Assessment Report. Sekolah Tinggi Ilmu Kesehatan … · 6 nonconformities requiring attention were identified. ... seperti contoh : ... Jumlah judul buku teks : ...

Report Author BUDI SISWANTO Page 1 of 25 Visit Start Date 24/09/2014

Assessment Report.

Sekolah Tinggi Ilmu Kesehatan 'Aisyiyah Yogyakarta

Assessment Report.


Introduction.

This report has been compiled by BUDI SISWANTO and relates to the assessment activity detailed below:

Visit ref/Type/Date/Duration Certificate/Standard Site address

8065140

Continuing Assessment (Surveillance)

24/09/2014

3.5 day(s)

No. Employees: 60

FS 600796

ISO 9001:2008

Sekolah Tinggi Ilmu Kesehatan

'Aisyiyah Yogyakarta

Jl . Ring Road Barat 63

Mlangi Nogotirto Gamping Sleman

Yogyakarta

55292

Indonesia

The objective of the assessment was to conduct a surveillance assessment and look for positive evidence to ensure that elements of

the scope of certification and the requirements of the management standard are effectively addressed by the organisation's

management system and that the system is demonstrating the ability to support the achievement of statutory, regulatory and

contractual requirements and the organisations specified objectives, as applicable with regard to the scope of the management

standard, and to confirm the on-going achievement and applicability of the forward strategic plan and where applicable to identify

potential areas for improvement of the management system.

The scope of the assessment is the documented management system with relation to the requirements of ISO 9001 : 2008 and the

defined assessment plan provided in terms of locations and areas of the system and organisation to be assessed.

Management Summary. Overall Conclusion

The objectives of this assessment have been achieved.

I would like to thank all the audit participants for their assistance and co-operation which enabled the audit to run smoothly and to

schedule.

Based on the objective evidence detailed within this report, the areas assessed during the course of the visit were generally found to

be effective.

Corrective actions with respect to nonconformities raised at the last assessment have been reviewed and found to be effectively

implemented.

6 nonconformities requiring attention were identified. These, along with other findings, are contained within subsequent sections of

the report.

A nonconformity relates to a single identified lapse, which in itself would not indicate a breakdown in the management system's

ability to effectively control the processes for which it was intended. It is necessary to investigate the underlying cause of any issue to

determine corrective action. The proposed action will be reviewed for effective implementation at the next assessment.

Assessment Report.


Areas Assessed & Findings. Top Management (Ketua & Wakil Ketua) : 4.1, 5.1, 5.2, 5.3, 5.4, 5.5.1, 5.5.2, 5.5.3

Auditee : Mrs. Warsiti & team

The Top Management headed by Leader of Institution has demonstrated a strong commitment to the implementation and continual

improvement of the QMS in meeting with their customers requirements.

Vision : "Menjadi Perguruan Tinggi kesehatan terbaik ditahun 2016," which is describe in the strategic planning of institution 2011 -

2016.

Organization has established and documented a Quality Management System since April 2013. and the purpose of implementation

Quality Management System to ensuring the satisfaction of stakeholder thru developing of documented management system.

Expectation of stakeholder has been determine in the strategic planning of institution 2011-2016.

The Quality Policy established by Top Management and relevant with the nature of business. Copies of this quality policy are

communicated and posted at strategic area such as meeting room and also at the site office and all employees are understood and

aware the spirit of quality policy in relation to their jobs, meeting, web etc.

The organization had set measurable objectives in the strategic planning of institution 2011-2016 called "Indikator keberhasilan

Implementasi program 2011-2016" in line with accreditation objective.

Advantage in implementing the quality management system has been keenly felt by the organization and assist organizations in

gaining accreditation better than the previous year, which was declared obtain accreditation "A" in 2016.

The organisation structure established by Top Management (SK no. 30/SENAT-STIKES/SK/III/2013) which present the organisation

function and position of the Director and Managers. All managers are individually and collectively responsible for ensuring that

activities are adequately planned, resourced, controlled and monitored including subject to continual performance improvement.

Responsibility and Authority of all level were determine and communicated.

Verified appointed letter for Management Representative no. 74/SK-STIKES/Au/XII/2012 on 12 December 2012. Verified the

evaluation of performance for each department including customer satisfaction on 2013.

Communication processes are established within the organization various levels and function through emails, notice board, meeting

etc. Continual improvement will be concern to ensuring the achievement of challenge objective such as competency of graduation

which is improving in the learning process.

Opportunity for improvement.

Type Area/Process Clause

Opportunity for

improvement

Top Management (Ketua & Wakil Ketua) 5.1

Scope FS 600796

Details: - Sebaiknya perlu dipertimbangkan untuk penerapan sistem manajemen mutu, bisa dilakukan secara online

dan integrated di setiap fungsi yang relevan.

- Perlu dipertimbangkan pula untuk dilakukan pengembangan secara online terkait kemudahan akses publik

dan brand kampus bisa lebih ditonjolkan di dalam website serta beberapa bukti bahwa banyak keunggulan

organisasi bisa ditunjukkan seperti contohnya dengan adanya testimonial atau chat online.

Assessment Report.


Management Representative / BPM-P : 4.1, 4.2, 5.4, 5.6, 8.2.2, 8.3, 8.5

Auditee : Mr Syaifudin & Mr Bayu

Unit Penjaminan Mutu/Management Representative has responsibilities for ensuring compliance to the ISO 9001:2008 requirement

and effectiveness of implementation. Mandatory element was implemented and documented in :

1. SOP Document and record Control (SAY/BPM.P/SM/03))

2. SOP Internal Audit (SAY/BPM.P/SM/02)

3. SOP Non conforming, corrective and preventive action (SAY/BPM.P/SM/07)

Documentation system comprises of categories of document (Company document system, Project Document System, External

Documents) and determined in Quality manual, Quality procedure, Work Instruction and supporting document and Form/Record.

Quality manual was approved and covered all relevant clauses of ISO 9001:2008.

Control of documents have been performed in the procedure no. SAY/BPM.P/SM/03 and verified some record such as : the master list

document internal and external, distribution of document.

Management review has not been conducted once per semester as required in the procedure SAY/BPM.P/SM/01. Last management

review conducted on 12 Sept 2014. Minutes of meeting has been recorded in Notulen rapat.

Internal audit conducted once per semester as describe in the procedure SOP Audit Mutu Internal, Doc. No: (SAY/BPM.P/SM/02).

Internal Audit has been conducted on 11-20 Aug. 2014 as per Audit Plan. Auditors found to be Impartial and independent of the

areas audited. There were more than 274 NC raised and it was noted that date of completion and follow up activity including of

evidence of effectiveness for closed out finding

8.3 Controlling of non conformance product

SOP Pengendalian Produk tidak sesuai (SAY/BPM.P/SM/07) has been established. The nonconformities which need to be recorded has

been identified in the procedure

8.5.1 Improvement, 8.5.2 Corrective action, 8.5.3 Preventive action

SOP Perbaikan dan pencegahan Doc. No. (SAY/BPM.P/SM/07) has been established. Form Permintaan tindakan perbaikan dan

pencegahan has been determined.

Observations.


Observations Management Representative / BPM-P 4.2.3

Scope FS 600796

Details: - Sebaiknya perlu dipertimbangkan untuk ditinjau ulang prosedur pengendalian dokumen terkait

pengendalian dokumen eksternal

- Di dalam pengendalian dokumen terhadap perubahan / revisi dokumen, sebaiknya perlu dipertimbangkan

untuk diidentifikasi untuk bisa mampu telusur dengan mudah history revisi dokumennya dan dilakukan

secara lebih efektif, seperti contoh : history revisi dokumen dimasukkan ke dalam dokumen yang direvisi.

- Sebaiknya perlu dipertimbangkan untuk ditinjau ulang form distribusi dan penarikan dokumen dibuat lebih

efisien.

Assessment Report.



Observations Management Representative / BPM-P 8.2.2

Scope FS 600796

Details: - Sebaiknya perlu dipertimbangkan untuk ditinjau kembali hasil internal audit, untuk temuan audit bisa

dikategorikan atau menggunakan sistem lain, seperti contoh : skoring.

- Untuk tindakan perbaikan dari temuan internal audit, sebaiknya perlu ditinjau untuk keefektifannya



Opportunity for

improvement

Management Representative / BPM-P 8.5.2

Scope FS 600796

Details: Sebaiknya perlu dipertimbangkan untuk mekanisme tindakan perbaikan dan pencegahan untuk semua

ketidaksesuaian ataupun ketidaktercapaian bisa ditinjau ulang.

Perpustakaan : 5.4, 6.3, 6.4, 7.5, 8.2, 8.4, 8.5

Auditee : Ms. Nisa' & team

1. Process Overview

Borrowing books --> registration --> library card --> book out --> returning books --> books governance

2. Key Process/parameter

- Control of the books like with e-library, e-catalogs based IT

- Quality objective have been established. Achievement of quality objective for 2014 was monitored yearly. The record is available in

place.

The quality objective measured for baseline in year 2013-2014 are:

1. Jumlah judul buku teks : 50/years

2. Jumlah judul disertasi/thesis/skripsi : 375/years

3. Jumlah judul jurnal ilmiah : 1/years

4. prosiding seminar : 1/2 years

5. kompetensi pustakawan : 50%

6. naskah publikasi hasil penelitian dosen dan mahasiswa di portal garuda : 80%

7. koleksi buku terinput di SIM : 100%

3. Applicable requirement / regulatory

- UU No. 43 th. 2007

- Buku Pegangan perpustakaan perguruan tinggi.

- UU RI no. 12 / 2012

4. Objective evidence

- Verified implementation of : Prosedur Pengelolaan Koleksi Perpustakaan document no. SAY/PUS/PBM/16 dated 19 August 2013,

Assessment Report.


Prosedur Layanan Perpustakaan document no. SAY/PUS/PBM/15. dated 16 August 2013, Procedure Pelayanan Bebas Pustaka.

- Sasaran Mutu Perpustakaan dan Rencana Mutu Perpustakaan (doc. no. SAY/BPM-P/SM/RO)

- Daftar Pemesanan Koleksi Perpustakaan Stikes 'Aisyiyah Yogyakarta Bulan Maret 2013

- Portal Garuda http://garuda.dikti.go.id/statistik/dokumen, which states the amount of thesis uploaded by Stikes 'Aisyiyah

Yogyakarta

- Surat Keterangan Keanggotaan Forum Pustakaan Perguruan Tinggi di Indonesia (FPPTI) Daerah Istimewa Yogyakarta

- Hasil Penilaian Presentasi Final Pemilihan Pendidik dan Tenaga Kependidikan Berprestasi Sesuai Standar BSNP Tingkat Nasional

Tahun 2011 no. 2376/E.4.2/2011

- The DDC Dewey Decimal Classification and Relative Index is used managed the Spesification for library room temperature is

between 22 - 24 degree celcius, humidity 44% - 55%.

- No. 610.7367/Sim/b/1987 with Buku Belajar Merawat di bangsal bedah karangan Simon, THS with. No. invt. C.1 (156).

5. Conclusion

In general process and activities in this department is found well managed.

Observations.


Observations Perpustakaan 5.4.1

Scope FS 600796

Details: Sebaiknya untuk pengukuran kinerja perpustakaan disesuaikan dengan target sasaran mutu yang telah

ditetapkan, agar mempermudah monitoringnya, dan tindakan perbaikan merujuk ke akar permasalahannya.


Observations Perpustakaan 8.2.3

Scope FS 600796

Details: Untuk menjaga kesesuaian antara data aktual dan sistem untuk jumlah, jenis, spesifikasi buku di

perpustakaan, sebaiknya dipertimbangkan untuk dilakukan stock opname secara berkala dalam durasi

waktu yang tidak terlalu lama dengan metoda yang lebih mudah tanpa mengganggu aktifitas

perpustakaan.



Opportunity for

improvement

Perpustakaan 4.2.4

Scope FS 600796

Details: Sebaiknya dipertimbangkan untuk dilakukan kontrol terhadap proses migrasi dari manual ke sistem.

Assessment Report.


Prodi D3 Kebidanan : 5.4, 5.5.1, 6.2, 7.1,7.3, 7.5.1, 7.5.2, 7.5.3, 7.6, 8.2.1, 8.2.3, 8.2.4, 8.3, 8.4, 8.5

Auditee : Mrs Anjarwati & Team

1. Process Overview

Proccess of increase the competence of lecturers with training, and continuing education to a higher level, define of curricullum,

conduct research and dedication of community .


- Quality objective have been established. Achievement of quality objective for 2014 was monitored monthly. The record is available

in place.

Process Inputs : Training request, manpower, curricullum, research

Process Outputs : Training schedule, training realization, training evaluation, training record, journal, performance evaluation report,

SAP, syllabus etc.


- UU RI no. 12 / 2012

- Kurikulum Pendidikan NERS edisi 2010

- KKNI (Kualifikasi KUrikulum Nasional Indonesia)


- Verified implementation of : SOP Prodi Kebidanan DIII, Prosedur sistem mutu tentang urain tugas

- Pelaksanaan ujian akhir semester genap tahun akademik 2013-2014

- Program structure D3 Kebidanan on 2013 & 2014 on semester genap and 2014 & 2015 semester genap

- Syllabi of # BD3105, semester III, Asuhan kebidanan, # BD 3104

- Competency of lecture for each subject on 2013/2014

- Evaluation of lecture on 2013-2014

- Tugas akhir (SOP no. SAY/AK/PBM/05)

- Ujian Tugas, Skripsi, bimbingan & examination : # 201010105229 # 201010105009

- SK Dosen pembimbing dan penguji no. SK-STIKES/Ad/XII/2012

- Laporan pelaksanaan Ujian Akhir Semester 2013-2014

- Validation of exam paper on 2013-2014 semester genap

- Laporan evaluasi pembelajaran teori & tutorial 2013-2014

- Accreditation got B until 24 Sept. 2014, but already processed to BAN PT (based on letter from BAN PT dated 03 Aug 2016) and

waiting response from BAN PT

- Rencana Pengembangan studi lanjut dosen prodi kebidanan jenjang diploma III Stikes 2012 - 2018giatan pelatihan item

development dan item review dosen kebidanan

- Laporan kegitan pelatihan item development dan item review dosen kebidanan STIKES "AISYIAH" Yogyakarta dates 5 Feb. 2014

- Rekapitulasi indeks kinerja dosen kebidanan semester genap tahun akademik 2013-2014

- Evaluasi terhadap dosen pengampu oleh mahasiswa semester I & III prodi kebidanan DIII 2013-2014

- Daftar prestasi dan penghargaan mahasiswa/wi 2013-2014

- Persyaratan kelulusan berdasarkan yudisium 2013-2014

5. Conclusion

In general process and activities in this department is found well managed

Assessment Report.


Observations.


Observations Prodi D3 Kebidanan 7.5.2

Scope FS 600796

Details: Sebaiknya dipertimbangkan untuk dilakukan validasi soal secara contain soal bukan hanya sekedar

jumlahnya saja.



Opportunity for

improvement

Prodi D3 Kebidanan 8.4

Scope FS 600796

Details: Untuk analisa butir soal ujian, sebaiknya perlu dipertimbangkan untuk hasil analisa tidak hanya berdasarkan

dari hasil ujian yang masuk ke bank soal saja, tetapi lebih kepada contain soal disesuaikan dengan

materinya.


Opportunity for

improvement

Prodi D3 Kebidanan 7.4.2

Scope FS 600796

Details: Sebaiknya dipertimbangkan untuk setiap pembelian bahan kimia yang dilakukan bisa disertakan MSDS atau

COAnya.

Bagian Kemahasiswaan dan Pemberdayaan Alumni : 5.4, 7.5, 8.4, 8.5

Auditee : Mr. Dwi

1. Process Overview

The proses in Bagian Kemahasiswaan and Pemberdayaan Alumni consist of :

- Program Penerimaan Mahasiswa Baru

- Pengembangan Ekstra kulikuler dan koordinir Organizasi Mahasiswa

- Pengelolaan Beasiswa

- Program Orientasi Mahasiswa Baru

- Pelayanan Kesehatan Mahasiswa

- Penyebaran informasi lowongan kerja

- Pembekalan calon wisudawan dalam menghadapi dunia kerja

- Pelacakan alumni


- Parameter kelulusan mahasiswa baru

Assessment Report.


- Evaluasi kegiatan orientasi mahasiswa baru

- tracer survey alumni ..etc


- UU RI no. 12 / 2012

- Statuta STIKES


- Verified implementation of : SOP Pelacakan Alumni (no. SAY/KPA/PBM/12), SOP Registrasi (no. SAY/KPA/PBM/02), Prosedur

Layanan Karir (no. SAY/KPA/PBM/07)

- Data Peserta diterima dan registrasi period 2013-2014

- Layan Karir" no. SAY/AK/PBM/07 dated 15 July 2013

- Pengumuman no. 326/STIKES/Ak/VIII/2013 about "Pembekalan Alumni" dated 21 August 2013

- Notulen Rapat dated 19 August 2013 about "persiapan Pembekalan Alumni"

- Kalender Kegiatan Kemahasiswaan Tahun Akademik 2013-2014 on 16-21 September 2013

- Seleksi international summer scholl at the university of tokhusima Japan 2014 with result of Dina A, Nurmala, Firstyono.

- Laporan kegiatan mahasiswa baru LPJ Mataf on 25 - 30 Aug. 2014

- Kuisioner pengguna lulusan program studi D3 kebidanan period. 2013-2014

- Laporan Studi pelacakan pengguna alumni period Dec. 2013

- Laporan Program layanan bimbingan karir pembekalan alumni period 2013-2014

- Laporan kegiatan seleksi penerimaan mahasiswa baru STIKES period 2013-2014

- Penerima beasiswa peningkatan prestasi studi (PPS) STIKES on 8 Feb. 2014

- Kartu Tanda Pesert Dana Sehat Muhammadiyah as DP.

5. Conclusion

In general process and activities in this department is found well managed.

Observations.


Observations Bagian Kemahasiswaan dan Pemberdayaan Alumni 4.2.3

Scope FS 600796

Details: Sebaiknya ditinjau ulang SOP registrasi terkait registrasi online


Observations Bagian Kemahasiswaan dan Pemberdayaan Alumni 8.2.1

Scope FS 600796

Details: Sebaiknya dipertimbangkan untuk survey dari alumni dijadikan dasar untuk melakukan develop materi

pembelajaran untuk lebih mendekatkan dunia kerja dengan materi mata kuliah.

Assessment Report.




Opportunity for

improvement

Bagian Kemahasiswaan dan Pemberdayaan Alumni 7.1

Scope FS 600796

Details: Sebaiknya dipertimbangkan untuk dibuatkan standart baku penerimaan mahasiswa baru dari beberapa

parameter yang sudah kita tetapkan

Administrasi Akademik : 4.5,8.2.3,7.5.1,7.5.4,7.5.5,8.4

Auditee: Pak Dono dan tim

Process overview

Departement ini bertanggung jawab, antara lain:

1. Penjadualan perkuliahan

2. Pelayanan akademik, seperti: pengambilan ijasah, legalisir ijasah, pengisian KRS (her) dll

3. Membantu proses yudisum (kelengkapan administratif)

4. MEmbantu pelaksanaan UTS dan UAS

5. Pengelolaan ijasah

Key Process/parameter

Sasaran mutu 2014 sudah ditetapkan, antara lain:

1. Pengembangan staff akademik sesuai dengan kompetensi: 100%

2. Ketersediaan kalender akademik 2 minggu sebelum pembelajaran

3. ketersediaan guku akademik 100%

4. Pelaksanaan Her mahasiswa sesuai jadual

5. Pelaksanaan perkuliahan berbasi IT: 80%

6. Indeks kepuasan pelayana akademik > 2,5

Rencana kerja (rencana mutu) terkait sasaran mutu sudah disusun.

Pencapaian sasaran mutu tahun 2013, dimonitor dan dilaporkan setahun sekali.

Applicable requirement / regulatory

UU RI no. 12 / 2012

Objective evidence

- Rekapitulasi Her-registrasi mahasiswa semester gasal 2013/2014

- SIM (Sistem Informasi Manajemen Perguruan Tinggi Terpadu): SIM Akademik

- Kalender Akademik 2014/2015

- Buku Akademik

- Jadual ujian remedial Prodi Ilmu Keperawatan (S1) semester gasal 2013/2014

- Bukti Serah terima soal Her. Mata Kuliah: Keperawatan Dasar I

- Berita Acara ujian, mata kuliah Keperawatan Dasar I

- Daftar hadir ujian remidi, mata kuliah Keperawatan Dasar I

- Serah teriam soal, mata kuliah Gawat Darurat I

- Berita Acara ujian, Gawat Darurat I

Assessment Report.


- Daftar hadir ujian remidi, Gawat Darurat I

- RKS mahasiswa remidi semester 4, Prodi Ilmu Keperawatan

- Mahasiswa NIM 201010201001 dan NIM 201010201002

- Daftar pengumpulan berkas yudisium

- Formulir persyaratan yudisium dan wisuda

- Rekapitulasi penggunaan kertas ijasah, tgl. 19 Agt. 2014 ----> 818 lulusan

- SK Kepala Sekolah Tinggi Ilmu Kesehatan "Aisyiyah" #76/SK-STIKES/Ad/VIII/2014 tgl. 9 Agt. 2014

- SOP Ujian #SAY/AK/PBM/04

- SOP Her Rregistrasi #SAY/PA/PBM/14

- SOP Registrasi #SAY/PA/PBM/02

- SOP Yudisium #SAY/AK/PBM/02

- SOP Wisuda #SAY/AK/PBM/13

- Indeks kepuasan pelayanan akademik TA 2013/2014: 2.64

Conclusion

Secara umum, proses di bagian Administrasi Akademik berjalan dengan biak, Bukti-bukti pekerjaan bisa diperlihatkan dengan

lengkap.

Observations.


Observations Administrasi Akademik 7.5.5

Scope FS 600796

Details: Agar dibuatkan bukti serah terima buku akademik yang didistribusikan kepada dosen, sebagai bukti

pendukung (data) terkait sasaran mutu "Ketersediaan Buku Akademik".

Laboratorium : 4.5,8.2.3,5.5.1,7.5.1,7.5.2,7.5.3,7.5.4,7.5.5,8.4

Auditee: Ibu Irma dan tim

Process overview


Koordinasi praktikum untuk Ilmu keperawatan dan fisioterapi: membuat jadual praktikum, daftar hadir praktikum, menyediakan alat-

alat lab. dll.


Sasaran mutu 2014 sudah dibuat, antara lain:

1. Ketersediaan alat praktikum sesuai dengan rasio jumlah alat: jumlah mahasiswa 1:5 tiap prodi

2. Ketersediaan phantom praktikum 1:20

3. Load penggunaan ruang praktikum 1:8 jam

4. Indeks kepuasan stakholder layanan lab. minila 3.5




UU RI no. 12 / 2012

Assessment Report.


Objective evidence

- SOP Praktikum #SAY/AK/PBM/11

- Struktur organisasi Laboratorium dan uraian tugasnya

- Jadual praktikum, semester gasal 2013/2014

- Daftar inventaris: USG, CTG, EKG, Nebulizer, Phantom

- Sistem informasi administrasi (SIM) inventaris alat lab.

- Kart kendali alat (pengecekan seblum dipakai): USG, CTG, EKG, Nebulizer, Phantom

- Perjanjian penangana limbah B3 lab. biomedis dengan RS PKU Jogyakarta, #0037/KS.14.5.3/VII/2011

- Kartu kendali alat nebulizer 27 Agt. 2014 dan 20 Sept. 2014

- Daftar hadir kuliah praktek; Keperawatan gawat darurat tgl. 6, 12, 13, 24 Sept. 2014

- Rekap mengajar dosem; SIM laboratorium

- Indeks kepuasan stakholder 2013/2014; semester gasal: 3.16, semester genap: 3.15

Conclusion

Secara umum aktivitas di laboratorium berjalan dengan baik,

Observations.


Observations Laboratorium 7.5.5

Scope FS 600796

Details: 1. Persediaan bahan kimia di laboratorium biomedis agar dimasukan ke dalam SIM inventasi lab, sehingga

stok bahan kimia dan penggunannya bisa termonitor dengan lebih baik.

2. Limbah B3 yang dihasilkan dari bahan kimia yang digunakan praktek di lab. biomedis, dikirimkan ke RS

PKU Jogyakarta (ada perjanjian kerjasamanya).

Berita acara / catatan pengirian agar dibuatkan.

Prodi Keperawatan : 4.5,6.2.1,7.3,7.4.1,8.2.3,8.2.4,8.4

Auditee: Ibu Suratini dan tim

Process overview

Secara garis besar departement ini bertanggung jawab melakukan perencanaan perkuliahan, pelaksanaan perkuliahan, monitoring

hasil perkuliahan.



1. Minimal 8% mahasiswa berprestasi di tingkat nasional dan minimal 1% di tingkat internasional

2. Mahasiswa menyelesaikan studi tepat waktu 100%

3. Lulusan memiliki TOEFL 450, min 50^%

4. Nilai kinerja dosen >= 3

5. Indeks kepuasan stakeholder: 3.5



Assessment Report.



- UU RI no. 12 / 2012

- Kurikulum Pendidikan NERS edisi 2010

- KKNI (Kualifikasi KUrikulum Nasional Indonesia)

Objective evidence

- Jadual workshop kurikulum prodi Ilmu keperawatan 22-27 Jjuli 2014

- SK tim pengkaji KKNI, #38/SK-STIKES/Ad/V/2013 tgl. 1 Mei 2014

- Hasil Kajian KKNI

- Buku Kurikulum 2008, disetujui oleh Rektor (Kepala STIKES)

- Laporan workshop kurikulum

- Identifikasi perubahan kurikulum

- SOP #SAY/AK/PBM/08 "Desain dan pengendalian kurikulum".

- Peninjaan silabus/SAP/modul mamta kuliah

- Silabus/rancangan pembelajaran; "Keperawatan jiwa" (3 SKS) dan "Konsep keperawatan gerontik" (4 SKS)

- Panduan akademik TA 2013/2014

- Panduan Praktikum TA 2014/2015

- Kualifikasi dosen mengajar di STIKES; terdiri dari pendidikan, pengalaman, pelatihan dan keterampilan

- CV Dosen luar untuk keperawatan jiwa (PAk Sutejo) dan konsep keperawatan gerontik (Bu Wasilah)

- Panduan tutorial keperawatan jiwa dan konsep keperawatan gerontik, disetujui oleh Ka. Prodi

- Monitoring perkuliahan tutorial (setiap 4 bulan). Bulan Desember 2013 (konsep keperawatan gerontik) dan Maret-April 2014

(keperawatan kejiawaan).

- Laporan evaluasi dosen per semester 2013/2014

- Kriteria penilaian dosen

- Laporan verifikasi arsip-arsip UTS/UAS TA 2013/2014

- Daftar nilai mahasiswa, Mahasiswa NIM 201010201001 dan NIM 201010201002

- Pengajuan penyusunan tugas akhir mahasiswa dan berita acara ujian proposal (dan ujian hasil). Mahasiswa NIM 201010201001 dan

NIM 201010201002

- Rapat Prodi TA 2013/2014 tgl. 22 Jan. 2014

Conclusion

Secara umum proses di Prodi Ilmu keperawatan berjalan degan baik.

Observations.


Observations Prodi Keperawatan 7.5.1

Scope FS 600796

Details: 1. Perlu dibuatkan panduan untuk pembuatan soal UTS/UAS, agar bobot/mutu soal bisa distandarkan

2. Master soal UTS/UAS harus diverifikasi oleh pejabat yang berwenang untuk memastsikan bahwa soal tsb

sudah mencakup materi perkuliahan yang disebutkan dalam silabus.

Assessment Report.



Observations Prodi Keperawatan 6.2.1

Scope FS 600796

Details: Agar dibuatkan alat monitoirng untuk melihat gap kompetensi, yang bisa membandingkan antara

kompetensi dosen sebenarnya dengan persyaratan kompetensinya.

Hal ini untuk memudahkan pengembangan kompetensi dosen.

Kerjasama internasional dan Humas : 5.4,8.2.3,7.5.1,7.5.5

Auditee: Ibu Indri dan tim

Process overview


melakukan kerjasama dengan instansi luar negeri (internasional), melakukan kerjasama dengan instansi nasional, melakukan

kegiatan yang bermanfaat bagi masyarakat, promosi sekolah.



1. Kompetensi staf humas yang profesional yang memiliki profesi kehumasan dan bahasa asing: 3 orang

2. Kerjasaam nasioanl dengan mira: 110

3. Kerjasaam nasioanl dengan mira: 10

4. Saran promosi melibatkan IT: 20 tayangan

5. kegiatan rutin melibatkan masyarakat: 4 per tahun




Tidak ada peraturan spesifik terkait aktivitas di Humas

Objective evidence

- Daftar kerjasama STIKES dengan instansi luar negeri

- MOU dengan National Taipe University of Nursing & Health Science, Taiwan

- MOU dengan Taipe Hospital

- MOU dengan Khon University, Thailand

- MOU dengan RS PKU Jogyakarta

- MOU dengan ASRI MEdical Center

- MOU dengan RS Sardjito Jogyakarta

- Laporan CSR, tgl. 26 Juni 2014

- SOP #SAY/PMS/HUM/16

- SOP #SAY/PMS/HUM/17

- Laporan kegiatan internasional summer school di Jepang, Agustus 2014

- Angaran promosi 2014

- Laporan ketersediaan dana/promosi 2014

- List bahan-bahan promosi

Assessment Report.


Observations.


Observations Kerjasama internasional dan Humas 7.5.1

Scope FS 600796

Details: Petugas promosi dikirimkan oleh STIKES ke SMA-SMA untuk mempromosikan STIKES.

Standar kompetensi (keterampilan) untuk seorang petugas promosi sebaiknya dibuatkan untuk memastikan

bahwa petugas promosi memiliki keterampilan yang dibutuhkan untuk melakukan promosi sekolah.

Karena petugas promosi memberikan kesan pertama kepada sekolah SMA, sehingga harus benar-benar

memiliki keterampilan yang cukup, untuk menunjang keberhasilan promosi.

During the course of the visit logos were found to be used incorrectly.

Letter, email, busisness card

Nonconformities Raised at Last Assessment. Ref Area/Process Clause

961434N0 5.4.2

Scope FS 600796

Details: The organization not define clearly the quality management system planning in order to meet the quality

objective.

Requirements:

Quality objectives

Top management shall ensure that quality objectives, including those needed to meet requirements for

product [see 7.1 a)], are established at relevant functions and levels within the organization. The quality

objectives shall be measurable and consistent with the quality policy.

5.4.2 Quality management system planning Top management shall ensure that

a) the planning of the quality management system is carried out in order to meet the requirements given in

4.1, as well as the quality objectives, and

b) the integrity of the quality management system is maintained when changes to the quality management

system are planned and implemented.

Objective

Evidence:

Quality objective of Laboratorium define in document no. SAY/BPM-P/SM/RO dated 25 July 2013.

Actions: Achieve the quality objective target was already done of analisys based monitoring and corrective action

effectiveness

Closed?: Yes

Ref Area/Process Clause

961434N0 8.4

Assessment Report.


Scope FS 600796

Details: The activity of data analysis not found to be effectively implemented in order to achieve the quality

objective target

Requirements:

Analysis of data

The organization shall determine, collect and analyse appropriate data to demonstrate the suitability and

effectiveness of the quality management system and to evaluate where continual improvement of the

effectiveness of the quality management system can be made. This shall include data generated as a result

of monitoring and measurement and from other relevant sources.

The analysis of data shall provide information relating to

a) customer satisfaction (see 8.2.1),

b) conformity to product requirements (see 8.2.4),

c) characteristics and trends of processes and products, including opportunities for preventive action (see

8.2.3 and 8.2.4), and

d) suppliers (see 7.4).

Objective

Evidence:

Sasaran Mutu LP3M no. SAY/BPM-P/SM/RO

Actions:

Closed?: No

Justification


961434N1 7.4

Scope FS 600796

Details: The organization has not implemented the purchasing process based on .

Procedure no. SAY/BUSDM/PSM/20.0.2, the actual implementation based on Perpress no. 54 tahun 2010.

Requirements: Purchasing

Objective

Evidence:

Procurement SOP no:SAY/BUSDM/PSM/20.0.2

Actions: Purchasing process was implemented by organization in accordance Procedure No. SAY/BUSDM/PSM/20.0.2

and based on Perpress No. 54 th. 2010.

Closed?: Yes


961434N2 7.5.2

Assessment Report.


Scope FS 600796

Details: The organization not define the use of spesific methods and procedures to validate and control the process

in order to achieve the quality objective targets.

Requirements:

Validation of processes for production and service provision

The organization shall validate any processes for production and service provision where the resulting

output cannot be verified by subsequent monitoring or measurement and, as a consequence, deficiencies

become apparent only after the product is in use or the service has been delivered.

Validation shall demonstrate the ability of these processes to achieve planned results.

The organization shall establish arrangements for these processes including, as applicable,

a) defined criteria for review and approval of the processes,

b) approval of equipment and qualification of personnel,

c) use of specific methods and procedures,

d) requirements for records (see 4.2.4), and

e) revalidation.

Objective

Evidence:

Sasaran Mutu Unit Keuangan no. SAY/BPM-P/SM/RO dated 25 July 2013

Actions: The organization was define the use of specific methods and procedures to validate and control the process

in order to achieved the quality objective targets.

Closed?: Yes


961964N2 7.5.1

Scope FS 600796

Details: It was found during audit that result of "Ujian Skripsi" was not input in the system but "IPK" has been

issued for "Judisium".

Requirements:

Control of production and service provision

The organization shall plan and carry out production and service provision under controlled conditions.

Controlled conditions shall include, as applicable,

a) the availability of information that describes the characteristics of the product,

b) the availability of work instructions, as necessary,

c) the use of suitable equipment,

d) the availability and use of monitoring and measuring equipment,

e) the implementation of monitoring and measurement, and

f) the implementation of product release, delivery and post-delivery activities.

Objective

Evidence:

# NIM 201210104306

Actions: Result of "Ujian Skripsi" was input in the system before issued for "Judisium."

Assessment Report.


Closed?: Yes


961964N5 4.2.3

Scope FS 600796

Details: There is no In adequate evidence that tutorial and practicum handbook was controlled as well as

procedure.

Requirements:

Control of documents

Documents required by the quality management system shall be controlled. Records are a special type of

document and shall be controlled according to the requirements given in 4.2.4.

A documented procedure shall be established to define the controls needed

a) to approve documents for adequacy prior to issue,

b) to review and update as necessary and re-approve documents,

c) to ensure that changes and the current revision status of documents are identified,

d) to ensure that relevant versions of applicable documents are available at points of use,

e) to ensure that documents remain legible and readily identifiable,

f) to ensure that documents of external origin determined by the organization to be necessary for the

planning and operation of the quality management system are identified and their distribution controlled,

and

g) to prevent the unintended use of obsolete documents, and to apply suitable identification to them if they

are retained for any purpose.

Objective

Evidence:

# Modul Praktikum informatika kesehatan # ilmu dasar keperawatan III

Actions: Tutorial and practicum handbook for "Modul Praktikum Informatika Kesehatan - Ilmu dasar keperawatan"

was controlled as well as procedure.

Closed?: Yes


961964N6 6.3

Scope FS 600796

Details: It was found that record of maintenance was not consistently done in "kartu kendali peralatan"

Requirements:

Infrastructure

The organization shall determine, provide and maintain the infrastructure needed to achieve conformity to

product requirements. Infrastructure includes, as applicable,

a) buildings, workspace and associated utilities,

Assessment Report.


b) process equipment (both hardware and software), and

c) supporting services (such as transport, communication or information systems).

Objective

Evidence:

No evidence that inspection has been done in June 2013 at "kartu kendali peralatan" of IR Portable.

Actions: "Kartu Kendali Perawatan" was controlled and monitored periodically, such as : IR Portable.

Closed?: Yes

Minor Nonconformities Arising from this Assessment. Ref Area/Process Clause

1104525N1 Management Representative / BPM-P 5.6.2

Scope FS 600796

Details: Tinjauan manajemen telah dilakukan dengan cukup baik sesuai dengan prosedur Tinjauan Manajemen,

tetapi belum cukup bukti bahwa notulen tinjauan manajemen terakhir tanggal 12 Sept. 2014 sudah sesuai

input dan output tinjauan manajemen sesuai standart, seperti : umpan balik pelanggan, kinerja proses dan

kesesuaian produk dan perubahan yang dapat mempengaruhi sistem manajemen mutu.

Requirements:

The input to management review shall include information on

a) results of audits,

b) customer feedback,

c) process performance and product conformity,

d) status of preventive and corrective actions,

e) follow-up actions from previous management reviews,

f) changes that could affect the quality management system, and

g) recommendations for improvement.

Objective

Evidence:

Tinjauan Manajemen 12 Sept. 2014


1104525N2 Perpustakaan 8.5.2

Scope FS 600796

Details: Sasaran mutu untuk perpustakaan 2013-2014 sudah ditetapkan dan dimonitoring oleh organisasi dengan

baik, tetapi belum cukup bukti secara konsisten untuk beberapa sasaran mutu yang tidak tercapai belum

ada tindakan korektif (sebagian besar masih tindakan koreksi) dan ditinjau keefektifannya, seperti :

- Jumlah Judul bahan pustaka berupa buku teks 50 judul/thn

- Jumlah Judul bahan pustaka berupa desertasi/tugas akhir 375 judul/thn

- Peningkatan kompetensi pustakawan min. 50%

- Naskah publikasi hasil penelitian dosen dan mahasis

Assessment Report.


Requirements:

Corrective action

The organization shall take action to eliminate the causes of nonconformities in order to prevent

recurrence.

Corrective actions shall be appropriate to the effects of the nonconformities encountered.

A documented procedure shall be established to define requirements for

a) reviewing nonconformities (including customer complaints),

b) determining the causes of nonconformities,

c) evaluating the need for action to ensure that nonconformities do not recur,

d) determining and implementing action needed,

e) records of the results of action taken (see 4.2.4), and

f) reviewing the effectiveness of the corrective action taken.

Objective

Evidence:

Laporan Tahunan unit perpustakaan 2013/2014


1104525N3 Perpustakaan 4.2.4

Scope FS 600796

Details: Daftar rekaman terhadap beberapa buku perpustakaan belum cukup bukti telah dikendalikan dengan cukup

baik, seperti ditemukan ketidaksesuaian antara aktual buku dengan rekamannya (seperti nama

pengarangnya), seperti :

- Buku dengan kode pustaka No. 158/don/a1990, No. inventaris. C.1(6321) dengan judul buku "Asih Asah

dan Asuh: keutamaan Kaum wanita dgn penerbit kanisius dengan nama pengarang Don, Hillary th 1990

- Buku dengan kode pustaka No. 610.7367/Sim/b/1987 dengan judul "Buku Belajar Merawat di bangsal

bedah" karangan Simon, THS dengan No. invt. C.1 (156).

Requirements:

Control of records

Records established to provide evidence of conformity to requirements and of the effective operation of the

quality management system shall be controlled.

The organization shall establish a documented procedure to define the controls needed for the

identification, storage, protection, retrieval, retention and disposition of records.

Records shall remain legible, readily identifiable and retrievable.

Objective

Evidence:

SIMPTT Perpustakaan dan actual book.


1104525N4 Prodi D3 Kebidanan 6.2.2

Scope FS 600796

Details: Pelaksanaan pelatihan sudah sesuai dengan program yang telah ditetapkan, tetapi belum ada cukup bukti

Assessment Report.


bahwa telah dilakukan evaluasi keefektifan hasil pelatihan untuk beberapa pelatihan yang telah dilakukan,

seperti pelatihan untuk "item development dan item review dosen kebidanan STIKES "AISYIAH" Yogyakarta

dates 5 Feb. 2014."

Requirements:

Competence, training and awareness

The organization shall

a) determine the necessary competence for personnel performing work affecting conformity to product

requirements,

b) where applicable, provide training or take other actions to achieve the necessary competence,

c) evaluate the effectiveness of the actions taken,

d) ensure that its personnel are aware of the relevance and importance of their activities and how they

contribute to the achievement of the quality objectives, and

e) maintain appropriate records of education, training, skills and experience (see 4.2.4).

Objective

Evidence:

Laporan kegiatan pelatihan item development dan item review dosen kebidanan STIKES "AISYIAH"

Yogyakarta dates 5 Feb. 2014.


1104525N5 Laboratorium 8.2.3

Scope FS 600796

Details: 1. Berdasarkan kartu kendali alat nebulizer, ada penggunaan alat tsb di tgl. 27 Agt. 2014 dan 20 Sept.

2014. Tetapi di dalam buku peminjaman alat nebulizer, di tgl. tsb tidak ada catatan peminjamannya.

2. Berdasarkan daftar hadir kuliah praktek Keperawatan gawat darurat (di dalam data monitoring

perkuliahan), ada kegiatan praktikum di tgl. 6, 12, 13, 24 Sept. 2014.

Tetapi catatan penggunaan alat pada tanggal-tanggal tsb tidak ada, seperti yang dipersyaratkan di

prosedur SAY/AK/PBM/11.

Requirements: Monitoring and measurement of processes

The organization shall apply suitable methods for monitoring and, where applicable, measurement of the

quality management system processes. These methods shall demonstrate the ability of the processes to

achieve planned results. When planned results are not achieved, correction and corrective action shall be

taken, as appropriate.

NOTE When determining suitable methods, it is advisable that the organization consider the type and

extent of monitoring or measurement appropriate to each of its processes in relation to their impact on the

conformity to product requirements and on the effectiveness of the quality management system.

Objective

Evidence:

Kartu kendali nebuklizer 27 Agt. 2014 dan 20 Sept. 2014; Monitoring perkuliahan bulan Sept. 2104


1104525N6 Prodi Keperawatan 7.5.2

Scope FS 600796

Assessment Report.


Details: Belum ada bukti bahwa Panduan teori / modul teori (bahan ajar) yang dibuat oleh dosen divalidasi untuk

memastikan bahwa modul teori tsb sudah sesuai dengan silabus perkuliahan.

Requirements: Validation of processes for production and service provision

The organization shall validate any processes for production and service provision where the resulting

output cannot be verified by subsequent monitoring or measurement and, as a consequence, deficiencies

become apparent only after the product is in use or the service has been delivered.

Validation shall demonstrate the ability of these processes to achieve planned results.

The organization shall establish arrangements for these processes including, as applicable,

a) defined criteria for review and approval of the processes,

b) approval of equipment and qualification of personnel,

c) use of specific methods and procedures,

d) requirements for records (see 4.2.4), and

e) revalidation.

Objective

Evidence:

Modul teori keperawatan kejiwaan dan keperawatan gerontik

Assessment Participants. On behalf of the organisation:

Name Position

Mrs. Warsiti, S.Kp., M.Kep.,Sp.Mat Head of stikes

Mrs. Mufdlilah, S.Pd.,S.SiT.,M.Sc WK1

Mrs. Yuli Isnaeni, S.Kp, M.Kep.,Sp.Kom WK2

Mrs. dra Umu Hani EN, M. Kes WK3

Mr Syaifudin Management Representative

Mr. Ery Khusnal, MNS Ka. Prodi S1 keperawatan

Please see attendance list for the detail etc.

The assessment was conducted on behalf of BSI by:

Name Position

Danang Gunarto Team Leader

BUDI SISWANTO Team Member

Assessment Report.


Continuing Assessment. The programme of continuing assessment is detailed below.

Site Address Certificate Reference/Visit Cycle

Sekolah Tinggi Ilmu Kesehatan

'Aisyiyah Yogyakarta

Jl . Ring Road Barat 63

Mlangi Nogotirto Gamping Sleman

Yogyakarta

55292

Indonesia

FS 600796

Visit interval: 12 months

Visit duration: 3.5 Days

Next re-certification: 01/09/2016

Re-certification will be conducted on completion of the cycle, or sooner as required. An entire system re-assessment visit will be

required.

Re-certification Plan.

SEKOLA-0047476443-000|FS 600796

Visit1 Visit2 Visit3 Visit4

Business area/Location Date (mm/yy): 08/13 09/14 09/15 07/16

Duration (days): 5 3.5 3.5 5

Top Management X X X X

Management Representative/BPM-P X X X X

Biro Sumber Daya X X X

Bagian Administrasi Akademik X X X X

Prodi D3 Kebidanan X X X

Prodi D4 Bidan Pendidik X X X

Prodi S1 Keperawatan X X X

Prodi S1 Fisioterapi X X X

Laboratorium X X X

Perpustakaan X X X

Pusat Bahasa X X X

Bagian Pengembangan Teknologi Informasi X X X

Assessment Report.


Keuangan X X X

Bagian Kerjasama Internasional dan Humas X X X

Bagian Kemahasiswaan dan Pemberdayaan Alumni X X X

Bagian Kajian Islam dan Pembinaan Kader X X X

Lembaga Penelitian dan Pengabdian Masyarakat X X X

Recertification X

Next Visit Plan. Visit objectives:

CAV

The objective of the assessment is to conduct a surveillance assessment and look for positive evidence to ensure the elements of the

scope of certification and the requirements of the management standard are effectively addressed by the organisation's management

system and that the system is demonstrating the ability to support the achievement of statutory, regulatory and contractual

requirements and the organisations specified objectives, as applicable with regard to the scope of the management standard, and to

confirm the on-going achievement and applicability of the forward strategic plan.

The scope of the assessment is the documented management system with relation to the requirements of ISO 9001 : 2008 and the

defined assessment plan provided in terms of locations and areas of the system and organisation to be assessed.

Date Assessor Time Area/Process Clause

Assessor 1 Please see A218 form for the detail plan

Please note that BSI reserves the right to apply a charge equivalent to the full daily rate for cancellation of the visit by the

organisation within 30 days of an agreed visit date.

Notes. The assessment was based on sampling and therefore nonconformities may exist which have not been identified.

If you wish to distribute copies of this report external to your organisation, then all pages must be included.

BSI, its staff and agents shall keep confidential all information relating to your organisation and shall not disclose any such

information to any third party, except that in the public domain or required by law or relevant accreditation bodies. BSI staff, agents

and accreditation bodies have signed individual confidentiality undertakings and will only receive confidential information on a 'need

to know' basis.

This report and related documents is prepared for and only for BSI’s client and for no other purpose. As such, BSI does not accept or

assume any responsibility (legal or otherwise) or accept any liability for or in connection with any other purpose for which the Report

may be used, or to any other person to whom the Report is shown or in to whose hands it may come, and no other persons shall be

entitled to rely on the Report.

Should you wish to speak with BSI in relation to your registration, please contact your customer service officer.

Assessment Report.


PT BSI Group Indonesia

Menara Bidakara 2

17th Floor, Unit 5

Jl. Jend. Gatot Subroto Kav. 71-73

Komplek Bidakara, Pancoran

Jakarta Selatan 12870 - Indonesia

Tel: +62 21 8379 3174 - 77 Fax:+62 21 8379 3287

Email. [email protected], [email protected]

mailto:[email protected]

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