Organisational Survey - Technical Review-2

THE INTERNATIONAL SOCIETY FOR QUALITY IN HEALTH CARE LTD
(Komisi Akreditasi Rumah Sakit)
ISQua International Standards for External Evaluation Organisations,

4th Edition
Technical Review
© The International Society for Quality in Health Care Limited

E-mail: accreditationadmin@isqua.org : Web - http://www.isqua.org
Response to technical review
Nicola McCauley-Conlan
Accreditation Manager
Date: 4th September 2018
The self-assessment tool for the KARS organisational survey has been assessed for technical accuracy and specific comments about individual criteria are below. Please
note that this is not a full assessment and does not include comments on your ratings. A copy of this technical review will be added to the overall evidence for the
surveyors.
General comments on SAT
• Please note that the survey team will also be provided with the progress report from the previous accreditation cycle. Please include details in this SAT as to how
the surveyor recommendation from 2015 was addressed.
• If evidence is not available on ISQua Collaborate – please add (available onsite) after the document name.
• Please note that the evidence should be in English. Please translate the relevant text and state on what page number the text can be found.
• If evidence is not in English, please ensure that this is clear in the document name.
• Please note that 2 professional translators should be available at the time of survey.
• Please complete and upload the required document checklist with your final submission. This lists the minimum documents to be provided at technical review in
English, however, you are encouraged to provide additional evidence in English with your final submission.
• Please do a full spell check of your final submission and review all sentence structures to ensure that they are clear.
• Please ensure that black font is used throughout the SAT.
© ISQua Assessment Tool for Standards for External Evaluation Organisations, 4th Edition, V1.2 Page 2 of 87
KARS Organisational Survey – Technical Review
Organisational Profile
Organisational Information:
Current Accreditation Status: Accredited by ISQua Date of Award: March 2015
Type (e.g. Society, for profit, not for profit, government body) Not for profit
Type of external evaluation programme, e.g. accreditation, certification, inspection, evaluation, standards setting:
Accreditation
Year of initial operation: 2013
Number of employees: (specify full-time/part-time): Governing Body: 8
Board of Management: 9
Surveyor: 604 (part time)
Office staff: 13 (full time)
Number and location of offices: 1
Geographical spread of services: (e.g. international, country specific): INDONESIA
Standards Details
Details of all sets of standards in use: Owned by: Current accreditation status:
Standar Nasional Akreditasi Rumah Sakit (SNARS) Edisi 1 / National Standard on Hospital KARS
Accreditation, 1st edition
Survey Details
Number of surveys in the last 12 Year
month period: 2017= 3 up to 3 up to
Average days per Average number of surveyors in a Number of surveyors
the 5 the 6 604
889 survey: team: available:
days surveyors
surveys
Types of organisations surveyed in last 12 month period:
Hospitals
Surveyor Training Details

Current Accreditation Status: Accredited by ISQua Date of Award: January 2017
Number of surveyor training programmes held in the last 12 month period: Year 2016:
- Refreshing for Surveyors : 3
- Surveyors Training Programme: 3
Year 2017:
- Refreshing for Surveyors : 3
Number of surveyors who attended training programmes held in the last 12 Year 2016:
month period: - Refreshing for Surveyors : 285
Year 2017:
- Refreshing for Surveyors :383
Please list the titles of the courses/sessions held: Refreshing for Surveyors
Surveyors Training Programme
Standard 1: Governance Self-assessment evidence Technical Review
1.1 A clear vision and purpose or mission provides the basis Self - Rating 4 Technical Review
for the external evaluation organisation’s planning and
direction
a) are communicated to stakeholders, and Is text missing from the sentence highlighted in yellow?
Governing Body revises the vision and missions as well as
b) are regularly reviewed internal rules of KARS to adjust with the change of Is evidence 1.1.6 missing?
environment by concerning inputs from all parties.
This could include: Should the text highlighted in green be 2016 – 2020?
Guidance
i. the governing body being responsible for developing The mission and vision is communicated to stakeholders
the vision and mission, with staff input; through:
ii. communication with stakeholders such as policy, a) KARS website.
professional, funding and service user groups and b) the form of brochures by KARS
participating organisations; c) displayed as a standing banner in front of KARS office
iii. reviews taking place at defined intervals, e.g. three d) in each KARS planning document
yearly, or when there is a significant change in the e) by Chairman and Vice of Chairman in the opening
external evaluation organisation’s mandate ceremony in seminars, webinars, trainings, workshop, etc.
Change communication includes

• Written mission and vision or evidence to support
Suggested Evidence
Review is done regularly, based on KARS Internal Rules.

existence (may be in plans, brochures)
The review of the vision and mission has been discussed
• Evidence of how made available to stakeholders
along with strategic plan Composition Workshop 2018-2020,
• Evidence of how reviews are planned and take place
Due to rapid changes of the environment (ex Universal
coverage in 1st January 2014), another review strategic plan
Evidence:
1.1.1. Meeting of the Regulatory Body: establishes vision
and mission, there is input from members
1.1.2. Internal Rules of KARS
1.1.3. July 2015 Strategic Plan revision TOR
1.1.4. Strategic Plan 2016-2020
1.1.5. KARS website screenshots, examples of brochures,
banners, slide material Dr. Sutoto at various workshops on
KARS's vision and mission
1.1.7. Meeting review on vision and mission, with the
decision that the vision and mission remain (invitation,
material, attendance list, minutes)
1.2 The external evaluation organisation is guided by a Self - Rating 4 Technical Review
defined set of values that are evident in all services and
activities.
The organisational values are shared with staff and KARS philosophy and ethics of the organization is defined The hyperlink for the evidence highlighted in green is
Guidance
should be displayed; this could be on websites, by its aim to improve value to patients in healthcare. To incorrect – please review.
promotional materials, and information materials. execute the improvement of value, KARS is committed to
motivate organizations, guide and facilitate organizations.
See also criterion 4.4. There are standard operating procedures for the ethics and
philosophy of the organization and guidelines as to how to
• Written set of values (may be in plans, brochures, interact between stakeholders.
Suggested Evidence
displayed on walls and on website)

• How the values are implemented in all services and Ethical principles of the organization
activities 1.Principles on respecting the regulations
2.Principles on confidentiality
3.Principles of conflict of interest
4.Principles of trust and honesty
5.Principles of unity
Ethical principles for staff:

1.Principles on respecting the regulations
2.Principles on confidentiality
3.Principles of conflict of interest
4.Principles of trust and honesty
5.Principles of justice
6.Principles of unity
7.Principles on cleanliness
KARS internal regulation: the values adopted in executing

accreditation are
1.Integrity
2.Profesionalism
3.Commitment
4.Teamwork
5.Social responsibility
Written records and documentation on planning, brochure,

website, etc
Evidence:
1.1.4. Strategic Plan 2016-2020
2.1.3a RKA / Business Plan 2016
2.1.3b RKA / Business Plan 2017
3..1.1 Policy and Risk Management (Quality Policy and
Planning)
1.2.1 Vision and Mission Banner Display
1.2.2 Print preview of KARS contained Vision & Mission web
1.2.3 Philosophy and Ethic Policy of Organization
1.2.4 Employee Ethic
1.2.5 Surveyor Ethic Code Revision 26 June 2013
1.2.6. Sample of surveyor's signature on Ethic Code

surveyor form before they survey, updated plus sample
conflict statement
1.2.7. Proof of the results of the 2018 KARS congress
1.3 Policies are in place to ensure that accreditation or Self - Rating 4 Technical Review
Core certification decisions are independent and objective,
solely based on the relevant standards, the findings of
the surveyors and other objective evidence related to the
standards, and to ensure that conflicts of interest are
avoided in all decision making. In 2012, it was legal and independent Please clarify whether your organisation provides
consultancy services. If your organisation does provide
The arrangements ensure that external evaluation The policy of guaranteeing accreditation and certification is consultancy services, please explain how consultancy is
activities are strictly separated from consultancy or independent and objective: separated from the external evaluation activities.
provision of internal audit. 1. The surveyor must sign a statement of no conflict of
interest and will be cross-checked to the hospital that will be Please review the document names as ‘survivor’ has
accredited. been used in error for ‘surveyor’ in some of the
Examples of consultancy include preparing or producing documents. Please correct this throughout the SAT.
Guidance
2. The surveyor's code of ethics was read in front of the

documentation or procedures, and giving specific advice, board of directors on D-1 day to be known
instructions or solutions towards achieving compliance 3. RS makes an assessment of the professionalism of Please translate the evidence highlighted in yellow.
with the standards. surveyors, and may report if there is an emphasis or
violation of the code of ethics during the survey Please provide the document highlighted in green as
Advising on understanding of standards or the external 4. The surveyor may not announce graduation and see the evidence.
evaluation process, arranging training and participating results of the simulation survey or the results of self
as a trainer is not considered consultancy, provided that, assessment by RS
where the advice or course relates to standards or 5. Surveyor data without identity is sent by the secretariat to
external evaluation, this is confined to the provision of the counselor. The counselor assesses the results of the
generic information that is freely available in the public survey without knowing the identity of the hospital or
domain; i.e. the trainer or consultant should not provide surveyor and determining the graduation (two tiers system)
client-specific solutions. 6. There is a firewall where the surveyor is not a supervisor
at the hospital.
• Policy on how accreditation or certification decisions 7. In the event that there is a discrepancy in the results of a
Suggested Evidence
are made to ensure impartiality survey evaluation that is far different between the surveyor
• Statement on consultancy and the counselor, an assessment board meeting will be
held to decide the graduation.
8. Everything is done through IT so there is no personal
contact. This ensures the independence of the survey
results
In 2012, it was legal and independent
Evidence :
1.3.1. meeting for the preparation of new policy for the
implementation of accreditation, review and policy
1.3.2. example of consultation meeting limiting survivor as a

mentor and as an accreditation survey
1.3.3. Proof of form no conflict of interest signed by survivor
1.3.4 scheme for making accreditation graduation decisions
1.3.5. The KARS website can translate to English
1.3. 6. screen shot of proof of guidance from the web site
1.5 There is a documented policy for handling information Self - Rating 4 Technical Review
obtained from, or about, clients in the course of the
external evaluation process.
INFORMATION POLICY OF EXTERNAL EVALUATION Please review this finding and ensure it is clear what
PROCESS RELATED TO HOSPITAL information is made publicly available
The policy ensures that clients are fully informed about
disclosed information.
Please clarify what is meant by the text highlighted in
green.
The public should have access to information about KARS surveyor must sign a letter of agreement that will keep
Guidance
organisations which have been accredited or certified medical secrets in connection with information needed Please provide the policy to support this rating.
(criterion 8.9) by the external evaluation organisation. during the survey, including copying or photographing. The
agreement letter is submitted to the director of hospital 7
The policy may include how the information is made days before the survey begins.
available to the public without breaking confidentiality; The hospital data contained in the system are not made by
this may be achieved by limiting information made HR and will be requested by KARS and given to survivors 7
publicly available from the survey report except when days before the survey after the survivor signs the statement
required by law.
Hospitals in Indonesia must be accredited (according to Law
Therefore the policy explicitly states, what information is No. 44 of 2009 article 40 paragraph 1) and carried out by
made public, including description of how and when. It external evaluation institutions by the National Accreditation
explicitly identifies other information that can be Body that has been certified by ISQUA (Permenkes 34 of
disclosed, including how and to whom, and makes 2017)
reference to possible legal requirements for disclosure.
It is expected that through the hospital accreditation process
• Relevant policy can (1) Increase public confidence that the hospital
Suggested Evidence
• How clients are made aware of any information which emphasizes, its goals on patient safety and quality of
may be made publicly available service, (2) Provide a safe and efficient work environment so
that staff feel satisfied, (3) Listen to patients and their
families, respect their rights, and involve them as partners in
the service process, (4) Create a culture of learning from
incident reports on patient safety, (5). Building leadership
that prioritizes cooperation, this leadership sets priorities for
and for the creation of sustainable leadership to achieve
quality and patient safety at all levels.
Each hospital can submit an accreditation survey to the
Accreditation Commission
Hospital (KARS) if it meets all the following criteria:
1. The hospital is located in the territory of Indonesia

2. Public hospitals and hospitals specifically for all hospital
classes
3. Hospital operating license is still valid
4. If the hospital permit has expired, submit a survey request
can be done, if the Health Service requests an extension of
the operational permit
must be accredited. For this reason the hospital sends a
letter / requirement
from the Health Office to KARS and surveys can be carried
out. Survey results
given in the form of a certificate of accreditation results that
can be used
to take care of operational permits. If an operational permit
has been issued, the hospital
send the permit document to survey@kars.or.id and the
Accreditation Commission The hospital will provide an
accreditation certificate to the hospital.
5. Director / Head of Hospital is medical staff (doctor or
dentist)
6. The hospital is fully operational by providing services
Inpatient, outpatient, and emergency services are complete
24 hours a day and 7 days a week.
7. The hospital has a Liquid Waste Management Installation
(IPLC) permit that is still applies.
8. The hospital has permission to manage hazardous and
toxic waste materials
which is still valid or cooperation with third parties who have
permits as processing of toxic and hazardous waste
materials that are still in force and / or permission as a valid
transporter.
9. All medical personnel providing care at the hospital
already have a Certificate of Registration (STR) and Practice
License (SIP)
10. The organization implements or is willing to carry out
obligations in improving quality of care and patient safety.
Evidence:
1.5.1 Screenshot the accredited hospitals in KARS website
1.5.2 Screenshot amounts to visiting sikars website
1.5.3 Policy evaluation
1.6 There is an explicit set of ethical principles, endorsed by Self - Rating 4 Technical Review
the governing body, which informs all decision making.
ETHICAL PRINCIPLES
The principles could include: Please ensure that the ethical principles listed in the self-
Guidance
i. Confidentiality 1. Confidentiality assessment tool match those in the evidence (or explain
ii. Independence KARS keeps all things related to the accreditation process why they are different).
iii. Objectivity confidential
iv. Fairness except the status of hospital accreditation results, that is if
the hospital has been accredited,
• Ethical principles which guide the behaviour of the not accredited, or if accreditation is withdrawn by KARS.
Suggested Evidence
organisation (may be in manuals, employment Hospital accreditation status is displayed on the KARS site
agreements) as Accredited.
If the validity period of the accreditation certificate has
• Evidence of governing body endorsement
expired or accreditation status then
the hospital's accreditation status was removed on the
KARS website. Hospital
can provide information or announce the results of
accreditation accordingly
hospital wishes. However, if the hospital delivers information
it is not appropriate regarding the accreditation status, KARS
has the right to clarify the information.
All KARS survivors in carrying out the accreditation survey

in the hospital make a statement that will keep all results
achieved by the hospital, results of monitoring and read out
RS.
All documents and regulations of hospitals surveyed that are
read and opened will not be uploaded and copied
2. Free or independence
All Survior KARS were given provisions before going down
to the field for an accreditation survey with knowledge
through workshops and training then competency tests and
hospital internships were held and required to graduate with
grades above 80.
Surveyor will take the oath and sign the integrity pact.
3. Objectivity
After getting the assignment information via e-mail, the
survivor is required to make a letter of no conflict of interest
with the hospital to be assessed.
4. Justice
The hospital can reject potential survivors who are
considered to have a conflict of interest
Hospitals are required to make an assessment of survivor's
professionalism during the accreditation survey
The hospital if objected to the results of the survey can
submit an appeal
The results of the graduation survey accreditation decision

through the two tiers system of the first assessment barriers
to the survey results after being uploaded will be assessed
by the caretaker counselor where the counselor cannot
know which rs and who survivor assessed.
After uploading the counselor will be seen if there is an
assessment discrepancy by the KARS assessment board
All of the survey management systems mentioned above
have been submitted and approved by the governing body
Evidence:
1.6.1. Policy of Organizational Philosophy and Ethic
1.6.3. KARS employee ethics
1.6.4. Approval of the regulatory body
1.7 There is a code of conduct which guides the interaction Self - Rating 4 Technical Review
of staff, surveyors, clients, stakeholders, and the public in
general.
KARS compiles Ethics & Organizational Philosophy to Please translate the evidence highlighted in yellow into
provide ethical guidance and guidelines for all organizational English.
The code of conduct should enable ethical concerns to components in carrying out their main duties and functions
Guidance
be raised and ensure a positive attitude towards and in interacting with all stakeholders Please clarify what is meant by the text highlighted in
complainants. Attention to Ethics is also included in the KARS Internal green (is this evidence which will be provided onsite?).
Regulation (Article 30).
A documented process may be required to ensure ethical KARS also compiled a Surveillance Code of Ethics during
concerns are recognised and addressed. the survey, a commitment to things that should not be done
and things that must be done (must be read 1 day prior to
• Code of Conduct hospital accreditation survey)
Suggested Evidence
• Evidence of how this is made available to staff, For monitoring, KARS formed the Ethics and Discipline
surveyors, clients, stakeholders and the public Committee
• Evidence of reported ethical concerns being
addressed Evidences:
1.6.1. Policy of Organizational Philosophy and Ethic
1.1.2. Internal Rules of KARS
1.7.1 Code of Ethics of KARS Surveyor During Survey
1.6.3. KARS employee ethics
1.7.2 Ethics & Discipline Committee Decree
1.7.3 Executive Chairman Decree on Sanctions for
violations of Ethics Surveyor
CASE STUDY KED
1.7.4 Surveyor Integrity Pact
Proof of socialization
1.9 The governing body supports a culture of safety, quality Self - Rating 4 Technical Review
improvement and excellence and is accountable for
creating a sustainable organisation.
The governing body should work with the organisation to Please review this finding and clearly outline how the
Guidance
identify and manage risks and identify strategic The Governing Body supports a culture of continuous quality governing body supports a culture of safety, quality
opportunities for improvement. See standard 3. improvement and safety and excellence. improvement and excellence and is accountable for
The composition of the Governing Body is very strategic in creating a sustainable organisation.
The governing body may also have a role in supporting establishing health service accreditation policies in
the external accreditation organisation; this may be in an Indonesia. Including setting a recognized organization (pass
advisory capacity from individual members who have ISQua accreditation.
particular skills.
Evidence:
Featured (Invitation, Materials, Attendance List and Minutes
/ Deciding KARS to become a member of ISQua including
accredited by ISQua)
Risk Management (In business Continuity of KARS as an
organization for accreditation surveyors in addition to
providing education and training to hospitals in need
(Regulation of Health Minister No 34 of 2017)
Risk management (in financial / building fire insurance)
Risk management (in human Resources / Health Insurance
and Travel Insurance, BPJS employment and health
insurance)
• Governing body terms of reference, meeting Risk of in environmental management
Evidence
Suggested
agendas/papers Risk IT management (in information / own server and back

• Minutes of meetings and decision making up in data banks)
Decree on risk management is made one part with the
approval of the Supervisory Board
1.10 The governing body defines and documents overall Self - Rating 4 Technical Review
Core authority and responsibility for:
a) overseeing the strategic planning process,
b) developing and approving accreditation/certification The Supervisory Board Oversees the Strategic Plan, Please review this criterion so that a) – f) are clearly
standards used by the organisation, Approves Accreditation Certification and Kars Has Legal addressed. For example, does the governing body define
c) ensuring the organisation meets legal and regulatory Entity And Monitor Kars Performance Etc. responsibility for ensuring appropriate communication
requirements as well as reporting, monitoring, and plans and strategies are in place (d)?
accountability obligations, The process of drafting SNARS 1st Ed is outlined in planning
d) approving the organisation's corporate policies and which includes objectives, resources and timeframes.
ensuring the policies are followed, The preparation SNARS 1st Ed has been established in the
e) ensuring appropriate communications plans and 2016-2020 KARS strategic plan
strategies are in place, .
f) monitoring the organisation's performance including The implementation of SNARS 1st Ed is allocated to KARS
the achievement of the strategic goals and objectives budget plans for 2016, 2017 and 2018.
These may be included in the annual plan, strategic The objectives, processes and schedules for the
Guidance
documents or operational documents. Other areas may development of SNARS 1st Ed are as described and
include: detailed in the Standard Development Plan.
i. overseeing the business development and marketing
process; Evidence:
ii. ensuring research plans and strategies are in place 1.1.4. Strategic Plan 2016-2020
as appropriate in view of the overall mission and 1.1.2. Internal Rules of KARS
vision of the external evaluation organisation 1.10.1. Budget plan for the preparation of SNARS 1
(Standard Development Plan)
4. Invitation, Material, Attendance List and Minutes
• Annual plan
Evidence
Suggested
Management and Supervisory Board

• Strategic documents 5. Job in the regulatory and supervisory bodies
• Job descriptions 6. Annual Plan KARS
1.11 The governing body defines and documents overall Self - Rating 4 Technical Review
Core authority and responsibility for financial activities
including:
a) approving the organisation's capital and operating
budgets and providing overall financial oversight;
b) ensuring the organisation is adequately resourced to
meet its objectives;
c) approving major transactions such as capital
investments or major equipment purchases
Responsibility may be delegated to the chief executive or Delegation of Authority to Management to manage financial Please review this criterion and address a) – c). As per
Guidance
equivalent or to a chief financial officer. See also criteria and organizational governance the required document checklist, please provide evidence
2.6 -2.9. to support this criterion (e.g. job description of person
Based on the results of the SWOT Analysis, KARS in the responsible for overall financial activities).
2016-2020 strategic plan is included in quadrant I (STAR).
• Terms of reference In this position the strategies taken are:
Suggested Evidence
• Budget approval 1. Offensive strategy, namely:

• Financial reports • proactive to capture big opportunities and;
• Job description • face the challenges that exist to continue to improve their
capacity and performance with;
• use the strengths that are owned and;
• eliminate weaknesses through Organizational Wide
Quality Improvement.
2. Aggressive strategies or growth strategies, namely:

increasing the level of organization operations including
improving service performance, benefit performance and
financial performance through improving infrastructure and

increasing the quantity and quality of human resources
Evidence:
1. New Internal Rules
2. See principle 2.6 - 2.9 about finance
1.13 The governing body defines stakeholders and Self - Rating 4 Technical Review
establishes responsibility for maintaining communication.
Notes: Please consider translating the evidence highlighted in
Stakeholders (see standard 1.1) include: yellow into English.
Stakeholders may include but not be limited to clients. a. policy: Ministry of Health
Guidance
Activities may include the external evaluation b. professional associations: IDI (Indonesian Medical
organisation: Association), Indonesian Nursing Association (PPNI),
Indonesian Midwives Association (IBI)
c. service user groups: Indonesian Hospital Association
i. actively seeking the opinions of clients, professional
(PERSI)
bodies, policy and funding authorities, and other
d. participating organisations: Indonesian hospitals
stakeholders on the development, evaluation and
improvement of services;
ii. developing plans for communication and for making
KARS has invited the stakeholders including:
strategic alliances to support and strengthen its
a) Ministry of Health (representative of policy maker)
programmes and key communities;
b) IDI (Indonesian Medical Association), PPNI (Indonesian
iii. contributing to projects, committees and networks
Nursing Association), HISFARSI (Indonesian Hospital
aligned with its strategic direction;
Pharmacists Association), IBI (Indonesian Midwives
iv. ensuring impartiality
Association), PDGI (Indonesian Dentists Association),
PDSRI (Indonesian Radiologists Association), those are
• Communication plan representative of professional associations
Suggested Evidence
• Stakeholder surveys and results (not post- c) PERSI (Indonesian Hospitals Association), ARSADA
assessment evaluations) (Province/District Hospitals Association), ARSSI (Private
• List of memberships of outside committees, projects, Hospital Association), those are representative of service
etc user group
d) Several hospitals from various type of hospitals
(representative of the participating organisations)
They were asked for any suggestions during revising
hospital accreditation standards.
KARS itself routinely conducts workshops for hospitals

preparing for accreditation. KARS works with the Indonesian
Hospital Associations (e.g. PERSI, ARSSI) in organising
workshops and seminars to help hospitals understand the

accreditation standards and comply with the standards.
KARS also contributes as speakers in seminars and
conferences held by various organisations (e.g. Ministry of
Health, PERSI, HISFARSI
KARS realised that the organisation has been developing

rapidly since the last 4 years and need to be supported by
Information and Communication Technology. Therefore,
KARS has cooperation with Bina Nusantara University.
Questionnaires to stake holder has been made (Ministry of

Health, PERSI, IDI, KKI, YLKI)
The content of KARS’s website is always updated and now

includes questionaires, bulletin and other features
KARS is a member of ISQUA and routinely attends

meetings. KARS is also a member of Asqua (Asian Society
for Quality in Healthcare).
Evidence:
1.13.1 Examples of the cooperation proposal from various
organisations
1.13.2 Examples WSAB Program
1.13.3 Correspondences documentation between KARS
and various organisations, minutes of meeting (Ministry of
Health, Binus,)
1.13.4 Questionnaires of stakeholders satisfaction survey
print preview of KARS’ website
1.3.5 TOR of Focus group discussion on improvement of
KARS administrative services
1.3.6 TOR of Focus group discussion on socialization of
new organization of KARS
1.3.7 Administration Service Improvement Program 2014
1.3.8 Planning for KARS Organization Socialization (New)
2014
1.3.9 Membership Certificate of ISQua and ASQua
Standard 2:Strategic, Operational and Financial
Self-assessment evidence Technical Review
Management.
2.1 The governing body delegates responsibility for the Self - Rating 4 Technical Review
Core operational management of the external evaluation
organisation, including survey functions, to a chief executive
KARS is a non-profit organization that is formed based on Please review this finding to ensure it is clear (it is not
or equivalent.
Notarial Deed No. 15 where the organs of the Accreditation clear what is meant by organs here).
Commission consist of the Governing Body, Supervisory
Examples could include the governing body: Body and Executive Chairman, which are determined by the Please provide as evidence the job description of the
Guidance
Executive Board to conduct or lead the Governing Body Executive Chair.

i. defining the chief executive’s role and authority in a Organ is the Executive Chair of KARS where the tasks set Also, please clarify if a) – h) are the responsibilities of
position description; by the Governing Body eg : the Chair?
ii. setting annual performance objectives for the chief
executive and evaluates their achievement; A. Establish policies for implementing hospital accreditation Please translate the evidence highlighted in yellow into
iii. requiring management to develop appropriate plans and to conform to international standards. English.
strategies to achieve the goals and objectives of the B. Establish accreditation standards and
external evaluation organisation; accreditation instruments according to the
iv. receiving regular and accurate reports from procedures for assessing hospital accreditation
management on the strategic, operational and financial C. Establish Hospital accreditation status.
performance of the external evaluation organisation D. Propose the formation of an Adhoc committee and
Discipline to the Governing Body
• Chief Executive’s job description, current performance E. Make a report of the Board Executive to the Governing
Suggested Evidence
objectives Body
• Strategies and planning processes F. Prepare annual KARS income and expenditure budget
• Examples of management reports to governing body (RAB) to get approval from Governing Body
G. Prepare Annual Financial Reports
H. Develop a Strategic Plan for KARS.
The Performance Target for the Executive Chair is contained

in the work plan and budget, and the achievement can be
seen in the annual realization for each year. Which includes
among others:
- Achievement Accreditation Graduation Results

- Survey
- Guidance
- Workshop
- Financial
The task of the Supervisory Body is to supervise and advise

the Management in carrying out their duties.
Evidence :
2.1.1 Internal Regulation of the Hospital Accreditation
Commission.
2.1.2 Description of the duties of the board and the
supervisory body.
Management.
2.1.3 Report of the board to the Governing Body on the work
plan and budget:
2.1.3a Year 2016
2.1.3b Year 2017
2.1.3c Year 2018
2.1.4 Budget realization report to the Governing Body.
2.1.4a Year 2016
2.1.4b Year 2017
2.1.4c Year 2018 First Semester
2.1.5 Renstra Report for the 2016-2020 period.
2.2 The lines of responsibility within the external evaluation Self - Rating 4 Technical Review
Core organisation are:
a) clearly defined KARS is a non-profit organization that is independent. In Please provide the organisational chart as evidence
b) made known to staff and, carrying out the activities referring to the organizational (listed in required document checklist as key evidence).
c) ensure staff and surveyors are free from influence by structure of KARS which clearly describes the command line
those who have a direct interest in the services and starting from the Executive Chair of KARS in every function Please consider translating the evidence highlighted in
accreditation/certification decisions in the organization and separating the independent surveyor yellow into English.
functions and also the coordination lines are clearly
Examples should include: described in the organizational structure and all these
Guidance
i. the organisational chart showing the lines of authority, functions have been described clearly in the job description
responsibility and allocation of functions; .
ii. lines of responsibility being made known to staff at
orientation and whenever there is a change of If there are changes in regulations related to the organization
responsibilities or if there is new staff acceptance, an orientation program is
conducted for the introduction of the organizational structure
• Organisational chart
Suggested Evidence
to explain the authority of the duties and responsibilities of

• Orientation programme each division.
Evidence:
2.1.1 Internal Regulation of the Hospital Accreditation
Commission.
2.2.1 Orientation Form.
2.2.2 Implementation of Staff Orientation.
2.3 The external evaluation organisation: Self - Rating 4 Technical Review

a) takes responsibility for all activities outsourced to
another organisation KARS has collaborated with third parties for some activities Please consider translating the evidence highlighted in
b) defines its requirements for any outsourced work in which include eg: yellow into English.
documented agreements
c) makes decisions to award contract based on the 1. Development of the IT system includes facilities and
outsourced organisation’s competency, ability to meet infrastructure in the operation of KARS (With BINUS
quality and health and safety requirements, cost University)
effectiveness, and
Management.
d) monitors outsourced work 2. Development of Webinars (with Gadjah Mada University)
3. HR Development and Workshop in collaboration with
This criterion is relevant in cases, where parts of the hospital organizations (PERSI). And with LP4M UNAIR
Guidance
external survey activities are outsourced. All outsourced for Standardization socialization that must be fulfilled by
activities which impact on the organisation have been the Hospital.
approved by the governing body.
The form of cooperation is outlined in a Cooperation Contract
This criterion is not relevant to contracts with individual which includes, among others:
surveyors as this is included in criterion 6.3. It applies to, for
example, technical experts, evaluators, education and a. Scope of work
where evaluation methods are carried out on behalf of the b. Qualification
organisation by another body. c. Job requirements and quality
d. Cost
That the external organisation takes responsibility for e. Job monitoring
outsourced activities implies that any outsourced activities
will be included in the ISQua survey, as if they were Procurement of services with third parties has been
performed by the external evaluation organisation itself. regulated in KARS regulations.
• Examples of contract/tenders for services outsourced

Evidence
Suggested
Evidence :
• Contractual decision making process
2.3.1 Workshop on Cooperation with hospital organizations
• Monitoring of outsourced work
(PERSI).
2.3.2 Evaluation of contracts.
2.4 The external evaluation organisation: Self - Rating 4 Technical Review

a) defines what types of supplies are considered major
supplies; In carrying out the organization, KARS has used information Please consider translating the evidence highlighted in
b) defines its major supplies requirements in documented technology that plays an important role to support the yellow into English.
agreements; improvement of the quality and operational activities of
c) makes contractual decisions on the basis of KARS. KARS has also equipped facilities and infrastructure Please clarify if the text in red is evidence which will be
competency, ability to meet quality and health and by purchasing tools (Software and Hardware). And has provided onsite?
safety requirements and cost effectiveness, and established SISMADAK to be used by hospitals in managing
d) monitors the contracted work data in hospitals to improve quality in hospitals. It should be clear how the work is monitored (e.g. are
Collaborating with BINUS University. there key performance indicators?).
Major supplies are deliveries of goods or services that are
Guidance
critical for the external evaluation organisation’s ability to KARS has also completed remote workshops and guidance
perform its external survey activities at the required through a Webinar in collaboration with Gadjah Mada
performance level. University.
Examples may be Bukti:

i. IT services, equipment and programs; 2.4.1 Examples of contracts with
ii. bookkeeping and accountancy services; 2.4.1a BINUS University
iii. human resource administration 2.4.1b Gadjah Mada University (UGM).
Contracts may include key performance indicators to enable
detailed monitoring.
Management.
2.4.2 The reason for choosing cooperation with Binus and
UGM is because both universities are competent in
information technology.
2.4.3 Evaluation.
• Examples of contracts
Evidence
Suggested
• Decision making process

• Monitoring of contracts
2.5 A strategic plan, developed through a defined process, Self - Rating 4 Technical Review
Core contains achievable and measurable goals (or directions)
and objectives.
In accordance with the KARS regulation, the Strategic Plan Please include the hyperlink to the strategic plan.
for the 2016-2020 period has been prepared which is used
as a reference in the preparation of budget planning for Please note that the list of signatures is dated 2018 so
The aim of a strategic plan is to direct the external revenues and expenditures in the form of RAB made every it is not clear how this evidence relates to the
Guidance
evaluation organisation’s services, programmes and year. development of the 2016 – 2020 strategic plan.
activities and guides decision-making and resource
allocation. The strategic plan could include: Evidence :
2.1.5 KARS Strategic Plan for 2016 – 2020
2.5.1 Evidence of the Strategic Plan drafting meeting which
i. being based on an analysis of the external evaluation shows the involvement of various stakeholders.
organisation’s strengths, weaknesses, opportunities and
threats;
ii. using information from research, performance
measurement and risk analysis;
iii. providing direction for a specified number of years, e.g.
four years
• Strategic plan
Evidence
Suggested
• Evidence of stakeholder involvement
2.6 An annual operating plan defines the external evaluation Self - Rating 4 Technical Review
Core organisation’s objectives, and the resources required to
Management.
achieve them. The plan is developed in accordance with the The one-year operational plan is contained in the annual The annual operating plan is a key document and the
strategic plan. budget income and expenditure plan (RAB), to meet the 2018 version must be provided in English with the final
KARS operational activities target group activities consisting SAT (see required document checklist).
The annual operating plan could be: of accreditation surveys, verification surveys, guidance,
Guidance
simulation surveys and workshops. Please translate the evidence highlighted in yellow into
i. based on the strategic plan goals and objectives, and English.
ii. include timelines and responsibilities This plan can be seen in the annual income and expenditure
budget report for each year.
The operating plan may be integrated with the financial plan
and/or the budget into one document. Evidence :
2.1.3 Report of the board to the Governing Body on the work
plan and budget:
2.1.3a Year 2016
2.1.3b Year 2017
• Annual operating plan
Evidence
Suggested
2.1.3c Year 2018
2.7 The external evaluation organisation has processes for Self - Rating Technical Review
Core financial planning and budgeting.
The financial statements prepared by the Governing Body Please consider translating the evidence highlighted in
each year are audited by a Public Accountant Office and yellow into English.
based on the Public Accountants' report carried out from
Financial planning is delegated by the governing body (see 2016 to 2017 get unqualified opinion is an audit opinion Please add a self-rating.
Guidance
1.11) and could include: issued if the financial statements are considered as providing
information which is free from material misstatement. Please clarify why some text is in red (or change to
i. a financial and resource plan developed and used to black).
prioritise the strategic and operational objectives, Evidence :
strategies and activities; 2.7.1 Financial Report of the Hospital Accreditation
ii. budgets based on the financial plan that are developed Commission for the years ended December 31, 2016 and
with the participation of staff and incorporate 2015 along with the Independent Auditor’s Report HARRIS
performance measures; & GINDO
iii. budgets used to monitor and report regularly on financial 2.7.2 Financial Statements of the Hospital Accreditation
performance Commission for the years ended December 31, 2017 and
2016 along with the Independent Auditor's Report HARRIS
Financial plans may form part of the annual operating plan. & GINDO
2.7.3 Regulation on Budget Preparation
Financial planning processes may be supported by policies 2.7.4 Financial reports to the Governing Body
and procedures.
• Finance plans
Evidence
Suggested
• Financial policies and procedures

• Budgets
Management.
2.8 An effective financial system is used to record and track Self - Rating 4 Technical Review
income and expenditure and past, current and projected
financial positions.
KARS has implemented an accounting system supported by Please provide and translate the evidence highlighted
information and technology so that it can present timely and in yellow.
accurate financial reports
The financial system could include financial reports that: 1. Monthly Report. Please add a self-rating.
Guidance
i. are timely and accurate; 2. Annual Report.

Please clarify why some text is in red (or change to
ii. used by managers to manage their budgets; black).
iii. produce results in a useful form to enable the governing Based on the report, the Chief Executive makes a report after
body to monitor the external evaluation organisation’s making a financial report after receiving a recommendation It is noted that a chief executive is referenced here (but
performance against budget and overall financial viability from the Supervisory Body. is not noted in 2.1 – is this the same as the Executive
Chair? Please clarify.
Evidence :
2.1.4 Budget realization report to the Governing Body.

• Financial reports 2.1.4a Year 2016
Evidence
Suggested
2.1.4b Year 2017

2.1.4c Year 2018 First Semester
2.9 Appropriate internal and independent systems of financial Self - Rating 4 Technical Review
and asset control protects the external evaluation
organisation’s assets.
KARS has made regulations for Capital Expenditure (Asset Please consider translating the evidence highlighted in
purchase) to record assets purchased (Fixed Asset). As for yellow.
asset monitoring, asset registers have been carried out
Systems should be in place which could include: especially for Office Inventories and are protected from risk Please clarify why some text is in red (or change to
Guidance
through fire insurance for buildings and their contents. black)

i. documentation of delegated authority and accountability KARS also guarantees BPJS for Management, Officials
for purchasing and incurring expenses; (Structural and Functional) and Staff through BPJS Health Please explain what is meant by BPJS.
ii. an effective system of asset control with controls for and Employment.
cash, debtors, inventory and equipment; KARS also provides travel insurance guarantees for
iii. a comprehensive insurance programme that protects Surveyor and Advisors.
financial assets, buildings, contents, physical assets and The annual audit report is reported to the Government Body.
staff and surveyors when travelling;
iv. an independent and comprehensive annual financial Evidence:
audit undertaken by appropriately qualified persons with 2.9.1 List of assets.
results reported to the governing body 2.9.2 Office Inventory List.
• Policies and procedures 2.9.3 Asset / Building Insurance Policy that protects against
Evidence
Suggested
• Asset register the risk of fire.

• Details of insurance policies held 2.9.4 Labor Insurance.
• External financial audit 2.7.2 Financial Statements of the Hospital Accreditation
Commission for the years ended December 31, 2017 and
Management.
2016 along with the Independent Auditor's Report HARRIS
& GINDO
2.10 Progress in achieving strategic and annual objectives, Self - Rating 4 Technical Review
including financial and, if appropriate, research objectives, is
measured regularly and achievement is evaluated.
The financial target is determined based on the increase in Please review this criterion as it relates to more than
net assets (Remaining Operating Results) each year based just financial targets. Please review and address how
on the financial statements along with the liquidity ratio, progress in achieving strategic and annual objectives,
Progress is monitored and could include: solvability and profitability. including financial and, if appropriate, research
Guidance
objectives, is measured regularly and achievement is

i. the strategic and annual plan being reviewed and Evidence: evaluated.
revised in accordance with a planned schedule and 2.10.1 Evaluation of the performance of Executive Board
progress results; from 2016 - 2017 Please review the guidance and suggested evidence
ii. chief executive/senior management performance being and provide additional text and evidence.
evaluated against set annual performance objectives;
iii. organisational achievement being evaluated against Please translate the evidence highlighted in yellow into
defined indicators and targets; English.
iv. financial effectiveness being measured by achievement
of budget and other defined targets, e.g. financial ratios;
v. if the organisation’s mission includes research there may
be a research plan to define the external evaluation
organisation’s annual research objectives, strategies
and activities and the resources required to achieve
them
• Evidence of monitoring of all planned objectives
Evidence
Suggested
• Chief executive/senior management performance

evaluations
• Financial indicators
Standard 3: Risk Management and Performance
Improvement
3.2 The risk management framework is supported by a risk Self - Rating 4 Technical Review
Core management plan, policies, procedures and a risk register.
KARS risk management is managed by quality andrisk Please translate the evidence highlighted in yellow and
management committee. clarify what is the difference between this document
and the risk register referenced in 3.1.
The risk management plan includes reporting, reviewing Risk Management Plan is drafted early in 2013 and
Guidance
and monitoring of risks. established by the KARS Governing Body. Please provide as evidence the risk management plan
(in English).
The procedure should detail how risks are managed, These commitee identifies KARS risks, compiles a list of
identified, reported and acted upon together with the risks, sets priorities and formulate Risk Action Plan.
process used to record them.
Risks involved:
A risk register should be kept of all identified risks. The risk 1. Strategic risk dependent on the changes in internal and
register is a live document which is updated on a regular external regulations that might affect KARS operations.
basis. The identified risks may be rated in accordance with 2.Natural disasters
their severity or risk to the organisation. 3.Financial risks
• Documented risk management plans, policies and 4.Operational risks: staff gets sick, transportation delays, IT
Suggested Evidence
procedures information deleted

• Risk register
Evidence:
3.2.1 Documents of Worker Insurance administration:
Jamsostek.
3.2.2 Travel flight insurance (Garuda tickets).
3.2.3 Policy and Risk Management.
3.2.4 KARS Risk Lists.
3.2.5 Risk Action Plan /Risk Mitigation Plan, such as
actions taken when the fire accident occurs.
3.3 Risks are identified, analysed, reported, reviewed and acted Self - Rating 4 Technical Review
Core upon.
KARS compiles policy documents and Quality Planning as This criterion relates specifically to risk – please review
This may include: a frame of reference and a commitment to improve the fully to ensure that it addresses how risks are identified,
Guidance
quality of KARS service. analysed, reported, reviewed and acted upon.

i. analyses of information from a variety of sources;
ii. identification of potential consequences; The whole KARS commissioners or head of division are Please review the ISQua guidance for further details.
iii. assessment of the significance of the risks in terms of responsible for improving quality in their respective fields.
likelihood, consequences and outcomes; The entire quality improvement activity plans are discussed Please provide an example of a risk report.
iv. identification and implementation of risks management in commissioner regular meetings and taken into action.
strategies e.g. how risks can be avoided, reduced, Barriers in implementing the procedure will be analysed
transferred, shared, retained and planned for, and and improvement is conducted in order to improve quality.
v. how staff are kept appraised of identified risks
Improvement
• Risk reports To measure quality improvement, KARS has set
Suggested Evidence
• Closure of identified risks performance indicators for each program contained in the
• Minutes of meetings KARS Strategic Plan 2012-2016.
Furthermore researches on the accreditation process are

conducted by educational institutions in Indonesia and
customer satisfaction surveys are also the basis for the
KARS for improving the quality.
Evidence :
3.3.1 Quality Planning and Policy.
3.3.2 Accreditation researchs.
3.3.3 Strategic Plan 2012-2016.
3.3.4 Meeting minutes of ISQua team.
3.4 The governing body receives reports at least twice per year Self - Rating 4 Technical Review
and more frequently if necessary:
a) on the monitoring of risks, KARS activities are monitored and reported annually to the Please review this criterion as it relates specifically to
b) the effectiveness of the risk management plan, Governing Body. Monitoring is also conducted during the reporting of risks to the governing body.
strategies and, discussion at regular meetings of commissioners.
c) systems for minimising risk, the assessment of new It should be clear how frequently this occurs, and the
risks, and revision of the plan At the regular meeting of the commissioners are also evidence should relate specifically to the requirements
Reports to the governing body could include: discussed the achievements and obstacles of KARS of the criterion.
Guidance
i. review of the frequency and severity of damages and implementation activities such as :
losses incurred; Accreditation survey , Guidance , Workshop , etc. .
ii. analysing incident and adverse event trends;
iii. reviewing policies and procedures that might prevent or In addition, each complaint from the hospital or from other
minimise risk; stakeholders related services will be discussed and KARS
iv. assessing new or increased risk; improvement plan arrangement will be arranged and revise
v. assessing the effectiveness of risk management its procedures if necessary.
education and communication strategies Financial monitoring is conducted every year by the audit
and is done by the Independent Auditor ( Certified Public
• Reports to the governing body Accountants ). Financial statements audited the
Suggested Evidence
Independent Auditor are submitted to the Governing Body.

Other than external audit, internal audit is also conducted
each month by KARS auditor.
To improve the quality KARS changed the accreditation

system from 2007 versions to 2012 in 2012 by adopting the
accreditation system. Along the year of 2013, KARS had
done some improvements in order to prepare for ISQua
accreditation.
Evidence :
3.4.1 KARS Commissioner Meeting Minutes.
3.4.2 Meeting minutes of ISQua team.
Improvement
3.4.3 Accreditation Standard Composition Reports.
3.4.4 Quality improvements socialization for staffs
(secretary meeting minutes 3 Oct 2013).
3.5 A framework, developed in consultation with stakeholders, Self - Rating 4 Technical Review
is used to manage and identify opportunities for quality
improvement.
For improving quality management system: Please include the hyperlink to the evidence highlighted
KARS esteblished Quality and risk Management Team in green.
with clear job description within the Quality Improvement
The framework could include: and Risk Management Team.on 2014.This decree has
Guidance
been renewed on January 2017 by restructurize that the

i. evidence of a designated person with responsibility for team becomes The Quality and Risk Managment
promoting and coordinating quality improvement; Commitee andhas responsibility to the KARS Chairman
ii. how stakeholders are involved; Eksekutive (not to R &D dIvision anymore ) ,replacing the
iii. links to other frameworks and strategies; Chief of the Commitee and some of the members.
iv. setting of quality indicators;
v. how evidence based decision making, innovation and Stakeholder are involved by recieve the quality and Risk
research being promoted managment report twice a year.For staff satisfaction and
Indicator of Surveior Training Programe once a year
• Quality improvement framework The frame work of risk managment and quality
Suggested Evidence
improvment are established base on KARS strategic plan

(Tujuan 1.Strategi 5 RENSTRA KARS 2016-2020.
Also linked with Surveyor TranningProgramme , delivery of
survey programme.
The Commitee reviewed Policy of qualityimprovement plan

2017-2018 ,added 5 new quality indicators for surveiyor
training programe from 8indicators up to 13 indicators as
well.
These indicaors are :

• Indicators 1-5 for quality improvement survey
proccess.
• Indicators 6-7 for surveyor competencies and
survey team leader.
• Indicators 8 for staff satisfaction
• Indicators 9-13 for Serveyor Training Programme:
I.Indicator for quality improvment survey

proccess :
Improvement
1. Delay in notification result of survey to hospitals
>30calendar days. Standard: number of delay<
5%
2. Delay in delivery of the results of the survey to
KARS> 5 working days.
Standard: number of delay <20%
3. Ability to meet survey demand as needed by
hospital
Standard: 100% compliance figures
4. Hospitals satisfaction survey on the
mplementation
of the accreditation survey.
Standard: 80% satisfaction rate
5. Hospitals assessment on the recommendations
resulting from the survey
II.Indicators for surveyor competencies and survey

team leader.
6. Assessment of the ability of survey team
members (STM) by Head of Surveying Team/
Survey Team Leader(STL).
Standard:Proper 95%.
7. Assessment of the ability of STL by STM .
III.Indicator for staff satisfaction :

8. The level of KARS staff satisfaction
Standard: satisfaction rate 100%
IV.Indicator for Serveyor Training Programme:

9. Percentage of aplicans that pass for selection,the
target of 80 %
10. Pencentage of attendance of training invitation
, the target of 90%
11. Average trainee satisfaction ,the target of 80 %
12. Percentage who failedon competency test not
more than 15 %
13. Percentage of participants passed an internship
against participants passed the competency test
Improvement
Every analisis of each quality indicator follow by
implamantation of decision making.
From evidence based data, KARS identify the Training
Need Assesment and than delivers planty of work shop
both for surveyor and the Hospital.
KARS makes innovation by changes the 2012 version of

hospital accreditation standard to SNARS 1st Ed.
Evidence :
3.5.1 Deccre of KARS Quality and Risk Management
Commitee with Job Description.
3.5.2 Policy of quality improvement 2017-2018.

3.5.3 KARS Strategic Plan
3.5.4 Indicatorsfor Quality Improvment Plan 2017 and
2018 page 13-15 in Policy of quality improvement 2017-
2018
3.6 Systems are in place to support the quality improvement Self - Rating 4 Technical Review
framework.
The former Quality Improvment Policy 2014-2016 have Please explain how staff are made aware of the quality
Systems could include: been renewed by Quality Improvment Policy 2017-2018 improvement process.
Guidance
i. a quality improvement policy; Staff collecting the data and help to changes into
ii. staff awareness of the quality improvement process; informaytyion the form of statistics.
iii. review of key quality indicators;
iv. audits and reviews Review of quality indicator carried out by the quality and
risk management commitee twice a yearrelated indicator
• Quality improvement policy quality improvment survey proccess once a year for STP
Suggested Evidence
• Audit schedule indicator and staff satisfaction.

• Minutes of review of quality related activities
I.Indicator for quality improvment survey
proccess :
1. Delay in notification result of survey to hospitals
>30calendar days. Standard: number of delay<
5%
2. Delay in delivery of the results of the survey to
ICAHO> 5 working days.
Standard: number of delay <20%
3. Ability to meet survey demand as needed by
hospital
Standard: 100% compliance figures
4. Hospitals satisfaction survey on the
mplementation
Improvement
of the accreditation survey.
5. Hospitals assessment on the recommendations
resulting from the survey
II.Indicators for surveyor competencies and survey

team leader.
6. Assessment of the ability ofsurvey team members
(STM) by Survey Team Leader (STL).
7. Assessment of the ability of STL by STM .
III.Indicator for staff satisfaction :

8. The level of KARS staff satisfaction
Standard: satisfaction rate 100%
IV.Indicator for Serveyor Training Programme:

9. Percentage of aplicans that pass for selection,the
target of 80 %
10. Pencentage of attendance of training invitation
,the target of 90%
11. Average trainee satisfaction ,the target of 80 %
12. Percentage who failedon competency test not
more than 15 %
13. Percentage of participants passed an internship
against participants passed the competency test
Every analisis of each quality indicator follow by

implamantation of decision making. From evidence based
data, KARS identify the Training Need Assesment and
than delivers planty of workshop both for surveyor and the
Hospital.
Evidence :
3.6.1 Policy of quality improvement2017-2018.
3.6.2 Staff awareness of the quality improvement process.
3.6.3 Review quality indicators (13 indicators ) in Quality
improvment report 2017-2018.
3.6.4 Minutes meeting QRM Committee.
Improvement
3.7 A quality improvement plan is implemented which includes Self - Rating 4 Technical Review
processes for
a) identifying, recording and analysing improvement Opportunity for improvement Please review this criterion as it should specifically
opportunities address a quality improvement plan – please review so
b) implementing improvements The organisation supports by restucturize the QRM Team it is clear how this is addressed (see ISQua guidance
c) monitoring and evaluating of improvement to brcome QRM Cimmitee ,wich directly responsible to for what the plan includes).
There may be more than one plan for different activities but KARS Executive chairman
Guidance
each plan includes : The QRM Commitee reviewed Policy of quality

i. timelines, improvement 2017-2018 and developed the new policy
ii. responsibilities, and added quality indicators from 8 indicators up to 13
iii. monitoring processes indicators as well. The 13 existing indicators has been
analized .
Every result of the analysis of the same indicators as the
• The quality improvement plan
Evidence
Suggested
plan, RTL implementation is always monitored and

• Minutes/notes of meetings that show quality evaluated. Monitoring and evaluation by QRM Committee.
improvement process in action
• Evidence of demonstrable improvement Evidence :
3.7.1 Examples of RTL implementation and examples of
evidence results of RTL implementation.
3.8 The governing body receives reports at least twice per year, Self - Rating 4 Technical Review
or more frequently if necessary, on the outcome of quality
improvement activities and the revision of the quality
improvement plan. Governing body recieve the qualityimprovment report for Please review and if available, provide evidence of the
quality improvement survey proccess and for surveyor quality improvement reports (please note that they
competencies and survey team leader.twice a year and should include information about quality improvement
Reports may include: for staff Satisfaction and for Surveiyor Training projects and not just indicators).
Guidance
Programe once a year

i. quality improvement projects planned and completed; KARS has a complaint management guide. Every
ii. processes or practices changed as a result of risk or complaint is always resolved according to the procedure
improvement activities; within the time limit set in the procedure.
iii. complaints received and resolved within the timeframes
Evidence :
3.8.1 Policy of quality improvement 2017-2018.
• Quality improvement reports 3.8.2 Quality improvment report 2017-2018.
Evidence
Suggested
• Updated quality improvement plans 3.8.3 Examples of handling complaints.
3.9 The external evaluation organisation identifies key Self - Rating 4 Technical Review
performance criteria and monitors its performance against
them.
If available, please provide evidence of the indicator
results.
Improvement
Key performance criteria may include In 2014 KARS establishment of the KARS Quality and Risk
Guidance
i. performance against accepted standards; Management Commitee, eight quality indicators consisting
ii. performance against defined indicators and other of three existing and five new indicators were established
relevant measures; to evaluate the accreditation program.
iii. compliance with policies, procedures and guidelines
iv. progress against the quality improvement plan, and In 2017,QRM Team has been restructurized be come the
v. results are reported and communicated to staff QRM Commitee,which has a responsibility to KARS
Executive Chairman
For 2017-2018 ,KARS QRM Commitee esteblish 13

• Management reporting against business and strategic indicator consisting the eight existing indicators.
Suggested Evidence
plans
• Internal audit activities The six Indicator relate to Hospital’s satisfaction on the
accreditation survey.
The two indicators relate to surveyor competencies and

survey team leader.
One indicator is satisfaction of KARS Staff
The new five indicators relate to Serveyor Training

Programme
All Indicator has been evaluated . We make comparative

analysis of the 2017 to 2018. And the anlysis result are
used for KARS improvment plan
3.10 Policies and procedures (electronic or paper based) are in Self - Rating 4 Technical Review
place for all aspects of the external evaluation
organisations’ operations and are developed, implemented
and cyclically reviewed in consultation with stakeholders. Please review and explain how stakeholders are
KARS have Guidelines and Regulatory Document Control involved.
Guidelines to formalise the process for the regular review
Policies and procedures: of policies and documentation. Since 2014.These guidlines Please provide as evidence samples of policies and
Guidance
has been updated on 2017. procedures. l

i. reflect contemporary practice and standards; These guidelines
ii. are clear, concise and logical;
iii. are readily accessible Evidence :
3.10.1 General Guideline On Documentation.
3.10.2 Guideline On The Control Of Regulatory Document.
• Samples of policies and procedures
Evidence
Suggested
Improvement
3.11 An effective system of document control is in place for both Self - Rating 4 Technical Review
electronic and paper based documents/records that ensures
the appropriate versions are accessed, used and available
to staff, clients, and other stakeholders. KARS has General Guideline On Documentation Please provide the document control guidelines as
and Document Control Guidelines whichhas been reviced evidence here.
on 2017.
The document control system could include: In this regulation numbering systems have been arranged
Guidance
both manually and electronically, distribution systems,

i. a document control policy and/or procedure; outboarding, Control is included for accreditation
ii. a register (electronic or paper based) being maintained documents.
of all documents with the respective issue or
amendment status, the authorising person and the Documents for conducting surveys are already online in the
distribution list/procedure identified; SIKAR system, starting from downloading report templates
iii. the distribution of all accreditation or certification related for the surveyors and reporting systems.
documents being controlled to ensure that only current,
appropriate documentation is used; KARS has an electronic document management system
iv. new or revised documents being reviewed and approved (DMS) which is used to maintain and version control key
for adequacy by appropriately authorised and competent documents, policies and procedures.
personnel prior to them being issued and implemented;
v. systems to prevent the unintended use of obsolete To ensure appropriate access for participating
documents, and to apply suitable identification to them if organisations, surveyors and staff, the DMS is managed by
they are retained for any purpose, password control.
vi. identification of key records, such as, survey reports
• Evidence of document control To ensure currency, each document is version controlled
Suggested Evidence
and automatically at a two (2) year period the document

cannot be accessed as the policy of KARS states that a
document required viewing at two (2) year period.
The date of issue and date for review are programmed.

Tthe DMS has a reminder system to the reviewer 3
months before the due date of the document review.
Since 2014 KARS has developed DMS and SIKARS.

DMS (Database Management System) is a system that
manages KARS data.
SIKARS (KARS Information System) is an application for
managing KARS activities.
In 2018 KARS has developed SISMADAK, REDOWSKO

and SIRSAK.
SISMADAK (Management System for Accreditation
Documents) is a system of application of tools that is
intended for hospitals participating in the accreditation
program organized by KARS.
Improvement
REDOSWKO (Regulation, Documents, Observation,
Interview, Simulation, Confirmation) are surveillance tools
and hospitals in carrying out accreditation surveys.
SIRSAK (KARS-style RS Information System) is an
electronic medical system based on SNARS.
Evidence :
3.11.1 RENSTRA dan KPI.

3.11.2 Quality and risk management committee.
3.11.3 Policy of quality and Risk management 2017-2018.
3.12 A complaints management framework is in place which is Self – Rating 4 Technical Review
Core communicated to client organisations, surveyors and
stakeholders, provides for confidentiality, impartiality,
timeliness and feedback to the complainant. All letters / information about complaints were received by Please explain what is meant by an RS complaint.
the Executive Secretary of KARS. In accordance with the
substance of the complaint, it will be forwarded to the Please clarify if the Executive Chief is the same as the
The complaints management framework could include: Ethics and Discipline Committee or the heads of relevant Executive Chair?
Guidance
fields to be processed, then reported to the KARS

i. a policy and/or procedure; Executive Chair. Please provide as evidence your complaints policy.
ii. a complaint register;
iii. advice on how to make a complaint or express a Complaints can come from hospitals that are surveyed, Please consider the evidence highlighted in yellow into
concern; from surveyors or from other bodies and communities to English.
iv. complaints being encouraged and accepted in writing or hospitals that have been accredited.
verbally If there is an RS complaint, the supervisor will be handled
by the ethics committee and the supervisor's discipline.
The complaints process should include:
v. complaints being acknowledged within a reasonable The ethics and discipline committee records and follows up
timeframe e.g. within five working days of receipt; on all complaints.
vi. responses within a set timescale, and if this timescale is The ethical and disciplinary committee has regulations for
not met complainants are kept informed of any delays; handling disciplinary / supervisory violations.
vii. staff, surveyors or other personnel of the external
evaluation organisation who are complained about being The ethics and discipline committee has regulations
given an opportunity to respond; regarding the determination of classifications and sanctions
viii. complainants and those complained about being for violations of the surveior code of ethics.
advised of progress in the investigation and the
outcome; Evidence :
ix. findings from complaints being linked to the continuous
improvement process; 3.12.1 Decree by Executive Chief of KARS KARS No.
x. complaints about accredited or certified organisations 1111. in 2018 of the determination of classification and
being referred back to those organisations and followed sanctions violation of surveior code of ethics.
up to ensure they are addressed
Improvement
3.12.2 List of complaints of violations of the code of ethics
surveior.
3.12.3 Guidelines for handling appeal of survey results
from hospital.
3.12.4 Complaints handling/issue guidelines against
accredited hospitals.
3.12.5 Register book complains.
• Complaints documentation 3.12.6 Minutes of Ethics and Discipline Committee
Evidence
Suggested
meeting.
Standard 4: Human Resource Management Self-assessment evidence Technical Review
4.2 Human resources planning includes the determination of the Self - Rating 4 Technical Review
numbers and competencies of staff needed for the type and
level of activity, and, for changes in workload.
Secretariat staff needs are calculated based on workload Please note that as specified in the required document
indicators of staffing needs per type of activity. checklist, evidence must be provided of a human
Determination is based on the number of activity targets resources plan. It is noted that staff needs are
The planning process may include: that are planned for the next 3 years : calculated according to rules but please provide the
Guidance
i. a separate human resource plan or human resource For calculating staff requirements, data is needed: actual plan.
component within the operational plan and budget; 1. Estimated number of hospitals that will carry out the initial
ii. desired training, qualifications and experience being survey Please add the hyperlink to the evidence highlighted in
considered as part of the planning process; 2. Estimated number of hospitals that will carry out remedial green and please check the chapter which has been
iii. succession planning survey cited as this appears to be incorrect.
3. Estimated number of hospitals that will carry out re-
survey
Staff are actively involved in planning where appropriate 4. Estimated number of hospitals that will carry out the
and have opportunities to suggest improvement of the verification survey
scope of their roles. 5. Estimated number of hospitals that will carry out the
• Human resources plan simulation survey
Suggested Evidence
• Skills gap analysis 6. Estimated number of hospitals that will carry out survey
• Competency mapping o-site education
• Organizational development plan 7. Estimated number of workshops
8. Estimated number of scientific conference.
In carrying out staff duties, the average time needed to

carry out one activity is as follows:
Phone communication: 3 minutes
Correspondence: 40 minutes
Coordination with surveyor : 5 minutes
Coordination with speaker/source: 5 minutes
Prepare workshop logistic: 5 minutes
Surveyor/source ticket handling: 15 minutes for each survey
team/speaker
The time needed to carry out all work compared to the time
available is the time that a staff member has to complete the
job.
From the calculation above will be known the number of
staffing needed to complete the work. Furthermore, the
number of staffing needs will be compared with the number
of existing staff, the difference between the two is the
number of staff planned to be recruited.
In the Guideline on KARS governance CHAPTER V Job

Descriptions, Responsibilities and Authorities have
mentioned the accomplishment, job descriptions an
requirements of each position to which the staff planning will
refer to these provisions.
Evidence:
4.2.1. Staff Development Plan 2016-2018.
4.2.2. Skills gap analysis
4.2.3. Competency mapping
4.2.4. Guidelines on KARS Governance Chapter V Job
Description, Responsibilities and Authority
4.3 Recruitment and selection processes are transparent, Self - Rating 4 Technical Review
objective and equitable, comply with local legislation and
reflect clearly the professional profile and competencies
required for the type and level of activity of vacancy. Secretarial staff recruitment process refers to the Please review the text highlighted in green as the
organizing guidelines KARS Chapter VII as follows: . referenced chapter appears to be incorrect.
This could include: General requirements
Guidance
i. the requirements for all positions being detailed, usually 1. Maximum age when applying is 30 (thirty), unless to be
in a documented job description, and including specified otherwise by the Executive Chief of KARS;
• qualifications and competencies 2. Educational level of at least Diploma 3;
• tasks responsibilities 3. Physical and mentally healthy, proved by health
• performance measures certificate from hospital physician.
• reporting relationships and relationships with other Specific requirement: according to the requirement of
positions; vacant position.
ii. documented conditions of employment, e.g. work hours,
leave entitlements; Job vacancies are announced in printed or KARS websites
iii. all employees having a documented agreement or by including general and special requirements. The Head
contract of employment of HR Division monitors incoming applications and
• Job adverts conducts administrative screening in accordance with the
Suggested Evidence
requirements. Furthermore, candidates who pass the

• Examples of job descriptions, person specifications
administrative screening will conduct interviews and health
• Employment contract
examinations to be selected.
The next process is to make a contract between KARS
and employees to clarify the rights and obligations of both
parties.
Evidence:
4.1.3. Guidelines of KARS Governance Chapter VII
Recruitment
4.3.2 Recruitment SPO
4.3.3 SPO screening prospective new staff
4.3.4 Examples of PJ IT job vacancy
4.3.5 Example description of the position of IT IT
4.3.6. Examples of PJ IT contracts
4.4 An induction/orientation programme is provided to assist Self - Rating 4 Technical Review
Core new staff to understand their roles and responsibilities and
the current strategy, mission, goals and values.
Orientation is a period of introduction activities for every Please add the chapter highlighted in green.
new KARS staff. In order to take role and function
properly, they must correctly understand all of the things
The programme should include: related to KARS including the task and responsibility of
Guidance
their position.
i. new staff participating in a structured orientation The staff orientation program will be further explained in
programme which covers topics such as: the Guideline on KARS governance.
• the organisation’s programmes, services and key The orientation activity is conducted through:
personnel 1. Speech and face to face session
• fire, health and safety and accident reporting 2. Document reading
• relevant policies and procedures 3. Proctoring
• confidentiality 4. Work performance orientation
• quality improvement; 5. Evaluation on staff attitude during orientation through
ii. staff completion of all parts of the orientation programme feedback using the orientation checklist form/feedback
being documented; form
iii. the orientation programme being assessed for 6. Involved in any workshop and accreditation survey
effectiveness, e.g. by staff evaluation of the process and activities
testing of staff for understanding of the matters covered 7. Introduction to:
• Documented induction/orientation programme - KARS including the organization, hospital accreditation
Suggested Evidence
• Orientation webinars/trainings survey and workshop,

• New staff welcome kit - KARS officials and staff
• Orientation checklist with sign-off - Work policies and procedures
• Evidence of sign-offs of induction/orientation programme - Facility according to policies and procedures
in personnel file - Material for hospital accreditation survey activities
• Orientation calendar - Quality and risk management improvement
- Reporting in case of fire and evacuation procedure
- Staff safety and healthy program
- Principle of confidentiality
After orientation period, new staff will give feedback on the
orientation implementation
Furthermore, during one month, staff will follow the

proctoring and guidance period by the Head of Secretariat
in carrying out their tasks
Evidences:
4.1.3. Guidelines of KARS Governance (chapter ....)
4.4.2. SPO Staff Orientation
4.1.4. Staff Regulation Book
4.4.4. Examples of orientation reports (checklist)
4.4.5. Example feedback on implementing staff orientation
(checklist)
4.4.6. Examples of implementing proctoring
4.4.7. Example of staf file
4.5 There is a documented health and safety programme that is Self - Rating 4 Technical Review
Core systematically implemented, in accordance with the
local/regional regulations, which is reported, assessed and
reviewed periodically. To provide health protection and staff safety: Please add the hyperlink to the evidence highlighted in
• staff is covered for the cost of health services provided at green and specify the relevant page number/section.
health facilities that have been designated and determined
The health and safety programme could include: • every staff over 40 (forty) years old will be performed Please include details as to whether the health and
Guidance
medical check up every 2 (two) years and follow up the safety programme is assessed and reviewed.
i. health and safety assessments being undertaken; result if needed
ii. health and safety education programme for staff; • education on staff healthy and safety
iii. staff having access to first aid and rehabilitation after • provide first aid kid for accident during work
injury or illness; • provide comfortable, safe, functional and well maintained
iv. buildings and facilities that provide a comfortable, workspace
functional, secure and safe work environment; • information and practice on disaster management such
v. equipment and supplies that are sufficient and as fire and earthquake as well as evacuation order
appropriate for the tasks undertaken; • workload monitoring and management to reduce work-
vi. responses to internal emergencies being planned, related stress
communicated to all staff and practiced; • assessment of workplace is carried out to ensure that
vii. an active policy for minimising adverse impacts on the staff has ergonomic workspace, tool and equipment
environment;
viii. information from health and safety related risks fed back Evidences:
to staff; 4.5.1. Staff health and safety program (KARS Staff
ix. workloads are monitored and managed to limit work- Regulations book)
related stress; 4.5.2. Examples of staff health examination results
x. workplace assessments are undertaken to ensure staff 4.5.3. Report on the implementation of fire simulation and
have ergonomically safe workspaces, furniture and evacuation
equipment 4.5.4. Workload monitoring policy (Guidelines for
• Health and safety programme & policies necessary to Organizing KARS)
Evidence
Suggested
comply with regulations/legislation 4.5.5. Analysis of staff needs

• Results of health and safety assessments with evidence 4.5.6. Guidelines for disaster plan management
of action and review 4.5.7. First aid kit photos
• Health and safety past agendas/minutes 4.5.8. Photo of office staff and equipment
• Health and safety reports
• Attendance records of health and safety training /
webinars/ presentations to staff
4.6 Staff are supported through: Self - Rating Technical Review
a) work procedures to promote staff well-being,
b) mechanisms to identify and recognise best practices
and individual work contributions, a) Work procedure to improve staff healthy.
c) the resolution of workplace issues
This may include: All staff must maintain their health condition and eliminate Please review to ensure that c) the resolution of
Guidance
i. Procedures to promote well-being, e.g. smoking unhealthy habits such as smoking (inside or outside the workplace issues is addressed.
cessation, healthy lifestyle; office), consuming alcoholic beverages and other harmful
ii. staff recognition schemes through competitions; staff activities. Please cite the relevant chapters or pages in the
surveys, appraisal. It may also include how promotions b) The scheme of staff achievement is in the form of; hyperlinked evidence.
are managed and may or may not be financially driven; competition, staff survey, assessment. This can also
iii. staff being provided with appropriate supervision, include the improvement management steps and either is
support and advice; or not financially driven (Procedure of Staff Performance
iv. staff being enabled to make decisions within the defined Assessment)
scope of their role c) Staff is given appropriate supervision, support and
• Documented procedures advice
Suggested Evidence
d) Staff is allowed to make decision in the scope of their

• Documented policies
role that has been determined
• Staff recognition program
Evidence:
4.1.4. Staff Regulation Book Office Rules and other

regulations
4.6.1 Standard Operating Procedure: Staff Performance

Assessment. No. Document 04
4.1.4. Staff Regulation Book : Staff Supervision
4.1.4. Staff Regulation Book Staff authority

4.7 All staff upon completion of a satisfactory induction/ Self - Rating 4 Technical Review
orientation sign a confidentiality statement and agree to
abide by rules of the external evaluation body.
All staff completing the recruitment and orientation process Please cite the relevant point or page number in the
properly will sign a statement stating to maintain the evidence highlighted in green.
confidentiality and agree to comply with all regulations
The signed statement should be kept in the individual staff from external evaluation body. Please translate the evidence highlighted in yellow – is
Guidance
member’s personnel file this the confidentiality statement?

Evidence:
4.1.4. Staff Regulation Book Chapter Rules and Discipline
4.1.5 Oath of KARS’ staff
• Confidentiality statement
Evidence
Suggested
4.8 Temporary or locum staff, including advisors, have specific Self - Rating 4 Technical Review
admittance processes, induction and training programmes.
NA (Not available Temporary or locum staff, including Please review and explain how temporary or locum staff
advisors) would be inducted to their role.
The admittance process should reflect the role being
Guidance
undertaken and should include as a minimum:

i. health and safety,
ii. policies and procedures,
iii. confidentiality
• Admittance processes include tailored induction and

Evidence
Suggested
training programmes
• Orientation procedures and checklist
4.9 There is a programme for staff training, which includes; Self - Rating 4 Technical Review
internal continuous education and development to ensure a
competent workforce and considers individual professional
and career opportunities. KARS makes a KARS HR development program every year Please provide the 2018 SADM KARS development
(2016,2017 and 2018)The program consists of 2 program (in English).
components, namely.1. Increasing the number of staff
Staff training could include: based on the calculation of workload and the performance
Guidance
capabilities of each staff.2. Increased staff capacity in

i. in-house training provided on service delivery and carrying out tasks carried out through training.The training
workplace issues and developments; carried out consisted of three forms, namely:a) Inhouse
ii. staff given opportunities to attend off-site workshops, training to train things with regard to daily task
seminars and conferences; implementation which is usually related to IT usage, there
iii. staff training attendance monitored and documented; are 4 IT KARS programs namely SIKARS, SISMADAK,
iv. staff supported to undertake further education and SIRSAK and ReDOWSKob) Training in the form of
research as relevant to the work of the external attending workshops related to accreditation and patient
evaluation organisation; safety, for example effective communication workshops,
v. observing surveys PMKP workshops etc.c) Training for specific skills carried
• Staff training programmes out by third parties outside KARS, for example computer
Suggested Evidence
• Attendance records graphics training, training in making mobile applications.

• Organisational development plan d) Training to understand the survey process in the hospital,
• Leadership development the staff is included in the simulation survey process at the
• Professional development policy hospital.
• Observational survey policy and guidelines Evidence:
1. KARS HR development program in 2016
2. The 2017 SDSM KARS development program
3. The 2018 SADM KARS development program
4. Staff training program
5. List of staff participating in training
6. Staff training certificate
4.12 The evaluation of the human resources strategy and plans Self - Rating 4 Technical Review
are carried out on a regular basis and action is taken to
address identified issues and make improvements.
HR Strategy Evaluation is carried out in accordance with Please review this and provide examples of
the planning that has been made. improvements which have been made based on this
2. To see the staff's competence in working in the KARS evaluation.
The review could include: environment a Staff Satisfaction Survey is conducted once
Guidance
a year
i. the review of gaps or problems with service provision at 3. An emerging gap from the evaluation of the HR strategic
regular intervals to identify and address the cause; plan and from the results of Staff satisfaction is carried out
ii. assessment of staff satisfaction on a regular basis, e.g. Follow-up.
annually, and action being taken on issues identified;
iii. the use of performance measurements and indicators Evidence:
such as vacancies, staff satisfaction, staff turnover, • HR Evaluation Evaluation
absenteeism, staff injuries or work related conditions • Staff Satisfaction Questionnaire
and the results of exit interviews on retirement or • Results of the Staff Satisfaction Survey
resignation; • Recapitulation of results of Staff satisfaction surveys
iv. the results being shared with staff who are encouraged
to contribute to the solution of problems and
improvements
• Evidence of review
Evidence
Suggested
• Evidence of actions taken

• Evidence of indicator reporting
• Evidence of staff satisfaction survey
• Evidence of de-briefing and action plan for staff
satisfaction results
• Exit interview surveys
Standard 5: Information Management Self-assessment evidence Technical Review
5.2 The information management plan is reviewed and Self - Rating 4 Technical Review
updated on a regular basis.
KARS’ Information System Management Yearly Planning of Please clarify why the text is in red or change to black. If
2015,2016, 2017,and 2018 as well as the Medium-Term these documents are only available onsite, please ensure
The frequency of the review will depend on the criticality Plan on Information System Management of 2016-2020 are that this is clear from the document name.
Guidance
of the plan contents to the delivery of the operations. reviewed and or revised at least once a year, or as needed.
The frequency has been stated in KARS’s Document Control
Policy.
• Reports from review of information management plan Evidence:

Evidence
Suggested
• Updated plans 5.2.1 Meeting minutes of 2015, 2016 and 2017 IT plans.
5.2.2 Updated Plans as in Standard 5.1.
5.2.3 KARS’s Document Control Policy
5.3 Systems are in place to support information management Self - Rating 4 Technical Review
Core to ensure the following properties:
a) accuracy
b) integrity and reliability Please correct the font to black (throughout the SAT).
c) timeliness (responsiveness) KARS has a process for the management of the
d) security and confidentiality information system.
Systems should include:
Guidance
i. on-going maintenance; A Planning and Development document for 2016-2020 has

been developed.
ii. standard operating system including password setting
The IT system strategic plan contains an IT system
development plan for 2016-2020, Policies and procedures
• Information management plan
Suggested Evidence
are also made to operate the IT system

• Policies and procedures
KARS build information technology management systems
which include document management system as an archival
management application that ensures the validity, accuracy,
speed and security of data searches.
Validity is indicated by the presence, of the authority division

for authentication (login permissions), authorization (rights
access for data retrieval), accounting (transaction log).
Data is stored centrally on a hosted server at the provider,

thus ensuring data accessibility is consistently integrated.
And can be accessed by interested parties in real time.The
application can only be accessed by the user, which is
divided into:
1. Management,, to conduct monitoring and evaluation, and

to approve the results of graduation
2. Staff, based on each PJ's assignment
3.Surveyor, in accordance with the responsibilities and
assignments as surveyors
4. The hospital, to upload self-assessment and see the
results of the assessment and recommendations as well as
the schedule of activities
The data security system is protected using a password, at

least 8 digits. Every 3 months, the Surveillance is required to
change the password. If you forget the password, the user
can research the password by clicking Forgot Password on
the SIKARS application login page.
Every user who logs in to the application will be recorded in

the log file to be used as an access history.
To anticipate data loss due to damage to the server, data
backup is performed every day. Then, every week the data
is backed up to an external hard disk to be stored in a
safety box.
Every week, remote colocation server checks are carried

out. Monitor the availability of storage capacity and the use
of server memory, as well as the use of badwidth capacity.
Evidence:
5.3.1 Information System Management Planning and
Development of 2017
5.3.2 Information System Management Planning and
Development of 2018
5.3.3 KARS IT Plan (or Medium-Term Plan on Information
System Management of 2016-2020
5.3.4 KARS IT policy and procedure
5.5 Information is collected as described in the information Self - Rating 4 Technical Review
management plan and according to professional and
statutory requirements.
In the IT system policies and procedures have been set Please provide the evidence to support this rating.
about the terms of the requirements for the use of the IT
This should include: system, the following are the procedures for access rights
Guidance
i. copyright requirements being followed; for someone who wants to enter the IT KARS system
ii. identified data only being used with the express Certain data can only be used by personnel who behave
permission of those from whom it is collected and all and get permission. All data is guaranteed confidentiality
other data being made anonymous to preserve
confidentiality Information collected and stored on KARS computers is
only related to the KARS business process. Personal
documents are not permitted to be stored on staff
• Information management plan computers or on servers.
Suggested Evidence
Every document issued for external needs, must be

approved by the KARS leadership in writing or using a
memo.
Every document in any form will be kept confidential, and

its allotment is only for the benefit of the organization.
5.7 Data are available and accessible to those, who need it Self - Rating 4 Technical Review
and are used to inform decision making.
Data base is available for staff to make decisions such as Please expand on this finding and provide evidence to
assigning surveys and assigning guidance to hospitals, support this rating.
Data is also available for leaders to make hospital
Guidance
graduation decisions
• Information management plan

Evidence
Suggested
5.8 Critical business data/information, applications, computer Self - Rating 4 Technical Review
installations and networks are audited on a defined
schedule to enable identification of key risks, determine
any corrective and/or preventative actions required. The IT system strategic plan also contains routine checks Please review and provide evidence to support this
and corrective actions in the event that things do not match rating.
This could include: KARS have a series of evaluation measures provided for
Guidance
i. an audit plan for information management system; coverage and support in the use of the IT system, audit of
ii. example of recent audits reports; data integrity and the management and proof of backup
iii. examples of corrective and/or preventative action and restore processes of IT management and the
done against audit reports; development of educational programs as a result of
iv. information security incidents being identified, feedback from surveyors from a number of forums.
responded to, and followed up
There is a flowchart in place identifying how the reporting
• Audit plan mechanism is managed.
Evidence
Suggested
• Audit results, reports and corrective actions
5.9 Relevant staff are trained in how to run operational Self - Rating 4 Technical Review
systems correctly, are aware of information management
rules and how to develop and apply information security
controls. Training plan for IT staffKARS has also made training plans Please review as it is unclear how the evidence which
for IT staff has been provided supports that staff are trained on IT
systems.
Training could include: KARS has planned a training to create a mobile application
Guidance
in order to apply ReDOWSKo to surveyors

i. information systems training plan;
ii. policies on individual information security A training plan is also made for all surveyors to be able to
responsibilities; operate the ReDOWSKo application
iii. a training programme;
iv. training records
• Training plan A training plan is also made for all surveyor with Webinar
Suggested Evidence
• Staff records
Evidence:
5.9.1 Planning and Development of IT system management
2016 – 2018
5.9.2 Library Print screen in KARS WEB
5.9.3 Examples of surveyor mailing list documents
5.10 All information and educational resources relating to web Self - Rating 4 Technical Review
and or electronic based accreditation/certification tools
are produced to defined standards of use and
consistency. Contents are accurate, up to date, support KARS Web contains information about training for Please review this finding to ensure that you have also
quality improvement practice; and meet client surveyors addressed information and educational resources for
requirements. KARS also provides e-learning facilities for surveyors client organisations. Is client feedback collected and used
This could include: In addition there is also training through the Web Seminar to make improvements to resource materials? Is there a
Guidance
i. resource materials being prepared by people with for SISMADAK style guide? Please review the ISQua guidance to ensure
experience and credibility in the subject area; The training material can be downloaded by the surveyor that this criterion is fully addressed (some of the text from
ii. the materials being able to be downloaded and/or from the specified address 5.11 may be applicable here).
printed;
iii. client requirements being determined from The training certificate was also downloaded by a surveyor
mechanisms such as feedback, surveys, complaints from SIKARS itself
and queries;
iv. client requirements being considered when the
website, newsletters and education and other
information resources are being designed;
v. a style guide covering such items as colours, font and
the use of names and logos to encourage consistency
• Examples of information and education materials
Evidence
Suggested
• Documented style guide

• Evidence of client feedback
5.11 All written or electronic recorded material is reviewed and Self - Rating 4 Technical Review
edited before being published to ensure information
reliability and copyright. Contents are reviewed
periodically to ensure they are current. KARS have of a consistent approach to the production of Please review as it is unclear how the evidence which
information and educational materials. has been provided supports this finding. Please clarify
who is responsible for reviewing and editing information
This could include: KARS has developed a Manuscript Guidelines document to before it is published.
Guidance
provide consistency around the conformity of documents.

i. documented procedure for information and
educational material review; Publications are designed and developed internally as a
ii. resource materials being reviewed before publication, result of feedback from client
issue, sale or endorsements ensure accuracy, organisations/auditors/stakeholders and staff.
currency, independence and no breach of copyright;
iii. marketing materials; KARS have a processes to ensure accuracy of the
iv. web pages content.The review of these documents are managed
through the document management system (DMS).
The use of version control may be used to manage
published materials. The DMS is in an electronic format and is managed by
• Evidence of review password control. Each document is version controlled and
Evidence
Suggested
• Documented procedure automatically at a two (2) year period the document cannot
• Marketing materials be accessed as the policy of KARS states that a document
required viewing at two (2) year period.
Evidence:
5.11.1 KARS Stakeholders Questionnaire 2014

5.11.2 Print preview of KARS Survey on web
5.11.3 FTP back up result reports

5.11.4 Web visitor graphic
Standard 6: Surveyor Management Self-assessment evidence Technical Review
6.1 There is a plan to ensure that there are the number and Self - Rating 4 Technical Review
Core skill mix of surveyors to deliver quality survey services.
KARS plans the quinquennial need of surveyors and Please translate the evidence highlighted in yellow into
conducts annual analysis on surveyors’ needs to find out English.
The plan may be separate to, or included in, the annual their needs.
operating plan. It may include: Please review the text in green and remove or update.
i. separate surveyors planning documents linked to the Plan of the need of surveyors includes the number, type
planned programme of work or surveyor planning and qualification of surveyors.
Guidance
evident in the operational plan and reflected in the

budget; The purpose to conduct the analysis on surveyor’s needs it
ii. the inclusion in the planning of items such as overall
to predict their needs which will be the basis to develop
surveyor numbers, numbers of paid/employed or
volunteer surveyors, the range of health professional surveyor training program in the next year. The surveyor’s
backgrounds, cultural appropriateness, geographic need analysis is conducted in the end of each year and
location and skill mix based on:
• Surveyor management plan - the number of executed and delayed survey in the current
year
- prediction of the increased number of hospital in the next
year
- the number of expired accreditation certificate in the next
year
- target number of accredited hospital requested by the
Ministry of Health
To maintain the quality of surveyors, KARS organizes

Suggested Evidence
refreshing or upgrading of old surveyors once a year.

Upgrading is organized only if there is establishment of a
new accreditation standard.
Based on the need of training, refreshing or upgrading of

surveyors, KARS creates training and education budget
which is attached in the KARS Annual Plan and Budget.
Training, refreshing or upgrading of surveyor participants

will not be charged for training fee, however, the transport
and accommodation cost should be borne by participants.
The organizing cost for training of surveyor is the

responsibility of KARS. Training budget plan which has
been created by the Executive Treasurer of KARS includes

meal for trainees, trainers and organizing committee,
honorarium of trainers and organizing committee as well as
the material kit.
Evidence:
6.1_Surveyor Development Plan, 2016-2020
6.1.1_ Annual Plan and Budget 2016
6.1.2_Anual Plan and Budget 2017
6.1.3_Anual Plan and Budget 2018
6.1.4_
6.2 Surveyors are selected and appointed through a rigorous Self - Rating 4 Technical Review
Core and transparent process in accordance with competency
based selection criteria and the programme’s
requirements. Surveyors recruitment is started by conducting selection Please note the evidence in green has tracked changes
according to the requirements of surveyor stated in KARS on it – please review.
Regulation on Surveyor Management and Guideline for
The selection process could include competencies such Please translate the evidence highlighted in yellow into
Surveyor Training Programme.
as: English.
Surveyors selection including evaluation of administrative
i. personal attributes, including the ability to completeness and evaluation of surveyors’ qualifications. Please clarify why the text is in red or change to black.
Guidance
communicate effectively;
ii. professional qualifications and experience;
iii. contemporary knowledge of the health sector; and Evaluation of administrative completeness for surveyor
iv. substantial skills in at least one area relevant to the candidate including the completeness of the application
survey areas form, leadership recommendation, hospital accreditation
certificate and curriculum vitae.
• Surveyor selection procedure

Evaluation of qualification includes general qualification,
• Surveyor competencies
personal attribute, qualification specification according to
the type of surveyor which includes education background
Suggested Evidence
and work experience. KARS has 4 (four) types of surveyors

namely management surveyor, medical surveyor, nursing
surveyor and specific surveyor.
KARS has divided survey areas according to the

competence of the surveyors. Specific surveyor is assigned
in focused survey and survey in Type A and B hospitals
with numerous sub-specialty service.
In conducting selection, KARS also evaluates the

contemporary knowledge on health service including the
understanding of the rules and regulation related to hospital
and health.
Surveyors selection procedure is regulated in the Guideline

for Surveyor Training and Surveyor Selection Procedure
Evidence:
6.2_ KARS Regulation-on-Surveyor-Management- 2017
6.2.1_Guideline-for-Surveyor-Training Program
6.2.2_Surveyor Selection Procedure
6.2.2a_Form administration-surveyor selection
6.2.2b_Form qualification surveyor selection
6.2.3_Personal Attributes of Guideline for surveyor training
6.2.3a_Requirement qualification for management
surveyor
6.2.3b_ Requirement qualification medical surveyor
6.2.3c_ Requirement nursing surveyor
6.2.3d_General qualification of surveyor
6.2.4_ Duty Area of qualification hospital Accreditation
Surveyors
6.2.5_Administrative Completeness Evaluation of Surveyor
Candidate form
6.2.6_Recapitulation of Prospective Surveyor form
6.3 The responsibilities and expectations of surveyors are Self - Rating 4 Technical Review
clearly defined and surveyors sign a contract or
agreement to signify their acceptance of these.
Participants of surveyors training who have passed the As specified in the required document checklist, please
post-test on 1st phase (face to face training) is allowed to provide as evidence a sample surveyor contract /
Surveyor contracts or agreements could include: agreement.
continue to 2nd phase (internship training) and to be
i. responsibilities and expectations; appointed by the Executive Chief of KARS after
ii. any responsibility for tax and personal accident
successfully passing the internship.
insurance;
Guidance
iii. period of appointment;

iv. required availability; After being appointed, surveyors must sign:
v. support for the external evaluation organisation’s • Contract Management Between KARS and Surveyors
objectives;
which includes:
vi. commitment to comply with the external evaluation
organisation’s rules; - rights and obligations;
vii. maintenance of confidentiality and independence; and
viii. declaration of known and potential conflicts of interest
• Surveyor contracts/agreements - responsibilities to settle income tax and personal

accident insurance;
- time period of the contract
- required availability
- commitment to comply with the rule
- to give support in the evaluation of organization’s
objectives
- to maintain the confidentiality and liberty in
conducting survey and to notify any potential of
conflict of interest
• Code of Ethics of KARS Surveyor during survey
• Oath of KARS Surveyor
After the requirements are fulfilled, the trainee will receive a

certificate of competency which is valid for 5 (five) years
Suggested Evidence
before being appointed as KARS Surveyor through a

Decree by Executive Chair of KARS which is valid of 2
(two) years. There will be official inauguration to signify that
surveyors have been assigned.
Conflict of interest mentioned in point viii. is not only

included in the contract management but also in the
statement letter of surveyor which must be signed by each
surveyor at the time of their survey assignation. Each
surveyor is also obliged to sign the conflict of interest form
and Code of Ethics of KARS Surveyor in which conflict of
interest is included.
Evidence:
6.2.1_ Guideline for Surveyor Training Programme
6.3_Sample of the signed Contract Management Between
KARS and Surveyor
6.3.1_Sample of the signed Oath of Surveyor
6.3.2_Sample of the signed Code of Ethics of KARS
Surveyor
6.3.3_Sample of Conflict of Interest Statement Letter
6.8 The performance and on-going competence of surveyors Self - Rating 4 Technical Review
Core is evaluated regularly.
KARS commits to provide qualified surveyors, therefore Please consider translating the text highlighted in yellow
periodical competence evaluation is required to be into English.
continuously conducted through:
Performance and competence information could be 1. Post-test for surveyors in every refreshing or upgrading
gathered through: organized every year. Surveyor failing in post-test must
i. evaluation feedback being provided after each survey repeat the post-test and KARS will not assign surveyors
by those involved in the survey, e.g. clients, members who haven’t passed the post-test.
of the survey team, and other customers such as 2. Performance evaluation is carried out after accreditation
client managers and report editors;
Guidance
survey has been completed by the Head of Surveying

ii. evaluation results being shared with surveyors and
used to identify training needs and assist with Team, among surveyors and the surveyed hospital.
performance improvement; Hospital is obliged to fill out the questionnaire form on
iii. on-going competence of surveyors being reviewed surveyor performance once the accreditation survey has
over a period of time, e.g. annually, by reviewing been completed.
results of evaluations, participation in training, 3. Evaluation on survey report created by surveyor is
professional development and any change in role to conducted by counselor (senior surveyor appointed by
determine whether appointment should continue or
Executive Chief of KARS) after the name of hospital and
new roles can be assigned
• Tools used for evaluation surveyor in the report have been encrypted. Counselor will
• Evidence of competence review score survey report based on the evaluation result. The
selection of counselor is carried out by KARS Information
System.
If discrepancy is found in the assessment results between

the counselor and the surveyor which may affect the
accreditation status (for example: the assessment result of
Suggested Evidence
surveyor states that the accreditation status of the hospital

is Excellent and after being examined by the counselor, the
accreditation status is to be Major) the assessing board
which consists of anchors will evaluate the work of surveyor
and counselor and determine the correct accreditation
status.
The counselor and the assessing board can carry out

report evaluation, because each assessment element of
the accreditation standard is complemented with facts and
analysis. Based on that, the counselor and the assessing
board can assess whether the score and recommendations
given by the surveyor have been appropriate or not.
In addition, assessment can also be done by looking at the

scores with links between assessment elements in the
same or other chapters.
Based on the assessment result of counselor and

assessing board (if required), if there is any problem
regarding surveyor or counselor, KARS will summon and
schedule the respective person to revise the survey report
and to attend the Continuing Professional Development
(CPD)
Evidence :
6.8_Post-test result
6.8.1_Form of Evaluation on surveyor by the Head of
Surveying Team
6.8.2_Evaluation result on surveyor by the Head of
Surveying Team
6.8.3 _ Form of Evaluation among surveyor
6.8.4_Evaluation result among surveyors
6.8.5_Form of Evaluation on surveyor by hospital
6.8.6 _ Evaluation result on surveyor by the hospital
6.8.7_Evidence of CPD implementation
6.9 Information on the relevant competencies, experience Self - Rating 4 Technical Review
and performance of surveyors is maintained in an
individual record and is used to allocate roles.
Surveyor records include: Please consider translating the text highlighted in yellow
into English.
1. Information on each surveyor including the qualification,
training, education, professional status, affiliation,
Surveyor records could include: position, address, participation in training and
i. information in each individual record covering development which are available in KARS Information
qualifications, training, experience, professional System. Each surveyor has an account in KARS
status, affiliation, position, address, participation in
Guidance
Information System and is able to log in and input

training and development and performance evaluation
results; additional data on their own. After surveyors have
ii. surveyors being allocated roles according to their completed the training and workshop organized by KARS,
defined competencies, professional roles and they are obliged to add those information to their
experience data/profile by uploading the certificate.]
• Surveyor records 2. Performance evaluation result from Head of Surveying

• Feedback to surveyors Team, hospitals and among surveyors are submitted to
survei@kars.or.id
3. Surveyor evaluation is conducted through post-test during
training, internship mentor during internship and post-test
using KARS Information System during refreshing training
to which the result can be instantly provided afterwards
4. KARS Surveyor consists of management surveyor,
medical surveyor and nursing surveyor. The assignation
of surveyor is according to their experiences, required
competence and professional role. Head of Surveying
Team position is only assigned to surveyor who has
Suggested Evidence
conducted at least 3 (three) accreditation surveys. The

selection of surveyors names in accreditation survey
assignation is conducted by KARS Information System.
5. Surveyor must create survey report after accreditation
survey has been completed by keep maintaining its
confidentiality.
6. Surveyor will be given feedback from the evaluation result
by counselor in the form of recommendations through
KARS Information System after submitting the survey
report.
Evidence:
6.4.4_Sample of post-test result on face to face training
6.8.2_Evaluation result on surveyor by the Head of
Surveying Team
6.8.4_Evaluation result among surveyors
6.8.6 _ Evaluation result on surveyor by the hospital
6.9._Evaluation result on survey report drafting
6.10 The effectiveness of the surveyor selection, training and Self - Rating 4 Technical Review
development programme is evaluated and results are
used to make improvements to the management and
development of surveyors. Evaluation of 1st Phase (face to face) Please review and consider providing examples of the
Evaluation of trainees improvements which have been made to the
management and development of surveyors.
Evaluation may include measures of the effectiveness of: a. Evaluation of competency test Please consider translating the text highlighted in yellow
i. surveyor selection; The evaluation is carried out on the last day of training into English.
ii. performance management; through e-learning competency test application, with the
iii. training and development;
Guidance
passing grade of 80. If fail, the test can be repeated up to 5

iv. competence assessment times for 1 month.
b. b. Evaluation from trainees (feedback)
The purpose of this evaluation is to request inputs from
trainees on the training implementation. Trainees are given
questionnaires to be filled and returned to the organizing
committee on the last day of training.
• Measures to evaluate effectiveness of the surveyor
Feedback from trainees include:
training programme
• Examples of how evaluation has been used to make Training method
improvements - If the training information on the participation is easily
accessed
- If the course is in accordance with their expectations
- If the time is sufficient for delivering the theory
- If the time is sufficient for practicing
Trainer
- Trainer performance in time management
- Trainer performance in ability to provide satisfying
answers for every question
Suggested Evidence
- Trainer performance in mastering the presented materials

Training materials
- If the provided materials are useful and able to increase
knowledge
- If the materials are provided in sufficient medias
(documents, USB, etc.)
Facility
- If the provided facility is adequate for teaching and
learning
- If the other facility is adequate for supporting the training
(classrooms, meals, etc.)
Evaluation of trainers
The purpose of this evaluation is to request inputs
(feedback) from the trainers on the training implementation.
Feedback from trainers include:
• Training facility: if the room, audio-visual, sound system,
meal are adequate
• Training schedule: if the time for training is sufficient and

the topics discussions are in accordance with the needs
• Organizing committee: if the organizing committee are
communicative and skilful
• Trainees: if the qualification of trainees are in accordance
with the needs and if trainees are enthusiastic during
training
Evaluation of organizing committee

After the training has been completed, the organizing
committee conduct evaluation which includes:
• Budget: if the budget is enough or still lacking
• Hotel as the training venue
• Facility at the training venue
• Meal during training
Evaluation of 2nd Phase (Internship)

Evaluation of trainees and trainers
• Appraisal of trainees performance by trainers using the

Form 3 attached in the Guideline for Surveyor Training
Programme
• Appraisal of trainers performance by trainees using the
Appendix 7 in the Guideline for Surveyor Training
Programme
Evaluation of training program

Evaluation is conducted by Education and Training Division
after training has been completed. This evaluation is
necessary to improve the surveyor training program, based
on feedback from trainees, trainers and the achievement of
the target of training program.
Quality indicator of training

In order to improve the quality of training implementation,
these following indicators have been established to
measure the quality, which are:
1. Target of 80% for trainees who pass the selection
2. Target of 90% for the training attendance
3. Target of 80% for the trainee satisfaction

4. Target of 80% for trainees who pass the 1st phase
5. Target of 5% for trainees who fail in competency test
6. Target of 80% for trainees who attend internship after
completing 6 months of training
Evidence
6.10_ Evaluation result of competency test
6.10.1_ Evaluation result of trainees
6.10.2_ Evaluation result of trainers
6.10.3_ Evaluation result of organizing committee
6.10.4_ Evaluation result of internship trainees
6.10.4_ Evaluation result of training program
Standard 7: Survey and Client Management Self-assessment evidence Technical Review
7.0 The external evaluation programmes are consistent Overall rating 4 Overall Rating
with the organisational objectives, facilitate objective
and consistent decision-making and meet the needs
of participating organisations and other Please clarify what is meant by the text highlighted in
stakeholders. The KARS program is consistent with the goals of the green.
organization and has shown a continuous improvement of
the program. The decision to update the standard to the
new model is KARS innovation in improving quality
standards for client organizations. Organizations have
reached a good level of maturity in business survey
planning. The new management information system gives
KARS the potential to reach new heights. The opportunity
to talk with a number of clients is a high level of satisfaction
with the organization. Surveyor workforce is also very
mobilized and very clear and very strong to be part of this
organization. The survey team strongly believes that you
have access to information, globally and specifically.
However, the schedule of political debate surveys and
cultural sensitivity of the decision.
In the implementation of the survey, KARS in 2017 until

December 31 uses accreditation standards for the 2012
version, and on January 1st, 2018 uses 1st Edition of
National Standards of Hospital Accreditation (SNARS 1st
Edition).
What we have been done to do :

• Hospital Accreditation is based on regulation as it is writen
in Republic Indonesia law no 44 of 2009 concerning
hospital,
• Health Minister Regulation No. 428 of 2012 concerning
Accreditation in Indonesia Commission on Accreditation of
Hospital as a national accreditating body,
• Regulation of the Minister of Health No 12 of 2012
concerning accreditation of hospitals,
• Regulation of the Minister of Health No. 1691 of 2011
concerning hospitals and
• Ministry of Health No. 56/2014 concerning Classification
and Hospital Licenses and Standard House Accreditation
for Hospitals.
The provisions of hospital accreditation have been
regulated in the Minister of Health Regulation No. 34 of
2017 on Hospital Accreditation which serve as the
guideline for hospitals to pursue their accreditation as
an effort of quality and patient safety improvement
Document support :
• Accreditation Standard 2012 version

• 1st Edition of National Standards of Hospital
Accreditation
• Third edition Hospital Activity Guide
• SOP for survey procedures
• Survey Instruments
• Accreditation Documents
• Regulations and guidelines for surveyors.
All decisions will be made and carried out properly by
members, the management team and surveyors will follow
the SOP on the minutes of meetings and conversations.
The survey team chair will discuss this process in the
documentation. The survey results will be coordinated to
confirm consistency in the results and correct information
before being shown to KARS members for voting.
Policy: validation and evaluation of accreditation status will
be a quality control method.
7.1 The accreditation, certification and/or external evaluation Self - Rating 4 Technical Review
programmes provided by the organisation are developed
in response to a defined needs identification process.
KARS develops an accreditation program based on the Please include the hyperlink to the current strategic plan.
needs identification process. In the development also
The development of an accreditation, certification or includes the culture and expectations of the relevant Please clarify why the text is in red or change to black.
Guidance
other external evaluation programme could include government, paying attention to the needs of the
taking account of: community or other key interests. National priority areas
i. the culture and relevant expectations of government; that focus on security and quality in the system of providing
ii. the community and other key stakeholders; medical and nursing care, in this case based on the World
iii. any national or international health priority areas Patient Safety Alliance of WHO. The program can be
focused on safety and quality in health care delivery accomplished and financially feasible, and this process is
systems, e.g. WHO’s Global Patient Safety Alliance; well documented. Recommendations for this identification
iv. whether programmes can be achieved and whether KARS states that this Organization launched a new
they are financially feasible accreditation program in 2017, namely the 1st Edition of
National Standards of Hospital Accreditation. This program
is based on JCI standards and local requirements. KARS
This should be a documented process. has introduced a tracking methodology to validate
organizational compliance with standards. An improved
The governing body delegates responsibility for the information system will be implemented to support a better
development of programmes and standards, see criterion accreditation process. This new program is in line with the
1.10. expectations of the government and other stakeholders
• Development plan such as the Indonesian patient safety institution. Strong
Evidence
Suggested
• Strategic plan commitment from KARS to maintain the requirements to

• Operational plan support the country through national programs which
• Minutes of meetings include reducing maternal and infant mortality, reducing TB
morbidity and HIV AIDS and controlling antimicrobial
resistance and quality geriatric services that must be

carried out properly by the hospital.
What have we done
To improve the quality of affordable health services, this is
the main reason why KARS exists and continues to
develop standards. Supporting documents are:
Law: Law No. 36 of 2009 concerning health, paragraph
54.1, where health must focus on quality, security, quality,
justice and without discrimination.
Law: Law No. 44 of 2009 concerning hospitals, paragraph
40: Hospitals must be accredited every three years.
Accreditation standards, vision, mission, and all documents
developed by KARS, are supported by the health ministry
to agree that standards meet health standard requirements
for the people of Indonesia.
Regulation: Health Minister Regulation No. 34 of 2017
concerning Hospital Accreditation, which is a guide for
hospitals in carrying out their accreditation as an effort to
improve patient quality and safety. In 2016, KARS formed
a team consisting of health ministries, health professional
organizations, hospital associations and several hospital
directors to evaluate the hospital accreditation process in
Indonesia that had been carried out needing development
and also to significantly improve hospital quality.
The team analyzed hospital needs in improving service
quality by reviewing the 2012 version accreditation
standard, reviewing accreditation standards at the
international level. Based on the review and analysis of the
need to improve the quality of the hospital, the 5th edition
of the JCI Standard is used as a hospital accreditation
standard in Indonesia permitted by JCI. Opportunities for
improvement The organization develops a comprehensive,
structured and documented strategy for assessing the
needs of stakeholders and client organizations.
What we have done to improve the quality of affordable
health services, this is the main reason why KARS raises
its standards.
The effectiveness of organizational governance is
evaluated using indicators and other measures of
performance and individual and collective performance
evaluation of the governing body.
Trials carried out on 10 hospitals, consisting of hospitals
class A to class D and special hospitals
Evidence:
• 7.1.1 1st Edition of National Standards of Hospital

Accreditation
• 7.1.2 Regulation of the Minister of Health No. 34 of 2017
concerning Hospital Accreditation
• 7.1.3 report on the results of the Work Program meeting
• 1.1.viii 2014-2016 Strategic Plan
• 1.1.xi 2016-2020 Strategic Plan
• 2.5.ii 2016 and 2017 Business Plans, 2018
• 1.1.x.c KARS Board of Directors Meeting, ..............
• 1.1.x.a Minutes of KARS Directors Meeting, .................
• 3.6.iii Minutes of meeting on procedural changes .......
• 7.1.4 Program using additional instruments
7.2 Applicants for accreditation or certification are assessed Self - Rating 4 Technical Review
for suitability before agreeing to enter into the
programme.
Please explain what the process is after the application is
Procedure for submitting an accreditation survey submitted? Is there assigned staff to assess the
1.The hospital submits an application for an accreditation application forms for suitability?
Where programmes are voluntary, applicants should be survey sent via email to survei@kars.or.id or online via the
Guidance
assessed for suitability through an application process to website: www.kars.or.id no later than 1 (one) month before Please consider providing the evidence highlighted in
ensure that they fully understand what is expected and the date of implementation submitted by the hospital. yellow as evidence.
also that there are suitable standards available to be 2. The survey application letter is accompanied by the
surveyed against. This may be carried out through a following: See above comment re use of red font.
screening process, questionnaire or formal application a. Survey application that has been filled in and signed by
review and includes applicants providing details of their the Director / Head of the hospital.
organisation and the scope of the proposed survey on an b. The final self assessment results, with a minimum score
application form. of 80%.
c. Valid hospital operational permits.
• Process for assessment for suitability d. Doctor's certificate or dentist from the Director / Head of
Suggested Evidence
• Application form or equivalent for entry into the the hospital.

external evaluation programme e. Director's statement / head of hospital containing:
• Do not mind giving access to medical records to surveior.
• Not leaving the hospital during the survey activity.
• All medical personnel already have Registration certificate
and Practice license.
f. List of medical personnel who are equipped with the
Registration Certificate (STR) and Practice License (SIP)
and the validity period.
g. License wastewater management permit (IPLC).
h. License Toxic and dangerous ingredients (B-3) waste
management license or cooperation agreement with a third
party that has a valid B-3 waste processing permit and
transporter.
Evidence:
7.2.1 Process for problems and suitability
7.2.2 Application form for accreditation
7.3 Actual and potential clients are provided with full Self - Rating 4 Technical Review
Core information on the external evaluation programme.
Clients formally agree to comply with the requirements of
the programme and to abide by the defined As specified in the requirement document checklist,
responsibilities of an accredited or certified organisation. Application for an accreditation survey is accepted, please provide as evidence an example of the client
then: agreement form/contract (in English).
Information to clients could include: • KARS schedules an accreditation survey and notifies the
Guidance
survey schedule to the hospital with a copy to the Provincial Please also address how actual and potential clients are
i. information on and promotion of programmes and
Health Office. provided with full information on the external evaluation
services making the programme accessible to • The hospital enters into a contract of commitment with the programme.
organisations within its scope; Hospital Accreditation Commission which, among others,
ii. applicants providing details of their organisation and
contains:
the scope of the survey on an official application form;
1. Hospital readiness is continuously evaluated starting from
iii. applicants signing an agreement to comply with the
the submitted survey application, when the accreditation
requirements of the programme, supply any survey is carried out and during the 3-year accreditation
information needed and make all necessary cycle. This post-accreditation evaluation can be done at any
arrangements for the survey, including provision for
time with or without prior notice, which is carried out by
examining documentation and access to all areas,
KARS officials or senior surveior who are assigned to use
records and personnel; IDs from KARS. If the hospital refuses to be evaluated it can
iv. applicants acknowledging that any survey only risk the accreditation certificate being withdrawn by KARS.
includes information provided or made available by
2. Hospital readiness is carried out on time or according to
them;
the schedule twice as much as one year after the survey and
v. applicants accepting publication of/public access to two years after the survey. If the Hospital refuses to do a
survey findings and awards of certification/ verification survey then the risk of the accreditation
accreditation as required by law, statutory
certificate is withdrawn by KARS.
requirements or by the programme itself
3. Hospital willingness to provide accurate and non-false
Client responsibilities could include: data and information to KARS and surveior. If proven data
vi. only claiming accreditation or certification for and information is not accurate or falsified, the hospital is
services which have been granted accreditation ready to accept the risk of failing accreditation and the
or certification; hospital resubmits the application to be surveyed by KARS.
vii. not bringing accreditation or certification into 4. Hospital willingness to report changes in data in the
disrepute or making any misleading statement survey application (ownership, Director of Hospital,
regarding their accreditation or certification; licensing, services, buildings / buildings and facilities etc.) no
viii. not advertising or promoting their accreditation later than 10 days before the survey was conducted.
or certification if it has been suspended or 5. Hospital willingness to report if there are sentinel events,
ceased; changes in hospital class, changes in type or category of
ix. using accreditation or certification only to hospital, addition of services, either specialist or sub-
indicate that it has met the relevant standards; specialty, building changes of more than 25% of the current
x. ensuring that no certificate, logo or report is building during the 3-year accreditation cycle and willing to
used in a misleading manner; be surveyed focused as needed.
xi. making reference to accreditation or certification 6. Hospital willingness to complete licensing related to
in its documents, brochures or advertising only personnel and facilities (facilities).
in compliance with the requirements of the 7. Hospital willingness to allow KARS officials or senior
external evaluation body surveior who are assigned to use IDs from KARS to conduct
evaluations during the survey. Evaluation can be carried out
If clients are defined by law, statutory requirements or in all accreditation phases, including the three-year
contracts/agreements on a higher level than individual accreditation cycle.
providers, an individual agreement with each client 8. Hospital willingness to provide facilities and a safe
may be substituted with a set of requirements and environment for patients, families and staff in accordance
rules, readily accessible to all clients, and with laws and regulations. Hospital willingness to make
arrangements to advise them on any changes in survey payments no later than 7 days prior to the survey.
these requirements or rules.
• Information for clients on the survey process

Evidence
Suggested
• Client agreement
7.4 The external evaluation organisation defines its clients Self - Rating 4 Technical Review
and keeps a register of clients.
KARS as an organization External evaluation defines the Please provide the evidence highlighted in green.
client in this case is the Hospital that carries out health
services. The definition of the client is stated in the Please review the evidence provided as the contract may
Clients may be defined as healthcare provider
Guidance
Accreditation Pre Survey Policy and Survey Policy. General be more applicable above (in 7.3).
organisations who have signed a contract with the
Hospital Feasibility Requirements for submitting
external evaluation organisation.
Accreditation are Hospitals located in Indonesia, general You may wish to consider translating the evidence
Alternatively, if the external evaluation programme is
and special hospitals for all classes and operational permits highlighted in yellow into English.
established by law, other statutory requirements, or
are still valid KARS has a system register and client / RS
contracts/agreements on a higher level than individual
list and has a registration certificate from the client / RS and
providers, clients may be defined as all healthcare
a statement from the director that contains no objection to
provider organisations falling within the scope of the
giving access during accreditation. Every hospital that will
programme.
following the Survey and having been approved for
scheduled, it is preceded by a survey contract agreement
• Statement on clients
Evidence
Suggested
between KARS and the hospital.

• Client register
Evidence:
7.4.1 Client statement form
7.4.2 Example contract
7.4.3 Client statement and list of client
7.5 Self - Rating 4 Technical Review
The relationships with clients recognise their specific KARS as an external evaluation organization knows the Please clarify the text which is highlighted in green.
needs. Needs are met in ways that are consistent with specific needs of clients, among others, by providing
the requirements for impartiality. services and schedules for surveys, guidance and also It should be clear what information is provided to client
Relationships could include: continuous guidance and quality improvement. The survey organisations – what established regulations are relevant
Guidance
was not interrupted only at the time of the survey but could here?
i. clients’ service requirements and planned timelines be started from guidance, simulation surveys, workshops,
being agreed and documented; provision of trainings for accreditation preparation. The What type of preparation assistance does KARS provide
ii. defined contact points in the client organisation and activities of this preparation opportunity according to the to their client organisations? Is generic information
the external evaluation organisation being identified; needs of the hospital mean that it is not obligatory but for provided or does KARS offer a consultancy service?
iii. on-going communication and non-prescriptive advice hospitals that need according to client / hospital
assisting clients in their preparation for survey and specifications, KARS organization will provide preparation
continuous improvement activities; assistance from clients consistently and avoid elements of
iv. networking and education opportunities impartiality through the assistance process in accordance
with the established regulations The entire process of
• Client service plan and timelines guidance, workshops, verification surveys has a structured
Suggested Evidence
• Impartiality statement/document plan, has time planning, is agreed upon by both parties and
documented on the website and online reports. Planning
Training has been published to be known online through
the official KARS website KARS has an official website,
official contact and all client communication with KARS
through the Contact Points that have been set KARS has a
training / education organization that continues to improve
its networking and also conducts training / education to
improve the quality of services and continuous
improvement
Evidence :
7.5.1. Client service plan and timeline
7.5.2. Impartiality statement or document
7.6 Arrangements are in place to ensure impartiality and Self - Rating 4 Technical Review
Core avoidance of conflicts of interest in client relationships.
KARS has been regulated and has arrangements that As specified in the required document checklist, please
ensure there is no partiality and avoidance of conflicts of provide the impartiality policy (translated into English).
interest.
Impartiality arrangements include: KARS has a format, "STATEMENT OF NO CONFLICTS Please review this finding and clearly specify whether
Guidance
OF INTEREST." which must be sent before the evaluation. consultancy services are offered and if so, how they are
i. policies and structures to avoid self-interest threats KARS also has a Survey Code of Conduct. The Code of separated from the external evaluation services.
(e.g. the external evaluation organisation acting in Ethics Survey was read at D-1, signed by all Surveyors and
financial self-interest to promote selling of services); submitted to the director of the Hospital. KARS has a Please include all the evidence referenced in the finding
ii. self-review threats, e.g. the external evaluation regulation that those who carry out consultation, guidance (e.g. please provide the regulation highlighted in green).
organisation evaluating work done by itself and accreditation services are separate / different from
those who carry out the Evaluation, this aims to avoid
Policies and structures to assure that all clients have a conflicts of interest
similar access to information, relevant to their situation.
Separation of consultancy and evaluation services is an Evidence :

important prerequisite for impartiality, but does not 7.6.1. Sample of letter conflict of interest
exclude the external evaluation organisation from 7.6.2. Form Impartiality policy
providing education or advice to clients (criterion 1.3).
• Impartiality policy
Evidence
Suggested
7.7 Education and information materials are available for Self - Rating 4 Technical Review
clients which support the programme objectives and meet
their needs. Needs are met in ways that are consistent
with the requirements for impartiality. The Previous survey recommendation state that The recommendation referenced (highlighted in green)
As mentioned previously, the needs assessment of client was not in the 2015 ISQua survey report so it is unclear
organisations remains a key process to ensure their what this relates to – please remove or explain.
Education and information support could include: expectations are met. No formal client and stakeholder
Guidance
needs assessment has been carried out. Please also review the text in blue as this is not clear.
KARS is offering a wide range of capacity building services
i. survey of the needs of clients for education and to support organisations to better prepare for their survey. Please ensure it is clear how you ensure client needs are
development are assessed and programmes being Survey questionnaires are provided to clients following met. Please provide examples of education and
designed to meet these needs; education activities, but there is minimal evidence of quality information materials as evidence.
ii. clients being assisted to prepare for the survey, e.g. improvement initiatives using that data.
by the provision of on-site or off-site education, self- What we have Done
assessment assistance or pre-survey reviews KARS provides onsite training as required by hospitals.
KARS has appointed volunteer hospitals that are willing to
See also criteria 5.10 -5.11 illustrate accreditation standards.
• Examples of education and information materials Training includes:
Suggested Evidence
• Workshop for the current accreditation standards:

Akreditasi KARS / SNARS Ed.1.
• Workshop: patient safety (in conjunction with
hospital association)
• Workshop: improvement of quality care and patient
safety
• Workshop: How to decrease and manage
infectious diseases in the hospital based on
accreditation standards
• Seminars: directors and management team

appointed to manage accreditation
• Workshop: Assessor team in hospitals
• Workshop : Services of Pharmacy and Use of
Medicine
• Workshop: medical committe and nursing committe
• Workshop: patient centre care
Evidence could include:

a) assessment of the needs of participating organisations
for education and development are assessed and
programs being designed to meet these needs;
b) participating organisations being assisted to prepare
for the assessment, e.g. by the provision of on-site or off-
site education, self-assessment assistance or pre-
assessment reviews.
c) Appendix 5.10……..
d) Appendix 5.11………
Evidence :
7.7.1. Examples of education and information materials
7.8 Feedback on information and education materials used in Self - Rating 4 Technical Review
the accreditation process is obtained from users and
used to make improvements.
Each training above will be evaluated through a survey for Please review this criterion. Please clarify what
quality control and end user feedback for further education materials are provided and provide examples
improvement. of collected feedback and examples of improvements
This could include user feedback being sought on which have been made.
Guidance
resources such as the information materials, resources Each training will be evaluated. Analysed and used for
used at education sessions, manuals and reports. improvement. Please replace the 2014 agenda with evidence relating
Workshops were conducted in collaboration with the to the new standards you are using.
Association of Hospital and professional organizations with
key persons defined by KARS.
Based on the results of the evaluation questionnaire KARS
a workshop that would suit the needs of the hospital.
To prepare for accreditation, KARS also provides an

accreditation instrument SNARS Ed.1 to perform self-
• Examples of feedback assessment.
Evidence
Suggested
• Examples of improvements made Survey and results of the hospital self-assessment

application should have been sent to KARS Office no later
than1month before the survey conducted.
Hospital accreditation team can come to the KARS office for

a consultation regarding self-assessment filling, compliance
and implementation of the accreditation survey.
KARS use the data from post training questioner that filled
by the participant, to arrange training need assessment
Evidence :
Training Questionnaire Evaluation Result (di mba Dion)
Training schedule 2014 and 2015
Recap of workshops of accreditation standards from 2012
Jan to Nov 2014
Hospital Accreditation Survey Activity Guide third edition
7.9 The team for the survey of an organisation is selected to Self - Rating 4 Technical Review
provide a balance of skills and experience and to match
the needs and characteristics of the participating
organisation. The Previous survey recommendation state that The recommendation referenced (highlighted in green)
The surveyor selection is done by the executive secretariat. was not in the 2015 ISQua survey report so it is unclear
Staff are following comprehensive check list to ensure that what this relates to – please remove or explain.
There should be: every aspect of the process is respected. The surveyors
Guidance
are selected according to their skills and their level of If there is evidence of a documented process for
i. a selection process for surveyors that ensures that experience. selecting surveyors for teams, please provide this here
appropriate skills, expertise and experience are They are also selected based on their field of expertise. as evidence.
provided for each survey;
ii. prevention of conflicts of interest of survey team As mentioned in standard 2, the fire walls are based on the It is noted that you reference the need to better define
members, e.g. by checking if they have relationships good commitment of the executive secretary to ensure that the firewall – please outline any steps you are taking to
with competing or contracting agencies or with key surveyors are free of conflict of interest. Presently, a address this (this may be better positioned in 7.6).
people in the participating organisation, have had surveyor can be part of a survey team, be a lead surveyor,
previous employment with the organisation or have a mentor for the organisation as well as and counsellor and
provided consultancy services to it. a counsellor coordinator for report review and award
• Documented process for selecting surveyors decision.
Suggested Evidence
The organisation will need to better define the firewall in

order to protect its integrity.
Process of selection:
1. The Executive Secretary of KARS propose the names
of surveyors which selected based on competency,
track record, location of residence of the surveyors and
location of hospital, no later than 1 (one) month before
the implementation of the survey
2. The proposed names of the surveyors and Survey
Team Leader will be emailed to the Executive Chairman
of KARS.
3. Appointed surveyor should complete disclaimer
process by signing disclaimer form
4. The names of the surveyors may be discussed at

regular KARS meetings or discuss via email.
5. After the names of the surveyors approved by the
Executive Chairman of KARS then KARS confirms to
the surveyorsfor the approval.
6. If the surveyorshave approved then KARS sends the
names of the surveyors to the hospital.
7. If the surveyor is unwilling / unable to carry out the
survey on the date and to the hospital, then repeat point
1 to point 4, namely propose the name of the surveyor
to substitute the previous surveyor who could not
conduct the surveyuntil do the confirmation to
thesubstitutesurveyor for her/his approval.
8. If after confirmation to the hospital, the hospital not
approved the names of the surveyors along with the
reasons then repeat point 1 to point 4, the refusal from
the hospital max up to 2 times. The refusal of the
hospital recorded in the surveyor log book at KARS
Secretariat.
9. If the hospital has approved then the accreditation
survey will be carried out according to the date of the
survey
KARS has made training periodically to improve the skill

and knowledge and attitude from the existing surveyors
KARS appointed surveyor based on the result of the
training program, which become 710 surveyors by May
2018
Evidence :
SOP Implementation Of Hospital Accreditation Survey
Letter of Assignment Surveyor
7.10 The planning of the survey is transparent and timely. Self - Rating 4 Technical Review
1. The scope of the survey using the National Standard of It is noted that the JCI standards are referenced here but
Hospital Accreditation (SNAR) edition 1, has been agreed by the reason for this is unclear as it noted above that you
stakeholders. (Directorate General of Health Services, are using your own national standards now.
The survey plan could include: Ministry of Health RI, Relevant Institutions in the region,
Guidance
i. the scope of the survey and the standards to be used Work Unit / hospitals / health related professional Please provide evidence to support this finding.
being agreed with the participating organisation and associations)
made known to the survey team; 2. Sample curriculum vitae of the Survey Team from the
ii. the survey team biographies being sent to the client Chair of the Survey Team (KTS) and Team Members
and accepted by them; assigned as surveior
iii. the organisation is made aware of any observers, 3. Socialization and education of the organizations to be
translators or staff observing the survey; surveyed and related organizations such as: PERSI, PABI,
iv. pre-survey documentation being provided in a timely IDI, IAI, HISFARSI etc. 4. Pre-survey self assessment in
and comprehensive manner by relevant parties; SISMADAK which includes documents for verification of
v. the survey process being clearly defined and covering each Chapter, Hospital Operational Permit, Wastewater
the nature of, and timelines for, the provision of Management Permit (IPAL / IPLC), B-3 Waste Management
documentation and the survey timetable Permit, Medical Personnel who have STR, SIP, SPK and
• Documented survey plan RKK
Suggested Evidence
5. Availability of service policies, implementation /

implementation, evidence of implementation reports,
monitoring and evaluation as well as organized follow-up.
Proof by search and system which includes Regulation (Re),
Documentation (D), Observtion (O), Interview (W),
Simulation (S) and Confirmation (Ko) or ReDOWSKo.
The activities and average time schedule are as follows: H-
1 (Surveillance meeting with the hospital director for 1 hour);
Day One (opening, director's presentation and discussion 1
hour 15 minutes. Simultaneously: review of 2 hours
regulation, review of 1 hour 30 minutes data, facility search,
nursing system service simultaneously for 2 hours each,
meeting with RS 30 Accreditation Team and Survey team
meeting 3) hours).
Day Two (clarification of the first day of 1 hour, interview of
the owner for 1 hour, management, medical and nursing
interviews simultaneously 1 hour each; search for the
management, medical and nursing systems in 2 hours 45
minutes respectively; committee and medical leadership
interviews and the nursing committee and nursing pipeline
are 1 hour each, meetings with TARS 30 minutes, and 3 hour
survey team meetings
Day 3: clarification and input for the second day 1 hour,
review of other health, nursing and nursing staff KKS 1
hours, 45 minutes RJP simulation, 1 hour advanced system
search, 2 hours exit conference material preparation, 1 hour
exit conference, 30 minutes closure and 3 hour survey team
meeting H + 1 surveyors go home. Evidence: 1. Joint
Commission International Acreditation Standard for
Hospital, 2013, 5th ed., Joint Commission International, A
division of Joint Commission Resources, Inc. 2. National 1 st
edition of Hospital Accreditation Standards 2017, Hospital
Accreditation Commission in 2017 3. The 1 st edition of the

National Hospital Accreditation National Standard Survey
Instrument in 2018, Hospital Accreditation Committee
7.11 The survey is conducted according to a timetable that Self - Rating 4 Technical Review
shows the complete progress of the survey and is agreed
in sufficient time to make necessary arrangements.
1. Competence of the Survey Team (Certificate of Training Please consider providing the evidence highlighted in
/ Surveillance Training), Surveyor Assignment Letter from yellow as evidence.
KARS, Statement of Surveillance Willingness, Statement of
The timetable should: Compliance with the Surveillance Code of Ethics, Please review this finding to ensure that full sentences
Guidance
Statement of the absence of Conflict of Interest with the are used, and it is clear how all the text relates to the
i. enable each member of the survey team to be clear surveyed Hospital and understanding the Standard requirement of this criterion.
about his/her individual responsibilities; Chapters surveyed along with the ReDOWSKo system
ii. include locations for activities as appropriate Hospital Accreditation.
especially where sampling takes place or the client 2. Schedule of Accreditation Surveys, Survey Scenarios
has multi-sites; (such as survey scenarios in: IGD, Pharmacy, R. Inap, R.
iii. indicate which staff from the participating organisation Road, Laboratory, Radiology, Facilities and facilities, OK
are expected to participate in which parts of the etc.) according to the surveyor group (Management,
survey Medical and Nursing), having regulation checklist, survey
support checklist, search checklist and licensing checklist
• Examples of survey timetables etc. Web address / site that supports access to information
Suggested Evidence
related to hospital facilities 3. The provisions of the Hospital

Management regarding the Accreditation Team are
completed with the Working Groups (Pokja) of each
Chapter in SNARS. Evidence of coordination meetings
(invitation to meetings, material, attendance and minutes of
meetings) attended by all elements in the hospital such as
leaders, medical personnel, nursing staff, other health
workers and administrative staff. Including a list of hospital
staff who have SIP, STRA, SPK, RKK and a list of medical
staff entitled to write prescriptions etc.
Evidence :
7.11.1. Examples of survey timetables
7.12 The survey is conducted using appropriate tools and Self - Rating 4 Technical Review
guidelines and a transparent, valid and consistent
process.
The Previous survey recommendation stated that As noted previously, the recommendation referenced
KARS has developed a comprehensive surveyor guideline (highlighted in green) was not in the 2015 ISQua survey
to support them on survey. Unfortunately, the guideline
Supporting documentation could include: does not include information on the rating scale and the report so it is unclear what this relates to – please
Guidance
i. guidelines and survey tools that are used by survey technique used by KARS such as tracer remove or explain.
surveyors in the survey of performance against the methodology. However, the guidelines for the hospital
standards or their agreed equivalent being include the appropriate information. Is the text highlighted in blue an opportunity for
understandable and user friendly; The survey includes the opportunity to provide feedback improvement that your organisation has identified (it
ii. guidelines and survey tools assisting the application during the time on site. Each morning, except the first day, does not appear in your 2015 survey report)?
of rating scales; the organisation can provide clarification to the survey
iii. feedback on key findings being provided by the team. Also the schedule includes an exit conference. Please fully review this criterion and clearly explain what
survey team to the participating organisation at the However, there are important concerns with the capacity of tools and guidelines are available to ensure that there is
end of the survey; the organisation to face the growth considering the level of a valid and consistent survey process.
iv. debriefing template complexity and the logistic required by the new program.
• Examples of survey tools and guides The actual process still demonstrates a lot of variation of
Suggested Evidence
practices among surveyors. Those variations are actually

captured by the counsellor and should be used for
reinforcement.
Opportunity for Improvement
All documentation relating to the survey process be
reviewed to ensure it is consistent and comprehensive.
What we have Done
Assessment Tool
Accreditation instruments will be accessible on the public
website. Forms required can be filled in online.
Workshops are also available for hospitals that require
further training on how to use the instrument and conduct
the gap analysis.
There will also be training for hospitals that are being
accredited for the first time. This course for beginners is a
six month guidance course so that hospitals truly
understand the standards and ways of implementation.
Self-assessment is required for hospitals before they are
surveyed (Gap analysis), and the last self-assessment
must also be sent to KARS at least a month before survey
dates.
The process of application to complete all documents until
hospitals are informed of the accreditation date is five
working days. Hospitals will be informed within five working
days after all documentation is complete.
Assessment rating
Surveyor’s will use the scoring guidelines to understand
how to accredit hospitals based on the latest accreditation
standard.
Scoring is based on how well the hospitals have prepared
for accreditation standards based on interviews,
observation of practices and location and documentation.
Interviews with various levels of staff in the hospital
organizational chart based on their understanding of
individual job description, system in the work place within

their given competence.
Observation: work place, facility, and implementation of
medical and non-medical services are delivered.
For hospitals that will be accredited with the latest standard
for the first time, four months of training and guidance will
be provided and should they fail, accreditation can be
conducted within the next twelve months.
Tracer will be carried out on the track record of the hospital
during the last 1 year . Special to the hospital to be
accredited first time, have to provide the data that have
been evaluated at least 4 months before survei.Surveior
will perform search / tracer to the track record of the
hospital for 4 months prior to the survey .
Hospital documents will be reviewed to see how they have

covered the requirements of a hospital, based on national
standards/regulations and how they implement the written
documents.
At the end of each day the survey, team:
- discuss the day’s results (debriefing)
- Team leader will ensure that the next day’s schedule is
maximized (i.e. Surveyor Team Leaderwill add points to be
surveyed if necessary)
Survey Feedback.
The second morning before the survey starts:
-surveyor’s will ask their assigned hospital’sdirector further
clarification on questions they might have from the survey
the day before
Exit conference:
- Surveyor provides important recommendations that
should be included in the Strategic Improvement Plan )
- Hospital asked to fill out an evaluation survey were sent

directly to the KARS
KARS developed :
Survey Process Policy
Scoring Guideline
Lead Surveyor and surveyor Guideline
Evidence:
Scoring Policy (SNARS 1st Edition Book pp. 32-40)
Accreditation Survey Execution guidelines 3rd adn 4th
edition
Accreditation instrument (SNARS 1st Edition Book)
Program schedule of accreditation survey

Accreditation Survey Guidelines for Head of Surveyor
team
Implementation Evaluation Survey Form
7.13 The findings from the survey and the rating of Self - Rating 4 Technical Review
achievement against the standards assessed are
included in a written report.
The Previous survey recommendation stated that Please review reference to recommendation (highlighted
The surveyor has to follow very strict guidelines for report in green) as above.
writing. Each surveyor is in charge of 5 standards’ chapters.
Guidance on report writing could include: There is a comprehensive process for report production in Please review the sentences highlighted in blue as text
Guidance
collaboration with a counsellor. appears to be missing.

i. provision of a report that contains items such as an In 2013, the information management system for
executive summary which includes the dates of the accreditation was not implemented. At that time 57% of the Please consider translating the evidence highlighted in
survey, the names of the surveyors, the services and survey reports (14) took more than the targeted 60 days to yellow into English.
sites assessed, the scope of the survey, the finalise. With the new system there is a high expectation the
standards used, the findings of the team, comments, organisation will be able to produce 95% of its report ≤ 60 Please see above comments regarding use of red font.
an explanation of any differences from the information days.
given at the summation meeting, and The final report provided to the organisation does not include
recommendations on areas of insufficient their global performance as well as the performance against
achievement/compliance or needing improvement; each standards section. Even if the organisation is informed
ii. the participating organisation being given the as to the specific recommendations from the survey, KARS
opportunity to provide feedback on the findings in the will need to reconsider this position.
draft report to correct any issues of fact KARS mission is to create quality improvement and
• Report writing guidelines improved patient safety. We strongly believe that all client
Suggested Evidence
• Examples of reports organisations must have access to their global and specific
level of compliance as well as the surveyor recommendation.
This information will be very beneficial for prioritisation and
targeted quality improvement initiatives.
However, we can also appreciate the political debate and the
cultural sensitiveness that such a decision may create.
Recommendation
The organisation reopens the dialogue with its stakeholder
and client organisation on the desirability to make available
to client organisations both global and their specific level of
compliance.
What we have Done

Reporting on-line survey conducted by referring to the SOP
Online Report Of Hospital Accreditation Survey
In order to improve the quality and service of the hospital

accreditation survey, KARS to evaluate the accuracy of the
survey report.
Survey report has to discuss and decide between surveyor

one day after survey, and send to the lead surveyor that has
to give the feedback
Survey report has to upload in the accreditation system
maximum 5 days after survey
The result of the survey send to hospital maximum one
month after survey.
Evidence:
SOP Online Report Of Hospital Accreditation Survey
Example of survey report
The results of the evaluation of the accuracy of the survey
report
7.14 Documented review processes and guidelines are Self - Rating 4 Technical Review
followed to ensure the report is complete and accurate.
Policy: If available, please provide evidence to support this

1. Survey team chair can be from management surveyor, finding.
medical surveyor although nursing surveyor and selected
The processes could include: based on their competence and credibility.
Guidance
2. Task of the surveyor team chair:

i. editing and review being used to ensure the reports • make a survey schedule, coordinate with the Hospital
are complete, accurate, balanced, constructive and • coordinate with the surveyor team
consistent with the intent of the standards; 3. Surveyors must make survey reports no later than 5
ii. written procedures and guidelines being followed (five) days
when reports are further reviewed or assessed to work after conducting the survey, sent to the KARS
ensure accuracy, objectivity and consistency Secretariat through web address: accreditation.kars.or.id
4. The survey report is reviewed by the Councilor appointed
by KARS Information System (SIKARS)
5. Delays in sending survey reports from Surveyors are
• Documented processes and guidelines for report one of the aspect of assessing the performance of the
Suggested Evidence
writing surveyor.
6. Delay in the counselor's review is one the aspect of the
performance evaluation of the Councilor
A. Online hospital accreditation survey report by Surveyor
1. After receiving an assignment letter from the KARS

Secretariat, Surveior access to the system and can
download the Excel file
so that surveyors can fill in data offline at least 1 (one)
week
before do the survey
2. Make sure the excel document downloaded from the
system is saved on a flash disk or other storage media
3. The account used by the surveyor to log in is:
- Username: surveior personal email address

- Password: Default date and year of birth of the surveyor
(eg. 10011954)
4. After entering / logging into the web, for the charging
method offline, which is looking for the hospital data that
was assessed
5. Download the Excel file template
6. Fill in the results of the survey / assessment through the
Excel file template
7. Upload the Excel file template to the web
8. Submit data per chapter
9. After all chapters have been filled out / submitted, the
Chief of Surveillance mengapprove the survey report.
10. Automatic email notification to the KARS Secretariat
11. The results of a survey that has been disapproved
cannot be changed, but can still see the scores and
recommendations of the Councilor. The data can still be
accessed before 2 (two) weeks after being approved by the
Chairman of the Council
Evidence:
SOP of surveior report
7.15 The relationships with clients, and the support offered to Self - Rating 4 Technical Review
them, are reviewed regularly and improvements made
based on the evaluation and feedback provided.
Evaluation to the surveyor is done through: Please fully review this criterion to ensure it is addresses
1. Evaluation of the Councilor based on the survey report how the relationships with clients is reviewed regularly
2. Assessment of the surveillance team at the time of the and improvements made. Please provide examples of
Improvements may include: survey improvements which have been made. Please see the
Guidance
3. Assessment of hospital on the satisfaction of surveior ISQua guidance for further details.
i. updating policies and procedure; Surveyor re-education by:
ii. client educational materials; 1. Retraining Please consider translating the evidence highlighted in
iii. revision to process; 2. Penalties from the Ethics team yellow into English.
iv. revision of standards
Evidence: Please see above comments regarding use of red font.
7.15.1. Assessment form by Survey Team Chair
Evaluation of the counselor (mba dion)
Forms of evaluation from hospital on satisfaction of
surveyor
• Evaluation and feedback evidence
Evidence
Suggested
• Examples of improvements
Standard 8: Accreditation or Certification Self-assessment evidence Technical Review
Awards
8.0 The processes for determination, awarding and Overall rating 4 Overall Rating
maintenance of accreditation or certification are
objective, consistent and meet the external
evaluation organisation’s objectives. Since 2012, KARS used the 2012 Hospital Accreditation Please explain what is meant by the text highlighted in
Standards, and is used until the end of 2017. green.
Starting in 2018 a new standard is named SNARS Edition 1
(National Standards for Hospital Accreditation). This new
accreditation standard has gone through various stages of
improvement.
In addition to Hospital Accreditation Standards, there are

other instruments, Survey Management Guidelines,
Guidebooks for the Chair of the Survey Team, supporting
forms, and checklists.
When the survey takes place, the schedule is tight,

regulatory searches, document proof searches, system
searches, sampling methods and interview techniques are
also prepared. Survey reports are made using the standard
format in SIKARS (KARS Information System). The report
consists of scores of elements and standard, facts / findings,
analysis, and recommendations. Surveyors are asked to
attend training on the application of new standards,
implement programs, organizations and competency tests.
The Surveyor is obliged to comply with the Code of Ethics
established by signing a code of ethics document in each
implementation survey, as well as to take precautionary
measures against possible conflicts of interest. The survey
report is then uploaded to SIKARS and examined
anonymously by Councillor. This is a two tiers system with a
purpose to maintaining objectivity of valuation.
In line with the things mentioned above, KARS believes that

the accreditation process has been carried out, and the
determination of graduation has been carried out objectively,
consistently and in accordance with the objectives of KARS
There are four levels of accreditation status: basic; madya;
main; and plenary. Hospitals can only receive accreditation
at a lower level twice. If the survey results at the same level
the third time the Hospital will not be accredited.
Survey reports are reviewed anonymously by three

Councillors (senior surveyors) for accuracy and Councillor
makes the final decision for accreditation.
Awards
The use of accreditation certificates is stated in the policies
and contracts between KARS and hospitals. There are
systems and processes in place to ensure proper use of
accreditation certificates and logos by accredited hospitals.
There was a process followed to ensure continuous
improvement in the two verification surveys among the 2
accreditation surveys. The public has access to the names
of accredited hospitals on the KARS website. Complaints
about accredited hospitals are managed through a process
guided by policies and procedures. KARS standards and
policies handle actions that are needed when sentinel
events occur.
8.1 The external evaluation organisation states who is Self - Rating 4 Technical Review
Core responsible for determining the outcome of the survey;
that the award of accreditation or certification is made in
accordance with criteria, set by the governing body; and The regular accreditation process measures the application Please consider translating the evidence highlighted in
on the basis of the findings in the survey report. The of Hospital to 15 or 16 standard chapters. In addition, there yellow into English.
process is transparent, consistent, and impartial and is are special programs where hospitals are assessed for the
determined within a set timescale. Please review to ensure that only relevant evidence is
application of 4 standard chapters, namely the chapter PCI,
This could include accreditation and certification provided here (e.g. there is no need to include the
PFR, PSG, HSCP. This Special Program starts from 2014
Guidance
decisions being: certificates here as they are addressed in 8.2).

and ends in 2018.
i. confined to matters relevant to the scope of the * Decisions about passing are determined by the parties as
accreditation or certification being considered follows:
• The supervisor conducts an assessment and prepares
The set timescale in which all activities have to be met be
a report containing scores and values so that there is a
included in the criteria set by the governing body.
final value of achieving the standard by the Hospital
• Defined process and criteria for making accreditation
Suggested Evidence
decisions • Surveyors fill out reports using the form that has been
standardized and uploaded 7 days after the last day of
the survey through SIKARS (KARS information
system)
• SIKARS chose 3 counselors (Management, Medical,
Nursing) and the Councilor was in charge of reviewing
and checking the Surveillance report anonymously, not
knowing the name of the Surveillance and the name of
the Hospital. And decide the final value of achieving
RS standards.
• The counselor downloads the surveyor's report and
must upload a maximum of 7 days after the
assignment.
• The counselor's assessment system for surveyor
reports is as follows:
1. Use 6 indicators:
Awards
1) Recording of Facts and Preparation of analysis
relevant to AE and relevant in the context of
Structure / Process / Outcome
2) The use of language is specific, precise, easy to
understand and for learning from the hospital, for
facts and analysis
3) Determination of Scores in accordance with Facts
& Analysis
4) Preparation of Recommendations relevant to the
AE and its Facts & Analysis, relevant in the context
of Structure / Process / Outcome.
5) Use of language specific, precise, easy to
understand and for learning from the hospital, for
recommendations
6) Consistency of patterns related to Facts, Analysis,
Scores and Recommendations for all AEs
assessed.
2. Used scores 1-4. Score 4 means that the surveyor

complies with the rating criteria .Score 3,2,1, is a
surveyor's non-compliance gradation.
3. Assessment is carried out in each chapter.

The recapitulation of the counselor's assessment
data on the surveyor's report in 2017 shows the
average score is 3.974, with the percentage meeting
the evaluation criteria of 99.343%. This shows the
consistency of the surveyor's assessment of the
standard.
• If there is a significant difference between the
counselor and the supervisor, the Assessment Board
will review the report. This assessment is the final
decision of the hospital accreditation graduation
status.
• The final decision process is the approval of the
executive chairman in SIKARS
• For special programs of assessment from surveior and
executive chairman, without going through counselors
* Passing Level criteria:
Awards
1. Assessment of an EP is expressed as:
• Score of 10 (fully met), if the Assessment Element is
fulfilled 80-100%.
• score of 5 (partially met) if the Assessment Element
is fulfilled 20 - <80%.
• Score 0 (not met) if the Assessment Element is
fulfilled 0 - <20%
2. Each standard is assessed by giving a score on the AE

of the standard. The score is summed so that it can be
a total score for one chapter and be a value as a
percentage. One chapter is passed if the value is 80%
or more. It is stated that it does not pass if the value is
less than 80% to 20%. If there are chapters that get a
score of 20% or less then the entire chapter is declared
as not passing. Chapters with a value of 60% to less
than 80% may be remedial.
3. Hospital is assessed as applying to 15 chapters.

Hospitals that have clinical students will be assessed in
Chapter IHEH to become 16 chapters.
Graduation level :
1. Excellent level accreditation if passing with 15 or 16
Chapters: with five-starred.
2. Advanced level accreditation if passing with 12
Chapters: with four-starred
3. Intermediate level accreditation if passing with 8
Chapters: with three-starred
4. Basic level accreditation if passing with 4 Chapters:
with two-starred
For hospital passed special programs, hospital will be

stated with one-starred (pre-basic level)
* The process of running transparent, consistent, based on

specified time.
• The transparent process, among others, is that the
hospital receives a notification from the Surveyors team
no longer than 10 days before the date of the
Accreditation Survey. The hospital can refuse Surveyors
Awards
according to the regulations (see Standard 7). Survey
results can be seen directly by the Hospital through the
KARS website at the earliest 1 month after the Survey.
The hospital after the survey ends will fill out and send
an assessment questionnaire about the preparation
process of the Survey with KARS, the implementation of
the Survey and assessment of the Surveior Team and
feedback on the accreditation survey report. SNARS
books and Instrument Books can be owned by hospitals
and hospitals can request guidance, simulate surveys to
KARS and attend workshops organized by KARS.
• Consistency and impartiality process which is the
supervisors who are appointed to be have no conflict of
interest, the survey process runs with a prescribed time
of 3 to 5 days (see standard 7). The surveyor is
independent and the counsillor assigned is not aware of
the hospital surveyed and does not know the assessor
who assesses. The hospital must carry out Strategic
Improvement Planning according to the assessment
from the surveior and will be verified in the following year
so that the hospital makes improvements consistently.
• The consistency process also includes the counsillor’s
assessment to the Surveior including the criteria:
1. Record of Facts and Preparation analysis relevant to
AE relevant in the context of Structure / Process /
Outcome
2. The use of language is specific, precise, easy to
understand and for learning by the hospital, for facts
and analysis
3. Determination of Scores in accordance with Facts &
Analysis
4. Arrangement of Recommendations relevant to the AE
and its Facts & Analysis, relevant in the context of
Structure / Process / Outcome.
5. Use of specific language, precise, easy to understand
and for learning from the hospital, for
recommendations
6. Consistency of patterns related to Facts, Analysis,
Scores and Recommendations for all AEs assessed.
:
Awards
8.1.1 SNARS 1st Edition Survey Management Guideline

8.1.2 SNARS First Edition Book
8.1.3 Letter from a hospital to proposes accreditation (RS.
Santo Yusup Bandung)
8.1.4 Letter of approval for proposed accreditation hospital
from KARS to RS. Santo Yusup Bandung
8.1.5 Surveior assignment letter to RS. Santo Yusup
Bandung
8.1.6 Survey Contracts between KARS and RS. Santo
Yusup Bandung
8.1.7 Letter of information about accreditation result to
RSAB. Harapan Kita
8.1.8 Score of Evaluation Surveior by Counsillor in 2017
8.1.9 Minutes of Meeting by Executive Body about Score of
Evaluation Surveior by Counsillor
8.1.10 Sample of Certificate
8.1.11 Sample of certificate in Passing Level from Excellent
Level Accreditation
8.1.12 Sample of certificate in Passing Level from
Advanced Level Accreditation
8.1.13 Sample of certificate in Passing Level from
Intermediate Level Accreditation
8.1.14 Sample of certificate in Passing Level from Basic
Level Accreditation
8.1.15 Sample of certificate in Passing Level from Pre-
Basic Level Accreditation
8.1.16 List of accredited Hospital in KARS Website.
8.1.17 Regulation for Re-Accreditation and Verification
Survey
8.3 A transparent and clearly described appeals process Self - Rating 4 Technical Review
exists that can be applied when the outcome of a survey
is in dispute.
Awards
The appeals process should insure that persons or group After the passing level decision was stated, the results were Please consider translating the evidence highlighted in
Guidance
of persons that are competent and independent are in displayed on the KARS website www.kars.or.id and the yellow into English.
charge of the review procedure. hospital was emailed about passing level, remedial
conditions if any and Strategic Improvement Planning..
There should be a process defining a follow-up to appeal In Survey Contracts, Hospital can submit an appeal to
procedures and the transmission of the results of the KARS for the results of the Survey with a deadline of no
appeal process. longer than 1 month by depositing a survey rate.
Appeal received by KARS will be reviewed by the Assessing
Board consisting of the Executive Chairman and the Anchor.
If an appeal is accepted, then the Surveyors will be
appointed by the Executive Chairman and a re-survey
• Documented appeals process
Suggested Evidence
process is carried out according to the appeal submitted by

the Hospital.
If an appeal is not accepted, the Hospital will be informed to
this decision and the deposit will not be returned.
At present, Validation Standards for Survey Results and

Results / Appeal Results Standards - which must be made
if the Hospital is not satisfied with the results already
available.
The hospital has the right to appeal the survey results no

longer than 1 month after hospital was informed the
results. An appeal must be submitted in written form by the
Hospital Director to the KARS Executive Chairman.
Furthermore, the KARS Executive Chairman will conduct
an internal meeting to take further action.

Yusup Bandung
8.3.1 Guideline of Accreditation Results Complain
Management
8.3.3 Application letter for appeal from dr. Suyoto Hospital
8.3.4 Minutes of Meeting by KARS Executive Chairman
and Assessing Board about proposed appeal from dr.
Suyoto Hospital
8.3.5 Letter of approval for appeal in dr. Suyoto Hospital
from KARS
8.3.6 Surveior assignment letter for appeal in dr. Suyoto
Hospital from KARS
8.3.7 Report for appeal in dr. Suyoto Hospital from KARS
8.3.8 Application letter for appeal from Siloam Hospitals
Makassar
Awards
and Assessing Board about proposed appeal from Siloam
Hospitals Makassar
and Surveyors in charge about proposed appeal from
Siloam Hospitals Makassar
and Siloam Hospitals Makassar about proposed appeal
from Siloam Hospitals Makassar
8.3.12 Letter of approval for appeal in Siloam Hospitals
Makassar from KARS
8.3.13 Surveyors assignment letter for appeal in Siloam
Hospitals Makassar from KARS
8.3.14 Report for appeal in Siloam Hospitals Makassar
8.4 There is on-going monitoring of survey outcomes to Self - Rating 4 Technical Review
ensure consistency with the criteria for awarding
accreditation/certification.
The accreditation certificate is valid for 3 years. Please review this criterion as it relates to the ongoing
KARS monitors survey results (based on Strategic monitoring of survey outcomes (and not the continued
Improvement Planning) every year which is one year and maintenance of standards which is addressed in 8.5.).
The criteria are set by the governing body, see criterion
Guidance
two years later after the survey is carried out. The survey is The verification surveys should be addressed in 8.5.
8.1.
called a verification survey.
After receiving the survey results, the Hospital must fill in the
Strategic Improvement Planning including: Standard /
Asesessmen Element (AE), fulfillment of assessment
elements, Improvement Methods, Indicators of
Achievement, Time, Person in Charge (PIC) and Remarks
The purpose of the a verification survey is to see the
consistency of standard implementation and hospital
compliance in carrying out the quality of the Hospital.
• Accreditation/certification award criteria
Suggested Evidence
Verification Survey to see the implementation of

• Results of monitoring recommendations in the score of Asessment Elements (AE)
scores 0 and 5. Furthermore the surveior will give a new
score according to the results of the assessment.
• The first Verification Survey is carried out one year after the
date of the survey that has been carried out. The
supervisor has the task of verifying the Strategic
Improvement Planning that has been implemented and
which has not yet been implemented
• The second verification survey is carried out two years after
the date of the survey that has been carried out. The
supervisor has the task of conducting Strategic
Improvement Planning verification that has been carried
Awards
out and which has not been carried out as well as the
preparation of subsequent accreditation.
• The date of determining the date of the verification survey
can be changed, if the date is a Sunday or National
Holiday.
• If the hospital suspends or does not carry out a verification
survey, the accreditation certificate is withdrawn.
• The surveyor appointed is not the surveyor who conducted
the previous assessment.
Monitoring of survey results to ensure consistency is also

carried out by the councilor in charge of reviewing and
checking the surveior report. The councilor does not know
the name of the surveyor and the name of the hospital
surveyed (anonymously). The councilor will decide on the
final value of achieving hospital standards.
The recapitulation of the results of the councilor assessment

of the surveyor report in 2017 showed an average score of
3.974, with the percentage meeting the evaluation criteria of
99.343%. This shows the consistency of the surveior's
assessment of the standard.

8.1.2 SNARS Book Edition 1
8.1.17 Regulation for Re-Accreditation and Verification
Survey
8.4.1 Policy of Strategic Improvement Plan Of Verification
Survey
8.4.2 Assigment letter for Verification Survey
8.4.3 Verification Survey Report with excellent passing
level
8.4.4 Verification Survey report with advanced passing
level
8.4.5 Verification survey report with intermediate passing
level
8.4.6 Verification survey report with basic passing level
8.4.7 Photos of awarding accreditation certificate by KARS
to hospital
8.4.8 Assigment letter for councilor
Awards
8.5 The external evaluation organisation monitors the Self - Rating 4 Technical Review
Core continued maintenance of standards and quality
improvements by accredited or certified organisations.
• KARS carries out inpatients that have not been accredited, Please see comment above.
especially in terms of services and patients.
• The first Verification Survey is carried out one year after the Please clarify what is meant by the text highlighted in
Monitoring requirements should specify what should be date of the survey that has been carried out. The green.
Guidance
covered as a minimum to maintain accreditation or supervisor has the task of verifying the Strategic
certification, e.g. complaints, audit, risks etc. The criteria Improvement Planning that has been implemented and Please consider translating the evidence highlighted in
used in monitoring should be consistent with the criteria which has not yet been implemented yellow into English.
used in the original assessment or make it clear where • The second verification survey is carried out two years after
they are linked. the date of the survey that has been carried out. The
supervisor has the task of conducting Strategic
Monitoring could include: Improvement Planning verification that has been carried
out and which has not been carried out as well as the
i. submission by the accredited or certified organisation preparation of subsequent accreditation.
of a plan of the specific actions and timeframes in • The date of determining the date of the verification survey
which they will make any improvements can be changed, if the date is a Sunday or National
recommended in the survey report; Holiday.
ii. processes for validating the implementation of these • If the hospital suspends or does not carry out a verification
actions; survey, the accreditation certificate is withdrawn.
iii. review of specified documentation; • The surveyor appointed is not the surveyor who conducted
iv. a system of periodic self-assessments, annual or mid- the previous assessment.
term reviews, or random reviews • For special programs, the first year is added with 6 chapters
• Documented monitoring process from 15 chapters that have not been appointed.
Suggested Evidence
• Examples of monitoring reports Verification of the second year in addition to seeing the
publication of the results of the first verification, including
5 chapters that have not been pointed.

8.4.2 Assigment letter for Verification Survey
8.4.3 Verification Survey Report with excellent passing
level
8.5.1 Stategic Improvement Planning
8.6 There are processes for following up any concerns or Self - Rating 4 Technical Review
Core issues raised about an accredited/certificated client.
For this standard, KARS has regulations regarding the Please clearly indicate within which document this
process of handling issues against accredited hospitals / Re- process can be found (evidence 8.6.1)?
surveys
Awards
Processes could include: If KARS receives information or is listed in the mass media As specified in the required document checklist, evidence
Guidance
i. accredited or certified organisations against whom a about complaints about the hospital, KARS follows up on the must be submitted in English to demonstrate the
complaint is made to the external evaluation complaint by inviting the relevant Hospital Director to provide documented process for following up any concerns or
organisation being required to make available, when clarification on the issue. issues. Please translate the evidence highlighted in
requested, its records of complaints and subsequent yellow into English.
action taken; 8.1.1 SNARS 1st Edition Survey Management Guideline
ii. a defined system for following up with accredited or 8.6.1 The Guide for the Handling of ComplaintsIssues
certified organisations when a sentinel event occurs; Submitted to any Accreditation Hospital
iii. a re-survey if after evaluation of the issues raised 8.6.2 Survey Verification Report in RSAL. Dr. Mintohardjo
justifies this; 8.6.3 Root Cause Analysis about sentinel event from RSAL
iv. a re-survey if the client organisation has undergone dr. Mintohardjo
significant changes 8.6.4 Corresponding letter of RCA sent by RSAL dr.
• Documented process for following up any Mintohardjo
Suggested Evidence
concerns/issues 8.6.5 Minutes of Meeting by Executive Body about sentinel

event in RSAL. Dr. Mintohardjo
8.6.6 Letter of information for RCA evaluation survey in
RSAL. Dr. Mintohardjo
8.6.7 Surveior assignment letter for RCA evaluation survey
in RSAL. Dr. Mintohardjo
8.6.8 Report for RCA evaluation survey in RSAL. Dr.
Mintohardjo
8.7 The external evaluation organisation allows the use and Self - Rating 4 Technical Review
display of its accreditation or certification mark or logo, or
claims about accredited or certified status, only in
accordance with documented rules. Regulation regarding the use of logos have been quoted in Please consider providing the evidence highlighted in
the Logo Guidelines and contracts made by and between yellow in English.
KARS and Hospitals.
The rules could include:
Guidance

i. information given to the client;
Yusup Bandung
ii. a procedure for withdrawal of accreditation/
certification; 8.7.1 Logo guidelines
iii. monitoring of the correct use of the logo 8.7.2 SOP about using KARS logo
8.7.3 Minutes of meeting by Executive Body about regulation
of using KARS logo
8.7.4 Sample of using KARS logo by hospital
• Rules of accreditation or certification

Evidence
Suggested
Awards
8.10 The accreditation or certification processes and outcomes Self - Rating 4 Technical Review
are evaluated and the results used to make
improvements.
Implementation of Evaluation of the accreditation process Please review this finding and provide examples of
and outcome with the improvement efforts are as follows: improvements which have been made based on the
i. The hospital is asked to fill out the questionnaire as evaluation results.
Evaluation may include: follows:
Guidance
1. Pre-Survey Questions Form, Implementation Of Please review and if available, provide evidence relating
i. participating organisation satisfaction; Survey and Performance Surveyor (file 8.10.1) to how the new accreditation process has been
ii. validity and consistency of awards and their 2. Feedback from Hospital Accreditation Survey Report evaluated (i.e. the assessments with your new
maintenance; (file 8.10.2) standards).
iii. the appeals process; 3. Feedback Hospital With The 2012 Standard Version
iv. audits of documentation; Accreditation (file 8.10.3)
v. research on the outcomes of accreditation or
certification processes; The recap of questionnaire results can be seen in
vi. evaluation and evolution of decision rules on basis evidence 8.10.1, 8.10.2, 8.10.3
of the on-going experience with the decision
process ii. Evaluation is done through the Verification Survey system
• Evaluation process and the Two Tiers Methods system where the Councilor
Suggested Evidence
• Evaluation results evaluates the Surveyors and makes a passing level

• Improvements made from the results decision. (See item 8.1)
The results of the recapitulation can be seen in the score
of evaluation Surveior by Counsillor
iii. In the appeal process, a survey was conducted to assess
the discrepancy of the results of the Surveyors report and
opinions from the Hospital. This process is also an
evaluation process of the KARS Accreditation Survey
(See 8.3)
iv. In the process of audits of documentation, the Councilor

conducts a review / audit of the Surveyors report. This
audit will maintain the consistency of the Surveyors
accreditation assessment process using 6 indicators.
(See 8.1)
v. This process is in accordance with the point iv and

hospitals satisfaction according to the above mentioned..
KARS publishes SNARS (National Standard of Hospital
Accreditation) First Edition, which effectively start from
January 1, 2018, as a result of improvement efforts from
the Survey process that uses the 2012 Hospital
Accreditation Standards. A questionnaire is conducted to
survey their understanding about Hospital Accreditation
Standards 2012 version and it turns out that the
understanding of SNARS Edition I is getting better.
Awards
vi. This process is in accordance with point iv plus the role
of the Assessing Board if there is a significant difference
between the results of the Surveyors and the results of
the Councilor.

8.10.1 Pre-Survey Questions Form, Implementation Of
Survey and Performance Surveyor
8.10.2 Feedback Hospital Accreditation Survey Report
8.10.3 Feedback Hospital With The 2012 Standard Version
Accreditation
8.10.4 Feedback Surveyors to SNARS ED 1 and Version
2012

Organisational Survey - Technical Review-2

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Organisational Survey - Technical Review-2

Uploaded by

Copyright:

Available Formats

THE INTERNATIONAL SOCIETY FOR QUALITY IN HEALTH CARE LTD

(Komisi Akreditasi Rumah Sakit)

ISQua International Standards for External Evaluation Organisations,

© The International Society for Quality in Health Care Limited

General comments on SAT

Surveyor Training Details

Change communication includes

Review is done regularly, based on KARS Internal Rules.

displayed on walls and on website)

Ethical principles for staff:

KARS internal regulation: the values adopted in executing

Written records and documentation on planning, brochure,

1.2.6. Sample of surveyor's signature on Ethic Code

2. The surveyor's code of ethics was read in front of the

1.3.2. example of consultation meeting limiting survivor as a

Hospital (KARS) if it meets all the following criteria:

1. The hospital is located in the territory of Indonesia

All KARS survivors in carrying out the accreditation survey

The results of the graduation survey accreditation decision

agendas/papers Risk IT management (in information / own server and back

Management and Supervisory Board

• Budget approval 1. Offensive strategy, namely:

2. Aggressive strategies or growth strategies, namely:

financial performance through improving infrastructure and

KARS itself routinely conducts workshops for hospitals

workshops and seminars to help hospitals understand the

KARS realised that the organisation has been developing

Questionnaires to stake holder has been made (Ministry of

The content of KARS’s website is always updated and now

KARS is a member of ISQUA and routinely attends

Executive Board to conduct or lead the Governing Body Executive Chair.

The Performance Target for the Executive Chair is contained

- Achievement Accreditation Graduation Results

The task of the Supervisory Body is to supervise and advise

to explain the authority of the duties and responsibilities of

2.3 The external evaluation organisation: Self - Rating 4 Technical Review

• Examples of contract/tenders for services outsourced

2.4 The external evaluation organisation: Self - Rating 4 Technical Review

Examples may be Bukti:

• Decision making process

• Evidence of stakeholder involvement

2.1.3c Year 2018

• Financial policies and procedures

i. are timely and accurate; 2. Annual Report.

2.1.4 Budget realization report to the Governing Body.

2.1.4b Year 2017

through fire insurance for buildings and their contents. black)

• Asset register the risk of fire.

objectives, is measured regularly and achievement is

• Chief executive/senior management performance

procedures information deleted

quality of KARS service. analysed, reported, reviewed and acted upon.

Furthermore researches on the accreditation process are

Independent Auditor are submitted to the Governing Body.

To improve the quality KARS changed the accreditation

been renewed on January 2017 by restructurize that the

improvment are established base on KARS strategic plan

The Commitee reviewed Policy of qualityimprovement plan

These indicaors are :

I.Indicator for quality improvment survey

II.Indicators for surveyor competencies and survey

III.Indicator for staff satisfaction :

IV.Indicator for Serveyor Training Programme:

KARS makes innovation by changes the 2012 version of