Perencanaan - Program - PMKP Dan Pemilihan Prioritas Program
Perencanaan - Program - PMKP Dan Pemilihan Prioritas Program
Halaman
Daftar isi i
Materi bahan pemilihan prioritas program PMKP 1
Indikator area klinis 1
Indikator area manajerial 3
Indikator sasaran keselamatan pasien 4
Indikator Joint Commission International Library 4
Lampiran ...............................................................................
Undangan pemilihan prioritas program PMKP 16
Daftar undangan peserta rapat 17
Daftar hadir peserta undangan rapat 19
Susunan acara 23
Dokumentasi Gambar 24
4
MATERI
BAHAN PEMILIHAN PRIORITAS
PROGRAM PMKP
5
Materi Bahan Pemilihan Prioritas Program
Asesmen Pasien
Pelayanan Laboratorium
Pelaksana Ekspertisi
Kejadian Kegagalan Pelayanan Rontgen
Waktu tunggu pemeriksaan Radiologi cito
Tidak adanya kejadian tertinggalnya benda asing/lain pada tubuh pasien setelah
operasi
6
Kepatuhan melaksanakan proses time out pada pasien pre operasi
Marking
Penggunaan Antibiotika dan Obat Lainnya
Patients who received VTE (Venous thrombo embolism) prophylaxis (or reasons of
why this was not done) on the day of or day after hospital admission or surgery
ICU patients who received VTE prophylaxis (or reasons of why this was not done) on
the day of or day after hospital admission or surgery
Kesalahan dan Kejadian Nyaris Cedera Medikasi, Pencegahan Adverse Drug Event
Pasien paska pembiusan di transfer dari recorvery room IBS ke ruang rawat inap
sesuai dengan aldrette score
Reaksi anastesi,
Salah penempatan endotracheal tube.
Riset Klinis
7
Area manajerial
bat dan
P alkes
e emergency
n di ruang
g resisutasi
a IGD
d
a Ketersedian
a obat di RS
n
ru Ketersediaan
tin obat
al kemoterapi
ke di RS
s Pelaporan
d aktivitas
a yang
n diwajibkan
o oleh
b peraturan
at perundang -
p undangan;
e
nti Ketepatan
n waktu
g penyampaia
u n keuangan
nt sesuai
uk Pedoman
m Akutansi RS
e (PARS)
m
e Ketepatan
n waktu
u laporan
hi insiden
ke keselamatan
b pasien
ut
u Ketepatan
h waktu
a laporan dari
n unit kerja
p Ketepatan
as waktu
ie laporan RS
n; (RL)
K Kelengkapan
et laporan HIV
er
se
Laporan
di
KPRS paling
a
lambat 2 x
a
14 jam
n
o
Manajemen
ris pulang APS
ik
o; Dilakukan
FMEA
K setahun
ej sekali
a
di Pengadaan
a Barang
n beracun
te berbahaya
rt (B-3) yang
us dilengkapi
uk MSDS
li (Material
m Safety Data
b Sheet)
a Manajemen
h penggunaan
b sumber
e daya;
n
d Utilisasi Ct-
a Scan
taj Utilisasi
a ruang VIP
m
inf Utilisasi USG
ek Dopler 3
si Dimensi
us Utilisasi C-
K ARM
ej
a Utilisasi
di Ploroscopy
a Utilisasi
n peralatan
te kedokteran
rt canggih
us Harapan dan
uk kepuasan
ja pasien dan
ru keluarga;
m
su
Tingkat
nti
kepuasan
k
pasien RJ,
IGD, RI
K
ej
Survei
a
kepuasan
di
pasien
a
menggunaka
n
n Index
p
Kepuasan
as
Masyarakat
ie
(IKM)
n
Pr li
os
e Harapan dan
nt kepuasan
as staf;
i Tingkat
p kepuasan
as karyawan
ie
n Tingkat
ya kepuasan
n dokter
g Tingkat
m kepuasan
e perawat
n Demografi
gi pasien dan
si diagnosa
fo klinis
r
m Laporan 10
uli besar
r penyakit
a (demografi
n pasien)
gk Demografi
et pasien
p dengan
as diagnosis
ie klinik DHF
n
S Manajemen
ur keuangan
ve Cost
i recovery rate
ke Current
p Ratio
u
as
Return of
a
invesment
a
(ROI)
n
p
Pencegahan
as
dan
ie
pengendalia
n
n dari
d
kejadian
al
yang dapat
a
menimbulka
m
n masalah
sa
bagi
tu
keselamatan
b
pasein,
ul
keluarga
a
pasien dan
n
staf
se
ka
Edukasi
h tangan
a penunjang
n
d Ketaatan
hy penggunaan
gi Alat
e Pelindung
n Diri (APD)
e
K
et
a
at
a
n
cu
ci
8
Sasaran Keselamatan Pasien
Aspirin received within 24 hours of arrival to the hospital for patients having an acute
myocardial infarction (AMI).
Aspirin prescribed at discharge for patients who had an acute myocardial infarction.
Inpatient Mortality
Acute myocardial infarction (AMI) patients who expire during the hospital stay
Heart failure patients with documentation in the hospital record that left ventricular
systolic (LVS) function was evaluated before arrival; during hospitalization, or is
planned for after discharge
9
Adult Smoking Cessation Advice/Counseling
Stroke (STK)
Stroke Education
The total number of hours that all patients admitted to a hospital-based inpatient
psychiatric setting were maintained in physical restraint
The total number of hours that all patients admitted to a hospital-based inpatient
psychiatric setting were held in seclusion.
All documented falls by a patient with an injury level of “minor” (2) or greater.
Cesarean Section
10
Exclusive Breast Feeding
Pneumonia (PN)
Pneumococcal Vaccination
Pneumonia patients, aged 65 and older, who were screened for pneumococcal
vaccine status and were administered the vaccine prior to discharge, if indicated
Influenza Vaccination
Pneumonia patients, aged 50 and older, who during the flu season, were
screened for influenza vaccine status and were vaccinated prior to discharge, if
indicated
Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision Hip
Arthroplasty
Surgical patients with prophylactic antibiotics initiated within one hour prior to
surgical incision. Patients who received Vancomycin or a
Surgical patients with prophylactic antibiotics initiated within one hour prior to
surgical incision. Patients who received Vancomycin or a Flurooquinolone for
prophylactic antibiotics should have the antibiotics initiated within two hours prior
to surgical incision. Due to the longer infusion time required for Vancomycin and
Fluroquinolone, it is acceptable to start these antibiotics within two hours prior to
incision time.
Surgical patients, who had a Hip Arthroplasty, whose prophylactic antibiotics were
discontinued within 24 hours after Anesthesia End Time
11
Surgical patients, who had a Knee Arthroplasty, whose prophylactic antibiotics
were discontinued within 24 hours after Anesthesia End Time
This measure assesses the number of patients who received VTE prophylaxis or
have documentation why no VTE prophylaxis was given the day of or the day
after hospital admission or surgery end date for surgeries that start the day of or
the day after hospital admission.
This measure assesses the number of patients who received VTE prophylaxis or
have documentation why no VTE prophylaxis was given the day of or the day
after the initial admission (or transfer) to the Intensive Care Unit (ICU) or surgery
end date for surgeries that start the day of or the day after ICU admission (or
transfer).
12
NOTULEN RAPAT
PEMILIHAN PRIORITAS
PROGRAM PMKP
13
PEMERINTAH KABUPATEN KARAWANG
KARAWANG
Notulen Rapat
Hari : Sabtu
Pembahasan
:
1. 10 Indikator
Kunci/Prioritas Area Klinik
No
Area Klinis
Indikator
Standar
Asesmen Pasien
sebelum operasi
Pelayanan Laboratorium
Waktu tunggu hasil pelayanan
laboratorium
Pelayanan
Radiologi
Kejadian
Kegagalan
Kerusakan Foto ≤
Pelayanan Rontgen
2%
Prosedur Bedah
Angkaketidak
lengkapan
0%
informed concent
Penggunaan
Antibiotika
Penulisan
resep
sesuai
100%
formularium
Kesalahan
Medikasi
Kejadian
Nyaris
Cedera
0%
(Medication
Error)
&
Peresepan Obat
KNC
Penggunaan
Anestesi
Salah
penempatan
10%
Dan Sedasi
endotracheal tube.
Produk Darah
9
Ketersediaan,
Isi
Dan
Kelengkapan
Informed
100%
Penggunaan
RM
Pasien;
10
PPI, Surveilans
Dan
terlatih
yang terlatih 75 %
14
2. 5 Indikator Klinis Joint Commission International Library
International
No
Library of
Measure Short
Measure Description
Standar
Measures-
Name
Measure Sets
1
Acute
Aspirin at Arrival
Myocardial
hours
of
arrival
to
the
Infarction
hospital
for
patients
(AMI)
having
an
acute
myocardial
infarction
(AMI).
Stroke (STK)
Stroke Education
Ischemic or
hemorrhagic
100%
stroke
patients
or their
caregivers
who
were
addressing
ALL
of
the
following:
Activation
of
emergency
medical
system
(if
available
in
after
discharge,
medications prescribed at
discharge,
3
Children’s
Systemic
Use
of
systemic
100%
Asthma
Care
Corticosteroids for
corticosteroids in pediatric
(CAC)
Inpatient Asthma
patients
admitted
for
impatient
treatment
of
asthma
Perinatal
Care
Exclusive
Breast
Exclusive
breast
milk
100%
(PC)
Feeding
feeding
during
the
newborn's
entire
hospitalization
Pneumonia
Adult
Smoking
Adult smoking
cessation
100%
(PN)
Cessation
advice/counseling given to
Advice/Counseling
patients
who
smoke
cigarettes
and
who
are
hospitalized
for
pneumonia
No
Area Manajerial
Indikator
Standar
Pengadaan rutin
alkes
Ketersediaan
obat
dan
alkes
100%
dan obat
penting
untuk
emergency di
ruang
resisutasi
memenuhi
kebutuhan
IGD
pasien;
Pelaporan
aktivitas
yang
Ketepatan waktu penyampaian
Sebelum Tgl 7
keuangan
sesuai
setiap bulan
perundang - undangan;
Pedoman Akutansi RS (PARS)
Manajemen risiko;
100%
15
4
Manajemen penggunaan
Utilisasi Ct-Scan
100%
sumber daya;
Harapan
dan
kepuasan
Survei
kepuasan
pasien
2 kali / Tahun
Harapan
dan
kepuasan
staf;
Demografi
pasien
dan
Demografi
pasien
dengan
100%
diagnosa klinis
Manajemen keuangan
80%
Pencegahan
dan
100%
pengendalian
dari
kejadian
yang
dapat
menimbulkan
masalah
No
Sasaran Keselamatan
Indikator
Standar
Pasien
Ketepatan
Identitas
Jumlah
pasien
tanpa
0%
Pasien;
gelang identitas
Peningkatan
Komunikasi
hasil
laboratorium
per
100%
yang efektif
Peningkatan
keamanan
0%
obat
yang
perludi
yang
ditemukan
tanpa
waspadai
label alert
Kepastian
tepat
lokasi,
Time
out
dilaksanakan
100%
tepat
prosedur,
tepat
dengan
lengkap
sebelum
pasien operasi
operasi
Angka
kepatuhan
hand
100%
pelayanan kesehatan
hygiene
6
pelaksanaan
asesmen
100%
resiko
di
instalasi
rawat
inap
16
Penetapan Pelayanan Prioritas
HIGH RISK
HIGH VOLUME
HIGH COST
NO
PELAYANAN
JUMLAH
Rentang Nilai = 1 - 5
Rentang Nilai = 1 - 5
Rentang Nilai = 1 - 5
PRIORITAS
Bobot = 50
Bobot = 30
Bobot = 20
N
S
1
Aspirin at Arrival
5
50
250
30
150
20
40
440
2
Stroke Education
3
50
150
30
150
20
40
340
Systemic
3
Corticosteroids
5
50
250
30
150
20
60
460
for Inpatient
Asthma
4
Exclusive Breast
1
50
50
30
150
20
20
220
Feeding
Adult Smoking
5
Cessation
1
50
50
30
150
20
20
220
Advice/Counseling
Keterangan:
Pelayanan prioritas perbaikan : Children’s Asthma Care (CAC), Penggunaan kortikosteroid sistemik pada pengobatan asthma bagi
pasien-pasien anak yang menjalani rawat inap (Use of systemic corticosteroids in pediatric patients admitted for impatient treatment
of asthma)
17
Penetapan Area Prioritas
HIGH RISK
HIGH VOLUME
HIGH COST
AREA
NO
Rentang Nilai = 1 - 5
Rentang Nilai = 1 - 5
Rentang Nilai = 1 - 5
JUMLAH
PRIORITAS
Bobot = 50
Bobot = 30
Bobot = 20
N
S
N
S
N
1
ICU
4
50
200
3
30
90
4
20
80
370
2
IGD
5
50
250
3
30
90
3
20
60
400
3
IBS
3
50
250
3
30
90
3
20
60
300
4
Rawat Inap
3
50
150
5
30
150
3
20
60
360
5
Farmasi
4
50
200
5
30
150
3
20
60
350
Keterangan:
Score
No
Definisi
1
2
3
4
5
Min
Max
1
High Risk ( Indikator yang
Tidak Timbul
Timbul
Timbul
Timbul
Timbul Resiko
5
Resiko
Resiko
Resiko
Resiko
Sangat Besar
2
High Volume ( Indikator
Sangat
Jarang (2-5
Dpt terjadi
(beberapa
Sering sekali
5
Jarang (> 5
Thn/kali)
dlm 1-2 thn
kali/thn)
(terjadidlm
Thn)
minggu/bulan)
3
High Cost ( Indikator yang
Tidak timbul
Timbul
Timbul
Timbul
Timbul
dipilih merupakan kondisi
1
5
kerugian
kerugian
kerugian
kerugian
kerugian
yang menimbulkan
keuangan
keuangan
keuangan
keuangan
keuangan
kerugian keuangan)
kecil
sedang
besar
sangat besar
19
Kesimpulan :
Aspirin at Arrival
Stroke Education
Systemic Corticosteroids for Inpatient Asthma
Exclusive Breast Feeding
Adult Smoking Cessation Advice/Counseling
20
Pelayanan prioritas perbaikan : Children’s Asthma Care (CAC), Penggunaan kortikosteroid
sistemik pada pengobatan asthma bagi pasien-pasien anak yang menjalani rawat inap (Use
of systemic corticosteroids in pediatric patients admitted for impatient treatment of asthma)
Pemimpin Rapat
21
LAMPIRAN
22
UNDANGAN
23
DAFTAR HADIR
24
PEMERINTAH KABUPATEN KARAWANG
KARAWANG
Susunan Acara
PEMILIHAN PRIORITAS PROGRAM
Waktu
Acara
PIC
09.00
- 09.05
Pembukaan............................................................
Eva Puspa W, SKM, MM
09.06
– 09.25
Sambutan Direktur RSUD Karawang ....................
dr. H. Asep Hidayat Lukman, MM
09.26
– 11.45
Rapat Pembahasan pemilihan prioritas program
PMKP ...................................................................
dr Irwin, Sp.PD
11.46
– 11.50
Penutup/Do`a ........................................................
H. Deden Mustofa Kamil, SKM
25
DOKUMENTASI GAMBAR
26
27
Salah satu sudut peserta yang hadir saat rapat pembahasan pemilihan prioritas
program PMKP Sabtu, 12 Maret 2016 di Swiss Bellinn Hotel Karawang dari kiri, Heru
Pamuji, Amd.PK (Rekam Medis), Dadang Sukardi, Amd.PK (Rekam Medis), Ahmad
Rofiudin, Amd.PK (Rekam Medis), Kurniasih, S.Kep (Bidang Keperawatan), Ani
Muthia, SKM, MARS (Bidang Perencanaan)
28
Direktur RSUD Karawang, dr. H. Asep Hidayat Lukman, MM didampingi dr. Irwin,
Sp.PD Ketua Pokja PMKP saat pembukaan rapat pembahasan pemilihan prioritas
program PMKP Sabtu, 12 Maret 2016 di Swiss Bellinn Hotel Karawang.
dr. Irwin, Sp.PD Ketua Pokja PMKP saat presentasi rapat pembahasan pemilihan
prioritas program PMKP Sabtu, 12 Maret 2016 di Swiss Bellinn Hotel Karawang
29
dr. Ade Nurkacan, Sp.AN dan dr. Irwin, Sp.PD Ketua Pokja PMKP saat berdiskusi
pada rapat pembahasan pemilihan prioritas program PMKP Sabtu, 12 Maret 2016 di
Swiss Bellinn Hotel Karawang
Pose bersama saat setelah acara rapat pembahasan pemilihan prioritas program
PMKP Sabtu, 12 Maret 2016 di Swiss Bellinn Hotel Karawang. Dari kiri dr. Endang
Elisawaty, Sp.S, dr Achmad Rizky Herda, Sp.U, dr. Irwin, Sp.PD, dr. Irwan, dr. H.
Asep Hidayat Lukman, MM (Direktur RSUD Karawang), dr. Ade Nurkacan, Sp.AN,
Sutarman, S.Kep, Sri Endah, S.Kep, Ners (belakang) dan dr. David A, Sp.OG.
30