LAPORAN MUTU KESELAMATAN PASIEN RSUD DR R SOEDJONO

IAK 1 Kelengkapan Pengisian Asesmen Awal Medis 100% 96, 1% 97, 8% 98, 1%

NIFAS INT II I II 96% 93% INT I BEDA H 90% 87% VIP

IAK 2 Angka pengulangan pengambilan sampel darah 0, 5% 0, 4% 0, 3% 0,

IAK 2 Angka pengulangan pengambilan sampel darah 6, 0 % 5, 0 % 4,

IAK 3 Reject film analisis 2, 5% R DA ST AN TA RA RE

IAK 3 Reject film analisis 2, 50% 2, 00% 1, 50% IAK 3 Reject

IAK 4 Kepatuhan Pelaksanaan Sign In, Time out dan Sign Out 100% 100% 99,

IAK 4 Kepatuhan Pelaksanaan Sign In, Time out dan Sign Out 100% 99, 7%

IAK 5 Pemberian aspirin pada pasien Infark Myokard Akut 83, 3% 100% 100% 91,

IAK 5 Pemberian aspirin pada pasien Infark Myokard Akut 100% 90% 80% 70% 60%

IAK 6 Angka kesalahan penyerahan obat oleh instalasi farmasi 0, 6% 0% DA R

IAK 6 Angka kesalahan penyerahan obat oleh instalasi farmasi 5% 5% 4% 4% 3%

IAK 7 Assesment pre anastesi oleh dr Sp. An, sebelum dilakukan tindakan sedasi dan

IAK 8 Permintaan darah yang tak terpakai 10% 8, 6% 8, 0% 7, 0%

IAK 8 Permintaan darah yang tak terpakai 50, 0% 45, 0% 40, 0% 35,

IAK 9 Ketepatan pengembalian RM lengkap ≤ 1 x 24 setelah pasien KRS 99,

IAK 9 Ketepatan pengembalian RM lengkap ≤ 1 x 24 setelah pasien KRS %

IAK 10 KEJADIAN PHLEBITIS 3% 2, 6% 2, 5% 2% 2, 1% 1, 9%

NIFAS INT II I INT I BEDAH VIP ANAK ASKES VK MATA SYARAF ICU

IAM 1 Ketersediaan obat antikoagulan heparin bagi pasien AMI 100% 100% 100% DA R

IAM 1 Ketersediaan obat antikoagulan heparin bagi pasien AMI 100% 90% 80% 70% 60%

IAM 2 Ketepatan waktu pengiriman laporan SIMRS online ≤ tgl 15 BULAN KET JANUARI

IAM 3 KEGIATAN FMEA BULAN KET JANUARI BELUM TERLAKSANA JULI BELUM TERLAKSANA FEBRUARI BELUM

IAM 4 Utilisasi alat syringe pump 100% 90% 80% 70% 60% 50% 40% 30%

IAM 4 Utilisasi alat syringe pump DA AN ST A RA T RE 100%

10, 2 IAM 5 INDEKS KEPUASAN MASYARAKAT (IKM) 10 Series 1 9, 8 9,

• IAM 7 Laporan demografi penyakit di RSUD DR R Soejono Selong. NO

IAM 8 Persentase klaim BPJS 101, 00% 99, 00% 97, 00% eries 1 95,

IAM 9 Angka pasien dengan infeksi daerah operasi (IDO) 3, 7% 2, 9% 2%

IAM 9 Angka pasien dengan infeksi daerah operasi (IDO) 2, 50% 2, 00% 1,

INDIKATOR SASARAN KESELAMATAN PASIEN RSUD DR. R. SOEDJONO SELONG

ISKP 1 Persentase pasien dengan gelang identifikasi 100% 90% 80% 70% 60% Axis Title

ISKP 1 Persentase pasien dengan gelang identifikasi TA ST AN DA R RA S

ISKP 2 Angka kejadian dokter tidak bisa dihubungi 15 43 15 TA ST AN

ISKP 2 Angka kejadian dokter tidak bisa dihubungi 16 14 12 10 is Title

ISKP 3 Kepatuhan pemberian label obat high alert oleh farmasi 100% 84, 5% 82,

ISKP 3 Kepatuhan pemberian label obat high alert oleh farmasi 100, 0% 90, 0%

ISKP 4 Persentase pasien yang tidak diberikan marking tempat operasi 0% TA ST AN

ISKP 4 Persentase pasien yang tidak diberikan marking tempat operasi 100% 90% 80% 70%

ISKP 5 Tingkat kepatuhan petugas melakukan Hand Hygiene DA R AN ST TA RA

90, 0% 80, 0% 70, 0% 60, 0% 50, 0% 40, 0% 30, 0%

ISKP 6 Angka pasien jatuh 0% TA ST AN DA R 0% RE RA

INDIKATOR INTERNATIONAL LIBRARY OF MEASURE

IILM 1 Angka hospital acquired pneumonia ST AN RA T 0% DA R 0%

IILM 1 Angka hospital acquired pneumonia 100% 90% 80% 70% 60% Axis Title 50%

IILM 2 Pasien stroke atas advis dokter Sp. S dilakukan assesmen rehabilitasi medis 100%

IILM 3 Angka pasien decubitus 0% TA ST AN DA R 0% RE RA

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LAPORAN MUTU & KESELAMATAN PASIEN RSUD DR. R. SOEDJONO SELONG TAHUN 2018

RSUD DR. R. SOEDJONO SELONG

IAK 1 Kelengkapan Pengisian Asesmen Awal Medis 100% 96, 1% 97, 8% 98, 1% 96, 6% 92, 3% 94, 9% 96, 3% 96, 4% 98, 1% 98, 3% 96, 8% 100% R DA ST AN TA RA RE DE S V NO OK T PT SE AG US L JU N JU EI M R AP AR M B FE JA N x

NIFAS INT II I II 96% 93% INT I BEDA H 90% 87% VIP 95% ANAK ASKES 99% VK MATA SYAR ICU AF 99% 98% 100% IGD NEO HD OK 0% 100% 0% 0% R DA AN ST RE RA TA OK HD NE O D IG U IC AF AR SY A AT M VK S AS KE AK AN P VI H DA BE I T IN II T IN NI FA S IAK 1 Kelengkapan pengisian asesmen awal Medis sesudah masuk rumah sakit. RERA STAN TA DAR 98% 100% 90, 4% 90, 2% 99, 5% 87, 2% 96, 9% 95, 9% 98, 7% 96, 0% 95, 8% 100, 0% 99, 8% 0, 0% 95, 7% 100, 0% III 96, 2% 90, 5% 99, 2% 91, 0% 92, 1% 94, 6% 99, 0% 91, 7% 95, 7% 100, 0% 0, 0% 95, 6% 100, 0% IV 92, 8% 100, 0% 98, 6% 97, 0% 95, 8% 100, 0% 89, 3% 100, 0%100, 0% 0, 0% 97, 6% 100, 0%

IAK 2 Angka pengulangan pengambilan sampel darah 0, 5% 0, 4% 0, 3% 0, 8% 0, 7% 0, 4% 0, 7% 1, 0% 0, 9% 0, 5% 1, 0% JAN FEB MAR APR MEI JUN JUL AGUS SEPT OKT NOV DES 0, 7% 5% RERATA STANDAR

IAK 2 Angka pengulangan pengambilan sampel darah 6, 0 % 5, 0 % 4, 0 % 3, 0 % 2, 0 % NIFAS INT II INT I BEDAH VIP ANAK ASKES R DA AN ST TA RA RE OK HD NE O D IG U IC AF AR SY A AT M VK S AS KE AK AN P VI H DA BE I T IN II T IN FA NI 0, 0 % S 1, 0 % VK I MATA SYARA ICU IGD NEO HD OK RERAT STAND F A AR 0, 0% 0, 2% 1, 0% 0, 0% 1, 3% 1, 2% 0, 0% 1, 0% 0, 2% 1, 1% 0, 0% 0, 4% 5, 0% II 0, 0% 0, 4% 0, 3% 0, 0% 0, 9% 2, 2% 0, 5% 1, 0% 0, 0% 1, 7% 0, 0% 0, 3% 2, 4% 0, 0% 0, 6% 5, 0% III 0, 8% 1, 4% 2, 8% 1, 4% 1, 0% 1, 6% 0, 5% 3, 3% 0, 0% 0, 9% 0, 0% 0, 3% 1, 7% 0, 0% 0, 9% 5, 0% IV 0, 0% 0, 5% 1, 0% 0, 7% 2, 3% 4, 3% 1, 3% 0, 0% 2, 8% 0, 0% 0, 4% 1, 2% 0, 0% 0, 8% 5, 0%

IAK 3 Reject film analisis 2, 5% R DA ST AN TA RA RE NO OK T PT AG US L V 1, 1% JU N EI 2% 1, 7% 1, 6% 0, 9% M R AP AR M B FE N 1, 8% 1, 5% 0, 6% JA 2, 3% SE 1, 7% JU 1, 7% 2, 3% DE S 2, 5%

IAK 3 Reject film analisis 2, 50% 2, 00% 1, 50% IAK 3 Reject film analisis 1, 00% 0, 50% 0, 00% I II IV rerata STANDAR I II IV rerata STAND AR IAK 3 Reject film analisis 1, 96% 0, 99% 2, 20% 1, 66% 1, 70% 2, 00%

IAK 4 Kepatuhan Pelaksanaan Sign In, Time out dan Sign Out 100% 100% 99, 1% 100, 0% 100% 98, 8% 100% 99, 8% 100% TA ST AN DA R RA S RE DE NO V OK T PT SE US AG JU L JU N EI M R AP AR M B FE JA N 0, 0%

IAK 4 Kepatuhan Pelaksanaan Sign In, Time out dan Sign Out 100% 99, 7% 100% 99, 6% 99, 83% 100% I II IV rerata STANDAR

IAK 5 Pemberian aspirin pada pasien Infark Myokard Akut 83, 3% 100% 100% 91, 7% 100% 98, 6% 71, 8% 62, 5% 25% TA ST AN DA R RA S RE DE NO V 0, 0% OK T PT SE US AG JU L N JU EI M R AP AR M B FE JA N 0, 0%

IAK 5 Pemberian aspirin pada pasien Infark Myokard Akut 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% R RERAT STAND A AR TA OK OK HD HD NEO NE O IGD D U AF A VK S MATA SYARA ICU F 0% 0% 0% 100% 0% 0% 94% 100% II 0% 0% 100% 0% 75% 0% 0% 100% 75% 0% 0% 63% 100% III 0, 0% 0, 0% 100, 0% 0, 0% 66, 7% 100, 0% IV 0, 0% 0, 0% 100, 0% 75, 0% 97, 9% 0, 0% 63, 4% 100, 0% AN RE ST AR M BE NI SY 0, 0% DA 100% RA 0% IG 0% IC 0% AT 0% VI 50% DA 0% T I FA AS KE AK VK AN P H ANAK ASKES IN I INT I BEDAH VIP T II NIFAS INT II IN S 0%

IAK 6 Angka kesalahan penyerahan obat oleh instalasi farmasi 0, 6% 0% DA R 0% ST AN TA RE RA S 0, 0% DE NO V OK T PT SE AG US 0, 0% JU L N 0% JU EI 0% M R 0% AP AR 0% M B FE JA N 0% 0%

IAK 6 Angka kesalahan penyerahan obat oleh instalasi farmasi 5% 5% 4% 4% 3% Axis Title 3% 2% 2% 1% 1% R RERAT STAND A AR TA OK OK HD HD NE O NEO D U AF A VK S IGD 0% 1% 0% 0% II 0% 0% 0% 0% 0% 0% 0% 0% 0% IV 0% 0% 1% 0% 3% 0% 0% 0% AN RE ST AR SY M BE NI DA 0% RA 0% IG 0% IC 0% AT 0% VI 0% DA 0% T I FA AS KE AK MATA SYARA ICU F AN P H VK IN I ANAK ASKES T II NIFAS INT II INT I BEDAH VIP IN S 0%

IAK 7 Assesment pre anastesi oleh dr Sp. An, sebelum dilakukan tindakan sedasi dan Anastesi 100% 100% 97, 6% 100% 99, 7% 95, 3% 100% 90, 2% DA R AN ST TA RA RE S DE NO V OK T PT SE S AG U JU L JU N EI M AP R AR M B FE JA N 0, 0%

IAK 7 Assesment pre anastesi oleh dr Sp. An, sebelum dilakukan tindakan sedasi dan Anastesi 100% 99, 2% 100% 98, 33% 99, 38% 100% I II IV rerata STANDAR

IAK 8 Permintaan darah yang tak terpakai 10% 8, 6% 8, 0% 7, 0% 2, 5% 1, 9% R DA AN ST RE RA TA 0, 6% DE S V 0, 2% NO PT SE AG US L JU N JU EI M R AP AR OK T 0, 9% 0, 7% 0, 8% 0, 4% 0, 5% M B FE JA N 1%

IAK 8 Permintaan darah yang tak terpakai 50, 0% 45, 0% 40, 0% 35, 0% 30, 0% is Title 25, 0% 20, 0% 15, 0% 10, 0% 5, 0% INT I BEDAH I 1, 1% 4, 0% 0, 5% 0, 0% 0, 9% 0, 0% II 0, 9% 1, 4% 1, 6% 0, 0% III 15, 5% 5, 7% IV 0, 0% R DA AN ST RE RA TA OK HD NE O D IG U IC AF IGD NEO HD OK RERAT STAND A AR 0, 0% 0, 0% 1, 2% 10, 0% 0, 0% 0, 0% 0, 6% 10, 0% 1, 0% 22, 3% 17, 6% 2, 5% 2, 2% 6, 4% 0, 0% 33, 3% 19, 2% 17, 1% 0, 0% 7, 9% 10, 0% 0, 3% 0, 0% 0, 0% 0, 6% 10, 0% 3, 0% VK AR MATA SYARAF ICU 0, 0% ANAK ASKES SY M AT A VK S NIFAS INT II 0, 0% VIP AS KE AN AK P VI H DA BE I T IN II T IN NI FA S 0, 0% 0, 0%

IAK 9 Ketepatan pengembalian RM lengkap ≤ 1 x 24 setelah pasien KRS 99, 3% 100% 99, 9% 100, 0% 99, 7% 100, 0% 99, 9% 100% DA R AN ST TA RA RE S DE NO V OK T PT SE S AG U JU L JU N EI M AP R AR M B FE JA N 0, 0%

IAK 9 Ketepatan pengembalian RM lengkap ≤ 1 x 24 setelah pasien KRS % % % % % NIFAS INT II INT I BEDAH VIP ANAK ASKES VK I 100% 98% 100% 99% 100% II 100% 100% III 100% 99% 100% 100% IV 100% 100% MATA SYARAF R ST AN DA TA RE RA OK HD NE O D IG U IC AF AR SY M AT A VK S AS KE AN AK P VI H BE DA I T IN II T IN NI FA S % ICU IGD NEO HD OK RERATA STANDA R 100% 0% 100% 0% 0% 100% 100% 100% 100% 0% 0% 100%

IAK 10 KEJADIAN PHLEBITIS 3% 2, 6% 2, 5% 2% 2, 1% 1, 9% 1, 5% 1, 4% 0, 9% 1% 1, 0% 0, 4% R DA ST AN TA RA RE DE S V NO OK T SE PT 0, 0% AG US L JU N JU EI M R AP AR M B FE JA N 0, 0%

NIFAS INT II I INT I BEDAH VIP ANAK ASKES VK MATA SYARAF ICU IGD NEO HD OK R DA AN ST RE RA TA OK HD NE O D IG U IC AF SY AR A AT M VK S AS KE AK AN P VI H DA BE I T IN II T IN FA NI 9, 00 % 8, 00 % 7, 00 % 6, 00 % 5, 00 % 4, 00 % 3, 00 % 2, 00 % 1, 00 % 0, 00 % S IAK 10 KEJADIAN PHLEBITIS RERAT STAND A AR 0, 00% 1, 73% 0, 38% 0, 20% 0, 12% 1, 61% 0, 38% 0, 00% 0, 12% 0, 46% 3, 01% 0, 00% 2, 63% 0, 00% 0, 89% 3, 00% II 0, 00% 3, 54% 0, 76% 1, 06% 0, 55% 1, 45% 0, 43% 0, 00% 0, 60% 3, 32% 0, 00% 6, 77% 0, 00% 1, 81% 3, 00% III 0, 00% 4, 68% 0, 41% 4, 20% 0, 68% 2, 49% 1, 49% 0, 00% 1, 34% 5, 13% 0, 00% 8, 16% 0, 00% 1, 92% 3, 00% IV 0, 00% 1, 80% 0, 89% 0, 13% 1, 54% 0, 37% 0, 31% 0, 00% 0, 24% 4, 91% 0, 00% 1, 97% 0, 00% 0, 76% 3, 00%

RSUD DR. R. SOEDJONO SELONG

IAM 1 Ketersediaan obat antikoagulan heparin bagi pasien AMI 100% 100% 100% DA R AN ST TA RA RE NO V x S x DE x OK T PT SE S AG U JU L JU N EI M AP R AR M B FE JA N 75%

IAM 1 Ketersediaan obat antikoagulan heparin bagi pasien AMI 100% 90% 80% 70% 60% Series 1 50% 40% 30% 20% 10% 0% I Series 1 II I 100% III II 100% IV III 100% rerata IV 100% rerata 100% STANDAR 100%

IAM 2 Ketepatan waktu pengiriman laporan SIMRS online ≤ tgl 15 BULAN KET JANUARI TEPAT WAKTU JULI TIDAK TEPAT WAKTU FEBRUARI TEPAT WAKTU AGUSTUS TIDAK TEPAT WAKTU MARET TEPAT WAKTU SEPTEMBER TEPAT WAKTU APRIL TEPAT WAKTU OKTOBER TEPAT WAKTU MEI TEPAT WAKTU NOVEMBER TEPAT WAKTU JUNI TEPAT WAKTU DESEMBER TEPAT WAKTU

IAM 3 KEGIATAN FMEA BULAN KET JANUARI BELUM TERLAKSANA JULI BELUM TERLAKSANA FEBRUARI BELUM TERLAKSANA AGUSTUS BELUM TERLAKSANA MARET BELUM TERLAKSANA SEPTEMBER BELUM TERLAKSANA APRIL BELUM TERLAKSANA OKTOBER TERLAKSANA MEI BELUM TERLAKSANA NOVEMBER TERLAKSANA JUNI BELUM TERLAKSANA DESEMBER TERLAKSANA

IAM 4 Utilisasi alat syringe pump 100% 90% 80% 70% 60% 50% 40% 30% 20% 100% 0% II 100, 0% 94, 7% 100, 0% III 100% 0% 100% 0% 0% 0, 0% 100, 0% 0% 100% 100% 0% 0% R DA AN TA RERAT STAND A AR RA RE 0% 0, 0% 100, 0% 96, 3% 0, 0% 98, 2% 0, 0% 0% OK OK HD HD NEO NE O D IG IC AF IGD SY AR U MATA SYARA ICU F A AT VK M VK S ANAK ASKES AS KE AK AN P VI H DA BE I T IN II T INT I BEDAH VIP ST I NIFAS INT II IN NI FA S 0% 100% 0, 0% 98, 2% 100, 0% 0% 100% IV 100, 00%93, 33%100, 00% 0, 00%100, 00%0, 00% 98, 67%100, 00%

IAM 4 Utilisasi alat syringe pump DA AN ST A RA T RE 100% R 99, 2% S 96, 0% DE V 100% NO T 100% OK PT 100% SE US 100% AG JU N JU EI L 98, 9% 100% 97, 4% M R 98, 3% AP AR 100% M B 100% FE JA N 100%

10, 2 IAM 5 INDEKS KEPUASAN MASYARAKAT (IKM) 10 Series 1 9, 8 9, 6 9, 4 TW 1 Series 1 TW 2 TW 1 81, 63 TW 2 81, 66 TW 4 TW 3 TW 4 STANDAR 80

• INDEKS KEPUASAN KARYAWAN

• IAM 7 Laporan demografi penyakit di RSUD DR R Soejono Selong. NO 10 penyakit terbanyak 1 Hipoksia intrauterus dan asfiksia lahir 2 Kondisi lain yang bermula pada masa Perinatal 3 Penyulit kehamilan dan persalinan lainnya 4 Bayi lahir hidup sesuai tempat lahir 5 Persalinan tunggal spontan 6 Perawatan ibu yang berkaitan dengan janin Dan ketuban dan masalah persalinan 7 Pneumonia 8 Gagal jantung 9 Anemia lainnya 10 Persalinan macet

IAM 8 Persentase klaim BPJS 101, 00% 99, 00% 97, 00% eries 1 95, 00% 93, 00% 91, 00% I Series 1 II I 92, 90% III II 94, 40% IV III 94, 40% rerata IV rerata 93, 90% standar 100, 00%

IAM 9 Angka pasien dengan infeksi daerah operasi (IDO) 3, 7% 2, 9% 2% 1, 8% 1, 9% 1, 8% 2, 1% 1, 8% 1, 3% 1, 1% 0, 6% 0, 4% R DA AN ST TA RA RE DE S V NO OK T PT SE US AG L JU N JU EI M R AP AR M B FE JA N 0%

IAM 9 Angka pasien dengan infeksi daerah operasi (IDO) 2, 50% 2, 00% 1, 50% Angka pasien dengan infeksi daerah operasi (IDO) 1, 00% 0, 50% 0, 00% I II IV rerata standar I II IIIIV r st ea Angka pasien dengan infeksi daerah operasi (IDO) 1, 60% 2, 10% 2, 00% 1, 44% 1, 79% 1, 00% ra n ta d ar

INDIKATOR SASARAN KESELAMATAN PASIEN RSUD DR. R. SOEDJONO SELONG

ISKP 1 Persentase pasien dengan gelang identifikasi 100% 90% 80% 70% 60% Axis Title 50% 40% 30% 20% 10% R RERAT STAND A AR DA AN RE RA TA OK OK HD HD NEO NE O D IG U IC IGD SY AR AF MATA SYARAF ICU A AT M VK ST 99% ANAK ASKES AS KE AK AN P VI DA H INT I BEDAH VIP BE I T IN T II NIFAS INT II IN NI FA S 0% I 100% 100% 99% 100% 100% II 100% 100% 99% 100% 95% 0% 100% 0% 0% 99% 100% III 100% 100% 97% 100% 99% 100% 96% 0% 100% 0% 0% 99% 100%

ISKP 1 Persentase pasien dengan gelang identifikasi TA ST AN DA R RA S RE DE NO V OK T PT SE US AG JU L JU N EI M R AP AR M B FE JA N 99, 8% 99, 9% 99, 7% 100% 99, 7% 98, 3% 98, 6% 99, 4% 99, 6% 99, 7% 99, 9% 99, 5% 100%

ISKP 2 Angka kejadian dokter tidak bisa dihubungi 15 43 15 TA ST AN DA R RE RA S 0 DE 1 NO V JU L 0 OK T N 0 0 SE 0 US 0 JU EI M R AP AR M B FE N JA 1 AG 2 1 PT 8

ISKP 2 Angka kejadian dokter tidak bisa dihubungi 16 14 12 10 is Title 8 6 4 2 NIFAS INT II INT I BEDAH VIP ANAK ASKES VK IGD NEO HD OK R ST AN RA RE MATA SYARAF ICU DA TA OK HD NE O IG D U SY AR IC AF A M AT VK S AS KE AK AN P VI H DA BE I II T IN NI IN T FA S 0 RERAT STAND A AR I 0 0 0 7 1 0 0 0 3 0 0 11 0 II 0 0 0 14 0 1 0 0 16 0 III 0 0 0 0 0 IV 0 0 0 13 0 0 0 0 16 0

ISKP 3 Kepatuhan pemberian label obat high alert oleh farmasi 100% 84, 5% 82, 9% 85, 5% 82, 9% 80, 4% 81, 1% 90, 0% 83, 0% 74, 0% 62, 0% R DA AN ST RE RA TA 0, 0% DE S V 0, 0% NO OK T PT SE AG US L JU N JU EI M R AP AR M B FE JA N 0, 0%

ISKP 3 Kepatuhan pemberian label obat high alert oleh farmasi 100, 0% 90, 0% 80, 0% 70, 0% 60, 0% eries 1 50, 0% 40, 0% 30, 0% 20, 0% 10, 0% I Series 1 II I 84, 3% III II 81, 5% IV III 82, 3% rerata IV 0, 0% rerata 82, 7% STANDAR 100, 0%

ISKP 4 Persentase pasien yang tidak diberikan marking tempat operasi 0% TA ST AN DA R 0% RE RA S 0% DE 0% NO V 0% OK T SE AG 0% PT 0% US 0% JU L N 0% JU EI 0% M R 0% AP AR 0% M B 0% FE JA N 0%

ISKP 4 Persentase pasien yang tidak diberikan marking tempat operasi 100% 90% 80% 70% 60% Axis Title 50% 40% 30% 20% 10% R TA OK HD NE O D U AF 0% 0% II 0% 0% 0% 0% 0% 0% 0% 0% 0% IV 0% 0% 0% 0% 0% AN ST RE BE NI DA 0% RA 0% IG 0% IC 0% AR 0% AT 0% VI 0% DA 0% T 0% IN I FA SY A OK RERAT STAN A DAR M VK S HD AS KE AK NEO AN P H I IGD IN II NIFAS INT II INT I BEDA VIP ANAK ASKES VK MATASYARA ICU H F T S 0%

ISKP 5 Tingkat kepatuhan petugas melakukan Hand Hygiene DA R AN ST TA RA RE S DE NO V 58, 7% 58, 2% 59, 0% 60, 2% OK T PT SE S AG U JU L JU N EI M AP R AR M B 54, 0% FE JA N 51, 0% 58, 1% 63, 6% 64, 4% 65, 0% 63, 0% 62, 9% 64, 1% 100%

90, 0% 80, 0% 70, 0% 60, 0% 50, 0% 40, 0% 30, 0% 20, 0% 10, 0% NIFAS INT II INT I BEDAH VIP ANAK ASKES VK MATA SYARAF ICU IGD NEO HD OK R DA AN ST RE RA TA OK HD NE O D IG U IC AF AR SY M AT A VK S AS KE AN AK P VI H DA BE I T IN II T IN FA S 0, 0% NI is Title ISKP 5 Tingkat kepatuhan petugas melakukan Hand Hygiene RERATA STAND AR I 53, 7% 51, 4% 49, 4% 48, 9% 51, 3% 52, 8% 53, 0% 54, 8% 59, 5% 62, 7% 53, 9% 57, 0% 57, 5% 64, 2% 54, 4% 85, 0% II 66, 1% 60, 7% 60, 4% 63, 4% 46, 8% 63, 5% 57, 5% 60, 5% 76, 1% 75, 0% 68, 0% 66, 3% 69, 8% 63, 0% 68, 2% 64, 3% 85, 0% III 64, 1% 59, 8% 59, 9% 63, 0% 49, 6% 60, 4% 59, 8% 57, 4% 79, 5% 71, 2% 66, 1% 57, 4% 66, 0% 63, 6% 72, 6% 63, 4% 85, 0% IV 61, 4% 59, 6% 56, 3% 60, 0% 50, 4% 54, 7% 59, 5% 57, 8% 64, 6% 60, 9% 66, 7% 53, 8% 57, 1% 63, 6% 71, 8% 58, 6% 85, 0%

ISKP 6 Angka pasien jatuh 0% TA ST AN DA R 0% RE RA S 0% DE 0% NO V 0% OK T SE AG 0% PT 0% US 0% JU L N 0% JU EI 0% M R 0% AP AR 0% M B 0% FE JA N 0%

INDIKATOR INTERNATIONAL LIBRARY OF MEASURE

IILM 1 Angka hospital acquired pneumonia ST AN RA T 0% DA R 0% A S RE DE V NO T OK PT SE AG US L 0, 0% 0, 0% JU N 0% JU EI 0% M R 0% AP AR 0% M B 0% FE JA N 0%

IILM 1 Angka hospital acquired pneumonia 100% 90% 80% 70% 60% Axis Title 50% 40% 30% 20% 10% NIFAS INT II INT I BEDA VIP ANAK ASKE VK MAT SYAR ICU IGD NEO HD H S A AF R ST AN DA TA RA RE OK HD NE O D IG U IC AF AR SY A AT M VK S AS KE AK AN P VI H DA BE I T IN II T IN NI FA S 0% OK RERA STAN TA DAR I 0% 0% 0% 0% 0% 0% 0% 0% 0% III 0% 0% 0% 0% 0% IV 0% 0% 0% 0% 0%

IILM 2 Pasien stroke atas advis dokter Sp. S dilakukan assesmen rehabilitasi medis 100% 98, 9% 91, 7% 100% 100% 94, 8% 87, 0% 80% DA R AN ST TA RA RE S DE NO V OK T PT SE S AG U JU L JU N EI M AP R AR M B FE JA N 60, 0%

IILM 2 Pasien stroke atas advis dokter Sp. S dilakukan assesmen rehabilitasi medis 100% 90% 80% 70% 60% Axis Title 50% 40% 30% 20% 10% R RERAT STAND A AR DA TA OK OK HD HD NEO NE O IGD D IG IC AF U MATA SYARAF ICU A VK AT VK S ANAK ASKES AS KE AK P VI H DA I T INT I BEDAH VIP 100% 0% 0% 86% 100% II 0% 0% 100% 0% 68% 0% 0% 100% 0% 0% 89% 100% III 0% 0% 100% 0% 0% 100% IV 0% 0% 100% 0% 0% 100% ST RE SY AN 0% RA 99% AR 0% M 0% AN 0% BE 0% IN I NI IN II NIFAS INT II T FA S 0%

IILM 3 Angka pasien decubitus 0% TA ST AN DA R 0% RE RA S 0% DE 0% NO V 0% OK T SE AG 0% PT 0% US 0% JU L N 0% JU EI 0% M R 0% AP AR 0% M B 0% FE JA N 0%