Indikator Mutu Harian - November 2021

No Indikator 1 2 3 4 5
0 0 0 100 100
1
Kepatuhan Identifikasi Pasien 2 2 3 3

0 0 0 100 100
2
Kepatuhan Jam Visite Dokter Spesialis 2 2 3 3

3 0 0 0 0 0
Kepatuhan Upaya Pencegahan Risiko Cedera Akib 0 0 0 0

0 0 0 0 0
4
Kepatuhan Terhadap Clinical Pathway 0 0 0 0

Indikator Mutu Harian - Desember 2021

No Indikator 1 2 3 4 5
100 100 100 100 100
1
Kepatuhan Identifikasi Pasien 9 9 6 6 8 8 8 8 8 8

100 100 75 75 100

2
Kepatuhan Jam Visite Dokter Spesialis 9 9 6 6 6 8 6 8 8 8

3 0 0 0 0 0
Kepatuhan Upaya Pencegahan Risiko Cedera Akib 0 0 0 0 0 0 0 0 0 0

100 100 100 0 0

4
Kepatuhan Terhadap Clinical Pathway 2 2 2 2 1 1 0 0 0 0

Indikator Mutu Harian - januari 2022

No Indikator 1 2 3 4 5
100 100 100 100 100
1
Kepatuhan Identifikasi Pasien 10 10 12 12 15 15 15 15 11 11

90 100 87 93 100
2
Kepatuhan Jam Visite Dokter Spesialis 9 10 12 12 13 15 14 15 11 11

3 0 0 0 0 0
Kepatuhan Upaya Pencegahan Risiko Cedera Akib 0 0 0 0 0 0 0 0 0 0

0 0 100 100 100

4
Kepatuhan Terhadap Clinical Pathway 0 0 0 0 2 2 1 1 2 2
 6 7 8 9 10 11 12 13 14 15
100 100 100 100 100 100 100 100 100 100
4 4 2 2 5 5 7 7 6 6 7 7 7 7 8 8 8 8 10 10

75 100 80 71 100 86 100 88 100 100

3 4 2 2 4 5 5 7 6 6 6 7 7 7 7 8 8 8 10 10

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 0 0 100 0 100 0 0 100

0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 1 1

6 7 8 9 10 11 12 13 14 15
100 100 100 100 100 100 100 100 100 100
9 9 10 10 8 8 13 13 13 13 13 13 11 11 13 13 16 16 12 12

100 80 100 77 92 92 82 92 88 93
9 9 8 10 8 8 10 13 12 13 12 13 9 11 12 13 14 16 14 15

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 0 100 0 100 0 0 0 100 100

0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 1 1 1 1

6 7 8 9 10 11 12 13 14 15
100 100 100 100 100 100 100 100 100 100
11 11 9 9 10 10 7 7 10 10 7 7 9 9 11 11 11 11 12 12

91 100 90 100 100 100 100 91 91 92

10 11 9 9 9 10 7 7 9 9 7 7 9 9 10 11 10 11 11 12

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

100 0 100 0 0 0 0 0 0 100

1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 2 2
 16 17 18 19 20 21 22 23 24 25
100 100 100 100 100 100 100 100 100 100
8 8 8 8 7 7 8 8 6 6 4 4 6 6 8 8 9 9 10 10

100 88 100 100 83 100 83 63 89 90

8 8 7 8 7 7 8 8 5 6 4 4 5 6 5 8 8 9 9 10

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

100 0 0 100 0 0 100 0 0 0

1 1 0 0 0 0 2 2 0 0 0 0 2 2 0 0 0 0 0 0

16 17 18 19 20 21 22 23 24 25
100 100 100 100 100 100 100 100 100 100
12 12 17 17 15 15 16 16 20 20 12 12 12 12 10 10 11 11 9 9

100 82 93 88 95 92 92 80 91 89
12 12 14 17 14 15 14 16 19 20 11 12 11 12 8 10 10 11 8 9

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 0 0 100 0 100 100 100 0

0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0

16 17 18 19 20 21 22 23 24 25
100 100 100 100 100 100 100 100 100 100
14 14 16 16 11 11 11 11 14 14 11 11 11 11 12 12 15 15 12 12

79 94 100 100 79 91 82 92 87 100

11 14 15 16 11 11 11 11 11 14 10 11 9 11 11 12 13 15 12 12

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 0 100 0 100 100 0 0 0 0

0 0 0 0 1 1 0 0 3 3 1 1 0 0 0 0 0 0 0 0
 Target

26 27 28 29 30
100 100 100 100 100 100.00 100
10 10 7 7 8 8 11 11 12 12

90 100 75 82 83 89.83 80
9 10 7 7 6 8 9 11 10 12

100 100 0 0 0 100.00 100

1 1 1 1 0 0 0 0 0 0

100 0 0 100 100 100.00 80

1 1 0 0 0 0 1 1 1 1

26 27 28 29 30 31
100 100 100 100 100 100 100.00
10 10 15 15 15 15 17 17 13 13 12 12

100 87 87 94 85 92 90.05
10 10 13 15 13 15 16 17 11 13 11 12

0 0 0 0 0 0 100.00
0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 100 100 0 100.00

0 0 0 0 0 0 3 3 2 2 0 0

26 27 28 29 30 31
100 100 100 100 100 100 100.00
11 11 7 7 5 5 6 6 5 5 8 8

100 86 80 83 100 100 90.10

11 11 6 7 4 5 5 6 5 5 8 8

0 0 0 0 0 0 100.00
0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 100.00
0 0 0 0 0 0 0 0 0 0 0 0
Kepatuhan Identifikasi Pasien Februari 2 Maret 202 April 2022. Indikator Mutu Ke
Skor 100% 100% 100%
120%
Target 100% 100% 100%
100%

80%

60%

40%

20%

0%
Februari 2022

Kepatuhan Jam Visite Dokter Spesialis Februari 2 Maret 202 Apr-22 Indikator Mutu
Skor 82.14% 80.92% 85.46%
Target 80% 80% 80% 86.00%
85.00%
84.00%
83.00%
82.00%
81.00%
80.00%
79.00%
78.00%
77.00%
Februari 2022

Kepatuhan Upaya Pencegahan Risiko

Cedera Akibat Pasien Jatuh pada pasien Indikator Mutu K
Rawat Inap Risiko Cedera Ak
Februari 2 Maret 2022 Apr-22
Skor 100% 100% 100%
Target 100% 100% 100% 120%

100%

80%

60%

40%

20%

0%
Februari 2022
 60%

40%

20%

0%
Februari 2022

Kepatuhan Terhadap Clinical Pathway Februari 2 Maret 202 Apr-22

Skor 100% 0% 0% Indikator Mutu K
Target 100% 0% 0%
120%

100%

80%

60%

40%

20%

0%
Februari 2022
 Indikator Mutu Kepatuhan Identifikasi Pasien
120%

100%

80%

60%

40%

20%

0%
Februari 2022 Maret 2022 April 2022.

Indikator Mutu Kepatuhan Jam Visite Dokter

Spesialis
86.00%
85.00%
84.00%
83.00%
82.00%
81.00%
80.00%
79.00%
78.00%
77.00%
Februari 2022 Maret 2022 April 2022.

Indikator Mutu Kepatuhan Upaya Pencegahan

Risiko Cedera Akibat Pasien Jatuh pada pasien
Rawat Inap
120%

100%

80%

60%

40%

20%

0%
Februari 2022 Maret 2022 April 2022.
60%

40%

20%

0%
Februari 2022 Maret 2022 April 2022.

Indikator Mutu Kepatuhan Terhadap Clinical

Pathway
120%

100%

80%

60%

40%

20%

0%
Februari 2022 Maret 2022 April 2022.
Indikator Mutu Harian (Lokal/Internal RS) - Desember 2021

No Indikator 1 2
100.0% 100.0%
1 Kepatuhan pemakaian masker pada pasien TB rawat inap dan penunggu pasien
12 12 8 8

100.0% 100.0%
2 Kepatuhan petugas dalam melakukan identifikasi dengan benar pada saat melakukan tindakan
9 9 6 6

100.0% 100.0%
3 Kepatuhan menggunakan metode TBK pada saat melakukan komunikasi lisan/ melalui telepon
9 9 6 6

100.0% 100.0%
4 Kepatuhan pelaksanaan pengecekan ganda pemberian obat-obatan high alert pada unit perawatan
9 9 6 6

0.0% 0.0%
5 Kejadian pasien jatuh di ruangan
0 9 0 6

Indikator Mutu Harian (Lokal/Internal RS) - January 2022

No Indikator 1 2
100.0% 100.0%
1 Kepatuhan pemakaian masker pada pasien TB rawat inap dan penunggu pasien
8 8 12 12

100.0% 100.0%
2 Kepatuhan petugas dalam melakukan identifikasi dengan benar pada saat melakukan tindakan
10 10 12 12

100.0% 100.0%
3 Kepatuhan menggunakan metode TBK pada saat melakukan komunikasi lisan/ melalui telepon
10 10 12 12

100.0% 100.0%
4 Kepatuhan pelaksanaan pengecekan ganda pemberian obat-obatan high alert pada unit perawatan
10 10 12 12

0.0% 0.0%
5 Kejadian pasien jatuh di ruangan
0 10 0 12
 3 4 5 6 7 8 9 10
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
8 8 8 8 8 8 8 8 10 10 10 10 16 16 12 12

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

8 8 8 8 8 8 9 9 10 10 8 8 13 13 13 13

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

8 8 8 8 8 8 9 9 10 10 8 8 13 13 13 13

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

8 8 8 8 8 8 9 9 10 10 8 8 13 13 13 13

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0 8 0 8 0 8 0 9 0 10 0 8 0 13 0 13

3 4 5 6 7 8 9 10
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
12 12 8 8 8 8 6 6 6 6 6 6 4 4 10 10

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

15 15 15 15 11 11 11 11 9 9 10 10 7 7 10 10

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

15 15 15 15 11 11 11 11 9 9 10 10 7 7 10 10

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

15 15 15 15 11 11 11 11 9 9 10 10 7 7 10 10

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0 15 0 15 0 11 0 11 0 9 0 10 0 7 0 10
 11 12 13 14 15 16 17 18
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
12 12 10 10 12 12 16 16 8 8 12 12 16 16 16 16

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

13 13 11 11 13 13 16 16 12 12 12 12 17 17 15 15

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

13 13 11 11 13 13 16 16 12 12 12 12 17 17 15 15

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

13 13 11 11 13 13 16 16 12 12 12 12 17 17 15 15

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0 13 0 11 0 13 0 16 0 12 0 12 0 17 0 15

11 12 13 14 15 16 17 18
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
12 12 12 12 12 12 16 16 18 18 16 16 16 16 10 10

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

7 7 9 9 11 11 11 11 12 12 14 14 16 16 11 11

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

7 7 9 9 11 11 11 11 12 12 14 14 16 16 11 11

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

7 7 9 9 11 11 11 11 12 12 14 14 16 16 11 11

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0 7 0 9 0 11 0 11 0 12 0 14 0 16 0 11
 19 20 21 22 23 24 25 26
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
16 16 20 20 12 12 14 14 10 10 12 12 10 10 12 12

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

16 16 20 20 12 12 12 12 10 10 11 11 9 9 10 10

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

16 16 20 20 12 12 12 12 10 10 11 11 9 9 10 10

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

16 16 20 20 12 12 12 12 10 10 11 11 9 9 10 10

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0 16 0 20 0 12 0 12 0 10 0 11 0 9 0 10

19 20 21 22 23 24 25 26
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
10 10 14 14 4 4 2 2 10 10 10 10 10 10 10 10

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

11 11 14 14 11 11 11 11 12 12 15 15 12 12 11 11

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

11 11 14 14 11 11 11 11 12 12 15 15 12 12 11 11

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

11 11 14 14 11 11 11 11 12 12 15 15 12 12 11 11

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0 11 0 14 0 11 0 11 0 12 0 15 0 12 0 11
 27 28 29 30 31
100.0% 100.0% 100.0% 100.0% 100.0%
18 18 20 20 18 18 14 14 10 10

100.0% 100.0% 100.0% 100.0% 100.0%

15 15 15 15 17 17 13 13 12 12

100.0% 100.0% 100.0% 100.0% 100.0%

15 15 15 15 17 17 13 13 12 12

100.0% 100.0% 100.0% 100.0% 100.0%

15 15 15 15 17 17 13 13 12 12

0.0% 0.0% 0.0% 0.0% 0.0%

0 15 0 15 0 17 0 13 0 12

27 28 29 30 31
100.0% 100.0% 100.0% 100.0% 100.0%
10 10 8 8 10 10 8 8 8 8

100.0% 100.0% 100.0% 100.0% 100.0%

7 7 5 5 6 6 6 6 5 5

100.0% 100.0% 100.0% 100.0% 100.0%

7 7 5 5 6 6 6 6 5 5

100.0% 100.0% 100.0% 100.0% 100.0%

7 7 5 5 6 6 6 6 5 5

0.0% 0.0% 0.0% 0.0% 0.0%

0 7 0 5 0 6 0 6 0 5