Dr.

Grace Frelita, MM
Chief of Global Quality Development
Siloam International Hospitals
 1. Kebersihan. 6. Tersedianya Dokter
Spesialis
2. Kelancaran Proses
Pendaftaran Pasien & 7. Data Medical Record
Pasien Pulang. Lengkap

3. Staf Rumah Sakit yang 8. Penanganan Gawat

Sopan terutama Waktu Darurat
Menanggapi Telepon &
Permintaan Pasien 9. Harga Terjangkau & Data
Biling Jelas & Akurat.
4. Kecanggihan Tehnologi
10. Rasa dan Kehangatan
5. Kemampuan Para Perawat Makanan

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 1. Kebersihan Rumah Sakit
 Pencegahan Infeksi
 Kenyamanan dan Keindahan
 Aroma dan kesegaran udara
 Keselamatan

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 2. Kelancaran Proses Pendaftaran Pasien Rawat Inap dan
Pasien Pulang

 Proses Rawat Jalan Inap15

menit

 Proses Pemulangan
Pasien30 Menit

4
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 3. Staf Rumah Sakit yang Sopan

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  Menerima telepon dalam 3 (tiga) deringan
 Nine Golden Rules

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 4. Kecanggihan Teknologi
 Sesuai dengan kebutuhan
 Berdasarkan hasil penelitian
 Legal
 Mutakhir

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 5. Kemampuan Para Perawat

Skill, Knowledge &

Communication
 CME
 EBSCO e-Learning
 Penelitian Keperawatan

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 6. Tersedianya Dokter Spesialis
 Terjadwal
 Pendaftaran Langsung
 Perjanjian

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 7. Data Medical Record yang Lengkap
SHAA SHBB SHCC SHDD
Clinical Quality Indicators Target
2008 2009 2010 2008 2009 2010 2008 2009 2010 2008 2009 2010

MS1 - Drs' OPD

100% 66% 66% 93% 28% 61% 56% 0% 93% 97% 79% 73% 98%
Attendance
MS2 - Completed OPD
100% 98% 99% 99% 0% 81% 84% 86% 79% 75% 34% 66% 81%
Notes
MS3 - Completed
100% 99% 99% 100% 0% 85% 81% 76% 92% 97% 0% 74% 91%
Informed Consent

MS4 - Drs' IPD Visits 100% 92% 75% 100% 91% 60% 82% 0% 0% 89% 81% 90% 80%

MS5 - Drs' IPD

100% 90% 88% 100% 73% 79% 80% 86% 79% 80% 85% 92% 88%
Assessment
MS6 - Completed
100% 97% 98% 99% 34% 65% 55% 28% 27% 40% 58% 56% 90%
Discharge Forms

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 8. Penanganan Gawat Darurat yang Baik
Siloam Hospitals Group
ETC SERVICE & QUALITY INDICATORS June 2011
FACILITY & SERVICE QUALITY TARGET SHAA SHBB SHCC SHDD SHEE
% of time Ambulance 1 utilized for non-emergency cases < 1% 3.90% 0.00% 9.09% 0.00% n/a
% of time Ambulance 2 utilized for non-emergency cases < 10% 1.30% 5.00% 90.90% 0.00% n/a
Number of abandoned calls < 1.5% 0.26% 2.46% n/a n/a n/a
Average time to collect emergency call data < 1.5 minutes 0:01:32 0.11% n/a n/a n/a
Average time to depart hospital from time emergency call ends < 3 minutes 0:04:51 0:01:34 0:04:50 0:00:44 n/a
CLINICAL SERVICE QUALITY
Average time taken for ambulance doctor to contact patient/caller from time of original patient call 6 minutes 03:37 03:42 03:00 n/a n/a
Average Time of arrival to location from time of original patient call 12 minutes (Zone 1) 0:11:19 0:00:00 0:21:00 0:51:20 n/a
Pre-hospital care - Documentation of patient vital signs & assessment >95% 100.00% 100.00% 100.00% 86.36% n/a
% of Triage 3 Patients seen in ETC 20% 28.93% 2.83% 40.98% 0.00% n/a
ACS & Stroke pathway documentation >95% n/a 100.00% 100.00% n/a n/a
Acute CoronarySyndrome - Presentation average time to ECG time (diagnosis) 5 minutes n/a 00:02:00 00:07:00 0:01:50 n/a
Acute CoronarySyndrome - Average Door to Needle time (treatment) 1.5 hours n/a n/a n/a n/a n/a
Stroke Patients - Average Presentation time to CT / MRI 60 minutes n/a 00:30:22 02:01:00 0:32:08 n/a
Stroke Patients - Average Presentation time to contact Specialist time 15 minutes n/a 00:37:18 01:45:00 0:37:30 n/a
Medical Specialist On-call roster complete > 95% 100.00% 100.00% 100.00% 100.00% n/a
ETC MEDICAL TEAM PREPAREDNESS
% ETC nurses in LV that have completed EMT Basic 70% of total nurs. num 86.36% 63.16% 72.73% 66.67% n/a
% ETC nurses in LV that have completed EMT Intermediate 45% of total nurs. num 31.82% 52.63% 36.36% 38.10% n/a
% ETC nurses in LV that have completed EMT Paramedic 20% of total nurs. num 18.18% 10.53% n/a n/a n/a
Mock Drills in LV conducted per month 4 mock drills/mth n/a 4 1 2 n/a
LV ETC RMO (inclusive of all RMO's rotating through ETC) attendance at minimum 2 CME per month
& 1 additional training program per month (E-Learning, case presentation) >85% n/a 100.00% 91.66% 100.00% n/a

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 9. Harga Terjangkau& Data Billing yang Jelas dan
Akurat

High GOR
Low Pricing
High Scale Low Margin High Quality
Structure
High Competency

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  Kepastian Biaya
 Keterbukaan komponen biaya
 Akurasi Tagihan
 Kecepatan

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 10. Rasa dan Kehangatan Makanan
 Memastikan pasien menerima makanan yang cukup
 Nutrisi yang baik dan tepat
 Suhu makanan
 Penyajian yang menarik

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 TERIMA KASIH

grace frelita / Jabar / 13 Juli 2012