SENSUS HARIAN INDIKATOR SASARAN MUTU

UNIT : ..........................................................................................
JUDUL INDIKATOR AREA : ..........................................................................................
BULAN : ..........................................................................................
TAHUN : ..........................................................................................
AREA MONITORING : ..........................................................................................
SUMBER DATA : ..........................................................................................
SAMPLE SIZE : ..........................................................................................
Tanggal Tabulasi Jumlah Indikator Tabulasi Jumlah Indikator
Numerator (sesuai dengan Denumerator (sesuai dengan
formula) formula)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Jumlah
Verifikator Indikator Mutu Utama/ Jakarta, ………………………. ..........
Indikator Mutu Unit Penanggungjawab Unit

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PMKP/02/2018/REV.00
 LAPORAN BULANAN DARI UNIT KE KOMITE
MUTU

Nama Unit : ..........................................................................................

Indikator Sasaran Mutu : ..........................................................................................
Area : ..........................................................................................
Numerator : …….............

Denumerator : …….............

Formula : Numerator/ Denumerator x 100%

Target : …….............
Hasil Indikator Mutu Unit : .......................................
Kesimpulan : TERCAPAI/ TIDAK TERCAPAI
Analisa unit : (Tercapai/ Tidak Tercapai, alasan dan usulan)
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Rekomendasi
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Jakarta, …………… …......

Penanggungjawab Indikator Mutu Verifikator Komite Mutu
Kepala Instalasi/Penanggung Jawab Unit (Ketua/ Wakil Ketua/Sekretaris)
Terkait

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PMKP/02/2018/REV.00