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I. Topic i. pilih layanan kritikal yang

berdampak pada mutu
ii. layanan tersebut sangat
mugkin untuk ditingkatkan
II. Number of Medical i. RM dari seluruh kasus ( jika
Record jumlah kasusnya sedikit)
ii. Sampel dari RM yang dipilh
secara random sampling (jika
jumlah kasusnya banyak)
III. Indicator variable yang dapat digunakan
untuk mengukur perubahan
IV. Criterion an aim (mis: seluruh pasien
pasca hernia repair tidak boleh
ada infeksi)
V. Standard the degree of compliance
to the criteria which is deemed
(i.e. practice is satisfactory if
more 95 % compliance to the

VI. Result Compare performance with the

VII. Analysis identify problems and causes
for change
VIII. Revise how to on the difference
IX. Re-audit observe practice after change

(Sumber bacaan: Yadav, H.: Hospital management, 2006)

Kita boleh mulai dengan menggunakan STANDAR PELAYANAN MINIMAL dari

Kemenkes atau boleh menggunakan standar lain.

Contoh Medical Audit


I. Topic insiden infeksi luka pasca

operasi hernia
II. Number of Medical i. Jika jumlah kasus sedikit,
Record vii. semua kasus diikut-sertakan
viii. ii. Jika jumlah kasus banyak,
diambil sample yang dipilih
secara random (20-30 kasus)
III. Indicator post-operative infection rate
IV. Criterion tidak ada infeksi pasca operasi
(angka infeksi pasca operasi nol
V. Standard 95%
VI. Result mutu operasi dikatakan baik atau
memuaskan jika 95% dari sam-
pel tidak terjadi infeksi pasca
operasi, atau jika angka infeksi
hanya 5% dari sampel

VII. Analysis identifikasi problem dan penybab

pada struktur, proses dan hasil
(outcome) guna perubahan
VIII. Revise rancang upaya peningkatan
mutu dengan menutup gap pada
struktur, proses atau outcome
IX. Re-audit dilakukan audit kembali hanya
apabila rancangan peningkatan
telah dilaksanakan (misalnya
setelah enam bulan)

Audit Report Form
Title This should be the same as the title on the proforma. It
should also include the auditor’s name and title, the date of
the report, and the name of the individual hospital.
Background Clarify why the audit was done. For example, was the
project prompted by an identified local problem or
concern? The background should explain the rationale
for doing the audit. Summarise the evidence base for
the audit topic, giving full references at the end. If a
team was convened to undertake this audit, describe
how this was organised and who was involved.
Aim(s) of the audit Explain the aims of the project. Use BSMART guidelines
(benefits, specific, measurable, aligned/agreed, realistic, time
Standards Outline standards, guidelines or benchmarks, and their
source and strength of evidence. If not measured against
existing standards then stated intention to set standards at
the end of the project should be included and if so, which
aspects of care those standards pertain to.
Methodology State chosen population to be audited and how the sample
was selected, specifying whether a retrospective or
prospective approach was used Identify the size of the
sample, the time period, and how this was calculated or
agreed upon. The method of data collection, a list of who was
responsible for data collection, when this was done, and the
method of data input and analysis should be included
Results The number and percentage of cases meeting each criteria of
the standard should be included in the data analysis. Use
graphs and charts to enhance and simplify presentation. Both
raw figures & percentages are required. Confidentiality
guidelines should be strictly followed, omitting any identifiable
information of staff and/or patients.
Conclusions Present key points that flow from results - use bullet points
and avoid long paragraphs. Conclusions need to be
supported by the data, regardless whether the data points to
no firm conclusions or not. The conclusion should be
objective with factual statements
Recommendations & State recommendations for change should be made.
Action Plan Recommendations must be realistic and achievable. An
action plan should be agreed stating what changes will be
implemented, who will be responsible for carrying them out
and when this will be done. If appropriate a date for a re-
audit, if not already included in the report, should be stated
for the completion of the audit cycle.