DAFTAR ISI

Halaman

I.PENDAHULUAN..................................................................................... 1
A. Latar Belakang..................................................................................... 1
1. Profil Organisasi.............................................................................. 2
2. Kebijakan mutu................................................................................ 5
3. Proses pelayanan.............................................................................. 6
B. Ruang Lingkup.................................................................................... 9
C. Tujuan.................................................................................................. 9
D. Landasan hukum dan acuan................................................................. 9
E. Istilah dan definisi................................................................................ 10

II. SISTEM MANAJEMEN MUTU DAN SISTEM PENYELENGGARAAN

PELAYANAN........................................................................................ 13
A. Persyaratan Umum............................................................................... 13
B. Pengendalian dokumen........................................................................ 13
C. Pengendalian Rekam Implementasi..................................................... 15

III. TANGGUNG JAWAB MANAJEMEN............................................... 17

A. Komitmen manajemen......................................................................... 17
B. Fokus pada sasaran / pasien................................................................. 18
C. Kebijakan mutu.................................................................................... 18
D. Perencanaan sistem manajemen mutu dan pencapaian sasaran
kinerja/ mutu......................................................................................... 19
E. Tanggung jawab dan wewenang manajemen mutu.............................. 19
F. Wakil manajemen mutu / penanggung jawab mutu............................. 20
G. Komunikasi internal............................................................................. 20

IV. TINJAUAN MANAJEMEN................................................................. 21

A. Umum.................................................................................................. 21
B. Masukan tinjauan manajemen.............................................................. 22
C. Luaran tinjauan.................................................................................... 23

V. MANAJEMEN SUMBER DAYA......................................................... 24

A. Penyediaan sumber daya...................................................................... 24
B. Manajemen sumber daya manusia....................................................... 25
C. Infrastruktur......................................................................................... 25
D. Lingkungan kerja................................................................................. 25

VI. PENYELENGGARAAN PELAYANAN............................................. 27

A. Upaya kesehatan masyarakat.............................................................. 27
 1. Perencanaan UKM,akses dan pengukuran kinerja........................ 27
2. Proses yang berhubungan dengan sasaran.................................... 28
3. Pembelian...................................................................................... 29
4. Penyelenggaraan UKM................................................................. 29
5. Pengukuran,analisis dan penyempurnaan sasaran kinerja UKM.. 31
B. Upaya kesehatan perorangan.............................................................. 35
a. Perencanaan pelayanan klinis....................................................... 35
b. Proses yang berhubungan dengan pelanggan............................... 36
c. Pembelian...................................................................................... 37
d. Penyelenggaraan pelayanan klinis................................................ 37
e. Peningkatan mutu pelayanan klinis dan keselamatan pasien........ 40

VII. PENUTUP............................................................................................ 45