FORM 4PENILAIAN KINERJA STAF MEDIS

NAMA LENGKAP (dengan gelar)

DIAJUKAN UNTUK Proses Pengangkatan Kembali Staf Medis Proses Penambahan Kewenangan Klinis Rekredensial

baik sekali baik cukup kurang1. Patient Care

(praktisi menyediakan perawatan pasien yang tepat dan efektif untuk promosi kesehatan, pencegahan penyakit,pengobatan penyakit, dan perawatan di akhir hidup)

2. Medical/Clinical Knowledge *(menerapkan dan mengembangkan ilmu medis, ilmu klinis dan sosial,dan penerapan pengetahuan untuk perawatan pasien danpendidikan)

3. Technical Skills & Application *(demonstrated knowledge and application of the skills required,Includes knowledge and understanding of appropriate equipment,policies and procedures)

4. Practice-Based Learning & Improvement(using scientific evidence and methods to investigate, evaluate, and improve patient care practices)

5. Interpersonal & Communication Skills(enable them to establish and maintain professional relationshipswith patients, families, and other members of health care teams)

6. Professionalism(reflected in a commitment t continuous professionaldevelopment, ethical practice, an understanding and sensitivityto diversity and a responsible attitude toward patients, theirprofession, and society)

7. Personal & Professional Development(demonstrated experience and understanding of the need forcontinuation of both personal and professional development)

8. Teamwork(demonstrated ability to participate as an active member of the team, consistent with the philosophy and policies of the organization)

9. System-Based Practices(the understanding of the contexts and systems in which healthcare is provided)

10. Administration & Documentation(through the use of organizational processes ensure that allAdministration and documentation requirements are initiated andCompleted in a professional and timely manner)

*) Dilakukan oleh Komite Medik

11. Number of Services (see attachment)

12. Clinical Outcomes Review (see attachment)

HASIL PENILAIAN DIREKOMENDASI (UNTUK DILAKUKAN PENGANGKATAN KEMBALI)

TIDAK DIREKOMENDASI

KOMENTAR

TIM PENILAITanda tangan

Dr. Mulyadi Muchtiar MARS Dr. Juniwati Gunawan

Medical & Ancillaries Manager Chief Executive Officer

FORM 4 (lampiran)PENILAIAN KINERJA STAF MEDIS

NAMA LENGKAP (dengan gelar)

NUMBER OF SERVICES Previous Year Current Year

1. Number of Out-Patient

2. Number of In-Patient

3. Number of Surgery

Complex

Major

Minor

Simple

4. Number of Procedure

5. Average length of stay

CLINICAL OUTCOME REVIEW

This is particularly to review the clinical outcome performed by medical staff based on clinical indicator/clinical pathway/etc : 1. Unplanned Re-admission (72 hours)

2. Unplanned Return to OT

3. Unexpected Admit to Intensive Care

4. Nasocomial infection

Pressure UlcerILO (surgical side infection)

5. Mortality Rate