DATA AUDIT HAND HYGIENE

BULAN DESEMBER TAHUN 2015

CONTOH

Moment 1 Moment 2 Moment 3 Moment 4 Moment 5 Moment 1,2,3,4,5

Ruang No Profesi
Opp HW HR Opp HW HR Opp HW HR Opp HW HR Opp HW HR Opp HW HR HW/HR %
ICU 1 Perawat 1 1 1 1 1 1 1 1 1 1 5 2 3 5 100%
2 Perawat 1 1 1 1 1 1 1 1 4 1 3 4 100%
3 Perawat 1 1 1 1 1 1 3 0 3 3 100%
IRNA C 4 dr. Sp 1 1 1 1 1 1 3 0 3 3 100%
5 dr. Sp 1 1 1 1 1 1 3 0 3 3 100%
6 Perawat 1 1 1 1 1 1 1 1 1 1 5 1 4 5 100%
7 Perawat 1 1 1 1 2 0 2 2 100%
8 Perawat 1 1 1 1 1 1 1 1 1 1 5 1 4 5 100%
9 dr. Umum 1 1 1 1 3 0 1 1 33,33%
10 Bidan 1 1 1 1 1 1 1 4 0 3 3 75%
IRNA A 11 Perawat 1 1 1 1 1 1 1 1 1 1 5 2 3 5 100%
12 Perawat 1 1 1 1 1 1 1 1 4 0 4 4 100%
13 Perawat 1 1 1 1 1 1 1 1 1 5 1 3 4 80%
14 Perawat 1 1 1 1 1 1 1 1 4 0 4 4 100%
IRNA B 15 Perawat 1 1 1 1 1 1 1 4 0 3 3 75%
16 Perawat 1 1 1 1 1 1 1 1 5 2 1 3 60%
17 Bidan 1 1 1 1 1 1 1 4 0 3 3 75%
18 Perawat 1 1 1 1 1 1 1 1 4 1 3 4 100%
19 dr. Sp 1 1 1 1 1 1 3 0 3 3 100%
20 dr. Sp 1 1 1 1 1 1 3 0 3 3 100%
21 Perawat 1 1 1 1 1 1 1 1 4 1 3 4 100%
PERINA 22 Perawat 1 1 1 1 1 1 1 4 1 2 3 75%
23 Perawat 1 1 1 1 1 3 1 1 2 66,66%
24 Perawat 1 1 1 1 1 1 3 1 2 3 100%
 25 Perawat 1 1 1 3 0 0 0 0%
IGD 26 dr. Umum 1 1 1 1 1 3 1 1 2 66,66%
27 dr. Umum 1 1 1 1 3 0 1 1 33,33%
28 dr. Umum 1 1 1 1 1 3 0 2 2 66,66%
29 Perawat 1 1 1 1 1 1 1 1 1 5 2 2 4 80%
30 Perawat 1 1 1 1 1 1 1 4 0 3 3 75%
31 Perawat 1 1 1 1 1 1 3 2 1 3 100%
IRJA 32 Perawat 1 1 1 3 0 0 0 0%
33 Perawat 1 1 1 1 3 0 1 1 33,33%
34 Perawat 1 1 1 1 3 0 1 1 33,33%
Lab 35 Analis 1 1 1 1 1 1 1 4 1 3 4 100%
36 Analis 1 1 1 1 1 4 1 0 1 25%
37 Analis 1 1 1 1 1 1 4 0 2 2 50%
VK 38 Bidan 1 1 1 1 1 1 1 4 1 1 2 50%
39 Bidan 1 1 1 1 1 1 5 1 0 1 20%
40 Bidan 1 0 1 1 1 1 1 1 4 1 1 2 50%
TOTAL 40 0 21 22 0 14 11 11 0 40 8 25 38 6 26 150 25 86 111 74%
52,50% 63,63% 100% 82,50% 84,21% 74%
21 14 11 33 32 111

DATA AUDIT HAND HYGIENE

BULAN JULI 2016
RUMAH SAKIT SITI KHODIJAH PEKALONGAN
 Moment 1 Moment 2 Moment 3 Moment 4 Moment 5 Moment 1,2,3,4,5
Ruang No Profesi
Opp HW HR Opp HW HR Opp HW HR Opp HW HR Opp HW HR Opp HW HR HW/HR %
ICU 1 Perawat 1 0 1 0 2 0 0 0%
2 Perawat 1 0 1 0 1 1 1 1 4 2 0 2 50%
3 POS 1 0 1 0 1 1 1 1 4 2 0 2 50%
MARW 4 dr. Sp 1 0 1 0 1 0 3 0 0 0 0%
5 dr. Sp 1 0 1 0 1 1 3 1 0 1 33.33%
1 6 Perawat 1 1 1 1 1 1 3 0 3 3 100%
2 7 Perawat 1 0 1 0 1 1 3 0 1 1 33.33%
3 8 Perawat 1 0 1 1 1 1 3 0 2 2 66.67%
4 9 Perawat 1 0 1 1 2 0 1 1 50%
5 10 Perawat 1 0 1 0 2 0 0 0 0%
6 11 Perawat 1 0 1 0 1 0 3 0 0 0%
7 12 Perawat 1 1 1 1 1 1 1 1 1 5 0 5 5 100%
8 13 Perawat 1 1 1 1 1 1 1 1 1 1 5 2 3 5 100%
9 14 Perawat 1 1 1 1 1 1 1 1 0 1 1 0 5 2 3 5 100%
AROF 15 Perawat 1 1 1 1 1 1 1 1 4 0 4 4 100%
16 Perawat 1 1 1 1 1 1 1 1 4 0 4 4 100%
17 Perawat 1 1 1 1 1 1 1 1 4 0 4 4 100%
18 Perawat 1 0 1 0 1 1 1 1 1 4 0 3 3 75%
19 Perawat 1 1 1 1 1 1 1 1 4 0 3 3 75%
20 dr. Sp 1 0 1 0 1 1 3 0 1 1 33.33%
SHOF 21 Bidan 1 0 1 0 2 0 0 2 100%
22 Bidan 1 0 1 1 2 0 1 1 50%
23 Bidan 1 0 1 0 2 1 0 1 50%
24 Bidan 1 0 1 0 1 1 1 1 1 1 5 3 0 3 60%
25 Bidan 1 0 1 0 1 0 1 0 4 0 0 0 0%
25 dr. Sp 1 1 1 1 1 1 0 1 1 4 0 3 3 75%
Mina 26 dr. Sp 1 0 1 0 1 1 3 1 1 33.33%
27 dr. Sp 1 0 1 0 1 1 3 1 1 33.33%
 28 Perawat 1 0 1 1 1 1 3 2 2 66.67%
29 Perawat 1 0 1 1 2 1 1 50%
30 Perawat 1 0 1 1 1 1 3 2 2 66.67%
31 Perawat 1 0 1 1 1 1 3 0 2 2 66.67%
IGD 32 dr. Umum 1 0 1 0 1 0 3 0 0 0 0%
1 33 Perawat 1 0 1 0 1 0 1 0 1 0 4 0 0 0 0%
2 34 Perawat 1 0 1 0 1 1 1 1 1 1 5 3 0 3 60%
35 dr. Umum 1 0 1 0 1 0 3 0 0 0 0%
3 36 Perawat 1 0 1 0 1 0 3 0 0 0 0%
4 37 Perawat 1 0 1 0 1 0 1 0 3 0 0 0 0%
5 38 Perawat 1 0 1 0 1 0 1 0 4 0 0 0 0%
6 39 Perawat 1 0 1 1 1 1 3 0 2 2 66.67%
7 40 Bidan 1 0 1 0 1 0 3 0 0 0 0%
8 41 Perawat 1 0 1 0 1 0 3 0 0 0 0%
9 42 Bidan 1 0 1 0 1 1 1 1 4 2 2 50%
10 43 dr. Umum 1 0 1 0 1 0 3 0 0 0 0%
Perina 44 Bidan 1 0 1 1 1 1 3 2 0 2 66.67%
45 Bidan 1 0 1 1 1 1 3 2 0 2 66.67%
46 POS 1 0 1 0 1 0 3 0 0 0 0%
Lab 47 Analis 1 0 1 0 1 1 1 1 4 2 0 2 50%
48 Analis 1 0 1 0 1 0 1 0 1 1 5 1 0 1 20%
49 Analis 1 0 1 0 1 0 1 1 4 1 0 1 25%
50 Analis 1 0 1 0 1 1 1 1 4 2 0 2 50%

TOTAL 50 0 9 22 0 9 6 6 0 44 10 13 51 13 21 173 26 54 82 47%

18% 41% 100% 52% 67% 46%
9 9 6 23 34 80
 DATA AUDIT HAND HYGIENE
BULAN SEPTEMBER TAHUN 2016
RUMAH SITI KHODIJAH PEKALONGAN

Moment 1 Moment 2 Moment 3 Moment 4 Moment 5 Moment 1,2,3,4,5

Ruang No Profesi
Opp HW HR Opp HW HR Opp HW HR Opp HW HR Opp HW HR Opp HW HR HW/HR %
ICU 1 Perawat 1 1 1 1 1 1 1 1 1 1 5 2 3 5 100%
2 Perawat 1 1 1 1 1 1 1 4 2 1 3 75%
3 Perawat 1 1 1 1 1 1 4 2 0 2 50%
4 dr. Sp 1 1 1 1 1 1 1 1 4 0 4 4 100%
MARW 5 dr. Sp 1 1 1 1 1 1 1 1 5 3 1 4 80%
1 6 Perawat 1 1 1 1 1 1 1 1 5 3 0 3 60%
2 7 Perawat 1 1 1 1 1 1 1 1 1 1 5 3 2 5 100%
3 8 Perawat 1 1 1 1 1 1 1 1 4 4 4 100%
4 9 PEeawat 1 1 1 1 1 1 1 1 1 1 5 2 3 5 100%
5 10 Perawat 1 1 1 1 1 1 1 1 4 0 4 4 100%
6 11 Perawat 1 1 1 1 1 1 3 2 1 3 100%
Arofah1 12 Perawat 1 1 1 1 1 1 1 1 1 1 5 0 5 5 100%
2 13 Perawat 1 1 1 1 1 1 1 4 4 4 100%
3 14 Perawat 1 1 1 1 1 1 1 1 4 0 4 4 100%
4 15 Perawat 1 1 1 1 1 1 1 1 4 2 2 4 100%
5 16 Perawat 1 1 1 1 1 1 1 1 1 1 5 3 2 5 100%
17 sp 1 1 1 1 1 1 4 0 2 2 50%
shofa 1 18 Bidan 1 1 1 1 1 1 1 1 1 1 5 5 5 100%
2 19 Bidan 1 1 1 1 1 1 4 2 2 50%
3 20 Bidan 1 1 1 1 1 1 1 4 0 4 4 100%
4 21 pos 1 1 1 1 1 1 1 1 4 4 4 100%
5 22 Bidan 1 1 1 1 1 1 1 1 4 4 4 100%
6 23 Bidan 1 1 1 1 1 1 1 1 4 4 4 100%
igd 1 24 Bidan 1 1 1 1 1 1 4 2 2 50%
 2 25 Perawat 1 1 1 1 1 1 4 0 2 2 50%
3 26 Perawat 1 1 1 1 1 1 1 1 5 3 3 60%
4 27 Perawat 1 1 1 1 1 1 1 1 5 3 0 3 60%
5 28 Perawat 1 1 1 1 1 1 1 1 5 3 0 3 60%
6 29 Perawat 1 1 1 1 1 1 1 1 5 3 0 3 60%
30 dr umum 1 1 1 1 1 1 4 0 2 2 50%
mina 31 Perawat 1 1 1 1 1 1 1 4 4 4 100%
2 32 Perawat 1 1 1 1 1 1 1 1 4 0 4 4 100%
3 33 Perawat 1 1 1 1 1 1 1 1 4 4 4 100%
4 34 Perawat 1 1 1 1 1 1 1 3 0 3 3 100%
5 35 Perawat 1 1 1 1 1 1 1 1 1 1 5 5 5 100%
6 36 Perawat 1 1 1 1 1 1 1 1 1 1 5 5 5 100%
lab 37 Analis 1 1 1 1 1 1 1 1 1 1 5 2 3 5 100%
PERI 38 Perawat 1 1 1 1 1 1 1 1 4 4 4 100%
39 Perawat 1 1 1 1 1 1 1 1 4 4 4 100%
40 Perawat 1 1 1 1 1 1 1 1 1 1 4 4 4 100%
TOTAL 40 0 29 38 1 25 15 10 5 40 19 19 40 18 22 173 42 107 149 74%
52,50% 63,63% 100% 82,50% 84,21% 74%
21 14 11 33 32 111

DATA AUDIT HAND HYGIENE

BULAN AGUSTUS TAHUN 2016
RUMAH SITI KHODIJAH PEKALONGAN

Moment 1 Moment 2 Moment 3 Moment 4 Moment 5 Moment 1,2,3,4,5

Ruang No Profesi
Opp HW HR Opp HW HR Opp HW HR Opp HW HR Opp HW HR Opp HW HR HW/HR %
ICU 1 Perawat 1 1 1 1 1 1 4 2 2 50%
 2 Perawat 1 1 1 1 1 1 4 2 2 50%
3 Perawat 1 1 1 1 1 1 1 1 1 1 5 2 3 5 100%
4 dr. Sp 1 1 1 1 1 1 4 2 2 50%
MARW 5 dr. Sp 1 1 1 1 1 1 4 2 2 50%
1 6 Perawat 1 1 1 1 1 1 1 1 4 4 4 100%
2 7 Perawat 1 1 1 1 1 1 1 1 4 0 4 4 100%
3 8 Perawat 1 1 1 1 1 1 1 1 4 4 4 100%
4 9 dr. Umum 1 1 1 1 1 1 1 1 1 1 5 3 2 5 100%
5 10 Perawat 1 1 1 1 1 1 1 1 4 0 4 4 100%
6 11 Perawat 1 1 1 1 1 1 3 2 1 3 100%
7 12 Perawat 1 1 1 1 1 1 1 1 5 3 3 60%
8 13 Perawat 1 1 1 1 1 1 1 1 4 4 4 100%
PERI 1 14 Perawat 1 1 1 1 1 1 1 1 4 0 4 4 100%
2 15 Bidan 1 1 1 1 1 1 3 0 3 3 100%
3 16 SP 1 1 1 1 1 1 1 1 4 4 4 100%
4 17 Bidan 1 1 1 1 1 1 3 0 3 3 100%
5 18 Bidan 1 1 1 1 1 1 3 3 3 100%
SHOFA 19 POS 1 1 1 1 1 1 1 1 4 0 4 4 100%
20 POS 1 1 1 1 1 1 1 1 4 0 4 4 100%
21 SP 1 1 1 1 1 1 1 1 1 4 4 4 100%
1 22 Bidan 1 1 1 1 1 1 1 1 1 1 5 3 2 5 100%
2 23 Bidan 1 1 1 1 1 1 1 1 4 4 4 100%
3 24 Bidan 1 1 1 1 1 1 1 1 4 4 4 100%
4 25 Bidan 1 1 1 1 1 1 1 1 4 4 4 100%
5 26 Bidan 1 1 1 1 1 1 1 1 4 4 4 100%
6 27 Bidan 1 1 1 1 1 1 1 1 4 0 4 4 100%
arofah 28 Perawat 1 1 1 1 1 1 1 1 1 1 5 0 5 5 100%
29 Perawat 1 1 1 1 1 1 1 1 4 4 4 100%
30 sp 1 1 1 1 4 4 100%
31 Perawat 1 1 1 1 1 1 3 2 1 3 100%
 32 Perawat 1 1 1 3 0 0 0 0%
33 Perawat 1 1 1 1 1 1 1 1 4 0 4 4 100%
34 Perawat 1 1 1 1 1 1 3 0 3 3 100%
35 Perawat 1 1 1 1 2 2 2 100%
36 Analis 1 1 1 1 1 4 1 0 1 25%
37 Analis 1 1 1 1 1 1 4 0 2 2 50%
VK 38 Bidan 1 1 1 1 1 1 1 4 1 1 2 50%
39 Bidan 1 1 1 1 1 1 5 1 0 1 20%
40 Bidan 1 0 1 1 1 1 1 1 4 1 1 2 50%
TOTAL 40 0 29 36 0 26 8 5 3 38 9 24 36 10 23 157 27 100 131 74%
52,50% 63,63% 100% 82,50% 84,21% 74%
21 14 11 33 32 111
SeptemberOktober Nopember Desember
58.33 66.66 72.46 74

Audit Kepatuhan Hand Hygiene (%)

Petugas Bulan Nopember
Rumah Sakit QIM Th 2015

72.46 September
66.66 Oktober
80 58.33
70 Nopember
60
50
40
30
20
10
0

SeptemberOktober NopemberDesember
Hand Hygi 58.33 66.66 72.46 74
moment 1moment 2moment 3 moment 4moment 5
52.5 63.63 100 82.5 84.21

moment 1moment 2moment 3 moment 4moment 5

33.33 53.33 100 71.42 68.96
38.88 58.82 100 66.66 74.19
50 66.66 100 83.33 79.41

Audit Hand Hygiene (%)

Kepatuhan 5 Moment 2 Bulan terakhir
RS QIM Th 2015
100100100
100
90 83.33
79.41
71.42 74.19
80 68.96 Row 51
66.66 66.66
 Audit Hand Hygiene (%)
Kepatuhan 5 Moment 2 Bulan terakhir
RS QIM Th 2015
100100100
100
90 83.33
79.41
71.42 74.19
80 68.96 Row 51
66.66 66.66
70 58.82 Row 52
60 53.33 Row 53
50
50 38.88
40 33.33

30
20
10
0
moment 1 moment 2 moment 3 moment 4 moment 5
ber
 120%

100%

80%

60% %COMPLIANCE
STANDAR
40%

20%

0%
momen1 momen2 momen3 momen4 momen5 momen6

data JULI momen1 momen2 momen3 momen4 momen5 momen6

NUM 9 9 6 23 34 80
DEMOM 50 22 6 50 50 171
%COMPLIANCE 18% 41% 100% 46% 68% 47%
STANDAR 100% 100% 100% 100% 100% 100%
 KEPATUHAN HAND HIGIENE
AGUSTUS 2016
120%

100%

80%
%COMPLIANCE
STANDAR
60%

40%

20%

0%
momen1 momen2 momen3 momen4 momen5 momen6

data AGUSTUS momen1 momen2 momen3 momen4 momen5 momen6

NUM 29 26 8 33 33 127
DEMOM 40 36 8 38 36 157
%COMPLIANCE 73% 72% 100% 87% 92% 81%
STANDAR 100% 100% 100% 100% 100% 100%
120%

100%

80%

60% %COMPLIANCE
STANDAR
40%

20%

0%
momen1 momen2 momen3 momen4 momen5 MOMEN

DATA SEPT momen1 momen2 momen3 momen4 momen5 MOMEN

NUM 29 26 15 38 40 149
DEMOM 40 38 15 40 40 173
%COMPLIANCE 73% 68% 100% 95% 100% 86%
STANDAR 100% 100% 100% 100% 100% 100%
120%

100%

80%

60% %COMPLIANCE
STANDAR
40%

20%

0%
momen1 momen2 momen3 momen4 momen5 MOMEN

DATA OKTO momen1 momen2 momen3 momen4 momen5 MOMEN

NUM 29 29 9 40 38 144
DENOM 40 38 9 40 40 165
%COMPLIANCE 73% 76% 100% 100% 95% 87%
STANDAR 100% 100% 100% 100% 100% 100%
 DATA AUDIT HAND HYGIENE
BULAN NOVEMBER TAHUN 2016
RUMAH SITI KHODIJAH PEKALONGAN

Moment 1 Moment 2 Moment 3 Moment 4 Moment 5 Moment 1,2

Ruang No Profesi
Opp HW HR Opp HW HR Opp HW HR Opp HW HR Opp HW HR Opp HW
MARW 1 dr. Sp 1 1 1 1 0 1 1 0 4 2
2 Perawat 1 1 1 1 0 0 1 0 1 1 0 1 4 0
3 Perawat 1 0 1 0 0 0 0 1 0 1 1 0 1 4 0
4 Perawat 1 1 1 1 1 1 0 1 1 0 1 1 0 5 3
5 Perawat 1 1 1 1 1 1 1 1 4 0
6 Perawat 1 1 1 1 1 1 3 2
7 Perawat 1 1 1 1 1 1 1 1 4 0
ICU 8 Perawat 1 1 1 0 1 1 1 1 4 2
9 Perawat 1 1 1 1 1 1 4 2
10 Perawat 1 1 1 1 1 1 1 1 1 1 5 3
11 dr. Sp 1 1 1 1 1 1 4 0
shofa 12 Bidan 1 1 1 1 1 1 1 1 1 1 5
13 Bidan 1 1 1 1 1 1 4 2
14 Bidan 1 1 1 1 1 1 1 4 0
15 Bidan 1 1 1 1 1 1 1 1 4
16 Bidan 1 1 1 1 1 1 1 1 4
17 pos 1 1 1 1 1 1 1 1 4
Arofah 18 Perawat 1 1 1 1 0 0 0 1 1 1 1 4 0
19 Perawat 1 1 1 1 0 0 0 1 1 1 1 4
20 Asper 1 1 1 1 1 1 0 1 1 0 1 1 0 5 3
21 Perawat 1 1 1 1 1 1 1 1 1 1 4 0
22 Perawat 1 1 1 1 1 1 1 1 4 0
23 sp 1 1 1 1 1 1 4 0
PERI 24 Asper 1 1 1 1 0 0 0 1 1 1 1 4
25 Bidan 1 1 1 1 0 0 0 1 1 1 1 4
26 Bidan 1 1 1 1 0 0 0 1 1 1 1 4
igd 27 Bidan 1 0 1 1 1 1 1 1 4 2
28 Perawat 1 0 1 0 0 0 0 0 1 1 0 1 1 0 4 2
29 Perawat 1 1 1 1 1 1 1 1 4 0
30 Perawat 1 1 1 1 1 1 1 4 2
31 Perawat 1 1 1 1 1 1 1 4
32 Perawat 1 0 1 1 1 1 1 1 4
33 dr umum 1 1 1 1 1 1 4 0
mina 34 Perawat 1 1 1 1 1 1 1 1 4
35 Perawat 1 1 1 1 1 1 1 1 4 0
36 Perawat 1 1 1 1 1 1 1 1 4 0
37 Perawat 1 1 1 1 1 1 1 1 1 1 5
 38 Perawat 1 1 1 1 1 1 1 1 1 1 5
lab 39 Analis 1 1 1 1 1 1 1 1 1 5 3
40 Analis 1 1 1 1 1 1 1 1 1 5 2
TOTAL 40 0 29 38 1 28 9 6 3 40 15 25 40 12 26 167 30
73% 76% 100% 100% 95% 88%
 T HAND HYGIENE
EMBER TAHUN 2016
ODIJAH PEKALONGAN

Moment 1,2,3,4,5
HR HW/HR %
2 4 ###
4 4 ###
2 2 50%
2 5 ###
4 4 ###
1 3 ###
4 4 ###
1 3 75%
0 2 50%
2 5 ###
2 2 50%
5 5 ###
2 50%
4 4 ###
4 4 ###
4 4 ###
4 4 ###
4 4 ###
4 4 ###
2 5 ###
4 4 ###
4 4 ###
2 2 50%
4 4 ###
4 4 ###
4 4 ###
1 3 75%
0 2 50%
4 4 ###
1 3 75%
3 3 75%
3 3 75%
2 2 50%
4 4 ###
4 4 ###
4 4 ###
5 5 ###
 5 5 ###
2 5 ###
2 4 80%
117 147 88%
88%
 DATA AUDIT HAN
BULAN DESEMBER
RUMAH SITI KHODIJA

Moment 1 Moment 2 Moment 3

Ruang No Profesi
Opp HW HR Opp HW HR Opp
MARW 1 Perawat 1 1
2 Perawat 1 1 1 1 0
3 Perawat 1 0 1 0 0
4 Perawat 1 1 1 1 1
5 Perawat 1 1 1 1
6 dr. Sp 1 1
7 dr sp 1 1 1 1
ICU 8 Perawat 1 1 1 0
9 Perawat 1 1
10 Perawat 1 1 1 1 1
11 asper 1 1
shofa 12 Bidan 1 1 1 1 1
13 Bidan 1 1
14 Bidan 1 1 1
15 Bidan 1 1 1 1
16 Bidan 1 1 1 1
17 pos 1 1 1 1
Arofah 18 Perawat 1 1 1 1 0
19 Perawat 1 1 1 1 0
20 Asper 1 1 1 1 1
21 Perawat 1 1 1 1 1
22 Perawat 1 1 1 1
23 sp 1 1
PERI 24 Bidan 1 1 1 1 0
25 Bidan 1 1 1 1 0
26 Bidan 1 1 1 1 0
igd 27 Bidan 1 0 1 1
28 Perawat 1 0 1 0 0 0
29 Perawat 1 1 1 1
30 Perawat 1 1 1
31 Perawat 1 1 1
32 Perawat 1 1 1 1
33 dr umum 1 1 1
mina 34 Perawat 1 1 1 1
35 Perawat 1 1 1 1
36 Perawat 1 1 1 1
37 Perawat 1 1 1 1 1
 38 Perawat 1 1 1 1 1
lab 39 Analis 1 1 1 1 1
40 Analis 1 1 1 1 1
TOTAL 40 0 31 38 1 28 9
78% 76% 100%
 DATA AUDIT HAND HYGIENE
BULAN DESEMBER TAHUN 2016
MAH SITI KHODIJAH PEKALONGAN

Moment 3 Moment 4 Moment 5 Moment 1,2,3,4,5

HW HR Opp HW HR Opp HW HR Opp HW
1 1 0 1 1 0 4 2
0 1 0 1 1 0 1 4 0
0 0 1 0 1 1 0 1 4 0
1 0 1 1 0 1 1 0 5 3
1 1 1 1 4 0
1 1 1 1 3 2
1 1 1 1 4 0
1 1 1 1 4 2
1 1 1 1 4 2
1 1 1 1 1 5 3
1 1 1 1 4 0
1 1 1 1 1 5
1 1 1 1 4 2
1 1 1 1 4 0
1 1 1 1 4
1 1 1 1 4
1 1 1 1 4
0 0 1 1 1 1 4 0
0 0 1 1 1 1 4
1 0 1 1 0 1 1 0 5 3
1 1 1 1 1 4 0
1 1 1 1 4 0
1 1 1 1 4 0
0 0 1 1 1 1 4
0 0 1 1 1 1 4
0 0 1 1 1 1 4
1 1 1 1 4 2
0 0 1 1 0 1 1 0 4 2
1 1 1 1 4 0
1 1 1 1 4 2
1 1 1 1 4
1 1 1 1 4
1 1 1 1 4 0
1 1 1 1 4
1 1 1 1 4 0
1 1 1 1 4 0
1 1 1 1 1 5
 1 1 1 1 1 5
1 1 1 1 5 3
1 1 1 1 5 2
6 3 40 15 25 40 12 26 167 30
100% 100% 95% 89%
Moment 1,2,3,4,5
HR HW/HR %
2 4 100%
4 4 100%
2 2 50%
2 5 100%
4 4 100%
1 3 100%
4 4 100%
1 3 75%
0 2 50%
2 5 100%
2 2 50%
5 5 100%
2 50%
4 4 100%
4 4 100%
4 4 100%
4 4 100%
4 4 100%
4 4 100%
2 5 100%
4 4 100%
4 4 100%
2 2 50%
4 4 100%
4 4 100%
4 4 100%
1 3 75%
0 2 50%
4 4 100%
1 3 75%
3 3 75%
4 4 100%
3 3 75%
4 4 100%
4 4 100%
4 4 100%
5 5 100%
 5 5 100%
2 5 100%
2 4 80%
119 149 89%
89%
 KEPATUHANHAND HIGIENE BULAN JANUARI 2017
RUMAH SAKIT SITI KHODIJAH PEKALONGAN

momen1 momen2 momen3 momen4 momen5 KEPATUHAN

HASIL 8% 8% 60% 48% 48% 35%
STANDAR 85% 85% 85% 85% 85% 85%

KEPATUHAN HAND HIGIENE

JANUARI 2017
85% 85% 85% 85% 85% 85%

60%
48% 48%
35%
 KEPATUHAN HAND HIGIENE
JANUARI 2017
85% 85% 85% 85% 85% 85%

60%
48% 48%
35%

8% 8%
momen1 momen2 momen3 momen4 momen5 KEPATUHAN
HASIL STANDAR
 DATA AUDIT HAND HYGIENE
BULAN PEBRUARI TAHUN 2017
RUMAH SAKIT SITI KHODIJAH PEKALONGAN

Moment 1 Moment 2 Moment 3 Moment 4

Ruang No Profesi
Opp HW HR Opp HW HR Opp HW HR Opp HW
IGD 1 Bidan 1 0 0 1 0 0 0 0 0 1 0
2 Perawat 1 0 0 1 0 0 0 0 0 1 0
3 Perawat 1 0 0 1 0 0 0 0 0 1 0
4 Perawat 1 0 0 1 0 0 0 0 0 1 0
5 Dr umum 1 0 0 1 0 0 0 0 0 1 0
6 Perawat 1 0 0 1 0 0 0 0 0 1 0
7 Perawat 1 0 0 1 0 0 0 0 0 1 0
8 Perawat 1 0 0 1 0 0 0 0 0 1 0
laborat 9 analis 1 0 1 1 0 1 1 0 0 1 0
10 analis 1 0 1 1 0 1 1 1 0 1 1
11 analis 1 0 1 1 0 1 1 1 0 1 1
12 analis 1 0 0 1 0 0 1 1 0 1 1
Marwah 13 Perawat 1 0 1 1 0 1 0 0 0 1 0
14 Dr Sp 1 0 1 1 0 1 0 0 0 1 0
15 Dr Sp 1 0 0 1 0 0 0 0 0 1 0
16 Dr Sp 1 0 1 1 0 1 0 0 0 1 0
17 Perawat 1 0 0 1 0 0 0 0 0 1 1
18 Dr Sp 1 0 0 1 0 0 0 0 0 1 0
19 Perawat 1 0 0 1 0 0 0 0 0 1 0
20 Perawat 1 0 1 0 0 0 0 0 0 1 0
21 dr umum 1 0 0 1 0 0 0 0 0 1 0
22 Perawat 1 0 0 1 0 0 1 0 0 1 0
23 Perawat 1 0 1 1 0 1 0 0 0 1 0
24 Perawat 1 0 0 1 0 0 1 0 0 1 0
 25 Perawat 1 0 1 1 0 1 0 0 0 1 0
26 Perawat 1 0 0 1 0 0 1 0 0 1 0
ICU 27 Perawat 1 0 0 1 0 0 1 1 0 1 1
28 Perawat 1 0 0 1 0 0 1 1 0 1 1
29 Perawat 1 0 0 1 0 0 0 0 0 1 0
30 Perawat 0 0 0 1 0 0 0 0 0 0 0
31 Perawat 1 0 0 1 0 0 0 0 0 1 0
32 Perawat 1 0 0 1 0 0 0 0 0 1 1
33 Dr umum 1 0 0 1 0 0 0 0 0 1 1
34 dr. sp 1 0 0 1 0 0 0 0 0 1 0
35 dr. sp 2 0 0 2 0 0 0 0 0 2 0
36 Perawat 1 0 0 1 0 0 0 0 0 1 0
37 Perawat 2 0 0 2 0 0 0 0 0 2 0
38 Perawat 1 0 0 1 0 0 0 0 0 1 0
Arofah 39 Perawat 1 0 0 1 0 0 0 0 0 1 0
40 Perawat 1 0 0 1 0 0 1 1 0 1 1
41 Perawat 1 0 1 1 0 1 1 0 1 1 0
42 Perawat 2 0 0 2 0 0 2 0 0 2 0
43 Perawat 1 0 1 1 0 1 0 0 0 1 0
Mina 44 Perawat 1 0 1 1 0 1 1 1 0 1 1
45 Perawat 1 0 1 1 0 1 1 1 0 1 1
46 Perawat 1 0 1 1 0 1 1 1 0 1 1
SHOFA 47 Bidan 1 0 0 1 0 0 0 0 0 1 0
48 Bidan 1 0 0 1 0 0 0 1 0 1 1
49 Bidan 1 0 0 1 0 0 0 0 0 1 0
50 Bidan 1 0 0 1 0 0 0 0 0 1 0
Peri 51 Bidan 1 0 0 1 0 0 0 0 0 1 0
52 Perawat 1 0 0 1 0 0 0 0 0 1 0
53 Perawat 1 0 1 1 0 1 0 0 0 1 1
poli 55 Perawat 1 0 1 1 0 1 0 0 0 1 0
56 dr sp 1 0 0 1 0 0 0 0 0 1 0
 57 Perawat 1 0 1 1 0 1 1 0 1 1 0
58 Perawat 1 0 0 1 0 0 1 0 0 1 0
fisio 59 fisio 1 0 0 1 0 0 0 0 0 1 0
60 0 17 60 0 16 18 10 2 60 14
28% 27% 67% 58%

momen 1 momen 2 momen 3 momen 4

Hasil 28 27 67 58
Standart 85 85 85 85

KEPATUHAN HAND HIGIENE

RUMAH SAKIT SITI KHODIJAH BULAN PEBRUARI 2017

90 85 85 85 85 8

80

67
70
61
58
60

50

40
28 27
30

20

10

0
momen 1 momen 2 momen 3 momen 4 momen 5
 28 27
30

20

10

0
momen 1 momen 2 momen 3 momen 4 momen 5

Has i l Standa rt
A AUDIT HAND HYGIENE
N PEBRUARI TAHUN 2017
IT SITI KHODIJAH PEKALONGAN

Moment 4 Moment 5 Moment 1,2,3,4,5

HR Opp HW HR Opp HW HR HW/HR %
0 1 0 0 4 0 0 0 0%
1 1 0 1 4 0 2 2 50%
0 1 0 0 4 0 0 0 0%
0 1 0 0 4 0 0 0 0%
1 1 0 1 4 0 2 2 50%
0 1 0 0 4 0 0 0 0%
0 1 0 0 4 0 0 0 0%
1 1 0 1 4 0 2 2 50%
0 1 0 0 5 0 2 2 40%
0 1 1 0 5 3 2 5 100%
0 1 1 0 5 3 2 5 100%
0 1 1 0 5 3 0 3 60%
1 1 0 1 4 0 4 4 100%
1 1 0 1 4 0 4 4 100%
1 1 0 1 4 0 2 2 50%
1 1 0 1 4 0 4 4 100%
0 1 1 0 4 2 0 2 50%
0 1 0 0 4 0 0 0 0%
1 1 0 1 4 0 2 2 50%
0 1 0 0 4 0 0 0 0%
1 1 0 1 4 0 2 2 50%
1 1 0 1 4 0 2 2 50%
0 1 0 0 4 0 2 2 50%
1 1 0 1 4 0 2 2 50%
1 1 0 1 4 0 4 4 100%
1 1 0 1 4 0 2 2 50%
0 1 1 0 5 3 0 3 60%
0 1 1 0 5 3 0 3 60%
0 1 0 0 4 0 0 0 0%
0 1 0 0 2 0 0 0 0%
1 1 0 1 4 0 4 4 100%
0 1 1 0 4 2 0 2 50%
0 1 1 0 4 2 0 2 50%
0 1 0 0 4 0 0 0 0%
0 2 0 0 8 0 0 0 0%
0 1 0 0 4 0 0 0 0%
1 2 0 1 8 0 2 2 25%
1 0 0 1 4 0 2 2 50%
0 1 0 0 4 0 0 0 0%
0 1 1 0 5 3 0 3 60%
0 1 0 0 5 0 2 2 40%
0 2 0 0 10 0 0 0 0%
1 1 0 1 4 0 4 4 100%
0 1 1 0 5 2 3 5 100%
0 1 1 0 5 2 3 5 100%
0 1 1 0 5 2 3 5 100%
1 0 0 1 4 0 2 2 50%
0 1 1 0 5 3 0 3 60%
1 1 0 1 4 0 2 2 50%
1 1 0 1 4 0 2 2 50%
0 0 0 0 3 0 0 0 0%
0 0 0 0 3 0 0 0 0%
0 0 0 3 2 1 3 100%
0 1 0 0 4 0 2 2 50%
0 1 0 0 4 0 0 0 0%
 0 1 0 0 5 0 3 3 60%
0 1 0 0 5 0 0 0 0%
1 1 0 1 4 0 2 2 50%
21 56 13 21 255 35 79 114 45%
58% 61% 45%

momen 5 rata2
61 45
85 85

KEPATUHAN HAND HIGIENE

UMAH SAKIT SITI KHODIJAH BULAN PEBRUARI 2017

85 85 85 85 85

67
61
58

45

en 2 momen 3 momen 4 momen 5 rata2

en 2 momen 3 momen 4 momen 5 rata2

Has i l Standa rt
 37 Fisioterapi 1 1 0 1 0 0 0 1 0 1 0 4
Arofah 38 Perawat 1 1 0 1 0 0 0 1 0 1 0 4
39 Perawat 1 1 0 1 0 0 0 1 0 1 0 4
40 Perawat 1 1 0 1 0 1 0 1 0 1 0 5
41 Perawat 1 0 1 0 1 0 0 1 0 1 0 2
42 Perawat 1 1 0 1 0 1 0 0 1 0 1 3
43 Perawat 2 0 1 0 1 0 1 1 0 1 0 2
44 Perawat 1 1 0 1 0 0 0 1 0 1 0 4
45 Perawat 1 0 1 0 1 0 0 1 0 1 0 2
Mina 46 Perawat 1 1 0 1 0 0 0 1 0 1 0 4
47 Perawat 1 1 0 1 0 0 0 1 0 1 0 4
48 Perawat 1 1 0 1 0 0 0 1 0 1 0 4
49 Perawat 1 1 0 1 0 1 0 1 0 1 0 5
50 dr. SP 1 0 1 0 1 0 0 1 0 1 0 2
51 dr. SP 1 0 1 0 1 0 0 1 0 1 0 2
52 Perawat 1 1 0 1 0 0 0 1 0 1 0 4
53 Perawat 1 0 1 0 1 0 0 1 0 1 0 2
54 Perawat 1 1 0 1 0 0 0 1 0 1 0 4
55 Perawat 1 1 0 1 0 0 0 1 0 1 0 4
56 Perawat 1 1 0 1 0 1 0 1 0 1 0 5
57 Perawat 1 1 0 1 0 1 0 1 0 1 0 5
laborat 58 analis 1 1 0 1 0 1 0 1 0 1 0 5
59 analis 1 1 0 1 0 1 0 1 0 1 0 5
60 analis 1 1 0 1 0 1 0 1 0 1 0 5
61 40 20 40 20 16 1 54 6 54 6 204
67% 67% 94% 90% 90% 83%

Kepatuhan kebersihan tangan

bulan Maret 2017
100%
90%
80%
70%
60%
 Kepatuhan kebersihan tangan
bulan Maret 2017
100%
90%
Momen1 Momen2 Momen3 Momen4 Momen5 % hasil
80%
Hasil 67% 67% 94% 90% 90% 83%
70%
Standart 85% 85% 85% 85% 85% 85%
60%
50%
40%
30%
20%
10%
0%
Momen1 Momen2 Momen3 Momen4 Momen5 % has
 0 4 100%
0 4 100%
0 4 100%
0 5 100%
2 4 50%
2 5 60%
3 5 40%
0 4 100%
2 4 50%
0 4 100%
0 4 100%
0 4 100%
0 5 100%
2 4 50%
2 4 50%
0 4 100%
2 4 50%
0 4 100%
0 4 100%
0 5 100%
0 5 100%
0 5 100%
0 5 100%
0 5 100%
53 245 83%
83%

Kepatuhan kebersihan tangan

bulan Maret 2017
100%
90%
80%
70%
60%
 Kepatuhan kebersihan tangan
bulan Maret 2017
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Momen1 Momen2 Momen3 Momen4 Momen5 % hasil
 AUDIT KEPATUHAN HAND HIGIENE TRI BULAN 1
RUMAH SAKIT SITI KHODIJAH PEKALONGAN 2017

BULAN momen1 momen2 momen3 momen4 momen5 KEPATUHAN

JAN 8% 8% 60% 48% 48% 35%
PEBRUARI 28% 27% 67% 58% 61% 45%
MARET 67% 67% 94% 90% 90% 83%
STANDAR 85% 85% 85% 85% 85% 85%

AUDIT KEPATUHAN HAND HIGIENE TRIBULAN 1 RUMAH SAKIT SITI KHODIJAH PEKALONGAN 2017

100%
94%
90% 90% 90%
85% 85% 85% 85% 85% 85%
83%
80%
70% 67% 67% 67%
60% 60% 58% 61%
50% 48% 48% 45%
40%
35%
30% 28% 27%
20%
10% 8% 8%
0%
momen1 momen2 momen3 momen4 momen5 KEPATUHAN

JAN PEBRUARI MARET STANDAR

 DATA AUDIT HAND HYGIENE
BULAN APRIL TAHUN 2017
RUMAH SAKIT SITI KHODIJAH PEKALONGAN

Moment 1Moment 2Moment 3Moment 4Moment 5 % HASIL

HASIL 74% 74% 100% 96% 96% 86%
STANDAR 85% 85% 85% 85% 85% 85%

KEPATUHAN HAND HIGIENE

RS SITI KHODIJAH BULAN APRIL 2017

120%

100% 100%
96% 96%
86%
85%
80%
74% 74%
60%

40%

20%

0%
Moment 1 Moment 2 Moment 3 Moment 4 Moment 5 % HASIL
HASIL STANDAR
 MEI MOMEN 1 MOMEN 2 MOMEN 3 MOMEN 4 MOMEN 5 %
HASIL 82% 82% 100% 96% 96% 90%
STANDAR 85% 85% 85% 85% 85% 85%

KEPATUHAN HAND HIGIENE BULAN MEI 2017

120%

100%

80%

60%

40%

20%

0%
MOMEN 1 MOMEN 2 MOMEN 3 MOMEN 4 MOMEN 5 %
HASIL STANDAR
 JUNI MOMEN 1 MOMEN 2 MOMEN 3MOMEN 4MOMEN 5 %
HASIL 80% 78% 100% 100% 100% 90%
STANDAR 85% 85% 85% 85% 85% 85%

Kepatuhan Petugas RS Siti Khodijah

Bulan Juni 2017

120%
100%
85% 85% 100% 100% 100% 85%
85% 85% 85% 90%
80% 80% 78%
60%
40%
20%
0%
MOMEN 1 MOMEN 2 MOMEN 3 MOMEN 4 MOMEN 5 %
HASIL STANDAR
 AUDIT KEPATUHAN HAND HIGIENE TRI BULAN 2 TH 2017
RUMAH SAKIT SITI KHODIJAH PEKALONGAN 2018

BULAN momen1 momen2 momen3 momen4 momen5 KEPATUHAN

APRIL 74% 74% 100% 96% 96% 86%
MEI 82% 82% 100% 96% 96% 90%
JUNI 80% 78% 100% 100% 100% 90%
STANDAR 85% 85% 85% 85% 85% 85%

AUDIT KEPATUHAN PETUGAN HAND HIGIENE TRIBULAN 2 TH 2017 RS SITI KHODIJAH PEKALONGAN
120%
100% 100% 100%
100% 100% 96% 96% 90%
80% 82%
78%
74%82% 86%
80%
74%
60%

40%

20%

0%
momen1 momen2 momen3 momen4 momen5 KEPATUHAN
APRIL MEI JUNI STANDAR

PLAN DO STUDI ACTION

Kepatuhan Hand 1.Kepatuhan

Higiene petugas petugas diruang Bulan April, Mei,Juni Meningkatkan
Standar sudah kepatuhan petugas
85% rawat, dengan pengawasan
tercapai sesuai
kepatuhan petugas dengan kepatuhan dilapangan
di unit lab baik 85%

2.Melakukan audit
setiap hari di
masing2 ruang
selama 10 hari saat
jam sibuk
3.Data dibuat setiap
hari

4.Data dianalisa tiap

3 bulan
 DATA AUDIT HAND HYGIENE
BULAN JULI TAHUN 2017
RUMAH SAKIT SITI KHODIJAH PEKAL

Moment 1 MOMEN 2 MOMEN 3

Ruang No Profesi Opp
Y T Y T Y
Marwah 1 perawat 1 1 0 1 0 1
2 dr anto 1 0 1 0 1 0
3 perawat 1 0 1 0 1 0
4 perawat 1 1 0 1 0 0
5 perawat 1 1 0 1 0 1
6 perawat 1 1 0 1 0 0
7 perawat 1 1 0 1 0 0
8 perawat 1 1 0 1 0 1
9 perawat 1 1 0 1 0 0
10 perawat 1 1 0 1 0 0
11 perawat 1 1 0 1 0 0
12 perawat 1 1 0 1 0 0
13 perawat 1 1 0 1 0 0
14 perawat 1 1 0 1 0 0
15 perawat 1 1 0 1 0 0
16 perawat 1 1 0 1 0 0
17 perawat 1 0 1 0 1 0
18 perawat 1 1 0 1 0 0
19 perawat 1 0 1 0 1 1
Shofa 20 bidan 1 1 0 1 0 1
21 bidan 1 1 0 1 0 1
22 bidan 1 1 0 1 0 0
23 bidan 1 1 0 1 0 0
24 bidan 1 1 0 1 0 0
25 bidan 1 1 0 1 0 1
26 bidan 1 1 0 1 0 1
Perinatologi 27 perawat 1 1 0 1 0 0
28 bidan 1 1 0 1 0 1
29 perawat 1 1 0 1 0 0
30 bidan 1 1 0 1 0 0
31 perawat 1 1 0 1 0 0
32 bidan 1 1 0 1 0 0
33 bidan 1 1 0 1 0 0
Mina 34 perawat 1 1 0 1 0 0
35 perawat 1 1 0 1 0 0
36 perawat 1 1 0 1 0 0
IGD 37 perawat 1 1 0 1 0 1
 38 perawat 1 0 1 0 1 0
39 perawat 1 1 0 1 0 0
40 bidan 1 1 0 1 0 0
41 perawat 1 1 0 1 0 0
42 dr ylm 1 0 1 0 1 0
43 bidan 1 1 0 1 0 0
44 bidan 1 1 0 1 0 0
45 perawat 1 1 0 1 0 0
46 bidan 1 0 1 0 1 0
47 perawat 1 1 0 1 0 0
48 perawat 1 1 0 1 0 0
49 bidan 1 0 1 0 1 0
Laborat 50 asper 1 1 0 1 0 1
51 analis 1 1 0 1 0 1
52 analis 1 1 0 1 0 1
53 Analis 1 1 0 1 0 1
Fisioterapi 54 terapis 1 1 0 1 0 1
Dietary 55 ahli gizi 1 0 1 0 1 0
56 ahli gizi 1 0 1 0 1 0
Arofah 57 perawat 1 1 0 1 0 0
58 perawat 1 1 0 1 0 0
59 perawat 1 1 0 1 0 1
60 perawat 1 1 0 1 0 1
61 perawat 1 1 0 1 0 0
62 perawat 1 1 0 1 0 1
63 perawat 1 1 0 1 0 0
64 perawat 1 1 0 1 0 0
65 perawat 1 1 0 1 0 0
66 perawat 1 0 1 0 1 0
67 perawat 1 1 0 1 0 0
68 perawat 1 1 0 1 0 0
ICU 69 perawat 1 1 0 1 0 0
70 perawat 1 1 0 1 0 0
71 perawat 1 1 0 1 0 0
72 perawat 1 1 0 1 0 0
73 perawat 1 1 0 1 0 0
74 perawat 1 1 0 1 0 0
75 perawat 1 1 0 0 0 0
64 11 63 11 18
TOTAL 75
85% 85% 100%
IT HAND HYGIENE
ULI TAHUN 2017
I KHODIJAH PEKALONGAN

MOMEN 3 MOMEN 4 MOMEN 5 JUMLAH

%
T Y T Y T Y T Y+T
0 1 0 1 0 5 0 5 100%
0 1 0 1 0 2 2 4 50%
0 1 0 1 0 2 2 4 50%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 5 0 5 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 5 0 5 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 2 2 4 50%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 3 2 5 60%
0 1 0 1 0 5 0 5 100%
0 1 0 1 0 5 0 5 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 5 0 5 100%
0 1 0 1 0 5 0 5 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 5 0 5 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 5 0 5 100%
 0 1 0 1 0 2 2 4 50%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 0 1 0 1 0 4 4 0%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 2 2 4 50%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 2 2 4 50%
0 1 0 1 0 5 0 5 100%
0 1 0 1 0 5 0 5 100%
0 1 0 1 0 5 0 5 100%
0 1 0 1 0 5 0 5 100%
0 1 0 1 0 5 0 5 100%
0 1 0 1 0 2 2 4 50%
0 1 0 1 0 2 2 4 50%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 5 0 5 100%
0 1 0 1 0 5 0 5 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 5 0 5 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 2 2 4 50%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 1 0 1 0 4 0 4 100%
0 0 0 0 0 1 0 1 100%
0 73 1 73 1 291 24 315
92%
100% 99% 99% 92%
 DATA AUDIT HAND HYGIENE
BULAN AGUSTUS TAHUN 2017
RUMAH SAKIT SITI KHODIJAH PEKALONGAN

Moment 1 MOMEN 2 MOMEN 3 MOMEN 4 MOMEN 5 JUMLAH

Ruang No Profesi Opp
Y T Y T Y T Y T Y T Y T
Marwah 1 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
2 Perawat 1 1 0 1 0 1 0 1 0 1 0 5 0
3 Perawat 1 1 0 1 0 1 0 1 0 1 0 5 0
4 Perawat 1 1 0 1 0 1 0 1 0 1 0 5 0
5 Perawat 1 1 0 1 0 1 0 1 0 1 0 5 0
6 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
7 Perawat 1 0 1 0 1 0 0 1 0 1 0 2 2
8 Asper 1 1 0 1 0 0 0 1 0 1 0 4 0
9 DR spesialis 1 0 1 0 1 0 0 1 0 1 0 2 2
10 DR spesialis 1 1 0 1 0 0 0 1 0 1 0 4 0
11 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
12 Perawat 1 0 1 0 1 0 0 1 0 1 0 2 2
13 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
14 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
15 Perawat 1 1 0 1 0 1 0 1 0 1 0 5 0
Shofa 16 Bidan 1 1 0 1 0 0 0 1 0 1 0 4 0
17 Bidan 1 1 0 1 0 1 0 1 0 1 0 5 0
18 Bidan 1 1 0 1 0 1 0 1 0 1 0 5 0
19 Bidan 1 1 0 1 0 1 0 1 0 1 0 5 0
20 Bidan 1 1 0 1 0 1 0 1 0 1 0 5 0
21 Bidan 1 1 0 1 0 1 0 1 0 1 0 5 0
22 Bidan 1 1 0 1 0 1 0 1 0 1 0 5 0
Perinatologi 23 Asper 1 1 0 1 0 0 0 1 0 1 0 4 0
24 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
25 Bidan 1 1 0 1 0 0 0 1 0 1 0 4 0
 26 Bidan 1 1 0 1 0 0 0 1 0 1 0 4 0
27 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
28 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
29 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
30 Bidan 1 1 0 1 0 0 0 1 0 1 0 4 0
Mina 31 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
32 Perawat 1 0 1 0 1 0 0 1 0 1 0 2 2
33 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
34 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
IGD 35 Perawat 1 1 0 1 0 1 0 1 0 1 0 5 0
36 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
37 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
38 Bidan 1 1 0 1 0 0 0 1 0 1 0 4 0
39 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
40 Bidan 1 1 0 1 0 0 0 1 0 1 0 4 0
41 Perawat 1 1 0 1 0 1 0 1 0 1 0 5 0
42 dr Umum 1 0 1 0 1 0 0 1 0 1 0 2 2
43 dr Umum 1 0 1 0 1 0 0 0 1 0 1 0 4
44 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
Laborat 45 Asper 1 1 0 1 0 1 0 1 0 1 0 5 0
46 Analis 1 1 0 1 0 1 0 1 0 1 0 5 0
47 Analis 1 1 0 1 0 1 0 1 0 1 0 5 0
48 Analis 1 1 0 1 0 1 0 1 0 1 0 5 0
Fisioterapi 49 Terapis 1 1 0 1 0 0 0 1 0 1 0 4 0
Dietary 50 Gizi 1 0 0 0 0 0 0 1 0 1 0 2 0
51 Gizi 1 0 0 0 0 0 0 1 0 1 0 2 0
Arofah 52 Perawat 1 1 0 1 0 1 0 1 0 1 0 5 0
53 Perawat 1 1 0 1 0 1 0 1 0 1 0 5 0
54 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
55 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
56 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
57 Perawat 1 1 0 1 0 1 0 1 0 1 0 5 0
 58 Perawat 1 0 1 0 1 0 0 1 0 1 0 2 2
59 Perawat 1 1 0 1 0 1 0 1 0 1 0 5 0
60 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
61 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
62 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
63 DR Spesialis 1 0 1 0 1 0 0 1 0 1 0 2 2
64 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
65 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
66 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
ICU 67 DR spesialis 1 0 1 0 1 0 0 1 0 1 0 2 2
68 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
69 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
70 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
71 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
72 Perawat 1 1 0 1 0 0 0 1 0 1 0 4 0
61 9 61 9 21 0 71 1 71 1 285 20
72
87% 87% 100% 99% 99% 93%
AUDIT HAND HYGIENE
AGUSTUS TAHUN 2017
SITI KHODIJAH PEKALONGAN

JUMLAH
%
Y+T
4 100%
5 100%
5 100%
5 100%
5 100%
4 100%
4 50%
4 100%
4 50%
4 100%
4 100%
4 50%
4 100%
4 100%
5 100%
4 100%
5 100%
5 100%
5 100%
5 100%
5 100%
5 100%
4 100%
4 100%
4 100%
4 100%
4 100%
4 100%
4 100%
4 100%
4 100%
4 50%
4 100%
4 100%
5 100%
4 100%
4 100%
4 100%
4 100%
4 100%
5 100%
4 50%
4 0%
4 100%
5 100%
5 100%
5 100%
5 100%
4 100%
2 100%
2 100%
5 100%
5 100%
4 100%
4 100%
4 100%
5 100%
 4 50%
5 100%
4 100%
4 100%
4 100%
4 50%
4 100%
4 100%
4 100%
4 50%
4 100%
4 100%
4 100%
4 100%
4 100%
305 93%
93%
 DATA AUDIT HAND H
BULAN SEPTEMBER TA
RUMAH SAKIT SITI KHODIJA

Moment 1 MOMEN 2
Ruang No Profesi Opp
Y T Y T
Marwah 1 Perawat 1 0 1 0 1
2 Perawat 1 1 0 1 0
3 Perawat 1 1 0 1 0
4 Perawat 1 0 1 0 1
5 Perawat 1 1 0 1 0
6 Perawat 1 1 0 1 0
7 Perawat 1 1 0 1 0
8 Perawat 1 0 1 0 1
9 Perawat 1 1 0 1 0
10 Perawat 1 0 0 0 0
11 Perawat 1 1 0 1 0
12 Perawat 1 1 0 1 0
13 Perawat 1 1 0 1 0
14 Perawat 1 1 0 1 0
Shofa 15 Bidan 1 1 0 1 0
16 Bidan 1 1 0 1 0
17 Bidan 1 1 0 1 0
18 Bidan 1 1 0 1 0
19 Bidan 1 1 0 1 0
20 Bidan 1 1 0 1 0
21 Bidan 1 1 0 1 0
Perinatologi 22 Asper 1 1 0 1 0
23 Perawat 1 1 0 1 0
24 Perawat 1 1 0 1 0
25 Perawat 1 1 0 1 0
26 Bidan 1 1 0 1 0
27 Perawat 1 1 0 1 0
28 Asper 1 1 0 1 0
29 Bidan 1 1 0 1 0
Mina 30 Perawat 1 1 0 1 0
31 Perawat 1 1 0 1 0
32 Perawat 1 1 0 1 0
33 Perawat 1 1 0 1 0
IGD 34 Perawat 1 1 0 1 0
35 Perawat 1 1 0 1 0
36 Perawat 1 1 0 1 0
37 Bidan 1 1 0 1 0
 38 Perawat 1 1 0 1 0
39 Bidan 1 1 0 1 0
40 Perawat 1 1 0 1 0
41 dr HD 1 0 1 0 1
42 dr Y 1 0 1 0 1
43 Perawat 1 1 0 1 0
44 Bidan 1 1 0 1 0
Laborat 45 Asper 1 1 0 1 0
46 Analis 1 0 1 0 1
47 Analis 1 1 0 1 0
48 Analis 1 1 0 1 0
Fisioterapi 49 Fisioterapi 1 1 0 1 0
50 Fisioterapi 1 1 0 1 0
Dietary 51 Gizi 1 0 0 0 0
52 Gizi 1 0 0 0 0
Arofah 53 Perawat 1 1 0 1 0
54 Perawat 1 1 0 1 0
55 Perawat 1 1 0 1 0
56 Perawat 1 1 0 1 0
57 Asper 1 1 0 1 0
58 Perawat 1 1 0 1 0
59 Perawat 1 1 0 1 0
60 Perawat 1 1 0 1 0
61 Perawat 1 1 0 1 0
62 Asper 1 1 0 1 0
63 Perawat 1 0 1 0 1
64 DR FL 1 0 1 0 1
ICU 65 Perawat 1 1 0 1 0
66 Perawat 1 1 0 1 0
67 Perawat 1 1 0 1 0
68 Perawat 1 1 0 1 0
69 Perawat 1 1 0 1 0
70 Perawat 1 0 1 0 1
71 Perawat 1 1 0 1 0
72 Perawat 1 1 0 1 0
73 dr sp anastesi 1 1 0 1 0
73 61 9 61 9
87% 87%
TA AUDIT HAND HYGIENE
N SEPTEMBER TAHUN 2017
KIT SITI KHODIJAH PEKALONGAN

MOMEN 3 MOMEN 4 MOMEN 5 JUMLAH

Y T Y T Y T Y T Y+T
0 0 1 0 1 0 2 2 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
1 0 1 0 1 0 3 2 5
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
1 0 1 0 1 0 5 0 5
0 0 1 0 1 0 2 2 4
0 0 1 0 1 0 4 0 4
1 0 1 0 1 0 3 0 3
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
1 0 1 0 1 0 5 0 5
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
1 0 1 0 1 0 5 0 5
1 0 1 0 1 0 5 0 5
1 0 1 0 1 0 5 0 5
0 0 0 0 0 0 2 0 2
0 0 0 0 0 0 2 0 2
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
1 0 1 0 1 0 5 0 5
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
1 0 1 0 1 0 5 0 5
1 0 1 0 1 0 5 0 5
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 2 2 4
0 0 1 0 0 0 3 3
1 0 1 0 1 0 5 0 5
1 0 1 0 1 0 5 0 5
1 1 0 1 0 5 0 5
1 1 0 1 0 2 3 5
1 0 1 0 1 0 5 0 5
1 0 1 0 1 0 5 0 5
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 2 0 2
0 0 1 0 1 0 2 0 2
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
1 0 1 0 1 0 5 0 5
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 2 2 4
0 0 1 0 1 0 2 2 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 4 0 4
0 0 1 0 1 0 2 2 4
1 0 1 0 1 0 5 0 5
0 0 1 0 1 0 4 0 4
0 0 0 1 0 1 2 2 4
17 1 69 2 69 1 277 22 299
94% 97% 99% 93%
 %
50%
100%
100%
60%
100%
100%
100%
50%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
50%
0%
100%
100%
100%
40%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
50%
50%
100%
100%
100%
100%
100%
50%
100%
100%
50%
93%
 AUDIT KEPATUHAN HAND HIGIENE TRI BULAN 3 TH 2017
RUMAH SAKIT SITI KHODIJAH PEKALONGAN 2018

BULAN momen1 momen2 momen3 momen4 momen5 KEPATUHAN

Juli 85% 85% 100% 99% 99% 92%
Agustus 87% 87% 100% 99% 99% 93%
September 87% 87% 94% 97% 99% 93%
STANDAR 85% 85% 85% 85% 85% 85%

KEPATUHAN KEBERSIHAN TANGAN PETUGAS RS SITI KHODIJAH PEKALONGAN TRI WULAN 3 TAHUN 2017
100% 25% 25% 22% 22% 22% 23%
90%
80% 25% 26% 26%
25% 25% 26%
70%
60%
50% 25% 25% 26% 26% 26% 26%
40%
30%
25% 25% 26% 26% momen5; 26%25%
20%
10%
0%
momen1 momen2 momen3 momen4 momen5 KEPATUHAN
Juli Agustus September STANDAR

PLAN DO STUDI ACTION

1.Kepatuhan petugas diruang

Kepatuhan Hand Higiene rawat, Meningkatkan kepatuhan
petugas 85% Bulan Juli,Agustus,September, petugas dengan pengawasan
Standar sudah tercapai sesuai dilapangan
kepatuhan petugas di unit lab dengan kepatuhan baik 85%
IGD dan ICU

Dimasukkan dalan penilaian

2.Melakukan audit setiap hari kinerja karyawan
di masing2 ruang selama jam
sibuk

3.Data dibuat setiap hari

4.Data dianalisa tiap 3 bulan

 ACTION

ningkatkan kepatuhan
ugas dengan pengawasan
pangan

masukkan dalan penilaian

kinerja karyawan