pedoman pelayanan ppi rs lng badak.doc

7/24/2019 PEDOMAN PELAYANAN PPI RS LNG BADAK.doc

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PEDOMAN PELAYANAN KOMITE PENCEGAHAN

DAN PENGENDALIAN INFEKSI

RUMAH SAKIT

RUMAH SAKIT LNG BADAK BONTANG

2015

DAFTAR ISI

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SURAT KEPUTUSAN....................................................................................................................2

DIREKTUR RSU DADI KELUARGA..........................................................................................2

PEDOMAN PELAYANAN............................................................................................................2

PELAYANAN PENCEGAHAN DAN PENGENDALIAN INFEKSI...........................................2

RSU DADI KELUARGA...............................................................................................................2

BAB I PENDAHULUAN...............................................................................................................4

BAB II STANDART KETENAGAAN.........................................................................................75

BAB III STANDART FASILITAS................................................................................................79

BAB IV TATA LAKSANA PELAYANAN...................................................................................81

BAB V LOGISTIK........................................................................................................................88BAB VI KESELAMATAN KERJA.............................................................................................89

BAB VII KESELAMATAN PASIEN............................................................................................92

BAB VIII PENGENDALIAN MUTU.........................................................................................94

BAB I PENUTUP.......................................................................................................................99

BAB VI LANDASAN HUKUM..............................................................................................1!!

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M"#($6$ ,'# %"#(%/-'# ;3%-$3 63?"$-"#6 6"$'/ /'6$"# ,$3'#(

/"3'+''# "%,$'# %"#0"3'*'# #0' /',' IPCN 6'' /'6$"# /-'#(.

B"3;;3,$#'6$ ,"#('# IPCN 6'' "3',$ $#"6$ /;"#6$'- KLB.

M"%;#$;3 "/'*'# /"('6 ,'-'% %"#'-'#'# 6'#,'3 $6;-'6$

B"3;;3,$#'6$ ,"#('# #$ "3'$ -'$#. M"-''# /"#('+'6'# "3*','/

$#,''# $#,''# 0'#( %"#0$%/'#( ,'3$ SPO.

M"-''# $#?"6$('6$ %"#"'/'# ,'# %"-'6'#''# $#"6$ &$-' ',' KLB.

B""3' 6'%' ,"#('# TIM PPI ,'-'% %"-''# $#?"6$('6$ %'6'-'* KLB

HAI6@.

M"%&"3$ 6-'# # %"#("%&'#('# ,'# %"#$#(''# '3' PPI.

M"%&"3$ ;#6-'6$ /',' /"('6 "6"*''# 3%'* 6'$ .

. T('6 A#((;' -'&;3';3$%

M"-'6'#''# /"#0-*'# ,'# /"#,$,$'# "#'#( %'"3$ %'"3$ 0'#( &"3'$'#

,"#('# /"#("#,'-$'# $#"6$ #;6;;%$'- "/',' /"('6 -'&;3'.

M"%&'# /"-'6'#''# /"%"3$6''# 6+'& '' -3 /'6$"#

M"%'#' /"%"3$6''# -'&;3';3$% 6"6'$ SPO

M"-'6'#''# ('6 -'$# ,'3$ "' /'#$$' /"#("#,'-$ $#"6$ #;6;;%$'-.

(. T('6 A#((;' -$#"#)

M"%$6'*'# -$#"# $#"6$6 ,'# #;# $#"6$6

M"-'6'#''# /"%"3$6''# 6+'& -$#"# &"36$*.

M"%'#' /"#((#''# &'*'# ,"6$#"'# 6"6'$ '3'#.

M"%'#' "($''# *'#, *$($"#" ,$3'#( -$#"#.

*. T('6 A#((;' ($6$ )

M"%'#' "($''# *'#, *$($"#" ,$3'#( ($$.

M"%&'# /"-'6'#''# /"%"3$6''# &'*'# %''#'# ,'# 6+'& /"('6 ($6$.

M"%'#' /"#((#''# &'*'# ,"6$#"'# ($$.

$. T('6 A#((;' IPSRS )

M"%'#' /"-'6'#''# *'#, *$($"#" /"('6 IPSRS.

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M"%'#' /"#((#''# &'*'# ,"6$#"'#.

M"%&'# %"%/"36$'/'# $ '$3 &"36$* -$%&'* ,'# %'# ,$3'#( "3"#.

M"%'#' /3;6"6 /"%&''3'# $#"#"3';3.

M"#0$'/'# &'*'#2 *'6$- /"%"3$6''# -'&;3';3$%

C$ D)*t%)3'*) Ten!

K;%$" PPI %"3/''# #$ /"-'0'#'# 0'#( %"-''# "($''# 6"'3' ;%/3"*"#6$ ,'3$

6"$'/ #$ /"-'0'#'# ,$ 3%'* 6'$ )

1. ZMR IGD P;-$ 3'+' '-'# U#$ R'+' $#'/ S"3"'3$' '#'#6$ IPSRS G$6$ -$"#

'3%'6$ SMF -'&;3' I;

2. HCU H;6" ""/$#( CS@.

76


78/96

BAB III

STANDART FASILITAS

A$ F*)&)t* B!) Pet'!*

1. D"#'*

R'#('# PPIRS "3$#"(3'6$ ,"#('# 3'#('# /"3'#;3'# ,"#('# ;%$" -'$# R%'*

6'$,$-'#'$ 2.

2. S'#,'3 F'6$-$'6.

N; F'6$-$'6 J%-'*A F$6$ >&'#(#'#

G",#( /"3'#;3'# -'#'$ 2 1

B P"3'-''#M"' 1 &'*K36$ < &'*K;%/"3 1 &'*L$#" $#"3#" 1 #$A-%'3$ '' 1 &'*ATK 1 6"B /"3/6'''# PPI

B$ F*)&)t* Pe&-nn$

1. M"#06# "&*'# /"#,$,$'# ,'# /"-'$*'# /"('6 "6"*''# /"('6 -'&;3';3$%

3"-'+'# ,'# /$*' -'$#.2. M"%'6$'# ""36",$''# /"3-"#('/'# 0'#( ,$/"3-'# # %"#"3'/'# /"#"('*'#

,'# /"#("#,'-$'# $#"6$ 0'#( ,$3";%"#,'6$'# ,'# $#,''#:$#,''# "'%'#'#

&$;-;($6 APD@


79/96

BAB ITATA LAKSANA PELAYANAN

A. M"3/''# -'#('*: -'#('* /"-'0'#'# /"#"('*'# ,'# /"#("#,'-$'# I#"6$ ,$ %'6$#(

:%'6$#( #$ "3' 6&& )

1. T'' -'6'#' /"-'0'#'# #$ 63?"$-"#6

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'. P"#'#((#( '+'&1@ IPCN2@ IPCLN 3'#('# 0'#( ,$-''# 63?"$-"#6


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1@ IPCN /"('6 3'#('#2@ P"('6 CSSD


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=. T'' -'6'#' ;3%-'3$% '#$&$;(3'%'. P"#'#((#( '+'&

1@ K;%$" PPI2@ K;%$" '3%'6$,'' /"%"3$6''# "6"*''# 0'#( ',' ,$ HRD

2@ D'' "6"*''# '30'+'#.. T'' -'6'#'1@ HRD %"#("-'3'# /"%&"3$'*'# /"%"3$6''# "6"*''# 6"$'/ *'3$ -'#(

'*#.2@ K;%$" PPI %"#($,"#$$'6$ #$ 0'#( *'36 ,$-''# /"%"3$6''# "6"*''#

R'#( ;*;3 '$3&;3#" ) /"('6 ,$-''# /"%"3$6''# TB 6"$'/ < &-'# 6"'-$.U#$ G$$ ) /"%"3$6''# $/;$, $'/ 1 '*# 6"'-$'@ K'30'+'# %"-''# /"%"3$6''# "6"*''# 0'#( 6"6'$ ""#'#.

&@ H'6$- ,$$,"#$$'6$@ B"36'%' HRD %"-''# '#'-$6' ,'# /"#'''# "6"*''#.

,@ K;%$" PPI ,'# HRD %"-'/;3'# *'6$- /"%"3$6''# "6"*''# '30'+'#"/',' ,$3"3 ,'# SMF.

8. P"-'0'#'# 3"#;?'6$ &'#(#'#'. P"#'#((#( '+'&

1@ K"' ;%$" PPI2@ IPSRS

&. P"3'#(' "3'1@ P'/'# /"%&"3$'*'# 6",'#( ,$-''# 3"#;?'6$ &'#(#'#2@ P"%"3$6''# 6+'& -'#'$


83/96


84/96


85/96

BAB

LOGISTIK

A. Tt C% &+!)*t)# PPIRS

1. P"3"#'#''# &'3'#(.'. B'3'#( 3$#" )

1) K"3'6 HVS $#' /3$#"3 &;-/;$# ;3% 63?"$ *'3$'# ;3% 63?"$B-'#'# ;3% SPO 63?"$-"#6 & -$6.

2@ B'*'# ,"6$#"6$&. B'3'#( $,' 3$# )

1@ P3;/;6'- /"%"3$6''# -3 ,'# 6+'&2) P"#(',''# -"'-" ,'# &'##"3 "&"36$*'# '#('# "$' &' /"#"('*'# ,'#

/"#("#,'-$'# $#"6$ '#((#( '+'& &"36'%'.

2. P"3%$#''# &'3'#(.'. B'3'#( 3$#" ,$6'%/'$'# /',' &'($'# -;($6$ 3$#" 3%'* 6'$.&. B'3'#( $,' 3$#" ,$6'%/'$'# "3-"&$* ,'*- /',' ,$3"3 # ,$%$#''#

/"36"'#.


86/96

1. P"#"('*'# ,'# P"#("#,'-$'# PPI2. K"'%'#'# /'6$"# /"#(##( ,'# /"('6

B$ Ke*e&4tn ,n Ke*etn #e%( Pe!


87/96

2. L$%&'* '$3


88/96

1@ K;*;3 ;#' $#"6$

2@ K;*;3 ,3;/-" $#"6$


89/96


90/96

BAB III

PENGENDALIAN MUTU

A$ S)*te4 Penttn ,n Pe&"+%n

1. P"#"3'/'# 606"% /"#'''# ,'# /"-'/;3'# ,$ RSU D',$ K"-'3(' P3+;"3;

%"%/#0'$ '# )

'. M"#,'/''# ,'' # %"%"''# %'6'-'* %'6'-'* 0'#( &"3'$'# ,"#('#

"6"-'%''# /'6$"#

&. S"&'('$ &'*'# /"%&"-''3'# # %"#06# -'#('*:-'#('* '('3 KTD 0'#(

6"3/' $,' "3-'#( "%&'-$

. S"&'('$ ,'6'3 '#'-$6$6 # %"#,"6'$# -'#( 6' 6$6"% '6*'# /"-'0'#'# /'6$"#%"#',$ -"&$* '%'#

,. M"#3#'# %-'* $#6$,"# "6"-'%''# /'6$"# KTD ,'# KNC@

". M"#$#(''# % /"-'0'#'# ,'# "6"-'%''# /'6$"#

2. RSU D',$ K"-'3(' %"+'$&'# '('3 6"$'/ $#6$,"# "6"-'%''# /'6$"# ,$-'/;3'#

"/',' ;%$" "6"-'%''# /'6$"# 3%'* 6'$


91/96

'. 1 24 '% # "',$'# 0'#( %"3/''# 6"#$# "-"?"#6 &"3,'%/' "%'$'# ''

"*$-'#('# #(6$ %'0;3 6"'3' /"3%'#"#@. A/'&$-' /"-'/;3'# 6"'3' "3-$6 &"-%

6$'/ /"-'/;3'# KTD ,'/' ,$6'%/'$'# 6"'3' -$6'# "3-"&$* ,'*-.

&. 2 24 '% # "',$'# 0'#( &"3,'%/' -$#$6 > ;#6""#6$ > "/'3'*'# $,'

6$(#$$'# %$#;3 ,'# %;,"3'.

=. T$#,' -'# ,'3$ /"-'/;3'# )

'. T$#(' 3$6$; 3"#,'* ,'# %;,"3' )$#?"6$('6$ 6","3*'#' ;-"* &'($'#>#$ 0'#(

"3'$ $#6$,"# 5) +*' +*; +*"3" +*"# +*0@.&. T$#(' 3$6$; $#(($ ,'# "63$% ) R;; C'6" A#'-06$6 RCA@ 0'#( ,$;;3,$#'6$

;-"* ;%$" "6"-'%''# /'6$"#.

. B$-' $#6$,"# "6"-'%''# /'6$"# 0'#( "3',$ %"%/#0'$ $#(' 3$6$; %"3'*

"63$%@ %'' ;%$" "6"-'%''# /'6$"# 6"("3' %"-'/;3'# "',$'# "36"&

"/',' ,$3"6$ RSU D',$ K"-'3('.

,. B$-' $#6$,"# "6"-'%''# /'6$"# 0'#( "3',$ %"%/#0'$ $#(' 3$6$; #$#(

$#(($@ %'' ;%$" "6"-'%''# /'6$"# 6"("3' %"-'/;3'# "',$'# "36"&

"/',' D$3"6$ RSU D',$ K"-'3('.

". K;%$" "6"-'%''# /'6$"# RS P'#$ R'*'0 %"-''# 3"'/$-'6$ -'/;3'# $#6$,"#

"6"-'%''# /'6$"# ,'# '#'-$6$6#0' 6"$'/$(' &-'# "/',' ,$3"6$ RSU D',$

K"-'3('.

B$ Pene%"n In,)#t+% Ke*e&4tn P*)en$

1. K;%$" K"6"-'%''# P'6$"# RSU DADI KELUARGA %"#"'/'# $#,$';3

"6"-'%''# &"3,'6'3'# ''6 /"3$%&'#('# high ris, high impact, high volume, prone

problem.

2. K;%$" K"6"-'%''# P'6$"# RSU DADI KELUARGA %"#"-'6'# ,"$#$6$ ;/"3'6$;#'-

3""#6$ /"#(%/-'# ,'' /"3$;," '#'-$6$6 '3' /"3*$#('# 6%&"3 ,'' '3(" ,'#

/"#'#((#( '+'&.


92/96

C$ An&)*)* A#% M*&

1. D'-'% 3'#(' %"#$#(''# % ,'# "6"-'%''# /'6$"# RSU DADI KELUARGA%"#"3'/'# %";," root cause analysis RCA@ '' '#'-$6' ''3 %'6'-'* 0'$ 6'

"($''# $#?"6$('6$ "3633 0'#( &"3'# # %"-''# $,"#$$'6$ /"#0"&'&

%'6'-'* ,'6'3 ,'# # %"#"#'# $#,''# '('3 "',$'# 0'#( 6'%' $,' "3-'#(

"%&'-$.

2. RCA ,$-''# /',' $#6$,"# %",$6 "',$'# #0'3$6 ","3' ,'# KTD 0'#( 6"3$#( "3',$

,$ RSU DADI KELUARGA.


93/96

&@. A#(' "',$'# $#"6$ '3% $#6

@. A#(' "',$'# $#"6$ '3"#' 3'#66$ ,'3'*

,@. T'3(" 63?"$-"#6 '#(' "',$'# $#"6$ 15

"@. T"36",$'#0' B'*'#:&'*'# ,"6$#"6$ 0'#( 6"6'$ 3";%"#,'6$ ,'# '%'# &'($

-$#(#('#@. D$-''##0' "($''# /"%'#''#

(@. H'6$- 6+'& ) '#('# ,$#,$#( ,'# -'#'$ AC 0'#( %"%"#*$ 6'#,'3 SPM@

*@. H'6$- -3 ) P6 ,'3'* ,'# #( '""3

2). U#$ CSSD )

'@. I#,$';3 &;+$" ,$ "6 $%$' ,'# %$3;&$;-;($ ,$-'6'#''# ,'# *'6$-#0' &'$&@. M'$#"#" ';-'?" .

@. K'-$&3'6$ A;-'?" ""3#'- &'$

,@. I#,$';3 %"'#$ $%$' &$;-;($


94/96

P"#3#'# A#(' K%'# ,$ '3"' /"-'0'#'# *66

E$ F+%4'&*) ,%) )n,)#t+%6)n,)#t+% te%*e3't ,) t* ,& *e3!) 3e%)#'t

'@ K"-;%/; P"-'0'#'# N;#:B",'*1@ A#(' $#"6$ '3"#' J'3% I#6

2@ A#(' $#"6$ -' ;/"3'6$ 1!! T;'- /"#,"3$' 0'#( ,$;/"3'6$ ,'-'% 6' &-'#


95/96

BAB I

PENUTUP

S"&'('$ /"#/ $3'#0' ,'/' ,$$#(''# "%&'-$ &'*+' /"-'0'#'# /"#"('*'# ,'#

/"#("#,'-$'# $#"6$ &'#-'* 36'# %"3"' 0'#( &"3('6 ,$ #$ PPIRS 6''. N'%# ('

'#((#( '+'& 6"%' /$*' 0'#( &"3',' ,$ R%'* S'$ U%% D',$ K"-'3('.

Y'#( /'-$#( /"#$#( ,$-'6'#''# ,'-'% 3'#(' P"#"('*'# ,'# /"#("#,'-$'# $#"6$

','-'* /'0':/'0' ",'6$ PPI "/',' 6' /'6$"# ,'# /"#(##( R%'* 6'$.6"*$#(('

,'/' %"3&'* /"3$-' 0'#( 6"*'/"#0'%/'$'# 6'3'#' ,'# /3'6'3'#' PPI ./'0' /"#"('*'#

,'# /"#("#,'-$'# $#"6$ ,$6','3$ '' $,' %"%"3-'# ,'#' 0'#( &"6'3 6"*$#((' %"%"3-'#

,#('# /"#* ,'3$ %'#'("%"# 3%'* 6'$.

D"%$$'#-'* /",;%'# /"-'0'#'# /"#"('*'# ,'# /"#("#,'-$'# $#"6$ R%'* S'$

U%% D',$ K"-'3('-"&$* &'$ %"#"('* ,'3$ /',' %"#(;&'$.

P3+;"3; 1 '#'3$ 2!15

D$3"3

D% E* D)n,n)

94


96/96

BAB I

LANDASAN HUKUM

1. U#,'#( U#,'#( R"/&-$ I#,;#"6$' #;%;3 44 '*# 2!!9"#'#( R%'* 6'$.

2. K"/6'# M"#"3$ K"6"*''# RI #;%;3.129>M"#K"6>SK>2!!8 "#'#( 6'#,'3 %$#$%'-

/"-'0'#' R%'* S'$.

1999 "#'#(

6'#,'3 /"-'0'#'# R%'* 6'$.

7. K"/6'# M"#"3$ K"6"*''# #;%;3 1575>M"#"6>2!!5 "#'#( O3('#$6'6$ ,'# '' "3'

D"/'3"%"# K"6"*''#.

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