RS …………………….

IDENTIFIKASI POTENSIAL PELUANG PENINGKATAN PERFO

Dept./Unit/: ___________________ (Dibuat 2 rangkap, satu untuk unit. Co

Date: __________________________________ Dibuat oleh: ______________

Apa masalahnya atau Bagaimana anda mengetahuinya?

No peluang untuk peningkatan
performa?
Peluang peningkatan performa?
L PELUANG PENINGKATAN PERFORMANCE / KINERJA

rangkap, satu untuk unit. Copiannya dikirim ke KMKP.)

Dibuat oleh: ________________________________________

Aksi yang akan

Bagaimana hal ini
Apa kemungkinan dilaksanakan, dan siapa
berdampak pada
penyebab? yang bertanggungjawab
perawatan pasien?
menyelesaikan masalah?
 QUALITY IMPROVEMENT PROJECT WORKSHEET

PROJECT TITLE : Peningkatan Kepatuhan dalam pengisian lembar persetujuan/ Penola

TEAM LEADER dr. Alicia
TEAM MEMBER : Mareta
Novis
Agung
Ice

WHO WILL BENEFIT : v PATIENTS ☐FAMILY ☐STAFF

PROBLEM / OPPORTUNITY STATEMENT Kelengkapan pengisian Lembar Persetujuan/ Penolakan Tindakan M

(WHAT'S WRONG WITH QUALITY ?)

AIM / GOAL : Meningkatkan kelengkapan pengisian Lembar Persetujuan / Penolak

(WHAT ARE WE TRYING TO ACCOMPLISH?)
(TARGET & TIME)

MEASURE : ☐ STRUCTURE ☐ PROCESS ☐ OUTCOME

an lembar persetujuan/ Penolakan tindakan medis

ujuan/ Penolakan Tindakan Medis 10%

Lembar Persetujuan / Penolakan Tindakan Medis 100% dalam 1 tahun

FLOW CHART

ALUR PENGISIAN LEMBAR PERSETUJUAN/ PENOLAKAN TINDAKAN MEDIS

Pasien yang akan menerima tindakan

Siapkan Form Persetujuan/ Penolakan Tindakan Medis

Petugas menjelaskan Tindakan Yang Akan DIlakukan

Petugas Menjelaskan Cara Pengisian Form Tersebut

Pasien/ Keluarga Mengisi Form Tersebut

Petugas Melakukan Crosscheck pengisian form tersebut

 FISHBONE DIAGRAM
Number of Main Causes: 6

#REF! #REF!
Methods Manpower
#REF! #REF!
### ###
### ###
### xbbcbbbb ### hgljglflflflfhfjl
### #REF! ### #REF!
### ###
###
Hand Over Kurang Efektif ###
### #REF! ### #REF!
### ###
###
Regulasi Belum Tersosialisasi ### Kurangnya SDM
### #REF! ### #REF!
### ###
###
Tingkat Kepatuhan Rendah ###
### #REF! ### #REF!
### ###
### Pasien Meningkat ###
### #REF! ### #REF!
### ###
### ……………. ###
### #REF! ### #REF!
### ###
#REF! #REF!
Environment Machines
#REF! #REF!
NE DIAGRAM

#REF!

#REF!
###
###
###
### #REF!
###
###
### #REF!
###
###
Peningkatan Kepatuhan
### #REF! dalam pengisian lembar
### persetujuan/ Penolakan
tindakan medis
### ………….
### #REF!
###
### ……………
### #REF!
###
### ………….
### #REF!
###
#REF!
Material
#REF!
 ╗
╝

###
###
###
###
###
###
 Causes Regulasi Hand Over Tingkat
Kurangnya Pasien
Belum Kurang Kepatuhan
SDM Meningkat
Tersosialisasi Efektif Rendah
Criteria
Impact on patient 1 2 3 3 4
Reputation 3 3 3 2 4
Acceptance 3 3 2 1 3
Time Needed 3 3 2 1 3
Total Score 10 11 10 7 14

Impact Dampak semakin berat semakin tinggi nilai (5 -1)

Reputasi Reputasi buruk semakin tingi nilai (5-1)
Accept / Dpt
diterima /
dilaksanakan mudah dilaksanakan semakin tinggi nilai (5 -1)
Waktu yg dibutuhkan
waktu singkat semakin tinggi nilai (5-1)
0 0 0 0 0 0 0
0
Pareto Analysis

[Brief Project Description]

[Date]

[Chart Title]
16 100%

Cumulative %
14
Defects

80%
12

10
60%

40%
6

4
20%
2
[42]
0 0%
Causes [42]

Vital Few Useful Many Labels Cumulative%

The first 5 Causes cover 86.54% of the Total Defects

Cumulative Percentage Cutoff: 80%

# Causes Defects Cumulative%
1 Tingkat Kepatuhan Rendah 14 26.9%
2 Hand Over Kurang Efektif 11 26.9%
3 Kurangnya SDM 10 48.1%
4 Regulasi Belum Tersosialisasi 10 67.3%
5 Pasien Meningkat 7 86.5%
6
7
8
9
10
11
12
13

© 2009 Vertex42 LLC Templates by Vertex42.com

 ACTION PLAN TOOL

CAUSE WHAT
Tingkat Kepatuhan Melakukan Sosialisai
ACTION 1 Rendah

Sosialisasi SPO Hand over

ACTION 2 Hand Over Kurang Efektif
Suvervisi

Membuat Usulan Penambahan

ACTION 3 Kurangnya SDM
Tenaga

Regulasi Belum Sosialisai tentang Regulasi

ACTION 4 Tersosialisasi Pengisian Form RM

ACTON 5

ACTION 6

ACTION 7

ACTION 8

ACTION 9
 WHO WHEN WHERE
Minggu Pertama Bulan
Tim Riview Berkas Aula RSUD Sekayu
Agustus

Minggu Pertama Bulan

Kepala Ruangan Ruang Perawatan
Agustus
Minggu Kedua Bulan
Kepala Ruangan Ruang Perawatan
Agustus
Minggu Ketiga Bulan
Kabid Keperawatan Ruang Bidang Keperawatan
Agustus

Minggu Pertama Bulan

Rekam Medik Aula RSUD Sekayu
Agustus
Gantt Chart Version 1.7.3

[Project Name]
[Company Name] Today's Date:

Project Lead: ……………………… [Name]

Start Date: 1/2/2012 Monday

[42]

Duration (Days)

% Complete
Task (WHO)
WBS Tasks (WHAT) Lead Start (WHEN) End (WHEN)
Melakukan
1 Sosialisai Tim Riview Berkas 8/4/19 8/18/19 15 23%
1.1 materi 8/4/19 8/7/19 4 50%
1.2 psn t4 8/8/19 8/10/19 3 50%
1.2.1 und 8/11/19 8/13/19 3 0%
1.2.2 konsumsi 8/14/19 8/18/19 5 0%
1.3 8/19/19 8/18/19 0%
1.4 8/19/19 8/18/19 0%
Sosialisasi SPO
2 Hand over Kepala Ruangan 8/16/12 9/7/12 23 25%
2.1 Materi 8/16/12 8/20/12 5 25%
2.2 Tempat 8/21/12 8/25/12 5 25%
2.3 Konsumsi 8/27/12 8/31/12 5 25%
2.4 Undangan 9/3/12 9/7/12 5 25%
Membuat Usulan
3 Penambahan Tenaga Kabid Keperawatan 5/1/19 5/15/19 15 23%
3.1 Sub Task level 2 5/1/19 5/4/19 4 50%
3.2 Sub Task level 2 5/5/19 5/7/19 3 50%
3.2.1 Sub Task level 2 5/8/19 5/10/19 3 0%
3.2.2 Sub Task level 2 5/11/19 5/15/19 5 0%
3.3 Sub Task level 2 5/16/19 5/15/19 0%
3.4 Sub Task level 2 5/16/19 5/15/19 0%
Regulasi Pengisian
4 Form RM Rekam Medik 5/1/19 5/15/19 15 23%
4.1 Sub Task level 2 5/1/19 5/4/19 4 50%
4.2 Sub Task level 2 5/5/19 5/7/19 3 50%
4.2.1 Sub Task level 2 5/8/19 5/10/19 3 0%
4.2.2 Sub Task level 2 5/11/19 5/15/19 5 0%
4.3 Sub Task level 2 5/16/19 5/15/19 0%
4.4 Sub Task level 2 5/16/19 5/15/19 0%
5 0 0 5/1/19 5/15/19 15 23%
5.1 Sub Task level 2 5/1/19 5/4/19 4 50%
5.2 Sub Task level 2 5/5/19 5/7/19 3 50%
5.2.1 Sub Task level 2 5/8/19 5/10/19 3 0%
5.2.2 Sub Task level 2 5/11/19 5/15/19 5 0%
5.3 Sub Task level 2 5/16/19 5/15/19 0%
5.4 Sub Task level 2 5/16/19 5/15/19 0%
6 0 0 5/1/19 5/15/19 15 23%
6.1 Sub Task level 2 5/1/19 5/4/19 4 50%
6.2 Sub Task level 2 5/5/19 5/7/19 3 50%
6.2.1 Sub Task level 2 5/8/19 5/10/19 3 0%
6.2.2 Sub Task level 2 5/11/19 5/15/19 5 0%
6.3 Sub Task level 2 5/16/19 5/15/19 0%
6.4 Sub Task level 2 5/16/19 5/15/19 0%
7 0 0 5/1/19 5/15/19 15 23%
7.1 Sub Task level 2 5/1/19 5/4/19 4 50%
7.2 Sub Task level 2 5/5/19 5/7/19 3 50%
7.2.1 Sub Task level 2 5/8/19 5/10/19 3 0%
7.2.2 Sub Task level 2 5/11/19 5/15/19 5 0%
7.3 Sub Task level 2 5/16/19 5/15/19 0%
7.4 Sub Task level 2 5/16/19 5/15/19 0%
8 0 0 5/1/19 5/15/19 15 23%
8.1 Sub Task level 2 5/1/19 5/4/19 4 50%
8.2 Sub Task level 2 5/5/19 5/7/19 3 50%
8.2.1 Sub Task level 2 5/8/19 5/10/19 3 0%
8.2.2 Sub Task level 2 5/11/19 5/15/19 5 0%
8.3 Sub Task level 2 5/16/19 5/15/19 0%
8.4 Sub Task level 2 5/16/19 5/15/19 0%
9 0 0 5/1/19 5/15/19 15 23%
9.1 Sub Task level 2 5/1/19 5/4/19 4 50%
9.2 Sub Task level 2 5/5/19 5/7/19 3 50%
9.2.1 Sub Task level 2 5/8/19 5/10/19 3 0%
9.2.2 Sub Task level 2 5/11/19 5/15/19 5 0%
9.3 Sub Task level 2 5/16/19 5/15/19 0%
9.4 Sub Task level 2 5/16/19 5/15/19 0%

TEMPLATE ROWS: Copy and insert the entire section, or just the specific sub tasks, depending on which level you want to use (formulas are different for diff
1 Task Category 5/1/19 5/15/19 15 23%
1.1 Sub Task level 2 5/1/19 5/4/19 4 50%
1.2 Sub Task level 2 5/5/19 5/7/19 3 50%
1.2.1 Sub Task level 2 5/8/19 5/10/19 3 0%
1.2.2 Sub Task level 2 5/11/19 5/15/19 5 0%
1.3 5/16/19 5/15/19 0%
1.4 5/16/19 5/15/19 0%
 © 2006-2012 Vertex42 LLC 0
HELP

6/2/2012 Saturday
(vertical red line)

First Day of Week (Mon=2): 2 1/2/2012 1/9/2012

### 1/16/2012

Days Remaining
Days Complete
Working Days

02 - Jan - 12

09 - Jan - 12
10 3 12
3 2 2
2 1 2
2 0 3
3 0 5
-1 0 0
-1 0 0
17 5 18
3 1 4
4 1 4
5 1 4
5 1 4
11 3 12
3 2 2
2 1 2
3 0 3
3 0 5
-2 0 0
-2 0 0
11 3 12
3 2 2
2 1 2
3 0 3
3 0 5
-2 0 0
-2 0 0
 11 3 12
3 2 2
2 1 2
3 0 3
3 0 5
-2 0 0
-2 0 0
11 3 12
3 2 2
2 1 2
3 0 3
3 0 5
-2 0 0
-2 0 0
11 3 12
3 2 2
2 1 2
3 0 3
3 0 5
-2 0 0
-2 0 0
11 3 12
3 2 2
2 1 2
3 0 3
3 0 5
-2 0 0
-2 0 0
11 3 12
3 2 2
2 1 2
3 0 3
3 0 5
-2 0 0
-2 0 0

o use (formulas are different for different WBS levels)

11 3 12
3 2 2
2 1 2
3 0 3
3 0 5
-2 0 0
-2 0 0
1/17/2012 1/18/2012 1/19/2012 1/20/2012 1/21/2012 1/22/2012 1/23/2012

16 - Jan - 12
1/24/2012 1/25/2012 1/26/2012 1/27/2012 1/28/2012 1/29/2012 1/30/2012

23 - Jan - 12
1/31/2012 2/1/2012 2/2/2012 2/3/2012 2/4/2012 2/5/2012 2/6/2012

30 - Jan - 12
2/7/2012 2/8/2012 2/9/2012 2/10/2012 2/11/2012 2/12/2012 2/13/2012

06 - Feb - 12
2/14/2012 2/15/2012 2/16/2012 2/17/2012 2/18/2012 2/19/2012 2/20/2012

13 - Feb - 12
2/21/2012 2/22/2012 2/23/2012 2/24/2012 2/25/2012 2/26/2012 2/27/2012

20 - Feb - 12
2/28/2012 2/29/2012 3/1/2012 3/2/2012 3/3/2012 3/4/2012 3/5/2012

27 - Feb - 12
3/6/2012 3/7/2012 3/8/2012 3/9/2012 3/10/2012 3/11/2012 3/12/2012

05 - Mar - 12
3/13/2012 3/14/2012 3/15/2012 3/16/2012 3/17/2012 3/18/2012 3/19/2012

12 - Mar - 12
3/20/2012 3/21/2012 3/22/2012 3/23/2012 3/24/2012 3/25/2012 3/26/2012

19 - Mar - 12
3/27/2012 3/28/2012 3/29/2012 3/30/2012 3/31/2012 4/1/2012 4/2/2012

26 - Mar - 12
4/3/2012 4/4/2012 4/5/2012 4/6/2012 4/7/2012 4/8/2012 4/9/2012

02 - Apr - 12
4/10/2012 4/11/2012 4/12/2012 4/13/2012 4/14/2012 4/15/2012 4/16/2012

09 - Apr - 12
4/17/2012 4/18/2012 4/19/2012 4/20/2012 4/21/2012 4/22/2012 4/23/2012

16 - Apr - 12
4/24/2012 4/25/2012 4/26/2012 4/27/2012 4/28/2012 4/29/2012 4/30/2012

23 - Apr - 12
5/1/2012 5/2/2012 5/3/2012 5/4/2012 5/5/2012 5/6/2012 5/7/2012

30 - Apr - 12
5/8/2012 5/9/2012 5/10/2012 5/11/2012 5/12/2012 5/13/2012 5/14/2012

07 - May - 12
5/15/2012 5/16/2012 5/17/2012 5/18/2012 5/19/2012 5/20/2012 5/21/2012

14 - May - 12
5/22/2012 5/23/2012 5/24/2012 5/25/2012 5/26/2012 5/27/2012 5/28/2012

21 - May - 12
5/29/2012 5/30/2012 5/31/2012 6/1/2012 6/2/2012 6/3/2012 6/4/2012

28 - May - 12
6/5/2012 6/6/2012 6/7/2012 6/8/2012 6/9/2012 6/10/2012 6/11/2012

04 - Jun - 12
6/12/2012 6/13/2012 6/14/2012 6/15/2012 6/16/2012 6/17/2012 6/18/2012

11 - Jun - 12
6/19/2012 6/20/2012 6/21/2012 6/22/2012 6/23/2012 6/24/2012 6/25/2012

18 - Jun - 12
6/26/2012 6/27/2012 6/28/2012 6/29/2012 6/30/2012 7/1/2012 7/2/2012

25 - Jun - 12
7/3/2012 7/4/2012 7/5/2012 7/6/2012 7/7/2012 7/8/2012 7/9/2012

02 - Jul - 12
7/10/2012 7/11/2012 7/12/2012 7/13/2012 7/14/2012 7/15/2012 7/16/2012

09 - Jul - 12
7/17/2012 7/18/2012 7/19/2012 7/20/2012 7/21/2012 7/22/2012 7/23/2012

16 - Jul - 12
7/24/2012 7/25/2012 7/26/2012 7/27/2012 7/28/2012 7/29/2012 7/30/2012

23 - Jul - 12
7/31/2012 8/1/2012 8/2/2012 8/3/2012 8/4/2012 8/5/2012 8/6/2012

30 - Jul - 12
8/7/2012 8/8/2012 8/9/2012 8/10/2012 8/11/2012 8/12/2012 8/13/2012

06 - Aug - 12
8/14/2012 8/15/2012 8/16/2012 8/17/2012 8/18/2012 8/19/2012 8/20/2012

13 - Aug - 12
8/21/2012 8/22/2012 8/23/2012 8/24/2012 8/25/2012 8/26/2012

20 - Aug - 12
Graphs of Key Measures Put Your Center Name Here
LATIHAN SOAL ENTRI DATA INDIKATOR

Pengkajian Jumlah Pasien yg

Waktu Pelaporan
Pasien Baru Awal selesai Melakukan
Month % Hasil Kritis < 1
(Denum) dlm wkt 24 j Pemeriksaan
jam
(Num) Kritis

Pemeriksaan Kritis Waktu pelaporan

jan #N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A #DIV/0!
Graphs of Key Measures Put Your Center Name Here

Goal for Goal for

% with Acknow-
Notification ledgement
w/in 1 hr Time

100 60
100 60
100 60
100 60
100 60
100 60
100 60
100 60
100 60
100 60
100 60
100 60
100 60
100 60
100 60
100 60
100 60