4. dokumen mfk-rev
TRANSCRIPT
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DOKUMEN
MANAJEMEN FASILITAS &KESELAMATAN
Dr.Luwiharsih,MSc
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luwi-15 maret 2014 2
DOKUMEN
MANAJEMENFASILITAS &
KESELAMATAN
REGULASI SBGDASAR
PELAKSANAANKEGIATAN MFK
DOKUMENBUKTI/PELAKSANAAN KEGIATAN MFK
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3
KOMISI AKREDITASI RUMA SAKIT!"#!
slide dr djoti
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MANAJEMEN FASILITAS &KESELAMATAN
K$%$i%i'a' (a'%$r$'ca'aa'
MFK #) !) *) *.#
K$s$+aaa' (a' -$aa'a' MFK ) .#) .!
Baha' $raha0a MFK 1
K$sia%a' $'2ha(a%i
$'ca'a
MFK 3) 3.#
P$'2aa'a' -$a-ara' MFK 4) 4.#) 4.!) 4.*
P$ra+aa' $(is MFK 5) 5.#) 5.!
Sis$ ui+isasi 6Sis$
%$'(u-u'27
MFK 8) 8.#) 8.!) #")
#".#) #".!
P$'(i(i-a' sa9 MFK ##) ##.#) ##.!)
##.*
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Komisi Akreditasi Rumah Sakit
MFK # K$%auha' $rha(a% %$raura'%$ru'(a'2a'
MFK 2 Program Maajeme Risiko Fasilitas daligkuga !Master Program "
MFK 3 #ata iside ke$elakaa terkait %asilitas &ligkuga di RS 'aik utk (asie)(egujug da sta%
MFK 4 Program Keselamata da keamaa
MFK 5 Pegelolaa 'aha 'er'aha*a da lim'ah
MFK + #isaster (la
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Komisi Akreditasi Rumah Sakit
MFK 4 P$'c$2aha' (a' %$'a'2a'a'-$a-ara'
MFK , Pegelolaa alat medis
MFK .istrik da air tersedia 24 jam
MFK 10 Sistem utilitas da ku$i !sistem *g
(etig" lai*a
MFK 11 #iklat MFK
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Komisi Akreditasi Rumah Sakit
NASIONAL
PERATURANPERUNDANG:UNDANGAN
U'(a'2:u'(a'2
P$raura' P$$ri'ah PMK, KMK. P$r$'a-$r, KL
P$(;a'/Pa'(ua'
T$r-ai ('2 MFK
RUMA SAKIT
REGULASI
P$(;a' MFK
Pr;2ra MFK
SPO:! MFK
UNIT KERJAKETENTUAN TERTULIS
Pr;2ra sa9$0 +a 6K:* La7 Pr;2ra sa9$0 ra(i;+;2i 6K:
* ra(i;+;2i7
Pr;2ra/S-$'ari; $
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P$raura',
%$ru'(a'2a' &
-$$'ua':! 02
$r-ai ('2
sara'a,
%rasara'a &
9asi+ias (i RS
Pi%i'a' RS =
M$'2$ahui
%$raura',
%$ru'(a'2a' &
-$$'ua'
M$'$ra%-a'-$$'ua' s
M$$'uhi
-;'(isi s$suai
-$$'ua'
M$r$s%;'hasi+
%$$ri-saa'
luwi-m%k 20+213
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Pr;2ra
Ma'a>$$' Risi-;
Fasi+ias
Di+a-sa'a-a'
#. K$s$+aaa'
& -$a'a'
!. Baha'
$raha0a*. Ma'a>$$'
$$r2$'si
. K$a-ara'
1. P$ra+aa'
M$(is
3. Sis$
ui+ias
T$r-i'i aau (i
u%(a$
A(a $
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MANAJEMEN FASILITAS& KESELAMATAN
PROGRAM MANAJEMENRISIKO FASILITAS &
LINGKUNGAN
PERLU INDI?IDU @GMENGAASI/TIM RISKMANJ/K:* RS
BUAT PROGRAM
PENGAASAN
DATA ASILPENGAASAN
i'si($' -$c$+a-aa'
PROGRAM PENGAASANa. $r$'ca'a-a'
(rogram. $+a-sa'a-a'
(rogramc. $'(i(i-sta%(. $;'i;r & u>i$o'a
(rogram
$. $
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RAA 6R67.8S 767K + 98#A:MFK ;
K$s$+aaa'---Suatu tigkata keadaa
tertetu dimaa gedug) halamaua' uu & -husus. K$2iaa' %;-;- & ri'cia' -$2iaa'
K$2iaa' %;-;-
a Keselamata da Keamaa
' 9aha 'era$u da 'er'aha*a
$ #isaster Pla
d Ke'akara
e Sistem 7tilisasi .istrik) Air da sistem(edukug *ag (etig lai*a
% Peralata Medis
Komisi Akreditasi Rumah Sakit
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41 Ri$ia kegiata
Ri$ia kegiata dimasig2 kegiata meli(uti ;
8deti?kasi risiko
Aalisa risiko aluasi risiko
6ata kelola risiko
Pela(ora iside
Moitorig da Reiew iside da kegiata
dukasi sta% tetag risk register
1.Cara $+a-sa'a-a' -$2iaa'
3. Sasara'
4. S-$(u+ 6>a(wa+7 %$+a-sa'aa' -$2iaa'
5. E
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PROGRAM KESELAMATAN
DAN KEAMANAN (MFK 4)
Komisi Akreditasi Rumah Sakit
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#. P$'(ahu+ua'!. Laar $+a-a'2
*. Tu>ua' uu & -husus
. K$2iaa' %;-;- & ri'cia' -$2iaa'
1. Cara $+a-sa'a-a' -$2iaa'
3. Sasara'
4. S-$(u+ 6>a(wa+7 %$+a-sa'aa' -$2iaa'
5. E
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PR@:RAM KS.AMA6A#A KAMAA
I. P$'(ahu+ua'
II. Laar $+a-a'2
III.Tu>ua' uu & -husus
Tu>ua' uu =$'i'2-a-a' -$aa'a' &-$s$+aaa' %asi$',%$'2u'>u'2 (a' sa9 (iruah sa-i
Komisi Akreditasi Rumah Sakit
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. KEGIATAN & RINCIANKEGIATAN
#. Risi-; -$aa'a' (a' -$s$+aaa'
. Ma%%i'2risiko !ideti?kasi area *ag 'erisiko keamaa
da keselamata*a" misal*a ; ruag 'a*i
. M;'i;ri'2ar$a 0a'2 $risi-; terjadi*a masalah
keselamata da keamaa kamera keamaa di daerah
'erisiko) dega meem(atka sat(am di daerah 'erisiko
keamaa
. P$asa'2a' a(2$ 'a$/a'(a (egeal utuk semua
sta%) (egujug) (edagag
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. KEGIATAN & RINCIANKEGIATAN
!. Fasi+ias si-
P$$ri-saa' 9asi+ias si- se$ara kom(rehesi%
!me$atat semua (era'ot *ag tajam da rusak)
%asilitas *ag (erlu (er'aika) dll" R$s%;'/aci;' %+a' terhada( hasil
(emeriksaa
Susu' a'22ara' utuk meggati sistem)
(er'aika %asilitas *ag rusak) dll
M;'i;ri'2 %$+a-sa'aa' res(o
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. KEGIATAN & RINCIANKEGIATAN
*. E(u-asi sa9 terkait dg keselamata & keamaa
. M;'i;ri'2-$%auha' u'i
i'($%$'($'/%$'0$wa laha' thd (rogram
keamaa da keselamata RS
1. P$'caaa' & %$+a%;ra' i'si($'/c$($ra aki'at
%asilitas *g tdk mem'erika keamaa &
keselamata
3. P$+a%;ra' %$+a-sa'aa' -$2iaa' da re$aa
tidak lajut*a
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PROGRAM KEAMANAN &KESELAMATAN
?. Cara $+a-sa'a-a' -$2iaa'
%$r$ua', au(i, (++
?I. Sasara'
: a%%i'2 risi-; #""
: %$asa'2a' a(2$ 'a$ %$'2u'>u'2
#""
: (++
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PROGRAM KEAMANAN &KESELAMATAN
1. S-$(u+ 6>a(wa+7 %$+a-sa'aa'
-$2iaa'
3. E
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PROGRAM MANAJEMENBAAN/LIMBA
BERBAA@A
Komisi Akreditasi Rumah Sakit
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9A>A 9R9A>AA
I($'i-asi B*
P$'a'2a'a'
P$'0i%a'a'
P$'22u'aa'
Tu%aha'
P$ua'2a'
luwi / se(tem'er 2015
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PROGRAM MANAJEMENBAAN/LIMBA BERBAA@A
Komisi Akreditasi Rumah Sakit
#. P$'(ahu+ua'
!. Laar $+a-a'2
*. Tu>ua' uu & -husus
. K$2iaa' %;-;- & ri'cia' -$2iaa'
1. Cara $+a-sa'a-a' -$2iaa'
3. Sasara'
4. S-$(u+ 6>a(wa+7 %$+a-sa'aa' -$2iaa'
5. E
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. K$2iaa' %;-;- & ri'cia'-$2iaa'
#. M$+a-u-a' I'
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DISASTER PLAN6PROGRAM DISASTER7
Komisi Akreditasi Rumah Sakit
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S-$'ari;siu+asi
(isas$r
Siu+asi(isas$r
D$ri$'2
La%;ra'
P$s$ra = S$+uruh
%$2awai RS P$2awai (i
u'ii'($%$'($'luwi / se(tem'er 2015
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PROGRAM DISASTER
Komisi Akreditasi Rumah Sakit
#. P$'(ahu+ua'
!. Laar $+a-a'2
*. Tu>ua' uu & -husus
. K$2iaa' %;-;- & ri'cia' -$2iaa'
1. Cara $+a-sa'a-a' -$2iaa'
3. Sasara'
4. S-$(u+ 6>a(wa+7 %$+a-sa'aa' -$2iaa'
5. E
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. K$2iaa' %;-;- & ri'cia'-$2iaa'
P$'0usu'a' (isas$r %+a'
Siu+asi (isas$r
D$ri$'2
Komisi Akreditasi Rumah Sakit
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MATERI DISASTER PLAN#. I($'i-asi aha0a 0a'2 isa $r>a(i (i RS i'$r'a+ aau
$-s$r'a+.
2 meeta(ka %$ra' ruah sa-i dalam kejadia ts'
*. sra$2i -;u'i-asi (ada kejadia
. %$'2$+;+aa' su$r (a0a (d wkt kejadia) termasuk sum'er
da*a alterati%
1. %$'2$+;+aa' -$2iaa' -+i'is (d wkt kejadia) termasuk
alterati% tem(at *a
3. i($'i-asi & %$'u2asa' %$ra' & taggug jawa' sta%
(ada waktu kejadia
/ (roses utk $'2$+;+a -$a(aa' (arura/-$(aruraa' i+a
$r>a(i %$r$'a'2a' a'ara a'22u'2 >awa sa9 s$caraKomisi Akreditasi Rumah Sakit
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PROGRAM PENGAMANANKEBAKARAN
Komisi Akreditasi Rumah Sakit
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PROGRAM PERALATAN MEDIS
Komisi Akreditasi Rumah Sakit
#. P$'(ahu+ua'
!. Laar $+a-a'2
*. Tu>ua' uu & -husus
. K$2iaa' %;-;- & ri'cia' -$2iaa'
1. Cara $+a-sa'a-a' -$2iaa'
3. Sasara'
4. S-$(u+ 6>a(wa+7 %$+a-sa'aa' -$2iaa'
5. E
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. KEGIATAN & RINCIANKEGIATAN
1 8etarisasi alat medis di RS
2 Pere$aaa ke'utuha (eralatamedis
3 Pemiliha (eralata medis
4 Pemeriksaa
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PROGRAM SISTEMUTILITAS
Komisi Akreditasi Rumah Sakit
PROGRAM SISTEM
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PROGRAM SISTEMUTILISASI/PENDUKUNG
Komisi Akreditasi Rumah Sakit
#. P$'(ahu+ua'
!. Laar $+a-a'2
*. Tu>ua' uu & -husus
. K$2iaa' %;-;- & ri'cia' -$2iaa'
1. Cara $+a-sa'a-a' -$2iaa'
3. Sasara'
4. S-$(u+ 6>a(wa+7 %$+a-sa'aa' -$2iaa'
5. E
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. KEGIATAN & RINCIANKEGIATAN
P$'0$(iaa' air i'u (a' +isri- ! >a
s$hari & 4 hari s$i'22u
I($'i-asi ar$a 02 $risi-; i+a air (a'
aau +isri- $r2a'22u
P$'0$(iaa' ac-:u% air (a' +isri-
U>i c;a air (a' +isri- %$'22a'i s$ahu's$-a+i
Komisi Akreditasi Rumah Sakit
KEGIATAN & RINCIAN
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. KEGIATAN & RINCIANKEGIATAN
I($'i-asi sis$ -u'ci +ai''0a 6sis$
%$'i'2 +ai''0a7
P$$ri-saa' $r-a+a
P$rai-a' i+a a(a -$rusa-a'
Komisi Akreditasi Rumah Sakit
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RUMASAKIT
JUDUL
N; D;-u$' N;. r$a-a'
Pr;s$(ur
U'i$r-ai
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$a(i'2 & -;a-'0a (ic$a- %a(a s$ia% ha+aa'
K;a- RS (i$ri 'aa & +;2; RS 6i+a RS $%. L;2;7
Ju(u+ SOP = (i$ri >u(u+/'aa SOP s$suai %r;s$s
-$r>a'0a, isa+ = K;'su+asi $(is, Bi;%si 2i'>a+,
P$rsia%a' %asi$' ;%$rasi,(s N;. D;-u$' = (iisi s$suai ('2 -$$'ua' %$';;ra'
02 $r+a-u (i RS 0s 02 (iua sis$ais a2ar a(a
-$s$ra2aa'
N;. r$
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a+aa' = (iisi ';;r ha+aa' ('2 $'ca'u-a' >u2a
;a+ ha+aa' u- SOP s. Misa+ SOP ('2 1 ha+aa'
ha+aa' %$raa = #/1) ha+aa' -$(ua !/1,(s
Pr;s$(ur $a% (i$ri %$'aaa' s$suai -$$'au' 6isi+ah7
02 (i2u'a-a' RS, isa+'0a Pr;s$(ur, Pr;s$(ur $a%,
P$u'>u- %$+a-sa'aa', %r;s$(ur -$r>a,(s
Ta'22a+ $ri = (i$ri a'22a+ s$suai ('2 a'22a+ $ri'0a
02 harus s$suai ('2 a'22a+ (i$r+a-u-a''0a SOP $rs$u
Di$a%-a' Dir$-ur = (i$ri a'(a a'2a' Dir$-ur (a'
'aa >$+as
K;a- h$a(i'2 %a(a ha+aa':ha+aa' $ri-u'0a (a%a
ha'0a $ua = -;a- 'aa RS, >u(u+ SOP, N; (;-u$',
KOTAK HEADING
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. Pr;s$(ur=a2ia' i'i r%- a2ia' uaa 02
$'2urai-a' +a'2-ah:! -$2iaa' u- $'0$+$sai-a'
%r;s$s -$r>a , & sa9/%$u2as 02 $rw$ 'a'2.
Di(a+a'0a (% (ica'u-a' a+a/9;ru: +ir/9asi+ias
02 (i2u'a-a', wa-u, 9r$-u$'si (a+a %r;s$s -$r>a 02
(i2u'a-a'. Bi+a $u'2-i'-a', (iurai-a' s$cara
+$'2-a% u'sur:! 02 $'0a'2:-u = SIAPA, DIMANA,
KAPAN & BAGAIMANA 6h;, wha, wh$r$, wh$', h;w7
1. U'i $r-ai=$risi u'i:u'i 02 $r-ai & aau %r;s$(ur
$r-ai (a+a %r;s$s -$r>a s
ISI SOP
KEAMANAN &
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KEAMANAN &KESELAMATAN
#. SPO %$'a'2a'a' +a%;ra' -$hi+a'2a'
ara'2 (i RS
!. SPO %$$ria' a(2$ 'a$ u'u-%$'2u'>u'2
*. SPO %$$ri-saa' 9asi+ias
. SPO %$$ri-saa' u'i i'($%$'($'
1. SPO i+a a(a a0i hi+a'2 6-;($ %i'-7
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DISASTER
SPO -;($ $rah 6-$a-ara'7 SPO -;($ iru 62a2a+ >a'u'2/'a9as7
SPO -;($ %i'- 6a0i hi+a'27
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TERIMA KASI
Email : [email protected] : 08!"#
mailto:[email protected]:[email protected]