INDIKATOR MUTU

INDIKATOR MUTU RUMAH SAKIT

QUALITY INDICATORS of HOSPITAL

INDIKATOR MUTU NASIONAL
THE NATIONAL QUALITY INDICATORS

No

Judul Indikator (Indicators)
Standar (Standard)
Capaian (Achievements)

Justifikasi

(Justification)

Triwulan I (1st Quarterly)
Triwulan II (2nd Quarterly)
1 Kepatuhan identifikasi pasien
(Compliance identification of patient)
100% 100% 99,98% Tercapai
(Well done)
2 Emergency respon time pelayanan gawat darurat
(Emergency response time of emergency service)
100% 99,75% 99,97% Tercapai
(Well done)
3 Waktu tunggu rawat jalan

(Waiting time of ambulatory service)
100% 91,8% 76,1% a. Terdapat peningkatan pasien rawat jalan dari triwulan I ke triwulan II sebanyak 5%
b. Adanya regulasi baru bahwa pasien rawat jalan harus melakukan absen sidik jari dulu sebelum dilakukan
verifikasi kepesertaan.
a. There are 5% improvement the amount of ambulatory patient from first quarterly to second quarterly.
b. There is a new regulation of ambulatory patient is that they need to do fingerprint first before insurance verification.
4 Penundaan operasi elektif

(Postponement of elective operation)
5% 48,8% 1,19% Ini menunjukkan bahwa rencana tindak lanjut untuk penundaan operasi elektif telah berhasil
(It shown that hospital’s plan of action for postponement of elective operation is success)
5 Kepatuhan jam visite dokter spesialis

(Compliance visite hours of specialist doctors)
80% 81,03% 78,27% a. DPJP yang bukan dokter tetap di RSU Kertha Usada pada jam 08.00-14.00 masih pelayananan di Rumah Sakit lain.
b. DPJP visite mengikuti jadwal jam buka poliklinik sore.
c. DPJP ada seminar / Simposium kedokteran
a. Unpermanent specialists at Kertha Usada General Hospitals is still working at another hospital.
b. Specialists’ visit hours is depend on the opening hours of their afternoon polyclinic.
c. Specialists are attending seminar or symposium at that time
6 Waktu lapor hasil tes kritis laboratorium
(Time report of laboratory critical result)
100% 100% 100% Tercapai
Well done
7 Kepatuhan penggunaan formularium nasional bagi RS Provider BPJS
(Compliance the use of national formularium for hospital BPJS provider)
80% 98,2% 96,02% Tercapai
Well done
8 Kepatuhan Cuci tangan

(Compliance of washing hand)
85% 67,93% 63,5% Terkadang terdapat beberapa kondisi yang tidak memungkinkan untuk melakukan cuci tangan sebelum ke pasien, yaitu:
a. pasien yang terpasang ventilator tiba-tiba ingin melepas selang ETT.
b. Pasien dengan kasus gawat darurat
c. Pasien yang henti jantung.
Sometimes there are conditions that hand washing is impossible to do such as:
a. patient with ventilator who wants to release their endotracheal tube.
b. Patient with emergency case
c. Patient with cardiac arrest
9 Kepatuhan upaya pencegahan resiko cedera akibat pasien jatuh pada pasien rawat inap
(Compliance efforts to prevent risk of injury due to fall patient of hospitalization)
100% 100% 100% Tercapa
Well done
10 Kecepatan respon terhadap complain
(Response quickness to complaints)
>75% 99,91% 95,23% Tercapai
Well done
INDIKATOR MUTU PRIORITAS RUMAH SAKIT
THE HOSPITAL’S PRIORITY OF QUALITY INDICATORS
No

Judul Indikator (Indicators)
Standar (Standard)
Capaian (Achievements)

Justifikasi

(Justification)

Triwulan I (1st Quarterly) Triwulan II (2nd Quarterly)
1 Emergency Respon Time/ Waktu tanggap pelayanana Pasien Bedah di UGD ≤ 5 menit
(Emergency response time in Emergency Room ≤ 5 minutes)
100% 99,19% 99,88% Jumlah dokter jaga 2 orang, sedangkan 1 dokter harus melayani pasien on call
(General practitioner that work at UGD is 2 people and one of them should serving patients on call)
2 Kepatuhan Jam Visite dr. Spesialis Bedah

(Compliance visite hours of surgeon)
100% 82,75% 83,5% a. DPJP yang bukan dokter tetap di RSU Kertha Usada pada jam 08.00-14.00 masih pelayananan di Rumah Sakit lain.
b. DPJP visite mengikuti jadwal jam buka poliklinik sore.
c. DPJP ada seminar / Simposium kedokteran
a. Unpermanent specialists at Kertha Usada General Hospitals is still working at another hospital.
b. Specialists’ visit hours is depend on the opening hours of their afternoon polyclinic.
c. Specialists are attending seminar or symposium at that time
Persetujuan secara verbal oleh DPJP ke pasien sudah dilakukan dari pasien dijadwalkan operasi ketika di poliklinik yaitu kira kira 2-3 hari sebelum tindakan operasi dilakukan. Setelah mereka di rawat inap, perawat akan meminta ttd pasien dahulu kemudian DPJP akan melengkapi persetujuan di ruang operasi.
(Verbal Informed consent is done when the patient is scheduled in polyclinic more than 2-3 days before the surgery. When they inpatient, nurse will ask for patient’s sign first and the doctor complete the informed consent in the surgery room.)
3 Kelengkapan informed concent tindakan pembedahan

(Completeness of surgery informed consent)
100% 75,67% 63,41% Persetujuan secara verbal oleh DPJP ke pasien sudah dilakukan dari pasien dijadwalkan operasi ketika di poliklinik yaitu kira kira 2-3 hari sebelum tindakan operasi dilakukan. Setelah mereka di rawat inap, perawat akan meminta ttd pasien dahulu kemudian DPJP akan melengkapi persetujuan di ruang operasi.
(Verbal Informed consent is done when the patient is scheduled in polyclinic more than 2-3 days before the surgery. When they inpatient, nurse will ask for patient’s sign first and the doctor complete the informed consent in the surgery room.)
4 Kepatuhan pelaksanan prosedur site marking pada pasien yang akan dilakukan tindakan operasi
(Implementation compliance of site marking procedure for patient who will undergo a surgery)
100% 94,02% 91,44% Hal ini dikarenakan prosedur site marking dilakukan di ruang Ok, hal ini tidak sesuai dengan SPO yang berlaku
(It because site marking procedure is implemented at operating room which is not suitable with SOP)

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