DAFTAR ISI

PMKP 1. PENGELOLAAN KEGIATAN PMKP

Halaman

EP 1. UMAN Pembentukan Komite PMKP................................................ 1

SK Komite PMKP Lama.................................................................... 2
SK Komite PMKP Baru..................................................................... 3
UMAN Penyusunan Kebijakan PMKP Lama.................................... 4
SK Kebijakan PMKP Lama................................................................ 5
SK Pedoman Pengorganisasian Komite PMKP................................. 6
Pedoman Pengorganisasian PMKP.................................................... 7
UMAN Program PMKP 2019............................................................ 8
Program PMKP 2019.......................................................................... 9
Kebijakan Perencanaan, Pelaksanaan, Montitoring / Pengawasan dan Pelaporan
Program PMKP .................................................................................. 10
EP 2 SK PIC Data........................................................................................ 11
Pelatihan PIC Data.............................................................................. 12
Sertifikat PIC Data.............................................................................. 13
EP 3 Sertifikat Pelatihan Pimpinan RS........................................................ 14
Sertifikat Pelatihan Ketua PMKP....................................................... 15
Sertifikat Pelatihan Sekretaris PMKP................................................. 16
EP 4 UMAN Evaluasi Program PMKP 2018.............................................. 17
Laporan Program PMKP 2018........................................................... 18
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PMKP 2 MANAJEMEN DATA

EP 1 UMAN Penyusunan Pedoman.................................................................... 1

Pedoman PMKP........................................................................................ 2
UMAN Revisi Pedoman............................................................................ 3
Daftar dan Bahan Referensi Asuhan Klinis............................................... 4
Daftar dan Bahan Referensi Komite Medik dan Keperawatan................. 5
SK Penetapan Referensi............................................................................ 6
PMKP 2.1
EP 1 UMAN Panduan Sistem Manajemen Data................................................. 7
SK Manajemen Data.................................................................................. 8
Panduan Manajemen Data......................................................................... 9
SPO Pengumpulan Data............................................................................ 10
SPO Analisa Data...................................................................................... 11
SPO Publikasi Data................................................................................... 12
EP 2 Daftar Inventaris Sistem Manajemen Data Elektronik............................... 13
SISMADAK.............................................................................................. 14
SISMADAK PPI........................................................................................ 15
SIMRS....................................................................................................... 16
Formulir Sensus Harian............................................................................. 17
Aplikasi Microsoft Excel........................................................................... 18
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PMKP 3 PROGRAM PELATIHAN PMKP

EP 1 UMAN Penyusunan Program Diklat PMKP.............................................. 1

SK Diklat PMKP....................................................................................... 2
Program Diklat PMKP............................................................................... 3
Program Diklat RS..................................................................................... 4
RKA Program Pelatihan PMKP................................................................ 5
SPO Pelaksanaan Program Pelatihan......................................................... 6
EP 2 Sertifikat PMKP Pimpinan......................................................................... 7
Sertifikat Sekretaris PMKP....................................................................... 8
Sertifikat PIC Data..................................................................................... 9
Sertifikat Staf............................................................................................. 10
Daftar Hadir Pelatihan Internal dan Undangan......................................... 11
Laporan Pelatihan PMKP Perawat Orientasi............................................. 12
PMKP 4 Pemilihan Prioritas
EP 1 Bukti Rapat Pemilihan Prioritas................................................................. 13
SPO Pemilihan dan Penetapan Prioritas Pengukuran Mutu Pelayanan..... 14
EP 2 Bukti Koordinasi Komite PMKP dengan Unit Kerja................................. 15
UMAN Uji Coba Prioritas......................................................................... 16
Formulir Supervisi Komite PMKP............................................................ 17
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PMKP 5 PEMILIHAN DAN PENETAPAN PRIORITAS

EP 1 SK tentang Pemilihan dan Penetapan Prioritas Mutu Layanan.................. 1

UMAN Penyusunan Daftar dan Profil Indikator Mutu............................. 2
SK Daftar dan Profil Indikator Mutu......................................................... 3
EP 2-5 Daftar dan Profil Indikator Mutu............................................................ 4
EP 6 (Formulir Supervisi PMKP 3 EP 2 hal 17)................................................. 5
PMKP 5.1
EP 1 UMAN Penyusunan Pedoman Evaluasi Panduan Praktik Klinik.............. 6
Panduan Pemilihan, Penyusunan dan Evaluasi Pelaksanaan PPK............ 7
UMAN Penyusunan PPK.......................................................................... 8
PPK Bedah................................................................................................. 9
EP 2 UMAN Evaluasi Hasil Capaian Kepatuhan CP......................................... 10
Laporan Evaluasi DPJP terhadap Protokol Klinis..................................... 11
Audit Klinis BPH dr Mintardi................................................................... 12
Audit Klinis BPH dr Farid......................................................................... 13
Audit Klinis SC......................................................................................... 14
Audit Medis............................................................................................... 15
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PMKP 6 INDIKATOR MUTU UNIT KERJA

EP 1 SK Kriteria Pemilihan Indikator Mutu Unit............................................... 1

EP 2 dan 3
Indikator Mutu dan Profil Ruang Eboni.................................................... 2
Indikator Mutu dan Profil Ruang Farmasi................................................. 3
EP 4 Formulir Pengumpulan Data dan Pelaporan............................................... 4
EP 5 Bukti Pelaksanaan Supervisi Pimpinan Unit.............................................. 5

PMKP 7 Pengumpulan Data

EP 1 Uman Rapat Penyusunan Panduan Sistem Manajemen Data.................... 6
SK Panduan Manajemen Data................................................................... 7
Panduan Manajemen Data......................................................................... 8
EP 2 UMAN Rapat Koordinasi Pengumpulan Data Unit Pelayanan.................. 9
EP 3 Hasil Pengumpulan Data Indikator............................................................ 10
Hasil Pengumpulan Data Insiden Keselamatan Pasien............................. 11
Kepatuhan DPJP terhadap CP dan PPK.................................................... 12
EP 4 Publikasi 12 Indikator Mutu Nasional Website.......................................... 13
EP 5 Bukti Pelaksanaan Breenchmark 12 Indikator Mutu Kemenkes................ 14
Breenchmark RSU Muhammadiyah Singkil............................................. 15
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PMKP 7.1 ANALISIS DATA

EP 1 Sistem Manajemen Data (PMKP 2.1 EP 1 Pedoman PMKP).................... 1

EP 2 Bukti Pengumpulan, Analisis dan Rencana Perbaikan............................... 2
EP 3 Bukti analisis menggunakan metode dan teknik-teknik Run chart............ 3
EP 4 Analisis trend dan standar.......................................................................... 4
Analisis perbandingan dengan rumah sakit lain........................................ 5
Analisis perbandingan dengan praktik yang baik...................................... 6
EP 5 Sertifikat PIC Data..................................................................................... 7
Sertifikat Komite PMKP........................................................................... 8
EP 6 Laporan hasil analisis data ke direktur RS Januari-Maret 2019................. 9
Laporan hasil analisis data ke direktur RS April-Juni 2019...................... 10
Laporan hasil analisis data ke direktur RS Juli- September 2019............. 11
Laporan hasil analisis data ke direktur PT Januari-Maret 2019................ 12
Laporan hasil analisis data ke direktur PT April-Juni 2019...................... 13
Laporan hasil analisis data ke direktur PT Juli- September 2019............. 14
Laporan hasil analisis dan tindak lanjut ke kepala unit Januari- Maret 2019 15
Laporan hasil analisis dan tindak lanjut ke kepala unit April-Juni 2019... 16
Laporan hasil analisis dan tindak lanjut ke kepala unit Juli-September 2019 17
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PMKP 7.2 ANALISIS DATA PROGRAM PRIORITAS
EP 1 Bukti Analisa data program PMKP prioritas.............................................. 1
EP 2 Bukti Tindaklanjut Perbaikan..................................................................... 2
EP 3 Bukti Hasil Perbaikan Program Prioritas................................................... 3
EP 4 Bukti Hasil Efisiensi Sumber Daya Prioritas............................................. 4

PMKP 8
EP 1 SK Validasi data website............................................................................ 5
SK Validasi data........................................................................................ 6
SPO Validasi Data..................................................................................... 7
EP 2 Bukti Validasi Data Indikator Mutu........................................................... 8
UMAN Validasi Data Indikator Area Mutu.............................................. 9
EP 3 Bukti Validasi Data yang Dipublikasikan.................................................. 10
EP 4 Bukti Laporan Perbaikan Validasi Data..................................................... 11
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PMKP 9 SISTEM PELAPORAN IKP

EP 1 SK Panduan Sistem Pelaporan IKP............................................................ 1

Panduan Sistem Pelaporan IKP................................................................. 2
UMAN Penyusunan Panduan Sistem Pelaporan IKP................................ 3
Formulir Laporan IKP Internal.................................................................. 4
Lembar Investigasi Sederhana................................................................... 5
SPO Pelaporan Insiden.............................................................................. 6
EP 2 IKP Laboratorium, Radiologi dan Medical Eror (File Box)...................... 7
EP 3 Laporan IKP Juli- Oktober 2019................................................................ 8
SPO Identifikasi Pasien Sebelum Pemberian Obat................................... 9
Laporan IKP Januari – Juni 2019.............................................................. 10
Laporan IKP Oktober – Desember 2018................................................... 11
EP 4 Bukti Laporan IKP Juli- Oktober 2019 representasi pemilik..................... 12
Bukti Laporan IKP Januari – Juni 2019 representasi pemilik................... 13
Laporan Insiden Secara Elektronik............................................................ 14

PMKP 9.1 KEJADIAN SENTINEL

EP 1 SK Kejadian Sentinel Dalam Sistem Pelaporan IKP Eksternal dan Internal 15
SPO RCA................................................................................................... 16
EP 2 Laporan RCA.............................................................................................. 17
UMAN Penyusunan Laporan RCA........................................................... 18
EP 3 Bukti Pelaksanaan RCA............................................................................. 19
SPO Pelayanan Obat Pasien RI ODDD..................................................... 20
 DAFTAR ISI
PMKP 9.2 KTD
EP 1 SK Jenis KTD dalam Sistem Pelaporan IKP.............................................. 1
EP 2 UMAN Laporan Analisis Insiden............................................................... 2
Laporan Analsis Insiden Reaksi Transfusi................................................ 3
EP 3 UMAN Laporan Analisis Reaksi Obat yang Tidak diharapkan................. 4
Laporan Analisis Reaksi Obat yang Tidak diharapkan............................. 5
EP 4 UMAN Laporan Analisis Kesalahan Pengobatan (Medication Eror)........ 6
Laporan Analisis Kesalahan Pengobatan (Medication Eror).................... 7
EP 5 UMAN Laporan Analisis Insiden Terhadap Ketidakcocokan (Discrepancy)
antara diagnose Pra-operasi dan Post-operasi..................................................... 8
Laporan Analisis Insiden Terhadap Ketidakcocokan (Discrepancy) antara
diagnose Pra-operasi dan Post-operasi...................................................... 9
EP 6 UMAN Laporan Analisis Insiden terhadap Efek Samping Selama Sedasi
Moderat atau Mendalam dan Pemakaian Anestesi............................................. 10
Laporan Analisis Insiden terhadap Efek Samping Selama Sedasi Moderat atau
Mendalam dan Pemakaian Anestesi.......................................................... 11
EP 7 UMAN Laporan Analisis Kejadian Lainnya.............................................. 12
Laporan Analisis Kejadian Lainnya.......................................................... 13

PMKP 9.3 KNC DAN KTC

EP 1 SK Definisi dan Jenis KNC dan KTC........................................................ 14
Laporan Analisis Data KNC dan KTC...................................................... 15
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PMKP 10 PENGUKURAN DAN EVALUASI BUDAYA KESELAMATAN

EP 1 SK Sistem Pelaporan Budaya Keselamatan............................................... 1

UMAN Penyusunan Pedoman Budaya Keselamatan ............................... 2
Pedoman Budaya Keselamatan.................................................................. 3
SPO Pengukuran Budaya Keselamatan..................................................... 4
SPO Pelaporan Budaya Keselamatan........................................................ 5
EP 2 Bukti Hasil Pengukuran Budaya Keselamatan........................................... 6

PMKP 11 PENCAPAIAN PMKP

EP 1 Bukti Rencana Perbaikan Mutu dan UMAN.............................................. 7
EP 2, 4, 6 Bukti Tentang Hasil Rencan Perbaikan............................................. 8
EP 5 Bukti Perubahan Regulasi ( SPO Pasien Elektif)....................................... 9
Bukti Perubahan Regulasi (SPO RJ)......................................................... 10
Kerangka Acuan Perbaikan Mutu....................................................................... 11

PMKP 12 MANAJEMEN RESIKO

EP 1 SK Panduan Manajemen Resiko................................................................ 12
UMAN Penyusunan Panduan Manajemen Resiko.................................... 13
Panduan Manajemen Resiko...................................................................... 14
SK Program Manajemen Resiko............................................................... 15
UMAN Penyusunan Program Manajemen Resiko.................................... 16
Program Manajemen Resiko...................................................................... 17
EP 2,3 Bukti Daftar Risko Tingkat RS dan Strategi Pengurangan Resiko......... 18
EP 4 Bukti Hasil FMEA dan UMAN.................................................................. 19
EP 5 Bukti Tindaklanjut FMEA.......................................................................... 20