Indikator Mutu Nasional 20

No Unit Pelayanan Indikator Target Jan-22 Feb-22 Mar-22

1 Komite PPI Kepatuhan Kebersihan Tangan >=85% 99.86% 99.57 98.49%

2 Komite PPI Kepatuhan Penggunaan APD 100% 99% 100% 100%

Perina dan Perawatan

3 Anak lt.4
Ketepatan Identifikasi Pasien 100% 100% 100% 100%

Waktu tanggap Operasi Seksio

4 IGD Kebidanan
Sesarea Emergensi
>=80% 83.33% 83.33% 87.5%

5 Rawat Jalan Waktu Tunggu Rawat Jalan >=80% 85.09% 80.23% 82.94%

6 Kamar Operasi Penundaan operasi elektif <5% 0% 0% 0%

7 Rawat Inap Kepatuhan waktu visite dokter ≥80% 100% 100% 100%

8 Laboratorium Pelaporan Hasil Kritis Laboratorium 100% 100% 100% 100%

Kepatuhan Penggunaan
9 Farmasi Formularium Nasional/Formularium >=80% 89.70% 85.00% 86.11%
RS

Kepatuhan terhadap clinical

10 Rawat Inap pathway
(>=80%) 100% 100% 100%

Perina dan Perawatan Kepatuhan upaya pencegahan risiko

11 Anak Lt.4 pasien jatuh (100%)
100% 100% 100% 100%

Kecepatan Waktu Tanggap

12 Humas Terhadap Komplain
>=80% 100% 100% 100%
13 Komite PMKP Kepuasan Pasien >76.61% 90% 91% 89.46%
r Mutu Nasional 2022
Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22

98.5% 100% 100% 100% 100% 100%

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

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

86.67% 91.67% 93.33% 92.31% 92.86% 92.86%

85.7% 88.57% 86.44% 81.08% 80.35% 80.82%

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

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

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

76.43% 82.16% 81.03% 80.98%

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

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

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

89% 90% 87.48% 89.6% 99.68% 99.68%