Indikator Mutu
Tahun 2021
| 1 | Persentase Dokter Spesialis Datang Praktik Sesuai dengan Hari Praktiknya | 90% | 90% | 91% | 90% | 84% | - |
|---|---|---|---|---|---|---|---|
| 2 | Kepatuhan Waktu Visite Dokter Penanggungjawab Pelayanan (DJPJ) | ≥ 80% | 81% | 84% | 88% | 94% | - |
| 3 | Waktu Tanggap Pelayanan Dokter di Gawat Darurat | ≤ 5 menit setelah pasien datang | 7.5 Menit | 12 Menit | 17.5 Menit | 6.4 Menit | 8.4 Menit |
| 4 | Kematian Pasien ≤ 24 jam di Gawat Darurat | ≤ 2 per seribu | 2/310 | 2 | 3/295 | 3/254 | 2/273 |
| 5 | Kelengkapan Informed Consent Setelah Mendapatkan Informasi yang Jelas pada Tindakan Bedah Elektif | 100% | 88% | 95% | 68% | 79% | 85% |
| 6 | Kelengkapan Pengisian Rekam Medis Rawat Inap | 100% | 57% | 0% | 0% | 32% | 37% |
| 7 | Kelengkapan Resume Medis Rawat Inap | 100% | 96% | 93% | 93% | 98% | 99% |
| 8 | Kepuasan Pengunjung terhadap Layanan Rawat Jalan | 4.5 | 3,05 | 3,46 | 3,31 | 3,47 | 4,33 |
| 9 | Rerata Cycle Time Pelayanan di Klinik Rawat Jalan | 2 jam | 3:03:36 | 2:31:55 | 2:16:03 | 2:05:36 | - |
| 10 | Kepuasan Pelanggan Rawat Inap | 4.5 | 4.46 | 3.31 | 4.51 | 4.43 | 4.31 |
| 11 | Ketepatan Pemberian Diet Pasien Rawat Inap Sesuai Dengan Intruksi DPJP | 100% | 100% | 100% | 100% | 100% | 100% |
| 12 | Ketepatan Jam Distribusi Makan Pasien Rawat Inap | 100% | 100% | 100% | 100% | 100% | 100% |
| 13 | Waktu Tunggu Obat Racikan ≤ 60 menit | 100% | 63,64% | 83,87% | 92% | 67,72% | 72,73% |
| 14 | Waktu Tunggu Obat Racikan ≤ 30 menit | 100% | 85,23% | 81,55% | 84,64% | 81,72% | 94,08% |
| 15 | Waktu Lapor Hasil Tes Kritis Laboratorium < 30 menit | 100% | 99% | 100% | 98% | 100% | 100% |
| 16 | Monitoring Waktu Tunggu Hasil Radiologi Cito | 75% | 99,37% | 87,63% | 79,69% | 81,62% | 83,74% |
| 17 | Monitoring Kerusakan Film Radiologi | ≤ 2 % | 0,00% | 0,52% | 0% | 0% | 0% |
| 18 | Monitoring Waktu Tunggu Hasil Pelayanan Radiologi Thorax | 75% | 76,64% | 81,69% | 95,67% | 98,47% | 98,87% |
| 19 | Waktu Tanggap (Respons Time) Pelayanan Pemulasaraan Jenazah | 100% | 84,6% | 87,8% | 94% | 100% | 94,7% |
| 20 | Kesesuaian Parameter Limbah Cair Dengan Baku Mutu (STP Utama) | 90% | 93,30% | - | 90% | 93,30% | 93,33% |
| 21 | Kesesuaian Parameter Limbah Cair Dengan Baku Mutu (STP Gedung Parkir) | 90% | 90% | - | 90% | 90% | 90% |
| 22 | Kesesuaian Pengolahan Limbah Padat B3 dengan Aturan | 100% | 75% | 75% | 68.75% | 75% | 87,5% |
| 23 | Ketepatan waktu pengisian form pemeriksaan APAR | 100% | 95% | 95% | 95% | 95% | 95% |
| 24 | Ketepatan waktu pengisian form pemeriksaan Hydrant | 100% | 91% | 91% | 91% | 91% | 91% |
| 25 | Ketepatan Waktu Penanganan Keluhan 1x24 Jam | 75% | 75,51% | 78,31% | 60% | 78.05% | 77,78% |
| 26 | Ketepatan Waktu Pemeliharaan Genset (3-4 kali dalam sebulan) | 75% | 25% | 0% | 0% | 0% | 0% |
| 27 | Indeks Penyelesaian Pengadaan | 90% | 43% | 53% | 49% | 79% | 89% |
| 28 | TAT (turn around time), jangka waktu penyelesaian pengadaan | 45 Hari kalender | 12-115 hari kalender | 3-15 hari kalender | 12-49 hari kalender | 25-73 hari kalender | 35 hari kalender |
| 29 | Persentase hasil cucian yang memenuhi standar linen ekselen | 95% | 98,65% | 98,80% | 99,04% | 99,16% | 99,00% |
| 30 | Persentase ketepatan waktu distribusi linen bersih untuk ruang perawatan kurang dari 7 Jam | 75% | 94,89% | 96,42% | 94.61% | 94,95% | 99,76% |
| 31 | Kinerja Jaringan dan Server | 100% | 100% | 100% | 100% | 100% | 100% |
| 32 | Kinerja System Firewall RSUI | 0 Insiden | 0 Insiden | 0 Insiden | 0 Insiden | 0 Insiden | 0 Insiden |
| 33 | Angka penyelesaian permasalahan SIMRS | 100% | 100% | 100% | 100% | 100% | 100% |
| 34 | Ketepatan Waktu Penyerahan RAB/PKP ke Unit Keuangan | 2 Hari kerja | 2 Hari kerja | 2 Hari kerja | 1 Hari kerja | 1,6 Hari kerja | 1,5 Hari kerja |
| 35 | Ketepatan Waktu Monitoring dan Evaluasi Anggaran | Tanggal 10 setiap bulan, di luar hari libur | 50% | 50% | 100% | 0% | 100% |
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% | |