PEDOMAN MANUAL MUTU UPTD PUSKESMAS TAJI

TELAH DISETUJUI DAN DISAHKAN OLEH

KEPALA UPTD PUSKESMAS TAJI

KECAMATAN KARAS

KABUPATEN MAGETAN

TAJI, 22 PEBRUARI 2018

KEPALA UPTD PUSKESMAS TAJI

KABUPATEN MAGETAN

ROHMAT HIDAYAT

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 KATA PENGANTAR

Puji syukur kami panjatkan kepada Tuhan Yang Maha Esa karena atas rahmat dan
hidayahNya, kami dapat menyelesaikan penyusunan Pedoman Manual Mutu Puskesmas
Taji sebagai salah satu persyaratan akreditasi Puskesmas.

Akreditasi Puskesmas mempersyaratkan adanya pedoman manual mutu sebagai

panduan bagi Puskesmas untuk melakukan upaya peningkatan mutu dan kinerja yaitu
dengan pembakuan dan pengembangan sistem manajemen mutu dan upaya perbaikan
kinerja yang berkesinambungan yang dituangkan dalam pedoman manual mutu
Puskesmas

Demikian pedoman manual mutu ini kami buat dan kami menyampaikan ucapan
terimakasih yang sebesar – besarnya kepada semua pihak yang berkontribusi dalam
penyusunan pedoman manual mutu ini. Semoga pedoman manual mutu yang disusun
sebagai upaya peningkatan mutu dan kinerja Puskesmas ini dapat dilaksanakan dengan
sebaik – baiknya oleh seluruh karyawan Puskesmas Taji

Taji, 22 Pebruari 2018

Tim penyusun

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 DAFTAR ISI

HALAMAN JUDUL ..................................................................................................................................................

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HALAMAN PENGESAHAN ..................................................................................................................................
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KATA PENGANTAR ...............................................................................................................................................
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DAFTAR ISI ...............................................................................................................................................................
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BAB I PENDAHULUAN ..........................................................................................................................................
1
A. Latar belakang ..................................................................................................................................................
1
1. Profil Organisasi ..........................................................................................................................................
2
2. Kebijakan Mutu............................................................................................................................................
13
B. Ruang Lingkup ..................................................................................................................................................
16
C. Tujuan ................................................................................................................................................................
16
D. Landasan Hukum Dan Acuan .......................................................................................................................
17
E. Istilah Dan Definisi ............................................................................................................................................
17
BAB II SISTEM MANAJEMEN MUTU DAN SISTEM PENYELENGGARAAN PELAYANAN ...............
20
A. Persyaratan Umum ..........................................................................................................................................
20

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B. Pengendalian Dokumen ..................................................................................................................................
20
C. Pengendalian Rekaman ..................................................................................................................................
24
BAB III TANGGUNG JAWAB MANAJEMEN ....................................................................................................
25
A. Komitmen Manajemen .....................................................................................................................................
25
B. Fokus Pada Sasaran / Pasien ........................................................................................................................
25
C. Kebijakan Mutu ..................................................................................................................................................
25
D. Perencanaan Sistem Manajemen Mutu Dan Pencapaian Sasaran Kinerja / Mutu ..............................
26
E. Tanggung Jawab, Wewenang Dan Komunikasi .........................................................................................
27
F. Wakil Manajemen Mutu / Penannggung Jawab Manajemen Mutu .........................................................
32
G. Komunikasi Internal ...........................................................................................................................................
32
BAB IV TINJAUAN MANAJEMEN .......................................................................................................................
34
A. Umum .................................................................................................................................................................
34
B. Pertemuan Tinjauan Manajemen Mutu ........................................................................................................ 34
C. Karakteristik Pertemuan Tinjauan Manajemen ............................................................................................
34
D. Tujuan Pertemuan Tinjauan Manajemen .....................................................................................................
35

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E. Agenda Pertemuan Tinjauan Manajemen ...................................................................................................
35
F. Masukan / Input Pertemuan Tinjauan Manajemen .....................................................................................
36
G. Keluaran / Output Pertemuan Tinjauan Manajemen ..................................................................................
37
H. Langkah - Langkah Persiapan Dan Pelaksanaan Pertemuan Tinjauan Manajemen ...........................
38
I. Contoh Matrik Rencana Tindak Lanjut ..........................................................................................................
39
BAB V MANAJEMEN SUMBER DAYA .............................................................................................................
40
A. Penyediaan Sumber Daya ..............................................................................................................................
40
B. Manajemen Sumber Daya Manusia .............................................................................................................
40
C. Infrastruktur .........................................................................................................................................................
41
D. Lingkungan Kerja ..............................................................................................................................................
41
E. Realisasi Produk Pelayanan ............................................................................................................................
41
F. Proses Yang Berkaitan Dengan Pelanggan .................................................................................................
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BAB VI PENYELENGGARAAN PELAYANAN............................................................................................... 47
A. Upaya Kesehatan Masyarakat Puskesmas ..................................................................................................
47
B. Pelayanan Klinis ( Upaya Kesehatan Perorangan ) ....................................................................................
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C. Pengendalian Jika Ada Hasil Yang Tidal Sesuai ........................................................................................
59
D. Analisa Data .......................................................................................................................................................
59
E. Peningkatan Berkelanjutan...............................................................................................................................
59
F. Tindakan Korektif / Perbaikan..........................................................................................................................
59
Tindakan Pencegahan / Preventif.................................................................................................................... 60
BAB VII PENGUKURAN, ANALISA DAN PENGEMBANGAN .......................................................................
44
A. Umum ..................................................................................................................................................................
44
B. Monitoring Dan Pengukuran ............................................................................................................................
44
C. Peningkatan ........................................................................................................................................................
45
BAB VII PENUTUP .................................................................................................................................................
61
LAMPIRAN ...............................................................................................................................................................
62

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