. 6

3.3 Contract review ...................................................................................................................... 7

4 Findings and opportunities for improvement ...................................................... 7

4.1 Documentation and management system implementation ............................................... 7

4.2 Special features of stage 1 auditing ................................................................................... 10

4.3 Special features of stage 2 auditing ................................................................................... 10





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Audit Leader : Tengku Hermansyah

Audit Team : Suliswiyadi

Management System Representative : Mr. Dr. Ir. Gunawan Budiyanto, MP (Rector)

Mr. Dr. Suranto, M.Pol (Head BPM)

Audit Date : 2018.10.30

1 Audit result

The aim of the stage 1 audit was to review the organization’s readiness for the stage 2 audit. The results and find-ings are outlined in Section 4 of this report and permit appropriate planning of the stage 2 audit.

The organization is fully ready for a stage 2 audit.

X

The audit revealed weaknesses which may be rated as non-conformities in the stage 2 audit. The weak-nesses must be eliminated as discussed, so that the stage 2 audit can be carried out as scheduled.

The audit revealed critical weaknesses which will be rated as nonconformities in the stage 2 audit. Proof that these weaknesses have been eliminated must be submitted to the audit team by 2018.11.26-27 at the latest, so that the stage 1 audit can be concluded with a positive result and the planning for the stage 2 audit can be realized.

2 General issues

Purpose and objective of certification

The organization has documented the management system in accordance with the requirements and has clearly defined the scope of certification. Management system documentation as at Quality Management System (MM/UMY/02/01 ) was reviewed, i.e. dated 02 July 2018 rev 00

X

yes

no

The certification scope applies to the entire organization. X

yes

no

The selection of the audit team is appropriate for the scope of certification. X

yes

no

The scope matches the image presented by the organization (e.g. in brochures and on the Internet).

X

yes

no

The management system is appropriate for implementing corporate policy and objec-tives.

X

yes

no

The organization has established regulations to identify and comply with statutory and regulatory requirements.

X

yes

no





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Purpose and objective of certification

The organization performed internal audits in line with the requirements, i.e dated 17 to 27 September 2018

X

yes

no

The management review of Univesitas Muhammadiyah Yogyakarta was carried out in accordance with the requirements and was effective, i.e. dated 24 October 2018.

X

yes

no

The certification refers to multiple sites and is based on sampling.

yes X

no

Multi-site organization: The management representative has appropriate authorities over the sites included in the multi-site organization. *

yes

no

Sampling can be performed in the stage 2 audit as intended. *

yes

no

* tick only if applicable

Basic statements on ISO 9001:2015

The sequence and interactions of the relevant processes have been defined. X

yes

no

Input and output of the processes are defined. X

yes

no

Responsibilities and authorities of processes are determined X

yes

no

Performance indicators and the measure of processes are defined X

yes

no

The control of outsources processes is defined in the quality management system X

yes

no

Are any requirements of the standard to be excluded? (If “yes” see further information under Section 3 “Scope”)

yes X

no





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3 Scope

3.1 Description of the organization

Company Name : Universitas Muhammadiyah Yogyakarta

Address : Kampus Terpadu UMY, Jl. Brawijaya, Kasihan, Bantul, 55183, D. I. Yogyakarta, Indonesia

Top Management : Mr. Dr. Ir. Gunawan Budiyanto, MP

Management Representative : Mr. Dr. Suranto, M.Pol

Nr. Employee : 65

Scope organization : Four Pillars of Muhammadiyah Higher Education (Education, Research, Community Service, and Al Islam and Muhammadiyah Values) and its supporting processes comprising Faculty of Engineering (Electrical Engineering, Informatics engineering, Mechanical Engineering, and Civil Engineering Study Program), Faculty of Medicine and Health Sciences (Medicine, Dentistry, Nursing, and Pharmacy Study Program), Vocational Program (Diploma in Electromedical Engineering, Mechanical Engineering, and Accounting), Research, Publication and Community Service Office (LP3M), Education Development Office, Academic Administration Bureau, Library, Human Resources Bureau, Asset Management Bureau, General Affairs Bureau, Student Admission Bureau, Public Relations and Protocol Bureau, Quality Assurance Office, Planning and Development Office, Islamic Studies and Implementation Office.

Customer : Students. Parents of students, Government, Institution, In-dustries

Main processes : Education Services for Higher Education

Main product : Competence of Student

Policy : Vision: Menjadi Universitas yang unggul dalam pengembangan ilmu pengetahuan dan teknologi dengan berlandaskan nilai-nilai Islam untuk kemaslahatan.

Adapun Misi dari UMY adalah sebagai berikut.

a. Meningkatkan harkat manusia dalam upaya

meneguhkan nilai-nilai kemanusiaan dan

peradaban.

b. Berperan sebagai pusat pengembangan

Muhammadiyah untuk menyejahterakan dan





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mencerdaskan umat

c. Mendukung pengembangan Yogyakarta sebagai

wilayah yang menghargai keragaman budaya

d. Menyelenggarakan pendidikan, penelitian dan

pengembangan masyarakat secara profesional.

e. Mengembangkan peserta didik agar menjadi

lulusan yang beriman, bertaqwa dan berakhlak

mulia, berwawasan dan berkemampuan tinggi

dalam ilmu pengetahuan dan teknologi.

3.2 Scope of certification

Scope of certification: (per standard) Four Pillars of Muhammadiyah Higher Education (Education, Research, Community Service, and Al Islam and Muhammadiyah Values) and its supporting processes comprising Faculty of Engineering (Electrical Engineering, Informatics engineering, Mechanical Engineering, and Civil Engineering Study Program), Faculty of Medicine and Health Sciences (Medicine, Dentistry, Nursing, and Pharmacy Study Program), Vocational Program (Diploma in Electromedical Engineering, Mechanical Engineering, and Accounting), Research, Publication and Community Service Office (LP3M), Education Development Office, Academic Administration Bureau, Library, Human Resources Bureau, Asset Management Bureau, General Affairs Bureau, Student Admission Bureau, Public Relations and Protocol Bureau, Quality Assurance Office, Planning and Development Office, Islamic Studies and Implementation Office.

ISO 9001 standard requirements to be excluded None

Reasons for exclusions: None

The following sites and their scopes are included in the scope of certification:





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3.3 Contract review

The details of the organization, i.e. the type, size, number of employees, structure and purpose of the organization, collected in the stage 1 audit comply with the information submitted by the organization prior to the audit (for offer preparation and contract review).

4 Findings and opportunities for improvement

4.1 Documentation and management system implementation

Internal audits: The organization verified the implementation, maintenance and effectiveness of the management system by conducting internal audits. Key audit results in the period of assessment include:

• Implementation of each department

• Corrective action of finding

• Verification of corrective action

Site No. (CN ext.)

Sites included in cert. Name/address of site

No. of emp.

Scope and processes Standard(s) Au-dited

01

Universitas Muhammadiyah Yogyakarta

Kampus Terpadu UMY, Jl. Brawijaya, Kasihan, Bantul, 55183, D. I. Yogyakarta, Indonesia

65 Four Pillars of Muhammadiyah Higher Education (Education, Research, Community Service, and Al Islam and Muhammadiyah Values) and its supporting processes comprising Faculty of Engineering (Electrical Engineering, Informatics engineering, Mechanical Engineering, and Civil Engineering Study Program), Faculty of Medicine and Health Sciences (Medicine, Dentistry, Nursing, and Pharmacy Study Program), Vocational Program (Diploma in Electromedical Engineering, Mechanical Engineering, and Accounting), Research, Publication and Community Service Office (LP3M), Education Development Office, Academic Administration Bureau, Library, Human Resources Bureau, Asset Management Bureau, General Affairs Bureau, Student Admission Bureau, Public Relations and Protocol Bureau, Quality Assurance Office, Planning and Development Office, Islamic Studies and Implementation Office.

SNI ISO 9001:2015

X





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Management review: The areas of focus of the management review included:

• Objectives

• Risk and Opportunity

• All agendas of management review provided in PS/TPMU.UMY/001 rev 00 dated 20 June 2018

Objectives: Priority objectives include:

a. Persentase 100% prodi yang memiliki kurikulum PT sesuai dengan visi misi

Prodi, memenuhi kebutuhan stakeholder dan berorientasi ke masa depan.

b. Persentase 95% kelulusan OSCE (Objective Structure Clinical Examination);

UKMPPD (Uji Kompetensi Mahasiswa Program Profesi Dokter).

c. Angka Efisiensi Edukasi (AEE) = Jumlah lulusan/student body → target 10.

d. Persentase Kelulusan Tepat Waktu (FKIK : 83.3%),

e. Rata-rata IPK lulusan (target 3.42)

f. Jumlah penelitian per dosen per tahun (target 0.6)

g. Jumlah publikasi jurnal nasional/internasional/buku ajar/buku teks per dosen per

tahun (target 0.4)

h. Jumlah paten/HaKI per prodi per 3 tahun (target 1.3)

i. Jumlah publikasi SCOPUS per dosen per 5 tahun (target 5)

Review of management system documentation and verification of management system implementation revealed the following results:

No. Unit/Department/Site Opportunities for Improvement Rating*)

1

BPM

Pastikan adanya Pengesahaan Kebijakan Mutu oleh Rektor sebagai pimpinan dan pastikan dokumen kebijakan mutu yang didistribusikan & dikomunikasikan adalah yang telah disahkan (Klausul 5.2 ISO 9001:2015).

2

2 - Tidak ada bukti distribusi dokumen manual mutu & dokumen acuan kerja SMM (Prosedur) yang diterbitkan pertanggal 2 Juli 2018 (Klausul 7.5.3)

- Pastikan terkendalinya dokumen eksternal mis. Standar ISO 9001:2015 dan dokumen lainnya dari pemerintah atau pihak luar serta sebaiknya dokumen sistem manajemen yang ditetapkan di UMY berbasis ICT. (Klausul 7.5.3)

2

3 - Sebaiknya dibuatkan prosedur/metode identifikasi risiko dan peluang, tindakan penanganan dan evaluasi risiko/peluang untuk mendukung manajemen risiko yang diterapkan di Universitas/Fakultas/Program.(Klausul 4.1 dan 6.1).

- Pastikan input identifikasi risiko dan peluang adalah dari issue internal dan eksternal (bisa menggunakan SWOT Analysis sebagai tool identifikasi risiko dan peluang), untuk kemudian ditetapkan strategi untuk mengatasi/menyikapi risiko dan peluang yang ditentukan. (mis. Menggunakan strategi SO, ST, WO, WT).

1

4 Sangat disarankan Input peta proses (bisnis proses) yang ditetapkan di UMY mencakup semua interested par-ties/stakholder tidak sebatas dari mahasiswa, user dan orang tua. (Klausul 4.2 dan 4.4 ISO 9001:2015 & Tujuan Khusus Universitas Muhammadiyah Yogyakarta).

2





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5 Sebaiknya ditetapkan juga mitra (institusi, desa binaan, dsb) sebagai pihak berkepentingan dengan UMY untuk aktivitas penelitian dan pengabdian masyarakat. (Klausul 4.2 ISO 9001:2015)

2

6 BPM Untuk mendukung Sistem Manajemen Mutu yang efektif dan efisien, sangat disarankan dikembangkannya Integrasi sistem manajemen baik pada dokumen sistem maupun penerapannya, mis Rapat Tinjauan Manajemen → Rapat RKT, Rapim, dsb. Serta berbasis ICT untuk memudahkan mampu telusur dokumen/rekaman kerja sistem.

1

7 - PTK (permintaan tindakan koreksi) yang ditetapkan di AMI (Audit Mutu Internal) tidak mencakup analisa penyebab, koreksi dan korektif serta tindakan verifikasi perbaikan/korektif yang ditetapkan.(Klausul 9.2 ISO 9001:2015 dan ISO 19011:2011 tentang Audit SMM.

2

8 Pastikan dalam rapat tinjauan manajemen dibahas juga trend hasil survey kepuasan mahasiswa terhadap layanan universitas/fakultas. (Klausul 9.3.2). serta dipastikan keputusan rapat tinjauan manajemen mencakup PIC/PJ dan Batas Waktu pelaksanaannya. (Klausl 9.3.3 ISO 9001:2015)

2

9

Fakultas / Program

Direkomendasikan dalam analisa potensi risiko dan pengendaliannya, terlebih dahulu ditetapkan risk evaluasinya (berdasarkan High, Middle, Low), sebelum dilakukan mitigation actionnya

1

10

Sebaiknya dipastikan konsistensi nomenklatur penyebutan dokumen prosedur dengan SOP (praktik unit kerja) dengan penetapan pengendali dokumen pada prosedur system (dokumen BPM)

1

11 Direkomendasikan bahwa setiap temuan (NC), harus dipastikan untuk direspon dengan menjelaskan cause analysis (analisis penyebab) 5 M + 1E (Man, Money, Material, Method, Machine + Environment).

1

12 Direkomendasikan untuk dibuatkannya alur flowchart pada Standar Operasional Prosedur (SOP) dengan simbol-simbol yang baku (disarankan menggunakan program visio)

1

13 Sebaiknya ditunjukkan hasil report monitoring dan review RPS (Rencana Pembelajaran Semester) yang dilakukan oleh Tim Kurikulum Internal sebagaimana diminta dalam SOP pengembangan kurikulum

1

14 Tidak cukup bukti dilakukannya analisa penyebab dan tindaklanjutnya atas temuan audit internal: “Semua mata kuliah ada RPS, namun belum diverifikasi dan divalidasi”

2

*) Rating: 1 = Opportunities for improvement

2 = Probably rated as nonconformity in stage 2

3 = Not ready for certification (proof of elimination of weaknesses must be submitted before completion of the stage 1 audit)

In view of the fact that audits are always based on sampling, weaknesses may still exist which were not revealed and identified during the audit.





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The auditor/audit team and the certification body will treat all information gained during the audit with strict confi-dentiality.

4.2 Special features of stage 1 auditing

The audit was carried out on site.

4.3 Special features of stage 2 auditing

No further special features must be complied with.

The stage 2 audit was scheduled together with the client to take place on 2018.11.26-27

\ Date Tengku Hermansyah

2018.10.30 Audit Leader / Auditor(s)

CERTIFICATE

824 100 18088

2nd Stage Certification Audit Report as per SNI ISO 9001:2015

For


Kampus Terpadu UMY, Jl. Brawijaya, Kasihan, Bantul, 55183, D.I.

Yogyakarta, Indonesia

Contents

1 Audit result ................................................................................................. 3

2 Scope ........................................................................................................... 4

2.1 Description of the organization ........................................................................................ 4 2.2 Scope of certification ......................................................................................................... 5

3 Changes in the management system / Contract review .......................... 6

4 Audit findings ............................................................................................. 6

5 Dates ............................................................................................................ 10

Audit Report



SNI ISO 9001:2015 824 100 18088 2nd Stage Certification Audit

Rev. 20180910 / MS-0015679 Page 3/17

Audit Leader : Tengku Hermansyah

Audit Team : Erfi Ilyas

Management System Representative : Mr. Dr. Ir. Gunawan Budiyanto, MP (Rector)

Mr. Dr. Suranto, M.Pol (Head BPM)

Audit Date : 2018.11.26 to 27

1 Audit result

Management system effectiveness was verified on site by means of random sampling by an appropriately selected audit team. This applies in particular to the compliance of workflows with standard requirements and the descriptions in management system documentation. The special features of the organization’s business activities, the applicable statutory and regulatory requirements and the requirements set forth in other generally applicable documents were also taken into account. This was done by means of a sampling approach, by conducting interviews and reviewing the appropriate documentation. Audit findings and recommendations regarding opportunities for improvement have been set forth in Sections 4 of this report.

The last audit revealed nonconformities which have been demonstrably corrected. The corrections and corrective actions taken in this respect have been verified.

X

A stage 1 audit was performed and the organization found ready for certification. Identified weaknesses, if any, have been eliminated and the corrective action associated therewith verified.

X

The current audit revealed the following nonconformities:

Standard(s): No. of nonconformity

SNI ISO 9001:2015 4

The major nonconformities (No. x) with individual standard elements require a re-audit to verify the effectiveness of the corrections and corrective actions (probable date:.ddmmyyyy)

X

The organization has established and maintains an effective system to ensure compliance with its policy and objectives. The audit team confirms in line with the audit targets that the organization’s management system complies with, adequately maintains and implements the requirements of the standard(s).

The audit team therefore recommends (provided the effectiveness of corrections and/or corrective actions addressing the identified nonconformities has been verified):

X

Award of the new certificates.

Maintenance of the existing certification.

Inclusion of the changes (see Section 3) in the scope of application of existing certifications

Maintenance or issue of the certificates only after successful completion of a re-audit.

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2 Scope

2.1 Description of the organization

Company Name : Universitas Muhammadiyah Yogyakarta

Address : Kampus Terpadu UMY, Jl. Brawijaya, Kasihan, Bantul, 55183, D. I. Yogyakarta, Indonesia

Rector : Mr. Dr. Ir. Gunawan Budiyanto, MP

Management Representative : Mr. Dr. Suranto, M.Pol

Nr. Employee : 65

Scope organization : Four Pillars of Muhammadiyah Higher Education (Education, Research, Community Service, and Al Islam and Muhammadiyah Values) and its supporting processes comprising Faculty of Engineering (Electrical Engineering, Informatics engineering, Mechanical Engineering, and Civil Engineering Study Program), Faculty of Medicine and Health Sciences (Medicine, Dentistry, Nursing, and Pharmacy Study Program), Vocational Program (Diploma in Electromedical Engineering, Mechanical Engineering, and Accounting), Research, Publication and Community Service Office (LP3M), Education Development Office, Academic Administration Bureau, Library, Human Resources Bureau, Asset Management Bureau, General Affairs Bureau, Student Admission Bureau, Public Relations and Protocol Bureau, Quality Assurance Office, Planning and Development Office, Islamic Studies and Implementation Office.

Customer : Students. Parents of students, Government, Institution, Industries

Main processes : Education Services for Higher Education

Main product : Competence of Student

Vision: Menjadi Universitas yang unggul dalam pengembangan ilmu pengetahuan dan teknologi dengan berlandaskan nilai-nilai Islam untuk kemaslahatan.

Adapun Misi dari UMY adalah sebagai berikut.

- Meningkatkan harkat manusia dalam upaya meneguhkan nilai-nilai kemanusiaan dan peradaban.

- Berperan sebagai pusat pengembangan Muhammadiyah untuk menyejahterakan dan mencerdaskan umat.

- Mendukung pengembangan Yogyakarta sebagai wilayah yang menghargai keragaman budaya

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- Menyelenggarakan pendidikan, penelitian dan pengembangan masyarakat secara profesional.

- Mengembangkan peserta didik agar menjadi lulusan yang beriman, bertaqwa dan berakhlak mulia, berwawasan dan berkemampuan tinggi dalam ilmu pengetahuan dan teknologi.

2.2 Scope of certification

Scope of certification: (per standard):

Four Pillars of Muhammadiyah Higher Education (Education, Research, Community Service, and Al Islam and Muhammadiyah Values) and its supporting processes comprising Faculty of Engineering (Electrical Engineering, Informatics engineering, Mechanical Engineering, and Civil Engineering Study Program), Faculty of Medicine and Health Sciences (Medicine, Dentistry, Nursing, and Pharmacy Study Program), Vocational Program (Diploma in Electromedical Engineering, Mechanical Engineering, and Accounting), Research, Publication and Community Service Office (LP3M), Education Development Office, Academic Administration Bureau, Library, Human Resources Bureau, Asset Management Bureau, General Affairs Bureau, Student Admission Bureau, Public Relations and Protocol Bureau, Quality Assurance Office, Planning and Development Office, Islamic Studies and Implementation Office.

ISO 9001 standard requirements to be excluded from the scope:

None

Reasons for exclusions: None

In the stage 2 audit, auditing was performed at the sites identified in the table below.

The following sites and their scopes are included in the scope of certification:

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3 Changes in the management system / Contract review

No major changes have been made to the management system and the management system documentation since the last audit. The order details which form the basis of the audit (including number of employees, scope and sites) reflect the actual situation in the organization.

The description of the scope in the certificate appropriately reflects the scope of the management system.

A corresponding printing request is attached.

The audit plan was not changed during the audit.

4 Audit findings

The audit findings related to the audited standards are listed in the Annexes to this report (see. Annex ISO 9001:2015).

All information gained during the audit will be treated with strict confidentiality by the auditor and the certification body. In view of the sampling approach applied to the audit, weaknesses and nonconformities may still exist which have not been identified during the audit.

Site No. (CN ext.)

Sites included in cert. Name/address of site

No. of emp.

Scope and processes Standard(s)

Audited

/01

Universitas Muhammadiyah Yogyakarta

Kampus Terpadu UMY, Jl. Brawijaya, Kasihan, Bantul, 55183, D. I. Yogyakarta, Indonesia

65 Four Pillars of Muhammadiyah Higher Education (Education, Research, Community Service, and Al Islam and Muhammadiyah Values) and its supporting processes comprising Faculty of Engineering (Electrical Engineering, Informatics engineering, Mechanical Engineering, and Civil Engineering Study Program), Faculty of Medicine and Health Sciences (Medicine, Dentistry, Nursing, and Pharmacy Study Program), Vocational Program (Diploma in Electromedical Engineering, Mechanical Engineering, and Accounting), Research, Publication and Community Service Office (LP3M), Education Development Office, Academic Administration Bureau, Library, Human Resources Bureau, Asset Management Bureau, General Affairs Bureau, Student Admission Bureau, Public Relations and Protocol Bureau, Quality Assurance Office, Planning and Development Office, Islamic Studies and Implementation Office.

SNI ISO 9001:2015

X

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No. Unit/Department

Site

Positive findings

1. All - Komitmen yang baik di dalam penerapan sistem manajemen mutu serta peningkatan mutu berkelanjutan dari semua pimpinan, pejabat structural & fungsional dan civitas akademik UMY.

- Akreditasi A Unggul dari BAN-PT tahun 2018

- Semua kurikulum Program Studi sudah merujuk pada KKNI

- Manajemen Sistem terintegrasi yang berbasis ICT

The following recommendations and opportunities for improvement provided by the auditor are intended to contribute to the continuous improvement of the management system.

No. Unit/Department

Site

Recommendations and opportunities for improvement

1 BPM - Pastikan dilakukannya verifikasi atas tindakan perbaikan ketidaksesuaian yang telah dilaporkan auditee kepada auditor/lead auditor terkait pada form Ketidaksesuaian & Tindakan Perbaikan Audit Internal SNI ISO 9001:2015. (clause 9.2)

2 Admisi, Promosi dan Pemasaran

- Melalui pendekatan ISO 31000, sebaiknya organisasi meninjau kembali metode penetapan redaksi risiko dan peluang serta mempertimbangkan konteks organisasi (internal dan eksternal issues & interested parties) sebagai input penetapan risiko dan peluang.

3 BAA - Pastikan adanya keterangan status hasil pengecekan kecukupan fasilitas perkuliahan di awal semester dan tindak lanjut atas status pemeriksaan tersebut kepada pihak terkait (bila dibutuhkan). (Clause 8.5.1)

- Sebaiknya tersedia trend grafik rerata masa studi dan IPK per- prodi dalam satu periode wisuda yang dikomparasikan dengan grafik data (variable yang sama) pada periode sebelumnya sebagai bagian kinerja continual improvement.(Clause 9.1.3)

4 Aset - Pastikan informasi penanganan perbaikan sarana/prasarana mencakup

perihal kerusakan (Trouble), factor penyebab kerusakan (troubleshooting), tindakan perbaikan yang dilakukan (Repairing), Waktu Penyelesaian, dan status hasil pekerjaan (close/open).

- Pastikan ditetapkannya Daftar Supplier Barang/Jasa yang direkomendasikan oleh Bag. Aset pasca seleksi/evaluasi menggunakan kriteria yang ditetapkan mis. legalitas, komunikasi purna jual, garansi, dsb. (clause 8.4)

5 LPPI - Sangat disarankan untuk dilakukannya pengukuran output pendidikan

keislamanan dan kemuhammadiyahan terhadap lulusan UMY dalam konteks kehidupan social diantaranya melalui keterlibatan lulusan di forum keagamaan/social kemanusiaan/sebagai kader muhammadiyah. ( Tujuan Khusus UMY: Manual Mutu (MM/UMY/02/001) rev. 00 hal. 15)

6 BHP

• Sebaiknya ditetapkan prosedur penanganan infomasi/berita hoax di media social terkait dengan UMY sebagai bagian pengendalian risiko yang berpotensi terjadi.

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7 Perpustakaan

• Sangat disarankan setiap kegiatan stock opname koleksi buku perpustakaan diterbitkan berita acara stock opname yang menginformasikan perbandingan catatan stock di sistem dengan real fisik.

• Sebaiknya dilakukan pengukuran kepuasan pengunjung perpustakaan terhadap layanan perpustakaan secara periodic.

8 Biro Umum

• Pastikan adanya evaluasi kinerja outsourcing secara terdokumentasi dan dijadikan rujukan sebelum adanya perpanjangan/penghentian kontrak kerja.

• Sebaiknya disediakan Buku Log Kasus Keamanan yang terjadi dan ditangani oleh Security sebagai riwayat dan data trend perbaikan berkelanjutan.

• Sangat disarankan memastikan kelengkapan SIM Driver dan masa berlakunya oleh Kaur RT untuk menjamin ketaatan aturan pihak eksternal terhadap peraturan berkendara.

9 All & BPM • Disarankan agar dilakukan upaya yang lebih sistemastis untuk

mensosialisasikan kebijakan mutu agar dipahami dan diterapkan oleh seluruh dosen dan tenaga kependidikan.

• Sangat disarankan agar dilakukan upaya peningkatan pemahaman dan kemampuan dosen dan staf terkait dengan esensi persyaratan ISO 9001:2015 serta seri-seri pendukungnya seperti ISO 9000:2015, ISO/TS 9002:2016, dan ISO 19011:2018.

• Sangat disarankan agar dilakukan evaluasi terhadap efektifitas tindakan yang diambil untuk menghadapi risiko dan peluang

• Sangat disarankan agar diatur secara tegas dalam manual mutu terkait dengan sasaran mutu utamanya berkenaan dengan acuan dan teknis perumusan sasaran mutu dan tanggung jawab pemantauan ketercapaiannya. Apakah IKS otomatis dijadikan sasaran mutu atau acuan/rujukan penyusunan sasaran mutu.

• Sangat disarankan agar manual mutu menguraikan secara lebih rinci dan operasional bagaimana UMY memenuhi dan menerapkan setiap klausul ISO 9001:2015. Disarankan pula agar manual mutu menetapkan link dengan dokumen yang sudah eksis dalam sistem manajemen UMY.

• Sangat disarankan agar prosedur pengendalian dokumen dan prosedur pengendalian arsip mengatur pengendalian dokumen dan arsip pada tingkat unit kerja, utamanya terkait dengan pembuatan daftar dokumen (internal dan eksternal) dan daftar arsip.

• Formulir-formulir yang terkait dengan suatu prosedur sebaiknya dilampirkan pada prosedur tersebut.

• Referensi/Rujukan pada setiap prosedur sebaiknya tidak hanya persyaratan ISO 9001:2015 tetapi mencakup seluruh dokumen yang harus dirujuk untuk menjalankan proses yang diatur dalam prosedur tersebut.

• Mengingat standar ISO 9001:2015 tidak lagi ada persyaratan tentang tindakan pencegahan, sebaiknya keberadaan prosedur tindakan pencegahan ditinjau ulang.

• Disarankan menggunakan istilah koreksi untuk “correction” dan tindakan korektif untuk “corrective action” dan menggunakan istilah tersebut secara konsisten pada semua dokumen.

• Prosedur Audit Internal (PS/UMY/02/03) sebaiknya dilengkapi dengan definisi istilah koreksi (correction) dan tindakan korektif (corrective action)

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10 Badan Perencanaan Pengembangan

• Sebaiknya dipertimbangkan untuk melengkapi dokumen uraian jabatan dengan komponen: hasil kerja, bahan kerja, peralatan kerja, pedoman kerja, dan hubungan kerja.

• Sangat disarankan agar ditetapkan uraian jabatan untuk untuk staf minimal, urain tugas, tanggung jawab dan wewenang.

• Disarankan agar rencana kerja dalam dokumen sasaran mutu (Program pencapaian sasaran mutu) diuraikan secara lebih rinci dan disarankan pula agar sumber daya tidak hanya berkaitan dengan anggaran tapi mencakup seluruh sumber daya yang diperlukan untuk mencapai sasaran mutu.

11 Lembaga Pengembangan Pendidikan

• Sangat disarankan agar di unit kerja LPP tersedia uraian jabatan seluruh pejabat struktural LPP.

• Sangat disarankan agar program pencapaian sasaran mutu diisi secara lengkap

• Disarankan agar semua dokumen SOP yang diterbitkan LPP diberi identifikasi kode dokumen sesuai ketentuan Prosedur Pengendalian Dokumen

12 Fakultas/Progrm Vokasi

• Sangat disarankan agar disusun dan ditetapkan uraian jabatan dosen dan tenaga kependidikan dan standar kompetensi dosen dan tenaga kependidikan.

• Sangat disarankan agar ditetapkan masa simpan arsip mengacu pada regulasi atau peraturan perundang-undangan yang berlaku (FT)

• Disarankan untuk memastikan target sasaran mutu prodi tidak lebih rendah dari target universitas (FKIK)

• Disarankan agar dilakukan tinjauan terhadap rubrik penilaian dan gradasi nilai dalam dokumen RPS untuk memastikan kejelasan dan kemudahan penggunaannya (FT)

• Disarankan agar dilakukan tinjauan terhadap target sasaran mutu (IKS) untuk memudahkan pengukurannya. (Program Vokasi)

• Disarankan untuk mempertimbangkan pembentukan LSP P1 pada Program Vokasi

13 LP3M • Disarankan untuk menyusun analisis jabatan untuk seluruh Kepala Pusat Studi.

• Disarankan agar uraian tugas staf disusun lebih rinci dan dilengkapi dengan wewenang

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5 Dates

Due Date for the next audit

2019/11/27

Agreed date for the next audit 2019/10/27 (tentatively)

The auditor confirms his check that there is no conflict of interest, especially that neither he, nor his employer, the organizational unit to which he belongs or an associated partner in the private sphere has provided consulting services - including in-house training and internal audits - to the client on the implementation, development and maintenance of a management system within the last two years.

2018.12.17 Tengku Hermansyah

Date Audit Leader / Auditor(s)

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Annex ISO 9001

Item Audit result

Context of the organization

The organization has determined internal and external issues related to the following subject areas (Note: subject areas can be legal requirements, co-operations, competition, community etc.)

• Globalization and industries requirements

• Technological change for Lab

• Publication of Research

• Human Resources Development

• Requirements change

• Islamic Character Building

• International Accreditation

The organization has identified interested parties and the requirements of these parties. Examples for such determined interested parties are:

• Government

• Students

• Parents

• Industries

• Foundation

• Community

• Association

Policy/objectives Top Management has declared its quality policy binding and implemented. The quality policy is appropriate and provides a framework for the respective quality objectives. It commits all employees to pursue continuous quality system improvement.

With this purpose, the organization sets Quality Goals/ Quality objectives in 2018/2019

Objective Target Achievement

2018/2019

Persentase prodi yang memiliki kurikulum PT sesuai dengan visi misi Prodi, memenuhi kebutuhan stakeholder dan berorientasi ke masa depan

100% Duedate August 2019

kelulusan OSCE (Objective Structure Clinical Examination); UKMPPD (Uji Kompetensi Mahasiswa Program Profesi Dokter).

95% Duedate August 2019

Angka Efisiensi Edukasi (AEE) = Jumlah lulusan/student body

10 Duedate August 2019

Persentase Kelulusan Tepat Waktu (FKIK : 83.3%), Duedate August 2019

Rata-rata IPK lulusan 3.42 Duedate August 2019

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Item Audit result

Jumlah penelitian per dosen per tahun 0.6 Duedate August 2019

Jumlah publikasi jurnal nasional/internasional/buku ajar/buku teks per dosen per tahun

0.4 Duedate August 2019

Jumlah paten/HaKI per prodi per 3 tahun

1.3 Duedate August 2019

Jumlah publikasi SCOPUS per dosen per 5 tahun

5 Duedate August 2019

The required records are controlled. The records are established and are maintained. This applies to all documents inspected during the audit.

Process control including outsourced processes

The processes available in the organization have been identified and documented. Process workflows and interactions have been described and appropriately Controlled. The processes are evaluated at regular intervals by means of key Performance indicators. The significant product realization processes are as follows: Business Processes Proses bisnis yang dilakukan oleh Universitas Muhammadiyah Yogyakarta telah dipetakan menjadi 3 proses utama:

1. Proses Penjaminan Mutu 2. Proses Utama 3. Proses Pendukung

Proses Penjaminan Mutu

1. Pengendalian dokumen dan rekaman 2. Manajemen Risiko 3. Penetapan standar SPMI UMY 4. Audit Mutu Internal, Tindakan Koreksi dan Pencegahan 5. Rapat Tinjauan Manajemen

Proses Utama Proses ini merupakan proses yang langsung berhubungan dengan mahasiswa, proses utama ini terdiri atas upstream-midstream-downstream:

1. Penerimaan Mahasiswa Baru 2. Registrasi Mahasiswa 3. Pengisian KRS 4. Penyusunan RPKPS 5. Proses perkuliahan 6. Inisiasi Kampus dan Pendidikan Keislaman dan Kemuhammadiyahan 7. Ujian tengah semester 8. Ujuan akhir semester 9. Penerbitan KHS 10. Evaluasi hasi studi mahasiswa 11. Penulisan tugas akhir mahasiswa 12. KKN 13. Sidang tugas akhir mahasiswa 14. Rapat yudisium kelulusan mahasiswa 15. Pelaksanaan wisuda

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Item Audit result

Proses Pendukung Proses ini meliputi:

1. Praktik mahasiswa di lab/rumah sakit 2. Perpustakaan 3. Proses administrasi 4. Pusat Bahasa 5. Pusat computer 6. Informasi teknologi 7. Praktek Ibadah dan Baca Al Quran

Keseluruhan proses tersebut telah dilaksanakan dan diverifikasi kesesuaiannya dengan standar yang digunakan oleh organisasi.

The Development of Curriculum is Conducted by Vice Rector of Academic with Deans and Head of Competence Program as users of the curriculum with the review of process, Verification and Validation can be given. And the result of this development is verified and validated according to procedure of curriculum development :

• Kurikulum Fakultas

• Buku Akademik

• RPS & Kontrak Perkuliahan

• Daftar Nilai

• Transkip Nilai

To ascertain whether the learning process has to be absorbed by the students, the institute conducts the tests or exams. Before execution of the test, the questions must be made on or checked by the other lecture, also the points of question have to analyze associated with learning completeness and performing corrective action if the students do not meaclat minimum standards of completeness. Beside that the management will monitor and measure learning process to ensure all have been met with the education standards.

In the process of development of non-educational achievements, the institution provides guidance to extra-curricular activities. Such as: Foreign Language, Music & Arts, Sports, Research, etc.

In terms of monitoring and improvement of students violations, and provision of counseling, Vice Rector of Academic monitors the level of violations of students and followed up with providing guidance to students actively, by using devices such as; Student disciplinary rules and List of student violations.

In the development of employee competence, The Organization determined the training program annually for improvement of quality by using SOP Pengembangan SDM.

Outsource Process:

• Penempatan mahasiswa KKN

• Dosen luar biasa

These processes are appropriately reviewed and controlled

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Item Audit result

Risk-based thinking The requirements for risk-based thinking are being realized in the organization as follows:

Risk-based thinking has been applied for the following processes:

- Human Resources Development

- Curriculum Development

- Learning Process

- Research & Community Service

- Admission

- Sufficiency of Lab Facilities

Examples of risks and opportunities of processes identified are:

- Graduation of studends is delayed

- International accreditation researches of lectures are delayed

Examples of measures taken to react on identified risks are:

- Monitoring semester

- Monitoring periodically (annual) for curriculum and objectives achievement

Examples of risks and opportunities concerning the context of the organization are

• Accreditation of International and National Standards

Concerning risk based thinking the following tools are used

SWOT Analysis

Risk based thinking is not considered quantitatively for the processes: Not applicable as organization use quantitatively method.

Customer-related and other requirements

The organization analyses and evaluates customer requirements and/or enquiries and any documented, assumed, statutory and regulatory requirements within the scope of a production and feasibility study performed in a team. Offers are prepared and approved by Vice Rector of Academic fields. The person who prepared the offer reviews the contract to ensure its compliance with the offer, and documents this compliance in an order confirmation. The same procedure applies to amendments. The following process requirements significantly affect service quality:

1. Admission of students (by Test (PBT), Accomplishment (PSB), Superior Seedlings of Muhammadiyah Organization (PBUP), or National Exam Scores).

2. Realization of education by design, development and implementation of curriculum to student)

3. Research by Students and or Lectures submitted by KKN and Journal. 4. Community Development (exp. Economy Development and Islamic

Education) by student for 2 months before graduation exam. 5. Implementation of Al Islam & Al Muhammadiyah Values with reading Al

Quran, Praying Practices etc. 6. Evaluation of Student Competences in Mid Semester and Final Semester

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Item Audit result

Key regulatory, statutory and customer-related requirements include:

• Peraturan Menteri Pendidikan dan Kebudayaan no 049/2014; Permenristekdikti no. 44/2015 tentang Standar Nasional Pendidikan Tinggi

• Peraturan Menteri Pendidikan dan Kebudayaan no 050/2014 tentang Sistem Penjaminan Pendidikan Tinggi

• Undang Undang RI nomor 12 tahun 2012 tentang Sistem Pendidikan Tinggi.

• Undang Undang RI nomor 14 tahun 2005 tentang Guru dan Dosen

• Peraturan Pemerintah RI nomor 19 tahun 2005 tentang Standar Nasional Pendidikan

• Peraturan Menteri Pendidikan dan Kebudayaan tentang Standar Nasional Pendidikan Tinggi.

• Tim Pengembangan SPMI-PT, “Sistem Penjaminan Mutu Internal Perguruan Tinggi”,Bahan Pelatihan, Ditjen Dikti, 2014

• Kepmendiknas Nomor 232/U/200 tentang Pedoman Penyusunan Kurikulum Pendidikan Tinggi dan Penilaian Hasil Belajar Mahasiswa

• Kepmendiknas Nomor 045/U/2002 tentang Kurikulum inti Pendidikan Tinggi.

• Peraturan Pemerintah Nomor 19 tahun 2005; PP 32/2013; PP 13/ 2015 tentang Standar Nasional Pendidikan

• Sistem Penjaminan Mutu Perguruan Tinggi (SPM-PT), Dirjen Dikti, Depdiknas, 2008

• Undang-undang Republik Indonesia nomor 20 tahun 2003 tentang Sistem Pendidikan Nasional

• Peraturan Menteri Pendidikan dan Kebudayaan Republik Indonesia No. 49 Tahun 2014 tentang Standar Nasional Perguruan Tinggi

• Peraturan Pemerintah Republik Indonesia Nomor 13 tahun 2015 tentang Perubahan Kedua Peraturan Pemerintah Republik Indonesia Nomor 19 Tahun 2005 Standar Nasional Pendidikan

• Peraturan Menteri Riset dan Teknologi, dan Pendidikan Tinggi Republik Indonesia Nomor 44 Tahun 2015 tentang Standar Nasional Perguruan Tinggi

• Peraturan Menteri Pendidikan Nasional No. 232-U-2000 tentang Penyusunan Kurikulum

• Peraturan Presiden Republik Indonesia No. 8 Tahun 2012 tentang Kerangka Kualifikasi Nasional Indonesia

• Peraturan Menteri Pendidikan dan Kebudayaan Republik Indonesia No. 73 Tahun 2013 tentang Penerapan Kerangka Kualifikasi Nasional Indonesia Bidang Pendidikan Tinggi

• Peraturan Pemerintah Republik Indonesia Nomor 17 tahun 2010 tentang Pengelolaan dan Penyelenggaraan Pendidikan

• ISO 9001:2015 Quality Management System-Requirement

• ISO 9000:2005 Quality Management System-Fundamentals and Vocabulary

• SNI ISO 9000:2008 Sistem Manajemen Mutu Dasar-dasar dan Kosakata mengacu ISO 9000:2005, IDT

Customer satisfaction and complaints

The organization maintains documented and effective procedures governing the handling of information, data analyses, improvement actions and responses to customer feedback. The organization monitors and measures customer satisfaction by means of a self-assessment, including an analysis of complaints. Which done by BPM (QMR) - Questionnaire to students - Questionnaire to industries and Government as users

Internal audit and management review

The organization measures MS implementation, maintenance and effectiveness by means of annually scheduled system audits. The organization reliably carries out

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Item Audit result

these audits. The nonconformities identified in these internal audits had been corrected by the time the audit documented in this report was performed.

Internal audit was conducted in all sites 17 to 27 September 2018, and Internal Non conformity was verified in Laporan Audit Internal.

The nonconformities identified in these internal audits had been corrected by the time the audit documented in this report was performed.

• Internal Audit Schedule

• Internal Audit Report

• Status of Audit Logs Top management reviews the organization’s quality management system at regular intervals and in line with the requirements to ensure its continuous suitability, adequacy and effectiveness. The management review of Universitas Muhammadiyah Yogyakarta was carried out on 24 October 2018.

The areas of focus of the management review included:

Input of Management Review meeting

A. the status of actions from previous management reviews; B. changes in external and internal issues that are relevant to the quality

management system; C. information on the performance and effectiveness of the quality management

system, including trends in: 1. customer satisfaction and feedback from relevant interested parties; 2. the extent to which quality objectives have been met; 3. process performance and conformity of products and services; 4. nonconformities and corrective actions; 5. monitoring and measurement results; 6. audit results; 7. the performance of external providers;

D. the adequacy of resources; E. the effectiveness of actions taken to address risks and opportunities F. opportunities for improvement

Output of Management Review meeting

The output from management reviews include decisions and actions related to possible changes to policy, objectives, targets and other elements of the quality management system, consistent with the commitment to continual improvement, such as:

A. Opportunities for improvement; B. Any need for changes to the quality management system;

C. Resources needs.

Use of certificate and logo

The organization did not uses the logo yet and the certificate (e.g. on business cards, company brochures, websites etc.) in compliance with the requirements.

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Chapter of standard 4.1 4.2 4.3 4.4 5.1 5.2 5.3 6.1 6.2 6.3

Rating * 1 1 1 1 1 1 1 3 1 1

No. of nonconformity - - - - - - - 4/4 - -

Chapter of standard 7.1 7.2 7.3 7.4 7.5 8.1 8.2 8.3 8.4 8.5 8.6 8.7

Rating * 1 1 1 1 1 3 1 1 1 3 1 1

No. of nonconformity - - - - - 2/4 - - - 1/4 - -

Chapter of standard 9.1 9.2 9.3 10.1 10.2 10.3

Rating * 1 3 1 1 1 1

No. of nonconformity - 3/4 - - - -

* Rating: 1 = conforming

2 = not audited in this audit

3 = failed/nonconformity (see nonconformity report))

4 = not applicable

1 stage certification audit report as per sni iso 9001...

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