DATA MUTU UTAMA (INDIKATOR AREA KLINIS)

RSUD AJI MUHAMMAD PARIKESIT

TAHUN 2018
NO INDIKATOR JANUARI FEBRUARI MARET APRIL MEI JUNI JULI AGUSTUS SEPTEMBER OKTOBER NOVEMBER DESEMBER RERATA (%)
Kelengkapan assesmen awal medis dalam 1x24 jam di rawat inap
1.1 Standar (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
24.34%
Capaian (%) 17.81% 20.81% 13.53% 15.97% 15.47% 16.18% 19.77% 14.00% 93.77% 15.86% 32.74% 16.18%
Kelengkapan assesmen awal keperawatan dalam 1 x 24 jam di rawat inap
1.2 Standar (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
98.98%
Capaian (%) 98.76% 99.33% 99.21% 99.26% 98.04% 98.34% 98.84% 99.50% 99.60% 98.16% 99.56% 99.17%
Pelaksana ekspertise hasil pemeriksaan laboratorium pasien rawat inap
2.1 Standar (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
100.00%
Capaian (%) 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
Pelaksana ekspertise hasil pemeriksaan rontgen pasien rawat inap
3.1 Standar (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
83.54%
Capaian (%) 81.64% 86.36% 88.91% 88.09% 91.92% 69.51% 81.76% 88.00% 88.26% 87.72% 80.04% 70.32%
Angka tunda operasi elektif pasien rawat inap
4.1 Standar (%) 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
3.71%
Capaian (%) 4.90% 5.81% 5.15% 3.82% 2.93% 3.20% 2.76% 3.37% 3.03% 4.20% 2.67% 2.64%
Tidak adanya kejadian kesalahan pemberian obat oleh farmasi di rawat inap
5.1 Standar (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
99.99%
Capaian (%) 99.99% 99.99% 99.98% 100.00% 99.99% 99.99% 99.97% 100.00% 99.99% 99.99% 99.99% 99.99%
Kejadian desaturasi O2 saat durante anestesi pasien dengan general anestesi
6.1 Standar (%) 6% 6% 6% 6% 6% 6% 6% 6% 6% 6% 6% 6%
0.00%
Capaian (%) 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%
Kejadian reaksi transfusi darah di rawat inap
7.1 Standar (%) 0.01% 0.01% 0.01% 0.01% 0.01% 0.01% 0.01% 0.01% 0.01% 0.01% 0.01% 0.01%
0.20%
Capaian (%) 0.01% 0.01% 0.01% 0.006% 0.007% 0.02% 0.01% 0.01% 0.007% 0.00% 0.58% 1.73%
Penulisan resep atau permintaan obat sesuai dengan formularium di rawat inap
8.1 Standar (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
99.90%
Capaian (%) 99.85% 99.88% 99.96% 99.94% 99.95% 99.89% 99.87% 99.85% 99.89% 99.79% 99.96% 99.92%
Kelengkapan pengisian rekam medik 24 jam setelah selesai pelayanan rawat inap
9.1 Standar (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
87.62%
Capaian (%) 89.66% 90.03% 84.41% 89.84% 87.53% 78.72% 88.62% 92.65% 89.41% 88.49% 85.04% 87.02%
Angka Kejadian phlebitis di rawat inap
10.1 Standar (%) 1.5% 1.5% 1.5% 1.5% 1.5% 1.5% 1.5% 1.5% 1.5% 1.5% 1.5% 1.5%
3.15%
Capaian (%) 8.89% 6.46% 6.42% 7.92% 1.49% 1.20% 1.27% 1.04% 1.04% 0.72% 0.86% 0.43%
©KOMITE PMKP RSAMP
 RSUD AJI MUHAMMAD PARIKESIT
TAHUN 2018
N JANUA FEBRUA AGUSTU SEPTEMB OKTOBE NOVEMB DESEMBE RERATA
INDIKATOR MARET APRIL MEI JUNI JULI
O RI RI S ER R ER R (%)
Ketersediaan obat life saving dalam box emergency di rawat inap
1. Standar (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
1 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00%
Capaian (%) 100.00% 100.00% 100.00% 100.00% 100.00%
% % % % % % %
Angka pelaporan insiden keselamatan pasien di rawat inap
2. Standar (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
1 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00%
Capaian (%) 100.00% 100.00% 100.00% 100.00% 100.00%
% % % % % % %
Angka kejadian pulang sebelum dinyatakan sembuh di rawat inap
3.
Standar (%) 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
1 3.07%
Capaian (%) 2.43% 3.25% 2.83% 3.99% 3.38% 4.24% 3.41% 2.22% 2.74% 2.26% 2.52% 3.51%
Angka ketepatan waktu pemeliharaan alat
4.
Standar (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
1 92.53%
Capaian (%) 94.01% 87.28% 88.16% 86.36% 90.32% 85.59% 89.53% 94.89% 97.23% 97.87% 99.56% 99.56%
Angka kepuasan pelanggan di rawat inap
5.
Standar (%) 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
1 83.49%
Capaian (%) 83.70% 83.58% 84.60% 84.46% 82.81% 82.06% 81.29% 83.85% 84.07% 83.98% 83.73% 83.69%
Angka kepuasan pegawai
6.
Standar (%) 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%
1 40.00%
Capaian (%) 80.00% 80.00% 80.00% 80.00% 80.00% 80.00%
Angka ketersediaan pelaporan sepuluh besar penyakit di rawat inap
7. Standar (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
1 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00%
Capaian (%) 100.00% 100.00% 100.00% 100.00% 100.00%
% % % % % % %
Angka kejadian keterlambatan berkas penagihan BPJS
8.
Standar (%) 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
1 0.01%
Capaian (%) 0.06% 0.06% 0.05% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%
Angka baku mutu limbah cair
Standar BOD
30 30 30 30 30 30 30 30 30 30 30 30 14.346666
(mg/l)
9. 67
Capaian 40.14 29.77 12.46 4.61 5.39 15.54 11.76 19.13 6.67 14.64 2.54 9.51
1
Standar COD
80 80 80 80 80 80 80 80 80 80 80 80
(mg/l) 49.17
Capaian (mg/l) 78.59 43.69 42.56 44.09 31.63 67.7 47.31 58.98 47.94 41.95 21.69 63.88
 Standar TSS
30 30 30 30 30 30 30 30 30 30 30 30
(mg/l) 13.02
Capaian 21.2 17 8 13 7 23 9 8 8 12 14 16
Standar pH 6-9 6-9 6-9 6-9 6-9 6-9 6-9 6-9 6-9 6-9 6-9 6-9
7.64
Capaian 7.72 7.8 7.65 7.49 7.59 7.23 7.36 7.73 7.57 7 8.15 8.33
©KOMITE PMKP RSAMP

RSUD AJI MUHAMMAD PARIKESIT

TAHUN 2018
NO INDIKATOR JANUARI FEBRUARI MARET APRIL MEI JUNI JULI AGUSTUS SEPTEMBER OKTOBER NOVEMBER DESEMBER RERATA (%)

Angka ketepatan identifikasi pasien rawat inap

1.1 Standar (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
80.47%
Capaian (%) 75.93% 76.92% 76.92% 82.11% 83.22% 81.76% 81.88% 82.69% 83.13% 85.98% 68.18% 86.95%
Angka peningkatan komunikasi efektif di rawat inap
2.1 Standar (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
90.62%
Capaian (%) 93.75% 94.74% 94.07% 93.02% 92.39% 93.42% 95.21% 92.41% 92.21% 78.66% 72.00% 95.61%
Angka peningkatan keamanan obat yang perlu di waspadai (HAM) di rawat inap
3.1 Standar (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
97.21%
Capaian (%) 95.39% 95.43% 97.45% 97.69% 96.66% 97.80% 97.14% 97.04% 96.82% 96.42% 99.07% 99.57%
Angka kepastian tepat lokasi , tepat prosedur, tepat pasien operasi di rawat inap
4.1 Standar (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
100.00%
Capaian (%) 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
Angka pengurangan risiko infeksi melalui kepatuhan cuci tangan di rawat inap
5.1 Standar (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
74.77%
Capaian (%) 73.75% 75.00% 60.61% 63.09% 62.07% 52.72% 80.00% 84.00% 85.00% 85.00% 89.00% 87.00%
Angka pengurangan risiko pasien jatuh di rawat inap
6.1 Standar (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
92.14%
Capaian (%) 94.21% 90.45% 90.58% 90.00% 85.33% 88.75% 92.31% 89.33% 89.67% 100.00% 100.00% 95.04%
©KOMITE PMKP RSAMP