Ketidakmampuan Melakukan IMD Januari

Tanggal Nilai No Ruangan Nilai Target

1 0% 1. Neonatus 3% 0.50%
2 0%
3 0%
4 0% neonatus
5 0%
6 0% 4%
7 0% 3%
8 0%
3%
9 0%
10 0% 2% 1. Neonatus
11 0% 2%
12 0%
13 0% 1%
14 0% 1%
15 0%
0%
16 0% Nilai Target
17 0%
18 0%
19 0%
20 0%
21 0%
22 0%
23 0%
24 0%
25 0%
26 0%
27 0%
28 0%
29 0%
30 0%
31 100%
Total 3%
assesmen pra anastesi dan sedasi Januari

Tanggal Nilai
1 80%
2 60%
3 60%
4 0%
5 20%
6 40%
7 20%
8 20%
9 0%
10 0%
11 20%
12 80%
13 60%
14 0%
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Ketidakmampuan Melayani BBLR 1500-2500 gram Januari

Tanggal Nilai No. Ruangan Nilai Target

1 0% 1. Neonatus 1% 0.50%
2 0%
3 0%
1%
4 0%
5 0% 1%
6 0%
7 0% 1%
8 0%
1% 1. Neonatus
9 0%
10 0% 0%
11 0%
12 0% 0%
13 0%
0%
14 0%
Nilai Target
15 0%
16 0%
17 0%
18 0%
19 0%
20 0%
21 30%
22 0%
23 0%
24 0%
25 0%
26 0%
27 0%
28 0%
29 0%
30 0%
31 0%
1%
Visit Harian DPJP Januari No. Ruangan Nilai Target
Ruangan 1. Neonatus 97% 100%
Tanggal Neonatus Lantai 3 Lantai 4 2. Perawatan lantai 3 68% 100%
1 100% 80% 80% 3. Perawatan lantai 4 68% 100%
2 100% 40% 60%
3 100% 100% 100%
120%
4 100% 60% 80%
5 100% 40% 80% 100%
6 60% 60% 40% 80%
7 100% 40% 80%
60%
8 100% 60% 60%
9 100% 80% 80% 40%
10 100% 80% 100% 20% Nilai
11 100% 40% 60% Target
0%
12 100% 60% 80%

Perawatan lantai 3

Perawatan lantai 4
Neonatus
13 80% 80% 60%
14 100% 80% 80%
15 100% 80% 60%
16 100% 80% 60%
17 100% 60% 40% 1. 2. 3.
18 100% 60% 80%
19 100% 100% 60%
20 100% 80% 40%
21 100% 40% 60%
22 100% 40% 40%
23 100% 80% 80%
24 100% 60% 60%
25 100% 80% 80%
26 100% 80% 80%
27 80% 60% 40%
28 100% 80% 60%
29 100% 60% 80%
30 100% 100% 80%
31 100% 80% 60%
total 97% 68% 68%
Penundaan Operasi Elektif Januari

Tanggal Nilai No Ruangan Nilai Target

1 100% 1. Ok 100% 100%
2 100%
3 100%
4 100% 120%
5 100%
6 100% 100%
7 100% 80%
8 100%
60%
9 100%
10 100% 40% 1. Ok
11 100%
20%
12 100%
13 100% 0%
14 100% Nilai Target
15 100%
16 100%
17 100%
18 100%
19 100%
20 100%
21 100%
22 100%
23 100%
24 100%
25 100%
26 100%
27 100%
28 100%
29 100%
30 100%
31 100%
100%
Peningkatan komunikasi efektif Januari 2019
No L4 L3 Neo
1 100% 100% 100%
2 60% 80% 100% NO nama Ruangan Nilai Target
3 100% 100% 100% 1 Lantai 4 90% 100%
4 100% 100% 100% 2 Lantai 3 91% 100%
5 100% 100% 100% 3 Neonatus 98% 100%
6 60% 100% 100%
7 100% 100% 100%
8 100% 100% 100%
9 80% 80% 100%
10 100% 100% 100% 102%
11 100% 60% 100% 100%
98%
12 100% 100% 100%
96%
13 60% 80% 100% 94%
14 100% 100% 100% 92%
15 100% 100% 100% 90% Nilai
16 100% 60% 50% 88% Target
17 60% 100% 100% 86%
84%
18 100% 100% 100%
Lantai 4

Lantai 3

Neonatus
19 80% 80% 100%
20 100% 100% 100%
21 50% 100% 100% 1 2 3
22 100% 80% 100%
23 100% 100% 100%
24 60% 100% 100%
25 100% 80% 100%
26 100% 100% 100%
27 80% 100% 100%
28 100% 50% 100%
29 100% 100% 100%
30 100% 80% 100%
31 100% 100% 100%
90% 91% 98%
NO Nama Ruangan Nilai Target
1 OK 10% 1%

OK
12%

10%

8%
1 OK
6%

4%

2%

0%
Nilai Target
kepatuhan terhadap klinikal pathway Januari 2019

No Neonatus Lantai 3 Lantai 4 N0 Ruangan Nilai Target

1 100% 80% 60% 1 Neonatus 86% 80%
2 80% 60% 80% 2 Lantai 3 85% 80%
3 80% 80% 80% 3 Lantai 4 85% 80%
4 100% 100% 60%
5 60% 100% 80%
6 100% 100% 100% 87%
7 60% 80% 100% 86%
8 80% 60% 100% 85%
9 80% 80% 100% 84%
10 100% 60% 80% 83%
11 100% 80% 80% 82%
12 100% 100% 60% 81%
13 100% 100% 60% 80%
14 80% 100% 80%
79%
15 80% 80% 80%
78%
16 60% 80% 60%
77%
17 80% 60% 100%
Neonatus Lantai 3 Lantai 4
18 100% 60% 80% 1 2 3
19 100% 80% 100%
20 100% 60% 100%
21 80% 100% 100%
22 80% 100% 80%
23 60% 100% 100%
24 60% 100% 100%
25 80% 80% 60%
26 100% 80% 100%
27 100% 60% 100%
28 80% 100% 100%
29 100% 100% 60%
30 100% 100% 80%
31 100% 100% 100%
Nilai 86% 85% 85%
 Nilai
Target

Lantai 4
3
kepatuhan terhadap clinical pathway Februari 2019

No Neonatus Lantai 3 Lantai 4 No Ruangan Nilai Target

1 100% 100% 100% 1 Neonatus 86% 80%
2 100% 100% 100% 2 Lantai 3 86% 80%
3 100% 60% 100% 3 Lantai 4 89% 80%
4 100% 80% 80%
5 80% 80% 80%
6 60% 80% 80% 90%
7 80% 60% 80% 88%
8 80% 100% 80%
86%
9 100% 80% 100%
10 100% 80% 60% 84%
11 100% 60% 80% 82% Nilai
12 100% 60% 80% Target
80%
13 80% 80% 80%
14 80% 100% 80% 78%
15 60% 100% 100% 76%
16 80% 100% 100%
74%
17 100% 100% 100% Neonatus Lantai 3 Lantai 4
18 100% 80% 100% 1 2 3
19 80% 60% 100%
20 60% 100% 100%
21 60% 80% 80%
22 100% 80% 80%
23 100% 100% 80%
24 100% 100% 100%
25 80% 100% 80%
26 80% 100% 100%
27 60% 100% 80%
28 80% 100% 100%
Nilai 86% 86% 89%
pengurangan resiko jatuh Januari 2019

No. Neonatus lantai 3 lantai 4 OK VK UGD No Ruangan Nilai Target

1 100% 100% 100% 100% 100% 100% 1 Neonatus 100% 100%
2 100% 100% 100% 100% 100% 100% 2 Lantai 3 100% 100%
3 100% 100% 100% 100% 100% 100% 3 Lantai 4 100% 100%
4 100% 100% 100% 100% 100% 100% 4 OK 100% 100%
5 100% 100% 100% 100% 100% 100% 5 VK 100% 100%
6 100% 100% 100% 100% 100% 100% 6 IGD 100% 100%
7 100% 100% 100% 100% 100% 100%
8 100% 100% 100% 100% 100% 100%
9 100% 100% 100% 100% 100% 100%
10 100% 100% 100% 100% 100% 100%
11 100% 100% 100% 100% 100% 100%
12 100% 100% 100% 100% 100% 100%
13 100% 100% 100% 100% 100% 100%
14 100% 100% 100% 100% 100% 100%
15 100% 100% 100% 100% 100% 100%
16 100% 100% 100% 100% 100% 100%
17 100% 100% 100% 100% 100% 100%
18 100% 100% 100% 100% 100% 100%
19 100% 100% 100% 100% 100% 100%
20 100% 100% 100% 100% 100% 100%
21 100% 100% 100% 100% 100% 100%
22 100% 100% 100% 100% 100% 100%
23 100% 100% 100% 100% 100% 100%
24 100% 100% 100% 100% 100% 100%
25 100% 100% 100% 100% 100% 100%
26 100% 100% 100% 100% 100% 100%
27 100% 100% 100% 100% 100% 100%
28 100% 100% 100% 100% 100% 100%
29 100% 100% 100% 100% 100% 100%
30 100% 100% 100% 100% 100% 100%
31 100% 100% 100% 100% 100% 100%
100% 100% 100% 100% 100% 100%

120%

100%

80%

60% Nilai
Target
40%

20%

0%
Neonatus

Lantai 3

Lantai 4

IGD
OK

VK

1 2 3 4 5 6
 0%

Neonatus
2

Lantai 3
3

Lantai 4
4

OK
5

VK
6

IGD
pengurangan resiko jatuh Februari 2019

No. Neonatus lantai 3 lantai 4 OK VK UGD No Ruangan Nilai Target

1 100% 100% 100% 100% 100% 100% 1 Neonatus 100% 100%
2 100% 100% 100% 100% 100% 100% 2 Lantai 3 100% 100%
3 100% 100% 100% 100% 100% 100% 3 Lantai 4 100% 100%
4 100% 100% 100% 100% 100% 100% 4 OK 100% 100%
5 100% 100% 100% 100% 100% 100% 5 VK 100% 100%
6 100% 100% 100% 100% 100% 100% 6 IGD 100% 100%
7 100% 100% 100% 100% 100% 100%
8 100% 100% 100% 100% 100% 100%
9 100% 100% 100% 100% 100% 100%
10 100% 100% 100% 100% 100% 100%
11 100% 100% 100% 100% 100% 100%
12 100% 100% 100% 100% 100% 100%
13 100% 100% 100% 100% 100% 100%
14 100% 100% 100% 100% 100% 100%
15 100% 100% 100% 100% 100% 100%
16 100% 100% 100% 100% 100% 100%
17 100% 100% 100% 100% 100% 100%
18 100% 100% 100% 100% 100% 100%
19 100% 100% 100% 100% 100% 100%
20 100% 100% 100% 100% 100% 100%
21 100% 100% 100% 100% 100% 100%
22 100% 100% 100% 100% 100% 100%
23 100% 100% 100% 100% 100% 100%
24 100% 100% 100% 100% 100% 100%
25 100% 100% 100% 100% 100% 100%
26 100% 100% 100% 100% 100% 100%
27 100% 100% 100% 100% 100% 100%
28 100% 100% 100% 100% 100% 100%
29 100% 100% 100% 100% 100% 100%
30 100% 100% 100% 100% 100% 100%
31 100% 100% 100% 100% 100% 100%
100% 100% 100% 100% 100% 100%

120%

100%

80%

60% Nilai
Target
40%

20%

0%
Neonatus

Lantai 3

Lantai 4

IGD
OK

VK

1 2 3 4 5 6
 0%

Neonatus
2

Lantai 3
3

Lantai 4
4

OK
5

VK
6

IGD
kepatuhan cuci tangan januari 2019

No. Ruangan Nilai Target

1 IGD 87% 85%
2 VK 92% 85%
3 Neonatus 88% 85%
4 farmasi 88% 85%
5 Laboratorium 88% 85%
6 Lantai 4 92% 85%
7 Lantai 3 88% 85%
8 OK 92% 85%

94%
92%
90%
88%
86%
84% Nilai
82% Target
80%
Laboratorium
IGD

VK

OK
Lantai 3
Lantai 4
Neonatus

farmasi

1 2 3 4 5 6 7 8