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SUMMARY
EVALUATION OF SERVICE PERFORMANCE IN IGD RSUD PRAYALOMBOK TENGAH AFTER APPLYING QUALITY MANAGEMENT
SYSTEM OF ISO 9001 CERTIFICATION
I Ketut Sudarsana09/308520/PKU/11783
POST GRADUATE PROGRAMOF GADJAH MADA UNIVERSITY
MEDICINE FACULTYJOGJAKARTA
2011
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EVALUATION OF SERVICE PERFORMANCE IN IGD RSUD PRAYALOMBOK TENGAH AFTER APPLYING QUALITY MANAGEMENT
SYSTEM OF ISO 9001 CERTIFICATION
Filed byI Ketut Sudarsana
09/308520/PKU/11783
Has been approved by
Supervisory I Supervisory II
Dr.C.Tjahjono Koentjoro,MPH Dr.PH Ir.Valentina Dwi Yuli S, M.KesDate: Sept 2011 Date: Sept 2011
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ABSTRACT
Background: Anticipating the operationalization of new airport in LombokTengah province, in 2009 IGD RSUD Praya has been awarded ISO9001:2000 certificate as a result of some efforts to improve its quality.However, in the last 4 years there have been increasing number opatients in RSUD Praya with some complaints of IGD services, the resultof patients satisfaction survey in IGD RSUD Praya which has not beenreaching the expected target, and there has not yet been any evaluation tothe service performance improvement after applying ISO 9001:2000certification.Objective: Evaluating service performance in IGD RSUD Praya Lombok
Tengah Province after employing quality management system of ISO9001:2000 as well as finding out the causes of performance changes in
IGD RSUD Praya in accordance to articles in ISO 9001:2000.Method: The design of this study is explanatory case study with specialholistic single case design to evaluate service performance in IGD RSUDPraya after applying quality management system of ISO 9001:2000.Analysis and Result : Respond time service performance, IGD stafcompetency, and medical record completeness tend to improve matchedby the result of evaluation of applying ISO IGD RSUD in article 4, 5, 6, 7,and 8 of ISO 9001:2000 which findings from previous audit didnt appear inthe next audit. While the patient satisfaction to the service performancehas not reached the expected target as its stated in ISO. This is supportedby the result of interview stressing on the need to do survey towardpatients need and want in IGD RSUD Praya, and to evaluate optimally theresult of satisfaction survey, complaint, critics, and suggestion fromPatients in IGD RSUD Praya.Conclusion and Suggestion: There were different service performancein IGD RSUD Praya between pre and post application of qualitymanagement system of ISO 9001:2000 in which the service performancein IGD RSUD Praya tend to improve, yet patients satisfaction of serviceperformance in IGD RSUD Praya was below the expected target stated inISO. It is suggested that the application of ISO 9001:2000 should beconducted and evaluated continually.
Keywords: Evaluation, Quality Management System of ISO, Performance
Service in IGD.
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INTRODUCTION
The hospital is an organization engaged in health services and as a
referral center below the level of service, the hospital needs to improve the
quality of service to people in need and can provide quality service with
quality. Quality management system to support the micro-system service
to work optimally so as to meet the needs, expectations, and values o
customers.1
In the ISO 9001:2000 quality management system has been
revised to ISO 9001:2008 quality management system is based on the
quality management system and process model approach consists of five
elements or elements of the essential requirements of the quality
management system, management responsibility, resource management,
the realization products, as well as measurement, analysis and
improvement where there is a measurement of patient satisfaction in orde
to be eligible customers.2
ISO quality management standards for assessing hospital
performance using standardized quality system compared with the
assessment of function and purpose of the hospital, where there are 12
performance indicators as an instrument to measure the performance o
hospitals that must be taken to be a source of information for community.3
Praya Hospital as a hospital grade C of the Government of Central
Lombok regency, with a capacity of 147 beds TT, is the only government-
owned hospitals in NTB who already have the ISO 9001:2000 quality
standard of service to the Council obtained ISO 9001:2000 certification in
May 2009 from the Quality Assurance throughout the world, to anticipate
the operation of the New Lombok International Airport is located in Central
Lombok regency, and the efforts hospitals Praya, Central Lombok to win
the competition in improving the quality of the product or service that
meets customer and appropriate regulations.2
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ISO 9001:2000 certification assessment area hospital emergency
room Praya, Central Lombok by the number of employees as many as 33
people, consisting of 6 doctors, nursing staff 22 people,4
people porte
personnel, and administrative staff person, but before the implementation
of ISO 9001: 2000 IGD Praya Hospital has been accredited 5 service, one
of the emergency services in 2006 but until now has not done the
evaluation of the performance improvement of hospital services.
In implementing the ISO 9001:2000 IGD Hospital Praya, Central
Lombok have to set quality objectives as set out in clause 5.4.1 of ISO
9001:2000.4 Quality Objectives are established, among others : The
response time of ER patients, ER patients waiting times further for the
management, the incompleteness of the charging status of patients with
ER, the ER staff competence, and patient satisfaction. Quality objectives is
an indicator that should be measured to determine whether the Hospital
ER Praya, Central Lombok can achieve what purpose. Based on data from
the fields of development and quality control services Praya Hospital
(2010), there are still complaints from patients and the introduction o
Praya Hospital emergency room services, both in facilities, comfort,
cleanliness, and staff skills.Patient satisfaction survey results at Praya
Hospital ER ever do not ever reach their intended target, and results o
RAP-Home I (2006) and II (2008) regarding the SPM measurement
indicators in a hospital emergency department found the results of the
response time of 2, 25 minutes and 13.05 minutes, and the competence o
ER to 29% of doctors and nurses 71%.
In the implementation of quality management ISO 9001:2000, IGD
Hospital Praya, Central Lombok began certification in May 2009 has been
conducting internal audits four times, followed by four times the
management review, and 2 times the external audit in February 2010 in
J anuary 2011, but until now This has never been an evaluation o
performance enhancement services at the Hospital ER Praya.5
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RESEARCH METHODS
Evaluation is an activity to assess, measure, or compare what has
been done and achieved with what must be achieved and implemented.6
The study design will be used is a case study explanatori a holistic single
case design, to evaluate the service performance Praya Hospital
emergency room after the certification of ISO 9001:2000 quality
management. This design was chosen because of the problem under
study is a contemporary problem with multiple sources of data and
researchers are not there to control the events under study.7
The research was conducted in a hospital Praya Road. HLHasyim
Praya, Central Lombok which is the C-class hospital that is owned by the
government of Central Lombok district, and the only government-owned
hospitals in NTB who have obtained the certificate ISO 9001:2000.
In this study collected primary data in the form of quantitative data
on patient satisfaction to the emergency services, response time of
emergency patient handling, competency IGD, the completeness of filling
the ER medical records, as well as the suitability of the implementation of
ISO 9001:2000.
Patient or the introduction of 100 people who were given a
questionnaire relating to patient service satisfaction Praya Hospital
emergency room, while emergency room doctors and nurses involved
before and after ISO certification as much as 2 person interviews were
conducted to determine changes in the pattern of performance before and
after ISO 9001:2000 certification. Interview form of open questions with
interview guidelines, observation of emergency room patients and medical
records to determine the response time Praya Hospital emergency room
services started coming up to the patient's physician was calculated and
recorded the time, making the percentage of emergency room service
response time < 5 minutes. Check the list and form filling completeness of
patient records Praya Hospital emergency room by looking at the
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completeness of medical records to fill the relevant forms required ER
medical records are used, the percentage of patients who complete IGD
makes the filling of medical records. Chek conformance clause of ISO
9001:2000 list is used to determine the suitability of the implementation of
ISO in hospital emergency rooms Praya to see articles 4, 5, 6, 7, 8 ISO
9001:2000 is required, using the guidelines of ISO clause examination of
the suitability list. As for knowing the competency of trained personnel in
the emergency room doctors and nurses who have done and have a
certificate of competency required to use data Praya Hospital personnel.
Secondary data in the form of reports or documents concerning the
service performance Praya Hospital emergency room patient satisfaction,
response time, personnel competence, and completeness of medical
records prior to the implementation of ISO 9001:2000 IGD in 2008 and
after the implementation of ISO 9001:2000 in 2009, the year 2010. All data
both primary data and secondary data obtained and carried out data
processing and continued with the presentation of data.
RESULTS AND DISCUSSION
1.ER patient satisfaction service performance Praya
From the research results of service performance satisfaction ER
patient satisfaction results obtained with 82.4% of patients, with the
number of male respondents than female respondents are more numerous
and the largest age group is between 41-50 years. The result is still above
the minimum service standards for emergency >70%,8 but still below the
standard of hospital performance indicators by 90%,3 and is still below the
target achievement of the ISO quality by 85%. J udging from the
achievement of the ISO quality Praya Hospital emergency room on service
performance declined from the previous ER patient satisfaction by 84% in
March 2011, probably due to the understanding and needs of patients
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keiinginan Praya Hospital emergency room, this can be seen from the
findings of conformance clause of ISO 9001 using an instrument
assessment of an organization's quality management system of clause 4,
article 5, article 6, article 7, and paragraph 8 of ISO 9001:2000 with ISO
management representative and head of Praya Hospital ER IGD chief
Praya Hospital, but does not involve the management and support units
Praya Hospital emergency room, where the differences seen in verse 5
Management responsibility has not been set of customer needs and
desires are good, according to the guidelines,9 the importance of
communicating customer requirements and legislation Act, and clause 7
Product realization that not make the most of their communication with
customers by looking at the complaints of customers such as the use of
suggestion boxes, impressions and user messages, such as guidelines,9
of article 7 of the customer communication in which an organization must
establish and implement effective arrangements to communicate with
customers about the customer feedback, including customer complaints,
and according to,10 that service quality is a little hard to measure because
it generally is subjective because it involves patient satisfaction, it depends
on perception, background, socioeconomic, norms, education, culture,
personality and even It depends on perception, background,
socioeconomic, norms, education, culture, and even personality.
Prior to obtaining certification of ISO 9001 Implementation of patient
satisfaction with the performance of 60% increase in pre-certification to
ISO 9001 certification in May 2009 by 70%, probably due to the time at
which the previous certification preparation IGD Praya Hospital has also
undergone accreditation and RAP-Home, but in research These
researchers did not identify the impact of accreditation and RAP-Home.
Where by,11 revealed significant improvement in patient satisfaction in the
emergency room after the intervention and the nurse patient
communication.
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In the present study did not measure the external customer
satisfaction is employee Praya Hospital emergency room, where in the
opinion of,10
quality-oriented health services both internal and external
customers.
2. Service response time performance Praya Hospital ER
In this study conducted with the patient's medical record the
observation of emergency room Praya Hospital, regardless of the
classification of emergency room patients, such as emergency care
guidelines,12 which classifies patients with emergency, no emergency
room patients, emergency patients are not life threatening, no patients
emergency department did not use observations form the medical records
of emergency room response time Praya Hospital, obtained the results of
91%, judging from the achievement of quality objectives of ISO Praya
Hospital ER on the ER performance of the service response time has
increased compared with the previous March 2011 by 87% , and above
target at 85% ISO quality might be due to the understanding and
implementation of the ER response time communications, this can be
seen also from the results of ISO conformance clause, although the
differences are found clause 4 of the quality management system
requirements, where not all employees know IGD IGD operational
processes and management responsibility clause 5, where not all ER
personnel to get the quality policy of socialization, is due to new
employees in the ER so it is necessary to perform additional socialization
for the understanding of the ISO and operational processes Praya Hospital
emergency room, but in the resource management section 6 and
subsection 8 Measurement, analysis, improvement has been correspond
with reality. This is in accordance with the opinion,13 paragraph 8
Measurement, analysis, and improvement in which organizations must
plan and execute the process of measuring, monitoring, analysis and
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improvement is needed in order to ensure conformity of the quality
management system.
Before the implementation of ISO 9001 to obtain the response time
performance with 70% rise in pre-certification to ISO 9001 certification in
May 2009 by 80%, probably due to the time at which the previous
certification preparation IGD Praya Hospital also experiencing
accreditation and RAP-Home. Although pre-certification audit findings in
paragraph 4 where the quality management system requirements have not
been up to understand the quality policy is applied so that the necessary
understanding of the quality policy of the Hospital emergency room Praya
socialization.
Figures Praya Hospital ER response time of 3.9 minutes is
obtained, is the proper guidelines,14 to 858 Kepmenkes / Menkes / SK / IX
/ 2009 on standard hospital emergency room, where emergency room
patients should be treated no later than 5 (five ) minutes after the ER.
3. competence of service performance Praya Hospital ER
In this study physicians obtained Praya Hospital emergency room a
number of 6 people (100%) have had training and certification needed to
work in the ER, whereas ER nurse about 22 people (82%) have training
and have the necessary certificates, so that the results obtained from 91%,
the result is still above the standards of hospital performance indicators by
50%,3 and is above the target of achieving ISO quality objectives set at
90%, but still below the minimum standards of emergency services 100%.8
In terms of achieving IGD Praya ISO quality is still the same hospital from
the previous March 2011 for 91%, this is because in the span of time is not
been to the addition of Praya Hospital emergency room nurse who had
attended the training needed to meet both personal competence and
assistance to management, it This can be seen also conformance clause 6
Resource management in accordance with reality, accordance with the
guidelines,9section 6 in human resources, where the personnel performing
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work affecting product quality must be competent on the basis of
education, training, skills and experience.
Before obtaining ISO 9001 certification authority Competence IGD
implementation performance by 50% rise in pre-certification to ISO 9001
certification in May 2009 was 77%, probably due to the time at which the
previous certification preparation IGD Praya Hospital has also undergone
accreditation and RAP-Home, as well as before certification of all general
practitioners on duty at the hospital Praya was given a job as a doctor in
the emergency room Praya Hospital, but before certification of the ISO has
designated only six general practitioners who have the competence
requirements of duty in the ER, is in accordance with the guidelines,14
through Kepmenkes 858 / Menkes / SK / IX / 2009 standard hospital
emergency room, where general practitioners should receive emergency
training GELTS, ATLS, ACLS, and nurses trained in emergency nursing
BTLS, BCLS.
4.Completeness of medical record service performance Praya Hospital ER
This study obtained the medical records IGD is a complete fill 92%,
the result is still below the standard of hospital performance indicators by
95%,3 but still above the achievement of the ISO quality objectives set at
85%, and earlier than in March 2011 increased by 90%, it This can be
seen the absence of findings regarding the completeness of medical
record in paragraph 4 of the quality management system requirements, in
the opinion,13 and guidelines,9 where the organization should establish,
document, implement, and maintain a quality management system ISO
9001:2000 and continually improve effectiveness in accordance with the
requirements of paragraph 7 of standards and realization of products,
such as opinions,13 and guidelines,9 which organizations must plan and
develop the processes needed for product realization, planning of product
realization shall be consistent with the requirements of other processes of
the quality management system.
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Before the implementation of ISO 9001 performance of the
completeness of medical records obtained by the ER 65% increase in pre-
certification to ISO 9001 certification in May 2009 by 70%, probably
caused during the preparation for ISO certification, which previously IGD
Praya Hospital also experiencing accreditation and RAP-Home, but in this
study researchers did not identify the impact of accreditation and RAP-
Home, as well as the views of the audit findings pre sertfikasi clause 7
Product realization of the medical records that must be ensured that a
complete fill after repair did not reappear later audited.
5. Trend of changes in service performance Praya Hospital ER
Results Praya Hospital emergency room service performance
before and after application of ISO 9001:2000 is displayed in the form of
an image to see the trend of changes in performance post-implementation
services ISO 9001:2000 quality management system, in accordance with
the opinion,15 which monitors the activity of the development trend in
activity in several years can be seen on the graph by comparing against
established standards.
In this study measures the performance of personnel competence,
response time, completeness of medical records, patient satisfaction,
without a measure of financial performance because it has not been
specified in the ISO quality objectives Praya Hospital emergency as
performance goals and objectives Praya Hospital emergency services.
From the results of the evaluation of the implementation of ISO's
Hospital emergency room to see Praya in accordance with ISO 9001:2000
clause in the audit prior to certification, certification, until after the
certification audit findings, there are still improvements to be carried out,
followed in the management review to evaluate the improvement and
implementation of target , where the findings in previous audit findings are
not repeated in subsequent audit that shows the quality management
system performed consistently, such as guidelines,9 which clause 4 of the
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quality management system requirements, where the processes for quality
management system includes processes for management activities,
provision of resources , product realization and measurement, and
appropriate consultation,6 where the suit is the fulfillment of the
requirements or criteria, or a condition within the tolerance limits or
requirements established criteria, where the suitability of the quality
management system compared to the standard ISO 9001:2000.
After achieving ISO certification obtained ISO quality Praya Hospital
emergency room in the ER changes in patient satisfaction performance
improvement is less significant results obtained, most likely will remain,
although the performance of patient satisfaction is still above the target
ISO quality targets, but after the target increased to 85% quality
performance results Praya Hospital ER patient satisfaction has not
reached its intended target, this may be due to a lack of understanding of
the needs and desires of emergency room patients, according to the
results of interviews indicate that the survey will be added to the wishes
and needs of emergency Praya Hospital patient satisfaction
questionnaires as a complement to the room existing patients, and the
findings of the survey maximum, both from complaints, feedback, and
suggestions from patients Praya Hospital emergency department, and
need to be addressed in the management review to improve future, this
opinion,13 and guidelines,9 clause 8 Measurement, analysis and
improvement, the organization must plan and execute the process
measurement, monitoring, analysis and improvement is needed in order to
ensure conformity of the quality management system, and according to the
findings in paragraph 5 Responsibility management responsibility in which
the provision has not been keiinginan customer needs and good, and
clause 7 Product realization where communication with customers that
have not performed optimally, but the results of the study,16 revealed the
perception of quality of service to the patient and family satisfaction with
Servqual attributes do not all have a positive correlation.
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Changes in the performance of services which tend to increase the
response time, this might be due to the understanding and communication
of nurses and doctors who attended Praya Hospital emergency room,
according to an interview that emphasizes cooperation and communication
between doctors and nurses who know and understand and responsive in
responding to every patient who came to the emergency room Praya
Hospital, as well as findings regarding response time, both in Clause 4 of
the quality management system requirements, management responsibility,
paragraph 5, article 8 Measurement, analysis, improvement, does not
appear in a subsequent audit that shows the quality management system
implemented consistent, where according to,17 in his research stated
adherence to the response time identified beneficial for survival, and
reduce the severity of the disease.
Changes in the competence of service performance remains but the
phase tends to increase, this is because there is a phase in which the
absence of additional staff both doctors and emergency room nurse who
has been trained to the competencies required to work in the ER both
personal fulfillment and management assistance Praya Hospital , as well
as improved performance due to the addition of ER personnel who have
done the necessary training and competence of staff turnover has not
been competent IGD IGD with personnel who already have the
competencies required to work in the ER Praya Hospital, consistent with
the interview, stressing that the doctors and nurses on duty in the ER
Praya Hospital must have the competencies needed by way of personal
fulfillment and to help the hospital management, as well as findings
regarding the fulfillment of the competence of workers, both in Clause 4 of
the quality management system requirements , paragraph 5 Management
responsibility, Resource management section 6, in accordance with that
opinion,13 and guidelines,9 which organizations must apply and provide
necessary resources to properly implement and maintain QMS ISO 9001:
2000, as well as personnel performing work affecting product quality must
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be competent on the basis of education, training, skills and experience,
where the findings do not appear again showed the quality management
system applied consistently audited next.
Changes in the completeness of medical record service
performance is likely to increase significantly, this may be due to the habit
of doctors and nurses Praya Hospital emergency room, assisted by
administrative personnel in completing the medical records of patients'
medical records Praya Hospital emergency room, according to the results
of this interview, which emphasized in the doctor's habit to complete
medical records and emergency room nurse's role in helping to fill the
completeness of patient records of emergency room Praya Hospital, and
the role of medical records to remind and return the medical records of
patients who are not yet complete and periodically provide input to the
emergency room Praya Hospital . Audit findings regarding the
completeness of medical records IGD, both in Clause 4 of the quality
management system requirements, in accordance with that opinion,13 and
guidelines,9 which organizations establish, document, implement, and
maintain a quality management system ISO 9001:2000 and continually
improve effectiveness in accordance with standard requirements, clause 7
Product realization, clause 8 Measurement, analysis, improvement, does
not appear in a subsequent audit that shows the audit results are always
followed up and discussed in management review, and the quality
management system is implemented consistently.
From interviews to see the cause of emergency room services
Praya Hospital which is generally perceived performance tended to
increase after the implementation of quality management system ISO
9001:2000, felt after the implementation of ISO, IGD Praya Hospital may
work regularly use established standards to achieve the objectives to be
achieved in the ER quality objectives, but the results of the study,18 in
which hospitals are implementing ISO 9000 QMS is not all experience
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improved performance, as well as hospitals that implement CQI measures
do not all have an impact on hospital performance improvement.
Achievement of quality objectives IGD monitored and evaluated
through internal audits, management review, external audit, which
measures the performance does not automatically provide answers to how
well the actual performance of current and alternative fixes do not give to
be done and is simply a beginning point for further analysis,19
Changes in service performance Praya Hospital emergency rooms
as well as causing changes when viewed with the clauses of ISO through
interviews and checklists of compliance clauses of ISO 9001:2000, as in
the study,20 in which the ISO 9001:2000 quality management system can
be used as an indicator of performance by using ISO 9000 clause 4:20,
conducted in accordance with established standards and continuously
evaluated for improvement in order to improve the quality of services
provided, and in accordance with the guidelines,9 that the organization
that successfully manages to systematically and transparently to
determine the process that leads to improved organizational performance
and customer-oriented, and uses the principles of the eight quality
management, the organization will move toward improved performance.
CONCLUSION
From the results of research and discussion, and refer back to the
formulation of research questions and problems, it can be summed up as
follows:
1. There is a difference in the performance of emergency room
services Praya Hospital after the application of ISO 9001:2000
quality management system is seen from changes in the
emergency room service Praya Hospital performance before and
after implementation of quality management system ISO
9001:2000.
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2. Trend change in the performance of emergency services Praya
Hospital in general tend to increase after the certification of ISO
9001:2000 quality management system, but the performance of
emergency services Praya Hospital rooms of patients satisfaction
improvement has not reached the targets set in the ISO quality
objectives.
3. Changes in the performance of medical record completeness IGD is
quite dominant in the post sertfikasi ISO 9001:2000 seen from the
results change Praya Hospital emergency service performance and
conformance clause of ISO 9001:2000.
SUGGESTION
1.For Praya Hospital:
a. Implementation of ISO 9001 quality management system should be
implemented and evaluated consistently in order to improve service
performance Praya Hospital emergency room.
b. Applying ISO 9001 quality management in other units in order to
improve the environmental performance of hospital services Praya
Hospital as a whole.
c. Praya Hospital Management continues to implement ISO
9001:2000 quality management system has been updated with the
ISO 9001: 2008 with the proposed budget.
2.For further research:
Can be used a reference for future studies to better reduce the
flaws in this study that categorizes the response time in the triage criteria,
to evaluate the service performance of internal customer satisfaction /
employee IGD IGD financial performance and service, and involve the
relevant units / IGD support.
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