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Struktur organisasi berdasarkan peraturan menteri kesehatan republik indonesia nomor

1045/Menkes/PER/XI/2006 tentang pedoman organisasi rumah sakit di lingkungan

departemen kesehatan

RSU Kelas A dipimpin oleh seorang Kepala disebut Direktur Utama.

(2) Direktur Utama membawahi paling banyak 4 (empat) Direktorat.

(3) Masing-masing Direktorat terdiri dari paling banyak 3 (tiga) Bidang atau 3 (tiga) Bagian.

(4) Masing-masing Bidang terdiri dari paling banyak 3 (tiga) Seksi.

(5) Masing-masing Bagian terdiri dari paling banyak 3 (tiga) Subbagian.

dasar hukum tindakan perawat Sumber: PPNI

- UU nomor 23 tahun 1992, tentang kesehatan yang menyebutkan bahwa UU No. 23

Tahun 1992 tentang Kesehatan Pasal 32 ayat (4) menyebutkan bahwa; Pelaksanaan

pengobatan dan atau perawatan berdasarkan ilmu kedokteran dan atau ilmu

DIREKTURUTAMA

DIREKTORAT KOMITE DIREKTORAT DIREKTORAT DIREKTORAT

BAGIANBAGIAN BAGIANBAGIANBAGIAN BAGIANBIDANGBIDANG BAGIANBAGIAN BAGIAN

SUB

BAG

SMF

SUB

BAG

SUB

BAG

SUB

BAG

SUB

BAG

SUB

BAG

SUB

BAG

SUB

BAG

SUB

BAG

SUBBAG

SUBBAG

SUBBAGS

UBBAG

SUBBAG

SUBBAGS

UBBAG

SUBBAG

SUBBAGS

UBBAG

SUBBAG

SUBBAGS

UBBAG

SUBBAG

SUBBAGS

UBBAG

SUBBAG

SUBBAGs

eksi

seksi

seksi

seksi

seksi

seksi

SPI

BIDANG

seksi

seksi

seksi

KOMITE

INSTALASI

U P F

KJF

KJF

INSTALASI

KJF

INSTALASI

KJF

STRUKTUR ORGANISASI RUMAH SAKIT UMUM KELAS A

INSTALASI

keperawatan, hanya dapat dilaksanakan oleh tenaga kesehatan yang mempunyai

keahlian dan kewenangan untuk itu

- UU no 36 Tahun 2009 tentang kesehatan pasal 63 ayat 3 yang menyebutkan

pengendalian, pengobatan, dan/atau perwatan dapat dilakukan berdasarkan ilmu

kedokteran dan ilmu keperawatan atau cara lain yang dapat dipertanggungjawabkan

kemanfaatan dan keamanannya

- UU no 36 Tahun 2009 tentang kesehatan pasal 63 ayat 4 yang menyebutkan

pelaksanaan pengobatan dan/atau perawatan berdasarkan ilmu kedokteran atau ilmu

keperawatan hanya dapat dilakukan oleh tenaga kesehatan yang mempunyai keahlian

dan kewenangan untuk itu

- Pasal 53, ayat (1) juga menyebutkan bahwa tenaga kesehatan berhak memperoleh

perlindungan hukum dalam melaksanakan tugas sesuai dengan profesinya. Pasal 53,

ayat (2) menyebutkan bahwa tenaga kesehatan dalam melakukan tugasnya

berkewajiban untuk mematuhi standar profesi dan menghormati hak pasien.

- Keputusan menteri nomor 1239/Menkes/SK/XI/2001 tentang registrasi dan praktik

perawat tertuang pada Pasal 20 yaitu disebutkan bahwa (1) Dalam keadaan darurat

yang mengancam jiwa seseorang/pasien, perawat berwenang untuk melakukan

pelayanan kesehatan diluar kewenangan sebagaimana dimaksud dalam Pasal 15. (2)

Pelayanan dalam keadaan darurat sebagaimana dimaksud pada ayat (1) ditujukan

untuk penyelamatan jiwa. Isi Pasal 15 yaitu Perawat dalam melaksanakan praktik

keperawatan berwenang untuk :

a. melaksanakan asuhan keperawatan yang meliputi pengkajian, penetapan

diagnosa keperawatan, perencanaan, melaksanakan tindakan keperawatan dan

evaluasi keperawatan;

b. tindakan keperawatan sebagaimana dimaksud pada butir a meliputi : intervensi

keperawatan, observasi keperawatan, pendidikan dan konseling kesehatan;

c. dalam melaksanakan asuhan keperawatan sebagaimana dimaksud huruf a dan b

harus sesuai dengan standar asuhan keperawatan yang ditetapkan oleh organisasi

profesi;

d. pelayanan tindakan medik hanya dapat dilakukan berdasarkan permintaan

tertulis dari dokter.

- PERMENKES RI no. Hk.02.02/Menkes/148/2010 tentang Praktik Keperawatan

“Dalam keadaan darurat untuk penyelamatan nyawa seseorang/pasien dan tidak

ada di tempat kejadian, perawat dapat melakukan pelayanan kesehatan diluar

kewenangan sebagaiman dimaksud dalam pasal 8

- UU no 36 tahun 2009 pasal 83

(1) Setiap orang yang memberikan pelayanan kesehatan pada bencana harus ditujukan

untuk penyelamatan nyawa, pencegahan kecacatan lebih lanjut, dan kepentingan

terbaik bagi pasien

(2) Pemerintah menjamin perlindungan hukum bagi setiap orang sebagaiman

dimaksud pada ayat (1) sesuai dengan kemampuan yang dimiliki

Tindakan Keperawatan menurut Permenkes No. Hk.02.02/Menkes/148/2010 pasal 8

1) Memenuhi kebutuhan oksigen

2) Memenuhi kebutuhan nutrisi

3) Memenuhi kebutuhan integritas jaringan

4) Memenuhu kebutuhan cairan dan elektrolit

5) Memenuhi kebutuhan eliminasi

6) Memenuhi kebutuhan kebersihan diri dan lingkungan

7) Memenuhi kebutuhan istirahat dan tidur

8) Memenuhi kebutuhan obat-obatan

9) Memenuhi kebutuhan sirkulasi

10) Memenuhi kebutuhan rasa nyaman, aman dan keselamatan

11) Memenuhi kebutuhan manajemen nyeri

Dll

Sumber: THE UNIVERSITY OF CONNECTICUT HEALTH CENTER 1

JOHN DEMPSEY HOSPITAL-DEPARTMENT OF NURSING

STRUCTURE STANDARDS - EMERGENCY DEPARTMENT

NURSING PROCESS

1. Assessment

An initial triage assessment will be performed on each patient either by

the triage nurse, charge nurse or nurse admitting the patient to a

patient care area. Initial vital signs will be done during triage.

All pediatric patients will have a temperature, pulse, respiration and

weight taken (when indicated). All patients older than 8 years will

also have a blood pressure taken.

If vital signs are not done, reason for deferral must be documented on

the patient's chart.

All patients who are hypertensive need to have a blood pressure repeated

at least once prior to discharge or admission to the hospital. Refer to

ED Protocol: Blood Pressure Screening for the Adult Patient.

Patients who are classified as Level 4 or Level 5 shall have vital signs

repeated prior to disposition if initial vital signs were abnormal.

THE UNIVERSITY OF CONNECTICUT HEALTH CENTER 19



Rev. 5/06, 12/06, 9/08, 7/09, 11/09, 10/12

Patients who are classified as Level 3 shall have vital signs repeated

at least once or more frequently as warranted by the Nursing/MD staff.

Patients who are classified as Level 1 or Level 2 shall have vital signs

repeated frequently as warranted by the nursing/MD staff.

2. Planning

Refer to Department of Nursing Structure Standards.

3. Nursing Interventions


4. Evaluation


5. Documentation/Retention of Records

All patients in the ED have a triage assessment documented upon arrival,

and reassessment, interventions, procedures, completion of orders will

be documented in the electronic record. Documentation in the ED

includes the ED electronic record and additional forms as indicated,

i.e. ambulance run forms, consults, PEC. All documentation is signed

electronically. Paper documentation sent to HIM to be scanned into the

patient’s record.

B. NURSING RESPONSIBILITIES

The role of the professional nurse at JDH is consistent with the scope of

practice outlined in the State of Connecticut Nurse Practice Act (1975).

Nursing practice is directed by the Department of Nursing Manual, Lippincott

Nursing Practice Manual, Unit-specific practice Manuals, the Hospital

Administrative Manual, and in collaboration with other disciplines. Practice

is evaluated by competencies: orientation and annual.

The specialized, tertiary care setting demands assessment of specific

nursing responsibilities in each clinical area. Therefore, Unit Structure

Standards and Practice Manuals further define the professional nurse role in

each area of nursing practice.

1. Emergency equipment is checked daily by an RN.

2. ED nursing staff may perform the following bedside testing:

a. blood glucose

b. urine chemstrip

c. Hemocult slides, Gastroccult slides

d. I-STAT

e. urine pregnancy (Quick Vue)

f. pH check

g. rapid strep

THE UNIVERSITY OF CONNECTICUT HEALTH CENTER 20



Rev. 5/06, 12/06, 9/08, 7/09, 11/09, 10/12

3. Nursing staff at the change of each shift should perform room checks on

their assigned area.

4. All treatments and/or medications ordered in the ED must be signed by

the LIP.

A verbal order is generally not given, however, in an emergency

situation a verbal order is taken by nursing and the order shall be

entered into the electronic record by the nurse. When the order is

completed, the order shall be signed off by the nurse and co-signed by

the LIP.

It is the philosophy of the ED staff that we do not provide telephone

advice. Callers are advised to call their PMD, or seek medical

attention at a medical facility or ED.

The ED is equipped and supplied so that most standard procedures can be

performed when necessary to determine patient status. However, certain

procedures should be performed where optimal conditions exist for the

patient. Refer to Administrative Protocol: Procedures Not Performed in

the ED.


Evaluasi dan pengendalian mutu

Kriteria:

1. Ada data dan informasi mengenai:

Jumlah kunjungan

Kecepatan pelayanan (respon time)

Pola penyakit/kecelakaan (10 terbanyak)

Angka kematian

2. Instalansi/unit gawat darurat harus menyelenggarakan evaluasi terhadap

pelayanan kasus gawat darurat sedikitnya satu tahun sekali dalam setahun

Goal-Directed Measures of Success, sumber: The Emergency Department as a Complex

System

Mark Smith, MD

Chair, Department of Emergency Medicine

Washington Hospital Center

Clinical Professor of Emergency Medicine

The George Washington University School

of Medicine and Health Sciences

Washington, DC

The processes of ED care can be tracked and measured and the quality of their

outcomes can be judged. Many different quantitative metrics are used to assess

how well the Emergency Department is performing as a system that should be

optimized tor provide patient care. . For some of the measures, the goal is to score

high: patient satisfaction, clinical outcomes, medical staff satisfaction, managed

care organization

satisfaction, ED patient volume, revenue, hospital admissions (assuming the

hospital is still being paid on a modified fee for service basis), payor mix, and

community reputation. For other measures, the goal is to score low: patient

throughput or turnaround time, complaints, ambulance reroute/diversion time,

costs, malpractice cases and losses, and regulatory agency violations. These

measures are relatively precise, most

of the data are easily obtained, and the majority of these measures are considered

standard metrics that lend themselves to cross-ED comparison on a national scale

The existence of these measures means that the outcomes and consequences . both

intended and unintended-- of a given intervention that is designed to change and

improve a specific ED process can be assessed with reasonable precision..

*) Dokumentasi kolaborasi

Sumber: PENERAPAN INTEGRATED CARE PATHWAYS (ICP) SEBAGAI

BAGIAN SISTEM INFORMASI MANAJEMEN KEPERAWATAN

DI RUMAH SAKIT dari FIK UI

ICP (Integrated Care Pathway) merupakan format dokumentasi multidisiplin. Format

ini dikembangkan untuk

pengembangan multidisiplin (dokter, perawat, rehabilitasi, gizi, dan tenaga kesehatan lain)

yang diciptakan tidak terlalu rumit dan panjang. Pada format pengkajian multidisiplin

menunjukkan format pengkajian awal yang memungkinkan diisi oleh berbagai disiplin ilmu.

Pengisian ini terdiri dari data riwayat pasien, pemeriksaan fisik dan pengkajian skrining

lainnya yang diisi oleh multidisiplin sesuai kesepakatan.

Sasaran dari ICP adalah benar orang (the right people), benar instruksi (the righat

order), benar tempat (in the right place), melakukan hal yang benar (doing the right thing),

pada waktu yang tepat (in the right time), dengan hasil yang benar (with the right outcomes),

dan semua berfokus pada pengalaman pasien (all with attention to the patient experience)

Tujuan utama implementasi ICP menurut Depkes RI (2010) adalah untuk:

1. Memilih “best practice” pada saat pola praktek diketahui berbeda secara bermakna.

2. Menetapkan standar yang diharapkan mengenai lama perawatan dan penggunaan

pemeriksaan klinik serta prosedur klinik lainnya.

3. Menilai hubungan antara berbagai tahap dan kondisi yang berbeda dalam suatu proses

serta menyusun strategi untuk mengkoordinasikan agar dapat menghasilkan pelayanan

yang lebih cepat dengan tahapan yang lebih sedikit.

4. Memberikan peran kepada seluruh staf yang terlibat dalam pelayanan serta peran

mereka dalam proses tersebut.

5. Menyediakan kerangka kerja untuk mengumpulkan dan menganalisa data proses

pelayanan sehingga provider dapat mengetahui seberapa sering dan mengapa seorang

pasien tidak mendapatkan pelayanan sesuai standar.

6. Mengurangi beban dokumentasi klinik.

7. Meningkatkan kepuasan pasien melalui peningkatan edukasi kepada pasien, misalnya

dengan menyediakan informasi yang lebih tepat tentang rencana pelayanan.

Prasarana kolaborasi multidisiplin

Sumber: Three ways collaborative communications can revolutionize patient care

(www.avaya.com)

Programmable Internet Protocol (IP) phones, PDAs and touch-screen tablet devices

— powered by the latest generation of Session Initiation Protocol (SIP)-enabled

unified communications — can be used to keep clinical, administrative and operations

staff connected, whether by voice, video, instant message, e-mail or paging. These

devices can be programmed for voice-activated number lookup and dialing. Doctors

and other clinical staff can be located and communicated with via instant message

and“presence” capabilities. The latest video collaboration tools enable staff to

instantly set up voice conference calls and high-definition videoconferences,

removing and adding participants by simply touching a screen. Even equipment can

be easily located throughout the hospital with a simple click.

Sarana Kolaborasi

Sumber:

Chapter 33. Professional Communication and Team Collaboration

Michelle O’Daniel, Alan H. Rosenstein

The literature reviewed shows that effective teams are characterized by common

purpose and intent, trust, respect, and collaboration. Team members value familiarity

over formality and watch out for each other to make sure mistakes are not made.

Health care teams that do not trust, respect, and collaborate with one another are more

likely to make a mistake that could negatively impact the safety of patients.

One of the first crucial steps is organizational commitment and willingness to address

the situation. Commitment needs to come from the top down and bottom up, making a

statement about the way the organization does business. The rallying point should be

around behavioral standards and their relationship to patient safety. It’s ironic that

ever since the publication of the original IOM report, To Err Is Human, organizations

have spent the bulk of their time and efforts in improving patient systems rather than

addressing the human factor issues highlighted in the original report.2 Several recent

reports have suggested that while we have made progress in the patient safety

movement, we have a long way to go in meeting the IOM recommendations.62

Addressing defects in communication that affect collaboration, information exchange,

appreciation of roles and responsibilities, and direct accountability for patient care are

key components of any patient safety program. Clinical and administrative leaders

must set the tone by establishing and adhering to behavioral standards that support

agreed-upon code of conduct practices backed by a nonpunitive culture and zero-

tolerance policy.

The next step in the process is recognition and self-awareness. Organizations must be

able to assess the prevalence, context, and impact of behaviors to identify potential

opportunities for improvement. Doing an internal assessment will help pinpoint the

seriousness of the situation and provide clues to areas that need to be addressed.

Assessment information can be gained from formal methods such as incident reports,

survey tools, focus groups, department meetings, task forces or committees, direct

observation, suggestion boxes, and hot lines. Informal methods such as casual

meetings and gossip can also provide valuable surface information and should be

evaluated more deeply as to the source, relevance, and significance of the events to

determine next steps. In many organizations there are still remnants of reluctance to

address the issue head on for fear of antagonizing a prominent surgeon or staff

member. With growing concerns about workforce shortages, staff satisfaction and

retention, hospital reputation, liability and patient safety, and the need for compliance

to the latest Joint Commission proposed standards addressing disruptive behaviors,

organizations can no longer afford to take a passive approach to the situation.63–66

Creating opportunities for different groups to just get together is a highly effective

strategy for enhancing collaboration and communication. These group interactions

can be either formal or informal. Encouraging open dialogue, collaborative rounds,

implementing preop and postop team briefings, and creating interdisciplinary

committees or task forces that discuss problem areas frequently provides an upfront

solution that reduces the likelihood of disruptive events. When a disruptive event does

occur, some organizations have implemented a time-out, code

9 Patient Safety and Quality: An Evidence-Based Handbook for Nurses

white, or red light policy that addresses the issue in real time to prevent any further

serious consequences.59

Developing and implementing a standard set of behavior policies and procedures is

vital. These policies need to be consistent and universally applied. There should not

be a separate policy for any one particular discipline or service. For the medical staff,

the policies should become part of the medical staff bylaws with signed agreements to

abide by these policies at the time of appointment and recredentialing. Included in the

policies should be a standardized protocol outlining expected standards and the

process for addressing disruptive behavior issues, recommendations, followup plans,

and actions to be taken in the face of individual resistance or refusal to comply. Prior

to implementation, make sure all employees are familiar with the existence, purpose,

and intent of the policies and procedures.

For the process to unfold, the organization needs to encourage its employees to report

disruptive behaviors. The organization needs to address issues related to

confidentiality, fear of retaliation, and the common feelings that there is a double

standard and that nothing ever gets done. Reporting mechanisms should be made easy

and must be supported by the presence of a nonpunitive environment. The ideal

vehicle for reporting is to address the situation in real time, but concerns about

position, appropriateness, receptiveness, fear, hostility, and retaliation are significant

impediments.67 Appropriate vehicles for reporting may include reporting of the

incident to a superior, filing an incident report, using a complaint or suggestion box,

or reporting directly to a task force or interdisciplinary committee with assigned

responsibilities for addressing these issues.59 Besides maintaining confidentiality and

reducing risks of retaliation, one of the most crucial aspects of the reporting system is

to give recognition and assurance that the complaints will be addressed and actions

will be taken. Responses should be timely, appropriate, consistent, and provide

necessary feedback and followup.

Taking action though appropriate intervention strategies is next. On one level, generic

educational programs can do a lot to spread the message and teach basic skills

necessary to promote effective communication. Appropriate topics should include

sessions on team dynamics, communication skills, phone etiquette, assertiveness

training, diversity training, conflict management, stress management, and any other

courses necessary to foster more effective team functioning and communication flow.

Courses should be offered to all staff and employees at the organization: physicians,

physicians in training, nurses, nursing students, and all other staff who have patient

contact or play a role in the delivery of patient care. For individuals who have

consistently exhibited disruptive behavior, education may need to be supported by

more focused sessions and specific counseling. Another important strategy is to

promote and assure competency training at all levels of the health care team. This is a

key factor affecting trust and respect, which have such a strong influence on team

collaboration.

Focused team training programs have been of particular value. One of the newer

approaches to improving team collaboration and patient safety is through the

principles learned from the aviation industry. Fostering an environment of trust and

respect, accountability, situational awareness, open communication, assertiveness,

shared decisionmaking, feedback, and education, interdisciplinary CRM training has

brought significant improvements to communication flow in the perioperative

setting.52, 53

Having a clinical champion or early adopter who actively promotes the importance of

appropriate behavior, communication, and team collaboration can be an extremely

valuable asset. Champions can come from the executive ranks or through the

voluntary interest and enthusiasm of other staff members. Co-champions may be even

more effective. Some

10 Communication & Teamwork

organizations have reported that having a nurse and physician (or other health care

professional) go through a joint training program will help foster mutual cooperation

and collaboration between the different disciplines.59 Followup and feedback bring

closure to the process. It is important to let people know that their input is welcomed,

followup actions will be taken, and appropriate feedback will be provided.

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