SISTEMATIKA IRAD

SISTEMATIKA
1.

2.
3. 4. 5. 6. 7.

Falsafah dan Tujuan Administrasi & Pengelolaan Staf dan Pimpinan Fasilitas & Peralatan Kebijakan & Prosedur Pengembangan & Program Pendidikan Evaluasi & Pengendalian Mutu

SISTEMATIKA
1.

2.
3. 4. 5. 6. 7.

Falsafah dan Tujuan ( 3 Parameter) Administrasi & Pengelolaan ( 2 ) Staf dan Pimpinan ( 4 ) Fasilitas & Peralatan ( 4 ) Kebijakan & Prosedur ( 2 ) Pengembangan & Prog Pendidikan (1) Evaluasi & Pengendalian Mutu ( 2 ) Total : 18 Parameter

SISTEMATIKA (FAS FKPE)

1.

2.
3. 4. 5. 6. 7.

Falsafah dan Tujuan ( 3 Parameter) Administrasi & Pengelolaan ( 2 ) Staf dan Pimpinan ( 4 ) Fasilitas & Peralatan ( 4 ) Kebijakan & Prosedur ( 2 ) Pengembangan & Prog Pendidikan (1) Evaluasi & Pengendalian Mutu ( 2 ) Total : 18 Parameter

BIMBINGAN AKREDITASI
DI RUMAH SAKIT MOJOSARI 10 MARET 2008 OLEH TIM DINAS KESEHATAN PROPINSI JAWA TIMUR

SISTEMATIKA PENILAIAN PELAYANAN RADIOLOGI RUMAH SAKIT

SISTEMATIKA
1.

2.
3. 4. 5. 6. 7.

Falsafah dan Tujuan Administrasi & Pengelolaan Staf dan Pimpinan Fasilitas & Peralatan Kebijakan & Prosedur Pengembangan & Program Pendidikan Evaluasi & Pengendalian Mutu

SISTEMATIKA
1.

2.
3. 4. 5. 6. 7.

Falsafah dan Tujuan ( 3 Parameter) Administrasi & Pengelolaan ( 2 ) Staf dan Pimpinan ( 4 ) Fasilitas & Peralatan ( 4 ) Kebijakan & Prosedur ( 2 ) Pengembangan & Prog Pendidikan (1) Evaluasi & Pengendalian Mutu ( 2 ) Total : 18 Parameter

SISTEMATIKA (FASFKPE)
1.

2.
3. 4. 5. 6. 7.

Falsafah dan Tujuan ( 3 Parameter) Administrasi & Pengelolaan ( 2 ) Staf dan Pimpinan ( 4 ) Fasilitas & Peralatan ( 4 ) Kebijakan & Prosedur ( 2 ) Pengembangan & Prog Pendidikan (1) Evaluasi & Pengendalian Mutu ( 2 ) Total : 18 Parameter

AKREDITASI PELAYANAN RADIOLOGI

TIM AKREDITASI DINKES PROPINSI JAWA TIMUR MOJOSARI 2008

STD.1 FALSAFAH DAN TUJUAN

Pelayanan Radiologi berupa radiodiagnostik & radioterapi dengan mempertimbangkan aspek: 1. Bahaya radiasi 2. Perkembangan Iptek 3. Cost-benefit ratio 4. Kemampuan SDM

S.1.P1
0 : Tak ada falsafah & tuj instalasi 1 : Ada tapi lisan, dibuat Ka.Inst. 2 : Ada tertulis,tapi tdk mengacu visi & misi,by Ka.Inst 1 : Ada tertulis,blm mengacu,by Ka.Inst & staf 2 : Ada tertulis,mengacu,by Ka.Inst & Staf 3 : sda 4 plus diberlakukan by pimpinan

S.1.P.2 : Yan Rad=Yan RS=Yan Profesi

0 : Tidak ada standar pelayanan 1 : Ada std pelay sesuai Depkes,tertulis, Std pelay profesi tertulis tidak ada 2 : sda, tak ada std SMF Radiologi & SK Direktur 3 : Ada Sk Dir, tidak ada Std SMF Rad RS 4 : lengkap 5 : semua std ada plus evaluasi iptek

S.1.P.3. YAN RAD 24 JAM

0
1

2
3

4
5

: Pel Emergensy tidak ada,hanya on call : Rutin &UGD ad tapi jam kerja saja,petugas on call : sda, petugas on site : sda plus petugas on call, ekspertise di luar jam kerja by non DrSpR : sda,petugas on site dan expertise by DrSpR : Ada rutin 24 jam,petugas on site,ekspertise oleh Dr.SpR di luar jam kerja

Std.2.ADMINSTRASI &PENGELOLAAN: Bagan Organisasi & uraian tugas

0 : Tidak ada struktur organisasi 1 : 2 : 3 : 4 : 5 : Ada + uraian tugas lengkap by Dir RS

S.2.P.2 :
0 : Tidak ada petugas khusus pencatatan 1 2 3 4 5 : Ada, sesuai kebutuhan,evaluasi

DO
D : 1. Buku Register pasien atau data komputer 2. Arsip 3. Standar/pola ketenagaan

Std.3. STAF & PIMPINAN

Pimpinan unit pelayanan Radiologi sebaiknya oleh dokter spesialis Radiologi terdaftar dibantu staf yang berkompeten dan profesional Kebutuhan SDM proporsional dengan aktivitas pelayanan

S.3.P.1: Kepala SpRD

0 : Pimpinan bukan nakes 1 2 3 4 5 : Pimpinan Dr Sp Radiologi purna waktu

S.3.P.2 Staf Medik Fungsional Radiologi

0 : Pelaksana GP/ Spesialis non radiologi 1 2 3 4 5 :Pelaksana Dr SpRad

DO
Sub Spesialisasi Radiologi: 1. Radiologi anak 2. Radiologi neuro 3. Radiologi intervensional 4. Kedokteran nuklir

Bidang Kekhususan : 1. Multi Slice CT 2. Helical CT 3. MRI 4. Angiografi 5. USG Dopler : USG plus visualisasi pembuluh darah 6. Mammografi : Khusus payudara

S.3.P.3 STAF PELAKSANA RADIOGRAPHER

0 : Operator non nakes, non training 1 2 3 4 5 : Operator adalah Radiographer purna waktu, sesuai kebutuhan

S.3.P.4 Rapat Berkala

0 : Tidak ada rapat 1 2 3 4 5 : Ada jadwal rapat,hadir lengkap,notulen dan RTL

Std.4.Fasilitas & Peralatan Standar Ruangan Imaging(aman,luas & nyaman)

Ruang Kabinet

Ruang Baca

RUANG SCREENING

RUANG TUNGGU

S.4.P1
0 : Ruang tidak memenuhi standar 1 2 3 4 5 : Std ruang memenuhi syarat: ada prasarana penunjang, nyaman, sistem komunikasi

DO
1. 2. 3.

Std Pelayanan Radiologi kelas C&D (1993) Std Pelayanan Radiologi kelas A&B (1995) Ijin BATAN

S.4.P.2 : Tipe Ruangan

0: 1: 2: 3: 4: 5: Ruang a: R.Periksa+kamar gelap Ruang a + R.TungguPasien + R. Petugas + R.R.Adm + R.Ekspertise + > 1 R.Periksa

S.4.P.3. Kualitas Peralatan

0 : Jumlah minim,tak terawat 1 2 3 4 5 : Jumlah , jenis, ability peratan cukup,terawat, ikuti iptek

DO
R/F Table: u/ fluroscopy Image intensifer : zooming gambar Buckystand : kaset film u/ zooming foto thorax Mobile unit Iptek : - CT Scan helical,MRI - Color USG - Digital X-ray - Multi slice CT

CT SCAN

MEDICAL SONOGRAPHY

MAMOGRAPHY

IMAGE TRANSFER

BUCKY STAND

Case Studies
Multislice CT

Case 1

HISTORY: 83 Y/O M, EVALUATE INFRARENAL AORTIC ANEURYSM. FINDINGS: THERE IS EVIDENCE OF AN INFRARENAL AORTIC ANEURYSM WITH A MAXIMUM DIAMETER AT ITS MID PORTION OF 5 CM AP X 5.2 CM ANEURYSM PROJECTS INFERIORLY TO JUST PROXIMAL TO THE BIFURCATION OF THE ILIAC ARTERIES SCANNING PARAMETERS: 3 X 3IMAGE THICKNESS WITH A 1.5 MM RECONSTRUCTION AT 3.5 PITCH. THE CONTRAST INJECTION RATE WAS 3CC/SEC. IT WAS MONITERED WITH SURESTART FOR TIMING OF THE SCAN.

3D rendering reformat

Curved multiplanar

Case 2

HISTORY: 68 Y/O M WITH AN INFRARENAL AAA 5 X 5 CM BY CT ON JULY 29. FOLLOW UP SIZE OF THE AAA. FINDINGS: IN THE ABDOMEN, THERE IS STABLE SIZE OF A 5 CM AP X 5 CM TRANS X 5.4 CM CC INFRARENAL AAA. IMPRESSION: UNCHANGED SIZE AND LOCATION OF A AAA WHICH IS INFRARENAL IN LOCATION BUT INVOLVES THE IMA. SCANNING PARAMETERS: 3 X 3IMAGE THICKNESS WITH A 1.5 MM RECONSTRUCTION AT 3.5 PITCH. THE CONTRAST INJECTION RATE WAS 3CC/SEC. IT WAS MONITERED WITH SURESTART FOR TIMING OF THE SCAN.

3D rendering

Case 3

HISTORY: 49 YR M, STATUS POST ASCENDING/DESCENDING AORTA DISSECTION REPAIR/BENTALL PROCEDURE. RULE OUT DISSECTION. FINDINGS: THERE IS CONTINUED EVIDENCE OF AORTIC DISSECTION EXTENDING FROM THE AORTIC ROOT TO INCLUDE THE ARCH, DESCENDING AORTA, BIFURCATION INTO COMMON ILIACS, AND BIFURCATION INTO INTERNAL AND EXTERNAL ILIAC. SCANNING PARAMETERS: 5 X 5 IMAGE THICKNESS WITH A 3 MM RECONSTRUCTION AT 3.5 PITCH. THE CONTRAST INJECTION RATE WAS 3CC/SEC. IT WAS MONITERED WITH SURESTART FOR TIMING OF THE SCAN.

3D rendering

Case 4

HISTORY: 42 Y/O M. RIGHT TIBIAL PLATEAU CT WITH THIN CUTS ASSESS FRACTURE. FINDINGS: THERE IS A SCHATZKER TYPE V FRACTURE OF THE PROXIMAL TIBIA. IN ADDITION, THERE IS SOME COMMINUTION INVOLVING THE TIBIAL PLATEAU ANTERIORLY AND TIBIAL PLATEAU POSTERIORLY.

IMPRESSION: COMMINUTED SCHATZKER TYPE V BICONDYLAR FRACTURE. SCANNING PARAMETERS: 2 X 2IMAGE THICKNESS WITH A 1MM RECONSTRUCTION AT 3.5 PITCH.

3D rendering of AP tibia

Case 5

HISTORY: 29 Y/O M. FRACTURE. EVALUATE. FINDINGS: THERE IS POSTERIOR FRACTURE DISLOCATION OF THE RIGHT SHOULDER. THERE IS A FRACTURE THROUGH THE NECK OF THE GLENOID IMPRESSION: 1. POSTERIOR FRACTURE DISLOCATION OF THE RIGHT SHOULDER AND COMMINUTED FRACTURE OF THE SCAPULA MAINLY INVOLVING THE NECK OF THE GLENOID WITH INTERARTICULAR EXTENSION AT THE SUPERIOR ASPECT OF THE GLENOHUMERAL JOINT. SCANNING PARAMETERS: 3 X 3 X 1.5 MM HELICAL AXIAL CT IMAGES WERE OBTAINED THROUGH THE RIGHT SHOULDER.

 3D rendering of AP scapula

Case 6

HISTORY: 32 Y/O F WITH HIGH GRADE LEFT INTERNAL CAROTID ARTERY STENOSIS AND POOR IMAGING OF THE DISTAL INTERNAL CAROTID ARTERY. FINDINGS: THERE IS APPROXIMATELY 50% STENOSIS OF THE DISTAL RIGHT INTERNAL CAROTID ARTERY AT THE GENU OF THE CAROTID SIPHON. LEFT CAROTID ARTERY: THERE IS A TIGHT STENOSIS IN THE PROXIMAL LEFT INTERNAL CAROTID ARTERY SCANNING PARAMETERS: 1 x 1 SLICE THICKNESS WITH A .5MM RECONSTRUCTION, HELICAL PITCH WAS 3.5. 100 CC CONTRAST WAS INJECTED AT 3 CC PER SECOND WITH 18 SECOND SCAN DELAY.

Lt. and Rt. carotid arteries

S.4.P.4. OBAT & PERALATAN BASIC LIFE SUPPORT FOR ALERGI BAHAN KONTRAS

0 : Tak ada 1 2 3 4 5 : Ada lengkap obat,cairan infus,02 dan peralatan

DAFTAR OBAT & PERALATAN

Daftar obat - adrenalin inj - anti histamin - Kortison - Dopamin Daftar Peralatan - alkes: needle,spuit - infus set dan standar infus - suction pump

DAFTAR MEDIA KONTRAS

Iodinated agents Iohexol (Omnipaque, GE Healthcare) Iodixanol (Visipaque, GE Healthcare) Iopromide (Ultravist, Bayer Healthcare) Ioversol (Optiray, Tyco/Mallinckrodt) Iopamidol (Isovue, Bracco Diagnostics) Gadolinium agents Gadobenate (MultiHance, Bracco Diagnostics) Gadodiamide (Omniscan, GE Healthcare) Gadoteridol (ProHance, Bracco Diagnostics) Gadoversetamide (OptiMARK , Tyco/Mallinckrodt) Gadopentetate (Magnevist, Berlex)

Std.5 KEBIJAKAN DAN PROSEDUR

PERLU PROTAP (SOP) WRITTEN SOP

PROTAP ATAU SOP

PROTOKOL

Body Protocols
Appendicitis Scan Biphasic CT of Liver Biphasic Pancreas (Pancreatic Protocol) Chest, Abdomen, Pelvis Scan Adrenal Mass (Pheochromocytoma IS suspected) Renal Mass Evaluation Routine Abdomen/Pelvis I Think There Is a Stone Scan (Stone Scan)

Chest Protocols

Abdominal Aortic Aneurysm (AAA) Aortic Dissection Coronary Calcification on EBCT revision Coronary Calcification on Multislice Interstitial Lung Disease (HRCT) Airway Study McLennan Pulmonary Embolism (PE) Chest only Pulmonary Embolism (PE) with Deep Venous Thrombosis (DVT) Pulmonary Nodule Standard Chest CT

Neuro Protocols

Adult Head CT Adult Sinus CT Adult Orbit CT Adult Neck CT Salivary Gland CT Functional Larynx CT CTA Circle of Willis CTA Carotids Lumbar Myelogram Thoracic Myelogram Cervical Myelogram Adult Trauma Face and Trauma Orbit CT (for patients who cannot have direct coronals) Adult IAC CT - Axial with coronal reconstructions (Direct coronals should be done if possible, using other protocol) Adult IAC CT Adult TMJ CT

Orthopedic Protocols

Trauma Pelvis CT Protocol Ankle CT Protocol Cervical Spine Thoracic Spine Lumbar Spine CT Protocol Shoulder CT Sacro-Iliac Joint CT Wrist CT Protocol Single Cut Hip CT

Pediatric Protocols

Routine Head CT Craniosynatosis Neck/Larynx Sinus/Maxillofacial CT Orbit/Sella CT IAC or TMJ CT C-Spine Trauma CT Chest CT and/or Abdomen CT and/or Pelvis CT High-Resolution Chest CT Dynamic Airway Study (on Imatron) EBCT Scanning Protocol for CF Subjects Who Have Signed Consent Form CT Protocol for Cystic Fibrosis in Children

S.5.P.1. SOP PERSIAPAN PEMERIKSAAN TEKNIS & ADMINISTRASI

0 :Tidak ada 1 2 3 4 5 : Lengkap,diketahui direktur

CONTOH SOP TEKNIS

1. 2.

SOP PENANGANAN ORAL & RECTAL CONTRAS AGENT OLEH RADIOGRAPH SOP PENANGANAN ANTI AXIETY, NAUSEA,ANTI EMETIC,ANTI COAGULAN BY GP/RN

Std.6. PENGEMBANGAN STAF DAN PROGRAM PENDIDIKAN

SEMUA STAF INSTALASI PELATIHAN SEMINAR DLL

S.6.P.1. PLANNING SDM

0 : TIDAK ADA PLAN & ANALISIS 1 2 3 4 5 : WRITTEN PLANNING

DO

PROTAP TEKNIS - Jadwal pemeriksaan khusus - protap : a. Pemeriksaan lambung & usus b. Pemeriksaan ginjal c. USG Abdomen d. CT Scan Abdomen

PROTAP ADMINISTRATIP - Prosedur pendaftaran - Prosedur pembayaran - Prosedur Pengambilan pemeriksaan - Prosedur penyimpanan dokumen - dll

Std.7. EVALUASI DAN PENGENDALIAN MUTU

ADA PROSEDUR EVALUASI METODE : GKM,QA,TQC SELF ASSESTMENT

S.7.P.1. Ada evaluasi provider

0 :tidak ada 1 2 3 4 5 :Ada analisa darievaluasi tertulis,RTL

DO

Contoh Evaluasi: - Angket,Kotak saran - Aspek keamanan petugas - Aspek penyimpanan bahan radiologi - Efek samping dan Medical Error - Review pembuatan dan labeling iv contras Mekanisme evaluasi mutu & profesional provider : - evaluasi teknik - evaluasi teknik kualitas pencucian - evaluasi expertise - evaluasi kecepatan pelayanan/expertise

Adverse Reactions
Non-anaphylactoid reactions (nausea, vomiting, cardiac arrhythmia, pulmonary edema, seizure, renal failure) Anaphylactoid reactions (urticaria, laryngeal edema, bronchospasm, circulatory collapse)

Medication Errors in Radiology

Wrong time 17 3 Wrong route 19 3 Extra dose 20 3 Wrong patient 33 5 Wrong drug preparation 33 5 Prescribing error 52 8 Wrong administration technique 82 13 Omission error 96 15 Unauthorized/wrong drug 135 22 Improper dose/quantity 166 27

PROPERLY AND SAFELY STORED

Medications are stored and secured under conditions suitable for product stability and safety safe storage safe handling security

Medications are Properly and Safely Stored

Unauthorized persons, in accordance with hospital policy and applicable law or regulation cannot have access to medications What medications can radiology technicians access? What medications can radiology technicians administer?

S.7.P.2. PROGRAM MUTU

0 : TIDAK ADA 1 2 3 4 5 : ADA, MIS : GKM, QA, PEER REVIEW PRINSIP : PDCA (PLAN,DO,CHEK,ACTION)

DO

PROGRAM MELIPUTI : - MUTU ADMINISTARTIP - RESPON TIME PELAYANAN - MUTU FILM ,RADIOGRAFER, PENCUCIAN - REVISI SOP ( KE-BERAPA) - PROG. PENINGKATAN SKILL (TRAINING,WORKSHOP)

CONTOH RESPON TIME 1. Breast Ultrasound:

Patient Preparation: No preparation Duration of this procedure: about 15 minutes Technical Details: This includes 2D and Doppler Ultrasound imaging of breasts. This study is useful in: * Detection of focal breast disease * Characterization of the lesions * Assessment of vascularity pattern of the lesions

2.Chest (Thorax) ultrasound

Patient Preparation: No preparation Duration of this procedure: about 15 minutes Technical Details: This test is done usually as secondary investigation to clarify the doubts in chest radiography. Chest ultrasound can image the structures which are not air filled and when there in no air filled structure between it and the ultrasound probe. Chest ultrasound is useful in: * Detecting pleural and pericardial effusion, even when they are minimal * Differentiation between consolidation of lung and pleural effusion * Assessment of pleural mass, pulmonary mass that is abutting the chest wall or heart. Point to be noted here that, if the mass is located deep inside the lung, there won't be any window for ultrasound beam, so assessment won't be possible.

MEDICATION RECONCILIATION IN RADIOLOGY

What is Required by the Joint Commission? Three Required Steps to the Process 1. Obtain and document a complete list of patients current medications on entry to the organization (with involvement of the patient) 2. Compare the medications the organization provides to those on the list to identify and resolve discrepancies

10

MEDICATION RECONCILIATION IN RADIOLOGY (2)

Medication Reconciliation What is Required by the Joint Commission? Three Required Steps to the Process 3. Communicate the patients current medication list to the next provider on patient transfer or discharge Medication Reconciliation

Our Challenge (Tantangan)

Improve medication process and medication safety in Radiology Meet regulatory standards established by Joint Commission Decision to use or not use contrast is not always determined at the time the procedure is ordered Failure to perceive contrast as a drug, belief that contrast is safe, inability to visualize a workable process, doubt that pharmacists can add safety or value to process, computerized prescriber order entry, the decision to use contrast is not always made when the procedure is ordered, and contrast media is purchased and stored in the radiology department.

RANGKUMAN REKOMENDASI PELAYANAN RADIOLOGI

STANDAR 1 2 3 4 5 6 7 PARAMETER 3 2 4 4 2 1 2 18 REKOMENDASI

RANGKUMAN REKOMENDASI PELAYANAN RADIOLOGI

STANDAR
1

PARAMETER
3
5

15

2 3 4 5 6 7

2 4 4 2 1 2 18

5 5 5 5 5 5

10 20 20 10 5 10 90

RANGKMAN PENILAIAN
NO STD 5 4 3 2 1 0 JML JML P %

PERSENTASE PENCAPAIAN STANDAR

JUMLAH NILAI % = -------------------------- X 100 JUMLAH PARAMETER