296498555 Pedoman Komite Medis Edit

8/16/2019 296498555 Pedoman Komite Medis Edit

http://slidepdf.com/reader/full/296498555-pedoman-komite-medis-edit 1/22

RSUD DR. DJASAMEN SARAGIH KOTA

PEMATANGSIANTAR JL. SUTOMO NO. 230 TELP (0622) 23823-23824-22959 FAX (0622) 23824

SURAT KEPUTUSAN DIREKTUR

RSUD DR. DJASAMEN SARAGIH KOTA PEMATANGSIANTAR

Nomor: -------------------------

Tentang:

PEDOMAN PENYELENGGARAAN KOMITE MEDIK

RSUD dr. DJASAMEN SARAGIH

Direk!r "SUD #r. D$%&%'e S%r%i*

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k1'ie 'e#ik

3. %*/% !!k 'e7%k&%%k% kei%% k1'ie 'e#ik #e% +%ik

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D$%&%'e S%r%i*

5. %*/% %%r e#1'% &e+%%i'%% #i'%k&!# #%7%' +!ir (4)

#i%%& 'e'!%i kek!%% *!k!' er7! #ie%k% 'e7%7!i

S!r% e!!&% Direk!r.

Mei% , . Peraturan Presiden No.77 tahun 2015 tentang PedomanOrganisasi

Rumah Sakit2) Peraturan Menteri Kesehatan Repubik !ndonesia nomor

755"M#NK#S"P#R"!$"2011 tentang Pen%eenggaraanKomite Medik di Rumah Sakit.

&) Pedoman Kredensia dan Ke'enangan Kinis (ClinicalPrivilege) di Rumah Sakit dari Perhimpunan Rumah SakitSeuruh !ndonesia tahun 200.

*) Kebi+akan Pea%anan Rumah sakit.5) Medical Staf By Laws Rumah Sakit RS,- dr. -+asamen

Saragih

Me'er*%ik% , Me'1 er 1'ie Me#ik N1'1r, 04MT."SML91'#i&:203 eri*%7

Pe#1'% Pee7e%r%% 1'ie Me#ik "SUD #r. D$%&%'e S%r%i*

er%%7 30 J!7i 203



MEMUTUSAN

PEDOMAN PEN;ELEN<<A"AAN OMTE MED

"SUD #r. DJASAMEN SA"A<=

Per%'% , Me'+er7%k!k% e#1'% ee7e%r%% k1'ie 'e#ik "SUD #r.

D$%&%'e S%r%i* &e+%%i'%% er7%'ir

e#!% , Me%'%%k% ke%#% &e7!r!* $%$%r% #i k1'ie 'e#ik #% % erk%i

'e'e#1'%i e#1'% ee7e%r%% &er% 'e7ek%i r1&e#!r %

#ier7!k%

ei% , Me%'%%k% ke%#% ke!% k1'ie 'e#ik !!k 'e7%k!k% e'%%!%

monitoring #% e>%7!%&i %%& e7%k&%%% e#1'% ii

ee'% , e!!&% ii '!7%i +er7%k! &e$%k %%7 #ie%k%.

e7i'% , i7% #ike'!#i% *%ri er#%% keke7ir!% #%7%' &!r% ke!!&% ii %k%

#i%#%k% ei$%!% ke'+%7i.

Die%k% #i , PEMATAN<SANTA"

T%%7 ,

Direk!r "SUD #r. D$%&%'e S%r%i*

?????????????????????????????

#r.

N"P,



PEDOMAN PENYELENGGARAAN KOMITE MEDIK

RSUD dr. DJASAMEN SARAGIH

KATA PENGANTAR

er#%&%rk% Per'eke& e% ee7%r%% 1'ie Me#i& #ir!'%* &%ki

#i'%k&!#k% !!k 'e'er+%iki #% 'eik%k% kier$% 1'ie Me#i& #i r!'%* &%ki.

De% %#%% Per'eke& N1. 55@MENES@PE"@4A@20-- #i*%r%k% #%% 'eik%k%

r1Be&i1%7i&'e #%7%' 'e7%k!k% ee#%7i% k1'ee&i #% eri7%k! %r% &%B 'e#i&

%%r ke&e7%'%% %&ie er$%'i. D%7%' er%!r% er&e+! $!% #ie%&k% +%*/% 1'ie

Me#i& *%% 'e%%i '%&%7%* ker1Be&i% #%ri &%B '1#i& &%$% #% +!k% 'e%%i

ee717%% r!'%* &%ki.

De% er%!r% er&e+! $!% "SUD #r. D$%&%'e S%r%i* 'eer%k% '1#e7 1'ie

Me#i& % 'e$%'i %% ke717% k7ii& !!k 'e7i#!i %&ie. De% e%!r%er&e+! #i*%r%k% &e'!% &%B 'e#i& "SUD #r. D$%&%'e S%r%i* #%% #ike#%7ik%

#e% 'e%!r ke/e%% k7ii&% (clinical privilege) !!k 'e7%k!k% e7%%%

'e#i&% #% *%% &%B 'e#i& % 'e'e!*i &%r% #% k1'ee&i eri7%k! ere! &%$%

% +17e* 'e7%k!k% e7%%% 'e#i&.

Pe#1'% ee7e%r%% 1'ie Me#ik "SUD #r. D$%&%'e S%r%i* #i!%k%

&e+%%i e#1'% % 'e%!r r1Be&i1%7i%& &e1r% &%B 'e#i& #e% %#%% e#1'%

ee7e%r%% 1'ie Me#i& % +ere% %#% Per'eke& N1.

55@MENES@PE"@@20 #%% #i!%k% &e+%%i %#!% #%7%' 'e$%7%k%

e1r%i&%&i% 1'ie Me#ik #i "SUD #r. D$%&%'e S%r%i*

.



DAFTAR ISI

A I PENDAHULUAN

A. LATA" ELAAN<

. TUJUANC. EENAN<AN LNS

D. PENU<ASAN LNS

A II KOMITE MEDIK

A. ONSEP DASA" OMTE MED

. PE"ANAN OMTE MED DALAM MENE<AAN

P"OFESONALSME

C. TU<AS OMTE MED

D. PEN<O"<ANSASAN OMTE MED

E. =UUN<AN OMTE MED DEN<AN PEN<ELOLA "UMA=

SAT. PE"ANAN O"<ANSAS PE"UMA=SATAN DALAM

PEME"DA;AAN OMTE MED D "UMA= SAT

A III SUKOMITE KREDENSIAL

A. TUJUAN

. ONSEP

C. EAN<<OTAAN

D. MEANSME "EDENSAL DAN PEME"AN EENAN<AN

LNS A< STAF MEDS D "UMA= SAT

A I! SUKOMITE MUTU PROFESI

A. TUJUAN

. ONSEP

C. EAN<<OTAAN

D. MEANSME E"JA

A ! SUKOMITE ETIKA DAN DISIPLIN PROFESI

A. TUJUAN

. ONSEP

C. EAN<<OTAAN

D. MEANSME E"JA

A !I PETUNJUK TEKNIS PENYUSUNAN PERATURAN INTERNAL STAF

MEDIS

A. PENDA=ULUAN

. FO"MAT DAN SUSTANS PE"ATU"AN NTE"NAL STAF MEDS

A !II PENUTUP



A I

PENDAHULUAN

A. LATAR ELAKANG

"!'%* &%ki 'er!%k% i&i!&i % &%% k1'7ek& #% +eri&ik1 ii (high

risk ) er7e+i* #%7%' k1#i&i 7ik!% rei1%7 #% 71+%7 % &%% #i%'i&

er!+%*%%. S%7%* &%! i7%r e7%%% 'e#i& %#%7%* %% ke717% k7ii& (clinical

governance) % #i7%k&%%k% &%B 'e#i&. Direk!r r!'%* &%ki +er%!$%/%+ %%&

&e%7% &e&!%! % er$%#i #i r!'%* &%ki *%7 ii &e&!%i % #i'%k&!# #%7%' P%&%7 46

UU N1. 44 T%*! 2009 e% "!'%* S%ki.

e+er%#%% &%B 'e#i& #%7%' r!'%* &%ki &%% ei k%re% k!%7i%&

e7%%% r!'%* &%ki &%% #ie!k% 17e* kier$% %r% &%B 'e#i& #i r!'%* &%ki

er&e+!. ;% 7e+i* ei 7%i kier$% &%B 'e#i& %k% &%% 'e'e%r!*ike&e7%'%% %&ie #i r!'%* &%ki. U!k i! r!'%* &%ki er7! 'ee7e%r%k% %%

ke717% k7ii& (clinical govarnance) % +%ik !!k 'e7i#!i %&ie. =%7 ii &e$%7%

#e% %'%% er%!r% er!#%-!#%% % erk%i #e% ke&e*%% #%

er!'%*&%ki%.

Per%!r% Meeri e&e*%% "e!+7ik #1e&i% N1. 55@Me(ke&@20 e%

Pee7e%r%% 1'ie Me#ik #i "!'%* S%ki ii #i'%k&!#k% !!k 'e'er+%iki

#% 'eik%k% kier$% k1'ie 'e#i& #i r!'%* &%ki. Per%!r% Meeri e&e*%% ii

#i*%r%k% !r! 'e7!r!&k% er&e&i ke7ir! % 'e%% k1'ie 'e#ik %#%7%*

/%#%* !!k 'e'er$!%k% ke&e$%*er%% %r% &%B 'e#i&. Se$%7% #e% &e'%%

r1Be&i1%7i&'e &e*%r!&% k1'ie 'e#ik 'e7%k!k% ee#%7i% k1'ee&i #%

eri7%k! %r% &%B 'e#i& %%r ke&e7%'%% %&ie er$%'i. Pe'%*%'% self governance” &eeri % #i%!r #%7%' e!!&% Meeri e&e*%% "e!+7ik

#1e&i% 1'1r 63@MENES@S@2000 e% Pe#1'% Per%!r% er%7 S%B

Me#i& #i "!'%* S%ki #%% #i&%7%*%rik% &e+%%i i#%k% ee717%% ('%%$e'e)

r!'%* &%ki. A%7%i +i7% &r!k!r k1'ie 'e#ik #i7e%kk% &e$%$%r #e% ke%7% @

#irek!r r!'%* &%ki keke7ir!% e'%*%'% “self governance” #i%%& #%% er$%#i

ke&i'%&i!r% #%7%' ee717%% e7%%% 'e#i&. 1#i&i &e'%%' ii e! i#%k

#%% #i+i%rk% #% *%r!& #ier+%iki.

Per%!r% Meeri e&e*%% ii 'e%% ke'+%7i “professional self governance”

#e% 'e7e%kk% &r!k!r k1'ie 'e#i& #i+%/%* ke%7%@#irek!r r!'%* &%ki k%re% #i

#1e&i% ke%7%@#irek!r r!'%* &%ki &%'%i %#% 7ik%r ere! +erer% &e+%%i

governing board . De% e%%% er&e+! '%k% #%%7%* #ik%%k% +%*/% &e'!% i&!ker1Be&i% (kre#e&i%7 e$%%% '!! r1Be&i #% ee%k% #i&i7i r1Be&i) +er%#%

#%7%' ee#%7i% governing board #% &e$%7% #e% *%7 i! ke%7%@#irek!r r!'%*

&%ki 'ee#i%k% &e%7% &!'+er #%% %%r% 7%i 'e7i!i /%k! e%% +i%% &%r%%

#% r%&%r%% %%r %% ke717% k7ii& #%% er&e7e%r% #e% +%ik. e%7% #irek!r

r!'%* &%ki *%r!& 'e$%'i %%r &e'!% iB1r'%&i ker1Be&i% &ei% &%B 'e#i&

er&e7e%r% #% er#1k!'e%&i #e% +%ik &e*i% #%% #i%k&e& 17e* k1'ie

'e#i&. A%r %% ke717% k7ii& (clinical governance) er7%k&%% #e% +%ik #i /i7%%*

"e!+7ik #1e&i% &e7!r!* r!'%* &%ki +eker$%&%'% #%7%' *%7 %k&e& iB1r'%&i

ker1Be&i% ii 'e7%7!i 1r%i&%&i r1Be&i er!'%*&%ki%.

Le+i* $%!* 7%i +i7% k1'ie 'e#ik 'e%%i +er+%%i *%7 % +er&iB%

ee717%% &eeri 'i&%7% %ii% r!'%* 'e#i& %ii% ee%*% #% ee#%7i%

iBek&i %ii% B%r'%&i #% er%i *%7 ii %k% 'er%!k% B!&i ker1Be&i% #e%



B!&i ee717%% r!'%* &%ki. O7e* k%re%% #%7%' Per%!r% Meeri e&e*%% ii

k1'ie 'e#i& #ie%&k% *%% 'e%%i '%&%7%* ker1Be&i% &%$% #% +!k%

'e%%i ee717%% r!'%* &%ki % &e*%r!&% #i7%k!k% 17e* ke%7%@#irek!r

r!'%* &%ki. e%7% #irek!r r!'%* &%ki #%% 'e'+e!k +er+%%i %ii%@1k$% #%7%'

r%k% 'eik%k% '!! e7%%% r!'%* &%ki. P%ii%@1k$% er&e+!

+er%!$%/%+ 7%&! ke%#% ke%7%@#irek!r r!'%* &%ki."!'%* &%ki *%r!& 'eer%k% '1#e7 k1'ie 'e#ik % 'e$%'i %% ke717%

k7ii& (clinical governance) !!k 'e7i#!i %&ie. D%7%' '1#e7 er&e+! &ei% &%B

'e#i& #ike#%7ik% #e% 'e%!r ke/e%% k7ii&% (clinical privilege) !!k

'e7%k!k% e7%%% 'e#i& *%% &%B 'e#i& % 'e'e!*i &%r%-&%r% k1'ee&i

#% eri7%k! &%$%7%* % +17e* 'e7%k!k% e7%%% 'e#i&. Pe%!r% ke/e%%

k7ii& er&e+! #i7%k!k% #e% 'ek%i&'e e'+eri% !!k 'e7%k!k% e7%%%

'e#i& ke/%$i+% 'e'e!*i &%r%-&%r% k1'ee&i #% eri7%k! ere! !!k

'e'er%*%k% ke'%'!% k7ii& #% e%+!% iGi. U!k 'e7i#!i ke&e7%'%%

%&ie k1'ie 'e#ik #i r!'%* &%ki *%r!& 'e'i7iki kei% 'ek%i&'e #i%%&. F!&i

7%i #i7!%r kei% B!&i #i%%& #i7%k&%%k% 17e* ke%7%@#irek!r r!'%* &%ki.

U!k 'e$%'i %%r k1'ie 'e#ik +erB!&i #e% +%ik 1r%i&%&i #%%%7%k&%% k1'ie 'e#ik #i!%k% #%7%' ere%%% ier%7 &%B 'e#i& %

#i&!&! #e% +ere#1'% %#% Per%!r% Meeri e&e*%% ii. P%#% ri&i%

er%!r% ier%7 &%B 'e#i& 'er!%k% #%&%r 1r'%iB +%i &ei% &%B 'e#i& %%r

eri% +!#%% r1Be&i % +%ik #% %k!%+e7.

. TUJUAN

Per%!r% Meeri e&e*%% ii +er!$!% !!k 'e%!r %% ke717% k7ii&

(clinical governance) % +%ik %%r ke&e7%'%% %&ie #i r!'%* &%ki e'eri%*

!&% e'eri%* #%er%* #% &/%&% er'%&!k r!'%* &%ki e#i#ik% 7e+i* er$%'i #%

er7i#!i &er% 'e%!r ee7e%r%% k1'ie 'e#ik #i&ei% r!'%* &%ki #%7%'

r%k% eik%% r1Be&i1%7i&'e &%B 'e#i&.

". KE#ENANGAN KLINIS $Clinical Privilege%

P%#% #%&%r% &e'!% e7%%% 'e#i& % er$%#i #i&e+!%* r!'%* &%ki #%

%ki+%% 'e$%#i %!$%/%+ i&i!&i r!'%* &%ki i! &e#iri *%7 ii &e&!%i #e%

kee!% er%!r% er!#%-!#%% % 'e%!r e% er!'%*&%ki%.

Pe%!r% ii #i#%&%rk% %#% e'ikir% +%*/% r!'%* &%ki +er*%k 'e7%r% &e'!%

e7%%% 'e#i& #i r!'%*&%ki% ke!%7i +i7% r!'%* &%ki 'eiGik% &%B 'e#i&

ere! !!k 'e7%k!k% e7%%% 'e#i& er&e+!. De% #e'iki% +i7% &e1r% &%B

'e#i& e7%* #iiGik% 'e7%k!k% e7%%% 'e#i& #% r1&e#!r k7ii& 7%i% #i&e+!%*

r!'%* &%ki +er%ri % +er&%k!% e7%* #ii&i'e/%k% #% 'e'er17e* *%k k*!&!&( privilege) 17e* r!'%* &%ki. =%k &%B 'e#i& er&e+! #%7%' Per%!r% Meeri e&e*%%

ii &e7%$!% #i&e+! &e+%%i ke/e%% k7ii& (clinical privilege).

"!'%* &%ki *%r!& 'e%!r e'+eri% ke/e%%% k7ii& (clinical privilege)

&ei% &%B 'e#i& &e&!%i #e% k1'ee&i% % %%. De% #e'iki% e'+eri%

ke/e%% k7ii& er&e+! (clinical privilege) er&e+! *%r!& 'e7i+%k% k1'ie 'e#ik

% #i+%! 17e* 'ir% +e&%ri% &e+%%i i*%k % %7i 'ee%*!i '%&%7%*

ker1Be&i% % +er&%k!%.

e/e%% k7ii& &ei% &%B 'e#i& #%% &7%i +er+e#% /%7%!! 'erek%

'e'i7iki &e&i%7i&%&i % &%'%. Se1r% &%B 'e#i& #%ri &e&i%7i&%&i ere! #%% &%$%

7e+i* k1'ee #%ri%#% % 7%i% !!k 'e7%k!k% $ei& e7%%% 'e#i& ere!

#%7%' +i#% &e&i%7i&%&i er&e+!. De% #e'iki% ke/e%% k7ii& !!k &ei%&e&i%7i&%&i i7'! ke#1ker% *%r!& #irii 7e+i* 7%$!.



"ii% ke/e%% k7ii& &ei% &e&i%7i&%&i #i r!'%* &%ki #ie%k% 17e*

k1'ie 'e#ik #e% +ere#1'% %#% 1r'% ker1Be&i% % #ie%k% 17e*

k17ei!' &ei% &e&i%7i&%&i. 1'ie 'e#ik /%$i+ 'ee%k% #% 'e#1k!'e%&i

&%r%-&%r% % erk%i k1'ee&i % #i+!!*k% 'e7%k!k% &ei% $ei& e7%%%

'e#i& &e&!%i #e% kee%% k17ei!' &ei% &e&i%7i&%&i i7'! ke#1ker%.

D1k!'e%&i &%r% !!k 'e7%k!k% e7%%% 'e#i& er&e+! #i&e+! &e+%%i +!k! !i*. De% #e'iki% &ei% rek1'e#%&i k1'ie 'e#ik %%& ke/e%% k7ii&

!!k &%B 'e#i& e% #%% #ier%!$%/%+k% &e%r% *!k!' k%re% +!k! !i*

er&e+! 'e%! %#% +er+%%i 1r'% r1Be&i % #ie%k% 17e* k17ei!' &ei%

&e&i%7i&%&i.

D%7%' e7%k&%%% #i7%%% &!%! e7%%% 'e#i& ere! er%%

#i7%k!k% 17e* %r% &%B 'e#i& #% $ei& &e&i%7i&%&i % +er+e#%. Sei% k17ei!' #%ri

&e&i%7i&%&i % +er+e#% er&e+! 'e%%k% +%*/% %r% #1ker &e&i%7i&@#1ker ii

&e&i%7i& #% k17ei!'% k1'ee !!k 'e7%k!k% e7%%% 'e#i& ere! er&e+!.

D%7%' &i!%&i er&e+! k1'ie 'e#ik 'e!&! +!k! !i* !!k e7%%% 'e#i&

ere! er&e+! #e% 'e7i+%k% 'ir% +e&%ri #%ri +e+er%% &e&i%7i&%&i erk%i.

Se7%$!% e'+eri% ke/e%% k7ii& ke%#% &%B 'e#i& % %k% 'e7%k!k%i#%k% ere! er&e+! %k% #i#%&%rk% %#% +!k! !i* % e7%* #i&!&!

+er&%'%.

e/e%% k7ii& &e1r% &%B 'e#i& i#%k *%% #i#%&%rk% %#% kre#e&i%7

er*%#% k1'ee&i kei7'!% #% keer%'i7%% &%$% %k% e%i $!% #i#%&%rk%

%#% ke&e*%% Bi&ik ke&e*%% 'e%7 #% eri7%k! (behavior) &%B 'e#i& er&e+!.

Se'!% B%k1r #i%%& %k% 'e'e%r!*i ke&e7%'%% %&ie +%ik &e%r% 7%&!

'%!! i#%k 7%&!.

U!k r!'%* &%ki e#i#ik% ke/e%% k7ii& &e1r% &%B 'e#i& 7e+i*

+er&iB% k*!&!& k%re% % +er&%k!% 'e'!%i !%& 'e'+i'+i &%B 'e#i&

% &e#% #%7%' '%&% e#i#ik%. U!k i! B%k!7%& ke#1ker% +erer% #%7%'

'ee!k% ke/e%% k7ii& &e1r% &%B 'e#i& #%7%' r!'%* &%ki e#i#ik%.

D. PENUGASAN KLINIS $clinical appointment %

P%#% #%&%r% r!'%* &%ki *%r!& 'e%!r ke/e%% k7ii& &ei% &%B 'e#i&

k%re% *%r!& +er%!$%/%+ %%& ke&e7%'%% %&ie keik% 'eeri'% e7%%%

'e#i&. U!k i! ke%7%@#irek!r r!'%* &%ki *%r!& 'e%!r *%% &%B 'e#i& %

k1'ee7%* % 'e%%i %&ie.

D%7%' *%7 k1'ie 'e#ik 'erek1'e#%&ik% &e1r% &%B 'e#i& !!k

ke/e%% k7ii& ere! &ee7%* #ikre#e&i%7 #% ke%7%@#irek!r r!'%* &%ki #%%

'ee!$!i% '%k% ke%7%@#irek!r r!'%* &%ki 'eer+ik% &!%! &!r% ke!!&%

!!k 'e!%&k% &%B 'e#i& % +er&%k!% !!k 'e7%k!k% e7%%% 'e#i& #ir!'%* &%ki. Pe!%&% &%B 'e#i& er&e+! #i&e+! &e+%%i e!%&% k7ii& (clinical

appointment ).

De% 'e'i7iki &!r% e!%&% k7ii& &e1r% &%B 'e#i& er%+! 'e$%#i

%1% ke71'1k &%B 'e#i& % 'e'i7iki ke/e%% k7ii& !!k 'e7%k!k%

e7%%% 'e#i& #i r!'%* &%ki er&e+!. D%7%' ke%#%% ere! ke%7%@#irek!r r!'%*

&%ki #%% !7% 'eer+ik% &!r% e!%&% k7ii& &e'e%r% 'i&%7%% !!k

k1&!7% %'! % #ier7!k% &e'e%r% 17e* r!'%* &%ki. e%7%@#irek!r r!'%* &%ki

#%% 'e!+%* 'e'+ek!k% !!k /%k! ere! %%! 'e%k*iri e!%&% k7ii&

&1r% &%B 'e#i& +er#%&%rk% eri'+%% k1'ie 'e#i& %%! %7%&% ere!. De%

#i+ek!k% %%! #i%k*iri% e!%&% k7ii& &e1r% &%B 'e#i& i#%k +ere/e% 7%i

'e7%k!k% e7%%% 'e#i& #i r!'%* &%ki er&e+!. Mek%i&'e e!%&% k7ii& ii'er!%k% &%7%* &%! i&r!'e !%'% %% ke717% k7ii& % +%ik.



A II

KOMITE MEDIK

A. KONSEP DASAR KOMITE MEDIK

1'ie 'e#ik 'e$%7%k% B!&i !!k 'ee%kk% r1Be&i1%7i&'e #e%

'ee#%7ik% &%B 'e#i& % 'e7%k!k% e7%%% 'e#i& #i r!'%* &%ki.

Pee#%7i% er&e+! #i7%k!k% #e% 'e%!r &e%r% rii ke/e%% 'e7%k!k%

e7%%% 'e#i&. Pee#%7i% ii #i7%k!k% &e%r% +er&%'% 17e* ke%7%@#irek!r r!'%*

&%ki #% k1'ie 'e#ik. 1'ie 'e#ik 'e7%k!k% kre#e&i%7 'eik%k% '!!

r1Be&i #% 'ee%kk% #i&i7i r1Be&i &er% 'erek1'e#%&ik% i#%k 7%$!% ke%#%

ke%7% #irek!r r!'%* &%ki &e#%k% ke%7%@#irek!r r!'%* &%ki 'ei#%k7%$!i

rek1'e#%&i k1'ie 'e#ik.

1&e r1Be&i1%7i&'e #i%%& #i#%&%rk% %#% k1r%k &1&i%7 %%r% r1Be&i'e#i& #e% '%&%r%k%. Di&%! i*%k r1Be&i 'e#i& &e%k% !!k 'e'r1ek&i

'%&%r%k% #e% 'e7%k!k% e%i&% (kre#e&i%7) er*%#% &%B 'e#i& % %k%

'e$%7%k% r%kik #%7%' '%&%r%k%. =%% &%B 'e#i& % +%ik-7%* %

#ierke%k% 'e7%k!k% e7%%% %#% '%&%r%k%. Se#%k% &%B 'e#i& %

+e7!' 'e'e!*i &%r% #%% 'e$%7%i r1&e& e'+i%% %%r 'e'i7iki k1'ee&i

% #ier7!k% &e*i% #%% #ierke%k% 'e7%k!k% e7%%% %#% '%&%r%k%

&ee7%* 'e7%7!i kre#e&i%7. Di7%i i*%k ke71'1k r1Be&i &%B 'e#i& 'e'er17e* *%k

i&i'e/% !!k 'e7%k!k% r%kik ke#1ker% &e%r% ek&k7!&iB #% i#%k +17e* %#% i*%k

7%i % 'e7%k!k% *%7 er&e+!. De% *%k i&i'e/% er&e+! %r% &%B 'e#i& #%%

'e'er17e* '%B%% ek11'i& #% re&i&e r1Be&i. N%'! #e'iki% +i7% %#% &%B

'e#i& % 'e7%k!k% e7%%r% &%#%r% r1Be&i #%% #i7%k!k% i#%k% #i&i7i r1Be&i. Ti#%k% #i&i7i ii +er+e!k e%!*% *%k i&i'e/% ere&+! %%r

'%&%r%k% er*i#%r #%ri r%ki&i 'e#i& % i#%k r1Be&i1%7.

D%7%' #!i% %% #i+%%k e%r% k1r%k &1&i%7 %%r% r1Be&i 'e#i& #e%

'%&%r%k% #i!%k% #%7%' +e!k !#%-!#% r%kik ke#1ker% (medical

practice). Pe7%k&%%% ee#%7i% r1Be&i 'e#i& #%7%' ke*i#!% &e*%ri-*%ri

#i7%k&%%k% 17e* &e!%! 7e'+%% % #i+e!k 17e* !#%-!#% r%kik ke#1ker%

% +i%&%% #i&e+! &e+%%i k1&i7 ke#1ker%. Le'+%% er&e+! &e7%i 'e'+erik%

iGi !!k 'e$%7%k% r1Be&i $!% +er/e% 'e%!*k% %%! 'e%+! iGi

er&e+! +i7% er$%#i e7%%r% &%#%r r1Be&i. Ti#%k% #i&i7i r1Be&i er&e+!

#i7%k!k% &ee7%* 'e7%7!i r1&e& &i#% #i&i7i r1Be&i.

D%7%' %%r% r!'%* &%ki k1r%k &1&i%7 er$%#i %%r% %r% &%B 'e#i& %'e7%k!k% e7%%% 'e#i& #e% %&ie. 1r%k er&e+! #i!%k% #%7%' #1k!'e

er%!r% ier%7 &%B 'e#i&. Pee#%7i% r1Be&i 'e#i& #i7%k&%%k% 'e7%7!i %%

ke717% k7ii& !!k 'e7i#!i %&ie % #i7%k&%%k% 17e* k1'ie 'e#ik. De%

#e'iki% k1'ie 'e#ik #ir!'%* &%ki #%% #i%%71ik% #e% k1&i7 ke#1ker% %#%

%%% %&i1%7. 1'ie 'e#ik 'e7%k&%%k% B!&i kre#e&i%7 e$%%% '!! r1Be&i

#% #i&i7i r1Be&i 'e7%7!i i% &!+k1'ie %i! &!+k1'ie kre#e&i%7 &!+k1'ie '!!

r1Be&i #% &!+k1'ie eik% #% #i&i7i r1Be&i.

. PERANAN KOMITE MEDIK DALAM MENEGAKKAN PROFESIONALISME

1'ie 'e#ik 'e'e% er% !%'% #%7%' 'ee%kk% r1Be&i1%7i&'e &%B

'e#i& % +eker$% #ir!'%* &%ki. Per% er&e+! 'e7i!i rek1'e#%&i e'+eri% iGi'e7%k!k% e7%%% 'e#i& #ir!'%* &%ki er'%&!k rii%% 'e'e7i*%r% k1'ee&i



#% eik% r1Be&i &er% 'ee%kk% #i&i7i r1Be&i. U!k i! ke%7%@#irek!r r!'%*

&%ki +erke/%$i+% %%r k1'ie 'e#i& &e%i%&% 'e'i7iki %k&e& iB1r'%&i rii e%

'%&%7%* ker1Be&i% &ei% &%B '1#i& #ir!'%* &%ki.

Mir% +e&%ri 'e'e% er%% ei #%7%' e7%k&%%% B!&i k1'ie

'e#ik. Mir% +e&%ri %#%7%* &eke71'1k &%B 'e#i& #e% re!%&i #% k1'ee&i

r1Bei % +%ik !!k 'ee7%%* &e%7% *%7 % erk%i #e% r1Be&i 'e#i& er'%&!k e>%7!%i ke/e%% k7ii&. S%B 'e#i& #%7%' 'ir% +e&%ri er&e+! +er%&%7 i#%k er+%%&

#%ri &%B 'e#i& % e7%* %#% #ir!'%* &%ki er&e+! &%$% e%i #%% $!% +er%&%7 #%ri

7!%r r!'%* &%ki 'i&%7% er*i'!% &e&i%7i& k17ei!' %%! B%k!7%& ke#1ker%.

1'ie 'e#ik +er&%'% ke%7% #irek!r r!'%* &%ki 'e'+e!k %ii% % er#iri #%ri

+e&%ri er&e+! !!k 'e$%7%k% B!&i kre#e&i%7 e$%%% '!! r1Be&i '%!!

ee%k% #i&i7i #% eik% r1Be&i #i r!'%* &%ki.

Se7%i i! #i&%#%ri +%*/% r!'%* &%ki #%% 'e'+!!*k% +e+er%% %ii% 7%i

#%7%' r%k% %% ke717% k7ii& % +%ik &eeri %ii% iBek&i 1&1k1'i%7 %ii%

rek%' 'e#i& #% &e+%%i%. P%ii%-%ii% er&e+! er7! #ik11r#i%&ik% &e%r%

B!&i1%7 17e* &e+!%* k1'ie ere! % +er%!$%/%+ %#% ke%7%@#irek!r

r!'%* &%ki. 1'ie ere! er&e+! +erer% 'eik%k% '!! r!'%* &%ki %i#%k 7%&! +erk%i% #e% r1Be&i 'e#i& &e*i% er7! #i+e!k &e%r% er&e#iri

%%r #%% 'e7%k!k% !%&% &e%r% 7e+i* erB1k!&.

". TUGAS KOMITE MEDIK

1'ie 'e#ik +er!%& 'ee%kk% r1Be&i1%7i&'e &%B 'e#i& % +eker$%

#ir!'%* &%ki. 1'ie 'e#ik +er!%& 'e7%k!k% kre#e&i%7 +%i &e7!r!* &%B 'e#i&

% %k% 'e7%k!k% e7%%% 'e#i& #i r!'%* &%ki 'e'e7i*%r% k1'ee&i #% eik%

%r% &%B 'e#i& #% 'e%'+i7 i#%k% #i&i7i +%i &%B 'e#i&.

T!%& 7%i &eeri ee#%7i% iBek&i 1&1k1'i%7 rek%' 'e#i& #% &e+%%i%

#i7%k&%%k% 17e* ke%7%@#irek!r r!'%* &%ki #% +!k% 17e* k1'ie 'e#ik. 1'ie

'e#ik 'e7%k&%%k% !%&% 'e7%7!i i% *%7 !%'% %i!,

. "ek1'e#%&i e'+eri% iGi !!k 'e7%k!k% e7%%% 'e#i& #i7%k!k%

'e7%7!i &!+k1'ie kre#e&i%7

2. Me'e7i*%r% k1'ee&i #% eri7%k! %r% &B% 'e#i& % e7%* 'e'er17e*

iGi #i7%k!k% 17e* &!+k1'ie '!! r1Be&i 'e7%7!i %!#i 'e#i& #%

ee'+%% r1Be&i +erke7%$!%

3. "ek1'e#%&i e%!*% ke/e%% k7ii& ere! *i% e%+!%

iGi 'e7%k!k% e7%%% 'e#i& #i7%k!k% 'e7%7!i &!+k1'ie eik% #%

#i&i7i r1Be&i.

De% #e'iki% !%&-!%& 7%i #i7!%r !%&-!%& #i%%& % erk%i #e%

e7%%% 'e#i& +!k%7%* 'e$%#i !%& k1'ie 'e#ik e%i 'e$%#i !%&ke%7%@#irek!r r!'%* &%ki #%7%' 'ee717% r!'%* &%ki.

D. PENGORGANISASIAN KOMITE MEDIK

P%#% #%&%r% k1'ie 'e#ik +!k% 'er!%k% k!'!7% %%! *i'!%

ke71'1k &%B 'e#i& B!&i1%7@#e%re'e k7iik &e+!%* r!'%* &%ki. P%r% &%B 'e#i&

% er%+! #%7%' ke71'1k &%B 'e#i& B!&i1%7 #e%re'e k7iik #i1r%i&%&i

17e* ke%7%@#irek!r r!'%* &%ki.

1'ie 'e#ik #i+e!k 17e* ke%7%@#irek!r r!'%* &%ki #% +er%!$%/%+

ke%#% ke%7%@#irek!r r!'%* &%ki. Or%i&%&i k1'ie 'e#ik &ek!r%-k!r%% er#iri

#%ri ke!% &ekre%ri& #% %1%. e!% k1'ie 'e#ik #ier%k% 17e* ke%7%@#irek!r

r!'%* &%ki &ekre%ri& #% %1% #i!&!7k% 17e* ke!% k1'ie 'e#ik #% #ie%k%17e* ke%7%@#irek!r r!'%* &%ki. D%7%' *%7 /%ki7 ke!% k1'ie 'e#ik #ier7!k% '%k%



/%ki7 ke!% #i!&!7k% 17e* ke!% k1'ie 'e#ik #% #ie%k% 17e* ke%7% #irek!r

r!'%* &%ki.

J!'7%* er&1i7 k1'ie 'e#i& % eBekiB +erki&%r &eki%r 7i'% &%'%i &e'+i7%

1r% er'%&!k ke!% #% &ekre%ri&. N%'! #e'iki% !!k r!'%* &%ki #e% $!'7%*

&%B 'e#i& er+%%& #%% 'ee&!%ik% #e% &i!%&i &e$%!* !%& #% B!&i k1'ie

'e#i& e% er7%k&%%. %7%!! r!'%* &%ki 'e'i7iki &%B 'e#i& % er+%%& $!'7%*% +!#%% r1Be&i1%7i&'e % %k!%+e7 *%r!& e% #ie%kk% 'e7%!i

ee7e%r%% r%% ke717% k7ii& % +%ik. P%&ie *%r!& e% er7i#!i %%

'e7i*% +e&%r kei7% $!'7%* &%B 'e#i&. Per&1%7i% er&e+! #ii7i* #%ri &%B 'e#i& %

'e'i7iki re!%&i +%ik #%7%' r1Be&i% % 'e7i!i k1'ee&i &ik% #% *!+!%

ierer&1%7 % +%ik.

Mek%i&'e e%'+i7% ke!!&% #i+i#% ker1Be&i% #%7%' &ei% kei%%

k1'ie 'e#i& #i7%k&%%k% &e%r% &e*% #e% 'e'er*%ik% %&%&-%&%& k17ei%7i%&.

Per%!r% ier%7 &%B r!'%* &%ki %k% 'ee%k% 7e+i* rii e% 'ek%i&'e

er&e+!.

D%7%' 'e7%k&%%k% !%&% k1'ie 'e#ik #i+%! 17e* &!+k1'ie kre#e&i%7

&!+k1'ie '!! r1Be&i #% &!+k1'ie eik% #% #i&i7i r1Be&i. D%7%' *%7 er#%%keer+%%&% $!'7%* &%B 'e#i& B!&i &!+k1'ie-&!+k1'ie ii #i7%k&%%k% 17e*

k1'ie 'e#ik.

e!% &!+k1'ie kre#e&i%7 &!+k1'ie '!! r1Be&i #% &!+k1'ie eik% #%

#i&i7i r1Be&i #i!&!7k% 17e* ke!% k1'ie 'e#ik #% #ie%k% 17e* ke%7%@#irek!r

r!'%* &%ki. Di7%i i*%k #%7%' e7%%% 'e#i& &e*%ri-*%ri #ir!'%* &%ki

ke%7%@#irek!r r!'%* &%ki #%% 'ee71'1kk% &%B 'e#i& +er#%&%rk%

#i&i7i@&e&i%7i&%&i e'i%% %%! #e% %r% 7%i +er#%&%rk% ke+!!*% r!'%* &%ki

&e&!%i er%!r% ier%7 r!'%* &%ki.

%ki7 ke!% &ekre%ri& #% ke!%-ke!% &!+k1'ie #irek1'e#%&ik% 17e* ke!%

k1'ie 'e#ik #% #ie%k% 17e* ke%7%@#irek!r r!'%* &%ki #e% 'e'er*%ik%

'%&!k% #%ri &%B 'e#i& % +eker$% #ir!'%* &%ki. Se7%i i! ke%7%@#irek!r r!'%*

&%ki 'e%k% +e+er%% &%B 'e#i& #ir!'%* &%ki er&e+! !!k 'e$%#i %1%

e!r!& k1'ie 'e#ik #% %1% &!+k1'ie-&!+k1'ie #i+%/%* k1'ie 'e#ik.

D%7%' 'e$%7%k% !%& #% B!&i% k1'ie 'e#ik &e%i%&% 'e7i+%k%

'ir% +e&%ri !!k 'e%'+i7 !!&% r1Be&i1%7. "!'%* &%ki +er&%'% k1'ie 'e#ik

'ei%k% 'ir% +e&%ri % 'e7i!i +er+%%i '%%' +i#% i7'! ke#1ker% &e&!%i

ke+!!*%%. Mir% +e&%ri er&e+! %k% #i+!!*k% &ei% &!+k1'ie #%7%'

'e$%7%k% !%&%.

E. HUUNGAN KOMITE MEDIK DENGAN PENGELOLA RUMAH SAKIT

e!% k1'ie 'e#ik +er%!$%/%+ ke%#% ke%7%@#irek!r r!'%* &%ki.Di&%! i*%k ke%7%@#irek!r r!'%* &%ki +erke/%$i+% !!k 'ee#i%k% &e%7%

&!'+er #%% %%r k1'ie 'e#ik #%% +erB!&i #e% +%ik !!k 'e$%7%k%

r1Be&i1%7i&'e &%B 'e#i& &e&!%i #e% kee!% #%7%' Per%!r% Meeri e&e*%%

ii. Di7%i i*%k k1'ie 'e#ik 'e'+erik% 7%1r% %*!% #% 7%1r% +erk%7% e%

kei%% ker1Be&i% % #i7%k!k% ke%#% ke%7%@#irek!r r!'%* &%ki. De%

#e'iki% 7ik! *!+!% %%r% ke%7%@#irek!r r!'%* &%ki #e% k1'ie 'e#ik

%#%7%* #%7%' *%7-*%7 % 'e%k! r1Be&i1%7i&'e &%B 'e#i& &%$%. =%7-*%7 %

erk%i #e% ee717%% r!'%* &%ki #% &!'+er #%%% #i7%k!k% &ee!*% 17e*

ke%7%@#irek!r r!'%* &%ki.

U!k 'e/!$!#k% %% ke717% k7ii& % +%ik ke%7%@#irek!r r!'%* &%ki

+eker$%&%'% #%7%' *%7 e%!r% ke/e%% 'e7%k!k% i#%k% 'e#ik #ir!'%*



&%ki. er$%&%'% er&e+! #%7%' +e!k rek1'e#%&i e'+eri% ke/e%% k7ii& !!k

'e7%k!k% e7%%% 'e#i& #% rek1'e#%&i e%+!%% 17e* k1'ie 'e#ik.

U!k 'e/!$!#k% e7%%% k7ii& % +%ik eBekiB r1Be&i1%7 #% %'%

+%i %&ie &eri er#%% kei%% e7%%% % erk%i er% #e% '%&%7%*

ker1Be&i%. e%7%@#irek!r r!'%* &%ki +eker$%&%'% #e% k1'ie e'#ik !!k

'e!&! e%!r% e7%%% 'e#i& %%r e7%%% % r1Be&i1%7 er$%'i '!7%i#%ri %&ie '%&!k r!'%* &%ki *i% ke7!%r #%ri r!'%* &%ki.

F. PERANAN ORGANISASI PERUMAHSAKITAN DALAM PEMERDAYAAN

KOMITE MEDIK DI RUMAH SAKIT

"!'%* &%ki &%% +erkeei% #e% k1'ie 'e#ik k%re% &%%

'ee!k% +%ik +!r!k% %% ke717% k7iik #ir!'%* &%ki er&e+!. Mee7e%r%k%

k1'ie 'e#ik 'er!%k% *%7 % k1'7ek& #% 'e'er7!k% +er+%%i &!'+er #%%

iB1r'%&i % erk%i #e% ker1Be&i%.

Sei% r!'%* &%ki 'e'ii7iki k%%&i%& &!'+er #%% % +er+e#% &e*i%

ke7!%r% % #i*%&i7k% #%7%' 'e7%k!k% !%% e'+er#%%% k1'ie 'e#ik !

+er+e#% !7%. A%r !%% e'+er#%%% k1'ie 'e#ik ii 7e+i* +er#%% !% #% +er*%&i7 !% 1r%i&%&i er!'%*&%ki% +erer% &er% 'e7%k!k% e'+er#%%%

k1'ie 'e#i& %%r %% ke717% k7ii& er&e7e%r% 7e+i* 'er%% #i&e7!r!* /i7%%*

#1e&i%.



A III

SUKOMITE KREDENSIAL

A. TUJUAN

. T!$!% U'!'

U!k 'e7i#!i ke&e7%'%% %&ie #e% 'e'%&ik% +%*/% &%B 'e#i& %

%k% 'e7%k!k% e7%%% 'e#i& #ir!'%* &%ki kre#i+e7.

2. T!$!% *!&!&

%. Me#%%k% #% 'e'%&ik% &%B 'e#i& % r1Be&i1%7 #% %k!%+e7 +%i

e7%%% #i r!'%* &%kiH

+. Ter&!&!% $ei&-$ei& ke/e%% k7ii& +%i &ei% &%B 'e#i& %

'e7%k!k% e7%%% 'e#i& #ir!'%* &%ki &e&!%i #e% %+% i7'!

ke#1ker%@ke#1ker% ii % #ie%k% 17e* 17ei!'e#1ker%@e#1ker% <ii #1e&i%H

. D%&%r +%i ke%7%@#irek!r r!'%* &%ki !!k 'eer+ik% e!%&% k7ii& +%i

&ei% &%B 'e#i& !!k 'e7%k!% e7%%% 'e#i& #ir!'%* &%kiH

#. Ter$%%% re!%&i #% kre#i+i7i%& %r% &%B 'e#i& #% i&i!&i r!'%* &%ki

#i*%#%% %&ie e%#% #%% #% e'%k! keei% r!'%* &%ki

7%i%.

. KONSEP

. 1&e P%&iB re#e&i%7

S%7%* &%! !%% r!'%* &%ki #%7%' 'e$%7%k% !%& #% %!$%/%+% !!k

'e$%% ke&e7%'%% %&ie% %#%7%* #e% 'e$%% &%#%r #% k1'ee&i %r%&%B 'e#i& % %k% +er*%#%% 7%&! #e% %r% %&ie #ir!'%* &%ki. U%%

ii #i7%k!k% #e% %r% 'e%!r %%r &ei% e7%%% 'e#i& % #i7%k!k%

er*%#% %&ie *%% #i7%k!k% 17e* &%B 'e#i& % +e%r-+e%r k1'ee.

1'ee&i ii 'e7i!i #!% %&ek k1'ee&i r1Be&i 'e#i& % er#iri #%ri

ee%*!% keer%'i7% #% eri7%k! r1Be&i1%7 &er% k1'ee&i Bi&ik #%

'e%7. %7%!! &e1r% &%B 'e#i& e7%* 'e#%%k% brevet &e&i%7i&%&i #%ri

k17ei!' i7'! ke#1ker% % +er&%k!% %'! r!'%* &%ki /%$i+ 'e7%k!k%

>eriBik%&i ke'+%7i ke%+&%*% +!ki k1'ee&i &e&e1r% #% 'ee%k%

ke/e%% k7ii& !!k 'e7%k!k% e7%%% 'e#i& #%7%' 7ik! &e&i%7i&%&i

er&e+! *%7 ii #ike%7 #e% i&i7%* credentialing.

Pr1&e& credentialing ii #i7%k!k% #e% #!% %7%&% !%'%. A7%&% er%'% +%%k B%k1r % 'e'e%r!*i k1'ee&i &ee7%* &e&e1r% 'e#%%k% &eriBik%

k1'ee&i #%ri k17ei!'. Perke'+%% i7'! #i+i#% ke#1ker% !!k &!%!

e7%%% 'e#i& ere! &%% e&% &e*i% k1'ee&i % #ier17e* &%%

'eeri'% &eriBik% k1'ee&i +i&% k%#%7!%r&% +%*k% #%% #i%% &e+%%i

i#%k% % i#%k %'% +%i %&ie. Se7%i i! 7ik! &!%! %+% i7'!

ke#1ker% ere! &e%i%&% +erke'+% #%ri /%k! ke /%k! &e*i% &!%!

i#%k% % &e'!7% i#%k #i%$%rk% %#% eeri'% brevet %#% eri1#e ere!

#%% &%$% #i%$%rk% %#% eri1#e &e7%$!% +%*k% #i%% 'er!%k% &!%!

ke'%'!% % &%#%r. =%7 ii 'e%ki+%k% +%*/% &eke71'1k &%B 'e#i& %

'e%#% &eriBik% k1'ee&i ere! #%% &%$% 'e'i7iki 7ik! k1'ee&i

% +er+e#%-+e#%.



A7%&% ke#!% ke%#%% ke&e*%% &e&e&1r% #%% &%$% 'e!r! %ki+% e%ki

ere! %%! +er%'+%*% !&i% &e*i% 'e!r%i ke'%% e7%%% 'e#i&

% #i7%k!k%%. 1'ee&i Bi&ik #% 'e%7 #ii7%i 'e7%7!i !$i ke7%%k%

ke&e*%% +%ik Bi&ik '%!! 'e%7. Ti#%k% >eriBik%&i k1'ee&i r1Be&i 'e#i&

er&e+! 17e* r!'%* &%ki #i&e+! &e+%%i 'ek%i&'e credentialing #% *%7 ii

#i7%k!k% #e'i ke&e7%'%% %&ie. Ti#%k% >eriBik%&i k1'ee&i ii $!%#i7%k!k% %#% r1Be&i 7%i !!k ke%'%% k7ie%. Mi&%7% k1'ee&i r1Be&i

eer+% (pilot ) % &e%i%&% #ierik&% &e%r% er%!r #%7%' eri1#e ere!

17e* er!&%*%% eer+%%.

See7%* &e1r% &%B 'e#i& #i%%k% k1'ee 'e7%7!i &!%! r1&e& kre#e&i%7

r!'%* &%ki 'eer+ik% &!%! iGi +%i % +er&%k!% !!k 'e7%k!k%

&er%k%i% e7%%% 'e#i& ere! #ir!'%* &%ki er&e+! *%7 ii #ike%7 &e+%%i

ke/e%% k7ii&. T%% %#%% ke/e%% k7ii&. T%% %#%% ke/e%%

k7ii& er&e+! &e1r% &%B 'e#i& i#%k #ierke%k% !!k 'e7%k!k% e7%%%

'e#i& #ir!'%* &%ki er&e+!. L!%&% 7ik! ke/e%% k7ii& &e1r% #1ker

&e&i%7i&@#1ker ii &e&i%7i& #%% &%$% +er+e#% #e% k17e%% #%7%' &e&i%7i&%&i

% &%'% er%! %#% kee%% k1'ie 'e#ik e% k1'ee&i !!k 'e7%k!k% i% e7%%% 'e#i& 17e* % +er&%k!% +er#%&%rk% *%&i7 r1&e&

kre#e&i%7. D%7'% *%7 e7%%% 'e#i& &e1r% &%B 'e#i& #%% &%$% #i%+!

&e*i% i#%k #ierke%k% !!k 'e7%k!k% e7%%% 'e#i& ere! #i

7ik!% r!'%* &%ki er&e+!. Pe%+!% ke/e%% k7ii& er&e+! #i7%k!k%

'e7%7!i r1&e#!r ere! % 'e7i+%k% k1'ie 'e#ik. e/%$i+% r!'%* &%ki

!!k 'ee%k% ke/e%% k7ii& er&e+! e7%* #i%!r #e% e%& #%7%'

er%!r% er!#%-!#%% e% er!'%*&%ki% +%*/% &ei% r!'%* &%ki

/%$i+ 'e!&! #% 'e7%k&%%k% hospital by laws, % #%7%' e$e7%&%

er%!r% er!#%-!#%% er&e+! #ie%k% +%*/% &ei% r!'%* &%ki /%$i+

'e7%k&%%k% ke717% k7ii& % +%ik. =%7 ii *%r!& #ir!'!&k% 17e* &ei% r!'%*

&%ki #%7%' er%!r% &%B 'e#i& r!'%* &%ki %%r% 7%i #i%!r ke/e%% k7ii&.

e7e'%*% r!'%* &%ki #%7%' 'e$%7%k% B!&i kre#e&i%7 %k% 'ei'+!7k%

%!$%/%+ *!k!' +%i r!'%* &%ki #%7%' *%7 er$%#i kee7%k%% e7%%%

'e#i&. Sei% r!'%* &%ki /%$i+ 'e7i#!i %&ie% #%ri &e%7% e7%%% 'e#i&

% #i7%k!k% 17e* &ei% &%B 'e#i& #ir!'%* &%ki er&e+! *%7 ii #ike%7 &e+%%i

the duty of due care. T%!$%/%+ r!'%* &%ki er&e+! +er7%k! i#%k *%%

er*%#% i#%k% % #i7%k!k% 17e* &%B 'e#i& e%/%i r!'%* &%ki &%$% e%i

$!% &ei% &%B 'e#i& % +!k% +er&%!& e%/%i (&%B 'e#i& %'!). "!'%* &%ki

/%$i+ 'ee%*!i #% 'e$%% ke%'%% &ei% e7%%% 'e#i& % #i7%k!k%

#%7%' 7ik!%% #e'i ke&e7%'%% &e'!% %&ie % #i7%%i% &e+%%i

+%i% #%ri the duty of due care.U!k 'e'e!*i ke+!!*% &%B 'e#i& #ir!'%* &%ki #%7%' r%k% 'eik%k%

e7%%% r!'%* &%ki 'e'er7!k% e%'+%*% &%B 'e#i& ke%7%@#irek!r r!'%*

&%ki 'ee!k% ke+!!*% #% e%'+%*% &%B 'e#i&. 1'ie 'e#ik #%%

#i'i% 17e* ke%7%@#irek!r r!'%* &%ki !!k 'e7%k!k% k%$i% k1'ee&i %71

&%B 'e#i&.

2. Mek%i&'e re#e&i%7

Mek%i&'e kre#e&i%7 #% rekr#!&i%7 #ir!'%* &%ki %#%7%* %! $%/%+

k1'ie 'e#ik % #i7%k&%%k% 17e* &!+k1'ie kre#e&i%7. Pr1&e& kre#e&i%7

er&e+! #i7%k&%%k% #e% &e'%% keer+!k%% %#i7 1+ekiB &e&!%i #e%

r1&e#!r #% er#1k !'e%&i.D%7%' r1&e& kre#e&i%7 &!+k1'ie kre#e&i%7 'e7%k!k% &er%k%i% kei%%



er'%&!k 'e!&! 'ir% +e&%ri #% re7%k!k% ei7%i% k1'ee&i

&e1r% &%B 'e#i& % 'e'i% ke/e%% k7ii& ere! Se7%i i!

&!+k1'ie kre#e&i%7 $!% 'ei%k% +er+%%i i&r!'e kre#e&i%7 %

#i&%*k% ke%7%7@#irekr!r r!'%* &%ki &r!'e er&e+! %7i &e#iki

re7i!i ke+i$%k% r! '% * &%ki e%! kre#e&i%7 #% ke/e%% k7ii&

e#1'% ei7%i% k1'ee&i k7ii& B1!7ir % #ier7!k%.P%#% %k*ir r1&e& kre#e&i%7 k1'ie '#ik 'eer+ik% rek1re#%&i ke%#%

ke%7%@#irek!r r!'%* &%ki e% 7ik! ke/e%% k7ii& &e1r% &%B

'e#i&.

". KEANGGOTAAN

S!+k1'ie kre#e&i%7 #i r!'%* &%ki er#iri %%& &ek!r%-k!r%%

3(i%) 1r% &%B 'e#i& % 'e'i7iki &!r% e!%&% k7ii& {clinical

appointment) #i r!'%* &%ki er&e+! #% +er%&%7 #%ri #i&i7i i7'! % +er+e#%.

Pe1r%i&%&i% &!+k1'ie kre#e&i%7 &ek!r%-k!r%% er#iri #%ri ke!%

&ekre%ri& #% %1% % #ie%k% 17e* #% +er%!!$%/%+ ke%#% ke!%k1'ie '#ik.

D. MEKANISME KREDENSIAL DAN PEMERIAN KE#ENANGAN KLINIS

AGI STAF MEDIS DI RUMAH SAKIT

e%7%@#irek!r r!'%* &%ki 'ee%k% +er+%%i ke+i$%k% #% r1&e#!r +%i

&%B 'e#i& !!k 'e'er17e* ke/e%% k7ii& #e% +ere#1'% %#% er%!r%

ier%7 &%B 'e#i& (medical staff laws). Se7%i i! e%7%@#irek!r r!'%* &%ki

+er%!$%/%+ %%& er&e#i%% +er+%%i &!'+er #%% % #i+!!*k% %%r

kei%% ii #%% er&e7e%r%. U!k 'e7%k&%%k% kre#e&i%7 #i+!!*k% +e+er%%

i&r!'e %%r% 7%i #%% rii% ke/e%% k7ii& !!k &e&i%7i&%&i 'e#i&, 'ir%

+e&%ri % 'erere&e%&ik% i% &e&i%7i&%&i 'e#i& #% +!k! !i* (white paper )

!!k &ei% e7%%% 'e#i&. Sei% r!'%* &%ki 'ee'+%k% i&r!'e er&e+!

&e&!%i #e% ke+!!*%% Se%r% %ri& +e&%r %*%% e'+eri% ke/e%%

k7ii& % *%r!& #i%!r 7e+i* 7%$! 17e* r!'%* &%ki %#%7%* &e+%%i +erik! ,

. S%B 'e#i& 'e%$!k% er'1*1% ke/e%% k7ii& ke%#% ke%7%@#irek!r

r!'%* &%ki #e% 'ei&i B1r'!7ir #%B%r rii% ke/e%% k7ii& % e7%*

#i&e#i%k% r!'%* &%ki #e% #i7ek%i +%*%-+%*% e#!k!.

2. erk%& er'1*1% &%B 'e#i& % e7%* 7ek% #i&%'%ik% ke%#%

ke%7%@#irek!r r!'%* &%ki ke%#% k1'ie 'e#ik.

3. %$i% er*%#% B1r'!7ir #%B%r rii% ke/e%% k7ii& % e%* #ii&i 17e*

e'1*1.4. D%7%' re7%k!k% k%$i% &!+k1'ie kre#e&i%7 #%% 'e'+e!k %e7 %%!

%ii% ad-hoc #e% 'e7i+%k% 'ir% +e&%ri #%ri #i&i7i % &e&!%i #e%

ke/e%% k7ii& % #i'i% +er#%&%rk% +!k! !i* (while paper ).

5. S!+k1'ie kre#e&i%7 'e7%k!k% &e7ek&i er*%#% %1% %e7 %%! %ii% ad-

hoc #e% 'e'eri'+%k% re!%&i %#%% k1B7ik keei% +i#%

#i&i7i #% k1'ee&i % +er&%k!%

6. Pek%$i% 17e* &!+k1'ie kre#e&i%7 'e7i!i e7e'e ,

%. k1'ee&i ,

. +er+%%i %re% k1'ee&i &e&!%i &%#%r k1'ee&i % #i&%*k% 17e*

7e'+%% e'eri%* % +er/e% !!k i!H

2. k1iiBH3. %BekiBH



4. &ik1'11r

+. k1'ee&i Bi&ikH

. k1'ee&i 'e%7 #% eri7%k!H

#. eri7%k! ei& (ethical standing ).

. e/e%% k7ii& % #i+erik% 'e%k! #er%$% k1'ee&i dan %k!% r%kik

8. D%B%r rii% ke/e%!% k7ii& ( deitneation of clinical privilege) #ier17e* #e%

%r% ,

%. 'e!&! #%B%r ke/e%% k7ii& #i7%k!k% #e% 'e'i% '%&!k%( #%ri &ei%

ke71'1k &%B 'e#i&.

+. 'ek%$i ke/e%% k7ii& +%i e'1*1 #e% 'e!%k% #%B%r rii%

ke/e%% k7ii& ( delineation ofclinical privilege).

. 'ek%$i !7% #%B%r rii% ke/e%% k7ii& +%i &%B 'e#i& #i7%k!k% &e%r%

eri1#ik.

9. "ek1re#%&i e'+eri% ke/e%% k7ii& #i7%k!k% 17e* k1'ie 'e#ik +er#%&%rk%('%&!k% #%ri &!+k1'ie kre#e&i%7

0. S!+k1'ie kre#e&i%7 'e7%k!k% rekre#e&i%7 +%i &ei% &%B 'e#i& %

'e%$!k% er'1*1% %#% &%% +er%k*ir% '%&% +er7%k! &!r% e!%&% k7ii&

(clilllcal appointment). #e()%( rek1'e(#D&i +er!% ,

%. ke/e%% k7i(i& % +er&%k!% #i7%$!k%H

+. ke/e%% k7ii& 6%() +er&%()k!%( #i%'+%*H

. ke/e(8()%( k7ii& % +er&%k!% #ik!r%iH

#. ke/e%% k7ii& % +er&%k!% #i+ek!k !(!k /%k! ere!H

e. ke/e%% k7ii& % +er&%k!%

#i!+%*@#i'1#iBik%&iHB. ke/e%% k7ii& % +er&%k!% #i%k*iri

--. %i &%B 'e#i& % ii 'e'!7i*k% k/e%% k7ii& % #ik!r%i %%!

'e%'+%* ke/e%% k7ii& % #i'i7iki #%% 'e%$!k% er'1*1% ke%#%

k1'ie 'e#ik 'e7%7!i ke%7%@#irek!r r!'%* &%ki Se7%($!% k1'ie re#ik

'ee7e%r%k% e'+i%% r1Be&i %%r% 7%i 'e7%7!i 'ek%i&'e e#%'i%(pructuring).

2. rieri% % *%r!& #ieri'+%k% #%7%' 'e'+ek% rek1r#%&i k/%%

k7ii&,

%. e#i#ik%,

) 7!7!& #%ri &ek17%* ke#1ker% % er%kre#i%&i 7!7!& #%ri &ek17%* ke#1ker% 7!%r eeri

#% &!#%* #irei&r%&iH

2) 'ee7e&%ik% r1r%' e#i#ik% k1&!7%

+. eriGi% (lisensi) ,

) 'e'i7iki &!r% %#% rei&r%&i % &e&!%i #e% +i#% r1Be&i2) 'e'i7iki i$i r%kek #%ri #i%& ke&e*%% &ee'% % '%&i* +er7%k!



. kei%% e$%%% '!! r1Be&i ,

) 'e$%#i %1% 1r%i&%&i % 'e7%k!k% ei7%i% k1'ee&i +%i %1%%H

2) +er%ri&i%&i %kiB #%7%r r1&e& e>%7!%&i '!! k7ii&

#. k!%7iBik%&i er&1%7 ,) ri/%% #i&i7i #% eik r1Be&iH

2) ke%1%% #%7%' er*i'!% r1Be&i % #i%k!iH

3) ke%#%% &e*% $%&'%i #% 'e%7 er'%&!k i#%k er7i+% e!%% 1+% er7%r% #%

%7k1*17 % #%% 'e'e%r!*i k!%7i%& e7%%% er*%#% %&ieH

4) ri/%% keer7i+%% #%7%' i#%k% keker%&%H

5) 'eri7iki %&!r%&i r1ek&i r1Be&i ( professional mmunity nsurances).

e. e%7%'% #i +i#% ker1Be&i% ,

) ri/%% e7.%7 e7%k&%%% r%kik r1Be&iH

2) ri/%% !!% 'e#i& %i%! k7%i' 17e* %&ie &e7%'% 'e$%7%k% r1Be&i

3. er%k*ir% ke/e%% k7ii&

e/e%% k7ii& %k% +er%k*ir +i7% &!r% e!%&% k7ii& (clinical appointment ) *%+i&

'%&% +er7%k!% %%! #i%+! 17e* ke%7%@#irek!r r!'%* &%ki. S!r% e!%&% k7ii& !!k

&ei% &%!& 'e#i& 'e'i7iki '%&% +er7%k! !!k eri1#e ere!'i&%7% #!% %*!. P%#%

%k*ir '%&% +er7%k!% &!r% e!%&% rer&e+! r!'%* &%ki *%r!& 'e7%k!k% rekre#e&i%7

er*%#% &%B 'e#i& % +er&%k!%. Pr1&e& rekre#e&i%7 ii 7e+i* &e#er*%% #i+%#ik%

#e% r1&e& kre#e&i%7 %/%7 &e+%%i'%% #i!r%ik% #i%%& k%re% r!'%* &%ki e7%*

'e'i7iki iB1r'%&i &ei% &%B 'e#i& % re7%k!k% e7%%% 'e#i& #i r!r%* &%ki

er&e+!

4. Pe%+!% er!+%*%@'1#iBik%&i #% e'+eri% ke'+%7i ke/e%% k7ii&

Peri'+%% e%+!% ke/e%% k7ii& ere! 17e* ke%7%@#irek!r r!'%* &%ki

#i#%&%rk% %#% kier$% r1Be&i #i7%%% 'i&%7% &%B re#i& % +er&%k!%

er%! ke&e*%%% +%ik Bi&ik '%!! 'e%7. Se7%i i! e%+!% ke/e%%

k7ii& $!% #%% #i7%k!k% +i7% er$%#i kee7%k%% 'e#i& % #i#!% k%re% ik1'ee&i

%%! k%re% i#%k% #i&i7i #%ri k1'ie 'e#ik. N%'! #e'iki% ke/e%% k7ii& %

#i%+! er&e+! #%% #i+erik% ke'+%7i +i7% &%B 'e#i& er&e+! #i%% e7%* !7i*

k1'ee&i% D%7%r *%7 ke/e%% k7ii& ere! &e1r% &%B 'e#i& #i%k*iri k1'ie

'e#ik %k% 'e'i% &!+k1'ie '!! r1Be&i !!k 'e7%k!k% +er+%%i !%% e'+i%%

%%r k1'ee&i % +er&%k!% !7i* ke'+%7i. 1'ie re#ik #%% 'erek1'e#%&ik%ke%#% ke%7%@#irek!r r!'%* &%ki e'+eri% ke'+%7i ke/e%% k7ii& ere! &ee7%*

'e7%7!i r1&e& e'+i%%. P%#% #%&%r% kre#e&i%7 e% #i!$!k% !!k 'e$%%

ke&e7%'%% %&i &%'+i7 e% 'e'+i% k1'ee&i &e7!r!* &%B 'e#i& #i r!'%* &%ki

er&e+!. De% #e'iki% $e7%&7%* +%*/% k1'ie 'e#ik #% er%!r% ier%7 &%B re#i&

'e'e% er%% ei #%7%' r1&e& kre#e&i%7 #% e'+eri% ke/e%% k7ii& !!k

&ei% &%B 'e#i&.



A I!

SUKOMITE MUTU PROFESI

A. TUJUAN

S!+k1'ie '!! r1Be&i +erer% #%7%' 'e$%% '!! r1Be&i 'e#i& #e%

!$!% H

%. 'e'+erik% er7i#!% er*%#% %&ie %%r &e%i%&% #i%%i 17e* &%B 'e#i&

% +er'!! k1'ee ei& #% r1Be&i1%7

+. 'e'+erik% %&%& ke%#i7% +%i &%B 'e#i& !!k 'e'er17e* ke&e'%% 'e'e7i*%r%

k1'ee&i (maintaining competence #% ke/e%% k7ii& (clinical privilege)H

. 'ee%* er$%#i% ke$%#i% % %k #i*%r%k% ('e#i%7 'i&*%.I)H

#. 'e'%&ik% k!%7i%& %&!*% 'e#i& % #i+erik% 17e* &%B 'e#i& 'e7%7!i !%% e'+er#%%% e>%7!%&i kier$% r1Be&i % +erke&i%'+!% (on-going professional

practice evaluation) '%!! e>%7!%&i kier$% r1Be&i % erB1k!& ( focused

professional practice evaluation).

. ONSEP

&e'!% %&ek k1'ee&i &%B re#i& #%7%' 'e7%k!k% e%%7%k&%%% %&!*% 'e#i&

(medical .,77 care management ). M!! &!%! e%%7%k&%%% %&!*% 'e#i& er%!

%#% !%% &%B 'e#i& 'e'e7i*%r% k1'ee&i &e1i'%7 '!ki !!k

'e'er%*%k% '!! #i7%k!k% !%% e'%%!% #% ee#%7i% '!! r1Be&i

'e7%7!i ,

%. 'e'%%! k!%7i%& 'i&%7% '1ri re1r k%&!& &!7i r1#e r!%% k%&!&ke'%i% (death case). %!#i 'e#i& $1!r%7 re%#iH

+. i#%k 7%$! er*%#% remusn k!%7i%& 'i&%7% e7%i*% &ik% ( short course)

%ki>i%& e#i#ik% +erke7%$!% e#i#ik% ke/e% %'+%*%.

C. EAN<<OTAAN

S!+k1'ie '!! r1Be&i #i r!'%* &%ki er#iri %%& &ek!r%-k!r%% 3

(i%) 1r% &%B 'e#i& % 'e'i7iki &!r% e!%&% k7ii& (clinical appointment ) #i

r!'%* &%ki er&e+ #% +er%&%7 #%ri #i&i7i i7'! % +er+e#%. Pe1r%i&%&i%

&!+k1'ie '!! r1Be&i &ek!r%-k!r%% er#iri #%ri ke!% &ekre%ri& #%

%1% % #ie%k% 17e* #% +er%!$%/%+ ke%#% ke!% k1'ie 'e#ik.

D. MEANSME E"JA

e%7%@#irek!r r!'%* &%ki 'ee%k% ke+i$%k% #% r1&e#!r &e7!r!*

'ek%i&'e ker$% &!+k1'ie '!! r1Be&i +er#%&%rk% '%&!k% k1'ie 'e#i&.Se7%i

i! ke%7%@#irek!r r!'%* &%ki +er%!$%/%+ %%& er&e#i%% +er+%%i &!'+er

#%% % #i+!!*k% %%r kei%% ii #%% er&e7e%r%.

. A!#i Me#i&

D%7%' er%!r% er!#%-!#%% e% er!'%*&%ki% e7%k&%%% %!#i 'e#i&

#i7%k&%%k% &e+%%i i'7e'e%&i B!&i '%%$e'e k7ii& #%7%' r%k% eer%%

%% ke717% k7ii& % +%ik #i r!'%* &%ki A!#i 'e#i& i#%k #i!%k% !!k 'e%ri%#% %%! i#%k% ke&%7%*% &e1r% &%B 'e#i& #%7%' &%! k%&!&. D%7%' *%7 er#%%



7%1r% ke$%#i% #e% #!%% ke7%7%i% &e1r% &%B 'e#i& 'ek%i&'e %

#i!%k% %#%7%* 'ek%i&re #i&i7i r1Be&i +!k%% 'ek%i&'e %!#i 'e#i&. A!#i

re#i& #i7%k!k% #e% 'ee#e%k% re&ek er*%#% &e'!% &%B 'e#i& ( no blammig

culrure) #e% %r% i#%k 'ee+!k% %'% (no 7i'i) i#%k 'e'er&%7%*k% (no

blaming ) #% i#%k 'e'er'%7!k% (no shaming ).

A!#i 'e#i& % #i7%k!k% 17e* r!'%* &%ki %#%7%* kei%% e>%7!%&i r1Be&i &e%r%&i&e'ik % 'e7i+%k% 'ir% +e&%ri ( peergroup) % er#iri #%ri kei%% peer-

review surveillance #% assessment er*%#% e7%%% 'e#i& #i r!'%* &%ki.

D%7%' eeri% %!#i re#i& er&e+! #i%%& r!'%* &%ki k1'ie 'e#ik %%! '%&i-

'%&i ke71'1k &%B 'e#i& #%% 'ee7e%r%k% e>%7!%&i kier$% r1Be&i %

erB1k!& ( $%!&e# PK((.I8$(JrJU practice evaluation). Se%r% !'!' e7%k&%%% %!#i

'e#i& *%r!& #%% 'e'e!*i 4 (e'%) er% ei %i! ,

%. &e+%%i &%r%% !(!k 'e7%k!k% ei7%i% er*%#% k1'ee&i '%&i-'%&i

&%B 'e#i& e'+eri e7%%% #i r!'%* &%kiH

+. &e+%%i #%&%r !!k e'+eri% ke/e%% k7ii& (clinical privilege) &e&!%i

k1'ee&i % #i'i7ikiH

. &e+%%i #%&%r +%i k1'ie 'e#ik #%7%' 'erek1'e#%&ik% e%+!% %%! e%!*% ke/e%% k7ii& (clinical privilege)! #%

#. &e+%%i #%&%r +%i k1'ie 'e#ik #%7%' 'erek1'e#%&ik%

er!+%*%(@'1#iB7k%&i rii% ke/e%% k7ii& &e1r% &%B 'e#i&.

A!#i 'e#i& #%% !7% #i&ee%r%k% #e% 'e7%k!k% e>%7!%&i

+erke&i(%'+!()%( (on-going professional practice evaluation), +%ik &e%r%

er1r%% '%!! ke71'1k.=%7 i(i #%% #i7%k!k% #e% +e+er%% %r% %%r% 7%i #%% 'er!%k%

kei%% % +er+e!k &ik7!& &e+%%i !%% er+%ik% % er!& 'eer!&

&e+%)%i'%(% er%!' #i+%/%* ii ,

er#%&&rk% &ik7!& #i%r%& '%k% 4%k%*-4%%k%* 3e7%k&%%% %!#i '1#i&

#i7%k&%%k% &e+%% i*e ki7 ,

%. Pe'i7i*% 13ik 6% %k% #i7%k!k% %!#i.

T%*%3 3er%'% #%ri %!#i 'e#i& %#%7%* 3e'i7i*% 13ik 6% %k% #i7%k!k%

%!#i. Pe'i7i*% 13ik er&e+! +i&% +er!3% 3e%!7%% 3e6%ki ere!

#i r!'%* &%ki ('i&%76% "yphus abdominalis), 3e%% 1+% ere!

('i&%76%, 3e!%% %i+i1ik)8 e% 3r1&e#!r %%! i#%k% ere!8

e% iBek&i 1&1k1'i%7 #i r!'%* &%ki8 e% ke'%i% k%re% 3e6%ki

ere!8 #% 7%i-7%i. Pe'i7i*% 13ik ii &%% 3ei8 #%7%' 'e'i7i*13ik %%r 'e'3er*%ik% $!'7%* k%&!& %%! e3i#e'i171i 3e6%ki 6% %#%

#i r!'%* &%ki #% %#%6% keii% !!k 'e7%k!k% 3er+%ik%. Se+%%i

211* #i r!'%* &%ki k%&!& typhus abdominalis 2!k!3 +%6%k #e% %k%

ke'%i% 2!k!3 ii. =%7 ii e!6% 'e$%#i '%&%7%* #% ii #i7%k!k%

3er+%ik%. C11* 7%i6% %k% &ek&i1 &e&%re% 6% 2!k!3 ii #i r!'%*

&%ki 6% 'e7e+i*i #%ri %k% %&i1%7. U!k 'ee%*!i 3e6e+%+6%

&e*i% #%3% #i7%k!k% 3er+%ik% '%k% 3er7! #i7%k!k% %!#i er*%#%3

&ek&i1 &e&%ri% er&e+!. Pe'i7i*% #% 3ee%3% 13ik %%! '%&%7%* 6%

ii #i7%k!k% %!#i #i3i7i* +er#%&%rk% ke&e3%k%% k1'ie 'e#ik #%

ke71'31k &%B'e#i&.

+. Pee%3% &%#%r #% krieri%8



See7%* 13ik #i3i7i* '%k% 3er7! #ie!k% krieri% %%! &%#%r 3r1Be&i 6%

$e7%&8 1+6ekiB #% ri# erk%i #e% 13ik er&e+!. Mi&%76% 13ik 6%

#i3i7i* typhus abdominalis '%k% 3er7! #ie%3k% 3r1&e#!r 32'erik&%%8

#i%1&i& #% 3e%1+%% typhus abdominalis. Pee%3% &%#%r #%

3r1&e#!r ii 17e* 'ir% +e&%ri (peer#group) #%@%%! #e% ik%% 3r1Be&i&ee'3%. A#% #!% 7e>e7 &%#%r #% krieri% 6%i! must do 6% 'er!3%k%

%+&17! 'ii'!' krieri% #% should do 6% 'er!3%k% %'+%*% krieri%

6% 'er!3%k% *%&i7 3ee7ii% 6% +er+%&i& +!ki.

. Pee%% $!'7%* k%&!&@&%'e7 % %k% #i%!#i

D%7%' 'e%'+i7 &%'e7 +i&% #e% 'e!%k% 'e1#e e%'+i7% &%'e7.

S%7%* &%! 'e1#e % #i!%k% !!k 'ee!k% $!'7%* &%'e7 %#%7%*

'e!%k% r!'!& S7e>i (Se>i77% e. %7. 960,82) &e+%%i +erik! ,

U77US S7!>i ,

N

I ---------

KNe)

eer%% ,

, Uk!r% S%'e7

N , Uk!r% P1!7%&i

e , er&e ke71%r% kei#%ke7ii% k%re% ke&%7%*% e%'+i7% &%'e7 %

'%&i* #%% #i17erir &%77 #iiik% 'i&%7% 0

#. Me'+%#ik% &%#%r@krireri% #e% e%k&%%% e7%%%.

S!+k1rie '!! r1Be&i %%! i' e7%k&%% %!#i 'e#i& 'e'e7%$%ri rek%' 'e#i&

!!k 'ee%*!i %%k%* krieri% %7% &%#%r #% r1&e#!r % e7%* #ie%k%

%#i e7%* #i7%k&%%k% %7% e7%* #i%%i #%7%' '%&%7%* %%! k%&!&-k%&!& %

#ie7%$%ri. D%% e% k%&!&-k%&!& % i#%k 'ere!*i krieri% % e7%*

#ie%k% #ii&%*k% #% #ik!'!7k% !!k #i %%7i&i&. Mi&%7% #%ri 200 k%&!&

%#% 20 k%&!& % i#%k 'ere!*i krieri% %%! &%#%r '%k% 20 k%&!& er&e+!

%%r #ii&%*k% #% #ik!'!7k%.

e. Me7%k!k% %%7i&i& k%&!& ;-Qi i#%k &e&!%i &%#%r #% krieri%

S!+k1'ie '!! r1B&i %%! i' e7%k&%% %!#i 'e#i& 'eer%*k% ke 20 k%&!&

er&e+! %#% 'ir% +e&%ri ( peer group) !!k #ii7%i 7e+i* 7%$!. %&!&-k%&!&

er&e+! #i %%7i&i& #% #i#i&k!&ik% %% ke'!ki% ee+%+% #% 'e%%

er$%#i kei#%k&e&!%i% #e% &%#%r. =%&i7% , +i&% $%#i er#%% ('i&%7%) 5

k%&!& % ei'%%; er*%#% &%#%r %#%i%* acccptable k%re%

e!7i %%! k1'7ik%&i % %k #i#!% &e+e7!'% (unforeseen). e71'1k ii

#i&e+! #e>i%&i (% acceptable. Si&%% %,5 k%&!& %#%7%* #e>i%&i )'

unacceptable #% *%7 ii #ik%%k% &e+%%i defisiensi . U!k 'e7%k!k% %%7i&i&

k%&!& er&e+! %%+i7% #ier7!k% #%% 'e!#% k1&!7% %'! %%! %k%r #%ri7!%r % +i%&%% #%ri r!'%* &%ki e#i#ik%.



B. Meer%k% r+%ik%.

Mir% +e&%ri (peer group) 'e7%k!k% i#%k% k1rekiB er*%#% ke7i'% k%&!& %

#eBi&ie&i er&e+! &e%r% k17ei%7 #% 'e*i#%ri $blaming culture$, =%7 ii

#i7%k!k% #e% 'e'+!% rek1'e#%&i !%% er+%ik%% %r%-%r% ee%*%#% e%!7%% 'e%#%k% r1r%' e#i#ik% #% e7%i*% e!&!%

#% er+%ik% r1&e#!r % %#% #% 7%i &e+%%i%.

. "e%% re%!#i.

Me'e7%$%ri 7%i 1ik % &%'% #i /%k! ke'!#i% 'i&%7% &ee7%* 6 e%')

+!7% ke'!#i%. T!$!% re%!#i #i7%k&%%k% %#%7%* !!k 'ee%*!i %%k%*

&!#%* %#% !%% er+%ik%. =%7 ii +!k% +er%ri 1ik %!#i %#%7%* &%'% er!&

'eer!& %!#i % #i7%k!k% 6 (e%') +!7% ker!#i% ii 7e+i* !!k 'e7i*%

!%% er+%ik%. N%'! &%'+i7 'e7i*% !%% er+%ik% ii S!+k1'ie '!!

r1Be&i %%! i' e7%k&%% %!#i #% 'ir% +e&%ri (peer group) #%% 'e'i7i* 1ik % 7%i.

2. Merek1re#%&ik% Pe#i#ik% erke7%i!% D%i S%B Me#i&.

%. S!+k1'ie '!! r1Be&i 'ee!k% ere'!%-ere'!% i7'i%* % *%r!&

#i7%k&%%k% 17e* '%&i-'%&i ke71'1k &%B 'e#i& #e% e%!r%-

e%!r% /%k! % #i&e&!%ik%.

+. Pere'!% er&e+! #%% !7% +er!% e'+%*%&% k%&!& er&e+! %%r% 7%i

'e7i!i k%&!& ke'%i% (death case), k%&!& &!7i '%!! k%&!& 7%k%

. Sei% k%i ere'!% i7'i%* *%r!& #i&er%i 1!7e&i ke&i'!7% #% #%B%r

*%#ir e&er% % %k% #i$%#ik% eri'+%% #%7%' ei7%i% #i&i7i r1Be&i

#. N1!7e&i +e&er% #%B%r *%#ir 'e$%#i #1k!'e@%r&i #%ri &!+k1'ie '!!

r1Be&i.

e. S!+k1'ie '!! r1Be&i +er&%'%-&%'% #e% ke71'1k &%B 'e#i& 'ee!k%

kei%%-kei%% i7'i%* % %k% #i+!% 17e* &!+k1'ie '!! r1Be&i %

'e7i+%k% &%B 'e#i& r!'%* &%ki &e+%%i %r%&!'+er #% e&er% %kiB.

B. Sei% ke71'1k &%B 'e#i& /%$i+ 'ee!k% 'ii'%7 &%! kei%% i7'i%* %

%k% #i7%k&%%k% #e% &!+k1'ie '!! r1Be&i er %*!.

. S!+k1'ie '!! r1Be&i +er&%'% #e% +%i% e#i#ik% R. e7ii% r!'%*

&%ki 'e'B%&i7i%&i kei%% er&e+! #% #e% 'e!&%*%k% &%!% %k% kre#i

#%ri ik%% r1Be&i.*. S!+k1'ie '!! r1Be&i 'ee!k% kei%%-kei%% i7'i%* % #%% #iik!i

17e* '%&i-'%&i &%B 'e#i& &ei% %*! #% i#%k 'e!r%i *% !i

%*!%%.

. S!+k1'ie '!! r1Be&i 'e'+erik% er&e!$!% er*%#% er'i%% &%B

'e#i& &e+%%i %&!% ke%#% #irek&i.

3. Me'B%&i7i%&i Pr1&e& Pe#%'i% (%roctoring) +%7 S%B Me#i& %

M.r+!!*k%.

%. S!+k1'ie '!! r1Be&i 'ee!k% %'% &%B 'e#i& % %k% 'e#%'ii

&%B 'e#i& % &e#% 'e%7%ri &%k&i #i&i7i@'e#%%k% e!r%%clinical privilege.



+. 1'ie 'e#ik +erk11r#i%&i #e% ke%7%@#irek!r r!'%* &%ki !!k

'e'B%&i7i%&i &e'!% &!'+er #%% % #i+!!*k% !!k r1&e& e#%'i%

(proctormg) er&e+!.

A !

SUKOMITE ETIKA DAN DISIPLIN PROFESI

A. TUJUAN

S!+k1'ie eik% #%( #i&i7i r1Be&i %#% k1'ie 'e#ik #i r!'* &%ki #i+e!k

#e% !$!%,

. 'e7i#!i %&ie #%ri e7%%% &%B 'e#i& % i#%k 'e'e!*i &%r%

(un&ualified) #% i#%k 7%%k. ( un'itllnprtp*" ) !!k 'e7%k!k% %&!*% k7ii&

(clinical +l",-).2. 'e'e7i*%r% #% 'eik%k% '!! r1Be&i1%7i&'e &%B 'e#i& #i r!'%* &%ki.

. ONSEP

Sei% &%B 'e#i& #%7%' 'e7%k&%%k% %&!*% '#i& #i r!'%* &%ki *%r!&

'eer%k% ri&i-ri&i r1Be&i1%7i&'e ke#1ker% kier$% r1Be&i1%7 %

+%ik &e*i% #%% 'e'er7i*%k% kier$% r1Be&i % +%ik. De% kier$%

r1B&i1%7 % +%ik er&e+! %&ie %k% 'e'er17e* %&!*% 'e#i& % %'%

#%( eBekiB. U%% eik%% r1Be&i1%7i&'e &%B 'e#i& #i7%k!k% #e%

'e7%k&%%k% r1r%' e'+i%% r1B&i1(%7i&r(e ke#1ker% #% !%%

e#i&i7i% +ereri7%k! r1Be&i1%7 &%B 'e#i& #i 7ik!% r!'%* &%ki.

D%7%' e%%% %&!*% 'e#i& i#%k $%r% #i$!'%i ke&!7i% #%7%' e%'+i7% ke!!&% ei& &e*i% #ier7!k% %#%% &!%! !i ker$% %

#%% 'e'+%! 'e'+erik%( eri'+%% #%7%' e%'+i7% ke!!&% ei&

er&e+!.

Pe7%k&%%% ke!!&% &!+k1'ie eik% #% #i&i7i r1Be&i #i r!r%* &%ki

'er!%k% !%% e#i&i7i% 17e* k1'ie 'e#ik er*%#% &%B 'e#i& #i r!'%*

&%ki %. +er&%k!% &e*i% e7%k&%%% #% ke!!&% i(i i#%k erk%i %%!

i#%k %#% *!+!%% #e% r1&e& ee%k% #i&i7i r1Be&i ke#1ker% #i

7e'+%% e'eri%* ee%k% eik% 'e#i& #i 1r%i&%&i r1Be&i '%!!

ee%k% *!k!'.

Pe%!r% #% eer%% ee%k% #i&i7i r1Be&i +!k%7%* &e+!%*

ee%k% #i&i7i kee%/%i% % #i%!r #%7%' %% eri+ kee)%/%i%( %#%

!'!'(6%. S!+k1'ie ii 'e'i7iki &e'%()% % +er7%#%&k% %%r% 7%i,

. er%!r% ier%7 r!'%* &%kiH

2. er%!r% ier%7 &%B 'e#i&H

3 eik r!'%+ &%kiHS

4. (1r'%-( 1 r' % '! ! #%( (1r'%-(1r'% +i1eik%

T171k !k!r #%7%' !%% e#i&i7i% eri7%k! r1Be&i1%7 &%B 'e#i& %%r% 7%i ,

. e#1'% e7%%% ke#1ker% #i r!'%* &%kiH

2. r1&e#!r ker$% e7%%% #i r!'%* &%kiH

3. #%B%r ke/e%% k7ii& #i r!'%* &%kiH4. e#1'% &%r%-&%r% k!%7iBik%&i !!k 'e7%k!k% e7%%% 'e#i& (white paper)



#i r!'%* &%kiH5. 1#e Eik e#1ker% #1e&i%H

6. e#1'% eri7%k! r1Be&i1%7 ke#1ker% (+!k! ee7e%r%% r%kik

ke#1ker% % +%ik)H

.e#1'% e7%%r% #i&i7i ke#1ker% % +er7%k! #i #1e&i%H

8. e#1'% e7%%% 'e#ik@k7iikH9.&%#%r r1&e#!r 1er%&i1%7 %&!*% 'e#i&

C. EAN<<OTAAN

S!+k1'ie eik% #%( #i&i7i r1Be&i #i r!'%* &%ki er#iri %%& &ek!r%-k!r%% 3

(i%) 1r% &%B 'e#i& % 'e'i7iki &!r% e!%&% k7ii& (clinical appotntment) #i

r!'%* &%ki er&e+! #%( +er%&%7 #%ri #i&i7i i7'! % +er+e#%. Pe1r%i&%&i%

&!+k1'ie eik% #% #i&i7i r1Be&i &ek!r%-k!r%% er#iri #%ri ke!% &ekre%ri&

#% %1% % #ie%k% 17e* #% +er%())!() $%/%+ ke%#% ke!% k1'ie 'e#ik.

D. MEANSME E"JA

e%7%@#irek!r r!'%* &%ki 'ee%k% ke+i$%k% #% r1&e#!r &e7!r!* 'ek%i&'e

ker$% &!+k1'ie #i&i7i #% eik% r1Be&i +er#%&%rk% '%&!k% k1'ie 'e#i&. Se7%i

i! ke%7%@#irek!r r!'%* &%ki +er%!$%/%+ %%& er&e#i%% +er+%)%i &!'+er

#%% % #i+!!*k% %%r kei%% ii #%% er&7e%r%

Pee%k% #i&i7i r1Be&i #i7%k!k% 17e* &e+!%* I % #i+e!k 17e* ke!%

&!+k1'ie eik% #% #i&i7i r1Be&i. P%e7 er#iri 3 (i%) 1r% &%B 'e#i& %%! 7e+i*

#%7%' $!'7%* %$i7 #e% &!&!(%( &e+%%i +ek! ,

A !I

PETUNJUK TEKNIS PENYUSUNAN PERATURAN INTERNAL STAF

MEDIS

A. PENDA=ULUAN

. FO"MAT DAN SUSTANS PE"ATU"AN NTE"NAL STAF MEDS

A !II

PENUTUP

296498555 Pedoman Komite Medis Edit

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