Audit Report Template



Draft Audit ReportSurveillance audit for DOCVARIABLE "CLIENT NAME" \* MERGEFORMAT Rumah Sakit Jiwa Daerah Surakarta DOCVARIABLE "AUDIT ADDRESS" \* MERGEFORMAT Jl. Ki Hajar Dewantoro No. 80, Jebres, SURAKARTA, Central Java, IndonesiaCertificate No.: DOCVARIABLE "CERTIFICATE NUMBER" \* MERGEFORMAT QEC27323Audit Date: DOCVARIABLE "DATE OF AUDIT" \* MERGEFORMAT 12/18/2014 - 12/19/2014Work Item I.D.: DOCVARIABLE "WORK ITEM ID" \* MERGEFORMAT AS-406819BACKGROUND INFORMATIONSAI Global conducted an audit of DOCVARIABLE "CLIENT NAME" \* MERGEFORMAT Rumah Sakit Jiwa Daerah Surakarta on DOCVARIABLE "DATE OF AUDIT" \* MERGEFORMAT 12/18/2014 - 12/19/2014.The purpose of this audit report is to summarise the degree of compliance with relevant criteria, as defined on the cover page of this report, based on the evidence obtained during the audit of your organisation. This audit report considers your organisation’s policies, objectives, and continual improvement processes. Comments may include how suitable the objectives selected by your organisation appear to be in regard to maintaining customer satisfaction levels and providing other benefits with respect to policy and other external and internal needs. We may also comment regarding the measurable progress you have made in reaching these targets for improvement.SAI Global audits are carried out within the requirements of SAI Global procedures that also reflect the requirements and guidance provided in the international standards relating to audit practice such as ISO/IEC 17021, ISO 19011 and other normative criteria. SAI Global Auditors are assigned to audits according to industry, standard or technical competencies appropriate to the organisation being audited. Details of such experience and competency are maintained in our records.In addition to the information contained in this audit report, SAI Global maintains files for each client. These files contain details of organisation size and personnel as well as evidence collected during preliminary and subsequent audit activities (Documentation Review and Scope) relevant to the application for initial and continuing certification of your organisation.Please take care to advise us of any change that may affect the application/certification or may assist us to keep your contact information up to date, as required by SAI Global Terms and Conditions.This report has been prepared by SAI Global Limited (SAI Global) in respect of a Client's application for assessment by SAI Global. The purpose of the report is to comment upon evidence of the Client's compliance with the standards or other criteria specified. The content of this report applies only to matters, which were evident to SAI Global at the time of the audit within the audit scope. SAI Global does not warrant or otherwise comment upon the suitability of the contents of the report or the certificate for any particular purpose or use. SAI Global accepts no liability whatsoever for consequences to, or actions taken by, third parties as a result of or in reliance upon information contained in this report or certificate.Please note that this report is subject to independent review and approval. Should changes to the outcomes of this report be necessary as a result of the review, a revised report will be issued and will supersede this report.Standard(s): DOCVARIABLE STANDARD(S) \* MERGEFORMAT 9001:2008 | CertificationCode(s): DOCVARIABLE CODE(S) \* MERGEFORMAT 86Scope of Certification: DOCVARIABLE "SCOPE OF CERTIFICATION" \* MERGEFORMAT Operations of mental/psychiatric hospital for outpatient service emergency service and radiology.Number of Staff:80Shifts: DOCVARIABLE SHIFTS \* MERGEFORMAT nilTotal audit duration: DOCVARIABLE "TOTAL AUDIT DURATION" \* MERGEFORMAT 32 hrsAudit Team: DOCVARIABLE "AUDIT TEAM" \* MERGEFORMAT Desti Hilvawaty - AuditorOther Participants: DOCVARIABLE "OTHER PARTICIPANTS" \* MERGEFORMAT dr. Adi Soekardi - Technical ExpertDefinitions and action required with respect to audit findingsLegend to symbols: Compliant ! Area of Concern NCR Opportunity for ImprovementNon-conformance: Based on objective evidence, the absence of, or a significant failure to implement and/or maintain conformance to requirements of the applicable standard. Such issues may raise significant doubt as to the capability of the management system to achieve its intended outputs.NOTE: The “applicable Standard” is the Standard which SAI Global are issuing certification against, and may be a Product Standard, a management system Standard, a food safety Standard or another set of documented criteria.Action required: This category of findings requires SAI Global to issue a formal NCR; to receive and approve client’s proposed correction and corrective action plans; and formally verify the effective implementation of planned activities. Correction and corrective action plan should be submitted to SAI Global prior to commencement of follow-up activities as required. Follow-up action by SAI Global must ‘close out’ the NCR or reduce it to a lesser category within 90 days for surveillance audits. If significant risk issues (e.g. safety, environmental, food safety, product legality/quality, etc.) are detected during an audit these shall be reported immediately to the Client and more immediate or instant correction shall be requested. If this is not agreed and cannot be resolved to the satisfaction of SAI Global, immediate suspension shall be recommended.In the case of an already certified client, failure to close out NCR within the time limits means that suspension proceedings may be instituted by SAI Global. Follow-up activities incur additional charges.Area of Concern: Area of the system for which the client is required to investigate potential nonconformity. Action required: SAI Global may require client to formulate preventive action plan for approval prior to next planned audit / certification decision or alternatively may follow up client’s preventive action at the next planned audit. Lack of client attention to such issues implies that a preventive action system is not working effectively, and could result in an NCR being raised at a later date.Opportunity for Improvement:A documented statement, which may identify areas for improvement however shall not make specific recommendation(s). Action required: Client may develop and implement solutions in order to add value to operations and management systems. SAI Global is not required to follow-up on this category of audit finding. Executive Overview The objective of this audit was to determine continuing compliance of your organisation’s management system with the audit criteria; and its effectiveness in achieving continual improvement and system objectives. Based on the evidence verified and findings of this audit, the management system is being managed and utilised by all employees interviewed. There is appropriate input and support from top management. There have been no issues identified that need immediate attention although the contents of this report should be fully reviewed to determine any ongoing system improvement opportunities. The recommendation from this audit is that your certification continues.Meeting Attendance Register see attendance registerNamePositionEntryExitReview of any changes including documentation There has been no significant change to the organisation scope and structure since last audit.The management system manual revision was reviewed and found to be in conformance with the requirements of the standard. Use of marks and/or any other reference to certificationThe use of the Standards Mark and claims of certification appear to be in accordance with the guidelines available via the SAI Global website. Actions taken on previous audit issuesAll Areas of Concern have been followed up and are now considered adequately addressed or sufficient evidence of progress and action was identified to enable final verification during the next audit..Management responsibilities, commitment and performance monitoring There continues to be a satisfactory level of input and support from top management to ensure the quality management system provides the intended controls, customer satisfaction and improvement opportunities. The health and performance of the system continues to be monitored via KPI’s and related targets. The stated quality objectives are being met, such as registration (medical records), outpatient services, emergency services, radiology, human resources, IPSRS, sanitation, procurement, training and education services, laundry, pharmacy IGD, and marketing.Management review Management review has been performed on 25 November 2014. Records of the most recent management review meetings were verified and found to meet the requirements of the standard. All inputs were reflected in the records, and appear suitably managed as reflected by resulting actions and decisions.Opportunities for Improvement:Direkomendasikan notulen rapat tinjauan manajemen juga mereview (membahas) hasil evaluasi performance auditor internal sebagai input untuk improvement.Internal Audits Internal audits are being conducted at planned intervals to ensure conformance to planned arrangements, the requirements of the standard and the established management system. Internal audit has done on 12 November 2014. It appears the several of internal auditor assigned were independent from areas audited. Internal audit checklists were used as audit guidance and audit record. There were several negative internal audit findings identified which were followed up by issuance of corrective action request. Internal auditor performance evaluation has been performed with 5 aspects, i.e. attendance (kehadiran), politeness (kesopanan), hospitality (keramahan), relevant (keterkaitan), and seriously (keseriusan).Customer satisfaction The customer’s perception of meeting customer requirements is adequately managed by the company. The information obtained is being utilized to drive management system improvement as referred to “KEPMENPAN no. 25/2004” with the result of very good, such as: outpatient services 3.54 (88.51%), radiology 3.76 (93.42%), IGD 3.71 (92.92%), pharmacy 3.44 (86.11%), plaint handling The company is implementing an effective process for the management of customer complaints, including the implementation of appropriate corrective action measures. Complaint handling has been recorded and followed up. Several records has sighted during audit, such as logbook complaint handling and complaint report.Opportunities for Improvement:Sangat disarankan laporan rekapitulasi dan /atau logbook keluhan pelanggan ditambahkan informasi terkait dengan penanggung jawab tindakan koreksi, waktu verifikasi (termasuk nama personal/verifikatornya).Continual Improvement The company is implementing an effective process for the continual improvement of the management system through the use of the quality policy, quality objectives, audit results, data analysis, the appropriate management of corrective and preventive actions and management review. Review of functions, processes, departments auditedFunctions & processes verified: This audit included a review of the controls and interactions between functions and the impacts of those processes on internal and external customers. Details regarding the personnel interviewed and objective evidence reviewed are maintained on file at SAI Global. The relationship between the various aspects of your organisation have been enhanced or restricted by the management system in the following ways: Outpatient ServiceAreas of ConcernDitemukan pasien RM 55659 atas nama Astri Wahyuningtyas umur 31 tahun tanggal 29 November 2014 pasien pos rawat jalan pada lembar rekam medis rawat jalan hanya menuliskan pasien pulang dengan perbaikan tanpa pemeriksaan fisik diagnostic dan diagnosis.Surat pelimpahan wewenang untuk paramedic rawat jalan belum ditetapkan mengenai sejauh mana kompetensi yang diberikan.Registration and Medical Record ControlOpportunities for Improvement:Disarankan untuk mekanisme back up data pasien in-aktif terkait dengan electronic data agar ditetapkan.Sangat disarankan untuk pemantauan barang terkait dengan kartu status rekam medis dibuatkan kartu stok.PurchasingAreas of Concern Proses pengadaan pekerjaan (“Perencanaan pembangunan kontruksi jalan pada RSJD Ska”) teleh selesai dilaksanakan sesuai dengan kontrak SPK No. 602.51/193.1/01/2014 tanggal 20 January 2014, dimana pekerjaan dilaksanakan pada rentang waktu 45 hari dan telah disahkan oleh kedua belah pihak (pihak ke-1 PPK RSJD Ska dan pihak ke-2 CV bangun Cipta Ska). Namun pada kontrak tersebut terdapat kerancuan waktu yang ditetapkan, yaitu sejak 21 January 2013 sampai 6 March 2014.Prosedur evaluasi supplier telah ditetapkan pada prosedur 03.28.03, dimana aspek evaluasi terdiri dari 4 aspek (harga, kualitas, kelengkapan barang dan kelengkapan administrasi), sedangkan untuk aspek pelayanan belum ditetapkan, seperti aktual yang dilakukan untuk CV Bangun Cipta dan PT Medika Pratama jaya. Opportunities for Improvement:Sangat disarankan untuk prosedur pengadaan barang dan jasa serta prosedur evaluasinya, agar ditinjau ulang terkait dengan peraturan yang belum ditetapkan, seperti Perpres No. 70 tahun 2012, seperti aktual dilakukan.Sanitation Areas of Concern Hasil inspeksi makanan minuman telah merujuk pada Kemenkes RI No. 1204/Menkes/SK/X/2004 tentang persyaratan kesehatan lingkungan rumah sakit. Berdasarkan pengamatan pasa form “Inspeksi sanitasi penyehatan makanan minuman” yang dilakukan bulanan, terlihat selama periode 2014 utnuk aspek tempat penyimpanan bahan makanan dan makanan jadi > 6 jam T =: -5 s.d. – 1C (STD 30 – 90) hasilnya adalah nol, padahal makanan yang diberikan kurang dari 6 jam/ langsung diberikan, sehingga skor hasil penilaian rendah. Juga untuk aspek Lantai dapur sebelum dan sesudah kegiatan dibersihkan dengan antiseptic (STD 50 – 200), hasilnya adalah nol, aktualnya dibersihkan tanpa menggunakan antiseptic. Begitu pula resume (follow up) belum dijelaskan pada setiap laporan bulanan.Berdasarkan pengamatan lapangan ditemukan beberapa inkonsistensi dalam pemilahan sampah medis dan non medis, seperti di area:IGD: tong sampah medis berisi sisa makanan dan telurDi depan Ruang perawatan Wisanggeni ditemukan botol bekas infuse dextrose 5% berserakan di luar.APD staff cleaning service tidak dipakai (ruang Wisanggeni)R. Gizi: insect killer belum difasilitasi, sedangkan spray killer tidak berfungsi. etcOpportunities for Improvement: Disarankan untuk insect killer ada pada setiap ruangan perawatan.Sangat disarankan tempat sampah non medis diperbanyak terutama pada area terbuka dan ruang perawatan, ruang VIP, Larasati dan Wisanggeni.Sangat disarankan untuk kolam indicator diisi dengan ikan sebagai parameter pencemaran limbah air.A proposed plan for the next audit is included on the last page of this report.Thank you for the cooperation and hospitality extended.This report was prepared by: Desti Hilvawaty and dr. Adi SoekardiNEXT AUDIT PLANDuring our next audit the issues identified as requiring attention will be reviewed to ensure they have been adequately addressed, as well as the following set out in the plan below:This plan is a draft and can be modified to suit the availability of relevant people.Audit type :DateAuditorAudit meetings plus functions/ processes/ areas/ shifts audited# ShiftApprox. timeEntry MeetingReport Preparation/ Exit Meeting ................
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