KATA PENGANTAR

Puji syukur kehadirat Tuhan Yang Maha Esa, atas berkah dan rahmat_Nya sehingga
tersusunlah buku Pedoman Mutu Rumah Sakit Umum Malahayati ini.
Saat ini kebutuhan akan standar pelayanan merupakan suatu hal yang sangat penting,
khususnya di Bagian Mutu, buku ini akan menjadi acuan dan pedoman bagi petugas untuk
menyelenggarakan pelayanan kesehatan yang berkualitas dan bermutu tinggi kepada pasien
sesuai dengan batasan dan tanggung jawab masing-masing. Disamping itu, dalam rangka
meningkatkan mutu rumah sakit dan melaksanakan visi dan misinya, diperlukan Pedoman
PelayananMutu agar senantiasa dapat menjaga mutu pelayanan Rumah Sakit.
Buku ini masih jauh dari sempurna, oleh karena itu masukan dan saran dari berbagai pihak
sangat kami harapkan untuk revisi dikemudian hari.

Bireuen, 01 Agustus 2015

Direktur RSU Malahayati

dr. Hasna Laura

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 DAFTAR ISI

SK Pedoman Mutu............................................................................................................... i
Kata Pengantar..................................................................................................................... ii
Daftar isi.............................................................................................................................. iii
Bab I Pendahuluan............................................................................................................ 1
A. Latar Belakang ........................................................................................................ 1
B. Dasar Hukum........................................................................................................... 2
Bab II Gambaran Umum RSU Malahayati.................................................................... 3
A. Deskripsi RSU Malahayati...................................................................................... 3
B. Sejarah Umum RSU Malahayati............................................................................. 3
Bab III Visi, Misi, Nilai Budaya, Tujuan, Motto RSU Malahayati.............................. 4
A. Visi........................................................................................................................... 4
B. Misi.......................................................................................................................... 4
C. Falsafah.................................................................................................................... 4
D. Tujuan...................................................................................................................... 5
E. Motto....................................................................................................................... 5
Bab IV Sejarah Perkembangan Upaya Peningkatan Mutu.......................................... 6
Bab V Konsep Dasar Upaya Peningkatan Mutu............................................................ 7
Bab VI Upaya Peningkatan Mutu dan Keselamatan Pasien......................................... 9
Bab VII Prinsip Dasar Upaya Peningkatan Mutu......................................................... 34
Bab VIII Indikator Mutu Rumah Sakit.......................................................................... 36
A. Indikator Area Klinis............................................................................................... 36
B. Asessmen Pasien...................................................................................................... 36
C. Pelayanan Laboratorium.......................................................................................... 36
D. Indikator Area Manajerial....................................................................................... 45
Bab IX Metode Pengendalian Kualitas Mutu................................................................. 64
Bab X Pengorganisasian................................................................................................... 68
Bab XI Uraian Tugas ....................................................................................................... 69
Bab XII Tata Hubungan Kerja........................................................................................ 77
Bab XIII Pola Ketenagaan dan Kualifikasi Personil..................................................... 79
Bab XIV Penilaian Kinerja............................................................................................... 80
Bab XV Kegiatan Peningkatan Mutu dan Keselamatan Pasien................................... 82
A. Kegiatan.................................................................................................................. 82
B. Rincian Kegiatan dan Pelaksanaan.......................................................................... 82
C. Manajemen Resiko Klinik....................................................................................... 83
D. Root Cause Analysis/ Failure Mode Effect Analysis.............................................. 83
E. Indkator Klinik Pelayanan Medis............................................................................ 84

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 F. Audit Klinis Pelayanan Medis................................................................................. 84
G. Clinical Pathways.................................................................................................... 86
H. Pendidikan Staf........................................................................................................ 86
I. Quality Champion.................................................................................................... 86
J. Pencegahan dan Pengendalian Infeksi..................................................................... 86
K. Akreditasi RS........................................................................................................... 87
L. Monitoring Implementasi........................................................................................ 87
M. Survei ISO 9001 : 2008 untuk seluruh unit............................................................. 88
N. Monitoring sasaran mutu unit.................................................................................. 88
Bab XVI Fasilitas dan Peralatan...................................................................................... 89
Bab XVII Pertemuan/ Rapat............................................................................................ 90
A. Rapat Rutin.............................................................................................................. 90
B. Incident Report........................................................................................................ 90
Bab XVIII Pencatatan dan Pelaporan............................................................................. 91
A. Pencatatan dan Pelaporan........................................................................................ 91
B. Pelaporan Program Kerja PMKP............................................................................. 91
Bab XXI Monitoring dan Evaluasi.................................................................................. 93
A. Monitoring............................................................................................................... 93
B. Evaluasi Kegiatan.................................................................................................... 93
C. Dokumen Bukti........................................................................................................ 93
Bab XX Penutup.................................................................................................................. 94
Daftar Pustaka

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