June 20, 2008

gr

persalinan
Project

Eklamsi/Preeklamsi
persalinan perdarahan
Criteria

Survival rate BBLSR <1500

Kejadian kematian ibu karena

Kejadian kematian ibu karena

1 = Low or no problems
Problem Prone in 3 = Medium or moderate problems
30
90
90

Organization=10
9 = High or frequent problems

1 = Low or no relationship
Relates to patient 3 = Moderate relationship
72
72
72

satisfaction=8
9 = High relationship

1 = Low volume
mission of
associated
area

High volume event 3 = Moderate Volume

Is this project

organnization?

27
27
81
project

=9
9 = High Volume
the
Is the clearly

1 = Low or not related

serious threat to
Project Prioritization Matrix

thethat presents
with addressing

Related to a
target forIsthis

3 = Moderately related
project

7
7

standard required
21

for accreditation=7
9 = Directly related; element of performance
patient safety? patient safety?
serious threat to

9 = Low or eacy to measure

areaa that presents a
the target for this
an addressing an

Easy to Measure=6 3 = Moderately difficult to measure

54
54
54

1 =Difficult to measure
0
0
0
0
0
0
0
0
0

Priority Score (Max = 108; Min = 12

190
250
318

1
June 20, 2008
menit
Project

Emergency
Criteria

Angka Kematian
di Gawat Darurat
Respon Time ≤ 5
1 = Low or no problems
Problem Prone in 3 = Medium or moderate problems

90
90
Organization=10
9 = High or frequent problems

1 = Low or no relationship
Relates to patient 3 = Moderate relationship

72
72

satisfaction=8
9 = High relationship

1 = Low volume
mission of
associated
area

High volume event 3 = Moderate Volume

Is this project

27
81
organnization?
project

=9
9 = High Volume
the
Is the clearly

1 = Low or not related

serious threat to
thethat presents
with addressing

Related to a
target forIsthis

standard required 3 = Moderately related

project

21
63
patient safety? safety?
Project Prioritization Matrix

for accreditation=7
9 = Directly related; element of performance

9 = Low or eacy to measure

areaa that presents a
the target for this
an addressing an

Easy to Measure=6 3 = Moderately difficult to measure

54
54
serious threat to patient

1 =Difficult to measure

Priority Score (Max = 108; Min = 12

264
360

2
June 20, 2008
hasil

menit
prosedur
Kepatuhan
Project

kalibrasi alat

pemeriksaan
POCT sesuai

lebih dari 120

Waktu tunggu
Criteria

kima darah tidak

1 = Low or no problems
Problem Prone in 3 = Medium or moderate problems

30
90
Organization=10
9 = High or frequent problems

1 = Low or no relationship
Relates to patient 3 = Moderate relationship

72
18

satisfaction=8
9 = High relationship

1 = Low volume
mission of
associated
area

High volume event 3 = Moderate Volume

9
Is this project

27
organnization?
project

=9
9 = High Volume
the
Is the clearly

1 = Low or not related

serious threat to
thethat presents
with addressing

Related to a
target forIsthis

standard required 3 = Moderately related

project

63
63
patient safety? safety?
Project Prioritization Matrix

for accreditation=7
9 = Directly related; element of performance

9 = Low or eacy to measure

areaa that presents a
the target for this
an addressing an

Easy to Measure=6 3 = Moderately difficult to measure

18
54
serious threat to patient

1 =Difficult to measure

Priority Score (Max = 108; Min = 12

210
234

3
June 20, 2008
Project

kritis Radiologi

Radiologi ≤ 75 menit
Waktu lapor Hasil Test

Waktu tunggu pelayanan

Criteria

radiologi CITO < 60 menit &

Waktu tunggu pemeriksaan
1 = Low or no problems
Problem Prone in 3 = Medium or moderate problems

90
90
Organization=10
9 = High or frequent problems

1 = Low or no relationship
Relates to patient 3 = Moderate relationship
72
72

satisfaction=8
9 = High relationship

1 = Low volume
mission of
associated
area

High volume event 3 = Moderate Volume

9
9
Is this project

organnization?
project

=9
9 = High Volume
the
Is the clearly

1 = Low or not related

Project Prioritization Matrix

serious threat to
thethat presents
with addressing

Related to a
target forIsthis

standard required 3 = Moderately related

project

21
63

for accreditation=7
9 = Directly related; element of performance
patient safety? patient safety?
serious threat to

9 = Low or eacy to measure

areaa that presents a
the target for this
an addressing an

Easy to Measure=6 3 = Moderately difficult to measure

54
54

1 =Difficult to measure

Priority Score (Max = 108; Min = 12

246
288

4
 9 = Directly related; element of performance
Project Prioritization Matrix

Easy to Measure=6 3 = Moderately difficult to measure

3 = Medium or moderate problems

Priority Score (Max = 108; Min = 12

9 = High or frequent problems

9 = Low or eacy to measure

1 = Low or no relationship
Relates to patient 3 = Moderate relationship
1 = Low or no problems

standard required 3 = Moderately related

1 =Difficult to measure
1 = Low or not related
High volume event 3 = Moderate Volume
9 = High relationship

9 = High Volume
1 = Low volume
Criteria Is this project
Is the clearly
associated
project
target forIsthis
with addressing
the
the target for this
project
an addressing an

for accreditation=7
Problem Prone in
Organization=10
mission of
area
thethat presents
areaa that presents a

satisfaction=8
organnization?
serious threat toserious threat to

Related to a
patient safety? patient safety?

=9
Project

Waktu Tunggu Obat Jadi 0

Kelengkapan label obat &

Kesesuaian dengan resep 0

Review Resep dilaporkan tiap

Bulan 0

Penggantian Obat Trolley

emergency <3 Jam

Penyimpanan Obat High Alert

di ruangan 0

Elektrolit pekat ditemukan di

ruangan yang ditentukan 0
tidak boleh menyimpan

Penyimpanan dan pelabelan

obat LASA 0
Penulisan Resep sesuai
Formularium Nasional 0
0
0
0
0
0
June 20, 2008 5
June 20, 2008
Project

IBS (elemen lengkap)

IBS (elemen lengkap)

Instruksi Pasca Operasi

Criteria

sebelum pasien keluar dari

sebelum pasien keluar dari
Laporan Operasi dilengkapi
1 = Low or no problems
Problem Prone in 3 = Medium or moderate problems

90
90
Organization=10
9 = High or frequent problems

1 = Low or no relationship
8 Relates to patient 3 = Moderate relationship
8

satisfaction=8
9 = High relationship

1 = Low volume
mission of
associated
area

High volume event 3 = Moderate Volume

Is this project

organnization?

27
81
project

=9
9 = High Volume
the
Is the clearly
Project Prioritization Matrix

1 = Low or not related

serious threat to
thethat presents

Related to a
with addressing
target forIsthis

standard required 3 = Moderately related

63
63
project

for accreditation=7
9 = Directly related; element of performance
patient safety? patient safety?

9 = Low or eacy to measure

serious threat to
areaa that presents a
the target for this
an addressing an

Easy to Measure=6 3 = Moderately difficult to measure

54
54

1 =Difficult to measure

Priority Score (Max = 108; Min = 12

188
242

6
June 20, 2008
Project

ICU< 72 jam
Pneumonia (VAP)
Ventilator Associated
Criteria

Rata-rata pasien kembali ke

1 = Low or no problems
Problem Prone in 3 = Medium or moderate problems
90
90

Organization=10
9 = High or frequent problems

1 = Low or no relationship
Relates to patient 3 = Moderate relationship
72
24

satisfaction=8
9 = High relationship

1 = Low volume
mission of
associated
area

High volume event 3 = Moderate Volume

9
9
Is this project

organnization?
project

=9
9 = High Volume
the
Is the clearly
Project Prioritization Matrix

1 = Low or not related

serious threat to
thethat presents

Related to a
with addressing
target forIsthis

standard required 3 = Moderately related

63
63
project

for accreditation=7
9 = Directly related; element of performance
patient safety? patient safety?

9 = Low or eacy to measure

serious threat to
areaa that presents a
the target for this
an addressing an

Easy to Measure=6 3 = Moderately difficult to measure

54
54

1 =Difficult to measure
0
0
0
0
0
0
0
0
0

Priority Score (Max = 108; Min = 12

288
240

7
June 20, 2008
practice

Unggulan
Project

alat medik sesuai best

Jumlah layanan Medik

Criteria

Terpenuhinya kebutuhan

1 = Low or no problems
Problem Prone in 3 = Medium or moderate problems
Organization=10
9 = High or frequent problems

1 = Low or no relationship
Relates to patient 3 = Moderate relationship
satisfaction=8
9 = High relationship

1 = Low volume
mission of
associated
area

High volume event 3 = Moderate Volume

Is this project

organnization?
project

=9
9 = High Volume
the
Is the clearly
Project Prioritization Matrix

1 = Low or not related

serious threat to
thethat presents

Related to a
with addressing
target forIsthis

standard required 3 = Moderately related

project

for accreditation=7
9 = Directly related; element of performance
patient safety? patient safety?

9 = Low or eacy to measure

serious threat to
areaa that presents a
the target for this
an addressing an

Easy to Measure=6 3 = Moderately difficult to measure

1 =Difficult to measure
0
0
0

Priority Score (Max = 108; Min = 12

8
June 20, 2008
Project

keperawatan.
Persentase tenaga

Terlaksananya Audit
Surat Penugasan Klinis
Criteria

keperawatan yang memiliki

1 = Low or no problems
Problem Prone in 3 = Medium or moderate problems

0
0
Organization=10
9 = High or frequent problems

1 = Low or no relationship
Relates to patient 3 = Moderate relationship
0
0

satisfaction=8
9 = High relationship

1 = Low volume
mission of
associated
area

High volume event 3 = Moderate Volume

0
0
Is this project

organnization?
project

=9
9 = High Volume
the
Is the clearly
Project Prioritization Matrix

1 = Low or not related

serious threat to
thethat presents

Related to a
with addressing
target forIsthis

0
0

standard required 3 = Moderately related

project

for accreditation=7
9 = Directly related; element of performance
patient safety? patient safety?

9 = Low or eacy to measure

serious threat to
areaa that presents a
the target for this

0
0
an addressing an

Easy to Measure=6 3 = Moderately difficult to measure

1 =Difficult to measure
0
0

Priority Score (Max = 108; Min = 12

9
June 20, 2008
medik )
Project

Angka ILO
poliklinik tepat waktu
Persentase jam buka
(Monitoring implementasi
Criteria

clinical pathway/ PPK/PPT

Waktu tunggu di rawat jalan

Tingkat kepuasan pelanggan

1 = Low or no problems
Problem Prone in 3 = Medium or moderate problems
30
90
90

Organization=10
9 = High or frequent problems

1 = Low or no relationship
Relates to patient 3 = Moderate relationship
8
8

24

satisfaction=8
9 = High relationship

1 = Low volume
mission of
associated
area

High volume event 3 = Moderate Volume

Is this project

organnization?

27
27
27
project

=9
9 = High Volume
the
Is the clearly
Project Prioritization Matrix

1 = Low or not related

serious threat to
thethat presents

Related to a
with addressing
target forIsthis

standard required 3 = Moderately related

63
63
63
project

for accreditation=7
9 = Directly related; element of performance
patient safety? patient safety?

9 = Low or eacy to measure

serious threat to
areaa that presents a
the target for this

Easy to Measure=6 3 = Moderately difficult to measure

an addressing an

54
54
18

1 =Difficult to measure
0
0
0
0
0
0
0
0
0

Priority Score (Max = 108; Min = 12

182
258
206

10
 9 = Directly related; element of performance
Project Prioritization Matrix

Easy to Measure=6 3 = Moderately difficult to measure

Problem Prone in 3 = Medium or moderate problems

Priority Score (Max = 108; Min = 12

9 = High or frequent problems

9 = Low or eacy to measure

1 = Low or no relationship
Relates to patient 3 = Moderate relationship
1 = Low or no problems

standard required 3 = Moderately related

1 =Difficult to measure
1 = Low or not related
High volume event 3 = Moderate Volume
9 = High relationship

9 = High Volume
1 = Low volume
Criteria Is this project
Is the clearly
associated
project
target forIsthis
with addressing
the
the target for this
project
an addressing an

for accreditation=7
Organization=10
mission of
area
thethat presents
areaa that presents a

satisfaction=8
organnization?
serious threat toserious threat to

Related to a
patient safety? patient safety?

=9
Project

LOS (Length of Stay) Rawat

Inap 30 24 9 63 6 132

Jam visite Dokter Spesialis 90 24 81 63 54 312

Tidak adanya kejadian pasien

jatuh 30 24 27 63 54 198

Kelengkapan Informed
Consent
Informed consent prosedur
(tindakan) terisi saat 0
ditandatangani pasien
Kelengkapan Pengisian
formulir transfer Internal 0
Ketepatan Jam visite Dokter
Spesialis 0
Kepatuhan Penggunaan CP 0
Angka ILO 0
0
0
0
0
June 20, 2008 11
June 20, 2008
Project

pasien terhadap
pasien terhadap

Kejadian drop out

Kejadian drop out

yang direncanakan
yang direncanakan
Criteria

pelayanan rehabilitasi
pelayanan rehabilitasi

1 = Low or no problems
Problem Prone in 3 = Medium or moderate problems
Organization=10
9 = High or frequent problems

1 = Low or no relationship
Relates to patient 3 = Moderate relationship
satisfaction=8
9 = High relationship

1 = Low volume
mission of
associated
area

High volume event 3 = Moderate Volume

Is this project

organnization?
project

=9
9 = High Volume
the
Is the clearly
Project Prioritization Matrix

1 = Low or not related

serious threat to
thethat presents

Related to a
with addressing
target forIsthis

standard required 3 = Moderately related

project

for accreditation=7
9 = Directly related; element of performance
patient safety? patient safety?

9 = Low or eacy to measure

serious threat to
areaa that presents a
the target for this
an addressing an

Easy to Measure=6 3 = Moderately difficult to measure

1 =Difficult to measure
0
0
0

Priority Score (Max = 108; Min = 12

12
June 20, 2008
menit
POTAS)
Project

menit (tidak termasuk

rekam medik pelayanan

Utama lantai 1 dan 2 ≤ 15

Criteria

Waktu pelayanan LIRI ≤ 30

rawat jalan di klinik Gedung
Waktu penyediaan dokumen

1 = Low or no problems
Problem Prone in 3 = Medium or moderate problems
Organization=10
9 = High or frequent problems

1 = Low or no relationship
Relates to patient 3 = Moderate relationship
satisfaction=8
9 = High relationship

1 = Low volume
mission of
associated
area

High volume event 3 = Moderate Volume

Is this project

organnization?
project

=9
9 = High Volume
the
Is the clearly
Project Prioritization Matrix

1 = Low or not related

serious threat to
thethat presents

Related to a
with addressing
target forIsthis

standard required 3 = Moderately related

project

for accreditation=7
9 = Directly related; element of performance
patient safety? patient safety?

9 = Low or eacy to measure

serious threat to
areaa that presents a
the target for this
an addressing an

Easy to Measure=6 3 = Moderately difficult to measure

1 =Difficult to measure
0
0

Priority Score (Max = 108; Min = 12

13
June 20, 2008
practice
Project

Gizi sesuai dengan best

(sesuai dengan Instruksi)

Criteria

pemberian makan ke pasien

Persentase ketepatan waktu
Persentase pemenuhan SPA
1 = Low or no problems
Problem Prone in 3 = Medium or moderate problems
Organization=10
9 = High or frequent problems

1 = Low or no relationship
Relates to patient 3 = Moderate relationship
satisfaction=8
9 = High relationship

1 = Low volume
mission of
associated
area

High volume event 3 = Moderate Volume

Is this project

organnization?
project

=9
9 = High Volume
the
Is the clearly

1 = Low or not related

Project Prioritization Matrix

serious threat to
thethat presents
with addressing

Related to a
target forIsthis
project

standard required 3 = Moderately related

for accreditation=7
9 = Directly related; element of performance
patient safety? patient safety?
serious threat to

9 = Low or eacy to measure

areaa that presents a
the target for this
an addressing an

Easy to Measure=6 3 = Moderately difficult to measure

1 =Difficult to measure
0
0

Priority Score (Max = 108; Min = 12

14
 Project Prioritization Matrix

9 = Directly related; element of performance

Easy to Measure=6 3 = Moderately difficult to measure

Problem Prone in 3 = Medium or moderate problems

Priority Score (Max = 108; Min = 12

9 = High or frequent problems

9 = Low or eacy to measure

1 = Low or no relationship
Relates to patient 3 = Moderate relationship
1 = Low or no problems

standard required 3 = Moderately related

1 =Difficult to measure
1 = Low or not related
High volume event 3 = Moderate Volume
9 = High relationship

9 = High Volume
1 = Low volume
Criteria Is this project
Is the clearly
associated
project
target forIsthis
with the
addressing
the target for this
project
an addressing an

for accreditation=7
Organization=10
mission of
area
thethat presents
areaa that presents a

satisfaction=8
organnization?
serious threat toserious threat to

Related to a
patient safety? patient safety?

=9
Project

Tidak terjadi kegagalan dalam

proses sterilisasi

Ketepatan waktu sterilisasi

dengan suhu tinggi/autoclave
(150menit manual & 220 menit
mechanical), suhu rendah/ Eto
2x24 jam

Temuan parameter mutu alat

steril yang tidak sesuai standar
Mikrobiolog yang ditindaklanjuti

Temuan supervisi penanganan

decontaminasi, alat steril, single-
use yang di re-use yang
ditindaklanjuti

June 20, 2008 15

June 20, 2008
Project

(downtime)

piranti lunak
Response time keluhan
Criteria

Frekuensi koneksi terputus

1 = Low or no problems
Problem Prone in 3 = Medium or moderate problems
Organization=10
9 = High or frequent problems

1 = Low or no relationship
Relates to patient 3 = Moderate relationship
satisfaction=8
9 = High relationship

1 = Low volume
mission of
associated
area

High volume event 3 = Moderate Volume

Is this project

organnization?
project

=9
9 = High Volume
the
Is the clearly
Project Prioritization Matrix

1 = Low or not related

serious threat to
thethat presents

Related to a
with addressing
target forIsthis

standard required 3 = Moderately related

project

for accreditation=7
9 = Directly related; element of performance
patient safety? patient safety?

9 = Low or eacy to measure

serious threat to
areaa that presents a
the target for this

Easy to Measure=6 3 = Moderately difficult to measure

an addressing an

1 =Difficult to measure
0
0
0
0
0
0
0
0
0
0
0
0
0

Priority Score (Max = 108; Min = 12

16
June 20, 2008
Project

lanjuti
Criteria

yang dilaporkan ≤ 48 jam

KTD/sentinel yang ditindak
Presentase laporan insiden

Jumlah pelaporan insiden KTD

1 = Low or no problems
Problem Prone in 3 = Medium or moderate problems

90
90
Organization=10
9 = High or frequent problems

1 = Low or no relationship
Relates to patient 3 = Moderate relationship

72
24
satisfaction=8
mission of
associated

9 = High relationship
area
Is this project

organnization?
project

1 = Low volume
with the
Is theclearly

High volume event 3 = Moderate Volume

27
27

=9
serious threat to

9 = High Volume
thethat presents
addressing
Project Prioritization Matrix

target forIsthis
project

1 = Low or not related

Related to a
standard required 3 = Moderately related
63
63
patient safety? patient safety?
serious threat to

for accreditation=7
9 = Directly related; element of performance
areaa that presents a
the target for this
an addressing an

9 = Low or eacy to measure

Easy to Measure=6 3 = Moderately difficult to measure

54
54

1 =Difficult to measure

Priority Score (Max = 108; Min = 12

306
258

17
June 20, 2008
Project

medik / klinik
Rekredensial

yang di monev
profesionalnya
dilakukan Kredensial -

Persentase kepatuhan
Persentase tenaga medis
Criteria

terhadap pembuatan 6 audit

Persentase tenaga medis yg

1 = Low or no problems
Problem Prone in 3 = Medium or moderate problems
Organization=10
9 = High or frequent problems

1 = Low or no relationship
Relates to patient 3 = Moderate relationship
satisfaction=8
9 = High relationship

1 = Low volume
mission of
associated
area

High volume event 3 = Moderate Volume

Is this project

organnization?
project

=9
9 = High Volume
the
Is the clearly
Project Prioritization Matrix

1 = Low or not related

serious threat to
thethat presents

Related to a
with addressing
target forIsthis

standard required 3 = Moderately related

project

for accreditation=7
9 = Directly related; element of performance
patient safety? patient safety?

9 = Low or eacy to measure

serious threat to
areaa that presents a
the target for this
an addressing an

Easy to Measure=6 3 = Moderately difficult to measure

1 =Difficult to measure
0
0
0

Priority Score (Max = 108; Min = 12

18
 Project Prioritization Matrix

9 = Directly related; element of performance

Easy to Measure=6 3 = Moderately difficult to measure

3 = Medium or moderate problems

9 = High or frequent problems

9 = Low or eacy to measure

1 = Low or no relationship

3 = Moderate relationship
1 = Low or no problems

standard required 3 = Moderately related

1 =Difficult to measure
1 = Low or not related
3 = Moderate Volume
9 = High relationship

9 = High Volume
1 = Low volume
Criteria Is this project
Is the clearly
associated
project
target forIs
with addressing
the
this
the target for this
project
an addressing an

for accreditation=7
High volume event

Priority Score
mission of
area
thethat presents
area
a that presents a

Relates to patient
Problem Prone in
Organization=10
organnization?
serious threat toserious
patientthreat to patient
safety? safety?

satisfaction=8

Related to a
Project

=9
Tindak lanjut Penanganan
pelaporan insiden 2 X 24 jam
30 72 27 63 6 198

Ketepatan waktu pelaporan

capaian indikator RS
30 72 81 21 54 258
Persentase rekomendasi
capaian indikator
90 24 27 63 18 222
Telusur 8 bab Akreditasi
SNARS ed 1, pertriwulan 90 72 81 63 54 360
tercapai 100%

19
 KAMUS INDIKATOR MUTU UNIT KERJA
(KOMITE MUTU)

a Judul Indikator: Telusur 8 Bab Akreditasi SNARS ed 1, pertriwulan tercapai 100%

Melaksanakan telusur Dokumen dan telusur lapangan dengan membandingkan kesesuaian

b Definisi: realisasi pelaksanaan dilapangan dengan standar akreditasi

Tujuan: Peningkatan Mutu Pelayanan

c Tujuan dan Dimensi mutu: Dimensi Mutu: Proees, Output dan Outcome

Untuk menjamin terlaksananya pelayanan sesuai Standar Akreditasi sehingga akan

meningkatkan Mutu Pelayanan dan Keselamatan Pasien, serta menjadikan pelaksanaan
Dasar pemikiran/Alasan pekerjaan sesuai standar Akreditasi adalah budaya kerja, bukan hanya pada saat Survei
d
pemilihan indikator: Akreditasi oleh KARS.

Numerator: Jumlah telusur dalam 3 bulan

Denominator: Jumlah target bab akreditasi yang akan ditelusur dalam 3 bulan (8 bab)
e
Jumlah telusur dalam 3 bulan X 100%
Formula Pengukuran:
Jumlah target bab akreditasi yang akan ditelusur dalam 3 bulan (8 bab)

f Metode Pengumpulan Data: Concurrent

Cakupan Data/Wilayah
g Semua unit kerja RSAB Harapan Kita
pengamatan:
Frekuensi Pengumpulan
h Triwulan
Data:

i Frekuensi analisis data: Triwulan

Metodologi Analisis Data:

j Sampel: Tidak Melakukan Sampling

Rencana Analisis: Menggunakan Diagram Garis

k Sumber Data: Formulir pencatatan telusur dokumen dan lapangan sesuai SNARS ed 1

Penanggung Jawab Pengumpul Data:

l Penanggung Jawab Data: drg. M. Syafrudin HaK, Sp.BM(K).,MPH.,Ph.D

Pengumpul Data: Sri Endah Setyaningrum, SKM

 Internal : Rapat internal
m Publikasi Data Pimpinan RS : 1x /setiap 3 bulan

n Target Capaian Tahun 2021= 100%