RUMAH SAKIT KEPRESIDENAN RSPAD GATOT SOEBROTO

KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN

INDIKATOR MUTU KLINIK 1 : KELENGKAPAN PENGISIAN ASESMEN AWAL 24 JAM DI RAWAT

INAP

JUMLAH TOTAL PASIEN

JUMLAH RM PASIEN YANG DIISI
TGL SAAT PENGAMBILAN HASIL TARGET
LENGKAP SETELAH 24 JAM
DATA

5 50 30 60% 100%
6 35 35 100% 100%
3 19 17 89% 100%
4 12 2 17% 100%
5 32 2 6% 100%
6 21 2 10% 100%
7 11 2 18% 100%
8 18 2 11% 100%
9 17 2 12% 100%
10 5 2 40% 100%
11 2 2 100% 100%
12 14 2 14% 100%
13 18 2 11% 100%
14 22 2 9% 100%
15 10 2 20% 100%
16 10 2 20% 100%
17 10 2 20% 100%
18 10 2 20% 100%
19 10 2 20% 100%
20 10 2 20% 100%
21 10 2 20% 100%
22 10 2 20% 100%
23 10 2 20% 100%
24 10 2 20% 100%
25 10 2 20% 100%
26 10 2 20% 100%
27 10 2 20% 100%
28 10 2 20% 100%
29 10 2 20% 100%
30 10 2 20% 100%
31 10 2 20% 100%

JUML 446 138 31%

 RUMAH SAKIT KEPRESIDENAN RSPAD GATOT SOEBROTO
KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN

REKAPITULASI BULAN JANUARI 2017

TANGGAL HASIL TARGET

1 60% 100%
2 100% 100%
3 89% 100%
4 17% 100%
5 6% 100%
6 10% 100%
7 18% 100%
8 11% 100%
9 12% 100%
10 40% 100%
11 100% 100%
12 14% 100%
13 11% 100%
14 9% 100%
15 20% 100%
16 20% 100%
17 20% 100%
18 20% 100%
19 20% 100%
20 20% 100%
21 20% 100%
22 20% 100%
23 20% 100%
24 20% 100%
25 20% 100%
26 20% 100%
27 20% 100%
28 20% 100%
29 20% 100%
30 20% 100%
31 20% 100%
 GRAFIK INDIKATOR MUTU BULAN JANUARI 2017

120%

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
100%
89%

80%
PERSENTASE

60%
60%

40%
40%

20% 20% 20% 20% 20%

17% 18%
20% 14%
11% 12% 11%
10% 9%
6%

0%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

HASIL TARGET
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%

18 19 20 21 22 23 24 25 26 27 28 29 30 31
 RUMAH SAKIT KEPRESIDENAN RSPAD GATOT SOEBROTO RUMAH SAKIT KEPRESIDENA
KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN KOMITE PENINGKATAN MUTU

INDIKATOR MUTU KLINIK 4 : WAKTU TUNGGU OPERASI ELEKTIF REKAPITULA

JUMLAH PASIEN DENGAN

JUMLAH TOTAL PASIEN
TGL WAKTU TUNGGU OPERASI HASIL TARGET TANGGAL
SAAT PENGAMBILAN DATA
<2HARI

1 10 5 50% 100% 1
2 10 2 20% 100% 2
3 40 2 5% 100% 3
4 10 2 20% 100% 4
5 10 2 20% 100% 5
6 10 2 20% 100% 6
7 10 2 20% 100% 7
8 10 2 20% 100% 8
9 10 2 20% 100% 9
10 10 2 20% 100% 10
11 10 2 20% 100% 11
12 10 2 20% 100% 12
13 10 2 20% 100% 13
14 10 2 20% 100% 14
15 10 2 20% 100% 15
16 10 2 20% 100% 16
17 10 2 20% 100% 17
18 10 2 20% 100% 18
19 10 2 20% 100% 19
20 10 2 20% 100% 20
21 10 2 20% 100% 21
22 10 2 20% 100% 22
23 10 2 20% 100% 23
24 10 2 20% 100% 24
25 10 2 20% 100% 25
26 10 2 20% 100% 26
27 10 2 20% 100% 27
28 10 2 20% 100% 28
29 10 2 20% 100% 29
30 10 2 20% 100% 30
31 10 2 20% 100% 31

JUML 340 65 19%

RUMAH SAKIT KEPRESIDENAN RSPAD GATOT SOEBROTO
OMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN

REKAPITULASI BULAN JANUARI 2017 GRAFIK INDIKATOR MUTU BULAN JANUARI 2017

120%
HASIL TARGET
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100
100%
50% 100%
20% 100%
5% 100% 80%
20% 100%
20% 100%
60%
20% 100% 50%
20% 100%
20% 100% 40%
20% 100%
20% 20% 20% 20% 20% 20% 20% 20% 20% 20%
20% 100% 20%
20% 100% 5%
20% 100%
20% 100% 0%
1 2 3 4 5 6 7 8 9 10 11 12
20% 100%
20% 100%
20% 100%
20% 100%
20% 100%
20% 100%
20% 100%
20% 100%
20% 100%
20% 100%
20% 100%
20% 100%
20% 100%
20% 100%
20% 100%
20% 100%
20% 100%
20% 100%
BULAN JANUARI 2017

% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%

8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
HASIL TARGET
00% 100% 100% 100% 100%

0% 20% 20% 20% 20%

27 28 29 30 31
 RUMAH SAKIT KEPRESIDENAN RSPAD GATOT SOEBROTO
KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN

INDIKATOR MUTU KTD : KESESUAIAN DIAGNOSA PRE DAN POST OPERASI

JUMLAH PASIEN YG
JUMLAH TOTAL PASIEN
TGL SESUAI DIAGNOSA PRE NILAI TARGET
SAAT PENGAMBILAN DATA
DAN POST OPERASI
1 10 2 20% 100%
2 10 2 20% 100%
3 10 2 20% 100%
4 10 2 20% 100%
5 10 2 20% 100%
6 10 2 20% 100%
7 10 2 20% 100%
8 10 2 20% 100%
9 10 2 20% 100%
10 10 2 20% 100%
11 10 2 20% 100%
12 25 2 8% 100%
13 10 2 20% 100%
14 30 2 7% 100%
15 10 2 20% 100%
16 10 2 20% 100%
17 10 2 20% 100%
18 10 2 20% 100%
19 10 2 20% 100%
20 10 2 20% 100%
21 60 2 3% 100%
22 70 2 3% 100%
23 10 2 20% 100%
24 10 2 20% 100%
25 10 2 20% 100%
26 10 2 20% 100%
27 10 2 20% 100%
28 10 2 20% 100%
29 10 2 20% 100%
30 10 2 20% 100%
31 10 2 20% 100%

JUML 455 62 14%

 120%
TGL NILAI TARGET

100%100%100%100%100%100%100%100%100%100%100%
1 20% 100% 100%
2 20% 100%
3 20% 100%
80%
4 20% 100%
5 20% 100%
6 20% 100% 60%
7 20% 100%
8 20% 100% 40%
9 20% 100%
10 20% 100% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%
20%
11 20% 100%
12 8% 100%
13 20% 100% 0%
14 7% 100% 1 2 3 4 5 6 7 8 9 10 11
15 20% 100%
16 20% 100%
17 20% 100%
18 20% 100%
19 20% 100%
20 20% 100%
21 3% 100%
22 3% 100%
23 20% 100%
24 20% 100%
25 20% 100%
26 20% 100%
27 20% 100%
28 20% 100%
29 20% 100%
30 20% 100%
31 20% 100%
00%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%

NI
TA

0% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%

8% 7%
3% 3%

6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
%100%100%100%100%

NILAI
TARGET

20% 20% 20% 20%

28 29 30 31
 RUMAH SAKIT KEPRESIDENAN RSPAD GATOT SOEBROTO
KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN

INDIKATOR MUTU KLINIK 9 : KELENGKAPAN REKAM MEDIK PASIEN 24 JAM SETELAH PASIEN
PULANG

50% 55% 53% 8

JUMLAH RM PASIEN YANG 100%
JUMLAH TOTAL PASIEN
TGL DIISI LENGKAP SETELAH NILAI TARGET
SAAT PENGAMBILAN DATA
PASIEN PULANG 24 JAM 90%
1 10 10 100% 100% 80%
2 11 9 82% 100% 70%
3 17 15 88% 100%
60%
4 10 2 20% 100% 50%
5 10 2 20% 100% 50% 45% 47%
6 10 2 20% 100% 40%
7 10 2 20% 100% 30%
8 10 2 20% 100% 1
20%
9 10 2 20% 100%
10 10 2 20% 100% 10%
11 10 2 20% 100% 0%
12 10 2 20% 100% 1 2 3
13 10 2 20% 100%
14 10 2 20% 100%
15 10 2 20% 100%
16 10 2 20% 100%
17 10 2 20% 100%
18 10 2 20% 100%
19 10 2 20% 100%
20 10 2 20% 100%
21 10 2 20% 100%
22 10 2 20% 100%
23 10 2 20% 100%
24 10 2 20% 100%
25 10 2 20% 100%
26 10 2 20% 100%
27 10 2 20% 100%
28 10 2 20% 100%
29 10 2 20% 100%
30 10 2 20% 100%
31 10 2 20% 100%

JUML 318 90 28%

 50% 55% 53% 83% 83% 83% 83% 83% 83% 83% 83% 83% 83% 83% 83% 83% 83% 83% 83% 83% 83% 83% 83% 83% 83% 83%
100%
90%
80%
70%
60%
50%
50% 45% 47%

40%
30%
20% 17% 17% 17% 17% 17% 17% 17% 17% 17% 17% 17% 17% 17% 17% 17% 17% 17% 17% 17% 17% 17% 17% 17%

10%
0%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
NILAI TARGET
83% 83% 83% 83% 83% 83% 83% 83% 83% 83% 83% 83%

17% 17% 17% 17% 17% 17% 17% 17% 17% 17% 17% 17%

20 21 22 23 24 25 26 27 28 29 30 31
 RUMAH SAKIT KEPRESIDENAN RSPAD GATOT SOEBROTO
KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN

INDIKATOR MUTU MANAJEMEN 3 : INSIDEN TERTUSUK JARUM

JUMLAH PERSONEL
TGL JUMLAH PERSONEL HASIL TARGET
TERTUSUK JARUM
1 15 2 13% 0%
2 10 1 10% 0%
3 10 1 10% 0%
4 10 0 0% 0%
5 10 0 0% 0%
6 10 0 0% 0%
7 10 0 0% 0%
8 10 0 0% 0%
9 10 0 0% 0%
10 10 0 0% 0%
11 10 0 0% 0% 25%
12 10 0 0% 0%
13 10 0 0% 0%
14 10 1 10% 0% 20%
15 10 1 10% 0%
16 10 0 0% 0%
17 10 2 20% 0% 15%13%
18 10 2 20% 0%
19 10 2 20% 0%
10%10%
20 10 2 20% 0% 10%
21 10 0 0% 0%
22 10 0 0% 0%
23 10 0 0% 0% 5%
24 10 0 0% 0%
25 10 0 0% 0%
0% 0% 0% 0% 0%
26 10 0 0% 0% 0%
27 10 0 0% 0% 1 2 3 4 5
28 10 0 0% 0%
29 10 0 0% 0%
30 10 0 0% 0%
31 10 2 20% 0%

JUML 315 16 5%
25%

20%20%20%20% 20%
20%

15%13%

10%10% 10%10%
10%

5%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
0%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
 20%

HASIL
TARGET

% 0% 0% 0% 0% 0% 0% 0%

4 25 26 27 28 29 30 31
 RUMAH SAKIT KEPRESIDENAN RSPAD GATOT SOEBROTO
KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN

INDIKATOR MUTU JCI LIBRARY : PNEUMONIA YANG DIBERIKAN KONSELING TENTANG

MEROKOK

JUMLAH PASIEN YANG

TGL
JUMLAH TOTAL PASIEN
DIBERIKAN KONSELING NILAI TARGET
120%
PNEUMONIA
TENTANG MEROKOK 100% 10
1 4 2 50% 100% 100%
2 4 2 50% 100%
3 4 2 50% 100% 80%
4 4 2 50% 100%

Axis Title
60%
50% 5
5 4 2 50% 100%
6 4 2 50% 100%
40%
7 5 2 40% 100%
8 5 2 40% 100% 20%
9 5 2 40% 100%
10 5 2 40% 100% 0%
11 5 2 40% 100% 1
12 4 2 50% 100%
13 4 2 50% 100%
14 4 2 50% 100%
15 4 2 50% 100%
16 4 2 50% 100%
17 4 2 50% 100%
18 5 2 40% 100%
19 5 2 40% 100%
20 5 2 40% 100%
21 5 2 40% 100%
22 5 2 40% 100%
23 4 2 50% 100%
24 4 2 50% 100%
25 4 2 50% 100%
26 4 2 50% 100%
27 6 2 33% 100%
28 6 2 33% 100%
29 6 2 33% 100%
30 6 2 33% 100%
31 6 2 33% 100%

JUML 144 62 43%

 120%
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
100%

80%
Axis Title

60%
50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%
40% 40% 40% 40% 40% 40% 40% 40% 40%
40%

20%

0%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
NILAI TARGET
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

50% 50% 50% 50% 50% 50%

40% 40% 40% 40% 40%
33% 33% 33% 33% 33%

16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
TARGET
 RUMAH SAKIT KEPRESIDENAN RSPAD GATOT SOEBROTO
KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN

INDIKATOR MUTU JCI LIBRARY : PASIEN ASMA ANAK YANG MENERIMA RELEIVERS SELAMA
PERAWATAN

Pasien asma anak 120%

JUMLAH TOTAL PASIEN yang menerima
TGL NILAI TARGET
ASMA ANAK
releivers selama
perawatan 100% 100% 10
100%
1 10 2 20% 100%
2 10 2 20% 100%
3 10 2 20% 100% 80%
4 10 2 20% 100%
5 10 2 20% 100%
6 10 2 20% 100% 60%
7 10 2 20% 100%
8 10 2 20% 100% 40%
9 10 2 20% 100%
10 10 2 20% 100% 20% 20% 20
11 10 5 50% 100% 20%
12 10 5 50% 100%
13 10 5 50% 100%
0%
14 10 5 50% 100% 1 2 3
15 10 2 20% 100%
16 10 2 20% 100%
17 10 2 20% 100%
18 10 2 20% 100%
19 10 2 20% 100%
20 10 2 20% 100%
21 10 2 20% 100%
22 10 2 20% 100%
23 10 2 20% 100%
24 10 2 20% 100%
25 10 2 20% 100%
26 10 2 20% 100%
27 10 2 20% 100%
28 10 2 20% 100%
29 10 2 20% 100%
30 10 2 20% 100%
31 10 2 20% 100%

JUML 310 74 24%

120%

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
100%

80%

60%
50% 50% 50% 50%

40%

20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%
20%

0%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
NILAI TARGET
00% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

50%

20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%

14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
NILAI TARGET
0% 100% 100%

0% 20% 20%

9 30 31
 RUMAH SAKIT KEPRESIDENAN RSPAD GATOT SOEBROTO
KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN

INDIKATOR MUTU JCI LIBRARY : PASIEN GANGGUAN KEJIWAAN DENGAN RESTRAIN

Pasien gangguan 25%

kejiwaan yang
JUMLAH TOTAL PASIEN ditempatkan di
TGL HASIL TARGET
JIWA
ruangan dengan 20% 20% 20
restrain / pengikatan 20%
selama perawatan.
1 10 2 20% 0%
2 10 2 20% 0%
3 10 2 20% 0% 15%
4 10 2 20% 0%
5 10 2 20% 0%
6 10 2 20% 0% 10%
7 10 2 20% 0%
8 10 2 20% 0%
9 10 2 20% 0%
5%
10 10 2 20% 0%
11 10 2 20% 0%
12 10 2 20% 0% 0% 0% 0%
13 10 2 20% 0% 0%
14 10 2 20% 0% 1 2 3
15 10 2 20% 0%
16 10 2 20% 0%
17 10 2 20% 0%
18 10 2 20% 0%
19 10 2 20% 0%
20 10 2 20% 0%
21 10 2 20% 0%
22 10 2 20% 0%
23 10 2 20% 0%
24 10 2 20% 0%
25 10 2 20% 0%
26 10 2 20% 0%
27 10 2 20% 0%
28 10 2 20% 0%
29 10 2 20% 0%
30 10 2 20% 0%
31 10 2 20% 0%

JUML 310 62 20%

25%

20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%
20%

15%

10%

5%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
0%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
HASIL TARGET
0% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%

% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

8 19 20 21 22 23 24 25 26 27 28 29 30 31
 RUMAH SAKIT KEPRESIDENAN RSPAD GATOT SOEBROTO
KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN

INDIKATOR MUTU JCI LIBRARY : PASIEN GANGGUAN KEJIWAAAN YG DITEMPATKAN DI RUANG

SEKLUSI

JUMLAH TOTAL PASIEN JUMLAH PASIEN DI

TGL HASIL TARGET
JIWA RUANG SEKLUSI
1 10 2 20% 0% 25%
2 10 2 20% 0%
3 10 2 20% 0%
20% 20% 20%
4 10 2 20% 0% 20%
5 10 2 20% 0%
6 10 2 20% 0%
7 10 2 20% 0% 15%
8 10 2 20% 0%
9 10 2 20% 0%
10 10 2 20% 0%
10%
11 10 2 20% 0%
12 10 2 20% 0%
13 10 2 20% 0%
5%
14 10 2 20% 0%
15 10 2 20% 0%
16 10 2 20% 0% 0% 0% 0%
0%
17 10 2 20% 0%
1 2 3
18 10 2 20% 0%
19 10 2 20% 0%
20 10 2 20% 0%
21 10 2 20% 0%
22 10 2 20% 0%
23 10 2 20% 0%
24 10 2 20% 0%
25 10 2 20% 0%
26 10 2 20% 0%
27 10 2 20% 0%
28 10 2 20% 0%
29 10 2 20% 0%
30 10 2 20% 0%
31 10 2 20% 0%

JUML 310 62 20%

25%

20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%
20%

15%

10%

5%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
0%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
HASIL TARGET
% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%

% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

8 19 20 21 22 23 24 25 26 27 28 29 30 31
 RUMAH SAKIT KEPRESIDENAN RSPAD GATOT SOEBROTO
KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN

INDIKATOR MUTU IPSG 1 : KEPATUHAN PENGGUNAAN GELANG IDENTITAS ( DITULIS LENGKAP )

JUMLAH PASIEN YG
JUMLAH TOTAL PASIEN
TGL MENGGUNAKAN GELANG HASIL
SAAT PENGAMBILAN DATA
DG BENAR & LENGKAP

1 15 15 100%
2 15 14 93%
3 10 2 20%
4 10 2 20%
5 10 2 20%
6 10 2 20%
7 10 2 20%
8 10 2 20%
9 10 2 20%
10 10 2 20%
11 10 2 20%
12 10 2 20%
13 10 2 20%
14 10 2 20%
15 10 2 20%
16 10 2 20%
17 10 2 20%
18 10 2 20%
19 10 2 20%
20 10 2 20%
21 10 2 20%
22 10 2 20%
23 10 2 20%
24 10 2 20%
25 10 2 20%
26 10 2 20%
27 10 2 20%
28 10 2 20%
29 10 2 20%
30 10 2 20%
31 10 2 20%

JUML 320 87 27%

TAS ( DITULIS LENGKAP )

120%
TARGET
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100
100% 93%
100%
100%
100% 80%
100%
100%
60%
100%
100%
100% 40%
100%
100% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20
20%
100%
100%
100% 0%
100% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
100% HASIL
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
00% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%

11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
HASIL TARGET
00% 100%

0% 20%

30 31
 RUMAH SAKIT KEPRESIDENAN RSPAD GATOT SOEBROTO
KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN

INDIKATOR MUTU IPSG 2 : KEPATUHAN PENERAPAN READ BACK

JUMLAH RM PASIEN YANG

JUMLAH TOTAL PASIEN
TGL DIISI LENGKAP SETELAH HASIL
SAAT PENGAMBILAN DATA
24 JAM
1 10 2 20%
2 10 2 20%
3 10 2 20%
4 10 2 20%
5 10 2 20%
6 10 2 20%
7 10 2 20%
8 10 2 20%
9 10 2 20%
10 10 2 20%
11 10 2 20%
12 10 2 20%
13 10 2 20%
14 10 2 20%
15 10 2 20%
16 10 2 20%
17 10 2 20%
18 10 2 20%
19 10 2 20%
20 10 2 20%
21 10 2 20%
22 10 2 20%
23 10 2 20%
24 10 2 20%
25 10 2 20%
26 10 2 20%
27 10 2 20%
28 10 2 20%
29 10 2 20%
30 10 2 20%
31 10 2 20%

JUML 310 62 20%

AD BACK

120%
TARGET

100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%
100% 100%
100%
100%
80%
100%
100%
100% 60%
100%
100% 40%
100%
100% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%
20%
100%
100%
100% 0%
100% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
100% HASIL TARG
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
00%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%

20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%

12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
HASIL TARGET
 RUMAH SAKIT KEPRESIDENAN RSPAD GATOT SOEBROTO
KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN

INDIKATOR MUTU IPSG 2 : KEPATUHAN PENERAPAN PELAPORAN NILAI KRITIS

JUMLAH TOTAL PASIEN JUMLAH PASIEN DENGAN

TGL HASIL
SAAT PENGAMBILAN DATA NILAI KRITIS

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

JUML 310 62 20%

AN NILAI KRITIS

120%
TARGET

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
100% 100%
100%
100% 80%
100%
100%
60%
100%
100%
100% 40%
100% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%
100% 20%
100%
100% 0%
100% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
100% HASIL
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% 100% 100% 100% 100% 100%

% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%

12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
HASIL TARGET
 RUMAH SAKIT KEPRESIDENAN RSPAD GATOT SOEBROTO
KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN

INDIKATOR MUTU IPSG 2 : KEPATUHAN PENERAPAN HAND OVER

JUMLAH TOTAL ITEM

JUMLAH ITEM YANG
KEGIATAN YANG
TGL DILAKUKAN SAAT HAND HASIL
DILAKUKAN SAAT HAND
OVER
OVER
1 7 2 29%
2 7 2 29%
3 7 2 29%
4 7 2 29%
5 7 2 29%
6 7 2 29%
7 7 2 29%
8 7 2 29%
9 7 2 29%
10 7 2 29%
11 7 2 29%
12 7 2 29%
13 7 2 29%
14 7 2 29%
15 7 2 29%
16 7 2 29%
17 7 2 29%
18 7 2 29%
19 7 2 29%
20 7 2 29%
21 7 2 29%
22 7 2 29%
23 7 2 29%
24 7 2 29%
25 7 2 29%
26 7 2 29%
27 7 2 29%
28 7 2 29%
29 7 2 29%
30 7 2 29%
31 7 2 29%

JUML 217 62 29%

SPO HAND OVER :
1. ADA PETUGAS KEDUA BELAH PIHAK / SHIFT
2. INFORMASI DAN INSTRUKSI HARUS DITULIS DAN DIBACAKAN
3. INFORMASI BERISI KEGAWATDARURATAN, KONDISI KRITIS, IDENTIFIKASI PASIEN BERISIKO, RISIKO KLINIS
DAN KESELAMATAN PASIEN
4. INFORMASI DAN INSTRUKSI PENTING TERSEBUT DISERAHTERIMAKAN KEPADA PETUGAS SELANJUTNYA
5. INFORMASI DAN INSTRUKSI PENTING DISAMPAIKAN DENGAN METODE SOAP
6. KOMUNIKASI EFEKTIF DENGAN CARA TBK/READ BACK HARUS DIDOKUMENTASIKAN
DI REKAM MEDIK
ND OVER

120%
TARGET
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 1
100%
100%
100%
100% 80%
100%
100%
60%
100%
100%
100% 40%
29% 29% 29% 29% 29% 29% 29% 29% 29% 29% 29% 29% 29% 29% 29% 29% 2
100%
100% 20%
100%
100%
0%
100%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
100%
100% HASIL
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
BERISIKO, RISIKO KLINIS

ETUGAS SELANJUTNYA
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

29% 29% 29% 29% 29% 29% 29% 29% 29% 29% 29% 29% 29% 29% 29% 29% 29% 29% 29% 29%

12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
HASIL TARGET
 RUMAH SAKIT KEPRESIDENAN RSPAD GATOT SOEBROTO
KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN

INDIKATOR MUTU IPSG 4 : KEPATUHAN PENERAPAN SITE MARKING

JUMLAH TOTAL PASIEN JUMLAH PASIEN YG

TGL RENCANA OPERASI YG DILAKUKAN SITE HASIL
HARUS DI SITE MARKING MARKING
1 10 2 20%
2 10 2 20%
3 10 2 20%
4 10 2 20%
5 10 2 20%
6 10 2 20%
7 10 2 20%
8 10 2 20%
9 10 2 20%
10 10 2 20%
11 10 2 20%
12 10 2 20%
13 10 2 20%
14 10 2 20%
15 10 2 20%
16 10 2 20%
17 10 2 20%
18 10 2 20%
19 10 2 20%
20 10 2 20%
21 10 2 20%
22 10 2 20%
23 10 2 20%
24 10 2 20%
25 10 2 20%
26 10 2 20%
27 10 2 20%
28 10 2 20%
29 10 2 20%
30 10 2 20%
31 10 2 20%

JUML 310 62 20%

RUMUS :
Jumlah rekam medik yang lengkap diisi oleh staf medis dan keperawatan dalam 24 jam dalam 1 bulan
(orang) : Jumlah pasien yang dinyatakan telah selesai pelayanan rawat inap pada periode yang sama x
100% = ___%
RUMUS :
Jumlah rekam medik yang lengkap diisi oleh staf medis dan keperawatan dalam 24 jam dalam 1 bulan
(orang) : Jumlah pasien yang dinyatakan telah selesai pelayanan rawat inap pada periode yang sama x
100% = ___%
MARKING

TARGET

100% 120%
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 1
100% 100%
100%
80%
100%
100%
60%
100%
100% 40%
100% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 2
100% 20%
100%
100% 0%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
100%
100% HASIL TARGE
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

4 jam dalam 1 bulan

periode yang sama x
4 jam dalam 1 bulan
periode yang sama x
% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%

13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
HASIL TARGET
 RUMAH SAKIT KEPRESIDENAN RSPAD GATOT SOEBROTO
KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN

INDIKATOR MUTU IPSG 4 : KEPATUHAN PENERAPAN TIME OUT

JUMLAH TOTAL PASIEN JUMLAH PASIEN YG

TGL HASIL
OPERASI DILAKUKAN TIME OUT
1 10 2 20%
2 10 2 20%
3 10 2 20%
4 10 2 20%
5 10 2 20%
6 10 2 20%
7 10 2 20%
8 10 2 20%
9 10 2 20%
10 10 2 20%
11 10 2 20%
12 10 2 20%
13 10 2 20%
14 10 2 20%
15 10 2 20%
16 10 2 20%
17 10 2 20%
18 10 2 20%
19 10 2 20%
20 10 2 20%
21 10 2 20%
22 10 2 20%
23 10 2 20%
24 10 2 20%
25 10 2 20%
26 10 2 20%
27 10 2 20%
28 10 2 20%
29 10 2 20%
30 10 2 20%
31 10 2 20%

JUML 310 62 20%

ME OUT

TARGET 120%

100% 100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100
100% 100%
100%
100% 80%
100%
100%
60%
100%
100%
100% 40%
100%
20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%
100% 20%
100%
100%
0%
100%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
100%
HASIL TARGET
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%100%100%100%

20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%

13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
HASIL TARGET
 RUMAH SAKIT KEPRESIDENAN RSPAD GATOT SOEBROTO
KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN

NDIKATOR MUTU IPSG 6 : KEPATUHAN PENERAPAN PENCEGAHAN PASIEN RISIKO JATUH DI RAWAT INAP

JUMLAH TOTAL PASIEN RISIKO JATUH DIKAJI DG

TGL HASIL TARGET
RISIKO JATUH LENGKAP
1 10 8 80% 100% 120%
2 10 8 80% 100%
100%100%100%100%100%100%100%100
3 10 8 80% 100% 100%
4 10 8 80% 100%
5 10 8 80% 100% 80% 80% 80% 80% 80% 80% 80% 80%
80%
6 10 8 80% 100%
7 10 8 80% 100%
60%
8 10 8 80% 100%
9 10 8 80% 100%
10 10 8 80% 100% 40%
11 10 8 80% 100%
12 10 8 80% 100% 20%
13 10 8 80% 100%
14 10 8 80% 100% 0%
15 10 8 80% 100% 1 2 3 4 5 6 7 8
16 10 8 80% 100%
17 10 8 80% 100%
18 10 8 80% 100%
19 10 8 80% 100%
20 10 8 80% 100%
21 10 8 80% 100%
22 10 8 80% 100%
23 10 8 80% 100%
24 10 8 80% 100%
25 10 8 80% 100%
26 10 8 80% 100%
27 10 8 80% 100%
28 10 8 80% 100%
29 10 8 80% 100%
30 10 8 80% 100%
31 10 8 80% 100%

JUML 310 248 80%

%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%

% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
HASIL TARGET
%100%100%100%100%

% 80% 80% 80% 80%

7 28 29 30 31
 RUMAH SAKIT KEPRESIDENAN RSPAD GATOT SOEBROTO
KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN

INDIKATOR MUTU IPSG 6 : KEPATUHAN PENERAPAN PENCEGAHAN PASIEN RISIKO JATUH DI RAWAT JALAN

JUMLAH TOTAL PASIEN JUMLAH PASIEN DENGAN

TGL HASIL
RISIKO JATUH INSIDEN JATUH
1 10 2 20%
2 10 2 20%
3 10 2 20%
4 10 2 20%
5 10 2 20%
6 10 2 20%
7 10 2 20%
8 10 2 20%
9 10 2 20%
10 10 2 20%
11 10 2 20%
12 10 2 20%
13 10 2 20%
14 10 2 20%
15 10 2 20%
16 10 2 20%
17 10 2 20%
18 10 2 20%
19 10 2 20%
20 10 2 20%
21 10 2 20%
22 10 2 20%
23 10 2 20%
24 10 2 20%
25 10 2 20%
26 10 2 20%
27 10 2 20%
28 10 2 20%
29 10 2 20%
30 10 2 20%
31 10 2 20%

JUML 310 62 20%

ISIKO JATUH DI RAWAT JALAN

TARGET

0% 25%
0%
0% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%
20%
0%
0%
0% 15%
0%
0%
0% 10%
0%
0%
5%
0%
0%
0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
0% 0%
0% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
0% HASIL TARGET
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
SIL TARGET