CURRICULUM VITAENama: Dr. Nico A. Lumenta, K.Nefro, MM Lahir: Magelang, 5 Nov 1943 Status : Menikah, 1 anak Alamat: Jl. Kayu Mas I/4, Pulo Mas,Jkt TimurPendidikan: *Dokter, 1970, FK.UKI, Jakarta *Konsultan Nefrologi (Ginjal-Hipertensi) 1982, Pernefri (Perhimpunan Nefrologi Indonesia)*Magister Manajemen, 1994, Sekolah Tinggi Manajemen PPM, Jkt.Jabatan:*RS Mediros : Wakil Direktur Medis, Ketua Komite Medis Organisasi:*Ketua KKP-RS (Komite Keselamatan Pasien Rumah Sakit)-PERSI 05 *KARS (Komisi Akreditasi Rumah Sakit) Dep Kes RI : Ketua Bidang Informasi & Kerjasama Institusi, Surveior / Pembimbing Akreditasi*Pengurus PERSI Pusat, Ketua Kompartemen Khusus, 2009-2012* Member Advisory Council Asia Pacific, Joint Commission International, 2009, 2010* PJ SubPokja Model Akreditasi Baru, Pokja Penyempurnaan Akreditasi RS, DitJen Bina Yan Med, 2010-2011Penghargaan: Kadarman Award 2007 (untuk Patient Safety), Sekolah Tinggi Manajemen PPMLain-lain : *Direktur Ketua RS.PGI.Cikini, Jakarta, 1983 1993*Dekan Fakultas Kedokteran UKI, 1988 1991 *Kepala Bagian Ilmu Penyakit Dalam FK-UKI, Jakarta, 1992 - 1995 *Kepala Renal Unit (Unit Ginjal) RS.PGI Cikini, 1973 1981

Dr. Nico A. Lumenta, K.Nefro, MMKARS

Seminar Perumahsakitan, Surabaya Hospital Expo VIIPERSI Jatim, Surabaya, 13 15 April 2011

Akreditasi RS merupakan salah satu pilihan cara/metode evaluasi eksternal mutu pelayanan kesehatan / RS :

Akreditasi Rumah Sakit / Pelayanan Kesehatan ISO Malcolm BalDridge, EFQM (Europian Foundation for Quality Mgt) Visitatie Lain : TQM (Total Quality Mgt) dan CQI (Continuous Quality Improvement)(European Research ProjectExPeRT,1996-1999)Evaluasi Eksternal Mutu Pelayanan Kesehatan

Kecenderungan AkreditasiSistem Akreditasi RS terlaksana dalam kondisi lingkungan yg hampir selalu berubah Sehingga fokus akreditasi juga mengalami perubahan :Dari pola memotret bergeser kepada pola video perjalanan yg berkesinambunganDari memandang survei sbg suatu ujian (Lulus atau Gagal), menjadi suatu bentuk tuntunan & validasi thd proses pelayanan yg kontinu, dan memakai rekomendasi surveior untuk perbaikan & peningkatan mutuDari pola persiapan menghadapi ujian menjadi penerapan standar yg kontinu untuk mencapai & memelihara sistem layanan berkesinambungan (continuum of care) Dari memandang survei hanya fokus pd struktur, proses, menjadi pola penilaian penerapan dan pengembangan indikator mutu dan keselamatan pelayanan RS

*Ten Potential Impacts of AccreditationCharles Shaw : Toolkit for Accreditation Programs. Some issues in the design and redesign of external health care assessment and improvement systems, ISQua, 2004

*Ten Potential Impacts of Accreditation (2)Charles Shaw : Toolkit for Accreditation Programs. Some issues in the design and redesign of external health care assessment and improvement systems, ISQua, 2004

UU no 44/2009 ttg Rumah SakitPasal 40 Akreditasi(1) Dalam upaya peningkatan mutu pelayanan RS wajib dilakukan akreditasi secara berkala menimal 3 (tiga) tahun sekali.(2) Akreditasi RS sebagaimana dimaksud pada ayat (1) dilakukan oleh suatu lembaga independen baik dari dalam maupun dari luar negeri berdasarkan standar akreditasi yang berlaku.(3) Lembaga independen sebagaimana dimaksud pada ayat (2) ditetapkan oleh Menteri.(4) Ketentuan lebih lanjut mengenai akreditasi RS sebagaimana dimaksud pada ayat (1), & ayat (2) diatur dengan Peraturan Menteri.

Akreditasi Internasionalutk RSPelatihanSurveiorStandar Pelayanan RS

J C I

RumahSakitIndonesia

Akreditasi

International AccreditationStandards for HC External Evaluation Org

AkreditasiAccred Std For HospitalJ C IInternational PrinciplesFor HC Standards12Diagram Akreditasi Internasional & Nasional(Badan Akreditor)Surveyor Training Standards3AkreditasiAkreditasiAkreditasi*

*16 PelayananSurveior = 4Parameter = 314DEP = 598(Daftar Elemen Penilaian) *Keselamatan Kerja, Kebakaran & Kewaspadaan BencanaInstrumenAkreditasiV.2007

Surveior Admministrator :

1.Adm&Man2. Rekam Medis3. Yan Farmasi4. K3*21111625Surveior Medis - 1:5.Yan Medis216.Yan GawatDarurat317.Yan KmOperasi258.Yan Intensif17Surveior Medis -2 :9.Yan Radiologi1810.Yan Laboratorium2311.Y RehabMedis1612.Yan Darah14Surveior Keperawatan :

13.Y.Keperawatan14.YanPeristi15.Yan Dal Infeksi16.Yan Gizi23162017

Kelompok Kerja Penyempurnaan Akreditasi Rumah SakitKep DirJen Bina YanMed :HK.03.05/I/1024/2010 , 24 Febr 2010

PenanggungJawab : DirekturJenderal Bina Pelayanan Medik Ketua: DR. Dr. Sutoto, M.Kes Wakil Ketua: Dr. Andi Wahyuningsih Attas, SpAn Sekretaris: Dr. Elzarita Arbain, M.Kes Penanggungjawab Penyusunan Permenkes: V.A. Binus Manik, SH, MH Penanggungjawab Akreditasi oleh lSQua: Dr. Muki Reksoprojo, SpOG Penanggung Jawab Model Akreditasi Baru: Dr. Nico A. Lumenta, K Nefro, MM Anggota : Prof.DR.Dr.AkmalTaher,SpU, DR.Faisal Baraas,SpJP(K),FIHA, Prof.DR.Dr.Arif Faisal,SpRad, Prof. DR. Dr. Cissy RS Prawira, SpA (K), MSc, Dr. Sri Endarini, Dr. Sri Kusumo Amdani, Dr. RobbyTandiari,SpRad,FICS, Dr. Robert Imam Sutedja, Dr. Supriyantoro SpP MARS, Dr. Mgs. Johan T. Saleh, MSc Tugas :a. melakukan penyusunan Peraturan Menteri Kesehatan tentang Akreditasi RS;b. mempersiapkan KARS untuk terakreditasi intemasional oleh ISQua;c. mempersiapkan model akreditasi baru.

RumahSakit

Standar

InstrumenAkreditasiKonsep Dasar Akreditasi Rumah Sakit*Badan AkreditasiSurvei Akreditasi RSSertifikat125436Memenuhi / Menerapkan / Comply(Standard : a statement that defines the performance expectations, sructures, or processes that must be in place for an organization to provide safe and high-quality care, treatment, and service. JCI, 2008)

*

Standar Pelayanan Rumah Sakit : Ps 3 c, Ps 5 a, ps 13 ayat 3, ps29 1.b, penjelasan ps 13 ayat 3, penjelasan ps 29 ayat 1.bStandar Profesi : Ps 13 ayat 3, ps 29 ayat 1.k, ps 32 ayat d, penjelasan ps 13 ayat 3Standar Prosedur Operasional : Ps 13 ayat 3, ps 32 ayat d, penjelasan ps 13 ayat 3, penjelasan ps 29 ayat 1.bStandar Pelayanan Kefarmasian : Ps 15 ayat 2 & 5Standar Rumah Sakit Pendidikan : Ps 22 ayat 2 Standar Mutu Pelayanan Kesehatan ps 29 ayat 1.gStandar Akreditasi : ps 40 ayat 2Standar Keselamatan Pasien : ps 43 ayat 1-2-5Standar Pelayanan Medis : penjelasan ps 13 ayat 3, penjelasan ps 29 ayat 1.bStandar Asuhan Keperawatan : penjelasan ps 13 ayat 3, penjelasan ps 29 ayat 1.bStandar Peralatan Medis : penjelasan ps 16 ayat 1Standar internasional (- Rekam Medis) penjelasan ps 29 ayat 1.h

66 ps

*

Standar Pendidikan Profesi Dokter & Dokter Gigi : Ps 7 ayat 1.b., ayat 2, Ps 26, Penjelasan UmumStandar Kompetensi Dokter & Dokter Gigi : Ps 8.cStandar Pelayanan Kedokteran & Kedokteran Gigi : Ps 44 & penjelasannyaStandar Profesi : Ps 50, 51Standar Prosedur Operasional : Ps 50, 51

88 ps

*Standar Profesi: Ps 24, Ps 150, Penjelasan Ps 77Standar Pelayanan: Ps 24, Ps 41, Penjelasan Ps 77Standar Prosedur Operasional :Ps 24Standar Pelayanan Minimal Kesehatan : Ps 51 Standar Mutu Pelayanan Kesehatan : Ps 55Standar -- Pelayanan Transfusi Darah : Ps 89Standar Mutu Pelayanan Farmasi : Ps 98Standar -- Narkotika, Psikotropika : Ps 103, -- Zat Aditif : Ps 113Standar -- MakananMinuman : Ps 111Standar -- Kesehatan Bayi & Anak : Ps 134Standar Mutu Gizi : Ps 141Standar angka kecukupan gizi : Ps 142Standar pelayanan gizi : Ps 142Standar tenaga gizi : Ps 142Standar baku mutu kesehatan lingkungan dan proses pengolahan limbah : Ps 163Standar Kesehatan Kerja : Ps 164Standar -- Gizi Masyarakat : Ps 179205 ps

RumahSakitInstrumenAkreditasi*Survei Akreditasi RSMemenuhi / ComplyAkreditasi Rumah Sakit di IndonesiaKARSBukan satu dokumenTerdiri dari 3 kelompokPenjelasan Ps 29 ayat (1) b : Yg dimaksud dgn standar pelayanan rumah sakit adalah SEMUA standar pelayanan yang berlaku di rumah sakit .........

Instrumen Standar ProsedurOperasional123Standar SpesifikRumah Sakit

Standar Akreditasi RS

*

Standar Pelayanan dalam 16 bidang kegiatan/pelayanan : Std : Yan Medis, Yan ICU, AsKep, Yan GD, Yan Anestesi-Re, Yan Rad, dsbStandar Keselamatan Pasien Rumah Sakit : 7 std, & 7 LangkahStandar RSI-KD : 9 standarStandar Profesi : std dari KolegiumStandar Pelayanan lainnya : std diluar 16 YanStandar Pelayanan Minimal RSPedoman : (slide berikut)Kepmenkes, Permenkes, dsb terkait dgn RSUU dan Peraturan lain *Standar Spesifik Rumah Sakit1

7. Pedoman

Beberapa contoh Pedoman : Ped Penyelenggaraan Rekam Medis, Ped Audit Medis, Ped Pengendalian Inf Nosokomial di RS, Ped Peraturan Internal RS, Petunjuk Pelaksanaan Indikator Mutu Yan RS, Ped Persetujuan Tindakan Medik, Ped Teknis Analisis Dampak Kesehatan Lingkungan, Ped Pengelolaan Lab Klin RS, Juklak Pemantapan Mutu Internal LabKes, Ped Keamanan Lab Mikrobiologi & Biomedis, Ped Yan Rehab Med, Indikator Klinik Yan RehMed di RS, Ped Yan Transfusi Darah, Ped Yan Perinatal pd RSU, Ped Yan Rawat Gabung di RS, .....dst.*

*2Standar Akreditasi Rumah Sakit

*

3Standar Prosedur Operasional

Dibuat oleh Rumah Sakit masing-masingMengacu kepada UU dan Peraturan yang berlakuBerdasarkan standar profesi

*

Standar Akreditasi Rumah Sakit *2

I. Kelompok Standar Pelayanan Berfokus pada PasienBab 1. Akses ke Pelayanan dan Kontinuitas Pelayanan (APK)Bab 2. Hak Pasien dan Keluarga (HPK)Bab 3. Asesmen Pasien (AP)Bab 4. Pelayanan Pasien (PP)Bab 5. Pelayanan Anestesi dan Bedah (PAB)Bab 6. Manajemen dan Penggunaan Obat (MPO)Bab 7. Pendidikan Pasien dan Keluarga (PPK)II. Kelompok Standar Manajemen Rumah SakitBab 1. Peningkatan Mutu dan Keselamatan Pasien (PMKP)Bab 2. Pencegahan dan Pengendalian Infeksi (PPI)Bab 3. Tata Kelola, Kepemimpinan, dan Pengarahan (TKP)Bab 4. Manajemen Fasilitas dan Keselamatan (MFK)Bab 5. Kualifikasi dan Pendidikan Staf (KPS)Bab 6. Manajemen Komunikasi dan Informasi (MKI)III. Sasaran Keselamatan Pasien Rumah SakitSasaran I : Ketepatan identifikasi pasienSasaran II : Peningkatan komunikasi yang efektifSasaran III : Peningkatan keamanan obat yang perlu diwaspadai (high-alert)Sasaran lV : Kepastian tepat-lokasi, tepat-prosedur, tepat-pasien operasiSasaran V : Pengurangan risiko infeksi terkait pelayanan kesehatanSasaran VI : Pengurangan risiko pasien jatuh

I. Kelompok Standar Pelayanan Berfokus pada PasienBab 1. Akses ke Pelayanan & Kontinuitas Pelayanan (APK)Admisi, Kebutuhan Yan Pasien, Kontinuitas Yan, Pemulangan, Rujukan, Tindak lanjut, Transfer Pasien, Transportasi : 23 Std, 85 EPBab 2. Hak Pasien & Keluarga (HPK)Nilai2 Pasien, Tanggung jawab Pasien, Informed Consent, Pemecahan masalah keluhan, Penelitian, Donasi Organ : 30 Std, 100 EPBab 3. Asesmen Pasien (AP)Asesmen Pasien, Pengumpulan Data & Info, Kebutuhan Yan Pasien, Rencana Yan, Yan Laboratorium, Yan Radiologi : 44 Std, 184 EPBab 4. Pelayanan Pasien (PP)Rencana Yan, Koordinasi, Monitor hasil, Modifikasi, Tindak lanjut, Yan Pasien Berisiko Tinggi, Yan Berisiko Tinggi, Terapi Makanan & Nutrisi, Manajemen Nyeri dan Yan Akhir Hidup : 22 Std, 74 EPBab 5. ........*

(I. Kelompok Standar Pelayanan Berfokus pada Pasien)Bab 5. Pelayanan Anestesi & Bedah (PAB)Organisasi & Manajemen, Yan Sedasi, Yan Anestesi, Yan Bedah, Persiapan, monitoring rencana pasca bedah: 14 Std, 51 EPBab 6. Manajemen & Penggunaan Obat (MPO)Organisasi & Manajemen, Seleksi & Pengadaan, Penyimpanan, Pemesanan & Pencatatan, Penyiapan & Penyaluran, Administrasi, Monitoring: 21 Std, 84 EPBab 7. Pendidikan Pasien & Keluarga (PPK)Efektifitas Pendidikan bagi Pasien/keluarga, Penilaian berdasarkan kebutuhan bahasa: 7 Std, 28 EPTotal Kelompok I : Standar = 161, EP = 606*

II. Kelompok Standar Manajemen Rumah SakitBab 1. Peningkatan Mutu dan Keselamatan Pasien (PMKP)Kepemimpinan & Perencanaan, Rancangan Proses Klinis & Proses Manajerial, Proses menilai & meningkatkan kinerja, Pengumpulan Data utk Monitoring Mutu, Analisis Data yg Dimonitor, Perbaikan : 23 Std 88 EP)Bab 2. Pencegahan dan Pengendalian Infeksi (PPI)Program Kepemimpinan & Koordinasi, Metoda penerapan program identifikasi & mengurangi risiko infeksi, Prosedur Isolasi, Teknik Pengamanan & Hand Hygiene, Integrasi Program dgn Peningkatan Mutu & Keselamatan Pasien - Pendidikan Staff tentang Program : 24 Std 87 EPBab 3. Tata Kelola, Kepemimpinan, dan Pengaturan (TKP)Tata Kelola Organisasi, Kepemimpinan Organisasi, Perencanaan Visi-Misi-Nilai, Pengaturan Departemen/Unit dan Pelayanan/Instalasi, Integrasi & koordinasi Yan, Etika Organisasi : 27 Std 98 EP*

(II. Kelompok Standar Manajemen Rumah Sakit)Bab 4. Manajemen Fasilitas dan Keselamatan (MFK)Kepemimpinan dan Perencanaan, Pemeliharaan lingkungan Keselamatan dan Keamanan, Bahan-bahan Berbahaya, Manajemen Kedaruratan, Pengamanan Kebakaran, Peralatan Medis, Sistem Pendukung / Utiliti, Pendidikan Staf : 23 Std, 82 EPBab 5. Kualifikasi dan Pendidikan Staf (KPS)Perencanaan SDM, Orientasi & Pendidikan, Staf Medis, Staf Keperawatan, Staf Kesehatan Professional lainnya, kompetensi, kredensial, kewenangan : 24 Std, 99 EPBab 6. Manajemen Komunikasi dan Informasi (MKI)Komunikasi dengan Komunitas, Pasien dan Keluarga, antar PPK didalam dan diluar RS, Kepemimpinan dan Perencanaan, Rekam Medis Pasien, Pengumpulan Data dan Informasi: 28 Std, 109 EPTotal Kelompok II : Standar = 149, EP = 563*

III. Sasaran Keselamatan Pasien Rumah SakitSasaran I : Ketepatan identifikasi pasien : 5 EPSasaran II : Peningkatan komunikasi yang efektif : 4 EPSasaran III : Peningkatan keamanan obat yang perlu diwaspadai (high-alert) : 4 EPSasaran lV : Kepastian tepat-lokasi, tepat-prosedur, tepat-pasien operasi : 4 EPSasaran V : Pengurangan risiko infeksi terkait pelayanan kesehatan : 3 EPSasaran VI : Pengurangan risiko pasien jatuh : 4 EPTotal Kelompok III : Standar = 6, EP = 24*

Jumlah TotalStandar dan Elemen PenilaianInstrumen Akreditasi V.2007

Jumlah StandarJumlah Elemen PenilaianKelompok I161606Kelompok II149563Kelompok III624Total : 3161193

BAB IAKSES KE PELAYANAN DAN KONTINUITAS PELAYANAN (APK) Gambaran UmumRS seyogyanya mempertimbangkan bhw yan di RS merupakan bagian dari suatu sistem yan yg terintegrasi dgn para profesional dibidang yan kes dan tingkat yan yg akan membangun suatu kontinuitas yan. Maksud & tujuannya adalah menyelaraskan kebutuhan pasien dibidang yan kes dgn yan yg tersedia di RS, mengkoordinasikan yan dan kemudian merencanakan pemulangan dan tindakan selanjutnya. Hasilnya adalah meningkatkan mutu yan pasien & efisiensi penggunaan sumber daya yg tersedia di RS. Informasi diperlukan untuk membuat keputusan yg benar tentang : Kebutuhan pasien yang mana yang dapat dilayani RSPemberian pelayanan yang efisien kepada pasienTransfer dan pemulangan pasien yang tepat ke rumah atau ke pelayanan lain.

Contoh : 1 std*I. Kelompok Standar Pelayanan Berfokus pada PasienBab 1. Akses ke Pelayanan & Kontinuitas Pelayanan (APK)Admisi, Kebutuhan Yan Pasien, Kontinuitas Yan, Pemulangan, Rujukan, Tindak lanjut, Transfer Pasien, Transportasi : 23 Std, 85 EP

Standar APK.I.Pasien diterima sebagai pasien RI atau didaftar untuk yan RJ berdasarkan pada kebutuhan yan kes mereka yg telah diidentifikasi dan misi serta sumber daya RS yg ada.

Maksud dan Tujuan APK.I.Menyesuaikan kebutuhan pasien dengan misi dan sumber daya RS tergantung pada keterangan yang didapat tentang kebutuhan pasien dan kondisinya lewat skrining pada kontak pertama. Skrining dilaksanakan melalui kriteria triase, evaluasi visual atau pengamatan, pemeriksaan fisik atau hasil dari pemeriksaan fisik, psikologik, laboratorium klinik atau diagnostik imaging sebelumnya. Skrining dpt terjadi disumber rujukan, pd saat pasien ditransportasi emergensi atau apabila pasien tiba di RS. Hal ini sangat penting bhw keputusan utk mengobati, mengirim atau merujuk hanya dibuat setelah ada hasil skrining & evaluasi.Hanya RS yg mempunyai kemampuan menyediakan yan yg dibutuhkan dan konsisten dgn misinya dapat dipertimbangkan untuk menerima pasien RI atau pasien RJ. . . . . . . . . . . *

Apabila RS memerlukan data tes skrining atau evaluasi sebelum penerimaan & pendaftaran ditetapkan dlm kebijakan tertulis. Pasien diberitahu bhw apabila dlm menerima yan dimasukkan dlm daftar tunggu atau penundaan lain berkenaan dgn yan & pengobatan. Pasien diberi informasi ttg sebab yg berkenaan dgn hal RS tersebut. Syarat ini berlaku untuk yan pasien RI & yan diagnosis pasien RJ

Elemen Penilaian APK.I.Skrining dilakukan pada kontak pertama didalam atau di luar RSBerdasarkan hasil skrining ditentukan apakah kebutuhan pasien sesuai dengan misi dan sumber daya RS. Pasien hanya diterima bila RS dpt menyediakan pelayanan yg dibutuhkan pasien RI & RJ dgn tepat. Ada cara utk melengkapi hasil tes diagnosis berkenaan dgn tanggung jawab utk menetapkan apakah pasien diterima, dipindahkan atau di rujuk. Ada kebijakan yg menetapkan skrining & tes diagnosa yg mana merupakan standar sebelum penerimaan pasien. Pasien tidak akan dirawat, dipindahkan atau dirujuk sebelum hasil tes yg dibutuhkan didapatkan sebagai dasar pengambilan keputusan. Kebijakan mendefinisikan bagaimana pasien diberitahukan apabila ada penundaan atau menunggu dlm pelayanan & pengobatan serta sebab yg berkaitan dgn hal RS tersebut.*

Nilai dan Manfaat yang diperoleh RS melalui akreditasi sistem baru

Terima kasihatas perhatiannyaDr. Nico A. Lumenta, K.Nefro, MMKARS

**Procedures were laid down for documenting hospitalisation for other illnesses whether cardiac or non-cardiac, and for events requiring the stopping of trial medication. Procedures were also defined for cases of worsening heart failure or renal function. For the former, sequential options included increasing the dose of diuretics, decreasing or discontinuing calcium channel blockers, adjustment of the digoxin dose, increasing the dose of other non-ACE inhibitor vasodilators and increasing the background lisinopril dose from 2.5 to 5 mg. For the latter, decreasing or discontinuing diuretics or calcium channel blockers or non-ACE inhibitor vasodilators was considered together with a decrease in background lisinopril therapy.Detailed procedures also existed for the starting and stopping of trial medication following an acute myocardial infarction. A listing of allowed and disallowed concomitant medication was provided and the procedure for recording serious adverse events was detailed.*Procedures were laid down for documenting hospitalisation for other illnesses whether cardiac or non-cardiac, and for events requiring the stopping of trial medication. Procedures were also defined for cases of worsening heart failure or renal function. For the former, sequential options included increasing the dose of diuretics, decreasing or discontinuing calcium channel blockers, adjustment of the digoxin dose, increasing the dose of other non-ACE inhibitor vasodilators and increasing the background lisinopril dose from 2.5 to 5 mg. For the latter, decreasing or discontinuing diuretics or calcium channel blockers or non-ACE inhibitor vasodilators was considered together with a decrease in background lisinopril therapy.Detailed procedures also existed for the starting and stopping of trial medication following an acute myocardial infarction. A listing of allowed and disallowed concomitant medication was provided and the procedure for recording serious adverse events was detailed.*Procedures were laid down for documenting hospitalisation for other illnesses whether cardiac or non-cardiac, and for events requiring the stopping of trial medication. Procedures were also defined for cases of worsening heart failure or renal function. For the former, sequential options included increasing the dose of diuretics, decreasing or discontinuing calcium channel blockers, adjustment of the digoxin dose, increasing the dose of other non-ACE inhibitor vasodilators and increasing the background lisinopril dose from 2.5 to 5 mg. For the latter, decreasing or discontinuing diuretics or calcium channel blockers or non-ACE inhibitor vasodilators was considered together with a decrease in background lisinopril therapy.Detailed procedures also existed for the starting and stopping of trial medication following an acute myocardial infarction. A listing of allowed and disallowed concomitant medication was provided and the procedure for recording serious adverse events was detailed.*Procedures were laid down for documenting hospitalisation for other illnesses whether cardiac or non-cardiac, and for events requiring the stopping of trial medication. Procedures were also defined for cases of worsening heart failure or renal function. For the former, sequential options included increasing the dose of diuretics, decreasing or discontinuing calcium channel blockers, adjustment of the digoxin dose, increasing the dose of other non-ACE inhibitor vasodilators and increasing the background lisinopril dose from 2.5 to 5 mg. For the latter, decreasing or discontinuing diuretics or calcium channel blockers or non-ACE inhibitor vasodilators was considered together with a decrease in background lisinopril therapy.Detailed procedures also existed for the starting and stopping of trial medication following an acute myocardial infarction. A listing of allowed and disallowed concomitant medication was provided and the procedure for recording serious adverse events was detailed.*Procedures were laid down for documenting hospitalisation for other illnesses whether cardiac or non-cardiac, and for events requiring the stopping of trial medication. Procedures were also defined for cases of worsening heart failure or renal function. For the former, sequential options included increasing the dose of diuretics, decreasing or discontinuing calcium channel blockers, adjustment of the digoxin dose, increasing the dose of other non-ACE inhibitor vasodilators and increasing the background lisinopril dose from 2.5 to 5 mg. For the latter, decreasing or discontinuing diuretics or calcium channel blockers or non-ACE inhibitor vasodilators was considered together with a decrease in background lisinopril therapy.Detailed procedures also existed for the starting and stopping of trial medication following an acute myocardial infarction. A listing of allowed and disallowed concomitant medication was provided and the procedure for recording serious adverse events was detailed.*Procedures were laid down for documenting hospitalisation for other illnesses whether cardiac or non-cardiac, and for events requiring the stopping of trial medication. Procedures were also defined for cases of worsening heart failure or renal function. For the former, sequential options included increasing the dose of diuretics, decreasing or discontinuing calcium channel blockers, adjustment of the digoxin dose, increasing the dose of other non-ACE inhibitor vasodilators and increasing the background lisinopril dose from 2.5 to 5 mg. For the latter, decreasing or discontinuing diuretics or calcium channel blockers or non-ACE inhibitor vasodilators was considered together with a decrease in background lisinopril therapy.Detailed procedures also existed for the starting and stopping of trial medication following an acute myocardial infarction. A listing of allowed and disallowed concomitant medication was provided and the procedure for recording serious adverse events was detailed.*Procedures were laid down for documenting hospitalisation for other illnesses whether cardiac or non-cardiac, and for events requiring the stopping of trial medication. Procedures were also defined for cases of worsening heart failure or renal function. For the former, sequential options included increasing the dose of diuretics, decreasing or discontinuing calcium channel blockers, adjustment of the digoxin dose, increasing the dose of other non-ACE inhibitor vasodilators and increasing the background lisinopril dose from 2.5 to 5 mg. For the latter, decreasing or discontinuing diuretics or calcium channel blockers or non-ACE inhibitor vasodilators was considered together with a decrease in background lisinopril therapy.Detailed procedures also existed for the starting and stopping of trial medication following an acute myocardial infarction. A listing of allowed and disallowed concomitant medication was provided and the procedure for recording serious adverse events was detailed.*Procedures were laid down for documenting hospitalisation for other illnesses whether cardiac or non-cardiac, and for events requiring the stopping of trial medication. Procedures were also defined for cases of worsening heart failure or renal function. For the former, sequential options included increasing the dose of diuretics, decreasing or discontinuing calcium channel blockers, adjustment of the digoxin dose, increasing the dose of other non-ACE inhibitor vasodilators and increasing the background lisinopril dose from 2.5 to 5 mg. For the latter, decreasing or discontinuing diuretics or calcium channel blockers or non-ACE inhibitor vasodilators was considered together with a decrease in background lisinopril therapy.Detailed procedures also existed for the starting and stopping of trial medication following an acute myocardial infarction. A listing of allowed and disallowed concomitant medication was provided and the procedure for recording serious adverse events was detailed.*Procedures were laid down for documenting hospitalisation for other illnesses whether cardiac or non-cardiac, and for events requiring the stopping of trial medication. Procedures were also defined for cases of worsening heart failure or renal function. For the former, sequential options included increasing the dose of diuretics, decreasing or discontinuing calcium channel blockers, adjustment of the digoxin dose, increasing the dose of other non-ACE inhibitor vasodilators and increasing the background lisinopril dose from 2.5 to 5 mg. For the latter, decreasing or discontinuing diuretics or calcium channel blockers or non-ACE inhibitor vasodilators was considered together with a decrease in background lisinopril therapy.Detailed procedures also existed for the starting and stopping of trial medication following an acute myocardial infarction. A listing of allowed and disallowed concomitant medication was provided and the procedure for recording serious adverse events was detailed.*Procedures were laid down for documenting hospitalisation for other illnesses whether cardiac or non-cardiac, and for events requiring the stopping of trial medication. Procedures were also defined for cases of worsening heart failure or renal function. For the former, sequential options included increasing the dose of diuretics, decreasing or discontinuing calcium channel blockers, adjustment of the digoxin dose, increasing the dose of other non-ACE inhibitor vasodilators and increasing the background lisinopril dose from 2.5 to 5 mg. For the latter, decreasing or discontinuing diuretics or calcium channel blockers or non-ACE inhibitor vasodilators was considered together with a decrease in background lisinopril therapy.Detailed procedures also existed for the starting and stopping of trial medication following an acute myocardial infarction. A listing of allowed and disallowed concomitant medication was provided and the procedure for recording serious adverse events was detailed.*Procedures were laid down for documenting hospitalisation for other illnesses whether cardiac or non-cardiac, and for events requiring the stopping of trial medication. Procedures were also defined for cases of worsening heart failure or renal function. For the former, sequential options included increasing the dose of diuretics, decreasing or discontinuing calcium channel blockers, adjustment of the digoxin dose, increasing the dose of other non-ACE inhibitor vasodilators and increasing the background lisinopril dose from 2.5 to 5 mg. For the latter, decreasing or discontinuing diuretics or calcium channel blockers or non-ACE inhibitor vasodilators was considered together with a decrease in background lisinopril therapy.Detailed procedures also existed for the starting and stopping of trial medication following an acute myocardial infarction. A listing of allowed and disallowed concomitant medication was provided and the procedure for recording serious adverse events was detailed.*Procedures were laid down for documenting hospitalisation for other illnesses whether cardiac or non-cardiac, and for events requiring the stopping of trial medication. Procedures were also defined for cases of worsening heart failure or renal function. For the former, sequential options included increasing the dose of diuretics, decreasing or discontinuing calcium channel blockers, adjustment of the digoxin dose, increasing the dose of other non-ACE inhibitor vasodilators and increasing the background lisinopril dose from 2.5 to 5 mg. For the latter, decreasing or discontinuing diuretics or calcium channel blockers or non-ACE inhibitor vasodilators was considered together with a decrease in background lisinopril therapy.Detailed procedures also existed for the starting and stopping of trial medication following an acute myocardial infarction. A listing of allowed and disallowed concomitant medication was provided and the procedure for recording serious adverse events was detailed.*Procedures were laid down for documenting hospitalisation for other illnesses whether cardiac or non-cardiac, and for events requiring the stopping of trial medication. Procedures were also defined for cases of worsening heart failure or renal function. For the former, sequential options included increasing the dose of diuretics, decreasing or discontinuing calcium channel blockers, adjustment of the digoxin dose, increasing the dose of other non-ACE inhibitor vasodilators and increasing the background lisinopril dose from 2.5 to 5 mg. For the latter, decreasing or discontinuing diuretics or calcium channel blockers or non-ACE inhibitor vasodilators was considered together with a decrease in background lisinopril therapy.Detailed procedures also existed for the starting and stopping of trial medication following an acute myocardial infarction. A listing of allowed and disallowed concomitant medication was provided and the procedure for recording serious adverse events was detailed.*Procedures were laid down for documenting hospitalisation for other illnesses whether cardiac or non-cardiac, and for events requiring the stopping of trial medication. Procedures were also defined for cases of worsening heart failure or renal function. For the former, sequential options included increasing the dose of diuretics, decreasing or discontinuing calcium channel blockers, adjustment of the digoxin dose, increasing the dose of other non-ACE inhibitor vasodilators and increasing the background lisinopril dose from 2.5 to 5 mg. For the latter, decreasing or discontinuing diuretics or calcium channel blockers or non-ACE inhibitor vasodilators was considered together with a decrease in background lisinopril therapy.Detailed procedures also existed for the starting and stopping of trial medication following an acute myocardial infarction. A listing of allowed and disallowed concomitant medication was provided and the procedure for recording serious adverse events was detailed.*Procedures were laid down for documenting hospitalisation for other illnesses whether cardiac or non-cardiac, and for events requiring the stopping of trial medication. Procedures were also defined for cases of worsening heart failure or renal function. For the former, sequential options included increasing the dose of diuretics, decreasing or discontinuing calcium channel blockers, adjustment of the digoxin dose, increasing the dose of other non-ACE inhibitor vasodilators and increasing the background lisinopril dose from 2.5 to 5 mg. For the latter, decreasing or discontinuing diuretics or calcium channel blockers or non-ACE inhibitor vasodilators was considered together with a decrease in background lisinopril therapy.Detailed procedures also existed for the starting and stopping of trial medication following an acute myocardial infarction. A listing of allowed and disallowed concomitant medication was provided and the procedure for recording serious adverse events was detailed.*Procedures were laid down for documenting hospitalisation for other illnesses whether cardiac or non-cardiac, and for events requiring the stopping of trial medication. Procedures were also defined for cases of worsening heart failure or renal function. For the former, sequential options included increasing the dose of diuretics, decreasing or discontinuing calcium channel blockers, adjustment of the digoxin dose, increasing the dose of other non-ACE inhibitor vasodilators and increasing the background lisinopril dose from 2.5 to 5 mg. For the latter, decreasing or discontinuing diuretics or calcium channel blockers or non-ACE inhibitor vasodilators was considered together with a decrease in background lisinopril therapy.Detailed procedures also existed for the starting and stopping of trial medication following an acute myocardial infarction. A listing of allowed and disallowed concomitant medication was provided and the procedure for recording serious adverse events was detailed.*Procedures were laid down for documenting hospitalisation for other illnesses whether cardiac or non-cardiac, and for events requiring the stopping of trial medication. Procedures were also defined for cases of worsening heart failure or renal function. For the former, sequential options included increasing the dose of diuretics, decreasing or discontinuing calcium channel blockers, adjustment of the digoxin dose, increasing the dose of other non-ACE inhibitor vasodilators and increasing the background lisinopril dose from 2.5 to 5 mg. For the latter, decreasing or discontinuing diuretics or calcium channel blockers or non-ACE inhibitor vasodilators was considered together with a decrease in background lisinopril therapy.Detailed procedures also existed for the starting and stopping of trial medication following an acute myocardial infarction. A listing of allowed and disallowed concomitant medication was provided and the procedure for recording serious adverse events was detailed.