DAFTAR ISI

Hal

Kata Pengantar .................................................................................................. i

Daftar Isi............................................................................................................. ii
BAB I. Pendahuluan
A. Latar Belakang1
1. Profil Organisasi............................................................................. 2
2. Kebijakan Mutu.............................................................................. 10
3. Proses Pelayanan ( Proses Bisnis ).................................................. 11
B. Ruang Lingkup.................................................................................... 16
C. Tujuan................................................................................................. 16
D. Landasan Hukum dan acuan.............................................................. 17
E. Istilah dan Defenisi.............................................................................. 19

BAB II. Sistim Manajemen Mutu dan Sistim Penyelenggaraan Pelayanan

A. Persyaratan Umum.............................................................................. 21
B. Pengendalian Dokumen....................................................................... 22
C. Pengendalian Rekaman....................................................................... 24

BAB III. Tanggung jawab Manajemen

A. Komitmen Manajemen......................................................................... 28
B. Fokus pada sasaran/ Pasien............................................................... 28
C. Kebijakan Mutu................................................................................... 29
D. Perencanaan sistim manajemen mutu dan pencapaian sasaran
kinerja mutu
............................................................................................................
............................................................................................................
35
E. Tanggung jawab, wewenang dan komunikasi....................................... 44
F. Penanggung jawab Manajemen Mutu................................................... 47
G. Komunikasi internal............................................................................ 48

BAB IV. Tinjauan Manajemen

A. Umum................................................................................................. 50
B. Masukan tinjauan manajemen............................................................ 50
C. Luaran tinjauan.................................................................................. 51

BAB V. Manajemen Sumber Daya

A. Penyediaan Sumber Daya.................................................................... 52
B. Manajemen Sumber Daya Manusia..................................................... 53
C. Infrastruktur....................................................................................... 55
D. Lingkungan kerja................................................................................. 56

BAB VI. Penyelenggaraan Pelayanan

A. Upaya Kesehatan Masyarakat (UKM.................................................... 58
1. Perencanaan UKM, akses, dan pengukuran kinerja/Penilaian
kinerja Puskesmas (PKP)
......................................................................................................
......................................................................................................
58
2. Proses yang berhubungan dengan sasaran..................................... 59
3. Pembelian....................................................................................... 63
4. Penyelenggaraan UKM.................................................................... 64
5. Pengukuran, analisa, dan penyempurnaan sasaran kinerja UKM
Puskesmas
 ......................................................................................................
......................................................................................................
68

B. Upaya Kesehatan Perorangan (UKP)..................................................... 77

1. Perencanaan pelayanan klinis........................................................ 77
2. Proses yang berhubungan dengan pelanggan................................. 78
3. Pembelian / pengadaan barang yang terkait dengan pelayanan
klinis Puskesmas
......................................................................................................
......................................................................................................
79
4. Penyelenggaraan pelayanan klinis.................................................. 79
5. Peningkatan mutu pelayanan klinis dan keselamatan pasien......... 82
6. Pengukuran , analisa, dan penyempurnaan................................... 87

BAB VII. Monitoring dan evaluasi....................................................................... 94

BAB VIII. Penutup............................................................................................... 95

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