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8/18/2019 MATERI PMKP
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PENINGKATANMUTU DAN
KESELAMATANPASIEN (PMKP)
LUWIHARSIH
KOMISI AKREDITASIRS dr Luwi - PMKP 2 juni 2013 1
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I. KELOMPOKSTANDAR
PELAYANAN
BERFOKUS PADAPASIEN
II. KELOMPOKSTANDAR
MANAJEMEN RS
IV. SASARANPROGRAM MDG’S
III. SASARANKESELAMATAN
PASIEN
STANDARAKREDIT
ASIVERSI2012
JCIEDIS
IIVTH2011
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II.KELOMPOKSTANDAR MANAJEMEN
RSN BABI P!"#"$%&'&" M'
K!*!+&,&'&" P&*#!"PMK
P
II P!"-!$&&" /&" P!"$!"/&+#&"
I"!%*#
PPI
III T&'& K!++& K!!,#,#"&" /&"P!"$&3&&"
TKP
IV M&"&4!,!" F&*#+#'&* /&"
K!*!+&,&'&"
MFK
V K&+#5%&*# /&" P!"/#/#%&" S'& KPS
VI M&"&4!,!" K,"#%&*# /&"I"3,&*#
MKI
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STD
E+!,!"P!"#+&" BUKTI
IMPLEMENTASI61. W&7&"-&3&
&*#!" *'& #,#"&"2. O8*!39&*#:. D%,!"
P!+&%*&"&&"
REGULASI 6•
K!8#4&%&";SK • P!/,&"• SPO• P3$3&,
• SKOR < 10 TERCAPAI
PENUH
• SKOR = TERCAPAI
SEBAGIAN
• SKOR 0 TIDAK
TERCAPAI
• TIDAKAPLIKABEL
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PENINGKATAN MUTUDAN KESELAMATAN
PASIEN (PMKP)
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A& #' M'>
M' 8!3*#&' !3*!*# /&"/#&&,# 8!38!/& +!3&"$ ?&"$ 8!38!/& "&,"
8!3#,+#%&*# &/&*!3#3#'&* *!*&' &+.
P!"#+&" #"/#%&'3 /&&'
/#$"&%&" "'% ,!"#+,' 8!38&$ %"/#*#.
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A& #' P!"#"$%&'&"M'>
D&+&, %&,* ,&"&+ S'&"/&3/ JCI6
P!"/!%&'&" '!3&/& 3*!*
!,8!+&4&3&" /&" 3*!* !38%&"?&"$ '!3* ,!"!3* /&3# 3*!*
!"?!/#&&" !+&?&"&" %!*!&'&"
*!* %!8'&" &*#!" /&" #&%2
?&"$ 8!3%!!"'#"$&" +""?&.
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A& #' P!"#"$%&'&"M'>
Perbaikan kualitas secara
terus menerus, perbaikan yang
terus menerus, perbaikan
kinerja di tingkat RS dan
manajemen mutu total.
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APA ITU KESELAMATANPASIEN RS
K!*!+&,&'&" &*#!" RS &/&+& *&' *#*'!,/#,&"& RS ,!,8&' &*&" &*#!" +!8#&,&" ?&"$ ,!+#'# &*!*,!" 3#*#%#/!"'#5%&*# /&" !"$!++&&" &+ ?&"$8!38"$&" /!"$&" 3#*#% &*#!"!+&3&" /&" &"&+#*#* #"*#/!" %!,&,&"8!+&4&3 /&3# #"*#/!" /&" '#"/&% +&"4'"?&*!3'& #,+!,!"'&*# *+*# "'%,!,#"#,&+%&" '#,8+"?& 3#*#% /&"
,!"-!$& '!34&/#"?& -!/!3& ?&"$/#*!8&8%&" +! %!*&+&&" &%#8&',!+&%*&"&%&" *&' '#"/&%&" &'& '#/&%,!"$&,8#+ '#"/&%&" ?&"$ *!&3*"?&/#&,8#+.
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APA ITU INSIDEN KESELAMATANPASIEN
Inid!n "!!#$%$&$n '$i!n (IKP)$d$#$* !&i$' "!j$di$n +, &id$"di!n,$j$ ".ndii +,
%!n,$"i/$&"$n $&$u /!r'.&!ni%!n,$"i/$&"$n !d!r$ +, d$'$&di!,$* '$d$ '$i!n&!rdiri d$riK!j$di$n Tid$" Di*$r$'"$n (KTD)K!j$di$n N+$ri !d!r$ (KN)K!j$di$n Tid$" !d!r$ (KT) d$nK!j$di$n P.&!ni$# !d!r$ (KP)
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INSIDEN KESELAMATAN PASIEN
K!j$di$n Tid$" Di*$r$'"$n (KTD) $d$#$* inid!n+$n, %!n,$"i/$&"$n !d!r$ '$d$ '$i!n
K!j$di$n N+$ri !d!r$ (KN) $d$#$* &!rj$din+$
inid!n +$n, /!#u% $%'$i &!r'$'$r "! '$i!n
K!j$di$n Tid$" !d!r$ (KT) $d$#$* inid!n +$n,ud$* &!r'$'$r "! '$i!n &!&$'i &id$" &i%/u#!d!r$
K.ndii P.&!ni$# !d!r$ (KP) $d$#$* ".ndii+$n, $n,$& /!r'.&!ni un&u" %!ni%/u#"$n
!d!r$ &!&$'i /!#u% &!rj$di inid!nK!j$di$n !n&in!# $d$#$* u$&u KTD +$n,
%!n,$"i/$&"$n "!%$&i$n $&$u !d!r$ +$n,!riu
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MATERI
1. PENINGKATAN
MUTU LAYANAN RS2. RISK MANAJEMEN
@ PATIENT SAFETY
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ISK MANAEMEN UALITIMPEMENT
DAHULUoF"$*# 3#*% ,&"&4!,!"
&+#'? #,39!,!"' /#
3,& *&%#' *!3#"$ %&+#/#+&%*&"&%&" *!-&3&
'!3#*& /&" &/&
!"&"$$"$ 4&7&8"?& /#
,&*#"$,&*#"$ "$*#
oM!,"? 4&+3!+&3&" ?&"$ 8!38!/&
oS'3%'3 3#*% ,&"&4!,!"
/&" &+#'? #,39!,!"'
'!3#*&
SEARA!"U&?& 3#*% ,&"&4!,!"
/&" &+#'? #,39!,!"'
/# RS &/&+& "'%
,!"/%"$ %!*!+&,&'&"
&*#!" /&" ,!"-&3# 4&+&"
"'% 8!%!34& *&,& +!8#
!!%'# /&" !5*#!" "'%,!"4&,#" &*&" &*#!"
?$ /#8!3#%&"&" &,&" /&"
8!3,' '#"$$#.
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RISK MANAGEMENT
R#*% #/!"'#5-&'#" (!.$."!&3,#** &"/ &/9!3*!!9!"' 3!3'#"$)R#*% -"'3+ (!.$. +**P3!9!"'#" &"/ +**3!/-'#")R#*% 5"&"-#"$C+,* ,&"&$!,!"'C"'3&-';+#-? 3!9#!7P&'#!"' 3!+&'#"* &"//#*-+*3!S&!'? &"/ *!-3#'?C33&'! &"/ 3!$+&'3?-,+#&"-!A--3!/#'&'#" -,+#&"-!
UALITY
IMPROVEMENTu$#i&+ %!&*.d.#.,+u$#i&+ M!$ur!:indi$&.r:D$*/.$rd: .r!%!$ur! !&
;!n*%$r"in,;!& 'r$&i!:#ini$#,uid!#in!Pr.%$n$,!%!n&
OVERLAPPINGFUNCTIONS
An$#+i .= $d
..&-$u! $n$#+i
Pr.$&i
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F"-'#" 3P3-!**
O84!-'#9!
I,39!,!"';I""9&'#"
I"'!3"&+
D&'&8&*!
C,&3&'#9!I"3,&'#"
DESIGN MEASURE ASSESS IMPROVE ANDREDESIGN
D!*#$"
R!/!*#$"
D!*#$"
I,39!
A**!**
M!&*3!
I,39!,!"' P3#3#'#!*
SIKLUS MUTU :METDE MUTU
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• $rr+ .u& '#$n• D..%!n& 'r./#!%
$nd ./!r
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RISKMANAJEMEN
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d r L u w i
- P M K P 2 j u n i 2 0 1 3
PENINGKATAN
MUTU KESELAMATAN
PASIEN
M!"#"$%&'%&",' !$r$
"!!#uru*$n dn,
&!ru %!n!ru,!"$3&"$#
3#*#% &!r*$d$''$i!n &$= /$i"
d$#$% 'r.! "#ini%$u'un
#in,"un,$n i"
21
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dr Luwi - PMKP 2 juni 2013
PMKPP!nd!"$&$n %!#i'u&i/$,$i%$n$ M!%i%'in d$n
%!r!n$n$"$n 'r.,r$%PMKP
M!r$n$n, 'r.! "#ini %$n$j!ri$# +, /$ru
dn, /$i" M!n,u"ur !/!r$'$
/$i"n+$ 'r.! /!rj$#$n%!#$#ui '!n,u%'u#$nd$&$
M!n,$n$#ii d$&$ M!n!r$'"$n
%!%'!r&$*$n"$n'!ru/$*$n +,di&i%/u#"$n d#% 'r.!
'!nin,"$&"$n %u&u
P!3+ ,!"/&&'/3"$&" #,#"&"
B!3'4&" ,!"$8&8/&?& RS
S!-&3& 3&%'#,!"$#/!"'#5%&*# ,!"$3&"$# 3#*#% !"?#,&"$&""?&
M!"$$"&%&" /&'& '%
,!,%*%&" /#3# /,&*&+&2 ?$ ,!"4&/#3#3#'&*
B!3'4&",!,!3'"4%&"'!34&/#"?& !38%&"8!3%!+&"4'&" 22
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FOKUS AREA STANDARPMKP
K!!,#,#"&" /&"!3!"-&"&&"
1 1.1 1.21.: 1. 1.=
R&"-&"$&" 3*!* %+#"#%
,&"&4!,!"
2 2.1
P!,#+#&" #"/#%&'3
!"$,+&" /&'&
: :.1 :.2
:.:)
V&+#/&*# /&" &"&+#*#* /&3##"/#%&'3 !"#+&"
.1 .2 ==.1 )
M!"-& /&"
,!,!3'&&"%&"
1011
BAB IPENINGKATAN MUTU KESELAMATAN PASIEN
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KEPEMIMPINAN DAN
PERENCANAAN
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KEPEMIMPINAN DAN
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KEPEMIMPINAN DANPERENCANAAN
S'&"/&3 PMKP.1
M!3!%& ?&"$ 8!3'&"$$"$ 4&7&8,!,#,#" ,!"4&+&"%&" RS (P!,#+#% D#3RS) 8!3&3'#*#&*# /+, !3!"-&"&&" !9&+&*# %!8!3&*#+&" 'r.,r$% PMKP
E+!,!" P!"#+&" PMKP.1
1 Pi%' S /!r'$r&ii'$i d$#$% !+&%*&"&&","#'3#"$ 'r.,r$% PMKP
2 Pi%'in$n S /!r'$r&ii'$i /&+&,
!3!"-&"&&"
3 Pi%'in$n S ,!"!'&%&" 3*!* &'&,!%&"#*,! !"$&7&*&" 'r.,r$% PMKP
4 Pr.,r$% PMKP /#+&3%&" .#!* 'i%'in$n S
"!'$d$ /$d$n '!n,!#.#$ (governance) dr Luwi - PMKP 2 juni 2013 25
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PERSIAPAN RUMAH SAKIT
M!n+uun K!/ij$"$n'!r!n$n$$n '!#$"$n$$n%.ni&.rin, '!#$"$n$$n
'!#$'.r$n PMKP
Dir!"&ur&!r#i/$&
$&$&$n "!/ij$"$n /i$ dij$di"$n
$&u dn, '!d.%$n PMKP $&$u!ndiri-2
D."u%!n #$'.r$n PMKP "!
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KEPEMIMPINAN DAN PERENCANAAN
S'&"/&3 PMKP.1.1.
Pi%'in$n RS 8!3%+&83&*# d$#$% %!#$"$n$"$n 'r.,r$%
PMKP KOMITE ;PANITIA;TIM MUTU KP
E+!,!" P!"#+&" PMKP.1.1.
1 Pi%'in$n S 8!3&3'#*#&*# /&+&, ,!+&%*&"&%&"
'r.,r$% PMKP #i*$& ju,$ TKP34 EP 2G KPS11 EP 1G
KPS14 EP 1 d$n KPS17 EP 1)
2 Pr.,r$% PMKP 8!3+&% /# *!+3 RS P3$3&,
M';&+#'? P+&"
3 Pr.,r$% %!n$n,$ni *#*'!, /&3# RS '!r$n$n 3&"-&"$&"
*#*'!, 3&"-&"$ +&"$ d$ri PMKP
4 Pr.,r$% %!n$n,$ni %3/#"&*# *!,& %,"!" d$ri
"!,i$&$n '!n,u"ur$n %u&u d$n "!,i$&$n '!n,!nd$#i$n
(#i*$& ju,$ TKP34 EP 2 d$n PPI10 EP 1)dr Luwi - PMKP 2 juni 2013 27
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PERSIAPAN RUMAH SAKIT
;!n&u" K.%i&!:P$ni&i$:Ti% PMKP #!n,"$'id!n,$n ur$i$n &u,$
;u$& Pr.,r$% PMKP +, "!,i$&$n +$n, "!,i$&$n'."."n+$ //
◦
U'$+$ P!nin,"$&$n Mu&u◦ K!!#$%$&$n P$i!n
ini$n "!,i$&$n P!nin,"$&$n Mu&u
M!n+uun "!/ij$"$n d$n 'r.!dur PMKP
M!n+uun '!d.%$n:'$ndu$n %u&u:%$nu$#%u&u:d!i,n %u&u (PMKP 2)
Pr.,r$% 'ri.ri&$ (PMKP 12)
Pr.,r$% di"#$& PMKP (PMKP 15)
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PERSIAPAN RUMAH SAKIT#ini$# P$&*w$+ (PMKP 21) %!%i#i* $r!$
'ri.ri&$ (*i,*
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PERSIAPAN RUMAH SAKIT Indi"$&.r %$n$j!ri$# (PMKP 32 PMKP 4)
'!%i#i*$n (!&!#$* di'i#i* !&i$' indi"$&.r
di/u$&"$n 'r.#:"$%u) '!n,u%'u#$n $n$#i$
r!n$n$ &ind$" #$nju& ($&i.n '#$n
'!r/$i"$nn+$)
Indi"$&.r SKP (PMKP 33 PMKP 4) '!%i#i*$n
(!&!#$* di'i#i* !&i$' indi"$&.r di/u$&"$n
'r.#:"$%u) '!n,u%'u#$n $n$#i$ r!n$n$
&ind$" #$nju& ($&i.n '#$n '!r/$i"$nn+$)M.ni&.rin, P!ni#$i$n "in!rj$ indi
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PERSIAPAN RUMAH SAKIT
K!!#$%$&$n P$i!nIKP (Inid!n K!!#$%$&$n P$i!n)
D!nii S!n&in!# KTD KN KP KTG
i&!% '!n$&$&$n d$n '!#$'.r$n$n$#i$ (ri" ,r$din, %!r$* A)
i" M$n$j!%!n 1 &$*un !"$#i
@MEA (PMKP 11)
A (M@K d$n 4 M@K 4 )In=!&i.n .n&r.# i" A!%!n:IA
(PPI) PPI 6 d$n PPI 7
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KEPEMIMPINAN DAN PERENCANAAN
S'&"/&3 PMKP.1.2
Pi%'in$n %!n!&$'"$n 'r.! +$n, dij$di"$n3#3#'&* un&u" di#$"u"$n !
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KEPEMIMPINAN DANPERENCANAAN
S'&"/&3 PMKP.1.:. Pi%'in$n %!%/!ri"$n 8&"'&" '!%"+$# d$n
du"un,$n #$inn+$ un&u" %!ndu"un, 'r.,r$%
PMKP
E+!,!" P!"#+&" PMKP.1.:.
1 P#,#"&" ,!,&&,# '!%"+$# /&" "*3
8&"'&" +" +$n, di/u&u*"$n un&u"
%!n!#uuri d$n %!%/$ndin,"$n *$i# d$ri!
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KEPEMIMPINAN DANPERENCANAAN
S'&"/&3 PMKP.1..
PMKP di in=.r%$i"$n "! &$= /u#!&in '$'$n'!n,u%u%$n r$'$& &$= "!,i$&$n uni& SDM
E+!,!" P!"#+&" PMKP.1..
1 I"3,&*# &!n&$n, 'r.,r$% PMKP di $%'$i"$n"!'$d$ &$=
2 K.%uni"$i di#$"u"$n !$r$ 3!$+!3 ,!+&+#*&+3&" +$n, !=!"&i= (#i*$& ju,$ TKP16 EP 2)
3 K.%uni"$i &!r%$u" "!%$ju$n d$#$% *$#!"!3&&" *&*&3&" %!*!+&,&'&" &*#!"
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KEPEMIMPINAN DANPERENCANAAN
S'&"/&3 PMKP.1.=.
S&$= di/!ri '!#$&i*$n un&u" i"u& !r&$ d$#$% 'r.,r$%
E+!,!" P!"#+&" PMKP.1.=.
1 Ad$ 3$3&, !+&'#&" /$,i &$= !u$i d!n,$n '!r$n$n%!r!"$ d$#$% 'r.,r$% '!nin,"$&$n %u&u d$n "!!#$%$&$n
'$i!n
2 S!.r$n, #"/#9#/ ?&"$ 8!3!"$!'&&" +&* ,!,8!3#%&"
!+&'#&"
3 S&$= /!r'$r&ii'$i d$#$% '!#$&i*$n !/$,$i 8&$#&" /&3#
!%!34&&" 3'#" ,!3!%&
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KEPEMIMPINAN PERENCANAAN
o 8!3&3'#*#&*# d$#$% '!r!n$n$$n
!
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PEMILIKRS
DIREKTURUTAMA RS
MONEV PENGAWASAN PMKP 1
PELAKSANAAN
P#P $
PERENCANAANP#P $
PELAPORANP#P $
BUATKEBIJAKANNYA
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PELAKSANAANP#P $.$
PANDUAN PMKP P3$3&, PMKP;&+#'?
P+&"
BENTUK
KOMITE;TIMMUTU
PENETAPANPRIORITAS
P#P $.%
SETIAP UNIT ADAPROGRAM MUTU
KP
HASIL KEG DI INFOKAN KE STAF
P#P $.&
PERLU BANTUANTEKNOLOGI (PMKP1.:)
DIKLAT MUTU D#3!%*# &3& #,RS K,#'! M'PJ !"$,+ /&'&
(PMKP 1.=)
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YANG DIPERSIAPKANRS
1. K!'!"'&" '!"'&"$ !3!"-&"&&"!+&%*&"&&" ,"#'3#"$ PMKP D#3' RS '!3+#8&' %!8#4&%&" &$&3
/#,&*%&" /# P!/,&" PMKP
2. F3, ,"#'3#"$
:. P3$3&, PMKP
. P!/,&" PMKP
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RANCANGAN PROSESKLINIS
DAN MANAJERIAL
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PEDOMAN MUTU KP
= CLINICAL PATHWAY D;!"?&%#' &'&3*!/3 '#"/&%&"
DESIGN MUTU CLINICAL PATHWAY
RANCANGAN PROSES
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RANCANGAN PROSESKLINIS
DAN MANAJERIALS'&"/&3 PMKP.2.
S %!%/u$& 3&"-&"$&" 8&3 /&" ,!+&%%&",/#5%&*# /&3# *#*'!, d$n 'r.! !u$i 'rini''!nin,"$&$n %u&u
E+!,!" P!"#+&" PMKP.2. P!/,&" PMKP
1 Prini' '!nin,"$&$n %u&u d$n $#$& u"ur d$ri 'r.,r$%di&!r$'"$n '$d$ 3&"-&"$&" 3*!* 8&3 &'& ?&"$/#,/#5%&*#
2 E#!%!n d$#$% M$"ud d$n Tuju$n d$ri *uru= $ :d idi,un$"$n $'$/i#$ r!#!
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RANCANGAN PROSES KLINIS MANAJERIAL
R&"-&"$&" 3*!* ?&"$ 8% &/&+& 6
$ ".ni&!n d!n,$n ,#*# /&" 3!"-&"& ru%$* $"i&G
/ %!%!nu*i %!8'&" &*#!" %!+&3$& *'& /&" +""?&
%!n,,un$"$n !/. 3&%'!% '!3%#"# &$nd$r +$n "#ini"!'u&$"$$n i#%i$* /!r/$,$i in=.r%$i /!r/$i /u"&i +,
r!#!
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RANCANGAN PROSES KLINIS DANMANAJERIAL
S'&"/&3 PMKP.2.1.
P!d.%$n 'r$"&!" "#ini d$n #ini$# '$&*w$+ d$n $&$u'r.&.".# "#ini di,un$"$n !/$,$i '!d.%$n d$#$%%!%/!ri"$n $u*$n "#ini
E+!,!" P!"#+&" PMKP.2.1.
1 S!&i$' &$*un 'i%'in$n %!n!n&u"$n '$#in, !di"i& +#,&
&3!& 3#3#'&* d!n,$n =."u '!n,,un$$n '!d.%$n "#iniclinical pat'(ays d$n:$&$u 'r.&.".# "#ini 5 #ini$#'$&*w$+ /$,$i%$n$ '!d.%$n "#inin+$ /$,$i%$n$'r.&.".#:SPn+$ !" $'$ d* !u$i dn, %$"ud &uju$n
2 S d#% %!#$"$n$"$n '!d.%$n 'r$"&!" "#ini c"inica"
!at#$a%s d$n:$&$u 'r.&.".# "#ini %!#$"$n$"$n 'r.! $)' *) d$#$% M$"ud d$n Tuju$n
3 S %!#$"$n$"$n '!d.%$n "#ini d$n c"inica" !at#$a%s $&$u'r.&.".# "#ini di !&i$' $r!$ 'ri.ri&$ +$n, di&!&$'"$n I,+!,!"'&*# /# R!%&, M!/#*
4 Pi%'in$n "#ini d$'$& %!nunju""$n /$,$i%$n$ '!n,,un$$ndr Luwi - PMKP 2 juni 2013 43
RANCANGAN PROSES KLINIS DAN
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RANCANGAN PROSES KLINIS DANMANAJERIAL
S&*&3&" /&3# 3,& *&%#' ,!+#'# 6
*'&"/&3/#*&*# /&3# 3*!* &*&" %+#"#* ,!"$3&"$# 3#*#% di d$#$% 'r.! $u*$n "#ini &!ru&$%$
*$#-*$# +$n, &!r"$i& d!n,$n #$n,"$* '!n,$%/i#$n "!'u&u$n+$n, "ri&iG
%!%/!ri"$n &*&" %+#"#* '!&' 7&%' $r$ +$n, !=!"&i=
d!n,$n %!n,,un$"$n u%/!r d$+$ !$r$ !i!nG !$r$ ".ni&!n ,!"$&*#+%&" ,' !+&?&"&" ?&"$
'#"$$# %!#$#ui $r$-$r$ /!r/$i /u"&i (evience'ase)
;!r/$,$i ru%$* $"i& %!n,,un$"$n /!r/$,$i $#$& un&u"%!n$'$i $$r$n ini %$u'un $$r$n #$inn+$ S!/$,$i .n&.*'$r$ 'r$"&ii '!#$+$n$n "!!*$&$n %!n,!%/$n,"$n 'r.!$u*$n "#ini d$n %!%/u$& "!'u&u$n $u*$n "#ini/!rd$$r"$n /u"&i i#%i$* &!r/$i" +$n, $d$ P!d.%$n 'r$"&!""#ini %!ru'$"$n $#$& +$n, /!r,un$ d$#$% u'$+$ %!%$*$%i
d$n %!n!r$'"$n i#%u '!n,!&$*u$n &!r/$i" '$d$ w$"&udr Luwi - PMKP 2 juni 2013 44
RANCANGAN PROSES KLINIS DAN
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RANCANGAN PROSES KLINIS DANMANAJERIAL
A#ur $u*$n "#ini (c"inica" care !at#$a%s) $d$#$* $#$& +,/!r%$n=$$& d#% u'$+$ ini u&" %!%$&i"$n $d$n+$ in&!,r$i "..rdin$i +, !=!"&i= dr +$n dn, %!n,un$"$n !$r$ !i!n SD+, &!r!di$ !$r$ !i!n P!d.%$n 'r$"&!" "#ini a"ur asu#ank"inis & 'r.&.".# "#ini $d$#$* r!#!
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RANCANGAN PROSES KLINIS DANMANAJERIAL
u%$* $"i& di*$r$'"$n d$'$& %!#$"$n$"$n"!,i$&$n di/$w$* ini !&i$' &$*un
1 Pi%'in$n "#ini %!%i#i* '$#in, !di"i& = +#,&&3!& 3#3#'&* !/$,$i =."u !'!r&i /#&$"*#*'$i!n 3*!/3 '.'u#$i $&$u !"?&%#' di%$n$ '$ndu$n (guie"ines) !at#$a%s d$n'r.&.".# d$'$& %!%'!n,$ru*i %u&u d$n"!!#$%$&$n d$ri $u*$n '$i!n !r&$%!%'!r"!i#
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C+#"#-&+ &'7&?*◦ K!!'$"$&$n &$&$ $&ur$n '!n,./$&$n +$n, &!r%$u"
!%u$ !#!%!n d$ri $u*$n:'!#$+$n$n
◦ r!n$n$ '!n$&$#$"$n$$n '$i!n +$n, /!ri=$& %u#&i
dii'#in +$n, /!rii d!&$i# #$n,"$*-#$n,"$*
'!n$n,$n$n !.r$n, '$i!n %u#$i %$u" S $%'$i
d!n,$n "!#u$r S
◦ %!ru'$"$n #$n,"$*-#$n,"$* 'r.&.".# &!r$'i d$n
&$nd$r '!#$+$n$n '$i!n #ini$# '$&*w$+ #!/i*
%!ru'$"$n '!n,in,$& (r!%ind!r) d$n '!r$n,"$&
!
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dr Luwi - PMKP 2 juni 2013 48
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dr Luwi - PMKP 2 juni 2013 49
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CLINICAL PATHWAY
Au$n PMK 1438 &$*un 2010 &!n&$n,&$nd$r '!#$+$n$n "!d."&!r$n
S&$nd$r '!#$+$n$n "!d."&!r$n $d$#$*'!d.%$n +$n, *$ru dii"u&i /$,i d."&!r d$n
d."&!r ,i,i d$#$% %!n+!#!n,,$r$"$n 'r$"&i""!d."&!r$n &!rdiri d$ri P!d.%$n N$i.n$#Pr$"&i" K!d."&!r$n (PNPK) d$n SP
PNPK !/$,$i $u$n '!n+uun$n SP di S
SP diuun d$#$% /!n&u" '$ndu$n 'r$"&i""#ini (#ini$# 'r$&i! ,uid!#in!) +, d'&di#!n,"$'i $#ur "#ini (#ini$# '$&*w$+)$#,.ri&%$ 'r.&.".# 'r.!dur &$ndin, .rd!r
dr Luwi - PMKP 2 juni 2013 50
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dr Luwi - PMKP 2 juni 2013 51
PEDOMAN NASIONALPELAYANAN KEDOKTERAN
PANDUAN PRAKTIK KLINIS
CLINICAL PATHWAY
In&!rn$&i.n$# !=!r!n! Si&!
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In&!rn$&i.n$# !=!r!n! Si&!#ini$# Juid!#in!
I"'!3"&'#"&+ J3"&+ 3 &+#'? I" H!&+'-&3!◦ ''6;;#"'-.3/43"&+*.3$;-"'!"';1=;=;:.
+
I"*'#''! M!/#-#"! 2011. S'&"/&3/* 3D!9!+#"$ T3*'73'? C+#"#-&+ P3&-'#-! G#/!+#"!*. ''6;;#,.!/;R!3'*;2011;C+#"#-&+P3&-'#-!G
#/!+#"!*W!C&"T3*';S'&"/&3/*.&* F++7#"$ 7!8*#'! !3* &" I"'!3"&'#"&+ -++!-'#"
C+#"#-&+ P3&-'#-! G#/!+#"!*6 ''6;;777.-+#"#-&+$#/!+#"!*.3$;-&3/#9&*-+&3,!
/#-#"!.',''6;;#,.!/;R!3'*;2011;C+#"#-&+P3&-'#-!G#/!+#"!*W!C&"T3*';S'&"/&3/*.&*
52 dr Luwi - PMKP 2 juni 2013
http://intqhc.oxfordjournals.org/content/15/5/377.fulhttp://intqhc.oxfordjournals.org/content/15/5/377.fulhttp://iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspxhttp://iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspxhttp://www.clinicalguidelines.org/cardiovascularmedicine.htmhttp://www.clinicalguidelines.org/cardiovascularmedicine.htmhttp://iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspxhttp://iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspxhttp://iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspxhttp://iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspxhttp://www.clinicalguidelines.org/cardiovascularmedicine.htmhttp://www.clinicalguidelines.org/cardiovascularmedicine.htmhttp://iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspxhttp://iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspxhttp://intqhc.oxfordjournals.org/content/15/5/377.fulhttp://intqhc.oxfordjournals.org/content/15/5/377.ful
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CLINICAL PATHWAY (PMK 1438:2010 &&, &$nd$r '!#$+$n$n "!d."&!r$n)
dr Luwi - PMKP 2 juni 2013 53
STANDAR PELAYANANKEDOKTERAN
PEDOMAN NASIONAL PRAKTIKKEDOKTERAN SPO
STANDAR PROSEDUROPERASIONAL RS
PANDUAN PRAKTIK KLINIS ALUR KLINIS
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PANDUAN PAKTIK KLINIS
P!n,!r&i$nAn$%!i
P!%!ri"$$n @ii"
Kri&!ri$ Di$,n.iDi$,n.i ;$ndin,
P!%!ri"$$n '!nunj$n,
T!r$'i
Edu"$iPr,.n.i
K!'u&$"$$n
dr Luwi - PMKP 2 juni 2013 54
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PEMILIHAN INDIKATORDAN PENGUMPULAN DATA
S'&"/&3 PMKP.:.
Pi%'in$n ru%$* $"i& %!n!&$'"$n indi"$&.r "uni d$#$%&ru"&ur ru%$* $"i& 'r.!-'r.! d$n *$i# (outcome) un&u" di&!r$'"$n di !#uru* ru%$* $"i& d$#$% r$n,"$'!nin,"$&$n %u&u d$n r!n$n$ "!!#$%$&$n '$i!n
E+!,!" P!"#+&" PMKP.:. L#&' &"/&";,&"&+,'"?&
1 Pi%'in$n ru%$* $"i& ,!"!'&%&" &3!& *&*&3&"un&u" '!ni#$i$n d$n '!nin,"$&$n "#ini %$n$j!ri$#
$$r$n "!!#$%$&$n '$!in2 P!"#+&" %!ru'$"$n /$,i$n d$ri 'r.,r$%
'!nin,"$&$n %u&u d$n "!!#$%$&$n '$i!n ADAINDIKAT
3 $i# '!ni#$i$n di$%'$i"$n "!'$d$ 'i*$" &!r"$i& d$#$%
%!"$ni%! '!n,$w$$n d$n !$r$ /!r"$#$ "!'$d$i% in$n d$n !%i#i" ru%$* $"i& !u$i &ru"&ur
dr Luwi - PMKP 2 juni 2013 55
PEMILIHAN INDIKATOR DAN PENGUMPULAN
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PEMILIHAN INDIKATOR DAN PENGUMPULANDATA
S'&"/&3 PMKP.:.1
Pi%'in$n ru%$* $"i& %!n!&$'"$n indi"$&.r "uni un&u"
%$in,-%$in, &ru"&ur 'r.! d$n *$i# (outcome) !&i$'u'$+$ "#ini
E+!,!" P!"#+&" PMKP.:.1. S#&%&" #"/#%&'3 ?$/##+# 4*'#5%&*# !,#+#&" ,!'/! !"-&'&'&"!"$,+&" &"&+#*& 9&+#/&*#
1 Pi%'in$n "#ini %!n!&$'"$n #"/#%&'3 %"-# un&u"!&i$' di $r!$ "#ini ('!#$+$n$n) +$n, di!/u& /# 1)*&, 11) /# M&%*/ /&" T4&".
2 P$#in, !di"i& = /&3# 11 #"/#%&'3 %+#"#* &3* /##+# (S!u$i dn, in&!rn$&i.$n# #i/r$r+)
3 Pi%'in$n ru%$* $"i& %!%'!r*$&i"$n %u$&$n i#%u(science) d$n /u"&i (evience) un&u" %!ndu"un, !&i$'indi"$&.r +$n, di'i#i*
4 P!ni#$i$n %!n$"u' &ru"&ur 'r.! d$n *$i# (.u&.%!)
5 $"u'$n %!&.d.#.,i d$n =r!"u!ni di&!&$'"$n un&u"dr Luwi - PMKP 2 juni 2013 56
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PEMILIHAN INDIKATORDAN PENGUMPULAN DATA
P!%i#i*$n indi"$&.r +$n, &!r"$i& d!n,$n $r!$ "#ini +$n,'!n&in, %!#i'u&i
1. &*!*,!" '$i!nG
2 '!#$+$n$n +&83&'3#,
3 '!#$+$n$n 3&/#+$# /$n di$,n.&i i%$,in,G
4 'r.!dur 8!/&
=. !"$$"&&" &"'#8#'#%& d$n ./$& #$inn+$G
6 "!$#$*$n %!di"$i medication error/ d$n K!j$di$nN+$ri !d!r$ (KNC)
7 '!n,,un$$n &"!*'!*# /&" *!/&*#G Mi ".%'#i"$i$n!&!i
8 '!n,,un$$n d$r$* d$n 'r.du" d$r$*G
9 "!&!r!di$$n ii d$n '!n,,un$$n r!"$% %!di '$i!nGMi KLPM
10 !n! $*$n d$n !n !nd$#i$n in=!"i ur
INDIKATOR AREA KLINIS (IAK)
H
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INDIKATOR AREA KLINIS (IAK)
dr Luwi - PMKP 2 juni 2013 58
N. AREA KLINIS INDIKATOR AREA KLINIS
1 A!%!n P$i!n P!n,"$ji$n $w$# "!'!r$w$&$n d$#$%24 j$%
P!n,"$ji$n $w$# %!di d$#$% 24 j$%
2 P!#$+$n$n L$/.r$&.riu% B$"&u &un,,u '!%!ri"$$n L$/ i&.
3 P!#$+$n$n $di.#.,i B$"&u &un,,u '!%!ri"$$n $di.#.,i
i&.4 Pr.!dur /!d$* '!r$i /!ri* &$n'$ '!%/!ri$n
'r.#$Ci $n&i/i.&i"
5 "!$#$*$n %!di"$imedication error/
d$n K!j$di$n N+$ri!d!r$ (KNC)
K!j$di$n N+$ri !d!r$ P!r!!'$n/$&
P!n!,$*$n $d
6 '!n,,un$$n &"!*'!*#/&" *!/&*#
D!$&ur$i "i,!n In&r$ An!&!i$A&$u S!d$i
C O N T
O H
INDIKATOR AREA KLINIS (IAK)
OH
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dr Luwi - PMKP 2 juni 2013 59
N AREA KLINIS INDIKATOR
7 '!n,,un$$n d$r$* d$n'r.du" d$r$*G
An$#ii r!$"i &r$n=ui
8 Pr.!dur .'!r$i K!&id$"!u$i$n di$,n.i 'r$ d$n'$$ /!d$*
9 K!#!n,"$'$n M K!#!n,"$'$n r!"$% %!di
10 !"-!$&&" /&"
!"$!"/&+#&" #"!%*#*39!#+&"* /&"!+&3&"
!n&i#$&.r A.i$&!d Pn!%.ni$ (AP)
In=!"i A#ir$n D$r$* (IAD)
In=!"i S$#ur$n K!%i* (ISK)
In=!"i D$!r$* '!r$i (ID)
.'i&$# A?uir!d Pn!u%.ni$ (AP)
11 i!& "#ini P!n!#i&i$n d!n,$n !&*i$# #!$r$n!
C O N T
O H
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Luwi-indi"$&.r %u&u 25 %!i 201360
INDIKATOR INTERNATIONAL LIBRARY
1) A-'! M?-&3/#&+ I"&3-'#" (AMI)
#"/#%&'3
2) H!&3' F+3! (HF) : #"/#%&'3
:) S'3%! (STK) #"/#%&'3
) C#+/3!"’* A*',& C&3! (CAC)
2#"/#%&'3
=) H*#'&+B&*!/ I"&'#!"' P*?-#&'3#-S!39#-! (HBIPS) 2 #"/#%&'3
) N3*#"$S!"*#'#9! C&3! (NSC)
:#"/#%&'3
) P!3#"&'&+ C&3! (PC) : #"/#%&'3
) P"!,"#& (PN) 2 #"/#%&'3
) S3$#-&+ C&3! I,39!,!"' P34!-' (SCIP)
PMKP:.1EP 2
INDIKATOR AREAKLINIS
PENJELASAN
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dr Luwi - PMKP 2 juni 2013 61
1. &*!*,!" &*#!"2. !+&?&"&"
+&83&'3#,:. !+&?&"&" 3&/#+$#/&" /#&$"*'#-#,&$#"$
. 3*!/3 8!/&=. !"$$"&&" &"'#8
8&' +". %!*&+&&" ,!/#%&*#
(,!/#-&'#" !333) KNC
. !"$$"&&" &"!*'!*#
*!/&*#. !"$$"&&" /&3&
3/% /&3&. %!'!3*!/#&&" #*#
!"$$"&&" RM
&*#!"
KLINIS
1. M&*#"$2 &3!&%+#"#* ,#"#,&+ &/&
1 #"/#%&'3
,#"#,&+ &/& 11#"/#%&'3 %+#"#*
2. D&3# 11 #"/#%&'3%+#"#* = #"/#%&'3,!"$$"&%&"#"/#%&'3 %+#"#*/&3# I"'!3"&'#"&+L#83&3?
:. B#+& /&3# 11#"/#%&'3 %+#"#* '*8
'/% &/& ?$,!"$$"&%&"#"/#%&'3 %+#"#*/&3# #"'!3"&'#"&++#83&3? ,&%& RS
&3*
PENJELASAN
INDIKATOR INTERNATIONAL
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INDIKATOR INTERNATIONALLIBRARY
P#+# /&3# 8% I"'!3"&'#"&+ +#83&3?
J,+& = #"/#%&'3 %+#"#*
U"'% &%3!/#'&*# '&& !3'&,& &"?&
/#8&'%&" 35+ #"/#%&'3 '#/&% !3+
/#+&%%&" !"$,+&" /&'& /&"
&"&+#*#* /&'&
dr Luwi - PMKP 2 juni 2013 62
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PEMILIHAN INDIKATORDAN PENGUMPULAN DATA
P#,#"&" RS ,!,8&' #+#&" 5"&+ %!$#&'&" !"#+&"
?&"$ /#'&3$!'%&". U"'% ,&*#"$2 &3!& #"# #,#"&"
,!"!'&%&" 6
3*!* 3*!/3 /&" &*#+ outcome/ ?&"$ &%&" /#"#+
%!'!3*!/#&&" #+, !"$!'&&" science/ /&"8%'# e0idence/ "'% ,!"/%"$ !"#+&"
8&$,&"& !"#+&" /#+&%%&"
8&$,&"& !"#+&" /#*!3&*#%&" /!"$&" 3!"-&"&
,!"?!+3 /&3# !"#+&" ,' /&" %!*!+&,&'&"&*#!"
3!%!"*# /&3# !"#+&".
dr Luwi - PMKP 2 juni 2013 63
PEMILIHAN INDIKATOR
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PEMILIHAN INDIKATOR PENGUMPULAN DATA
• I/!"'#5%&*# 3*!/3 3*!* &*#+ /&3#%!$&'&" ?&"$ &%&" /#"#+.
• P!"#+&" &3* '!3%* &/& ,#*&+"?&3#*#% ?&"$ &/& /# 3*!* 3*!/3 ?&"$*!3#"$ ,!"#,8+%&" 8&"?&% ,&*&+& &'&
/#+&%%&" /!"$&" 9+,! '#"$$# /&" &*#+?&"$ /&&' /!"$&" 4!+&* /#%!"&+# /&" ?&"$/&+&, %!"/&+# 3,& *&%#'.
• S!8&$ -"' 3,& *&%#' /&&' ,!,#+#
"'% ,!"#+ 3*!/3 8!/& '!3'!"'(-"'"?& !38%&" 8#8#3 *,8#"$) &'&*&' %!+,% a class/ '#"/&%&" 8!/&'!3'!"' (-"' 8!/& 3'!/#).
dr Luwi - PMKP 2 juni 2013 64
PEMILIHAN INDIKATOR
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PEMILIHAN INDIKATOR PENGUMPULAN DATA
• P!ni#$i$n $&$ 3*!* ?&"$ /#$"&%&" /&+&, ,!,#+#
3*!/3 8!/& "'% 8#8#3 *,8#"$ /' 4$&,!+&%%&" !"#+&" &'&* 3*!* /&+&, !,&*&"$&"alignment/ 3*'!*#* &/& 8!/& #"$$+ 'ipsurgery/.
• @r!" '!n,u%'u#$n d$&$ di"$i&"$n d!n,$n /!r$'$ !rin,
'r.!:'r.!dur &!r&!n&u dij$#$n"$n D$&$ !%u$ "$u $&$u$%'#! d$ri "$u +$n, di/u&u*"$n un&u" %!nunj$n,"!i%'u#$n d$n r!".%!nd$i di"u%'u#"$n d$#$% ju%#$* +$n,u"u'
• Indi"$&.r /$ru di'i#i* ji"$ indi"$&.r +$n, ud$* $d$ &id$" #$,i
/!r%$n=$$& un&u" %!#$"u"$n $n$#ii &!r*$d$' 'r.!'r.!dur $&$u *$i# (.u&.%!)
• $di S *$ru %!%'un+$i r!"$% j!j$" (track o* recor) d$ri".n&inui&$ '!ni#$i$n di $r!$-$r!$ +$n, di id!n&i"$iG &!&$'i'!ni#$i$n +$n, !/!n$rn+$ /i$ /!ru/$*
dr Luwi - PMKP 2 juni 2013 65
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PEMILIHAN INDIKATORDAN PENGUMPULAN DATA
S'&"/&3 PMKP.:.2.
Pi%'in$n ru%$* $"i& %!n!&$'"$n indi"$&.r "uni un&u"%$in,-%$in, &ru"&ur 'r.!-'r.! d$n *$i# %$n$j!ri$#
E+!,!" P!"#+&" PMKP.:.2.
P!"!'&&" #"/#%&'31 Pi%'in$n %$n$j!%!n %!n!&$'"$n indi"$&.r "uni un&u"
!&i$' $r!$ %$n$j!ri$# +$n, diur$i"$n di $) $%'$i i) d$riM$"ud d$n Tuju$n
2 Pi%'in$n %!n,,un$"$n #$nd$$n #+, /&" 8%'#
(!9#/!"-!) un&u" %!ndu"un, %$in,-%$in, indi$&.r+$n, di'i#i*
3 P!ni#$i$n %!#i'u&i *'3%'3 3*!* /&" &*#+('-,!)
4 $"u'$n %!&.d.#.,i d$n =r!"u!ni di&!&$'"$n un&u"
!&i$' '!ni#$i$n dr Luwi - PMKP 2 juni 2013 66
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PEMILIHAN INDIKATORDAN PENGUMPULAN DATA
I"/#%&'3 ?$ /##+# '!3%' /!"$&" &?& ,&"&4!,!",!+#'#
&. !"$&/&&" 3'#" '!r$#$&$n "!!*$&$n d$n ./$& '!n&in,un&u" %!%!nu*i "!/u&u*$n '$i!nG
8. !+&3&" $"&i
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PEMILIHAN INDIKATORDAN PENGUMPULAN DATA
S'&"/&3 PMKP.:.:.
Pi%'in$n ru%$* $"i& %!n!&$'"$n indi"$&.r"uni un&u" %$in,-%$in, $$r$n "!!#$%$&$n'$i!n (#i*$& K!#.%'." III)
E+!,!" P!"#+&" PMKP. :.:.
1 Pi%'in$n %$n$j!ri$# d$n "#ini %!n!&$'"$nindi"$&.r "uni un&u" %!ni#$i !&i$' S$$r$nK!!#$%$&$n P$i!n
2 P!ni#$i$n S$$r$n K!!#$%$&$n P$i!n &!r%$u"$r!$-$r!$ +$n, di&!&$'"$n di S$$r$nK!!#$%$&$n P$i!n I $%'$i I
3 D$&$ '!ni#$i$n di,un$"$n un&u" %!ni#$i
!=!"&i
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SASARAN KESELAMATANPASIEN
I K!&!&$'$n id!n&i"$i '$i!n
II P!nin,"$&$n K.%uni"$i +$n, !=!"&i=
III P!nin,"$&$n K!$%$n$n /$& +$n,
'!r#u diw$'$d$i
I K!'$&i$n &!'$& #."$i &!'$&'r.!dur &!'$& '$i!n .'!r$i
P!n,ur$n,$n rii". in=!"i &!r"$i&'!#$+$n$n "!!*$&$n
I P!n,ur$n,$n rii". j$&u*
dr Luwi - PMKP 2 juni 2013 69
PEMILIHAN INDIKATOR
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dr Luwi - PMKP 2 juni 2013 70
PEMILIHAN INDIKATORDAN PENGUMPULAN
DATAINDIKATOR KLINIS
11 AREA
KLINISPMKP :.1
EP 1
INDIKATOR
INTERNATIONAL
LIBRARY; JCI
P#P 1.$ EP %
INDIKATOR
S.K.PP#P 1.1
INDIKATORMANAJERIAL AREA
MANAJERIAL
P#P 1.%
DA*A D)U#PULA! DA! D) A!AL)SA
AKRED
PERTAMADATA BELUM
DIKUMPULKAN
INDIKATOR AREA INTERNATIONAL SKP
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dr Luwi - PMKP 2 juni 2013 71
KLINISPMKP :.1 EP 1
LIBRARY PMKP :.1 EP 2SKP
PMKP :.:
1 A!%!n P$i!n
2 P!#$+$n$n L$/3 P!#$+$n$n$di.#.,i4 Pr.!dur ;!d$*5 P!n,,un$$n
$n&i/i.&i"$6 K!$#$*$n%!di"$i KN
7 P!n,,un$$n$n!&!i !d$i
9 P!n,,un$$n
d$r$* 'r.du"d$r$*
10 PPI ur
10!n.u T*r.%/.!%
/.#i% (TE)
1K!&!&$'$n
id!n&i"$i'$i!n
2P!nin,"$&$n".%u ni"$i+$n, !=!"&i=
3P!nin,"$&$n K!$%$n /$&+$n, '!r#udiw$'$d$i
4K!'$&i$n&!'$& #."$i
&!'$& 'r.!dur &!'$&'$i!n .'!r$i
5P!n,ur$n,$nrii". in=!"i
&!r"$i&
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INDIKATOR
KUNCI
INDIKATOR
AREAKLINIS
(PELAYANAN)
INDIKATOR
KLINIS(+#83&3?)
SASARANKESELAMA
TANPASIEN
A!%!n&'$i!n
Id!n&i"$i'$i!n
Id!n&i"$i'$i!n
A!%!n&'$i!n
A'irin .n $ri
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DIMENSIMUTU
PMKP INDIKATORKLINIS
SKP
•A''r.'ri$&!n!•APMKP 31 Pr.!dur .'PMKP 31 $n&i/i.&i" '!n,,un$$n./$& #$inPMKP 31 in=!&i.n'r!
$ndr!'.r&in,
.in&!'#$!%!n&
SKP 1 SKP 4 SKP 5
dr Luwi - PMKP 2 juni 2013 73
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INDIKATOR MUTU
1. I"/#%&'3 /# &3!& %+#"#* 11 #"/#%&'3
2. L#,& /&3# 11 #"/#%&'3 /&3# JCI(P!"?&%#')
:. I"/#%&'3 ,&"&4!3#&+ #"/#%&'3
. I"/#%&'3 K!*!+&,&'&" P&*#!" #"/#%&'3
. N,!3 6 1 2 /&" 8#*& /# #"'!$3&*#%&"
dr Luwi - PMKP 2 juni 2013 74
PROFIL INDIKATOR
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PROFIL INDIKATOR
dr Luwi - PMKP 2 juni 2013 75
JUDUL
DIMENSI MUTUTUJUAN
DEFINISI OPERASIONAL
FREKUENSI PENGUMPULAN
DATAPERIODE ANALISA
NUMERATOR
DENOMINATOR
SUMBER DATA (#"%+*# !%*%+*#)
STANDAR
PJ PENGUMPUL DATA;PIC
UDUL Tid$" $d$n+$ "!$#$*$n
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UDUL Tid$" $d$n+$ "!$#$*$n'!%/!ri$n ./$&
DIMENSI MUTU K!!#$%$&$n "!n+$%$n$n
TUUAN T!r,$%/$rn+$ "!j$di$n"!$#$*$n d$#$% '!%/!ri$n./$&
DE@INISI PEASINAL K!$#$*$n %!%/!ri"$n ./$&%!#i'u&i 1 S$#$* d$#$% %!%/!ri"$n
j!ni ./$&2 S$#$* d$#$% %!%/!ri"$n
d.i3 S$#$* .r$n,
4 S$#$* ju%#$*
@EKUENSI PENJUMPULAN DATA 1 /u#$n
PEIDE ANALISA 3 /u#$n
dr Luwi - PMKP 2 juni 2013 76
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NUMEAT %# !#uru* '$i!n I@S +, diur
'!%/!ri$n ./$&
DENMINAT u%#$* !#uru*n '$i!n I@S +,di ur
SUM;E DATA Sur
STANDA 100 O
P PENJUMPULDATA:PI
K!'$#$ In&$#$i @$%$i
dr Luwi - PMKP 2 juni 2013 77
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dr Luwi - PMKP 2 juni 2013 78
VALIDASI DANANALISIS DARI DATA
PENILAIAN
INDIKATOR KLINIS
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INDIKATOR KLINIS
dr Luwi - PMKP 2 juni 2013 79
PEMILIHANINDIKATOR
PENGUMPULAN
DATA
VALIDASI
ANALISIS DATA
• METODESTATISTIK
T!'&%&"3!%!"*#"?&
DIBANDINGKAN• D#/+,
RS;'3!"• D"$ 3* +"• D"$ *'&"/&3
• D"$ 3&%'#%
INFORMASI
VALIDASI DAN
8/18/2019 MATERI PMKP
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VALIDASI DANANALISIS DARI DATA PENILAIAN
S'&"/&3 PMKP..
P!&u,$ d!n,$n '!n,$#$%$n '!n,!&$*u$n d$n"!&!r$%'i#$n u"u' %!n,u%'u#"$n d$n %!n,$n$#iid$&$ !$r$ i&!%$&i"
E+!,!" P!"#+&" PMKP..
T!+*3 /&'&1 D$&$ di"u%'u#"$n di$n$#ii d$n diu/$* %!nj$di
in=.r%$i Si&!%:SP '!n$&$&$n '!n,u%'u#$n $n$#i$ d$&$
2 r$n, +$n, %!%'un+$i '!n,$#$%$n "#ini $&$u%$n$j!ri$# '!n,!&$*u$n d$n "!&!r$%'i#$n &!r#i/$&d$#$% 'r.!
3 M!'/& /&" '!"#%'!"#% *'&'#*'#% di,un$"$nd$#$% %!#$"u"$n $n$#ii d$ri 'r.! /i#$ !u$i
4 $i# $n$#ii di#$'.r"$n "!'$d$ %!r!"$ +$n,dr Luwi - PMKP 2 juni 2013 80
VALIDASI DAN
8/18/2019 MATERI PMKP
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VALIDASI DANANALISIS DARI DATA PENILAIAN
S'&"/&3 PMKP..1
@r!"u!ni d$ri $n$#ii d$&$ di!u$i"$n d!n,$n 'r.!+$n, !d$n, di"$ji d$n !u$i d!n,$n "!&!n&u$n ru%$* $"i&
E+!,!" P!"#+&" PMKP..1. T!+*3 /&'&
1 @r!"u!ni %!#$"u"$n $n$#ii d$&$ di!u$i"$n d!n,$n'r.! +$n, !d$n, di"$ji #i*$& 'r.# i&!%'!n$&$&$n '!n,u%'u#$n $n$#ii d$&$
2 @r!"u!ni d$ri $n$#ii d$&$ !u$i d!n,$n "!&!n&u$n
ru%$* $"i& #i*$& 'r.# i&!% '!n$&$&$n'!n,u%'u#$n $n$#ii d$&$
dr Luwi - PMKP 2 juni 2013 81
VALIDASI DAN
8/18/2019 MATERI PMKP
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VALIDASI DANANALISIS DARI DATA PENILAIAN
S'&"/&3 PMKP..2. Pr.! $n$#ii di#$"u"$n d!n,$n %!%/$ndin,"$n !$r$in&!rn$# %!%/$ndin,"$n d!n,$n ru%$* $"i& #$in /i#$ &!r!di$d$n %!%/$ndin,"$n d!n,$n &$nd$r "!i#%u$n !r&$%!%/$ndin,"$n d!n,$n 'r$"&!" +$n, /$i"
E+!,!" P!"#+&" PMKP..2. '!+*3 /&'&
1 P!r/$ndin,$n di#$"u"$n /&3# 7&%' %! 7&%' /#/&+&,3,& *&%#'
2 P!r/$ndin,$n di#$"u"$n /!"$&" 3,& *&%#' +" +$n,
!j!ni /i#$ $d$ "!!%'$&$n3 P!r/$ndin,$n di#$"u"$n /!"$&" *'&"/&3 /i#$
%!%un,"in"$n
4 P!r/$ndin,$n di#$"u"$n /!"$&" 3&%'!% ?&"$ 8%
dr Luwi - PMKP 2 juni 2013 82
VALIDASI DAN
8/18/2019 MATERI PMKP
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VALIDASI DANANALISIS DARI DATA PENILAIAN
S$$r$n d$ri $n$#ii d$&$ $d$#$* $,$r d$'$& di#$"u"$n'!r/$ndin,$n /$,i ru%$* $"i& %!#$#ui !%'$& $r$
1 D!n,$n diri !ndiri d$#$% w$"&u &!r&!n&u !'!r&i d$ri/u#$n "! /u#$n $&$u $&u &$*un "! &$*un /!ri"u&n+$
2 D!n,$n ru%$* $"i& #$in +$n, $%$ !'!r&i
%!n,,un$"$n ata ase r!=!r!ni (#i*$& ju,$ MKI202EP 3)
3 D!n,$n &$nd$r !'!r&i di&!&$'"$n .#!* /$d$n$"r!di&$i i"$&$n 'r.=!i.n$# $&$u %!n,,un$"$n"!&!n&u$n +$n, di&!&$'"$n d$#$% und$n,-und$n,
$&$u '!r$&ur$n
4 D!n,$n 'r$"&!"-'r$"&!" +$n, di$"ui di "!'u&$"$$n!/$,$i '!d.%$n 'r$"&!" +$n, #!/i* /$i" $&$u '$#in,/$i"
dr Luwi - PMKP 2 juni 2013 83
VALIDASI DAN
8/18/2019 MATERI PMKP
84/118
VALIDASI DANANALISIS DARI DATA PENILAIAN
S'&"/&3 PMKP.=.
u%$* $"i& %!n,,un$"$n 'r.! in&!rn$#un&u" %!#$"u"$n
8/18/2019 MATERI PMKP
85/118
VALIDASI DANANALISIS DARI DATA PENILAIAN
$#id$i d$&$ %!nj$di $n,$& '!n&in, d$#$% *$# $ Indi"$&.r /$ru di&!r$'"$n "*uun+$ #"/#%&'3 %+#"#* +$n,
di%$"ud"$n un&u" %!%/$n&u S %!#$"u"$n !
8/18/2019 MATERI PMKP
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VALIDASI DANANALISIS DARI DATA PENILAIAN
E+!,!" !"'#"$ /&3# 9&+#/&*# /&'& ?&"$ '!3!3-&?&,!"-&% *!8&$ 8!3#%' 6
$) M!n,u%'u#"$n u#$n, d$&$ .#!* .r$n, "!du$ +$n, &id$"&!r#i/$& d$#$% '!n,u%'u#$n d$&$ !/!#u%n+$
/) M!n,,un$"$n $%'#! &$&i&i" $*i* d$ri $&$&$n "$u
d$n d$&$ #$in S$%'#! 100 O di/u&u*"$n *$n+$ ji"$ ju%#$*'!n$&$&$n "$u $&$u d$&$ #$inn+$ $n,$& "!i# ju%#$*n+$
) M!%/$ndin,"$n d$&$ $#i d!n,$n d$&$ +$n, di"u%'u#"$nu#$n,
d) K$#"u#$i $"ur$i dn, %!%/$,i j%# !#!%!n d$&$ +,di&!%u"$n dn, &.&$# j%# d$&$ !#!%!n di"$#i"$n dn, 100 T"$"ur$i 90 O $d$#$* '$&."$n +$n, /$i"
!) i"$ !#!%!n d$&$ +, di"!&!%u"$n &!rn+$&$ &id$" $%$ dn,$&$&$n $#$$n n+$ (%i$#n+$ d$&$ &id$" j!#$ d!niin+$) di#$"u"$n &ind$"$n ".r!"i dr Luwi - PMKP 2 juni 2013 86
VALIDASI DAN
8/18/2019 MATERI PMKP
87/118
VALIDASI DANANALISIS DARI DATA PENILAIAN
S'&"/&3 PMKP.=.1. ;i#$ ru%$* $"i& %!%'u/#i"$i"$n d$&$ $&$u
%!n!%'$&"$n d$&$ di w!/ i&! 'u/#i" 'i%'in$n ru%$*
$"i& %!nj$%in r!#i$/i#i&$ d$&$ SP 'u/#i"$i d$&$
E+!,!" P!"#+&" PMKP.=.1.
1Pi%'in$n ru%$* $"i& /!r&$n,,un, j$w$/ /$*w$ d$&$
+$n, di$%'$i"$n "! 'u/#i" d$'$& di
'!r&$n,,un,j$w$/"$n d$ri !,i %u&u d$n *$i#n+$
(.u&.%!)
2D$&$ +$n, di$%'$i"$n "!'$d$ 'u/#i" &!#$* di!
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VALIDASI DANANALISIS DARI DATA PENILAIAN
S'&"/&3 PMKP..
S %!n,,un$"$n 'r.! +$n, di&!&$'"$nun&u" %!#$"u"$n id!n&i"$i d$n '!n,!#.#$$n"!j$di$n !n&in!#
E+!,!" P!"#+&" PMKP. .
1 Pi%'in$n S %!n!&$'"$n d!nii "!j$di$n!n&in!# +$n, %!#i'u&i '$#in, !di"i& $)$%'$i d) +$n, di%u$& di M$"ud d$n
Tuju$n D!nii2 S %!#$"u"$n $n$#ii $"$r %$$#$* R-
&!r*$d$' !%u$ "!j$di$n !n&in!# +$n,&!rj$di d$#$% /$&$ w$"&u &!r&!n&u +$n,
di&!&$'"$n 'i%'in$n ru%$* $"i&dr Luwi - PMKP 2 juni 2013 88
VALIDASI DAN
8/18/2019 MATERI PMKP
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VALIDASI DANANALISIS DARI DATA PENILAIAN
S!&i$' ru%$* $"i& %!n!&$'"$n d!nii .'!r$i.n$#d$ri "!j$di$n !n&in!# +$n, %!#i'u&i !"ur$n,-"ur$n,n+$
$ "!%$&i$n &id$" &!rdu,$ d$n &id$" &!r"$i& d!n,$n
'!rj$#$n$n $#$%i$* '!n+$"i& '$i!n $&$u ".ndii+$n, %!nd$$ri '!n+$"i&n+$ (.n&.* /unu* diri)
/ "!*i#$n,$n =un,i u&$%$ (major) !$r$'!r%$n!n +$n, &id$" &!r"$i& d!n,$n '!rj$#$n$n
$#$%i$* '!n+$"i& '$i!n $&$u ".ndii +$n,%!nd$$ri '!n+$"i&n+$
$#$*-#."$i $#$*-'r.!dur $#$*-'$i!n .'!r$iGd$n
d '!nu#i"$n /$+i $&$u /$+i +$n, di'u#$n,"$ndr Luwi - PMKP 2 juni 2013 89
VALIDASI DAN
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VALIDASI DANANALISIS DARI DATA PENILAIAN
D!nii "!j$di$n !n&in!# +$n, di&!&$'"$n ru%$*$"i& %!#i'u&i $) $%'$i d) &!r!/u& di$&$ d$n d$'$& ju,$ %!#i'u&i "!j$di$n #$in !/$,$i%$n$ di*$ru"$n.#!* '!r$&ur$n '!r-und$n,-und$n,$n $&$u "!j$di$n+$n, di'$nd$n, .#!* ru%$* $"i& '$n&$ di%$u""$n
"!d$#$% d$=&$r "!j$di$n !n&in!# S!%u$ "!j$di$n+$n, %!%!nu*i d!nii &!r!/u& di#$"u"$n $!%!nd!n,$n %!#$"u"$n $n$#ii $"$r %$$#$* (root causeana"%sis . R) i"$ A %!n,un,"$' /$*w$'!r/$i"$n i&!% $&$u &ind$"$n #$in +$n, d$'$&
%!n!,$* $&$u %!n,ur$n,i rii". $,$r "!j$di$n!n&in!# &id$" &!ru#$n, "!%/$#i %$"$ ru%$* $"i& %!r$n$n, "!%/$#i 'r.! !r&$ %!n,$%/i# /!r/$,$i&ind$"$n +$n, !*$run+$
P!n&in, un&u" %!%'!r*$&i"$n /$*w$ i&i#$* "!j$di$n
!n&in!# &id$" !#$#u %!n,$r$* "!'$d$ "!"!#iru$nerror $&$u "!$#$*$n mistake %$u un %!%/!ridr Luwi - PMKP 2 juni 2013 90
VALIDASI DAN
8/18/2019 MATERI PMKP
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ANALISIS DARI DATA PENILAIAN
S'&"/&3 PMKP..
D$&$ di$n$#ii /i#$ &!rn+$&$ $d$ "!!nd!run,$n +, &d" diin,in"$n%$u'un
8/18/2019 MATERI PMKP
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ANALISIS DARI DATA PENILAIAN
S'&"/&3 PMKP..
u%$* $"i& %!n,,un$"$n 'r.! +$n, di&!&$'"$n
un&u" %!#$"u"$n id!n&i"$i d$n $n$#ii "!j$di$n
n+$ri !d!r$ : KN (near'miss events)
E+!,!" P!"#+&" PMKP.. '!+*3 /&'&
1 u%$* $"i& %!n!&$'"$n d!nii KN
2 u%$* $"i& %!n!&$'"$n j!ni "!j$di$n +$n, *$ru
di#$'.r"$n !/$,$i KN (#i*$& ju,$ MP71 un&u"
KN ./$&:%!di"$i)
3 u%$* $"i& %!n!&$'"$n 'r.! un&u" %!#$"u"$n
'!#$'.r$n KN (#i*$& ju,$ MP71 un&u" KN
./$&:%!di"$i)
4 D$&$ di$n$#ii d$n &ind$"$n di$%/i# un&u"dr Luwi - PMKP 2 juni 2013 92
R' C&*! A"&+?*#* 6
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?
A R' C&*! A"&+?*#* *!!%* ' /!'!3,#"! '! 3'-&*! &" !333 +3! 3
&--#/!"'.
M!&.d! !
8/18/2019 MATERI PMKP
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dr Luwi - PMKP 2 juni 2013 94
8/18/2019 MATERI PMKP
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dr Luwi - PMKP 2 juni 2013 95
PENILAIAN DAMPAKKLINIS;KONSEKUENSI;SEVERITY (1)
TK RIKS D % # # D %
8/18/2019 MATERI PMKP
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dr Luwi - PMKP 2 juni 2013 96
TK RIKS D!*%3#*# D&,&%
1 T/%*#$"#5-&"'
T#/&% &/& -!/!3&
2 M#"3 • C!/!3& 3#"$&" ,#* +%& +!-!'• D&&' /#&'&*# /"$ P:K
: M/!3&' • C!/!3& *!/&"$ ,#* 6 +%& 38!% • B!3%3&"$"?& "$*#
,'3#%;*!"*3#%;*#%+$#* &'&
#"'!+!%'&+ (3!9!3*#8!+. T/%8!38"$&" /"$ !"?&%#'• S!'#& %&** ?$ ,!!3&"4&"$
!3&7&'&"
M&?3 • C!/!3& +&*;8!3&' ,#* 6 -&-&' +,• K!#+&"$&" "$*# ,'3#%;*!"*3#%;
*#%+$#* &'& #"'!+!%'&+(#3!9!3*#8!+) '/% 8!38"$&" /"$!"?&%#'
= K&'&'3#% K!,&'#&" ?$ '/% 8!38"$&" /"$!34&+&"&" !"?&%#'
PENILAIAN
8/18/2019 MATERI PMKP
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PROBABILITAS;FREKUENSI
dr Luwi - PMKP 2 juni 2013 97
TINGKATRISIKO DESKRIPSI
1 S&"$&' 4&3&"$; 3&3! ( = '&";%&+#)
2 J&3&"$;"+#%!? ( 2 @ = '&";%&+#)
3 M"$%#"; P*#8+! (1 2 '&";%&+#)
4 S!3#"$;L#%!+? (8!8!3&& %&+#;'&")
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MATRIKS GRADINGRISIKO
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R#*#%
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LEVEL;BAND
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TINDAKAN
EKSTREM(SANGATTINGGI)
R#*#% !%*'3!, /#+&%%&" RCA &+#"$+&,& = &3# ,!,8'%&" '#"/&%&"*!$!3& !3&'#&" *&, %! D#3!%'3RS
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dr Luwi - PMKP 2 juni 2013 10
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MENCAPAI DANMEMPERTAHANKAN
PENINGKATAN
dr Luwi - PMKP 2 juni 2013 10
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MENCAPAI DANMEMPERTAHANKAN
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PENINGKATAN
S'&"/&3 PMKP..
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d$n "!!#$%$&$n '$i!n Pr.,r$% PMKP L$'.r$n "!,i$&$n
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sua# i"aksanakan & mem!erta#ankan)
dr Luwi - PMKP 2 juni 2013 10
MENCAPAI DAN MEMPERTAHANKANPENINGKATAN
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PENINGKATANS'&"/&3 PMKP.10.
K!,i$&$n '!r/$i"$n %u&u d$n "!!#$%$&$n '$i!ndi#$"u"$n un&u" $r!$ 'ri.ri&$ !/$,$i%$n$ +$n,
di&!&$'"$n 'i%'in$n ru%$* $"i&
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di%$u""$n "!d$#$% "!,i$&$n '!nin,"$&$n (#i*$&
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PENINGKATANE+!,!" P!"#+&" PMKP.10.
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6 Di/u$& '!ru/$*$n "!/ij$"$n +$n, di'!r#u"$n
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MEMPERTAHANKAN PENINGKATAN
S'&"/&3 PMKP.11. Pr.,r$% %$n$j!%!n rii". /!r"!#$nju&$n di,un$"$n un&u" %!#$"u"$n
id!n&i"$i d$n %!n,ur$n,i KTD d$n %!n,ur$n,i rii". #$in &!r*$d$'
"!!#$%$&$n '$i!n d$n &$=
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@MEA
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@MEA
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dr Luwi - PMKP 2 juni 2013 10
PE;EDAAN @MEA A
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PE;EDAAN @MEA A
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MENCAPAI DAN
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MENCAPAI DANMEMPERTAHANKAN PENINGKATAN
u%$* $"i& '!r#u %!n,,un$"$n '!nd!"$&$n'r.$"&i= d$#$% %!#$"$n$"$n %$n$j!%!n rii".S$#$* $&u $r$ %!#$"u"$nn+$ $d$#$* 'r.,r$%
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PENINGKATAN• ,&"&4!,!" 3#*#% &/&+& &"&+#*#* /&3# 3#*#% !'!r&i
!/u$* 'r.! un&u" %!#$"u"$n !
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PSES MANAEMEN
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ISIK1 Id!n&i"$i rii".2 P!#$'.r$n rii". (L$'.r$n Inid!n)
3 Pri.ri&$ rii". (Risk 1raing Matri2)
4In
ause na"%sis/ R)5 M$n$j!%!n rii".
dr Luwi - PMKP 2 juni 2013 11
PESIAPAN UMA SAKIT
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PESIAPAN UMA SAKIT
1. B!"'% T#,;K,#'!;P&"#'#& PMKP2. S*" P3$3&, PMKP
:. S*" %!8#4&%&" !3!"-&"&&" !+&%*&"&&" ,"!9
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S*" P!/,&" PMKP=. P&"/&";SPO *#*'!, !"-&'&'&" !+&3&" IKP B%
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. S*" P&"/&" C+#"#-&+ &'7&?
. T!'&%&" = -+#"#-&+ &'7&?
dr Luwi - PMKP 2 juni 2013 11
PESIAPAN UMA SAKIT
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PESIAPAN UMA SAKIT
;u"&i '!#$"$n$$n "!,i$&$n K.%i&!:P$ni&i$:Ti%PMKP n.&u#!n r$'$& /$*$ 'r.,r$% PMKP PPIMP #ini$# '$&*w$+ d##
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$i# A ri" ,r$din, TL ud$* di#$"u"$n
dr Luwi - PMKP 2 juni 2013 11
METODE PENILAIAN
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METODE PENILAIAN
1. P!3'!,&" P!"#"$%&'&" M' K!*!+&,&'&" P&*#!" D#3' P3!*!"'&*#
'!"'&"$ P3$3&, PMKP K!8#4&%&" PMKP
2. P!3'!,&" /"$ K,#'! M';T#, KPRS
-+#"#-&+ &'7&? FMEA RCA T!+*3
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dr Luwi - PMKP 2 juni 2013 11
H&3# P!3'&,&W&%' Sur
M$n$j!%!n
Sur
M!di
Sur
K!'!r$w$&$n
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dr Luwi - PMKP 2 juni 2013 11
M$n$j!%!n M!di K!'!r$w$&$n0.00 @
0.:0
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MDG*)
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Sur
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T!#uur '$i!n
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Hari Kedua
08.00-08.45 Klarifikasi dan masukan
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08.00 08.45 Klarifikasi dan masukan
(Pertemuan surveior dengan para pimpinan RS untuk klarifikasi)
08.45- 09.00 REHAT KOPI
09.00- 12.00 Telusur MK Telusur IndividuAPK! AP! PP!
PA"
Telusur HPK! PPK! SKP! PPI
12.00- 13.00 ISHOMA
13.00- 14.30 TelusurMK
Telusur APK! AP!PP! PA"
TelusurHPK! PPK! SKP! PPI
14.30 -15.30 Rumah Sakit mempresentasikan tentang :
• F!"# $anduan $raktik K%inis# "%ur K%inis&'%ini(a% $ath)a*#
ana+emen Risik,# nsiden Kese%amatan $asien# d%%
• ihadiri ,%eh se%uruh Sur/ei,r15.30 Surveior meminta daftar pega#ai! dan mengam$il se%ara sampling masing&
se'umla (total &* file) utk Telusur KPS
15.30 -1.00 Pertemuan Tim Surveior
dr Luwi - PMKP 2 juni 2013 11
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TERIMA
KASIH