materi pmkp

8/18/2019 MATERI PMKP

1/118

PENINGKATANMUTU DAN

KESELAMATANPASIEN (PMKP)

LUWIHARSIH

KOMISI AKREDITASIRS dr Luwi - PMKP 2 juni 2013 1


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I. KELOMPOKSTANDAR

PELAYANAN

BERFOKUS PADAPASIEN

II. KELOMPOKSTANDAR

MANAJEMEN RS

IV. SASARANPROGRAM MDG’S

III. SASARANKESELAMATAN

PASIEN

STANDARAKREDIT

ASIVERSI2012

JCIEDIS

IIVTH2011

dr Luwi - PMKP 2 juni 2013 2


3/118

II.KELOMPOKSTANDAR MANAJEMEN

RSN BABI P!"#"$%&'&" M'

K!*!+&,&'&" P&*#!"PMK

P

II P!"-!$&&" /&" P!"$!"/&+#&"

I"!%*#

PPI

III T&'& K!++& K!!,#,#"&" /&"P!"$&3&&"

TKP

IV M&"&4!,!" F&*#+#'&* /&"

K!*!+&,&'&"

MFK

V K&+#5%&*# /&" P!"/#/#%&" S'& KPS

VI M&"&4!,!" K,"#%&*# /&"I"3,&*#

MKI



4/118

STD

E+!,!"P!"#+&" BUKTI

IMPLEMENTASI61. W&7&"-&3&

&*#!" *'& #,#"&"2. O8*!39&*#:. D%,!"

P!+&%*&"&&"

REGULASI 6•

K!8#4&%&";SK • P!/,&"• SPO• P3$3&,

• SKOR < 10 TERCAPAI

PENUH

• SKOR = TERCAPAI

SEBAGIAN

• SKOR 0 TIDAK

TERCAPAI

• TIDAKAPLIKABEL



5/118

PENINGKATAN MUTUDAN KESELAMATAN

PASIEN (PMKP)



6/118

A& #' M'>

M' 8!3*#&' !3*!*# /&"/#&&,# 8!38!/& +!3&"$ ?&"$ 8!38!/& "&,"

8!3#,+#%&*# &/&*!3#3#'&* *!*&' &+.

P!"#+&" #"/#%&'3 /&&'

/#$"&%&" "'% ,!"#+,' 8!38&$ %"/#*#.



7/118

A& #' P!"#"$%&'&"M'>

D&+&, %&,* ,&"&+ S'&"/&3/ JCI6

P!"/!%&'&" '!3&/& 3*!*

!,8!+&4&3&" /&" 3*!* !38%&"?&"$ '!3* ,!"!3* /&3# 3*!*

!"?!/#&&" !+&?&"&" %!*!&'&"

*!* %!8'&" &*#!" /&" #&%2

?&"$ 8!3%!!"'#"$&" +""?&.



8/118

A& #' P!"#"$%&'&"M'>

Perbaikan kualitas secara

terus menerus, perbaikan yang

terus menerus, perbaikan

kinerja di tingkat RS dan

manajemen mutu total.



9/118

APA ITU KESELAMATANPASIEN RS

K!*!+&,&'&" &*#!" RS &/&+& *&' *#*'!,/#,&"& RS ,!,8&' &*&" &*#!" +!8#&,&" ?&"$ ,!+#'# &*!*,!" 3#*#%#/!"'#5%&*# /&" !"$!++&&" &+ ?&"$8!38"$&" /!"$&" 3#*#% &*#!"!+&3&" /&" &"&+#*#* #"*#/!" %!,&,&"8!+&4&3 /&3# #"*#/!" /&" '#"/&% +&"4'"?&*!3'& #,+!,!"'&*# *+*# "'%,!,#"#,&+%&" '#,8+"?& 3#*#% /&"

,!"-!$& '!34&/#"?& -!/!3& ?&"$/#*!8&8%&" +! %!*&+&&" &%#8&',!+&%*&"&%&" *&' '#"/&%&" &'& '#/&%,!"$&,8#+ '#"/&%&" ?&"$ *!&3*"?&/#&,8#+.



10/118

APA ITU INSIDEN KESELAMATANPASIEN

Inid!n "!!#$%$&$n '$i!n (IKP)$d$#$* !&i$' "!j$di$n +, &id$"di!n,$j$ ".ndii +,

%!n,$"i/$&"$n $&$u /!r'.&!ni%!n,$"i/$&"$n !d!r$ +, d$'$&di!,$* '$d$ '$i!n&!rdiri d$riK!j$di$n Tid$" Di*$r$'"$n (KTD)K!j$di$n N+$ri !d!r$ (KN)K!j$di$n Tid$" !d!r$ (KT) d$nK!j$di$n P.&!ni$# !d!r$ (KP)



11/118

INSIDEN KESELAMATAN PASIEN

K!j$di$n Tid$" Di*$r$'"$n (KTD) $d$#$* inid!n+$n, %!n,$"i/$&"$n !d!r$ '$d$ '$i!n

K!j$di$n N+$ri !d!r$ (KN) $d$#$* &!rj$din+$

inid!n +$n, /!#u% $%'$i &!r'$'$r "! '$i!n

K!j$di$n Tid$" !d!r$ (KT) $d$#$* inid!n +$n,ud$* &!r'$'$r "! '$i!n &!&$'i &id$" &i%/u#!d!r$

K.ndii P.&!ni$# !d!r$ (KP) $d$#$* ".ndii+$n, $n,$& /!r'.&!ni un&u" %!ni%/u#"$n

!d!r$ &!&$'i /!#u% &!rj$di inid!nK!j$di$n !n&in!# $d$#$* u$&u KTD +$n,

%!n,$"i/$&"$n "!%$&i$n $&$u !d!r$ +$n,!riu



12/118

MATERI

1. PENINGKATAN

MUTU LAYANAN RS2. RISK MANAJEMEN

@ PATIENT SAFETY



13/118

ISK MANAEMEN UALITIMPEMENT

DAHULUoF"$*# 3#*% ,&"&4!,!"

&+#'? #,39!,!"' /#

3,& *&%#' *!3#"$ %&+#/#+&%*&"&%&" *!-&3&

'!3#*& /&" &/&

!"&"$$"$ 4&7&8"?& /#

,&*#"$,&*#"$ "$*#

oM!,"? 4&+3!+&3&" ?&"$ 8!38!/&

oS'3%'3 3#*% ,&"&4!,!"

/&" &+#'? #,39!,!"'

'!3#*&

SEARA!"U&?& 3#*% ,&"&4!,!"

/&" &+#'? #,39!,!"'

/# RS &/&+& "'%

,!"/%"$ %!*!+&,&'&"

&*#!" /&" ,!"-&3# 4&+&"

"'% 8!%!34& *&,& +!8#

!!%'# /&" !5*#!" "'%,!"4&,#" &*&" &*#!"

?$ /#8!3#%&"&" &,&" /&"

8!3,' '#"$$#.



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RISK MANAGEMENT

R#*% #/!"'#5-&'#" (!.$."!&3,#** &"/ &/9!3*!!9!"' 3!3'#"$)R#*% -"'3+ (!.$. +**P3!9!"'#" &"/ +**3!/-'#")R#*% 5"&"-#"$C+,* ,&"&$!,!"'C"'3&-';+#-? 3!9#!7P&'#!"' 3!+&'#"* &"//#*-+*3!S&!'? &"/ *!-3#'?C33&'! &"/ 3!$+&'3?-,+#&"-!A--3!/#'&'#" -,+#&"-!

UALITY

IMPROVEMENTu$#i&+ %!&*.d.#.,+u$#i&+ M!$ur!:indi$&.r:D$*/.$rd: .r!%!$ur! !&

;!n*%$r"in,;!& 'r$&i!:#ini$#,uid!#in!Pr.%$n$,!%!n&

OVERLAPPINGFUNCTIONS

An$#+i .= $d

..&-$u! $n$#+i

Pr.$&i


15/118


F"-'#" 3P3-!**

O84!-'#9!

I,39!,!"';I""9&'#"

I"'!3"&+

D&'&8&*!

C,&3&'#9!I"3,&'#"

DESIGN MEASURE ASSESS IMPROVE ANDREDESIGN

D!*#$"

R!/!*#$"

D!*#$"

I,39!

A**!**

M!&*3!

I,39!,!"' P3#3#'#!*

SIKLUS MUTU :METDE MUTU


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• $rr+ .u& '#$n• D..%!n& 'r./#!%

$nd ./!r


17/118



18/118


RISKMANAJEMEN


19/118



20/118



21/118

d r L u w i

- P M K P 2 j u n i 2 0 1 3

PENINGKATAN

MUTU KESELAMATAN

PASIEN

M!"#"$%&'%&",' !$r$

"!!#uru*$n dn,

&!ru %!n!ru,!"$3&"$#

3#*#% &!r*$d$''$i!n &$= /$i"

d$#$% 'r.! "#ini%$u'un

#in,"un,$n i"

21


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dr Luwi - PMKP 2 juni 2013

PMKPP!nd!"$&$n %!#i'u&i/$,$i%$n$ M!%i%'in d$n

%!r!n$n$"$n 'r.,r$%PMKP

M!r$n$n, 'r.! "#ini %$n$j!ri$# +, /$ru

dn, /$i" M!n,u"ur !/!r$'$

/$i"n+$ 'r.! /!rj$#$n%!#$#ui '!n,u%'u#$nd$&$

M!n,$n$#ii d$&$ M!n!r$'"$n

%!%'!r&$*$n"$n'!ru/$*$n +,di&i%/u#"$n d#% 'r.!

'!nin,"$&"$n %u&u

P!3+ ,!"/&&'/3"$&" #,#"&"

B!3'4&" ,!"$8&8/&?& RS

S!-&3& 3&%'#,!"$#/!"'#5%&*# ,!"$3&"$# 3#*#% !"?#,&"$&""?&

M!"$$"&%&" /&'& '%

,!,%*%&" /#3# /,&*&+&2 ?$ ,!"4&/#3#3#'&*

B!3'4&",!,!3'"4%&"'!34&/#"?& !38%&"8!3%!+&"4'&" 22


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FOKUS AREA STANDARPMKP

K!!,#,#"&" /&"!3!"-&"&&"

1 1.1 1.21.: 1. 1.=

R&"-&"$&" 3*!* %+#"#%

,&"&4!,!"

2 2.1

P!,#+#&" #"/#%&'3

!"$,+&" /&'&

: :.1 :.2

:.:)

V&+#/&*# /&" &"&+#*#* /&3##"/#%&'3 !"#+&"

.1 .2 ==.1 )

M!"-& /&"

,!,!3'&&"%&"

1011

BAB IPENINGKATAN MUTU KESELAMATAN PASIEN



24/118

KEPEMIMPINAN DAN

PERENCANAAN


KEPEMIMPINAN DAN


25/118

KEPEMIMPINAN DANPERENCANAAN

S'&"/&3 PMKP.1

M!3!%& ?&"$ 8!3'&"$$"$ 4&7&8,!,#,#" ,!"4&+&"%&" RS (P!,#+#% D#3RS) 8!3&3'#*#&*# /+, !3!"-&"&&" !9&+&*# %!8!3&*#+&" 'r.,r$% PMKP

E+!,!" P!"#+&" PMKP.1

1 Pi%' S /!r'$r&ii'$i d$#$% !+&%*&"&&","#'3#"$ 'r.,r$% PMKP

2 Pi%'in$n S /!r'$r&ii'$i /&+&,

!3!"-&"&&"

3 Pi%'in$n S ,!"!'&%&" 3*!* &'&,!%&"#*,! !"$&7&*&" 'r.,r$% PMKP

4 Pr.,r$% PMKP /#+&3%&" .#!* 'i%'in$n S

"!'$d$ /$d$n '!n,!#.#$ (governance) dr Luwi - PMKP 2 juni 2013 25


26/118

PERSIAPAN RUMAH SAKIT

M!n+uun K!/ij$"$n'!r!n$n$$n '!#$"$n$$n%.ni&.rin, '!#$"$n$$n

'!#$'.r$n PMKP

Dir!"&ur&!r#i/$&

$&$&$n "!/ij$"$n /i$ dij$di"$n

$&u dn, '!d.%$n PMKP $&$u!ndiri-2

D."u%!n #$'.r$n PMKP "!

'!%i#i" S dr Luwi - PMKP 2 juni 2013 26


27/118

KEPEMIMPINAN DAN PERENCANAAN

S'&"/&3 PMKP.1.1.

Pi%'in$n RS 8!3%+&83&*# d$#$% %!#$"$n$"$n 'r.,r$%

PMKP KOMITE ;PANITIA;TIM MUTU KP

E+!,!" P!"#+&" PMKP.1.1.

1 Pi%'in$n S 8!3&3'#*#&*# /&+&, ,!+&%*&"&%&"

'r.,r$% PMKP #i*$& ju,$ TKP34 EP 2G KPS11 EP 1G

KPS14 EP 1 d$n KPS17 EP 1)

2 Pr.,r$% PMKP 8!3+&% /# *!+3 RS P3$3&,

M';&+#'? P+&"

3 Pr.,r$% %!n$n,$ni *#*'!, /&3# RS '!r$n$n 3&"-&"$&"

*#*'!, 3&"-&"$ +&"$ d$ri PMKP

4 Pr.,r$% %!n$n,$ni %3/#"&*# *!,& %,"!" d$ri

"!,i$&$n '!n,u"ur$n %u&u d$n "!,i$&$n '!n,!nd$#i$n

(#i*$& ju,$ TKP34 EP 2 d$n PPI10 EP 1)dr Luwi - PMKP 2 juni 2013 27


28/118


;!n&u" K.%i&!:P$ni&i$:Ti% PMKP #!n,"$'id!n,$n ur$i$n &u,$

;u$& Pr.,r$% PMKP +, "!,i$&$n +$n, "!,i$&$n'."."n+$ //

◦

U'$+$ P!nin,"$&$n Mu&u◦ K!!#$%$&$n P$i!n

ini$n "!,i$&$n P!nin,"$&$n Mu&u

M!n+uun "!/ij$"$n d$n 'r.!dur PMKP

M!n+uun '!d.%$n:'$ndu$n %u&u:%$nu$#%u&u:d!i,n %u&u (PMKP 2)

Pr.,r$% 'ri.ri&$ (PMKP 12)

Pr.,r$% di"#$& PMKP (PMKP 15)



29/118

PERSIAPAN RUMAH SAKIT#ini$# P$&*w$+ (PMKP 21) %!%i#i* $r!$

'ri.ri&$ (*i,*


30/118

PERSIAPAN RUMAH SAKIT Indi"$&.r %$n$j!ri$# (PMKP 32 PMKP 4)

'!%i#i*$n (!&!#$* di'i#i* !&i$' indi"$&.r

di/u$&"$n 'r.#:"$%u) '!n,u%'u#$n $n$#i$

r!n$n$ &ind$" #$nju& ($&i.n '#$n

'!r/$i"$nn+$)

Indi"$&.r SKP (PMKP 33 PMKP 4) '!%i#i*$n

(!&!#$* di'i#i* !&i$' indi"$&.r di/u$&"$n

'r.#:"$%u) '!n,u%'u#$n $n$#i$ r!n$n$

&ind$" #$nju& ($&i.n '#$n '!r/$i"$nn+$)M.ni&.rin, P!ni#$i$n "in!rj$ indi


31/118


K!!#$%$&$n P$i!nIKP (Inid!n K!!#$%$&$n P$i!n)

D!nii S!n&in!# KTD KN KP KTG

i&!% '!n$&$&$n d$n '!#$'.r$n$n$#i$ (ri" ,r$din, %!r$* A)

i" M$n$j!%!n 1 &$*un !"$#i

@MEA (PMKP 11)

A (M@K d$n 4 M@K 4 )In=!&i.n .n&r.# i" A!%!n:IA

(PPI) PPI 6 d$n PPI 7



32/118

KEPEMIMPINAN DAN PERENCANAAN

S'&"/&3 PMKP.1.2

Pi%'in$n %!n!&$'"$n 'r.! +$n, dij$di"$n3#3#'&* un&u" di#$"u"$n !


33/118


S'&"/&3 PMKP.1.:. Pi%'in$n %!%/!ri"$n 8&"'&" '!%"+$# d$n

du"un,$n #$inn+$ un&u" %!ndu"un, 'r.,r$%

PMKP

E+!,!" P!"#+&" PMKP.1.:.

1 P#,#"&" ,!,&&,# '!%"+$# /&" "*3

8&"'&" +" +$n, di/u&u*"$n un&u"

%!n!#uuri d$n %!%/$ndin,"$n *$i# d$ri!


34/118


S'&"/&3 PMKP.1..

PMKP di in=.r%$i"$n "! &$= /u#!&in '$'$n'!n,u%u%$n r$'$& &$= "!,i$&$n uni& SDM

E+!,!" P!"#+&" PMKP.1..

1 I"3,&*# &!n&$n, 'r.,r$% PMKP di $%'$i"$n"!'$d$ &$=

2 K.%uni"$i di#$"u"$n !$r$ 3!$+!3 ,!+&+#*&+3&" +$n, !=!"&i= (#i*$& ju,$ TKP16 EP 2)

3 K.%uni"$i &!r%$u" "!%$ju$n d$#$% *$#!"!3&&" *&*&3&" %!*!+&,&'&" &*#!"



35/118


S'&"/&3 PMKP.1.=.

S&$= di/!ri '!#$&i*$n un&u" i"u& !r&$ d$#$% 'r.,r$%

E+!,!" P!"#+&" PMKP.1.=.

1 Ad$ 3$3&, !+&'#&" /$,i &$= !u$i d!n,$n '!r$n$n%!r!"$ d$#$% 'r.,r$% '!nin,"$&$n %u&u d$n "!!#$%$&$n

'$i!n

2 S!.r$n, #"/#9#/ ?&"$ 8!3!"$!'&&" +&* ,!,8!3#%&"

!+&'#&"

3 S&$= /!r'$r&ii'$i d$#$% '!#$&i*$n !/$,$i 8&$#&" /&3#

!%!34&&" 3'#" ,!3!%&



36/118

KEPEMIMPINAN PERENCANAAN

o 8!3&3'#*#&*# d$#$% '!r!n$n$$n

!


37/118


PEMILIKRS

DIREKTURUTAMA RS

MONEV PENGAWASAN PMKP 1

PELAKSANAAN

P#P $

PERENCANAANP#P $

PELAPORANP#P $

BUATKEBIJAKANNYA


38/118


PELAKSANAANP#P $.$

PANDUAN PMKP P3$3&, PMKP;&+#'?

P+&"

BENTUK

KOMITE;TIMMUTU

PENETAPANPRIORITAS

P#P $.%

SETIAP UNIT ADAPROGRAM MUTU

KP

HASIL KEG DI INFOKAN KE STAF

P#P $.&

PERLU BANTUANTEKNOLOGI (PMKP1.:)

DIKLAT MUTU D#3!%*# &3& #,RS K,#'! M'PJ !"$,+ /&'&

(PMKP 1.=)


39/118

YANG DIPERSIAPKANRS

1. K!'!"'&" '!"'&"$ !3!"-&"&&"!+&%*&"&&" ,"#'3#"$ PMKP D#3' RS '!3+#8&' %!8#4&%&" &$&3

/#,&*%&" /# P!/,&" PMKP

2. F3, ,"#'3#"$

:. P3$3&, PMKP

. P!/,&" PMKP



40/118

RANCANGAN PROSESKLINIS

DAN MANAJERIAL


PEDOMAN MUTU KP

= CLINICAL PATHWAY D;!"?&%#' &'&3*!/3 '#"/&%&"

DESIGN MUTU CLINICAL PATHWAY

RANCANGAN PROSES


41/118

RANCANGAN PROSESKLINIS

DAN MANAJERIALS'&"/&3 PMKP.2.

S %!%/u$& 3&"-&"$&" 8&3 /&" ,!+&%%&",/#5%&*# /&3# *#*'!, d$n 'r.! !u$i 'rini''!nin,"$&$n %u&u

E+!,!" P!"#+&" PMKP.2. P!/,&" PMKP

1 Prini' '!nin,"$&$n %u&u d$n $#$& u"ur d$ri 'r.,r$%di&!r$'"$n '$d$ 3&"-&"$&" 3*!* 8&3 &'& ?&"$/#,/#5%&*#

2 E#!%!n d$#$% M$"ud d$n Tuju$n d$ri *uru= $ :d idi,un$"$n $'$/i#$ r!#!


42/118

RANCANGAN PROSES KLINIS MANAJERIAL

R&"-&"$&" 3*!* ?&"$ 8% &/&+& 6

$ ".ni&!n d!n,$n ,#*# /&" 3!"-&"& ru%$* $"i&G

/ %!%!nu*i %!8'&" &*#!" %!+&3$& *'& /&" +""?&

%!n,,un$"$n !/. 3&%'!% '!3%#"# &$nd$r +$n "#ini"!'u&$"$$n i#%i$* /!r/$,$i in=.r%$i /!r/$i /u"&i +,

r!#!


43/118

RANCANGAN PROSES KLINIS DANMANAJERIAL

S'&"/&3 PMKP.2.1.

P!d.%$n 'r$"&!" "#ini d$n #ini$# '$&*w$+ d$n $&$u'r.&.".# "#ini di,un$"$n !/$,$i '!d.%$n d$#$%%!%/!ri"$n $u*$n "#ini

E+!,!" P!"#+&" PMKP.2.1.

1 S!&i$' &$*un 'i%'in$n %!n!n&u"$n '$#in, !di"i& +#,&

&3!& 3#3#'&* d!n,$n =."u '!n,,un$$n '!d.%$n "#iniclinical pat'(ays d$n:$&$u 'r.&.".# "#ini 5 #ini$#'$&*w$+ /$,$i%$n$ '!d.%$n "#inin+$ /$,$i%$n$'r.&.".#:SPn+$ !" $'$ d* !u$i dn, %$"ud &uju$n

2 S d#% %!#$"$n$"$n '!d.%$n 'r$"&!" "#ini c"inica"

!at#$a%s d$n:$&$u 'r.&.".# "#ini %!#$"$n$"$n 'r.! $)' *) d$#$% M$"ud d$n Tuju$n

3 S %!#$"$n$"$n '!d.%$n "#ini d$n c"inica" !at#$a%s $&$u'r.&.".# "#ini di !&i$' $r!$ 'ri.ri&$ +$n, di&!&$'"$n I,+!,!"'&*# /# R!%&, M!/#*

4 Pi%'in$n "#ini d$'$& %!nunju""$n /$,$i%$n$ '!n,,un$$ndr Luwi - PMKP 2 juni 2013 43

RANCANGAN PROSES KLINIS DAN


44/118


S&*&3&" /&3# 3,& *&%#' ,!+#'# 6

*'&"/&3/#*&*# /&3# 3*!* &*&" %+#"#* ,!"$3&"$# 3#*#% di d$#$% 'r.! $u*$n "#ini &!ru&$%$

*$#-*$# +$n, &!r"$i& d!n,$n #$n,"$* '!n,$%/i#$n "!'u&u$n+$n, "ri&iG

%!%/!ri"$n &*&" %+#"#* '!&' 7&%' $r$ +$n, !=!"&i=

d!n,$n %!n,,un$"$n u%/!r d$+$ !$r$ !i!nG !$r$ ".ni&!n ,!"$&*#+%&" ,' !+&?&"&" ?&"$

'#"$$# %!#$#ui $r$-$r$ /!r/$i /u"&i (evience'ase)

;!r/$,$i ru%$* $"i& %!n,,un$"$n /!r/$,$i $#$& un&u"%!n$'$i $$r$n ini %$u'un $$r$n #$inn+$ S!/$,$i .n&.*'$r$ 'r$"&ii '!#$+$n$n "!!*$&$n %!n,!%/$n,"$n 'r.!$u*$n "#ini d$n %!%/u$& "!'u&u$n $u*$n "#ini/!rd$$r"$n /u"&i i#%i$* &!r/$i" +$n, $d$ P!d.%$n 'r$"&!""#ini %!ru'$"$n $#$& +$n, /!r,un$ d$#$% u'$+$ %!%$*$%i

d$n %!n!r$'"$n i#%u '!n,!&$*u$n &!r/$i" '$d$ w$"&udr Luwi - PMKP 2 juni 2013 44

RANCANGAN PROSES KLINIS DAN


45/118


A#ur $u*$n "#ini (c"inica" care !at#$a%s) $d$#$* $#$& +,/!r%$n=$$& d#% u'$+$ ini u&" %!%$&i"$n $d$n+$ in&!,r$i "..rdin$i +, !=!"&i= dr +$n dn, %!n,un$"$n !$r$ !i!n SD+, &!r!di$ !$r$ !i!n P!d.%$n 'r$"&!" "#ini a"ur asu#ank"inis & 'r.&.".# "#ini $d$#$* r!#!


46/118


u%$* $"i& di*$r$'"$n d$'$& %!#$"$n$"$n"!,i$&$n di/$w$* ini !&i$' &$*un

1 Pi%'in$n "#ini %!%i#i* '$#in, !di"i& = +#,&&3!& 3#3#'&* !/$,$i =."u !'!r&i /#&$"*#*'$i!n 3*!/3 '.'u#$i $&$u !"?&%#' di%$n$ '$ndu$n (guie"ines) !at#$a%s d$n'r.&.".# d$'$& %!%'!n,$ru*i %u&u d$n"!!#$%$&$n d$ri $u*$n '$i!n !r&$%!%'!r"!i#


47/118

C+#"#-&+ &'7&?*◦ K!!'$"$&$n &$&$ $&ur$n '!n,./$&$n +$n, &!r%$u"

!%u$ !#!%!n d$ri $u*$n:'!#$+$n$n

◦ r!n$n$ '!n$&$#$"$n$$n '$i!n +$n, /!ri=$& %u#&i

dii'#in +$n, /!rii d!&$i# #$n,"$*-#$n,"$*

'!n$n,$n$n !.r$n, '$i!n %u#$i %$u" S $%'$i

d!n,$n "!#u$r S

◦ %!ru'$"$n #$n,"$*-#$n,"$* 'r.&.".# &!r$'i d$n

&$nd$r '!#$+$n$n '$i!n #ini$# '$&*w$+ #!/i*

%!ru'$"$n '!n,in,$& (r!%ind!r) d$n '!r$n,"$&

!


48/118



49/118



50/118

CLINICAL PATHWAY

Au$n PMK 1438 &$*un 2010 &!n&$n,&$nd$r '!#$+$n$n "!d."&!r$n

S&$nd$r '!#$+$n$n "!d."&!r$n $d$#$*'!d.%$n +$n, *$ru dii"u&i /$,i d."&!r d$n

d."&!r ,i,i d$#$% %!n+!#!n,,$r$"$n 'r$"&i""!d."&!r$n &!rdiri d$ri P!d.%$n N$i.n$#Pr$"&i" K!d."&!r$n (PNPK) d$n SP

PNPK !/$,$i $u$n '!n+uun$n SP di S

SP diuun d$#$% /!n&u" '$ndu$n 'r$"&i""#ini (#ini$# 'r$&i! ,uid!#in!) +, d'&di#!n,"$'i $#ur "#ini (#ini$# '$&*w$+)$#,.ri&%$ 'r.&.".# 'r.!dur &$ndin, .rd!r



51/118


PEDOMAN NASIONALPELAYANAN KEDOKTERAN

PANDUAN PRAKTIK KLINIS

CLINICAL PATHWAY

In&!rn$&i.n$# !=!r!n! Si&!


52/118

In&!rn$&i.n$# !=!r!n! Si&!#ini$# Juid!#in!

I"'!3"&'#"&+ J3"&+ 3 &+#'? I" H!&+'-&3!◦ ''6;;#"'-.3/43"&+*.3$;-"'!"';1=;=;:.

+

I"*'#''! M!/#-#"! 2011. S'&"/&3/* 3D!9!+#"$ T3*'73'? C+#"#-&+ P3&-'#-! G#/!+#"!*. ''6;;#,.!/;R!3'*;2011;C+#"#-&+P3&-'#-!G

#/!+#"!*W!C&"T3*';S'&"/&3/*.&* F++7#"$ 7!8*#'! !3* &" I"'!3"&'#"&+ -++!-'#"

C+#"#-&+ P3&-'#-! G#/!+#"!*6 ''6;;777.-+#"#-&+$#/!+#"!*.3$;-&3/#9&*-+&3,!

/#-#"!.',''6;;#,.!/;R!3'*;2011;C+#"#-&+P3&-'#-!G#/!+#"!*W!C&"T3*';S'&"/&3/*.&*

52 dr Luwi - PMKP 2 juni 2013

http://intqhc.oxfordjournals.org/content/15/5/377.fulhttp://intqhc.oxfordjournals.org/content/15/5/377.fulhttp://iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspxhttp://iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspxhttp://www.clinicalguidelines.org/cardiovascularmedicine.htmhttp://www.clinicalguidelines.org/cardiovascularmedicine.htmhttp://iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspxhttp://iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspxhttp://iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspxhttp://iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspxhttp://www.clinicalguidelines.org/cardiovascularmedicine.htmhttp://www.clinicalguidelines.org/cardiovascularmedicine.htmhttp://iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspxhttp://iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspxhttp://intqhc.oxfordjournals.org/content/15/5/377.fulhttp://intqhc.oxfordjournals.org/content/15/5/377.ful


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CLINICAL PATHWAY (PMK 1438:2010 &&, &$nd$r '!#$+$n$n "!d."&!r$n)


STANDAR PELAYANANKEDOKTERAN

PEDOMAN NASIONAL PRAKTIKKEDOKTERAN SPO

STANDAR PROSEDUROPERASIONAL RS

PANDUAN PRAKTIK KLINIS ALUR KLINIS


54/118

PANDUAN PAKTIK KLINIS

P!n,!r&i$nAn$%!i

P!%!ri"$$n @ii"

Kri&!ri$ Di$,n.iDi$,n.i ;$ndin,

P!%!ri"$$n '!nunj$n,

T!r$'i

Edu"$iPr,.n.i

K!'u&$"$$n



55/118

PEMILIHAN INDIKATORDAN PENGUMPULAN DATA

S'&"/&3 PMKP.:.

Pi%'in$n ru%$* $"i& %!n!&$'"$n indi"$&.r "uni d$#$%&ru"&ur ru%$* $"i& 'r.!-'r.! d$n *$i# (outcome) un&u" di&!r$'"$n di !#uru* ru%$* $"i& d$#$% r$n,"$'!nin,"$&$n %u&u d$n r!n$n$ "!!#$%$&$n '$i!n

E+!,!" P!"#+&" PMKP.:. L#&' &"/&";,&"&+,'"?&

1 Pi%'in$n ru%$* $"i& ,!"!'&%&" &3!& *&*&3&"un&u" '!ni#$i$n d$n '!nin,"$&$n "#ini %$n$j!ri$#

$$r$n "!!#$%$&$n '$!in2 P!"#+&" %!ru'$"$n /$,i$n d$ri 'r.,r$%

'!nin,"$&$n %u&u d$n "!!#$%$&$n '$i!n ADAINDIKAT

3 $i# '!ni#$i$n di$%'$i"$n "!'$d$ 'i*$" &!r"$i& d$#$%

%!"$ni%! '!n,$w$$n d$n !$r$ /!r"$#$ "!'$d$i% in$n d$n !%i#i" ru%$* $"i& !u$i &ru"&ur


PEMILIHAN INDIKATOR DAN PENGUMPULAN


56/118

PEMILIHAN INDIKATOR DAN PENGUMPULANDATA

S'&"/&3 PMKP.:.1

Pi%'in$n ru%$* $"i& %!n!&$'"$n indi"$&.r "uni un&u"

%$in,-%$in, &ru"&ur 'r.! d$n *$i# (outcome) !&i$'u'$+$ "#ini

E+!,!" P!"#+&" PMKP.:.1. S#&%&" #"/#%&'3 ?$/##+# 4*'#5%&*# !,#+#&" ,!'/! !"-&'&'&"!"$,+&" &"&+#*& 9&+#/&*#

1 Pi%'in$n "#ini %!n!&$'"$n #"/#%&'3 %"-# un&u"!&i$' di $r!$ "#ini ('!#$+$n$n) +$n, di!/u& /# 1)*&, 11) /# M&%*/ /&" T4&".

2 P$#in, !di"i& = /&3# 11 #"/#%&'3 %+#"#* &3* /##+# (S!u$i dn, in&!rn$&i.$n# #i/r$r+)

3 Pi%'in$n ru%$* $"i& %!%'!r*$&i"$n %u$&$n i#%u(science) d$n /u"&i (evience) un&u" %!ndu"un, !&i$'indi"$&.r +$n, di'i#i*

4 P!ni#$i$n %!n$"u' &ru"&ur 'r.! d$n *$i# (.u&.%!)

5 $"u'$n %!&.d.#.,i d$n =r!"u!ni di&!&$'"$n un&u"dr Luwi - PMKP 2 juni 2013 56


57/118


P!%i#i*$n indi"$&.r +$n, &!r"$i& d!n,$n $r!$ "#ini +$n,'!n&in, %!#i'u&i

1. &*!*,!" '$i!nG

2 '!#$+$n$n +&83&'3#,

3 '!#$+$n$n 3&/#+$# /$n di$,n.&i i%$,in,G

4 'r.!dur 8!/&

=. !"$$"&&" &"'#8#'#%& d$n ./$& #$inn+$G

6 "!$#$*$n %!di"$i medication error/ d$n K!j$di$nN+$ri !d!r$ (KNC)

7 '!n,,un$$n &"!*'!*# /&" *!/&*#G Mi ".%'#i"$i$n!&!i

8 '!n,,un$$n d$r$* d$n 'r.du" d$r$*G

9 "!&!r!di$$n ii d$n '!n,,un$$n r!"$% %!di '$i!nGMi KLPM

10 !n! $*$n d$n !n !nd$#i$n in=!"i ur

INDIKATOR AREA KLINIS (IAK)

H


58/118



N. AREA KLINIS INDIKATOR AREA KLINIS

1 A!%!n P$i!n P!n,"$ji$n $w$# "!'!r$w$&$n d$#$%24 j$%

P!n,"$ji$n $w$# %!di d$#$% 24 j$%

2 P!#$+$n$n L$/.r$&.riu% B$"&u &un,,u '!%!ri"$$n L$/ i&.

3 P!#$+$n$n $di.#.,i B$"&u &un,,u '!%!ri"$$n $di.#.,i

i&.4 Pr.!dur /!d$* '!r$i /!ri* &$n'$ '!%/!ri$n

'r.#$Ci $n&i/i.&i"

5 "!$#$*$n %!di"$imedication error/

d$n K!j$di$n N+$ri!d!r$ (KNC)

K!j$di$n N+$ri !d!r$ P!r!!'$n/$&

P!n!,$*$n $d

6 '!n,,un$$n &"!*'!*#/&" *!/&*#

D!$&ur$i "i,!n In&r$ An!&!i$A&$u S!d$i

C O N T

O H


OH


59/118


N AREA KLINIS INDIKATOR

7 '!n,,un$$n d$r$* d$n'r.du" d$r$*G

An$#ii r!$"i &r$n=ui

8 Pr.!dur .'!r$i K!&id$"!u$i$n di$,n.i 'r$ d$n'$$ /!d$*

9 K!#!n,"$'$n M K!#!n,"$'$n r!"$% %!di

10 !"-!$&&" /&"

!"$!"/&+#&" #"!%*#*39!#+&"* /&"!+&3&"

!n&i#$&.r A.i$&!d Pn!%.ni$ (AP)

In=!"i A#ir$n D$r$* (IAD)

In=!"i S$#ur$n K!%i* (ISK)

In=!"i D$!r$* '!r$i (ID)

.'i&$# A?uir!d Pn!u%.ni$ (AP)

11 i!& "#ini P!n!#i&i$n d!n,$n !&*i$# #!$r$n!

C O N T

O H


60/118

Luwi-indi"$&.r %u&u 25 %!i 201360

INDIKATOR INTERNATIONAL LIBRARY

1) A-'! M?-&3/#&+ I"&3-'#" (AMI)

#"/#%&'3

2) H!&3' F+3! (HF) : #"/#%&'3

:) S'3%! (STK) #"/#%&'3

) C#+/3!"’* A*',& C&3! (CAC)

2#"/#%&'3

=) H*#'&+B&*!/ I"&'#!"' P*?-#&'3#-S!39#-! (HBIPS) 2 #"/#%&'3

) N3*#"$S!"*#'#9! C&3! (NSC)

:#"/#%&'3

) P!3#"&'&+ C&3! (PC) : #"/#%&'3

) P"!,"#& (PN) 2 #"/#%&'3

) S3$#-&+ C&3! I,39!,!"' P34!-' (SCIP)

PMKP:.1EP 2

INDIKATOR AREAKLINIS

PENJELASAN


61/118


1. &*!*,!" &*#!"2. !+&?&"&"

+&83&'3#,:. !+&?&"&" 3&/#+$#/&" /#&$"*'#-#,&$#"$

. 3*!/3 8!/&=. !"$$"&&" &"'#8

8&' +". %!*&+&&" ,!/#%&*#

(,!/#-&'#" !333) KNC

. !"$$"&&" &"!*'!*#

*!/&*#. !"$$"&&" /&3&

3/% /&3&. %!'!3*!/#&&" #*#

!"$$"&&" RM

&*#!"

KLINIS

1. M&*#"$2 &3!&%+#"#* ,#"#,&+ &/&

1 #"/#%&'3

,#"#,&+ &/& 11#"/#%&'3 %+#"#*

2. D&3# 11 #"/#%&'3%+#"#* = #"/#%&'3,!"$$"&%&"#"/#%&'3 %+#"#*/&3# I"'!3"&'#"&+L#83&3?

:. B#+& /&3# 11#"/#%&'3 %+#"#* '*8

'/% &/& ?$,!"$$"&%&"#"/#%&'3 %+#"#*/&3# #"'!3"&'#"&++#83&3? ,&%& RS

&3*

PENJELASAN

INDIKATOR INTERNATIONAL


62/118

INDIKATOR INTERNATIONALLIBRARY

P#+# /&3# 8% I"'!3"&'#"&+ +#83&3?

J,+& = #"/#%&'3 %+#"#*

U"'% &%3!/#'&*# '&& !3'&,& &"?&

/#8&'%&" 35+ #"/#%&'3 '#/&% !3+

/#+&%%&" !"$,+&" /&'& /&"

&"&+#*#* /&'&



63/118


P#,#"&" RS ,!,8&' #+#&" 5"&+ %!$#&'&" !"#+&"

?&"$ /#'&3$!'%&". U"'% ,&*#"$2 &3!& #"# #,#"&"

,!"!'&%&" 6

3*!* 3*!/3 /&" &*#+ outcome/ ?&"$ &%&" /#"#+

%!'!3*!/#&&" #+, !"$!'&&" science/ /&"8%'# e0idence/ "'% ,!"/%"$ !"#+&"

8&$,&"& !"#+&" /#+&%%&"

8&$,&"& !"#+&" /#*!3&*#%&" /!"$&" 3!"-&"&

,!"?!+3 /&3# !"#+&" ,' /&" %!*!+&,&'&"&*#!"

3!%!"*# /&3# !"#+&".


PEMILIHAN INDIKATOR


64/118

PEMILIHAN INDIKATOR PENGUMPULAN DATA

• I/!"'#5%&*# 3*!/3 3*!* &*#+ /&3#%!$&'&" ?&"$ &%&" /#"#+.

• P!"#+&" &3* '!3%* &/& ,#*&+"?&3#*#% ?&"$ &/& /# 3*!* 3*!/3 ?&"$*!3#"$ ,!"#,8+%&" 8&"?&% ,&*&+& &'&

/#+&%%&" /!"$&" 9+,! '#"$$# /&" &*#+?&"$ /&&' /!"$&" 4!+&* /#%!"&+# /&" ?&"$/&+&, %!"/&+# 3,& *&%#'.

• S!8&$ -"' 3,& *&%#' /&&' ,!,#+#

"'% ,!"#+ 3*!/3 8!/& '!3'!"'(-"'"?& !38%&" 8#8#3 *,8#"$) &'&*&' %!+,% a class/ '#"/&%&" 8!/&'!3'!"' (-"' 8!/& 3'!/#).


PEMILIHAN INDIKATOR


65/118

PEMILIHAN INDIKATOR PENGUMPULAN DATA

• P!ni#$i$n $&$ 3*!* ?&"$ /#$"&%&" /&+&, ,!,#+#

3*!/3 8!/& "'% 8#8#3 *,8#"$ /' 4$&,!+&%%&" !"#+&" &'&* 3*!* /&+&, !,&*&"$&"alignment/ 3*'!*#* &/& 8!/& #"$$+ 'ipsurgery/.

• @r!" '!n,u%'u#$n d$&$ di"$i&"$n d!n,$n /!r$'$ !rin,

'r.!:'r.!dur &!r&!n&u dij$#$n"$n D$&$ !%u$ "$u $&$u$%'#! d$ri "$u +$n, di/u&u*"$n un&u" %!nunj$n,"!i%'u#$n d$n r!".%!nd$i di"u%'u#"$n d$#$% ju%#$* +$n,u"u'

• Indi"$&.r /$ru di'i#i* ji"$ indi"$&.r +$n, ud$* $d$ &id$" #$,i

/!r%$n=$$& un&u" %!#$"u"$n $n$#ii &!r*$d$' 'r.!'r.!dur $&$u *$i# (.u&.%!)

• $di S *$ru %!%'un+$i r!"$% j!j$" (track o* recor) d$ri".n&inui&$ '!ni#$i$n di $r!$-$r!$ +$n, di id!n&i"$iG &!&$'i'!ni#$i$n +$n, !/!n$rn+$ /i$ /!ru/$*



66/118


S'&"/&3 PMKP.:.2.

Pi%'in$n ru%$* $"i& %!n!&$'"$n indi"$&.r "uni un&u"%$in,-%$in, &ru"&ur 'r.!-'r.! d$n *$i# %$n$j!ri$#

E+!,!" P!"#+&" PMKP.:.2.

P!"!'&&" #"/#%&'31 Pi%'in$n %$n$j!%!n %!n!&$'"$n indi"$&.r "uni un&u"

!&i$' $r!$ %$n$j!ri$# +$n, diur$i"$n di $) $%'$i i) d$riM$"ud d$n Tuju$n

2 Pi%'in$n %!n,,un$"$n #$nd$$n #+, /&" 8%'#

(!9#/!"-!) un&u" %!ndu"un, %$in,-%$in, indi$&.r+$n, di'i#i*

3 P!ni#$i$n %!#i'u&i *'3%'3 3*!* /&" &*#+('-,!)

4 $"u'$n %!&.d.#.,i d$n =r!"u!ni di&!&$'"$n un&u"

!&i$' '!ni#$i$n dr Luwi - PMKP 2 juni 2013 66


67/118


I"/#%&'3 ?$ /##+# '!3%' /!"$&" &?& ,&"&4!,!",!+#'#

&. !"$&/&&" 3'#" '!r$#$&$n "!!*$&$n d$n ./$& '!n&in,un&u" %!%!nu*i "!/u&u*$n '$i!nG

8. !+&3&" $"&i


68/118


S'&"/&3 PMKP.:.:.

Pi%'in$n ru%$* $"i& %!n!&$'"$n indi"$&.r"uni un&u" %$in,-%$in, $$r$n "!!#$%$&$n'$i!n (#i*$& K!#.%'." III)

E+!,!" P!"#+&" PMKP. :.:.

1 Pi%'in$n %$n$j!ri$# d$n "#ini %!n!&$'"$nindi"$&.r "uni un&u" %!ni#$i !&i$' S$$r$nK!!#$%$&$n P$i!n

2 P!ni#$i$n S$$r$n K!!#$%$&$n P$i!n &!r%$u"$r!$-$r!$ +$n, di&!&$'"$n di S$$r$nK!!#$%$&$n P$i!n I $%'$i I

3 D$&$ '!ni#$i$n di,un$"$n un&u" %!ni#$i

!=!"&i


69/118

SASARAN KESELAMATANPASIEN

I K!&!&$'$n id!n&i"$i '$i!n

II P!nin,"$&$n K.%uni"$i +$n, !=!"&i=

III P!nin,"$&$n K!$%$n$n /$& +$n,

'!r#u diw$'$d$i

I K!'$&i$n &!'$& #."$i &!'$&'r.!dur &!'$& '$i!n .'!r$i

P!n,ur$n,$n rii". in=!"i &!r"$i&'!#$+$n$n "!!*$&$n

I P!n,ur$n,$n rii". j$&u*


PEMILIHAN INDIKATOR


70/118


PEMILIHAN INDIKATORDAN PENGUMPULAN

DATAINDIKATOR KLINIS

11 AREA

KLINISPMKP :.1

EP 1

INDIKATOR

INTERNATIONAL

LIBRARY; JCI

P#P 1.$ EP %

INDIKATOR

S.K.PP#P 1.1

INDIKATORMANAJERIAL AREA

MANAJERIAL

P#P 1.%

DA*A D)U#PULA! DA! D) A!AL)SA

AKRED

PERTAMADATA BELUM

DIKUMPULKAN

INDIKATOR AREA INTERNATIONAL SKP


71/118


KLINISPMKP :.1 EP 1

LIBRARY PMKP :.1 EP 2SKP

PMKP :.:

1 A!%!n P$i!n

2 P!#$+$n$n L$/3 P!#$+$n$n$di.#.,i4 Pr.!dur ;!d$*5 P!n,,un$$n

$n&i/i.&i"$6 K!$#$*$n%!di"$i KN

7 P!n,,un$$n$n!&!i !d$i

9 P!n,,un$$n

d$r$* 'r.du"d$r$*

10 PPI ur

10!n.u T*r.%/.!%

/.#i% (TE)

1K!&!&$'$n

id!n&i"$i'$i!n

2P!nin,"$&$n".%u ni"$i+$n, !=!"&i=

3P!nin,"$&$n K!$%$n /$&+$n, '!r#udiw$'$d$i

4K!'$&i$n&!'$& #."$i

&!'$& 'r.!dur &!'$&'$i!n .'!r$i

5P!n,ur$n,$nrii". in=!"i

&!r"$i&


72/118

INDIKATOR

KUNCI

INDIKATOR

AREAKLINIS

(PELAYANAN)

INDIKATOR

KLINIS(+#83&3?)

SASARANKESELAMA

TANPASIEN

A!%!n&'$i!n

Id!n&i"$i'$i!n

Id!n&i"$i'$i!n

A!%!n&'$i!n

A'irin .n $ri


73/118

DIMENSIMUTU

PMKP INDIKATORKLINIS

SKP

•A''r.'ri$&!n!•APMKP 31 Pr.!dur .'PMKP 31 $n&i/i.&i" '!n,,un$$n./$& #$inPMKP 31 in=!&i.n'r!

$ndr!'.r&in,

.in&!'#$!%!n&

SKP 1 SKP 4 SKP 5



74/118

INDIKATOR MUTU

1. I"/#%&'3 /# &3!& %+#"#* 11 #"/#%&'3

2. L#,& /&3# 11 #"/#%&'3 /&3# JCI(P!"?&%#')

:. I"/#%&'3 ,&"&4!3#&+ #"/#%&'3

. I"/#%&'3 K!*!+&,&'&" P&*#!" #"/#%&'3

. N,!3 6 1 2 /&" 8#*& /# #"'!$3&*#%&"


PROFIL INDIKATOR


75/118

PROFIL INDIKATOR


JUDUL

DIMENSI MUTUTUJUAN

DEFINISI OPERASIONAL

FREKUENSI PENGUMPULAN

DATAPERIODE ANALISA

NUMERATOR

DENOMINATOR

SUMBER DATA (#"%+*# !%*%+*#)

STANDAR

PJ PENGUMPUL DATA;PIC

UDUL Tid$" $d$n+$ "!$#$*$n


76/118

UDUL Tid$" $d$n+$ "!$#$*$n'!%/!ri$n ./$&

DIMENSI MUTU K!!#$%$&$n "!n+$%$n$n

TUUAN T!r,$%/$rn+$ "!j$di$n"!$#$*$n d$#$% '!%/!ri$n./$&

DE@INISI PEASINAL K!$#$*$n %!%/!ri"$n ./$&%!#i'u&i 1 S$#$* d$#$% %!%/!ri"$n

j!ni ./$&2 S$#$* d$#$% %!%/!ri"$n

d.i3 S$#$* .r$n,

4 S$#$* ju%#$*

@EKUENSI PENJUMPULAN DATA 1 /u#$n

PEIDE ANALISA 3 /u#$n



77/118

NUMEAT %# !#uru* '$i!n I@S +, diur

'!%/!ri$n ./$&

DENMINAT u%#$* !#uru*n '$i!n I@S +,di ur

SUM;E DATA Sur

STANDA 100 O

P PENJUMPULDATA:PI

K!'$#$ In&$#$i @$%$i



78/118


VALIDASI DANANALISIS DARI DATA

PENILAIAN

INDIKATOR KLINIS


79/118

INDIKATOR KLINIS


PEMILIHANINDIKATOR

PENGUMPULAN

DATA

VALIDASI

ANALISIS DATA

• METODESTATISTIK

T!'&%&"3!%!"*#"?&

DIBANDINGKAN• D#/+,

RS;'3!"• D"$ 3* +"• D"$ *'&"/&3

• D"$ 3&%'#%

INFORMASI

VALIDASI DAN


80/118

VALIDASI DANANALISIS DARI DATA PENILAIAN

S'&"/&3 PMKP..

P!&u,$ d!n,$n '!n,$#$%$n '!n,!&$*u$n d$n"!&!r$%'i#$n u"u' %!n,u%'u#"$n d$n %!n,$n$#iid$&$ !$r$ i&!%$&i"

E+!,!" P!"#+&" PMKP..

T!+*3 /&'&1 D$&$ di"u%'u#"$n di$n$#ii d$n diu/$* %!nj$di

in=.r%$i Si&!%:SP '!n$&$&$n '!n,u%'u#$n $n$#i$ d$&$

2 r$n, +$n, %!%'un+$i '!n,$#$%$n "#ini $&$u%$n$j!ri$# '!n,!&$*u$n d$n "!&!r$%'i#$n &!r#i/$&d$#$% 'r.!

3 M!'/& /&" '!"#%'!"#% *'&'#*'#% di,un$"$nd$#$% %!#$"u"$n $n$#ii d$ri 'r.! /i#$ !u$i

4 $i# $n$#ii di#$'.r"$n "!'$d$ %!r!"$ +$n,dr Luwi - PMKP 2 juni 2013 80

VALIDASI DAN


81/118


S'&"/&3 PMKP..1

@r!"u!ni d$ri $n$#ii d$&$ di!u$i"$n d!n,$n 'r.!+$n, !d$n, di"$ji d$n !u$i d!n,$n "!&!n&u$n ru%$* $"i&

E+!,!" P!"#+&" PMKP..1. T!+*3 /&'&

1 @r!"u!ni %!#$"u"$n $n$#ii d$&$ di!u$i"$n d!n,$n'r.! +$n, !d$n, di"$ji #i*$& 'r.# i&!%'!n$&$&$n '!n,u%'u#$n $n$#ii d$&$

2 @r!"u!ni d$ri $n$#ii d$&$ !u$i d!n,$n "!&!n&u$n

ru%$* $"i& #i*$& 'r.# i&!% '!n$&$&$n'!n,u%'u#$n $n$#ii d$&$


VALIDASI DAN


82/118


S'&"/&3 PMKP..2. Pr.! $n$#ii di#$"u"$n d!n,$n %!%/$ndin,"$n !$r$in&!rn$# %!%/$ndin,"$n d!n,$n ru%$* $"i& #$in /i#$ &!r!di$d$n %!%/$ndin,"$n d!n,$n &$nd$r "!i#%u$n !r&$%!%/$ndin,"$n d!n,$n 'r$"&!" +$n, /$i"

E+!,!" P!"#+&" PMKP..2. '!+*3 /&'&

1 P!r/$ndin,$n di#$"u"$n /&3# 7&%' %! 7&%' /#/&+&,3,& *&%#'

2 P!r/$ndin,$n di#$"u"$n /!"$&" 3,& *&%#' +" +$n,

!j!ni /i#$ $d$ "!!%'$&$n3 P!r/$ndin,$n di#$"u"$n /!"$&" *'&"/&3 /i#$

%!%un,"in"$n

4 P!r/$ndin,$n di#$"u"$n /!"$&" 3&%'!% ?&"$ 8%


VALIDASI DAN


83/118


S$$r$n d$ri $n$#ii d$&$ $d$#$* $,$r d$'$& di#$"u"$n'!r/$ndin,$n /$,i ru%$* $"i& %!#$#ui !%'$& $r$

1 D!n,$n diri !ndiri d$#$% w$"&u &!r&!n&u !'!r&i d$ri/u#$n "! /u#$n $&$u $&u &$*un "! &$*un /!ri"u&n+$

2 D!n,$n ru%$* $"i& #$in +$n, $%$ !'!r&i

%!n,,un$"$n ata ase r!=!r!ni (#i*$& ju,$ MKI202EP 3)

3 D!n,$n &$nd$r !'!r&i di&!&$'"$n .#!* /$d$n$"r!di&$i i"$&$n 'r.=!i.n$# $&$u %!n,,un$"$n"!&!n&u$n +$n, di&!&$'"$n d$#$% und$n,-und$n,

$&$u '!r$&ur$n

4 D!n,$n 'r$"&!"-'r$"&!" +$n, di$"ui di "!'u&$"$$n!/$,$i '!d.%$n 'r$"&!" +$n, #!/i* /$i" $&$u '$#in,/$i"


VALIDASI DAN


84/118


S'&"/&3 PMKP.=.

u%$* $"i& %!n,,un$"$n 'r.! in&!rn$#un&u" %!#$"u"$n


85/118


$#id$i d$&$ %!nj$di $n,$& '!n&in, d$#$% *$# $ Indi"$&.r /$ru di&!r$'"$n "*uun+$ #"/#%&'3 %+#"#* +$n,

di%$"ud"$n un&u" %!%/$n&u S %!#$"u"$n !


86/118


E+!,!" !"'#"$ /&3# 9&+#/&*# /&'& ?&"$ '!3!3-&?&,!"-&% *!8&$ 8!3#%' 6

$) M!n,u%'u#"$n u#$n, d$&$ .#!* .r$n, "!du$ +$n, &id$"&!r#i/$& d$#$% '!n,u%'u#$n d$&$ !/!#u%n+$

/) M!n,,un$"$n $%'#! &$&i&i" $*i* d$ri $&$&$n "$u

d$n d$&$ #$in S$%'#! 100 O di/u&u*"$n *$n+$ ji"$ ju%#$*'!n$&$&$n "$u $&$u d$&$ #$inn+$ $n,$& "!i# ju%#$*n+$

) M!%/$ndin,"$n d$&$ $#i d!n,$n d$&$ +$n, di"u%'u#"$nu#$n,

d) K$#"u#$i $"ur$i dn, %!%/$,i j%# !#!%!n d$&$ +,di&!%u"$n dn, &.&$# j%# d$&$ !#!%!n di"$#i"$n dn, 100 T"$"ur$i 90 O $d$#$* '$&."$n +$n, /$i"

!) i"$ !#!%!n d$&$ +, di"!&!%u"$n &!rn+$&$ &id$" $%$ dn,$&$&$n $#$$n n+$ (%i$#n+$ d$&$ &id$" j!#$ d!niin+$) di#$"u"$n &ind$"$n ".r!"i dr Luwi - PMKP 2 juni 2013 86

VALIDASI DAN


87/118


S'&"/&3 PMKP.=.1. ;i#$ ru%$* $"i& %!%'u/#i"$i"$n d$&$ $&$u

%!n!%'$&"$n d$&$ di w!/ i&! 'u/#i" 'i%'in$n ru%$*

$"i& %!nj$%in r!#i$/i#i&$ d$&$ SP 'u/#i"$i d$&$

E+!,!" P!"#+&" PMKP.=.1.

1Pi%'in$n ru%$* $"i& /!r&$n,,un, j$w$/ /$*w$ d$&$

+$n, di$%'$i"$n "! 'u/#i" d$'$& di

'!r&$n,,un,j$w$/"$n d$ri !,i %u&u d$n *$i#n+$

(.u&.%!)

2D$&$ +$n, di$%'$i"$n "!'$d$ 'u/#i" &!#$* di!


88/118


S'&"/&3 PMKP..

S %!n,,un$"$n 'r.! +$n, di&!&$'"$nun&u" %!#$"u"$n id!n&i"$i d$n '!n,!#.#$$n"!j$di$n !n&in!#

E+!,!" P!"#+&" PMKP. .

1 Pi%'in$n S %!n!&$'"$n d!nii "!j$di$n!n&in!# +$n, %!#i'u&i '$#in, !di"i& $)$%'$i d) +$n, di%u$& di M$"ud d$n

Tuju$n D!nii2 S %!#$"u"$n $n$#ii $"$r %$$#$* R-

&!r*$d$' !%u$ "!j$di$n !n&in!# +$n,&!rj$di d$#$% /$&$ w$"&u &!r&!n&u +$n,

di&!&$'"$n 'i%'in$n ru%$* $"i&dr Luwi - PMKP 2 juni 2013 88

VALIDASI DAN


89/118


S!&i$' ru%$* $"i& %!n!&$'"$n d!nii .'!r$i.n$#d$ri "!j$di$n !n&in!# +$n, %!#i'u&i !"ur$n,-"ur$n,n+$

$ "!%$&i$n &id$" &!rdu,$ d$n &id$" &!r"$i& d!n,$n

'!rj$#$n$n $#$%i$* '!n+$"i& '$i!n $&$u ".ndii+$n, %!nd$$ri '!n+$"i&n+$ (.n&.* /unu* diri)

/ "!*i#$n,$n =un,i u&$%$ (major) !$r$'!r%$n!n +$n, &id$" &!r"$i& d!n,$n '!rj$#$n$n

$#$%i$* '!n+$"i& '$i!n $&$u ".ndii +$n,%!nd$$ri '!n+$"i&n+$

$#$*-#."$i $#$*-'r.!dur $#$*-'$i!n .'!r$iGd$n

d '!nu#i"$n /$+i $&$u /$+i +$n, di'u#$n,"$ndr Luwi - PMKP 2 juni 2013 89

VALIDASI DAN


90/118


D!nii "!j$di$n !n&in!# +$n, di&!&$'"$n ru%$*$"i& %!#i'u&i $) $%'$i d) &!r!/u& di$&$ d$n d$'$& ju,$ %!#i'u&i "!j$di$n #$in !/$,$i%$n$ di*$ru"$n.#!* '!r$&ur$n '!r-und$n,-und$n,$n $&$u "!j$di$n+$n, di'$nd$n, .#!* ru%$* $"i& '$n&$ di%$u""$n

"!d$#$% d$=&$r "!j$di$n !n&in!# S!%u$ "!j$di$n+$n, %!%!nu*i d!nii &!r!/u& di#$"u"$n $!%!nd!n,$n %!#$"u"$n $n$#ii $"$r %$$#$* (root causeana"%sis . R) i"$ A %!n,un,"$' /$*w$'!r/$i"$n i&!% $&$u &ind$"$n #$in +$n, d$'$&

%!n!,$* $&$u %!n,ur$n,i rii". $,$r "!j$di$n!n&in!# &id$" &!ru#$n, "!%/$#i %$"$ ru%$* $"i& %!r$n$n, "!%/$#i 'r.! !r&$ %!n,$%/i# /!r/$,$i&ind$"$n +$n, !*$run+$

P!n&in, un&u" %!%'!r*$&i"$n /$*w$ i&i#$* "!j$di$n

!n&in!# &id$" !#$#u %!n,$r$* "!'$d$ "!"!#iru$nerror $&$u "!$#$*$n mistake %$u un %!%/!ridr Luwi - PMKP 2 juni 2013 90

VALIDASI DAN


91/118

ANALISIS DARI DATA PENILAIAN

S'&"/&3 PMKP..

D$&$ di$n$#ii /i#$ &!rn+$&$ $d$ "!!nd!run,$n +, &d" diin,in"$n%$u'un


92/118

ANALISIS DARI DATA PENILAIAN

S'&"/&3 PMKP..

u%$* $"i& %!n,,un$"$n 'r.! +$n, di&!&$'"$n

un&u" %!#$"u"$n id!n&i"$i d$n $n$#ii "!j$di$n

n+$ri !d!r$ : KN (near'miss events)

E+!,!" P!"#+&" PMKP.. '!+*3 /&'&

1 u%$* $"i& %!n!&$'"$n d!nii KN

2 u%$* $"i& %!n!&$'"$n j!ni "!j$di$n +$n, *$ru

di#$'.r"$n !/$,$i KN (#i*$& ju,$ MP71 un&u"

KN ./$&:%!di"$i)

3 u%$* $"i& %!n!&$'"$n 'r.! un&u" %!#$"u"$n

'!#$'.r$n KN (#i*$& ju,$ MP71 un&u" KN

./$&:%!di"$i)

4 D$&$ di$n$#ii d$n &ind$"$n di$%/i# un&u"dr Luwi - PMKP 2 juni 2013 92

R' C&*! A"&+?*#* 6


93/118

?

A R' C&*! A"&+?*#* *!!%* ' /!'!3,#"! '! 3'-&*! &" !333 +3! 3

&--#/!"'.

M!&.d! !


94/118



95/118


PENILAIAN DAMPAKKLINIS;KONSEKUENSI;SEVERITY (1)

TK RIKS D % # # D %


96/118


TK RIKS D!*%3#*# D&,&%

1 T/%*#$"#5-&"'

T#/&% &/& -!/!3&

2 M#"3 • C!/!3& 3#"$&" ,#* +%& +!-!'• D&&' /#&'&*# /"$ P:K

: M/!3&' • C!/!3& *!/&"$ ,#* 6 +%& 38!% • B!3%3&"$"?& "$*#

,'3#%;*!"*3#%;*#%+$#* &'&

#"'!+!%'&+ (3!9!3*#8!+. T/%8!38"$&" /"$ !"?&%#'• S!'#& %&** ?$ ,!!3&"4&"$

!3&7&'&"

M&?3 • C!/!3& +&*;8!3&' ,#* 6 -&-&' +,• K!#+&"$&" "$*# ,'3#%;*!"*3#%;

*#%+$#* &'& #"'!+!%'&+(#3!9!3*#8!+) '/% 8!38"$&" /"$!"?&%#'

= K&'&'3#% K!,&'#&" ?$ '/% 8!38"$&" /"$!34&+&"&" !"?&%#'

PENILAIAN


97/118

PROBABILITAS;FREKUENSI


TINGKATRISIKO DESKRIPSI

1 S&"$&' 4&3&"$; 3&3! ( = '&";%&+#)

2 J&3&"$;"+#%!? ( 2 @ = '&";%&+#)

3 M"$%#"; P*#8+! (1 2 '&";%&+#)

4 S!3#"$;L#%!+? (8!8!3&& %&+#;'&")

5 S&"$&' *!3#"$; &+,*' -!3'" ('#&,#"$$; 8+&")

SKOR RISIKO < DAMPAK Q PROBABILITY

MATRIKS GRADINGRISIKO


98/118


P38&8#+#'&* T&%S#$"#5-&"'

1

MINOR2

M/!3&':

M&?3

K&'&'3*#%

=

S&"$&' *!3#"$'!34&/#(T#&,#"$$;8+&")

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M/!3&' M/!3&'

T#"$$# E%*'3#,

E%*'3#,

S!3#"$ '!34&/#(883 %&+#;'&")

M/!3&' M/!3&'

T#"$$# E%*'3#,

E%*'3#,

M"$%#" '!34&/#(1 2

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R!"/& M/!3&'

T#"$$# E%*'3#,

E%*'3#,

J&3&"$ '!34&/#( 2 =';%&+#)

2

R!"/& R!"/& M/!3&'

T#"$$# E%*'3#,

T#"/&%&" *!* T#"$%&' B&"/R# #%


99/118

R#*#%


LEVEL;BAND

S

TINDAKAN

EKSTREM(SANGATTINGGI)

R#*#% !%*'3!, /#+&%%&" RCA &+#"$+&,& = &3# ,!,8'%&" '#"/&%&"*!$!3& !3&'#&" *&, %! D#3!%'3RS

HIGH(TINGGI)

R#*#% '#"$$# /#+&%%&" RCA &+#"$+&,& = &3# %&4# /"$ /!'+ !3+'#"/&%&" *!$!3& *!3'& ,!,8'%&"'#"/&%&" ' ,&"&4!,!"

MODERATE

(SEDANG)

R#*#% *!/&"$ /#+&%%&" #"9!*'#$&*#

*!/!3&"& &+#"$ +&,& 2 ,#"$$.M&"&4!3;#,#"&" %+#"#* *!8%""?&,!"#+ /&,&% '!3&/& 8&&?& %!++& 3#*#%

LOW

(RENDAH)

R#*#% 3!"/& /#+&%%&" #"9!*'#$&*#

*!/!3&"& &+#"$ +&,& 1 ,#"$$

CONTOH


100/118

CONTOHD# RS Q &*#!" 4&' /&3# '!,&' '#/3 /&",!"#"$$&+ %!4&/#&" *!!3'# #"# !3"& '!34&/# %3&"$/&3# 2 '&" ?&"$ +&+

N#+ /&,&% 6 = (%&'&*'3#%) %&3!"& &*#!"

,!"#"$$&+N#+ 38&8#+#'&* 6 : (,"$%#" '!34&/#) %&3!"&!3"&

'!34&/# %3&"$ 2 '&" ?&"$ +&+

S%3#"$ 3#*#% 6 = Q : < 1=W&3"& B&"/* 6 M!3& (!%*'3#,)

C&'&'&" 6 F3, +&3&" S!"'#"!+. KTD KNC +#&'PMK 11 '&" 2011 '!"'&"$ K!*!+&,&'&" P&*#!"



101/118

MENCAPAI DANMEMPERTAHANKAN

PENINGKATAN



102/118


MENCAPAI DANMEMPERTAHANKAN


103/118

PENINGKATAN

S'&"/&3 PMKP..

P!nin,"$&$n %u&u d$n "!!#$%$&$n '$i!n &!r$'$i d$ndi'!r&$*$n"$n

E+!,!" P!"#+&" PMKP. . !38%&"2 ?&"$ '!+& /#+&%%&"

3* PDSA

1 u%$* $"i& %!%/u$& r!n$n$ d$n %!#$"$n$"$n '!nin,"$&$n %u&u

d$n "!!#$%$&$n '$i!n Pr.,r$% PMKP L$'.r$n "!,i$&$n

2 u%$* $"i& %!n,,un$"$n 'r.! +$n, ".ni&!n un&u" %!#$"u"$n

id!n&i"$i $r!$ 'ri.ri&$ un&u" '!r/$i"$n !/$,$i%$n$ +$n,

di&!&$'"$n 'i%'in$n '!r/$i"$n di $r!$ 'ri.ri&$

3 u%$* $"i& %!nd."u%!n&$i"$n '!r/$i"$n +$n, di$'$i d$n

%!%'!r&$*$n"$nn+$ a!oran'0 !e"aksanaan PMKP (!eraikan %g

sua# i"aksanakan & mem!erta#ankan)


MENCAPAI DAN MEMPERTAHANKANPENINGKATAN


104/118

PENINGKATANS'&"/&3 PMKP.10.

K!,i$&$n '!r/$i"$n %u&u d$n "!!#$%$&$n '$i!ndi#$"u"$n un&u" $r!$ 'ri.ri&$ !/$,$i%$n$ +$n,

di&!&$'"$n 'i%'in$n ru%$* $"i&

E+!,!" P!"#+&" PMKP.10. +#&' !38%&"

!38%&"

1 Ar!$ +$n, di&!&$'"$n 'i%'in$n ru%$* $"i&

di%$u""$n "!d$#$% "!,i$&$n '!nin,"$&$n (#i*$&

ju,$ PMKP3 EP 1) $r!$ "#ini %$n$j!ri$#

$$r$n "!!#$%$&$n '$i!n

2 SDM $&$u #$inn+$ +, di/u&u*"$n u&"dr Luwi - PMKP 2 juni 2013 10



105/118

PENINGKATANE+!,!" P!"#+&" PMKP.10.

3 P!ru/$*$n-'!ru/$*$n dir!n$n$"$n d$n diuji !n$n$ &ind$" #$nju& d$ri $n$#ii d$&$ A

@MEA d##

4 Di#$"$n$"$n '!ru/$*$n +$n, %!n,*$i#"$n

'!nin,"$&$n ;u"&i /$*w$ r!n$n$ &ind$"

#$nju& ud$* di#$"$n$"$n

5 T!r!di$ d$&$ +$n, %!nunju""$n /$*w$

'!nin,"$&$n &!r$'$i !$r$ !=!"&i= d$n#$n,,!n, *$i# '!r/$i"$n

6 Di/u$& '!ru/$*$n "!/ij$"$n +$n, di'!r#u"$n

un&u" %!r!n$n$"$n un&u" %!#$"$n$"$ndr Luwi - PMKP 2 juni 2013 10

MENCAPAI DAN


106/118

MEMPERTAHANKAN PENINGKATAN

S'&"/&3 PMKP.11. Pr.,r$% %$n$j!%!n rii". /!r"!#$nju&$n di,un$"$n un&u" %!#$"u"$n

id!n&i"$i d$n %!n,ur$n,i KTD d$n %!n,ur$n,i rii". #$in &!r*$d$'

"!!#$%$&$n '$i!n d$n &$=

E+!,!" P!"#+&" PMKP.11.

1 Pi%'in$n ru%$* $"i& %!n!r$'"$n "!r$n,"$ $u$n %$n$j!%!n rii".

+$n, %!#i'u&i $) $%'$i =) +$n, di%u$& di M$"ud d$n Tuju$n R#*%

M&"&4!,!"

2 P$#in, !di"i& !&i$' &$*un ru%$* $"i& %!#$"$n$"$n d$n

%!nd."u%!n&$i"$n '!n,,un$$n $#$& '!n,ur$n,$n-'r.$"&i=-&!r*$d$'-

rii". d$#$% $#$* $&u 'ri.ri&$ 'r.! rii". FMEA HVA ICRA

3 ;!rd$$r"$n $n$#ii 'i%'in$n ru%$* $"i& %!%/u$& r$n$n, u#$n,

d$ri 'r.! +$n, %!n,$ndun, rii". &in,,i R!"-&"& '#"/&% +&"4'


@MEA


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@MEA

1 S!#!& $ *i,*-ri" 'r.!2 A!%/#! $ &!$%

3 Di$,r$% &*! 'r.! $nd /r$in&.r%'.&!n&i$# =$i#ur! %.d! $nd &*!ir !!&

4 Pri.ri&i>! =$i#ur! %.d!5 Id!n&i=+ r..& $u! .= =$i#ur! %.d!

6 !d!i,n &*! 'r.!

7An$#+>! $nd &!& &*! n!w 'r.!

8 I%'#!%!n& $nd %.ni&.r &*! r!d!i,n!d'r.!


PE;EDAAN @MEA A


108/118

PE;EDAAN @MEA A

FMEA P3&%'#

@ P3*!* '!i"

Di$,r$% &+3 3*!*

A'$ +$n, 8#*&'!rj$diH

@."u '$d$ '!"*#

%!$&$&+&" 3*!*

u$&u i&!%

M!n!,$* %!$&$&+&"

*!8!+, '!34&/#

RCA

R!&%'#

K!4&/#&" '!i"

Di$,r$% %3"+$#*

A'$ +$n, '!+&&!rj$diH

@."u '$d$ %!$&$&+&"*#*'!,

M!n!,$* %!$&$&+&","-+ %!,8&+#


MENCAPAI DAN


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MENCAPAI DANMEMPERTAHANKAN PENINGKATAN

u%$* $"i& '!r#u %!n,,un$"$n '!nd!"$&$n'r.$"&i= d$#$% %!#$"$n$"$n %$n$j!%!n rii".S$#$* $&u $r$ %!#$"u"$nn+$ $d$#$* 'r.,r$%

%$n$j!%!n rii". +$n, dir!%i"$n %!#i'u&i".%'.n!n

id!n&i"$i rii".G

%!n!&$'"$n 'ri.ri&$ rii".G

'!#$'.r$n &!n&$n, rii".G %$n$j!%!n rii".G

in

M$n$j!%!n "#$i%-"#$i% +$n, &!r"$i&dr Luwi - PMKP 2 juni 2013 10



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PENINGKATAN• ,&"&4!,!" 3#*#% &/&+& &"&+#*#* /&3# 3#*#% !'!r&i

!/u$* 'r.! un&u" %!#$"u"$n !


111/118


PSES MANAEMEN


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ISIK1 Id!n&i"$i rii".2 P!#$'.r$n rii". (L$'.r$n Inid!n)

3 Pri.ri&$ rii". (Risk 1raing Matri2)

4In

ause na"%sis/ R)5 M$n$j!%!n rii".


PESIAPAN UMA SAKIT


113/118

PESIAPAN UMA SAKIT

1. B!"'% T#,;K,#'!;P&"#'#& PMKP2. S*" P3$3&, PMKP

:. S*" %!8#4&%&" !3!"-&"&&" !+&%*&"&&" ,"!9

!+&3&" PMKP (8#*& 4&/# *&' /"$ P!/,&" PMKP)

.

S*" P!/,&" PMKP=. P&"/&";SPO *#*'!, !"-&'&'&" !+&3&" IKP B%

!"-&'&'&" !+&3&" IKP P!3*#

. K!8#4&%&" 3*!/3 !"-&'&'&" !+&3&" &"&+#*&

9&+#/&*# /&" '#"/&% +&"4' "'% #"/#%&'3 ,'

. D!5"#*# S!"'#"!+ KTD KNC

. S*" P&"/&" C+#"#-&+ &'7&?

. T!'&%&" = -+#"#-&+ &'7&?


PESIAPAN UMA SAKIT


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PESIAPAN UMA SAKIT

;u"&i '!#$"$n$$n "!,i$&$n K.%i&!:P$ni&i$:Ti%PMKP n.&u#!n r$'$& /$*$ 'r.,r$% PMKP PPIMP #ini$# '$&*w$+ d##

;u"&i '!n$&$&$n '!n,u%'u#$n $n$#i$ d$&$indi"$&.r $r!$ "#ini $r!$ %$n$j!ri$# d$n $$r$n

"!!#$%$&$n '$i!n d$n '!#$'.r$n inid!n"!!#$%$&$n '$i!n

;u"&i &!#$* di#$"u"$n TL:'!r/$i"$n +, &!#$*di#$"u"$n /!rd$$r"$n *$i# $n$#ii indi"$&.r

;u"&i '!#$"$n$$n #ini$# P$&*w$+ d."u%!n&$i di M /u"&i &!#$* di#$"u"$n $udi&P TL ud$* di#$"$n$"$n

$i# A ri" ,r$din, TL ud$* di#$"u"$n


METODE PENILAIAN


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METODE PENILAIAN

1. P!3'!,&" P!"#"$%&'&" M' K!*!+&,&'&" P&*#!" D#3' P3!*!"'&*#

'!"'&"$ P3$3&, PMKP K!8#4&%&" PMKP

2. P!3'!,&" /"$ K,#'! M';T#, KPRS

-+#"#-&+ &'7&? FMEA RCA T!+*3

S#*'!, M&"&4!,!" D&'& !,#+#&"

!"$,+&" &"&+#*& 9&+#/&*# 3!"-&"&

'#"/&% +&"4'

#"/#%&'3 %+#"#* #"/#%&'3,&"&4!3#&+ #"/#%&'3 %!*!+&,&'&" &*#!"

/&'& *!"'#"!+ KTD KNC


H&3# P!3'&,&W&%' Sur

M$n$j!%!n

Sur

M!di

Sur

K!'!r$w$&$n


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M$n$j!%!n M!di K!'!r$w$&$n0.00 @

0.:0

P!%/u"$$n '!r&!%u$n

- P!r"!n$#$n

- P!nj!#$$n j$dw$# $$r$ ur

0.:0

P!'!,&" P!"#"$%&'&" M' /&" %!*!+&,&'&"

P&*#!" MDG*

(P3!*!"'&*# D#3!%'3 RS '!"'&"$ P3$3&, PMKP

MDG*)

S!,& *39!#30.:0

0.=

EAT KPI

Sur

1 D$=&$r '$i!n 'u#$n, 2 /u#$n &!r$"*ir d$n

%!%i#i*n+$

dii$'"$n u&" &!#$$* M T!r&u&u'

2 D$=&$r '$i!n r$w$& in$' d$n r!n$n$ .'!r$i d$n

&nd$"$n *$ri ini d$n %!%i#i*n+$ dii$'"$n u&"

T!#uur '$i!n

0.= @ T!#$$* T!#$$* T!#$$* d."u%!n

Hari Kedua

08.00-08.45 Klarifikasi dan masukan


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08.00 08.45 Klarifikasi dan masukan

(Pertemuan surveior dengan para pimpinan RS untuk klarifikasi)

08.45- 09.00 REHAT KOPI

09.00- 12.00 Telusur MK Telusur IndividuAPK! AP! PP!

PA"

Telusur HPK! PPK! SKP! PPI

12.00- 13.00 ISHOMA

13.00- 14.30 TelusurMK

Telusur APK! AP!PP! PA"

TelusurHPK! PPK! SKP! PPI

14.30 -15.30 Rumah Sakit mempresentasikan tentang :

• F!"# $anduan $raktik K%inis# "%ur K%inis&'%ini(a% $ath)a*#

ana+emen Risik,# nsiden Kese%amatan $asien# d%%

• ihadiri ,%eh se%uruh Sur/ei,r15.30 Surveior meminta daftar pega#ai! dan mengam$il se%ara sampling masing&

se'umla (total &* file) utk Telusur KPS

15.30 -1.00 Pertemuan Tim Surveior



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TERIMA

KASIH

materi pmkp

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