INDIKATOR PENINGKATAN MUTU DAN KESELAMATAN PASIEN
Angka Kelengkapan Pengkajian Keperawatan January February March Target > 80% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
82%
76%
86%
April 82%
May 70%
June 87%
July 74%
August 82%
September 70%
October 75%
Nov 80%
December 85%
Target > 80%
Waktu Tunggu Hasil Pelayanan Laboratorium klinik : Pemeriksaan darah lengkap dan kimia klinik (<140 Menit ) January Target > 90 %
81,4%
February 97,2%
March
April
87,5% 88,9%
May
June 97,2%
July 91,8%
87,7%
August 86,2%
September 92,4%
October
November 92,4%
December 91,8%
92,6%
100.0% 95.0% 90.0% 85.0% 80.0% 75.0% 70.0%
Target > 90 %
ANGKA PENGULANGAN PEMERIKSAAN RADIOLOGI January February March April Target <2 % 0.6% 0.5% 0.4% 0.3% 0.2% 0.1% 0.0%
0.2%
0.3%
0.1%
0.1%
May
June
July August Sept
Oct
Nov
Dec
0.5%
0.0%
0.1%
0.1%
0.0%
0.0%
0.2%
0.5%
Target <2 %
KETEPATAN PELAKSANAAN OPERASI ELEKTIVE
January February
Target 100 %
95.0% 90.0% 85.0% 80.0% 75.0% 70.0% 65.0%
82.1%
79.0%
March 78.0%
April
May
June
July
August
83.0% 77.0% 85.0% 79.0%
September October November
83.0%
89.0%
91.2%
December
90.1%
90.3%
Target 100 %
Pemberian Aspirin Pada Pasien AMI January February March
April
May
June
July
August September October November December
Target 100 % 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% 120.0% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0%
100,0%
100,0%
100,0%
100,0%
Target 100 %
PENULISAN RESEP YANG TIDAK JELAS
January
Target 0 % 0,04%
February March
April
0,03%
0,04%
0,21%
May
June
0,0% 0,16%
July
August
September October
November
0,21%
0,19%
0,23%
0,003%
0,17%
December
0,0%
0.25%
Axis Title
0.20% 0.15% 0.10% 0.05% 0.00%
Target 0 %
Pengkajian Pre-Anasthesi dilaksanakan untuk Pasien Pra Operasi Elektif dengan Anasthesi Umum January February March April
Target >80 % 77.2% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
May
June
July
August September October November December
62.0% 75.0% 63.0% 71.0% 69.0% 68.0% 65.0%
71.5%
72.0%
73.0%
75.0%
Target >80 %
KEJADIAN REAKSI TRANSFUSI DARAH January Target 0 % 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
0,0%
February March April 0,0%
0,0%
0,0%
May 0,0%
June
July
0,0% 0,0%
August 0,0%
September October November December 0,0%
0,0%
0,0%
0,0%
Target 0 %
Kelengkapan Pengisian Resume Medis 1 X 24 Jam January Target 95 %
90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
63,0%
February March 60,0%
75,0%
April
May
June
July
72,0%
75,0%
80,0%
81,0%
Novemb Decemb Septemb er er August er October 82,0%
83,0%
79,0%
80,0%
82,0%
Target 95 %
ANGKA PHLEBITIS January Target < 10/Mill Satuan /Mill
9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0
February
March
April
May
June
July
August
7,0
5,0
4,0
6,0
3,0
6,0
September October November December 7,5
6,8
7,2
7,8
VAP (VENTILATOR ASSOCIATED PNEUMOMIA) January
Target < 10/Mil
February
March
April
0,0
1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0
May
0,0
June
0,0
July
0,0
August
0,0
September
0,0
October
0,0
November
0,0
December
0,0
0,0
Target < 10/Mil
ILO (INFEKSI LUKA OPERASI) January
Target < 10%
9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0
February
March
April
May
June
July
August
September
October
0,0
0,0
0,0
0,0
0,0
0,0
0,0
0,0
November December
1,8
0,0
Target < 10 %
ISK (INFEKSI SALURAN KENCING) January February Target < 10/Mil
1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0
March
April
May
June
July
August
0,0
0,0
0,0
0,0
0,0
0,0
September October November December
0,0
0,0
0,0
0,0
Target < 10/Mil
INDIKATOR MUTU MANAJEMENT
KETERSEDIAN OBAT DAN ALKES EMERGENCY DI RUANG RESUSITASI IGD
January Target 100%
100%
February March 100%
100%
April
May 100%
June 100%
July 100%
August September October November December 100%
100%
100%
100%
100%
100%
120% 100% 80% 60% 40% 20% 0%
Target 100%
PENGGUNAAN APAR
Target <100
120% 100% 80% 60% 40% 20% 0%
January
February
March
April
-
-
-
-
May 100%
June 100%
July 100%
August 100%
September 100%
October 100%
Nove 100%
Dec 100%
PELAKSANAAN STANDAR PENANGANAN TERTUSUK JARUM
January February Target <100%
100%
-
March
April
May
June
July
-
100%
-
-
100%
August September October November December -
100%
-
-
-
Target <100% 120%
Target <100%
100%
80%
60%
40%
20%
0%
January
February
March
April
May
June
July
August
September
October
November
December
PEMANFAATAN ALAT CT SCAN, UNTUK CT SCAN KEPALA DALAM PROSES PENEGAKAN DIAGNOSE PASIEN YANG DILAKUKAN DI UNIT RADIOLOGI
January February Target 100%
100%
100%
March
April
May
June
July
100%
100%
100%
100%
100%
August September October November December 100%
100%
100%
100%
100%
120% 100% 80% 60% 40% 20% 0%
Target 100%
INDEKS KEPUASAN PASIEN January Target >90%
100% 98% 96% 94% 92% 90% 88% 86%
92%
February March 98%
96%
April
May 94%
June 91%
July 92%
August 96%
September October November December
99%
93%
92%
91%
94%
Target >90%
PELATIHAN YANG DILAKSANAKAN 20 JAM PERTAHUN
January
Target >60%
80% 70% 60% 50% 40% 30% 20% 10% 0%
February
65%
72%
March
April
59%
May
61%
June
65%
July
63%
August
70%
September October
69%
73%
70%
November December
68%
69%
Target >60%
10 PENYAKIT TERBANYAK DI RS.SYAFIRA TAHUN 2015 NO.
DIAGNOSA
TOTAL
1
HT
1850
2
ANC
1562
3
DM
1485
4
APP
1481
5
OBSERVASI FEBRIS
1213
6
CEPHALGIA
1212
7
ISPA
1039
8
KISTA ATERM
759
9
GAGAL GINJAL KRONIK
654
10
KATARAK
405
TOTAL
11660
2000 1800 1600 1400 1200 1000 800 600 400 200 0
NO. DIAGNOSA 1 POST EKSISI OBSERVASI 2 FEBRIS 3 DHF 4 APPENDICTOMY 5 HT 6 DYSPEPSIA 7 DM 8 POST SC 9 POST URS POST 10 LAPAROTOMY TOTAL
TOTAL 629 468 430 304 199 191 134 112 75 75 2617
700 600 500 400 300 200 100 0
KECEPATAN WAKTU PEMBERIAN INFORMASI TENTANG TAGIHAN PASIEN RAWAT INAP <2 JAM
Target >100%
January
February
March
April
May
June
July
August
September
October
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
November December 100%
100%
120% 100% 80% 60% 40% 20% 0%
Target >100%
JUMLAH REALISASI KALIBRASI ALAT MEDIS DENGAN USIA LEBIH DARI 1 TAHUN, ATAS INDIKASI YANG DITETAPKAN UNTUK KALIBRASI 1 TAHUN SEKALI January
February March
Target >85%
April
May
June
July
August September October November December
53%Target >85%
60%
50%
40%
30%
20%
10%
0%
January
February
March
April
May
June
July
August
September
October
November
December
INDIKATOR SASARAN KESELAMATAN
PERSENTASE TERPASANGNYA GELANG IDENTITAS PASIEN BARU RAWAT INAP January Target >100%
100.1% 100.0% 99.9% 99.8% 99.7% 99.6% 99.5% 99.4% 99.3% 99.2%
99,5%
February 100%
March 99,6%
April 100%
May 100%
June 99,8%
July 100%
August 99,6%
September October 100%
100%
November December 100%
100%
Target >100%
PERSENTASE PELAKSANAAN READ BACK DITANDATANGANI OLEH PEMBERI INSTRUKSI DALAM WAKTU 1X24 JAM
January February Target >100%
30%
32%
March
April
May
June
July
37%
32%
38%
40%
45%
August September October November December 50%
51%
50%
55%
50%
Target >100% 60% 50% 40% 30% 20% 10% 0%
KEPATUHAN PEMBERIAN LABEL OBAT HIGH ALERT OLEH FARMASI
Target >100%
99.90% 99.80% 99.70% 99.60% 99.50% 99.40% 99.30% 99.20%
January
February
March
April
May
June
July
August
September
October
November
December
99,6%
99,8%
99,8%
99,8%
99,4%
99,6%
99,7%
99,8%
99,8%
99,6%
99,7%
99,5%
Target >100%
KEPATUHAN PELAKSANAAN PROSEDUR SITE MARKING PADA PASIEN YANG AKAN DILAKUKAN TINDAKAN OPERASI
Target >100%
January
February
March
April
May
June
July
August
September
October
70%
68%
70%
67%
65%
75%
72%
68%
74%
69%
November December
72%
67%
Target >100% 76% 74% 72% 70% 68% 66% 64% 62% 60%
PERSENTASE KEBUTUHAN PETUGAS KESEHATAN DALAM MELAKUKAN KEBERSIHAN TANGAN DENGAN METODE ENAM LANGKAH DAN LIMA MOMEN
January
Target >80%
60% 50% 40% 30% 20% 10% 0%
February
30%
March
35%
April
34%
May
40%
June
38%
July
45%
August
46%
September
40%
October
40%
November
52%
December
54%
55%
Target >80%
INSIDEN PASIEN TIDAK JATUH SELAMA PERAWATAN RAWAT INAP DI RUMAH SAKIT
January February Target >100%
March
April
May
June
July
-
-
-
-
-
99,9%
August September October November December
12000%
10000%
Target >100%
8000%
6000%
4000%
2000%
0%
January
February
March
April
May
June
July
August
September
October
November
December
MDG’S
ANGKA KEMATIAN IBU TAHUN 2015
JAN
JUMLAH KEMATIAN
FEB MAR APR MEI JUN JULI AGST
1
2
SEPT
OKTO
NOV
DES
2
Total Target
5 0%
JUMLAH KELAHIRAN
260
219
209
215 251 258 376
PERSENTASE/TAHUN
268
263
293
296
268
3175
0,1%
ANGKA KEMATIAN BAYI TAHUN 2015
JUMLAH KEMATIAN
JUMLAH KELAHIRAN
JAN
FEB
MAR
APR
MEI
JUN
JUL
AGS
SEPT
OKT
NOV
DES
2
0
2
1
2
0
0
1
1
1
1
0
TOTAL TARGET
11 0%
262
219
209
215
260
PERSENTASE/TAHUN
258
376
268
263
293
296
268
3187
0,3%
PENEMUAN ANGKA HIV (+) DI RS. SYAFIRA MELALUI PELAYANAN VCT
PENEMUAN ANGKA HIV (+)
JAN
FEB
MAR
APR
50%
50%
50%
0%
MEI
JUN JULI
100% 0%
AGS
33% 100%
SEPT
OKT
NOV DES TARGET
100%
0%
30% 0%
<50%
ANGKA KESAKITAN TB TAHUN 2015
JAN
FEB
MAR
APR
MEI
JUN JUL
AGS
SEP
OKT
NOV
DES
TARGET
BTA (+) DIANTARA SUSPEK YANG DI PERIKSA BTA 52%
100%
72%
60%
42%
47%
66%
66%
40%
50%
60%
100%
> 15%
69%
56%
78%
72%
68%
70%
77%
72%
69%
77%
72%
>65%
BTA (+) DIANTARA SEMUA PASIEN TB PARU
68%
