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1. indikator area klinis
no judul indikator standar jan feb mar apr
1
kelengkapan pengisian asesmen awal DPJP
bagi pasien rawat inap dalam waktu 1 x 24
jam
100% 66.96% 78.32% 76.34% 76.06%
2 waktu lapor hasil nilai kritis 100% 100% 100% 100% 100%
3
Kesesuaian diagnosis DPJP dengan bacaan
radiologi
100% 99.79% 99.91% 99.95% 100%
4 Penundaan operasi elektif 0% 0.19% 0.00% 0.00% 0%
5 Penulisan resep sesuai formularium 100% 99.91% 99.38% 99.59% 99.74%
6 Adanya kesalahan pemberian obat 0% 0.00% 0.00% 0.00% 0%
7 Angka reaksi transfusi darah <0,01% 0.69% 0.00% 0.30% 0.35%
8 Kelengkapan pengisian resume medis 100% 100.00% 100.00% 100.00% 100%
9 Angka kejadian infeksi luka operasi <2% 0.00% 0.00% 0.00% 0.20%
10 Angka kejadian ulcus decubitus <1% 0.41% 0.00% 0.00% 0.00%
11 Angka kejadian petugas tertusuk jarum 0% 0.00% 0.00% 0.00% 0.00%
12 Angka kejadian VAP <5.8%o 0.00 0.00 0.00 0.00
13 Angka kejadian infeksi saluran kemih 4.7%o 0.00 0.00 0.00 0.00
14 Angka kejadian phlebitis <1%o 0.14 0.16 0.00 0.10
15 Penggunaan antibiotik sesuai peta kuman 100% 93.75% 94.53% 60.02% 93.75%
16 Waktu tunggu pasien rawat jalan 100% 99.30% 99.86% 100.00% 98.87%
17 Kepatuhan jam visite dokter 100% 100.00% 100.00% 100.00% 100.00%
18 Waktu tanggap pelayanan IGD < 5 menit 100% 100.00% 100.00% 100.00% 100.00%
19 Kepatuhan terhadap clinica l pathway 100% 100.00% 100.00% 100.00% 99.03%
20 Ketepatan pemasangan dilaiser reuse 100% 100.00% 100.00% 100.00% 100.00%
indikator area manajemen
no judul indikator standar jan feb mar apr
1
Ketepatan waktu supply consumable set
hemodialisis
100% 100.00% 100.00% 100.00% 100.00%
2
Alat hemodialisis dan water treatment
terkalibrasi
100% 100.00% 100.00% 100.00% 100.00%
3
Ketepatan waktu maintenance alat
hemodialisis
100% 100.00% 100.00% 100.00% 100.00%
4
Kecepatan respon terhadap komplain 1x24
jam
100% 100.00% 100.00% 100.00% 100.00%
5 Kepuasan pasien dan keluarga 80% 80.00% 78.00% 78.00% 83.01%
6 Berkas BPJS gagal klaim <0,05% 0.11% 0.70% 0.07% 0.09%
kator sasaran keselamatan pasien
no judul indikator standar jan feb mar apr
1 Ketepatan pemberian gelang identitas pasien 100% 100.00% 100.00% 100.00% 99.97%
2
Kelengkapan pengisian format timbang
terima pasien IGD ke rawat inap
100% 99.88% 99.88% 99.79% 100%

2. 3
Kelengkapan obat high alert di kotak
emergency
100% 97.66% 95.65% 96.88% 99.19%
4 Penandaan lokasi operasi 100% 100.00% 100.00% 100.00% 100%
5 Angka kepatuhan cuci tangan 85% 93.55% 94.41% 94.14% 96.45%
6 Tidak adanya pasien jatuh 0% 100.00% 100.00% 100.00% 100.00%

3. mei jun jul agu sep okt nov des rata-rata
74.78% 72.94% 85.16% 83.59% 86.72% 90.63% 93.75% 95.31% 81.71%
100% 100% 100% 100% 100% 100% 100% 100% 100.00%
99.95% 99.91% 100% 100% 100% 100% 100% 100% 99.96%
0% 0% 0% 0% 0% 0% 0% 0% 0.02%
99.77% 99.95% 99.86% 99.96% 99.98% 99.99% 99.99% 99.99% 99.84%
0% 1.95% 0% 0% 0% 0% 0% 0% 0.16%
0% 0.33% 0% 0% 0% 0% 0% 0% 0.14%
100% 100% 100% 100% 100% 100% 100% 100% 100.00%
0.00% 0.20% 0.00% 0.00% 0.19% 0% 0.00% 0% 0.05%
0.00% 0.80% 0.00% 0.00% 0% 0% 0% 0% 0.13%
0.00% 0.00% 0% 0% 0.00% 0% 0% 0.00% 0.00%
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.3 0.3 0.17 0.16 0.16 0.15 0.14
92.97% 96.88% 95.31% 95.31% 97.66% 98.44% 98.44% 99.22% 93.02%
99.51% 99.87% 99.98% 100% 100% 100% 100% 100% 99.78%
100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
100% 100% 100% 100% 100% 100% 100% 100% 99.92%
100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
mei jun jul agu sep okt nov des rata-rata
100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
80% 93% 93% 95% 98% 99% 96% 98% 89.25%
0.06% 0.13% 0.13% 0.13% 0.13% 0.14% 0.11% 0.11% 0.16%
mei jun jul agu sep okt nov des rata-rata
100% 100% 100% 100% 100% 100% 100% 100% 100.00%
100% 99.93% 100% 100% 100% 100% 100% 100% 99.96%

4. 98.44% 98.46% 97.66% 98.44% 100% 100% 100% 100% 98.53%
100% 100% 100% 100% 100% 100% 100% 100% 100.00%
94.15% 94.50% 93.40% 93.95% 94.07% 88.97% 89.55% 90.80% 93.16%
100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

5. 95.40% 97.80% 96.20% 98.50% 94.60% 95.60% 96.40% 96.20% 97.03%
91.70% 91.01% 92.07% 94.40% 93.70% 93.40% 90.40% 91.70% 91.10%
93.55% 94.41% 94.14% 96.45% 94.15% 94.50% 93.40% 93.95% 94.07%

6. 90.90% 89.30% 92.50%
87.04% 89.80% 89.10%
88.97% 89.55% 90.80%