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INDIKATOR PENINGKATAN MUTU DAN KESELAMATAN PASIEN
Angka Kelengkapan Pengkajian Keperawatan
January February March April May June July August September October Nov December
Target > 80% 82% 76% 86% 82% 70% 87% 74% 82% 70% 75% 80% 85%
0%10%20%30%40%50%60%70%80%90%
100%
Target > 80%
Waktu Tunggu Hasil Pelayanan Laboratorium klinik : Pemeriksaan darah lengkap dan kimia klinik (<140 Menit )
January February March April May June July August September October November December
Target > 90 % 81,4% 97,2% 87,5% 88,9% 97,2% 91,8% 87,7% 86,2% 92,4% 92,4% 91,8% 92,6%
70.0%
75.0%
80.0%
85.0%
90.0%
95.0%
100.0%
Target > 90 %
ANGKA PENGULANGAN PEMERIKSAAN RADIOLOGI
January February March April May June July August Sept Oct Nov Dec
Target <2 % 0.2% 0.3% 0.1% 0.1% 0.5% 0.0% 0.1% 0.2% 0.5% 0.1% 0.0% 0.0%
0.0%
0.1%
0.2%
0.3%
0.4%
0.5%
0.6% Target <2 %
KETEPATAN PELAKSANAAN OPERASI ELEKTIVE
January February March April May June July August September October November December
Target 100 % 82.1% 79.0% 78.0% 83.0% 77.0% 85.0% 79.0% 83.0% 89.0% 91.2% 90.1% 90.3%
65.0%70.0%75.0%80.0%85.0%90.0%95.0%
Target 100 %
January February March April May June July August September October November December
Target 100 % 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% 100,0%
Pemberian Aspirin Pada Pasien AMI
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
Target 100 %
PENULISAN RESEP YANG TIDAK JELAS
January February March April May June July August September October November December
Target 0 % 0,04% 0,03% 0,21% 0,04% 0,0% 0,16% 0,21% 0,19% 0,23% 0,17% 0,003% 0,0%
0.00%
0.05%
0.10%
0.15%
0.20%
0.25%
Axis
Titl
e
Target 0 %
Pengkajian Pre-Anasthesi dilaksanakan untuk Pasien Pra Operasi Elektif dengan Anasthesi Umum
January February March April May June July August September October November December Target >80 % 77.2% 62.0% 75.0% 63.0% 71.0% 69.0% 68.0% 65.0% 71.5% 72.0% 73.0% 75.0%
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
Target >80 %
KEJADIAN REAKSI TRANSFUSI DARAH
January February March April May June July August September October November December
Target 0 % 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0%
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
Target 0 %
January February March April May June July August Septemb
er October Novemb
er Decemb
er
Target 95 % 63,0% 60,0% 75,0% 72,0% 75,0% 80,0% 81,0% 82,0% 83,0% 79,0% 80,0% 82,0%
Kelengkapan Pengisian Resume Medis 1 X 24 Jam
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
Target 95 %
ANGKA PHLEBITIS January February March April May June July August September October November December
Target < 10/Mill 7,0 5,0 4,0 6,0 3,0 6,0 7,5 6,8 7,2 7,8
0.01.02.03.04.05.06.07.08.09.0
Satuan /Mill
VAP (VENTILATOR ASSOCIATED PNEUMOMIA)
00.10.20.30.40.50.60.70.80.9
1Target < 10/Mil
January February March April May June July August September October November December
Target < 10/Mil 0,0 0,0 0,0 0,0 0,0 0,0 0,0 0,0 0,0 0,0
January February March April May June July August September October November December
Target < 10% 0,0 0,0 0,0 0,0 0,0 0,0 0,0 0,0 1,8 0,0
ILO (INFEKSI LUKA OPERASI)
0.01.02.03.04.05.06.07.08.09.0
Target < 10 %
ISK (INFEKSI SALURAN KENCING)
January February March April May June July August September October November December
Target < 10/Mil 0,0 0,0 0,0 0,0 0,0 0,0 0,0 0,0 0,0 0,0
00.10.20.30.40.50.60.70.80.9
1Target < 10/Mil
INDIKATOR MUTU MANAJEMENT
KETERSEDIAN OBAT DAN ALKES EMERGENCY DI RUANG RESUSITASI IGD
January February March April May June July August September October November December
Target 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
0%
20%
40%
60%
80%
100%
120%
Target 100%
PENGGUNAAN APAR
January February March April May June July August September October Nove Dec
Target <100 - - - - 100% 100% 100% 100% 100% 100% 100% 100%
0%
20%
40%
60%
80%
100%
120%
PELAKSANAAN STANDAR PENANGANAN TERTUSUK JARUM
January February March April May June July August September October November December
Target <100% 100% - - 100% - - 100% - 100% - - -
0%
20%
40%
60%
80%
100%
120%
January February March April May June July August September October November December
Target <100%
Target <100%
PEMANFAATAN ALAT CT SCAN, UNTUK CT SCAN KEPALA DALAM PROSES PENEGAKAN DIAGNOSE PASIEN YANG DILAKUKAN DI UNIT RADIOLOGI
January February March April May June July August September October November December
Target 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
0%
20%
40%
60%
80%
100%
120%
Target 100%
INDEKS KEPUASAN PASIEN
January February March April May June July August September October November December
Target >90% 92% 98% 96% 94% 91% 92% 96% 99% 93% 92% 91% 94%
86%88%90%92%94%96%98%
100%
Target >90%
PELATIHAN YANG DILAKSANAKAN 20 JAM PERTAHUN
January February March April May June July August September October November December
Target >60% 65% 72% 59% 61% 65% 63% 70% 69% 73% 70% 68% 69%
0%10%20%30%40%50%60%70%80%
Target >60%
10 PENYAKIT TERBANYAK DI RS.SYAFIRA TAHUN 2015 NO. DIAGNOSA TOTAL
1 HT 1850
2 ANC 1562
3 DM 1485
4 APP 1481
5 OBSERVASI FEBRIS 1213
6 CEPHALGIA 1212
7 ISPA 1039
8 KISTA ATERM 759
9 GAGAL GINJAL KRONIK 654
10 KATARAK 405
TOTAL 11660
0200400600800
100012001400160018002000
NO. DIAGNOSA TOTAL 1 POST EKSISI 629
2 OBSERVASI FEBRIS 468
3 DHF 430 4 APPENDICTOMY 304 5 HT 199 6 DYSPEPSIA 191 7 DM 134 8 POST SC 112 9 POST URS 75
10 POST LAPAROTOMY 75
TOTAL 2617
0
100
200
300
400
500
600
700
KECEPATAN WAKTU PEMBERIAN INFORMASI TENTANG TAGIHAN PASIEN RAWAT INAP <2 JAM
January February March April May June July August September October November December
Target >100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
0%
20%
40%
60%
80%
100%
120%
Target >100%
JUMLAH REALISASI KALIBRASI ALAT MEDIS DENGAN USIA LEBIH DARI 1 TAHUN, ATAS INDIKASI YANG DITETAPKAN
UNTUK KALIBRASI 1 TAHUN SEKALI
January February March April May June July August September October November December
Target >85% 53% -
0%
10%
20%
30%
40%
50%
60%
January February March April May June July August September October November December
Target >85%
INDIKATOR SASARAN KESELAMATAN
PERSENTASE TERPASANGNYA GELANG IDENTITAS PASIEN BARU RAWAT INAP
January February March April May June July August September October November December
Target >100% 99,5% 100% 99,6% 100% 100% 99,8% 100% 99,6% 100% 100% 100% 100%
99.2%99.3%99.4%99.5%99.6%99.7%99.8%99.9%
100.0%100.1%
Target >100%
PERSENTASE PELAKSANAAN READ BACK DITANDATANGANI OLEH PEMBERI INSTRUKSI DALAM WAKTU 1X24 JAM
January February March April May June July August September October November December
Target >100% 30% 32% 37% 32% 38% 40% 45% 50% 51% 50% 55% 50%
0%
10%
20%
30%
40%
50%
60%Target >100%
KEPATUHAN PEMBERIAN LABEL OBAT HIGH ALERT OLEH FARMASI
January February March April May June July August September October November December
Target >100% 99,6% 99,8% 99,8% 99,8% 99,4% 99,6% 99,7% 99,8% 99,8% 99,6% 99,7% 99,5%
99.20%
99.30%
99.40%
99.50%
99.60%
99.70%
99.80%
99.90%Target >100%
KEPATUHAN PELAKSANAAN PROSEDUR SITE MARKING PADA PASIEN YANG AKAN DILAKUKAN TINDAKAN OPERASI
January February March April May June July August September October November December
Target >100% 70% 68% 70% 67% 65% 75% 72% 68% 74% 69% 72% 67%
60%62%64%66%68%70%72%74%76%
Target >100%
PERSENTASE KEBUTUHAN PETUGAS KESEHATAN DALAM MELAKUKAN KEBERSIHAN TANGAN DENGAN METODE ENAM LANGKAH DAN LIMA MOMEN
January February March April May June July August September October November December
Target >80% 30% 35% 34% 40% 38% 45% 46% 40% 40% 52% 54% 55%
0%
10%
20%
30%
40%
50%
60%Target >80%
INSIDEN PASIEN TIDAK JATUH SELAMA PERAWATAN RAWAT INAP DI RUMAH SAKIT
January February March April May June July August September October November December
Target >100% 99,9% - - - - -
0%
2000%
4000%
6000%
8000%
10000%
12000%
January February March April May June July August September October November December
Target >100%
MDG’S
JAN FEB MAR APR MEI JUN JULI AGST SEPT OKTO NOV DES Total Target
JUMLAH KEMATIAN 1 2 2 5
0% JUMLAH KELAHIRAN 260 219 209 215 251 258 376 268 263 293 296 268 3175
PERSENTASE/TAHUN 0,1%
ANGKA KEMATIAN IBU TAHUN 2015
JAN FEB MAR APR MEI JUN JUL AGS SEPT OKT NOV DES TOTAL TARGET
JUMLAH KEMATIAN 2 0 2 1 2 0 0 1 1 1 1 0 11
0% JUMLAH
KELAHIRAN 262 219 209 215 260 258 376 268 263 293 296 268 3187
PERSENTASE/TAHUN 0,3%
ANGKA KEMATIAN BAYI TAHUN 2015
PENEMUAN ANGKA HIV (+) DI RS. SYAFIRA MELALUI PELAYANAN VCT
PENEMUAN ANGKA HIV (+)
JAN FEB MAR APR MEI JUN JULI AGS SEPT OKT NOV DES TARGET
50% 50% 50% 0%
100% 0% 33% 100% 100% 0% 30% 0% <50%
ANGKA KESAKITAN TB TAHUN 2015
JAN FEB MAR APR MEI JUN JUL AGS SEP OKT NOV DES TARGET
BTA (+) DIANTARA
SUSPEK YANG DI PERIKSA BTA 52% 100% 72% 60% 42% 47% 66% 66% 40% 50% 60% 100% > 15%
BTA (+) DIANTARA
SEMUA PASIEN TB PARU 68% 69% 56% 78% 72% 68% 70% 77% 72% 69% 77% 72% >65%
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