PERENCANAAN PROGRAM PMKP

RS MASTHIKA MEDIKA
INDRAMAYU

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 PEMILIHAN PRIORITAS
PROGRAM PMKP
(PENINGKATAN MUTU & KESELAMATAN
PASIEN)

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 MATERI
BAHAN PEMILIHAN PRIORITAS
PROGRAM PMKP

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 Materi Bahan Pemilihan Prioritas Program
Peningkatan Mutu dan Keselamatan Pasien (PMKP)

Indikator Area Klinis

1. Asesmen Pasien
a. Asesmen awal medis lengkap dalam 24 jam pada pasien RI
b. Asesmen awal keperawatan lengkap dalam 24 jam pada pasien RI
c. Asesmen medis pasien bedah sebelum operasi
d. Asesmen medis anestesi sebelum operasi
e. Pelaksanaan skrining nutrisional
f. Asesmen nyeri pada pasien rawat inap
g. Asesmen risiko jatuh pada pasien rawat inap
h. Pre visit anestesi
i. Pasien stroke yang dilakukan assesmen rehabilitasi medis (International
Library)
j. Asesmen awal pasien emergency
2. Pelayanan Laboratorium
a. Waktu tunggu hasil pelayanan laboratorium
b. Pelaksana ekspertisi
c. Tidak adanya kesalahan pemberian hasil pemeriksa laboratorium
d. Waktu tunggu pemeriksaan laboratorium cito
e. Angka keterlambatan penyerahan hasil pemeriksaan
f. Angka kerusakan sampel darah
g. Angka kesalahan pengambilan sampel
h. Angka kesalahan pasien
i. Pelaporan nilai kritis laboratorium
3. Pelayanan Radiologi dan Diagnostic Imagin
a. Waktu Tunggu Hasil Pelayanan Thorax Foto
b. Pelaksana Ekspertisi
c. Kejadian Kegagalan Pelayanan Rontgen
d. Waktu tunggu pemeriksaan Radiologi cito
e. Angka pemeriksaan ulang
f. Angka penolakan expertise
g. Angka keterlambatan penyerahan hasil
h. Angka kesalahan posisi pemeriksaan
i. Angka reaksi obat kontras
j. Penyampaian hasil radiologis kristis kepada dokter pengirim
k. Respon time pem cito dari IGD
l. Respon time USG cito dari IGD non obsgyn
m. Respon time thorax konvensional
4. Prosedur Bedah
a. Waktu tunggu operasi elektif
b. Kejadian Kematian di meja operasi
c. Tidak adanya kejadian operasi salah sisi
d. Tidak adanya kejadian opersi salah orang
e. Tidak adanya kejadian salah tindakan pada operasi
f. Tidak adanya kejadian tertinggalnya benda asing/lain pada tubuh pasien
setelah operasi
g. Angka penundaan operasi
h. Angka keterlambatan dimulainya operasi
i. Angka infeksi luka/daerah operasi
j. Angka ketidak lengkapan informed concent
k. Angka ketidak lengkapan laporan operasi
l. Angka ketidak lengkapan laporan anestesi
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 m. Kepatuhan melaksanakan proses time out pada pasien pre operasi
n. Ketidaksesuaian Diagnosis pra dan pasca bedah
o. Marking
5. Penggunaan Antibiotika dan Obat Lainnya
a. Operasi bersih tanpa pemberian profilaxis antibiotik
b. Penulisan resep sesuai formularium
c. Penggunaan antibiotika di ICU sesuai dng hasil resistensi test
d. Pemberian aspirin pada pasien AMI (IIL)
e. Patients with ischemic stroke prescribed antithrombotic therapy at discharge
(IIL)
f. Patients with atrial fibrillation/flutter receiving anticoagulation therapy (IIL)
g. Pediatric asthma patients who received systemic corticosteroids during
hospitalization
h. 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
i. 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
6. Kesalahan Medikasi (Medication Error) & KNC
a. Ketepatan waktu pemberian antibiotika
b. Ketepatan waktu pemberian injectie antibiotik pada pasien rawat inap.
c. Kejadian Nyaris Cedera Peresepan Obat
d. Kesalahan dan Kejadian Nyaris Cedera Medikasi, Pencegahan Adverse
Drug Event
7. Penggunaan Anestesi dan Sedasi
a. Kelengkapan asesmen pre anestesia
b. Pasien paska pembiusan di transfer dari recorvery room IBS ke ruang
rawat inap sesuai dengan aldrette score
c. Efek samping anestesi pada pasien SC
d. Efek samping sedasi pada pasien endoscopy
e. Komplikasi anastesi karena overdosis,
f. Reaksi anastesi,
g. Salah penempatan endotracheal tube.
8. Penggunaan Darah dan Produk Darah
a. Angka keterlambatan penyediaan darah untuk operasi elektif
b. Angka kesalahan golongan darah
c. Angka kesalahan jenis darah
d. Angka reaksi transfusi darah
e. Angka perbedaan hasil skrining
f. Efektifitas penggunaan darah
g. Kebutuhan darah bagi setiap pelayanan tranfusi
h. Kejadian reaksi tranfusi

9. Ketersediaan, Isi dan Penggunaan RM Pasien;

a. Kelengkapan pengisian rekam medik 1x24 jam setelah selesai pelayanan
b. Kelengkapan Informed Concent setelah mendapatkan informasi yang jelas
c. Waktu penyediaan dokumen rekam medik pelayanan rawat jalan
d. Waktu penyediaan dokumen rekam medik pelayanan rawat inap
10. PPI, Surveilans dan Pelaporan
a. Ada anggota Tim PPI yang terlatih
b. Kejadian Phlebitis
c. Kepatuhan cuci tangan
d. Kepatuhan pemakain APD
e. Kegiatan pencatatan dan pelaporan infeksi nosokomial / HAI (Health Care
Associated Infection) di RS (min 1 parameter)

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Area manajerial

1. Pengadaan rutin alkes dan obat penting untuk memenuhi kebutuhan pasien;
a. Ketersediaan obat dan alkes emergency di ruang resusitasi IGD
b. Ketersedian obat bpjs di RS
c. Pengadaan alkes sesuai prosedur pengadaan barang
2. Pelaporan aktivitas yang diwajibkan oleh peraturan perundang - undangan;
a. Ketepatan waktu penyampaian keuangan sesuai Pedoman Akutansi RS
(PARS)
b. Ketepatan waktu laporan insiden keselamatan pasien
c. Ketepatan waktu laporan dari unit kerja
d. Ketepatan waktu laporan RS (RL)
e. Kelengkapan laporan HIV
f. Laporan KPRS paling lambat 2 x 14 jam
3. Manajemen risiko;
a. Kejadian tertusuk limbah benda tajam infeksius
b. Kejadian tertusuk jarum suntik
c. Kejadian pasien pulang APS
d. Dilakukan FMEA setahun sekali
e. Pengadaan Barang beracun berbahaya (B-3) yang dilengkapi MSDS
(Material Safety Data Sheet)
4. Manajemen penggunaan sumber daya;
a. Utilisasi Ct-Scan
b. Utilisasi ruang VIP
c. Utilisasi USG Dopler 3 Dimensi
d. Ketepatan waktu maintenance AC
5. Harapan dan kepuasan pasien dan keluarga;
a. Tingkat kepuasan pasien RJ, IGD, RI
b. Survei kepuasan pasien menggunakan Index Kepuasan Masyarakat (IKM)
c. Prosentasi pasien yang mengisi formulir angket pasien
d. Survei kepuasaan pasien dalam satu bulan sekali
6. Harapan dan kepuasan staf;
a. Tingkat kepuasan karyawan
b. Tingkat kepuasan dokter
c. Tingkat kepuasan perawat
7. Demografi pasien dan diagnosa klinis
a. Laporan 10 besar penyakit (demografi pasien)
b. Demografi pasien dengan diagnosis klinik DHF
8. Manajemen keuangan
a. Cost recovery rate
b. Current Ratio
c. Return of invesment (ROI)
9. Pencegahan dan pengendalian dari kejadian yang dapat menimbulkan masalah
bagi keselamatan pasein, keluarga pasien dan staf
a. Edukasi hand hygiene
b. Ketaatan cuci tangan penunjang
c. Ketaatan penggunaan Alat Pelindung Diri (APD)

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Sasaran Keselamatan Pasien

1. Ketepatan Identitas Pasien;

a. Jumlah pasien tanpa gelang identitas
b. Specimen tidak diberi label dengan 2 tanda pengenal
2. Peningkatan Komunikasi yang efektif
a. Verbal order di tandatangani dokter dalam 24 jam
b. hasil lab pertelp di read back
3. Peningkatan keamanan obat yang perlu di waspadai
a. % high alert medication yang masih ditemukan di unit perawatan
b. % high alert medication yang ditemukan tanpa label alert
4. Kepastian tepat lokasi, tepat prosedur, tepat pasien operasi
a. Time out dilaksanakan dengan lengkap sebelum operasi
b. Penandaan lokasi operasi ( side marker )
5. Pengurangan infeksi terkait pelayanan kesehatan
a. Angka kepatuhan hand hygiene
6. Pengurangan resiko jatuh
a. Jumlah pasien jatuh
b. pelaksanaan asesmen resiko di instalasi rawat inap

Joint Commission International Library of Measures

1. Acute Myocardial Infarction (AMI)

a. Aspirin at Arrival
Aspirin received within 24 hours of arrival to the hospital for patients
having an acute myocardial infarction (AMI).
b. Aspirin Prescribed at Discharge
Aspirin prescribed at discharge for patients who had an acute
myocardial infarction.
c. ACEI or ARB for LVSD
ACEI (angiotensin converting enzyme inhibitor) or ARB (angiotensin
receptor blocker) for patients who have LVSD (Left Ventricular Systolic
Dysfunction) after having an acute myocardial infarction.
d. Adult Smoking Cessation Advice/Counseling
Adult smoking cessation advice/counseling given to patients who had
an acute myocardial infarction.
e. Beta-blocker prescribed at discharge
Beta-blocker prescribed at discharge for patients who had an acute
myocardial Infarction
f. Inpatient Mortality
Acute myocardial infarction (AMI) patients who expire during the
hospital stay
2. Heart Failure (HF)
a. Evaluation of LVS Function
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
b. ACEI or ARB for LVSD
ACEI (angiotensin converting enzyme inhibitor) or ARB (angiotensin
receptor blocker) for heart failure patients who have LVSD (Left
Ventricular Systolic Dysfunction)

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 c. Adult Smoking Cessation Advice/Counseling
Adult smoking(cigarettes) cessation advice/counseling given to heart
failure patients
3. Stroke (STK)
a. Discharged on Antithrombotic Therapy
Ischemic stroke patients prescribed antithrombotic therapy at hospital
discharge
b. Anticoagulation Therapy for Atrial Fibrillation/Flutter
Ischemic stroke patients with atrial fibrillation/flutter who are prescribed
anticoagulation therapy at hospital discharge
c. Stroke Education
Ischemic or hemorrhagic stroke patients or their caregivers who were
given educational material addressing ALL of the following: Activation
of emergency medical system (if available in region), need for follow-
up after discharge, medications prescribed at discharge, risk factors for
stroke, and warning signs and symptoms of stroke.
d. Assessed for Rehabilitation
Ischemic or hemorrhagic stroke patients who were assessed for or
received rehabilitation services.
4. Children’s Asthma Care (CAC)
a. Relievers for Inpatient Asthma
Use of relievers in pediatric patients admitted for inpatient treatment of
asthma
b. Systemic Corticosteroids for Inpatient Asthma
Use of systemic corticosteroids in pediatric patients admitted for
impatient treatment of asthma
5. Hospital-Based Inpatient Psychiatric Service (HBIPS)
a. Hours of physical restraint use
The total number of hours that all patients admitted to a hospital- based
inpatient psychiatric setting were maintained in physical restraint
b. Hours of seclusion use
The total number of hours that all patients admitted to a hospital- based
inpatient psychiatric setting were held in seclusion.
6. Nursing-Sensitive Care (NSC)
a. Pressure Ulcer Prevalence (HospitalAcquired)
Patients that have hospital-acquired (nosocomial) category/stage II or
greater pressure ulcer(s) on the day of the prevalence study
b. Patient Falls
All documented falls with or without injury, experienced by patients in a
calendar month.
c. Falls with Injury
All documented falls by a patient with an injury level of “minor” (2) or
greater.
7. Perinatal Care (PC)
a. Elective Delivery
Patients with elective vaginal deliveries or elective cesarean sections at
>= 37 and < 39 weeks of gestation completed
b. Cesarean Section
Nulliparous women with a term, singleton baby in a vertex position
delivered by cesarean section

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 c. Exclusive Breast Feeding
Exclusive breast milk feeding during the newborn's entire
hospitalization
8. Pneumonia (PN)
a. 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
b. Adult Smoking Cessation Advice/Counseling
Adult smoking cessation advice/counseling given to patients who
smoke cigarettes and who are hospitalized for pneumonia
c. 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
9. Surgical Care Improvement Project (SCIP)
a. 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
Fluroquinolone 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
b. Prophylactic Antibiotic Received Within One Hour Prior to Surgical
Incision-Knee Arthroplasty
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.
c. Prophylactic Antibiotic Selection for Surgical Patients-Hip Arthroplasty
Surgical patients who received prophylactic antibiotics consistent with
current Hip Arthroplasty guidelines, Appendix C, Table 3.2,
Prophylactic Antibiotic Regimen Selection for Surgery
d. Prophylactic Antibiotic Selection for Surgical Patients-Knee
Arthroplasty
Surgical patients who received prophylactic antibiotics consistent with
current Knee Arthroplasty guidelines Appendix C, Table 3.2,
Prophylactic Antibiotic Regimen Selection for Surgery
e. Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery
End Time- Hip Arthroplasty
Surgical patients, who had a Hip Arthroplasty, whose prophylactic
antibiotics were discontinued within 24 hours after Anesthesia End Time
f. Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery
End Time Knee Arthroplasty

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 Surgical patients, who had a Knee Arthroplasty, whose
prophylactic antibiotics were discontinued within 24 hours
after Anesthesia End Time
g. Surgery Patients with Recommended Venous
Thromboembolism Prophylaxis Ordered
Surgery patients with recommended Venous
Thromboembolism (VTE) prophylaxis ordered anytime from
hospital arrival to 24 hours after Anesthesia End Time,
h. Surgery Patients Who Received Appropriate Venous
Thromboembolism Prophylaxis Within 24 hours Prior to
Surgery to 24 Hours After Surgery
Surgery patients who received appropriate Venous
Thromboembolism (VTE) prophylaxis within 24 hours prior
to Anesthesia Start Time to 24 hours after Anesthesia End
Time
10. Venous Thromboembolism (VTE)
a. Venous Thromboembolism Prophylaxis
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.
b. Intensive Care Unit Venous Thromboembolism Prophylaxis. 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).

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