Indikator Mutu
Tahun 2021
| 1 | Kesesuaian Parameter Limbah Cair Dengan Baku Mutu (STP Utama) | 90% | 93% | NA | 90% | 93% | 93% | 93% | NA | 73% | 88% | 90% | 97% | 93% |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2 | Kesesuaian Parameter Limbah Cair Dengan Baku Mutu (STP Gedung Parkir) | 90% | 90% | NA | 90% | 90% | 90% | 90% | NA | 87% | 93% | 90% | 90% | 93% |
| 3 | Kesesuaian Pengolahan Limbah Padat B3 dengan Aturan | 100% | 75% | 75% | 69% | 75% | 88% | 88% | 88% | 88% | 88% | 81% | 94% | 94% |
| 4 | Ketepatan waktu pengisian form pemeriksaan APAR | 100% | 95% | 95% | 95% | 95% | 95% | 95% | 95% | 95% | 95% | 95% | 95% | 95% |
| 5 | Ketepatan waktu pengisian form pemeriksaan Hydrant | 100% | 91% | 91% | 91% | 91% | 91% | 91% | 91% | 91% | 91% | 91% | 91% | 91% |
| 6 | Indeks Penyelesaian Pengadaan | 90% | 43% | 53% | 49% | 79% | 89% | 91% | 96% | 95% | 94% | 99% | 98% | 100% |
| 7 | TAT (Turn Around Time) Jangka Waktu Penyelesaian Pengadaan | 45 hari | 12-115 | 3-15 | 49 | 73 | 35 | 15 | 8 | 15 | NT : 9 T : 40 |
NT : 13 T : 41 |
NT : 12 T : - |
NT: 16-30 T: - |
| 8 | Penyelesaian kerjasama Pengadaan dan KSO | 80% | 60% | 100% | 100% | 100% | 90% | 60% | 80% | 100% | 100% | 100% | 50% | 88% |
| 9 | Penyelesaian kerjasama dengan Mitra Kerjasama | 80% | 67% | 83% | 80% | 50% | 52% | 63% | 81% | 93% | 92% | 65% | 72% | 95% |
| 10 | Penyelesaian Dokumen Legal RSUI | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| 11 | Persentase hasil cucian yang memenuhi standar linen ekselen | 95% | 99% | 99% | 99% | 99% | 99% | 98% | 98% | 99% | 99% | 99% | 98% | 99% |
| 12 | Persentase kepatuhan kebersihan tangan Petugas Laundry | 95% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| 13 | Persentase kepatuhan petugas Laundry menggunakan APD | 90% | 100% | 100% | 100% | 99% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| 14 | Persentase ketepatan waktu distribusi linen bersih untuk ruang perawatan kurang dari 7 Jam | 75% | 95% | 96% | 95% | 95% | 100% | 95% | 100% | 99% | 100% | 100% | 100% | 98% |
| 15 | Persentase nilai overall equipment effectiveness | 100% | 235% | 248% | 226% | 217% | 201% | 227% | 260% | 255% | 212% | 171% | 161% | 169% |
| 16 | Persentase kebersihan linen sesuai dengan standar mikrobiologi | 100% | NA | NA | NA | 100% | NA | NA | NA | NA | 100% | NA | NA | 100% |
| 17 | Jumlah institusi luar RSUI yang menggunakan Layanan Unit Laundry untuk Diklat | 1 | Data diambil Tahunan | 2 | ||||||||||
| 18 | Ketepatan Waktu Penanganan Keluhan 1x24 Jam | 75% | 76% | 78% | 60% | 78% | 78% | 80% | 96% | 95% | 88% | 91% | 92% | 96% |
| 19 | Ketepatan Waktu Pemeliharaan Genset | 75% | 25% | 0% | 0% | 0% | 0% | 0% | 8% | 15% | 75% | 0% | 75% | 25% |
| 20 | Ketepatan Waktu Kalibrasi Peralatan Medis | 0% | Data diambil Tahunan | 29% | 29% | |||||||||
| 21 | Kinerja Jaringan dan Server | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| 22 | Kinerja System Firewall RSUI | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% |
| 23 | Angka penyelesaian permasalahan SIMRS | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| 24 | Angka Penyelesaian Permasalahan Software Aplikasi | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| 25 | Angka Penyelesaian Permasalahan Perangkat Infrastruktur IT | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| 26 | Jumlah Modul/Aplikasi yang direalisasikan | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 75% | 100% | 100% | 100% |
| 27 | Jumlah Dokumentasi Kegiatan Pengembangan/Pemanfaatan Aplikasi | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| 28 | Jumlah Penambahan Fitur Aplikasi | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 67% | 67% |
| 29 | Persentase Dokter Spesialis Datang Praktik Sesuai dengan Hari Praktiknya | 90% | 90% | 91% | 90% | 84% | 84% | 83% | NA | NA | 78% | 86% | 82% | 92% |
| 30 | Kepatuhan Waktu Visite Dokter Penanggungjawab Pelayanan (DJPJ) | ≥ 80 | 81% | 84% | 88% | 94% | 91% | 88% | 91% | 90% | 90% | 91% | 96% | 93% |
| 31 | Ketepatan Waktu Pelayanan | ≤ 60 menit | 72 | 65 | 85 | 80 | 99 | 96 | 113 | 94 | 94 | 96 | 103 | 95 |
| 32 | Kemampuan Menangani Life Saving Anak dan Dewasa | 100% | 100% | 73% | 86% | 50% | 83% | 79% | 94% | 100% | 39% | 38% | 65% | 62% |
| 33 | Jam Buka Pelayanan Gawat Darurat | 24 JAM | 24 JAM | 24 JAM | 24 JAM | 24 JAM | 24 JAM | 24 JAM | 24 JAM | 24 JAM | 24 JAM | 24 JAM | 24 JAM | 24 JAM |
| 34 | Pemberi Pelayanan Kegawatdaruratan Yang Bersertifikat BLS/PPGD/GELS/ALS | 100% | 99% | 99% | 99% | 99% | 99% | 99% | 99% | 99% | 99% | 99% | 99% | 99% |
| 35 | Ketersediaan Tim Penanggulangan Bencana | 1 (satu) tim | 1 Tim | 1 Tim | 1 Tim | 1 Tim | 1 Tim | 1 Tim | 1 Tim | 1 Tim | 1 Tim | 1 Tim | 1 Tim | 1 Tim |
| 36 | Waktu Tanggap Pelayanan Dokter di Gawat Darurat | ≥ 5 menit setelah pasien datang | 7,5 | 12 | 17,5 | 6,4 | 8,4 | 10 | 8,2 | 4,5 | 8,3 | 17 | 15 | 14 |
| 37 | Kematian Pasien ≤ 24 jam di Gawat Darurat | ≤ 2 per seribu | 2/310 | 2/266 | 3/295 | 3/254 | 2/273 | 3/378 | 18/369 | 10/313 | 4/242 | 5/279 | 2/353 | 4/378 |
| 38 | Tidak adanya keharusan untuk membayar uang muka | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| 39 | Turn Around Time Pelayanan Pasien di IGD ≤ 8 Jam | 100% | NA | NA | 55% | 52% | 63% | 47% | 22% | 48% | 80% | 78% | 79% | 85% |
| 40 | Waktu Tanggap (Respons Time) Pelayanan Pemulasaraan Jenazah | 100% | 85% | 88% | 94% | 100% | 95% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| 41 | Peningkatan Pertumbuhan Kunjungan Rawat Jalan | 100% | 390% | 254% | 598% | 1781% | 591% | 479% | 805% | 823% | 576% | 797% | 389% | 261% |
| 42 | Kepuasan Pengunjung terhadap Layanan Rawat Jalan | 4,5 | 3,05 | 3,46 | 3,31 | 3,47 | 4,33 | 4,26 | 4,32 | 4,19 | 4,21 | 4,13 | 4,2 | 4,23 |
| 43 | Rerata Cycle Time Pelayanan di Klinik Rawat Jalan | <2 jam | 03:03:36 | 02:31:55 | 02:16:03 | 02:05:36 | 02:36:32 | 02:57:18 | 02:39:44 | 03:03:26 | 03:37:56 | 03:31:41 | 03:50:11 | 04:11:53 |
| 44 | Pemberi Pelayanan di Klinik Spesialis | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| 45 | Buka Pelayanan Sesuai Ketentuan | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| 46 | Waktu Tunggu di Rawat Jalan | <1 jam | 57 | 53 | 48 | 40 | 33 | 25 | 40 | 58 | 48 | 42 | 71 | 73 |
| 47 | Persentase checkout Pasien Sebelum Pukul 12:00 dengan Rekam Medis dan Administrasi Lengkap | 70% | 35% | 21% | 33% | 24% | 26% | 28% | 25% | 36% | 28% | 32% | 34% | 30% |
| 48 | Kepuasan Pelanggan Rawat Inap | 4,5 | 4,46 | 3,31 | 4,51 | 4,43 | 4,31 | 4,55 | 4,49 | 4,6 | 4,51 | 4,6 | 4,48 | 4,61 |
| 49 | Rerata Waktu Tunggu Pendaftaran Rawat Jalan | 10 Menit | 23 | 18 | 23 | 18 | 13 | 12 | 8 | 18 | 19 | 19 | 19 | 23 |
| 50 | Tingkat Kepuasan Pasien Rawat Jalan terhadap Layanan Admisi | 4,5 | 2,8 | 4 | 3,3 | 2,5 | 4,4 | 4,3 | 4,3 | 3,9 | 4,2 | 4,1 | 4,1 | 4,1 |
| 51 | Tingkat Kepuasan Peserta terhadap Penyelenggaraan Bicara Sehat Secara Keseluruhan (untuk mengukur kepuasan pelanggan eskternal) | 80% | 98% | 96% | 97% | 98% | 98% | 94% | 97% | 95% | 98% | 97% | 98% | 96% |
| 52 | Tingkat kepuasan unit kerja terhadap pembuatan edukasi kesehatan secara keseluruhan | 80% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | NA | NA | 100% | 100% |
| 53 | Jumlah Media Promosi Kesehatan 10 media setiap bulan | 100% | 100% | 100% | 100% | 100% | 100% | 400% | 200% | 158% | 175% | 250% | 142% | 133% |
| 54 | Survei kepuasan pelanggan eksternal yang dinilai dengan yang dengan Tingkat Kepuasan Follower Instagram RSUI terhadap Media Promosi Kesehatan (untuk mengukur kepuasan pelanggan eskternal) | 80% | Dilaksanakan Pada Bulan Juli dan Desember | 94% | Dilaksanakan Pada Bulan Juli dan Desember | 98% | ||||||||
| 55 | Kelengkapan informed consent setelah mendapatkan informasi yang jelas pada tindakan bedah elektif | 100% | 88% | 95% | 68% | 79% | 85% | 64% | 98% | 100% | 99% | 99% | 71% | 95% |
| 57 | Kelengkapan Resume Medis Rawat Inap | 100% | 96% | 93% | 93% | 98% | 99% | 94% | 91% | 96% | 89% | 99% | 99% | 100% |
| 58 | Persentase Sisa Makan Pasien Rawat Inap | ≤ 20% | 12% | 10% | 13% | 12% | 11% | 16% | 13% | 12% | 10% | 13% | 11% | 10% |
| 59 | Ketepatan Pemberian Diet Pasien Rawat Inap Sesuai Dengan Intruksi DPJP | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| 60 | Ketepatan Jam Distribusi Makan Pasien Rawat Inap | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| 61 | Waktu tunggu obat racikan ≤ 60 menit | 100% | 64% | 84% | 92% | 68% | 73% | 84% | 59% | 56% | 62% | 87% | 84% | 93% |
| 62 | Waktu tunggu obat jadi ≤ 30 menit | 100% | 85% | 82% | 85% | 82% | 94% | 96% | 53% | 63% | 61% | 93% | 91% | 95% |
| 63 | Tidak Ada Kesalahan Pemberian Obat | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| 64 | Kepuasan Pelanggan | >80% | 77% | 63% | 73% | 72% | 87% | 90% | 88% | 88% | 90% | 89% | 87% | 89% |
| 65 | Kepuasan Pelayanan Kasir | > 80% | 70% | 71% | 75% | 82% | 85% | 87% | 88% | 87% | 89% | 87% | 87% | 86% |
| 66 | Ketepatan Waktu Penyerahan RAB/PKP ke Unit Keuangan | 2 Hari kerja | 2 | 2 | 1 | 1,6 | 1,5 | 1,4 | 1,4 | 1,4 | 1,3 | 1,3 | 1,3 | 1,3 |
| 67 | Ketepatan Waktu Monitoring dan Evaluasi Anggaran | Tanggal 10 setiap bulan, di luar hari libur | 50% | 50% | 100% | 0% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| 68 | Proses Penerimaan usulan tarif dari Unit Pengusul sampai dengan terbit SK | 30 Hari Kerja | 56 | 21 | 19 | 16 | 0 | 43 | 0 | 18 | 0 | 0 | 0 | 0 |
| 69 | Indeks Penyelesaian tarif | 75% | 91% | 90% | 93% | 80% | 80% | 90% | 83% | 100% | 67% | 100% | 96% | 88% |
Tahun 2020
| INDIKATOR AREA KLINIS | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | Kelengkapan informed consent setelah mendapatkan informasi yang jelas pada tindakan bedah elektif | 100% | 100% | 83% | 83% | 100% | 93% | 97% | 93% | 96% | 87% | 100% | 47% | 93% | |
| 2 | Kelengkapan Pengisian Rekam Medis Rawat Inap | 100% | 51% | 34% | 44% | 74% | 45% | 81% | 45% | 56% | 54% | 37% | 61% | 73% | |
| 3 | Rerata Waktu Tunggu Obat Jadi ≤30 Menit | 100% | 100% | 100% | 100% | 100% | 100% | 98% | 100% | 100% | 100% | 100% | 100% | 100% | |
| 4 | Ketepatan Pemberian Diet Pasien Rawat Inap Sesuai Dengan Intruksi DPJP | 100% | 100% | 100% | 100% | 98% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 99.8% | |
| 5 | Waktu TAT Cito Tercapai | 80% | 72% | 65% | 70% | 70% | 71% | 70% | 76% | 80% | 87% | 91% | 78% | 78% | |
| 6 | Persentase Kelengkapan Asesmen Awal Keperawatan dalam 24 jam | 100% | 86.2% | 83.1% | 87.5% | 90.2% | 91% | 91.2% | 92.1% | 92.2% | 89.3% | 89.9% | 91.2% | 92.3% | |
| 7 | Persentase readmisi pasien < 72 jam pasca keluar perawatan dari unit intensif | 10% | 6% | 0% | 0% | 0% | 6% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | |
| 8 | Presentase dokter spesialis datang praktik sesuai dengan hari prakteknya | 90% | 82% | 65% | 57% | 94% | 70% | 82% | 92% | 84% | 80% | 82% | 83% | ||
| INDIKATOR AREA MANAJEMEN | |||||||||||||||
| 1 | Ketepatan Parameter Limbah Cair Dengan Baku Mutu | 90% | 97% | 97% | 97% | 90% | |||||||||
| 2 | Ketepatan Parameter Air Bersih Dengan Baku Mutu | 90% | 33% | 96% | 86% | 96% | |||||||||
| 3 | Ketepatan Waktu Pemeliharaan Genset | 90% | 60% | 50% | 100% | 0% | 20% | 25% | 20% | 0% | 0% | 25% | 0% | 0% | |
| INDIKATOR AREA SASARAN KESELAMATAN PASIEN | |||||||||||||||
| 1 | Persentase Kelengkapan Asesmen awal risiko jatuh pasien rawat inap | 100% | 93% | 94% | 94% | 100% | 93% | 94% | 94% | 93.2% | 93% | 94.1% | 94.6% | 95.2% | |
| 2 | persentase ketepatan pemberian antibiotik injeksi | 90% | 98% | 100% | 96% | 100% | 98% | 100% | 100% | 100% | 100% | 96.9% | 95.6% | 91.1% | |
| 3 | Persentase kelengkapan surgical safety checklist di kamar bedah | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | INDIKATOR WAJIB NASIONAL |
| 1 | Kepatuhan Identifikasi Pasien | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 98.9% | 99.6% | 97.9% | |
| 2 | Kepatuhan waktu Visite Dokter penanggungjawab pelayanan (DPJP) | 80% | 88% | 82% | 93% | 82% | 88% | 85% | 88% | 92% | 88% | 88% | 80% | ||
| 3 | Waktu Lapor Hasil Tes Kritis Laboratorium | 100% | 92% | 78% | 92% | 92% | 79% | 89% | 97% | 98% | 96% | 100% | 100% | 97% | |
| 4 | Kepatuhan upaya pencegahan risiko pasien jatuh: kelengkapan pengkajian ulang risiko jatuh pasien rawat inap | 100% | 85% | 85% | 88% | 100% | 85% | 85% | 85% | 81.8% | 90% | 82.1% | 84.4% | 82.2% | |
| 5 | Emergency Response Time (Waktu Tanggap Pelayanan Gawat Darurat ≤ 5 Menit) | 100% | 19% | 56% | 25% | 50% | 22% | 17% | 50% | 77% | 89.5% | 87% | 63% | 78% | |
| 6 | Penundaan Operasi Elektif | < 5% | 7% | 0% | 4% | 11% | 10% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | |