DAFTAR ISI

LEMBAR PENGESAHAN
KATA PENGANTAR
DAFTAR ISI

..................................................................................................i

............................................................................................................... ii

............................................................................................................................ iii

BAB I PENDAHULUAN

.................................................................................................. 1

1. LATAR BELAKANG .................................................................................................. 1

2. TUJUAN
............................................................................................................... 2
3. MANFAAT
............................................................................................................... 2
BAB II KONSEP DASAR MANAJEMEN RESIKO
........................................................... 3
1. DEFENISI
............................................................................................................... 3
2. RUANG LINGKUP
.................................................................................................. 3
BAB III PERAN DAN TANGGUNG JAWAB

DALAM MANAJEMEN RESIKO

....... 4

BAB IV TATA LAKSANA MANAJEMEN RESIKO

........................................................... 6
1. PROSES MANAJEMEN RESIKO
........................................................................ 6
2. KATEGORI RESIKO
..................................................................................... 7
BAB V PELAPORAN ............................................................................................................... 8
BAB VI PENDIDIKAN DAN PELATIHAN

........................................................................ 9

BAB VII INDIKATOR UNTUK KEBERHASILAN

........................................................... 10

BAB VIII MONITORING, AUDIT DAN REVIEW

........................................................... 11

LAMPIRAN

(iii)

ii
DAFTAR ISI

LEMBAR PENGESAHAN
KATA PENGANTAR
DAFTAR ISI

................................................................................... i

.............................................................................................................. ii

............................................................................................................................iii

BAB I PENDAHULUAN

.................................................................................................. 1

BAB II SEJARAH PERKEMBANGAN MUTU PELAYANAN RUMAH SAKIT

....... 2

BAB III KONSEP DASAR UPAYA PENINGKATAN MUTU PELAYANAN

.................... 6
A. MUTU PELAYANAN .................................................................................................. 6
B. MUTU PELAYANAN RUMAH SAKIT
...........................................................10
BAB IV UPAYA PENINGKATAN MUTU PELAYANAN
.............................................12
A. INDIKATOR, KRITERIA DAN STANDAR
...........................................................12
B. PRINSIP UPAYA PENINGKATAN
........................................................................12
BAB V PENGENDALIAN KUALITAS PELAYANAN........................................................... 14
BAB VI FOKUS UTAMA UPAYA PENINGKATAN MUTU
..............................................20
A. KEPEMIMPINAN DAN PERENCANAAN
...........................................................20
B. MANAJEMEN PROSES KLINIK
....................................................................... 20
C. PENGUKURAN, EVALUASI SERTA PENINGKATAN MUTU
................... 21
D. PENGUMPULAN DATA DAN EVALUASI
.......................................................... 21
E. VALIDASI DAN ANALISA DATA INDIKATOR MUTU
................................ 22
F. MENINGKATKAN DAN MEMPERTAHANKAN MUTU
................................ 22
G. PELAKSANAAN
................................................................................................. 25
BAB VII KESIMPULAN

...................................... ..........................................................26

(iii)
DAFTAR ISI
KATA PENGANTAR
DAFTAR ISI

............................................................................................................... i

............................................................................................................................ ii

BAB I PENDAHULUAN

.................................................................................................. 1

A. LATAR BELAKANG .................................................................................................. 1

B. TUJUAN
............................................................................................................... 2
4. MANFAAT
............................................................................................................... 2
BAB II KONSEP DASAR MANAJEMEN RESIKO
........................................................... 4
3. DEFENISI
............................................................................................................... 4
4. RUANG LINGKUP
.................................................................................................. 4
BAB III PERAN DAN TANGGUNG JAWAB

DALAM MANAJEMEN RESIKO

....... 5

BAB IV TATA LAKSANA MANAJEMEN RESIKO

........................................................... 7
3. PROSES MANAJEMEN RESIKO
........................................................................ 7
4. KATEGORI RESIKO
..................................................................................... 8
BAB V PELAPORAN ............................................................................................................... 10
BAB VI PENDIDIKAN DAN PELATIHAN

........................................................................ 11

BAB VII INDIKATOR UNTUK KEBERHASILAN

........................................................... 12

BAB VIII MONITORING, AUDIT DAN REVIEW

........................................................... 13

DAFTAR ISI
KATA PENGANTAR
DAFTAR ISI

............................................................................................................... i

............................................................................................................................ ii

BAB I PENDAHULUAN

.................................................................................................. 1

5. LATAR BELAKANG .................................................................................................. 1

6. TUJUAN
............................................................................................................... 2
7. MANFAAT
............................................................................................................... 2
BAB II KONSEP DASAR MANAJEMEN RESIKO
........................................................... 4
5. DEFENISI
............................................................................................................... 4
6. RUANG LINGKUP
.................................................................................................. 4
BAB III PERAN DAN TANGGUNG JAWAB

DALAM MANAJEMEN RESIKO

....... 5

BAB IV TATA LAKSANA MANAJEMEN RESIKO

........................................................... 7
5. PROSES MANAJEMEN RESIKO
........................................................................ 7
6. KATEGORI RESIKO
..................................................................................... 8
BAB V PELAPORAN ............................................................................................................... 10
BAB VI PENDIDIKAN DAN PELATIHAN

........................................................................ 11

BAB VII INDIKATOR UNTUK KEBERHASILAN

........................................................... 12

BAB VIII MONITORING, AUDIT DAN REVIEW

........................................................... 13

DAFTAR ISI
KATA PENGANTAR
DAFTAR ISI

............................................................................................................... i

............................................................................................................................ ii

BAB I PENDAHULUAN

.................................................................................................. 1

A. LATAR BELAKANG .................................................................................................. 1

B. TUJUAN
............................................................................................................... 4
BAB II PROGRAM PENDIDIKAN DAN PELATIHAN MUTU ............................................. 6
A. PRINSIP-PRINSIP DIKLAT MUTU
........................................................................ 6
B. ORIENTASI PADA PELANGGAN
........................................................................ 7
C. CONTINOUS IMPROVEMENT
........................................................................ 9
D. SCIENTIFIC APPROACH
..................................................................................... 11
E. PEMBENTUKAN TIM
..................................................................................... 13
BAB III PENTAHAPAN PROGRAM PENDIDIKAN DAN PELATIHAN
............ ....... 16
A. FASE INISIASI
................................................................................................... 16
B. FASE TRANSFORMASI
..................................................................................... 23
C. FASE INTEGRASI
.................................................................................................. 24
BAB IV PENUTUP

................................................................. .............................................. 26

ii

DAFTAR ISI
KATA PENGANTAR
DAFTAR ISI

............................................................................................................... i

............................................................................................................................ ii

BAB I PENDAHULUAN

.................................................................................................. 1

A. LATAR BELAKANG .................................................................................................. 1

B. TUJUAN
............................................................................................................... 3
C. RUANG LINGKUP
.................................................................................................. 3
BAB II KETENTUAN UMUM
....................................... ............................................. 4
A. DEFINISI
...................................... ........................................................................ 4
B. DASAR HUKUM
......................... ........................................................................ 5
BAB III PENGORGANISASIAN
................................................................ ............ ....... 7
A. VISI, MISI, NILAI, KERANGKA KERJA
........................................................... 7
B. PROGRAM PENINGKATAN MUTU
............................................................9
C. STRUKTUR KOMITE MUTU
........................................................................ 10
D. TATA HUBUNGAN KERJA
........................................................................ 12
E. STRUKTUR PENGORGANISASIAN ........................................................................ 14
BAB IV PROGRAM PENINGKATAN MUTU ............................................................16
A. KEPEMIMPINAN DAN PERENCANAAN
............................................................16
B. RANCANGAN PROSES KLINIS DAN MANAJERIAL
..................................18
C. PEMILIHAN INDIKATOR DAN PENGUMPULAN DATA
..................................20
D. VALIDASI DAN ANALISA DATA PENGUKURAN ...............................................24
E. MENCAPAI DAN MEMPERTAHAN PENINGKATAN MUTU .....................29
F. METODE PENINGKATAN MUTU
.........................................................................30
BAB V MONITORING DAN EVALUASI
.........................................................................33
A. MONITORING
...................................................................................................33
B. EVALUASI
................................................................................................................33

DAFTAR ISI
LEMBAR PENGESAHAN
KATA PENGANTAR
DAFTAR ISI

.............................................................................................. i

...........................................................................................................ii

....................................................................................................................... iii

BAB I PENDAHULUAN

............................................................................................. 1

BAB II PEMILIHAN INDIKATOR DAN PENGUMPULAN DATA ................................. .3

A. Indikator Mutu Rumah Sakit
................................................................... 3
B. Memilih dan Menentukan Prioritas Indikator
.......................................................3
C. Pemantauan Indikator Mutu
....................................................................5
D. Pengumpulan data
.................................................................................6
BAB III ANALISA DAN VALIDASI DATA
................................................... ............ .. 7
A. Analisa Data Mutu
............................................................................................. 8
B. Validasi Data
.............................................................................................10
BAB IVBENCHMARKING DATA DAN PENCAPAIAN INDIKATOR
......................13
A. Defenisi
.............................................................................................................. 13
B. Format Dokumentasi
............................................................................... 13
BAB V PELAPORAN DAN EVALUASI
..............................................................15
A. Pelaporan Data
....................................................................................15
B. Evaluasi
..............................................................................................................15

(iii)

(iii)

DAFTAR ISI
LEMBAR PENGESAHAN

............................................................................................ i

KATA PENGANTAR

............................................................................................ ii

DAFTAR ISI

....................................................................................................................... iii

BAB I PENDAHULUAN

............................................................................................. 1

BAB II TUJUAN UMUM DAN TUJUAN KHUSUS

....... ................................. 2
A. Tujuan Umum
...................................... ................................................................... 2
B. Tujuan Khusus
...........................................................................................................2
BAB III DEFENISI
...................................... ................................................... ............ .. 3
A. Keselamatan Pasien
............................................................................................. 3
B. Hazard
......................... ............................................................................................. 3
C. Keselamatan Pasien
............................................................................................. 3
D. Keselamatan Pasien Rumah Sakit
................................................................... 3
E. Cedera
....................................................................................................................... 3
F. Insiden Keselamatan Pasien
................................................................................ 4
G. Kejadian Tidak Diharapkan
................................................................................ 4
H. Kejadian Nyaris Cedera
............................................................................................. 4
I. Laporan Insiden RS
............................................................................................. 4
J. Laporan Insiden Keselamatan Pasien
................................................................... 4
K. Faktor Kontributor
............................................................................................. 5
L. Analisis Akar Masalah
............................................................................................. 5
BAB IV TATA LAKSANA LAPORAN ............................................ ......................6
A. Alur Pelaporan Insiden ke Tim KP di RS
......................................................6
B. Alur Pelaporan Insiden Keselamatan Pasien ke Tim KKP-RS
............................7
BAB V ANALISIS MATRIKS GRADING RESIKO
.............................................. 8
A. Dampak
.............. .................................................................................... 8
B. Probabilitas
............................................................................................................... 8
BAB VI PETUNJUK PENGISIAN LAPORAN IKP
........................................11
A. Formulir Laporan Insiden Interna
..................................................................11
B. Formulir Laporan Insiden Eksterna
..................................................................11
C. Petunjuk Pengisian Formulir Laporan IKP
.....................................................11
BAB VII ALUR PELAPORAN INSIDEN

.....................................................22

(iii)

DAFTAR ISI
KATA PENGANTAR
DAFTAR ISI

............................................................................................................... i

............................................................................................................................ ii

PROGRAM KERJA KOMITE MUTU ..................................................................................... 1

A.
B.
C.
D.
E.
F.
G.
H.

PENDAHULUAN
.................................................................................................. 1
TUJUAN
............................................................................................................... 2
SASARAN
............................................................................................................... 3
KEGIATAN POKOK DAN RINCIAN KEGIATAN
.............................................. 3
CARA MELAKSANAKAN KEGIATAN
........................................................... 4
JADWAL PELAKSANAAN KEGIATAN
........................................................... 7
PENCATATAN, PELAPORAN DAN EVALUASI KEGIATAN .................... 9
PENUTUP
............................................................................................................... 10

DAFTAR ISI

KATA PENGANTAR
DAFTAR ISI

...........................................................................................................i

....................................................................................................................... ii

BAB I PENDAHULUAN

............................................................................................. 1

BAB II PEMILIHAN INDIKATOR DAN PENGUMPULAN DATA ................................. .3

E. Indikator Mutu Rumah Sakit
................................................................... 3
F. Memilih dan Menentukan Prioritas Indikator
.......................................................3
G. Pemantauan Indikator Mutu
....................................................................5
H. Pengumpulan data
.................................................................................6
BAB III ANALISA DAN VALIDASI DATA
................................................... ............ .. 7
C. Analisa Data Mutu
............................................................................................. 8
D. Validasi Data
.............................................................................................10
BAB IVBENCHMARKING DATA DAN PENCAPAIAN INDIKATOR
......................13
C. Defenisi
.............................................................................................................. 13
D. Format Dokumentasi
............................................................................... 13
BAB V PELAPORAN DAN EVALUASI
..............................................................15
C. Pelaporan Data
....................................................................................15
D. Evaluasi
..............................................................................................................15

(ii)

DAFTAR ISI
KATA PENGANTAR
DAFTAR ISI

............................................................................................................... i

............................................................................................................................ ii

BAB I PENDAHULUAN

.................................................................................................. 1

A. LATAR BELAKANG .................................................................................................. 1

B. TUJUAN
............................................................................................................... 3
BAB II KEBIJAKAN UMUM PENGELOLAAN PADA BIDANG

................................ 4

BAB III PENYELENGGARAAN URUSAN PADA TUPOKSI BIDANG

............ ....... 5
A. PROGRAM
............ .................................................................................................. 5
B. KEGIATAN
.....................................................................................8
C. TINGKAT PENCAPAIAN STANDAR PELAYANAN MINIMAL
................... 8
D. KONDISI SARANA DAN PRASARANA YANG DIGUNAKAN
....................... 9
E. PERMASALAHAN DAN SOLUSI
........................................................................ 9
BAB IV KESIMPULAN DAN SARAN
.........................................................................11
A. KESIMPULAN
...................................................................................................11
B. SARAN
................................................................................................................11
LAMPIRAN

Ii
DAFTAR ISI
KATA PENGANTAR

............................................................................................................... i

DAFTAR ISI

............................................................................................................................ ii

PROGRAM KERJA KOMITE MUTU ..................................................................................... 1

I.

PENDAHULUAN

......................................................................................... 1

II.

LATAR BELAKANG

III.

TUJUAN ............................................................................................................... 4

IV.

KEGIATAN POKOK DAN RINCIAN KEGIATAN

V.

CARA MELAKSANAKAN KEGIATAN

VI.

SASARAN

VII.

JADWAL PELAKSANAAN KEGIATAN

VIII.

EVALUASI PELAKSANAAN KEGIATAN DAN PELAPORAN

IX.

PENCATATAN, PELAPORAN DAN EVALUASI

X.

PENUTUP ............................................................................................................... 20

................................................................................1

........................................ 5

...........................................................7

..................................................................................................13
...........................................................15
....................16

.................................18

ii
DAFTAR ISI
KATA PENGANTAR
DAFTAR ISI

............................................................................................................... i

............................................................................................................................ ii

PROGRAM KERJA KOMITE MUTU ..................................................................................... 1

BAB I

DEFENISI ROOT CAUSE ANALYSIS

..................................................... 1

BAB II RUANG LINGKUP .................................................................................................. 2

BAB III TATA LAKSANA

.................................................................................................. 3

BAB IV DOKUMENTASI

...................................................................................................11

ii