DECREE OF

PRESIDENT DIRECTOR OF Dr. WAHIDIN SUDIROHUSODO HOSPITAL

MAKASSAR
Number: HK.02.04/I/2296/2014

REGARDING
THE ENFORCEMENT OF RISK MANAGEMENT PROGRAM
IN Dr. WAHIDIN SUDIROHUSODO HOSPITAL MAKASSAR

PRESIDENT DIRECTOR OF Dr.WAHIDIN SUDIROHUSODO HOSPITAL

MAKASSAR,

Considering : a. Dr.Wahidin Sudirohusodo Hospital Makassar attempts to

improve the quality of service and safety of the hospital on
an ongoing basis, in reference to the applicable regulation.

b. In attempt to improve the quality of serviceand safety of the

hospital, Dr.WahidinSudirohusodoHospital Makassar
applying the standardof service in reference to the
applicable national and onternational standards of hospital
accreditation.

c. To increase the Quality Improvement and Patient Safety,

the hospital needs to establish Quality Iimprovement and
Patient Safety program of the hospitalin a
comprehensiveand integratedto meet the standard ofJoint
Commission International Accreditation.

d. Risk Management is a part of Quality Improvement and

Pastient Safety in Dr. WahidinSudirohusodo Hospital
Makassar.

e. Related to the a,b,canddpoints, it is necessary to enforce

the policy of Risk Management Program determined by
Decree of President Director of
Dr.WahidinSudirohusodoHospital Makassar.

In view of : 1. Indonesian Regulation No. 29 year 2004 aboutClinical

Practice.
2. Indonesian Regulation No.36 year 2009 aboutHealth
3. Indonesian Regulation No.44 year 2009 aboutHospital
4. Regulation of the Indonesian Minister of HealthNo.
1691/Menkes/PER/VIII/2011 aboutPatient Safety in
Hospital
5. Regulationof the Indonesian Minister of
HealthNo.1333/Menkes/SK/XII/1999 aboutService
Standard ofHospital
 6. Regulation of the Indonesian Minister of
HealthNo.1087/Menkes/SK/VIII/2010 aboutStandard of
Occupational Health and Safety in Hospital
7. Regulation of the Indonesian Minister of HealthNo.
1195/Menkes/SK/VIII/2010 aboutInternational Hospital
Accreditation Agency.
8. National Guide Bookon Patient Safety in Hospital,
secondary edition byMinistry of Health RI/KKP-PERSI year
2008
9. Regulation of the Indonesian Minister of
HealthNo.1677/Menkes/Per/XII/2005
aboutOrganizationandWork Procedures of
Dr.WahidinSudirohusodoHospital Makassarper of 27
December 2005.

DECIDED

To Determine :

FIRST :
DECREE OF PRESIDENT DIRECTOR ABOUT THE
ENFORCEMENT OF RISK MANAGEMENT PROGRAM IN
Dr.WAHIDIN SUDIROHUSODO HOSPITAL MAKASSAR.

SECOND : Risk Management Program in Dr.WahidinSudirohusodo Hospital

as of the first dictum included in the attachement of this decree.

THIRD : Risk Management Programbeing a reference

inDr.WahidinSudirohusodoHospital in managing high risk
processesto improvegood quality serviceby prioritising patients,
staffs and visitors safety.
: Risk Management Programincludes risk identification, risk
priority, risk reporting, FMEA implementation, adverse event
investigationandClaim Management, andactivity in order to the
improvement of risk management implementation in Dr.
Wahidin Sudirohusodo Hospital.

: The decree will be commenced by the date of signingand ifthere

is confusion in the issuing of this decree, there will be properly
revision.

Declared in : Makassar
On : 19Juni2014

PRESIDENT DIRECTOR,

ABDUL KADIR
NIP196205231989031001