Hospital as a health care institution must provide quality services to the community. Quality of service is a standard that will be made to increase the hospital accreditation. In addition to the accredited national standards, some hospitals in Indonesia, especially government hospitals, will also be accredited to use international standards. Actually in Indonesia has a lot of hospitals which are internationally accredited, but most private hospitals. This condition is to give the impression that government hospitals are less credible and less able to provide the best service both communities. To achieve this, the government in collaboration with international accreditation agency that is Joint Commission International (JCI), USA.

1. Linta Meyla Putri HOSPITAL ADMINISTRATION
“IMPROVING HOSPITAL ACCREDITATION BASED ON PATIENT-CENTERED
PROGRAMS AND QUALITY MANAGEMENT OF HEALTH CARE”
Linta Meyla Putri
101211131047
IKMB 2012
INRODUCTION
Nowadays people are increasingly
aware to choose a good health service.
Some examples are the people currently
no longer hesitate to ask question about
alternative treatments they will receive
according to their current financial
condition. They also no longer hesitate to
discuss with doctor about the use and side
effects of prescription drugs to them.
People are also starting to ask question
whether the critical medical devices that
are used to check them is sterile or not.
Even some people who want to see the
sterilization process. When there is a less
satisfactory service, today they dont
hestitate to reprimand medical staff who
concerned on that case or they’ll give their
complain to suggestion box. The people
want the best service for them according
their current condition .
Hospital as a health care institution
must provide quality services to the
community. Quality of service is a
standard that will be made to increase the
hospital accreditation. In addition to the
accredited national standards, some
hospitals in Indonesia, especially
government hospitals, will also be
accredited to use international standards.
Actually in Indonesia has a lot of hospitals
which are internationally accredited, but
most private hospitals. This condition is to
give the impression that government
hospitals are less credible and less able to
provide the best service both communities.
To achieve this, the government in
collaboration with international
accreditation agency that is Joint
Commission International (JCI), USA. JCI
chosen because most are affiliated with
major hospitals in the world and is one of
the accrediting agencies that are
considered inexperienced. International
accreditation is intended to equalize the
quality of hospital services by government
hospitals internationally. With the
international accreditation is expected to
grow also trust and recognition from the
community that the government hospitals
to provide the best health services . With
this recognition is expected to stem the
flow of people vying to seek treatment
abroad. With the international
accreditation, the government guarantees
the quality improvement of health service

2. Linta Meyla Putri, Improve Hospital Accreditation
2
in government hospitals without being
accompanied by rising prices .
LITTERATURE REVIEW
Minister In Health No.12/2012
tentang Akreditasi Rumah Sakit adalah
pengakuan terhadap Rumah Sakit yang
diberikan oleh lembaga independen
penyelenggara Akreditasi yang ditetapkan
oleh Menteri, setelah dinilai bahwa Rumah
Sakit itu memenuhi Standar Pelayanan
Rumah Sakit yang berlaku untuk
meningkatkan mutu pelayanan Rumah
Sakit secara berkesinambungan, its mean
that Accreditation is a process by which an
institution or disciplinary unit within an
institution periodically evaluates its work
and seeks an independent judgment by
peers that it achieves substantially its own
educational objectives and meets the
established standards of the body from
which it seeks accreditation. (Permenkes,
No.12 tahun 2012)
Health Care Accreditation is a
process in which an entity, sepate and
distinct from the health care organization,
usually nongovernmental, assesses the
health care organization to determine if it
meets a set of requirements designed to
improve quality of care. (JCI
Acccreditation Standards for Hospital,
2002)
The ideal modern hospital is a
place both where ailing people seek and
receive care and where clinical education
is provided to medical students, nurses,
and virtually the whole spectrum of health
professionals. It provides continuing
education for practicing physicians and
increasingly serves the function of an
institution of higher learning for entire
neighborhoods, communities, and regions.
In addition to its educational role, the
modern hospital conducts investigation
studies and research in medical sciences
both from clinical records and from its
patients, as well as basic research in
science, physics, and chemistry. (Wolper,
2011)
The Joint Commision is a private,
not-for-profit organization dedicated to
continuosly improving the safety and
quality of care provided to the public. The
Joint Commission is the nation’s principal
standards setter and evaluator for a
variety of health care organization,
including hospitals, critical access
hospitals, ambulantory care organization,
behavioral health care organizations,
home care organizations, labolatories,
long term care organizations, and office-
based surgery practices. (Accreditation
Process Guide for Hospitals, 2012)
Joint Commission International
(JCI) is a division of the JACHO (Joint
Commision on Accreditation of Healthcare
Organization). Joint Commission
International (JCI)’s mission is to improve
the quality of health care in the
international community by providing
worldwide accreditation services. (JCI
Acccreditation Standards for Hospital,
2002)

3. Linta Meyla Putri, Improve Hospital Accreditation
3
KARS (Komisi Akreditasi Rumah
Sakit) is a Commite Of Hospital
Accreditation in Indonesia, this is an
independent statue and the main job is
measuring the hospital services to give
accreditation.
DISSCUSSION
In general, many healthcare
centers have such primary objectives as
providing primary, secondary, or tertiary
care2 to the sick and injured; providing
healthcare at a reasonable cost doing
research working toward advancement of
medical knowledge; helping in the
maintenance of health and in the
prevention of sickness, recruiting
outstanding graduates from medical
schools, providing education, and training
employees in all the professional and
nonprofessional activities customarily
associated with a healthcare institution.
(Dunn, 2002)
To face the dynamics of society in
such a way, the government through the
Ministry of Health didn’t stay quite. The
Ministry of Health Republic of Indonesia
requires the implementation of hospital
accreditation in order to improve hospital
services in Indonesia. The foundations for
the hospital accreditation is UU No. 36 of
2009 on Health, UU no. 44 of 2009 on the
hospital and the Permenkes No.12/2012
on the organization and functioning of the
health ministry.
Accreditation means a recognition
given to the government hospital for
compliance with established standards.
Hospitals that have been accredited,
received recognition from the government
that all things in it are in accordance with
the standards. Facilities and infrastructure
owned hospital, has standards.
Procedures performed to patients are also
in accordance with the standard .
Based Health Ministry Of Indonesia
version accreditation standards , there are
three stages in the implementation of the
accreditation is a basic level of
accreditation, accreditation advanced and
complete level of accreditation.
a) Basic level accreditation services
assess the five activities in hospitals,
namely: Administration and
Management, Medical Services,
Nursing Services, Emergency Services
and Medical Records .
b) Advanced accreditation services
assess the 12 activities in hospitals,
namely: basic level service plus
accredited Pharmacy, Radiology,
Operating Room, Infection Control,
High Risk Services, Laboratory and
Safety , Fire and Disaster Awareness
(K-3).
c) Accreditation level 16 fully assess
service activities in hospitals, namely:
service accredited advanced plus
Intensive Care, Blood Transfusion
Services, Medical Rehabilitation
Services and Nutrition Services.
Hospitals may choose to implement a
basic level accreditation (5 services),
advanced (12 services) or full rate (16

4. Linta Meyla Putri, Improve Hospital Accreditation
4
services) depends on the ability, readiness
and needs of both the hospital at the time
of the first assessment or reassessment
after accredited. Certification is awarded to
hospitals in the form: not accredited,
conditional accreditation, full accreditation
and special accreditation. Not accredited
means that the assessment is 65% or one
service activity only reached 60%.
Conditional accreditation means appraisal
reach 65%-75% and valid for one year.
Full accreditation means that the
assessment is 75% and is valid for 3
years.
Special accreditation given if in three
consecutive years reaches hospital is fully
accredited and it is valid for 5 years. The
hospital shall implement the accreditation
of at least 6 months after the license
renewal decree exit and 1 year after
decree operating permit. Purpose of an
accreditation survey is for assesses an
organization’s compliance with JCI
standards and their intent statements.
For decades, hospitals participated in a
voluntary self-regulatory process. In the
early 1950s, a program of hospital self-
inspection, sponsored by the American
College of Surgeons, began expanding
into the present Joint Commission on
Accreditation of Healthcare Organizations
(JCAHO). Originally, the “Joint
Commission” surveyed and accredited
only hospitals. Today JCAHO
accreditation includes critical access
hospitals, pathology and clinical laboratory
services, home health agencies,
behavioral health care services, long-term
care facilities, ambulatory care centers,
health care networks and managed care.
The Joint Commission conducts a
voluntary survey program of hospitals. A
hospital must request and pay for a
survey.
The survey evaluates the organization’s
compliance based on
a) Interviews with staff and patients and
other verbal information
b) On-site observations of patients care
processed by the surveyors
c) The results of self-assessements when
part of the accreditation process.
The on-site survey process, as well as
continued self-assessment, help
organizations identify and correct
problems and improve the quality of care
and services.
Actually, as a hospital manager there
are two point that should have to improve
for Hospital Accreditation, such as
Improve Patient-Centered Standards and
Improve Health Care Management
Standards.
A. Strategi to Improve Patient-Centered
Standards, there are many standards
that must improved, such as :
1. International Patient Safety Goals
(IPSG)
The purpose of the IPSG is to promote
specific improvements in patient safety.
The goals highlights problematic areas
in health care and describe evidence
and expert-based concensus solutions
to these problems.

5. Linta Meyla Putri, Improve Hospital Accreditation
5
a) Identify Patients Correctly
b) Improve Effective communication
c) Improve the safety of high-alert
medications
d) Ensure correct-site, correct-
procedure, correct patient surgery
e) Reduce the risk of health care
assosiated infection
f) Reduce the risk of Patient Harm
resulting from falls
2. Access to Care and Continuity of Care
A health care organization should
consider the care it provides as part of an
integrated system of services, health care
practitioners and professionals, and levels
of care, which make up a continuum of
care. The goal is to correctly match the
patient’s health care needs with the
services available, to coordinate the
services provided to the patient in the
organization, and then to plan for
discharge and follow-up. The result is
improved patient care outcomes and more
efficient use of available resources.
3. Patient and Family Rights (PFR)
Each patient is unique, with his or her
own needs, strengths, values, and beliefs.
Health care organizations work to
establish trust and open communication
with patients and to understand and
protect each patient’s cultural,
psychosocial, and spiritual values. Patient
care outcomes are improved when
patients and, as appropriate, their families
or those who make decisions on their
behalf are involved in care decisions and
processes in a way that matches cultural
expectations. These processes are related
to how an organization provides health
care in an equitable manner, given the
structure of the health care delivery
system and the health care financing
mechanisms of the country.
4. Assessment of Patient (AOP)
An effective patient-assessment
process results in decisions about the
patient’s immediate and continuing
treatment needs for emergency, elective,
or planned care, even when the patient’s
condition changes. Patient assessment is
an ongoing, dynamic process that takes
place in many inpatient and outpatient
settings and departments and clinics.
Patient assessment consists of three
primary processes:
a) Collecting information and data on the
patient’s physical, psychological, social
status, and health history
b) Analyzing the data and information,
including the results of laboratory and
imaging diagnostic tests, to identify the
patient’s health care needs
c) Developing a plan of care to meet the
patient’s identified needs
Patient assessment is appropriate when it
considers the patient’s condition, age,
health needs, and his or her requests or
preferences. These processes are most
effectively carried out when the various
health professionals responsible for the
patient work together.
5. Care of Patients (COP)

6. Linta Meyla Putri, Improve Hospital Accreditation
6
A health care organization’s main
purpose is patient care. Providing the most
appropriate care in a setting that supports
and responds to each patient’s unique
needs requires a high level of planning
and coordination. Certain activities are
basic to patient care. For all disciplines
that care for patients, these activities
include
a) planning and delivering care to each
patient
b) monitoring the patient to understand the
results of the care
c) modifying care when necessary;
d) completing the care; and
e) planning the follow-up.
6. Anasthesia and Surgical Care (ASC)
The use of anesthesia, sedation, and
surgical interventions are common and
complex processes in a health care
organization. They require complete and
comprehensive patient assessment,
integrated care planning, continued patient
monitoring, and criteria-determined
transfer for continuing care, rehabilitation,
and eventual transfer and discharge.
Anesthesia and sedation are commonly
viewed as a continuum from minimal
sedation to full anesthesia. As patient
response may move along that continuum,
anesthesia and sedation use are
organized in an integrated manner.
7. Medication Management and Use
Medication management is an
important component in symptomatic,
preventive, curative, and palliative
treatment and management of diseases
and conditions. Medication management
encompasses the system and processes
an organization uses to provide
pharmacotherapies to its patients. This is
usually a multidisciplinary, coordinated
effort of staff of a health care organization,
applying the principles of effective process
design, implementation, and improvement
to the selecting, procuring, storing,
ordering/prescribing, transcribing,
distributing, preparing, dispensing,
administering, documenting, and
monitoring of medication therapies.
8. Patient and Family Education
Patient and family education helps
patients better participate in their care and
make informed care decisions. Many
different staff in the organization educate
patients and families. Education takes
place when the patient interacts with his or
her physicians or the nurses. Others
provide education as they provide specific
services, such as rehabilitation or nutrition
therapy, or prepare the patient for
discharge and continuing care. Because
many staff help educate patients and
families, it is important that staff members
coordinate their activities and focus on
what patients need to learn.
B. Strategi to improve Health Care
Organization Management Standards
1. Quality Improvement and Patient Safety
Approach to quality improvement and
patient safety. Integral to overall
improvement in quality is the ongoing
reduction in risks to patients and staff.
Such risks may be found in clinical

7. Linta Meyla Putri, Improve Hospital Accreditation
7
processes as well as in the physical
environment. This approach includes
a. leading and planning the quality
improvement and patient safety
program
b. designing new clinical and managerial
processes well
c. measuring how well processes work
through data collection
d. analyzing the data
e. implementing and sustaining changes
that result in improvement.
Quality and safety are rooted in the daily
work of individual health care
professionals and other staff. As
physicians and nurses assess patient
needs and provide care, this chapter can
help them understand how to make real
improvements that help patients and
reduce risks. Similarly, managers, support
staff, and others can apply the standards
to their daily work to understand how
processes can be more efficient,
resources can be used more wisely, and
physical risks can be reduced. This
approach takes into account that most
clinical care processes involve more than
one department or unit and may involve
many individual jobs. This approach also
takes into account that most clinical and
managerial quality issues are interrelated.
Thus, efforts to improve those processes
must be guided by an overall framework
for quality management and improvement
activities in the organization, overseen by
a quality improvement and patient safety
oversight group or committee. (Griffth &
R, 2006)
2. Prevention and Control of Infectious
Goal of an organization’s infection
prevention and control program is to
identify and to reduce the risks of
acquiring and transmitting infections
among patients, staff, health care
professionals, contract workers,
volunteers, students, and visitors. The
infection risks and program activities may
differ from organization to organization,
depending on the organization’s clinical
activities and services, patient populations
served, geographic location, patient
volume, and number of employees.
3. Governance, Leadership and Direction
Providing excellent patient care
requires effective leadership. That
leadership comes from many sources in a
health care organization, including
governing leaders (governance), leaders,
and others who hold positions of
leadership, responsibility, and trust. Each
organization must identify these
individuals and involve them in ensuring
that the organization is an effective,
efficient resource for the community and
its patients.
Effective leadership begins with
understanding the various responsibilities
and authority of individuals in the
organization and how these individuals
work together. Those who govern,
manage, and lead an organization have
both authority and responsibility.
Collectively and individually, they are

8. Linta Meyla Putri, Improve Hospital Accreditation
8
responsible for complying with laws and
regulations and for meeting the
organization’s responsibility to the patient
population served.
4. Facility Management and Safety
Health care organizations work to
provide safe, functional, and supportive
facilities for patients, families, staff, and
visitors. The construction of the modern
hospital is regulated or influenced by
federal laws, state health department
regulations, city ordinances, the standards
of the Joint Commission on Accreditation
of Healthcare Organizations, and national
and local codes (building, fire protection,
sanitation, etc.). (Wolper, 2011)
To reach this goal, the physical facility,
medical and other equipment, and people
must be effectively managed. In particular,
management must strive to
a. reduce and control hazards and risks
b. prevent accidents and injuries
c. maintain safe conditions.
Written plans are developed and include
the following six areas, when appropriate
to the facility and activities of the
organization:
a) Safety and Security
i. Safety The degree to which the
organization’s buildings, grounds, and
equipment do not pose a hazard or
risk to patients, staff, or visitors.
ii. Security Protection from loss,
destruction, tampering, or
unauthorized access or use.
b) Hazardous materials Handling, storage,
and use of radioactive and other
materials are controlled, and hazardous
waste is safely disposed.
c) Emergency management Response to
epidemics, disasters, and emergencies
is planned and effective.
d) Fire safety Property and occupants are
protected from fire and smoke.
e) Medical equipment Equipment is
selected, maintained, and used in a
manner to reduce risks.
f) Utility systems Electrical, water, and
other utility systems are maintained to
minimize the risk of operating failures.
5. Staff Qualifications and Educations
A health care organization needs an
appropriate variety of skilled, qualified
people to fulfill its mission and to meet
patient needs. The organization’s leaders
work together to identify the number and
types of staff needed based on the
recommendations from department and
service directors.
Recruiting, evaluating, and appointing
staff are best accomplished through a
coordinated, efficient, and uniform
process. It is also essential to document
applicant skills, knowledge, education, and
previous work experience. It is particularly
important to carefully review the
credentials of medical and nursing staff,
because they are involved in clinical care
processes and work directly with patients.
Health care organizations should provide
staff with opportunities to learn and to
advance personally and professionally.
Thus, in service education and other

9. Linta Meyla Putri, Improve Hospital Accreditation
9
learning opportunities should be offered to
staff.
6. Management of Communication and
Information
Providing patient care is a complex
endeavor that is highly dependent on the
communication of information. This
communication is to and with the
community, patients and their families, and
other health professionals. Failures in
communication are one of the most
common root causes of patient safety
incidents. To provide, coordinate, and
integrate services, health care
organizations rely on information about the
science of care, individual patients, care
provided, results of care, and their own
performance
Many things have to be improved to
increase the hospital accreditation, which
is centered on patient care and improving
the quality of health care management in
order to achieve optimal patient recovery.
To give satisfaction to the patient, then the
standard of hospital services should be
able to satisfy the patient. Therefore, it is
necessary to establish some sort of
independent commission hospital
standards in hospital organizational
structures. Whose task is to monitor the
development of hospital services in order
to meet standards. So this committee
served as a supervisor for the hospital as
well as an increase in the accreditation
committee, and it must be continunous
improvement.
Continuous improvement may also
be expressed when managers support
continuous quality improvement projects
that address specific problems or
performance gaps. An improvement
project involves assembling a team to
solve a problem or improve performance
in a designated area. The team is
responsible for designing and
implementing improvements to the
underlying work process. Managers may
demonstrate their support of project
teams by effectively initiating the project,
promoting buy-in, and taking specific
management actions that will help the
team succeed. (Kelly, 2003).
Strategies should aim at fostering
national accreditation initiatives and
providing guidance for national
accreditation efforts to ensure that
accreditation systems are developed in a
way that upholds the principles of health
for all. The following strategies may be
implemented by Member States in
collaboration with WHO. The strategy that
I’ll recommend are :
a) Raising awareness at national level and
encouraging debate by interested
stakeholders to develop consensus on
launching hospital accreditation.
b) Strengthening hospital inspection units
and improving administrative
procedures in ministries of health in
preparation for launching accreditation.
c) Establishing national hospital registers
with detailed profiles of individual
hospitals.

10. Linta Meyla Putri, Improve Hospital Accreditation
10
d) Studying efforts and experiences in
hospital accreditation in the Region and
exchanging experiences through a
network of interested institutions and
experts.
e) Collaborating with regional and
international bodies for advocacy of
hospital accreditation.
f) Participating in annual international
forums, meetings of the International
Society for Quality in Health Care to
update knowledge on hospital
accreditation and share experiences
with others.
g) Designating an expert advisory group
on hospital accreditation in the Region
to provide objective guidance to
national authorities in addressing
accreditation issues.
h) Reviewing periodically and
documenting progress in implementing
hospital accreditation in the Region.
Applying, after adaptation, the suggested
steps for implementing hospital
accreditation at national and local
(hospital) levels.
Improvement gradients are embedded
into the health care accreditation process.
First, the standards encourage
organizations to achieve particular criteria.
Second, accrediting bodies revise their
standards over time so they are based on
up-to-date research and accepted best
practices. Both of these elements elicit
continuous quality improvement efforts.
The goal is to contribute to the provision of
high-quality and safe health care services
and to improve patients’ health outcomes
(Braithwaite, 2010; Øvretveit, 2009).
CONCLUSION
Accreditation can be the single most
important approach for improving the
quality of health care structures. In an
accreditation system, institutional
resources are evaluated periodically to
ensure quality of services on the basis of
previously accepted standards. Standards
may be minimal, defining the bottom level
or base, or more detailed and demanding.
Accreditation is not an end in itself, but
rather a means to improve quality. The
accreditation movement is gaining
prominence due to globalization and
especially the global expansion of trade in
health services. It will eventually become a
tool for international categorization and
recognition of hospitals. When
implemented appropriately, accreditation
can strengthen the fundamental leadership
and steering role of national health
authorities.
In general, many healthcare centers
have such primary objectives as providing
primary, secondary, or tertiary care to the
sick and injured; providing healthcare at a
reasonable cost; doing research; working
toward advancement of medical
knowledge; helping in the maintenance of
health and in the prevention of sickness;
recruiting outstanding graduates from
medical schools; providing education; and
training employees in all the professional
and nonprofessional activities customarily

11. Linta Meyla Putri, Improve Hospital Accreditation
11
associated with a healthcare institution.
There are two things that need to be
noticed to improve hospital accreditation,
which is focused on patient care and
hospital management service
improvement. This must be followed with
some strategy and there should be special
committee to monitor the development of
services in the hospital.
We should improve Patient-Centered
Standards International Patient Safety
Goals (IPSG), Access to Care and
Continuity of Care, Patient and Family
Rights (PFR), Assessment of Patient
(AOP), Care of Patients (COP),
Anasthesia and Surgical Care (ASC),
Medication Management and Use , Patient
and Family Education . Health Care
Organization Management Standards
such as Quality Improvement and Patient
Safety, Prevention and Control of
Infectious , Governance, Leadership and
Direction, Facility Management and
Safety, Staff Qualifications and
Educations, Management of
Communication and Information

12. Linta Meyla Putri, Improve Hospital Accreditation
12
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