Pemantauan indikator mutu terkait program/pelayanan prioritas.
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No |
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Indikator Area Klinis |
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Juli |
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Agustus |
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September |
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Target |
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1 |
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Keterlambatan Waktu |
Operasi |
> 30 |
0% |
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0% |
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0% |
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0% |
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menit |
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2 |
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Ketidaklengkapan Informed Consent |
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0% |
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18,97% |
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0% |
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0% |
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3 |
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Operasi Ulang dengan diagnosa yang |
0% |
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0% |
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0% |
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0% |
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sama |
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4 |
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Penundaan Operasi Elektif |
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0,6% |
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0% |
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0,6% |
|
5% |
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5 |
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Ketidaklengkapan Laporan Operasi. |
|
2,4% |
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1,6% |
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0,8% |
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0% |
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6 |
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Ketidaklengkapan laporan anestesi |
|
1.32% |
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1.20% |
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0.96% |
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0% |
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7 |
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Ketidaklengkapan |
asssesmen |
pre |
|
1,3% |
|
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0,6% |
|
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0,96% |
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0% |
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anastesi. |
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8 |
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Infeksi Daerah Operasi |
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0% |
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2,8% |
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0% |
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1,5% |
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9 |
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Kelengkapan Assesmen Medis dalam |
|
97,84% |
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98,77% |
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92,24% |
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100% |
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waktu 24 jam setelah pasien Ranap. |
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Ketidakpatuhan |
pendokumentasian |
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10 |
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assesmen nyeri secara kontinyu di |
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10,35% |
|
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3,35% |
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0% |
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0% |
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status pasien. |
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11 |
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Tidak terlaporkannya |
hasil |
kritis |
0% |
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0% |
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0% |
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0% |
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laboratorium |
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12 |
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Keterlambatan hasil foto rawat jalan. |
0% |
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0% |
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0% |
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0% |
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13 |
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Waktu Tunggu Rawat jalan |
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69,51’ |
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55,24’ |
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83,88’ |
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60’ |
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14 |
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Kepatuhan terhadap CP. |
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63,64% |
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21,05% |
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9,09% |
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80% |
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Kualitas penggunaan antibiotik di area |
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15 |
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bedah RSUD Padangan menggunakan |
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18,75% |
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7,69% |
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17,19% |
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60% |
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metode Gyssen (Jumlah Gyssen 0 |
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dalam 1 bulan) |
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16 |
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Ketidaklengkapan Catatan Medis |
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0.00% |
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1.31% |
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0.17% |
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0% |
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Pasien |
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No |
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Indikator Area Manajeman |
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|
Juli |
|
Agustus |
|
September |
|
Target |
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|
1 |
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Keterlambatan menangani kerusakan alat. |
|
35% |
|
|
40% |
|
|
33,33% |
|
|
80% |
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2 |
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Keterlambatan respon time genset |
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0% |
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0% |
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0% |
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0% |
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3 |
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Linen Hilang |
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0,54% |
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0,11% |
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0,81% |
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0% |
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4 |
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Kecepatan terhadap respon komplain |
81,67% |
|
82,35% |
|
88% |
|
75% |
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5 |
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Ketidaklengkapan dokumen penagihan |
|
1,39% |
|
|
2,19% |
|
|
1,44% |
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0% |
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No |
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Indikator Sasaran keselamatan |
|
Juli |
|
Agustus |
|
September |
|
Target |
||||||||
|
|
Pasien |
|
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|||||||||||
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1 |
|
|
Kepatuhan Identifikasi Pasien. |
|
|
82,37% |
|
|
86,49% |
|
|
92,67% |
|
|
100% |
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||
2 |
|
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Waktu Lapor Hasil Kritis laboratorium |
100% |
|
100% |
|
100% |
|
100% |
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3 |
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Insiden Keamanan Obat yang perlu |
|
2,74% |
|
|
1,92% |
|
|
0,8% |
|
|
0% |
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diwaspadai |
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4 |
|
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Angka kelengkapan pengisian surgical |
100% |
|
100% |
|
100% |
|
100% |
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||||||||
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checklist di kamar operasi |
|
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5 |
|
|
Kepatuhan Hand Higiene |
|
|
67,40% |
|
|
67,30% |
|
|
68,24% |
|
|
85% |
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Kepatuhan Upaya Pencegahan Risiko |
|
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|
6 |
|
|
Cedera Akibat Pasien Jatuh pada |
|
72,34% |
|
|
85,31% |
|
|
87,09% |
|
|
100% |
|
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pasien Rawat Inap |
|
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