DAFTAR ISI

HALAMAN JUDUL................................................................................................................i
KATA PENGANTAR.............................................................................................................ii
LEMBAR PENGESAHAN....................................................................................................iii
DAFTAR ISI............................................................................................................................iv
DAFTAR TABEL....................................................................................................................v
DAFTAR GRAFIK.................................................................................................................vi
DAFTAR GAMBAR..............................................................................................................vii

BAB I PENDAHULUAN..................................................................................................................... 1

1.1 Latar Belakang..................................................................................................................................1

1.2 Tujuan Kegiatan...............................................................................................................................2

A. Tujuan Umum....................................................................................................................................2
B. Tujuan Khusus...................................................................................................................................2

BAB II GAMBARAN UMUM RSKD IBU DAN ANAK PERTIWI.....................................4

2.1 Sejarah, Visi, Misi dan Tujuan RSKD Ibu dan Anak Pertiwi.....................................................4
A. Sejarah..................................................................................................................................................4
B. Visi........................................................................................................................................................6
C. Misi.......................................................................................................................................................7
D. Tujuan.................................................................................................................................................12
E. Sasaran...............................................................................................................................................18
F. Motto...................................................................................................................................................18
G. Falsafah..............................................................................................................................................18
H. Nilai Budaya Kerja.........................................................................................................................19
I. Tugas Pokok.....................................................................................................................................19
J. Fungsi.................................................................................................................................................19

2.2 Struktur Organisasi dan Job Deskripsi RSKD Ibu dan Anak Pertiwi..................................21
A. Struktur Organisasi.........................................................................................................................21
B. Job Description................................................................................................................................25
C. Job Spesifikasi.................................................................................................................................37

2.3 Deskripsi Fisik dan Bangunan Disertai Outline..........................................................................46

 A. Letak RSKD Ibu Dan Anak Pertiwi..........................................................................................46
B. Denah dan Zonasi RSKD Ibu dan Anak Pertiwi....................................................................50

2.4 Sarana, Prasarana dan Peralatan RSKD Ibu dan Anak Pertiwi.....................................56

2.5 Jenis Pelayanan RSKD Ibu dan Anak Pertiwi.......................................................................63

2.6 Sumber Daya Manusia RSKD Ibu dan Anak Pertiwi................................................................65

BAB III GAMBARAN KINERJA................................................................................................. 69

3.1 Analisis Rencana Strategis RSKD Ibu dan Anak Pertiwi Tahun 2021..................................69
A. Visi......................................................................................................................................................69
B. Misi.....................................................................................................................................................69
C. Tujuan.................................................................................................................................................69
D. Sasaran...............................................................................................................................................69
E. Program..............................................................................................................................................70
F. Kegiatan.............................................................................................................................................70

3.2 Analisis Rencana Bisnis Anggaran RSKD Ibu dan Anak Pertiwi Tahun 2021...................74

3.3 Analisis Kinerja RS Berdasarkan Pedoman Penilaian Kinerja Badan

Layanan Umum Bidang Layanan Kesehatan...............................................................................78

3.4 Analisis Standar Pelayanan Minimal RSKD Ibu dan Anak Pertiwi
Berdasarkan Pedoman Penyusunan SPM di RS Kemenkes RI Tahun 2012...............................81

3.5 Kinerja Pelayanan RSKD Ibu dan Anak Pertiwi.....................................................................99

3.6 Survei Kepuasan Masyarakat...........................................................................................................104

3.7 Survey Kepuasan Tenaga Medis.....................................................................................................111

BAB IV INSTALASI............................................................................................................115
4.1 Instalasi Gawat Darurat (IGD)......................................................................................115
4.1.1 Organisasi dan Manajemen Instalasi Gawat Darurat di RSKD Ibu dan Anak
Pertiwi................................................................................................................ 115
4.1.2 Deskripsi Fisik dan Bangunan IGD.....................................................................116
4.1.3 Deskripsi Kegiatan Instalasi Gawat Darurat RSKD Ibu dan Anak
Pertiwi.................................................................................................................... 128
4.1.4 Kinerja Kegiatan Instalasi Gawat Darurat RSKD Ibu dan Anak Pertiwi...........132
 4.1.5 Sumber Daya Manusia Instalasi Gawat Darurat ................................................134
4.1.6 Kebijakan-Kebijakan di Instalasi Gawat Darurat...............................................145
4.2 Unit Rawat Jalan (Poliklinik)....................................................................................146
4.2.1 Struktur Organisasi Unit Rawat Jalan (Poliklinik).............................................146
4.2.2 Deskripsi fisik dan bangunan “Poliklinik”.........................................................146
4.2.3 Deskripsi Kegiatan “Poliklinik”.........................................................................151
4.2.4 Sumber Daya Manusia Poliklinik......................................................................153
4.2.5 Job Deskripsi Poliklinik (Poliklinik) RS. Khusus Ibu dan Anak Pertiwi..........153
4.2.6 Indikator Kinerja Instalasi Rawat Jalan (Poliklinik).........................................160
4.2.7 Standar Prosedur Operasional (SPO) Unit Rawat Jalan....................................173
4.3. Instalasi Rawat Inap..................................................................................................176
4.3.1. Organisasi dan Manajemen Instalasi Rawat Jalan di RSKD Ibu dan Anak
Pertiwi................................................................................................................176
4.3.2. Deskripsi Fisik dan Bangunan Instalasi Rawat Inap..........................................177
4.3.3. Deskripsi Kegiatan Instalasi Rawat Inap............................................................199
4.3.4. Kinerja Kegiatan Instalasi Rawat Inap...............................................................199
4.3.5. Sumber Daya Manusia Instalasi Rawat Inap......................................................211
4.3.6. Tata Hubungan Kerjasama dengan Unit Lainnya...............................................222
4.3.7. Kebijakan Instalasi Rawat Inap..........................................................................223
4.4 Instalasi Bedah...............................................................................................................224
4.4.1 Organisasi dan Manajemen Instalasi Bedah di RSKD Ibu dan Anak Pertiwi..224
4.4.2 Deskripsi Fisik dan Bangunan Instalasi Bedah.................................................225
4.4.3 Deskripsi Kegiatan Instalasi Bedah................................................................237
4.4.4 Kinerja Kegiatan Instalasi Bedah...................................................................239
4.4.5 Sumber Daya Manusia Instalasi Bedah..........................................................241
4.4.6 Kebijakan
Unit................................................................................................254
4.5 Instalasi High Care Unit..................................................................................................256
4.5.1 Organisasi dan Manajemen.................................................................................256
4.5.2 Deskripsi fisik dan bangunan..............................................................................256
4.5.3 Deskripsi KegiataN..........................................................................................260
4.5.4 Kinerja kegiatan...............................................................................................261
4.5.5 Sumber Daya Manusia.....................................................................................264
4.5.6 Analisa GAP HCU……………………………………………………………269
4.6 Instalasi Laboratorium..................................................................................................271
4.6.1 Organisasi dan Manajemen Instalasi Laboratorium...........................................271
4.6.2 Deskripsi Fisik dan Bangunan Instalasi Laboratorium......................................271
4.6.3 Deskripsi Kegiatan Instalasi Laboratorium.......................................................281
4.6.4 Kinerja Kegiatan Instalasi Laboratorium..........................................................285
4.6.5 Sumber Daya Manusia Instalasi Laboratorium.................................................288
4.6.6 Kebijakan Unit..................................................................................................294
4.6.7 Tata Hubungan Kerjasama dengan Unit Lainnya.............................................294
4.7 Instalasi Radiologi..........................................................................................................297
4.7.1. Organisasi dan Manajemen................................................................................297
4.7.2. Deskripsi fisik dan bangunan.............................................................................297
4.7.3. Deskripsi Kegiatan.............................................................................................301
4.7.4 Kinerja kegiatan..................................................................................................301
4.7.5 Sumber Daya Manusia.......................................................................................303
4.7.6 Kebijakan-Kebijakan..........................................................................................308
4.7.7 Analisa GAP Radiologi.......................................................................................308
4.7.8 Tata Hubungan Kerjasama dengan Instansi Lain...............................................309
4.8 Instalasi Farmasi........................................................................................................311
4.8.1 Organisasi dan ManajemenStruktur Organisasi Instalasi Farmasi Rumah Sakit
Khusus Ibu dan Anak Pertiwi 2021....................................................................311
4.8.2 Deskripsi Fisik dan Bangunan Instalasi Farmasi Rumah Sakit Khusus Ibu dan
Anak
Pertiwi.................................................................................................................311
4.8.3 Kondisi Ruangan dan Fasilitas............................................................................314
4.8.4 Sarana dan Peralatan............................................................................................319
4.8.5 Deskripsi Kegiatan Instalasi
Farmasi...................................................................320
4.8.6 Kualifikasi SDM Instalasi Farmasi Rumah Sakit Khusus Ibu dan Anak
Pertiwi..328
4.8.7 Uraian Jabatan.....................................................................................................329
4.8.8 Standar Pelayanan Minimum Instalasi Farmasi..................................................335
4.9 Instalasi Gizi...............................................................................................................337
4.9.1. Organisasi dan Manajemen Instalasi Gizi di RSKD Ibu dan Anak Pertiwi........337
4.9.2. Deskripsi Fisik dan Bangunan............................................................................338
 4.9.3. Deksripsi Kegiatan Instalasi...............................................................................352
4.9.4. Kinerja Kegiatan Instalasi Gizi...........................................................................355
4.9.5. Kepegawaian.......................................................................................................356
4.9.6. Kebijakan-kebijakan RSKD Ibu dan Anak Pertiwi.............................................362
4.9.7. Tata Hubungan....................................................................................................363
4.10. Rekam Medik.............................................................................................................365
4.10.1. Organisasi dan manajemen Rekam Medik..........................................................365
4.10.2. Deskripsi fisik dan bangunan Rekam Medik.......................................................365
4.10.3. Deskripsi Kegiatan Rekam Medik.......................................................................368
4.10.4. Kinerja kegiatan Rekam Medik...........................................................................369
4.10.5. Sumber daya manusia Rekam Medik..................................................................371
4.10.6. Kebijakan-kebijakan di Rekam Medik................................................................375
BAB V ALUR PROSES PELAYANAN............................................................................116
5.1 Alur Proses Pelayanan Instalasi Gawat Darurat..............................................................376
5.2 Alur Proses Pelayanan Instalasi Rawat Jalan…..............................................................388
5.3 Alur Proses Pelayanan Instalasi Rawat Inap…...............................................................389
5.4 Alur Proses Pelayanan Instalasi Bedah…….…..............................................................396
5.5 Alur Proses Pelayanan High Care Unit………...............................................................404
5.6 Alur Proses Pelayanan Instalasi Laboratorium…...........................................................418
5.7 Alur Proses Pelayanan Instalasi Radiologi…….............................................................421
5.8 Alur Proses Pelayanan Instalasi Farmasi…....................................................................423
5.9 Alur Proses Pelayanan Instalasi Gizi…..........................................................................435
5.10 Alur Proses Pelayanan Instalasi Rekam Medik............................................................437