DAFTAR ISI

HALAMAN
COVER
HALAMAN JUDUL.............................................................................................................i
SK MANUAL MUTU..........................................................................................................ii
KATA PENGATAR...........................................................................................................iv
DAFTAR ISI.......................................................................................................................v
DAFTAR LAMPIRAN......................................................................................................vii
BAB I PENDAHULUAN....................................................................................................1
A. Latar Belakang...........................................................................................................1
1. Profil Puskesmas....................................................................................................1
2. Kependudukan........................................................................................................2
3. Morbiditas................................................................................................................3
4. Keadaan Sosial Ekonomi dan Pendidikan..............................................................4
5. Tenaga Kesehatan..................................................................................................4
6. Pembiayaan Kesehatan..........................................................................................6
7. Sarana Kesehatan..................................................................................................6
8. Kebijakan Mutu.......................................................................................................8
9. Proses Pelayanan...................................................................................................8
B. Ruang Lingkup.........................................................................................................17
1. Ruang Lingkup......................................................................................................17
2. Tanggung Jawab...................................................................................................17
3. Kebijakan..............................................................................................................18
4. Dokumen Terkait...................................................................................................19
C. Tujuan......................................................................................................................20
D. Landasan Hukum dan Acuan..................................................................................20
E. Istilah dan Definisi....................................................................................................20
BAB II SISTEM PENYELENGGARAAN PELAYANAN.................................................22
A. Persyaratan Umum..................................................................................................22
B. Pengendalian Dokumen...........................................................................................23
C. Pengendalian Rekaman..........................................................................................25
BAB III PENYUSUNAN DOKUMEN...............................................................................29
A. Tata Naskah.............................................................................................................29
B. Kebijakan..................................................................................................................38
C. Manual Mutu............................................................................................................40
D. Rencana Lima Tahunan..........................................................................................43
E. Perencanaan Tingkat Puskesmas...........................................................................45
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 F. Pedoman dan panduan............................................................................................47
G.Penyusunan Kerangka Acuan Kegiatan...................................................................50
H. Penyusunan Kerangka Acuan Program..................................................................52
I. Standar Operasional Prosedur..................................................................................54
J. Prosedur Pengendalian Dokumen di Puskesmas....................................................60
K. Rekam Implementasi...............................................................................................63
L. Naskah Dinas...........................................................................................................63
BAB IV TANGGUNG JAWAB MANAJEMEN................................................................70
A. Komitmen Manajemen.............................................................................................70
B. Fokus Pada Sasaran/Pasien...................................................................................70
C. Kebijakan Mutu........................................................................................................70
D. Perencanaan Sistem Manajemen Mutu dan Pencapaian Sasaran Kinerja/Mutu...72
E. Tanggung Jawab,Wewenang Dan Komunikasi.......................................................73
F. Wakil Manajemen Mutu /Penanggung Jawab Mutu ...............................................74
G. Komunikasi Internal.................................................................................................74
BAB V TINJAUAN MANAJEMEN..................................................................................75
A. Umum.......................................................................................................................75
B. Masukan Tinjauan Manajemen................................................................................75
C. Luaran Tinjauan Manajemen...................................................................................75
BAB VI MANAJEMEN SUMBER DAYA........................................................................77
A. Penyediaan Sumber Daya.......................................................................................77
B. Manajemen Sumber Daya Manusia........................................................................77
C. Infrastruktur..............................................................................................................77
D. Lingkungan Kerja.....................................................................................................78
BAB VII PENYELENGGARAAN PELAYANAN.............................................................79
A. Upaya Kesehatan Masyarakat.................................................................................79
B. Pelayanan Klinis(Upaya Kesahatan Perseorangan)...............................................84
BAB VIII PENUTUP........................................................................................................96

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 DAFTAR LAMPIRAN

STRUKTUR TIM MANAJEMEN MUTU..........................................................................97

STRUKTUR TIM AUDIT INTERNAL..............................................................................98
STRUKTUR ORGANISASI BIDANG MUTU ADMINISTRASI DAN MANAJEMEN......99
STRUKTUR ORGANISASI BIDANG MUTU UKM.......................................................100
STRUKTUR ORGANISASI BIDANG MUTU UKP........................................................101
STRUKTUR ORGANISASI BIDANG MUTU KESELAMATAN PASIEN.....................102
STRUKTUR ORGANISASI BIDANG MUTU K3...........................................................103
STRUKTUR ORGANISASI BIDANG MUTU PPI.........................................................104
STRUKTUR ORGANISASI BIDANG MUTU PENGELOLA PENGADUAN................105
STRUKTUR ORGANISASI BIDANG MUTU KREDENSIALING.................................106
STRUKTUR ORGANISASI BIDANG MUTU TATA GRAHA.......................................107
STRUKTUR ORGANISASI PUSKESMAS KALAK.....................................................108
INDIKATOR MUTU ADMEN.........................................................................................109
INDIKATOR MUTU UKM..............................................................................................114
INDIKATOR MUTU UKP...............................................................................................122
INSTRUMEN PKP.........................................................................................................124
FOTO PER RUANGAN.................................................................................................143
CONTOH DOKUMEN SESUAI TATA NASKAH..........................................................150

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