This document summarizes quality indicators and achievement levels for Rumah Sakit Jiwa Tampan (Tampan Psychiatric Hospital) in 2017. It includes indicators in clinical areas (such as completeness of initial patient assessments and prescription accuracy), management areas (including drug availability and equipment calibration timeliness), patient safety targets, and use of restraints for psychiatric inpatients. Most indicators met or exceeded their targets for the year. Clinical areas achieved between 50-100% on indicators, management areas were 63-127%, and patient safety was 78-100%.

1. CAPAIAN MUTU
INDIKATOR
PRIORITAS RUMAH
SAKIT
TAHUN 2017

2. PEMILIHAN INDIKATOR MUTU PRIORITAS RSJ TAMPAN

3. PEMILIHAN INDIKATOR MUTU PRIORITAS
INDIKATOR JUMLAH
PRIORITAS AREA KLINIS 11
PRIORITAS AREA MANAJERIAL 9
PRIORITAS SASARAN KESELAMATAN PASIEN (SKP) 6
INTERNASIONAL LIBRARY 3
INDIKATOR MUTU UNIT 43

4. METODE YANG DIGUNAKAN DALAM PENINGKATAN MUTU
PLAN
IDENTIFIKA
SI
MASALAH
DAN
PERENCANA
AN
PERNYATAAN
DAN TUJUAN
DO
IMPLEMENTA
SI
STUDY
MONITORING
ANALISA
EVALUASI
ACT
EVALUASI
PERBAIKAN
BERKELANJU
TAN

5. INDIKATOR PRIORITAS RUMAH SAKIT
JIWA TAMPAN

6. CAPAIAN INDIKATOR AREA KLINIS 2017
97.1%
95.8%
50.0%
99.9%
99.9%
100.0%
85.0%
100.0%
0.0% 20.0% 40.0% 60.0% 80.0% 100.0% 120.0%
IAK-I
IAK-II
IAK-III
IAK-V
IAK-VI
IAK-IX
IAK-X
IAK-XI

7. INDIKATOR AREA KLINIS
• IAK-I
KELENGKAPAN ASESMENT AWAL SETIAP PASIEN RAWAT INAP
1X24 JAM
91%
92%
93%
94%
95%
96%
97%
98%
99%
100%
jan feb mar apr mei jun jul agust sept okt nov des
100%
97.14%
98.06%
96.43%
96.85%
98%
98.29%98.57%
98%
96.59%
94.89%
94.60%
97.50%
97.90%

8. • IAK-2
ANGKA KETEPATAN WAKTU PELAPORAN NILAI KRITIS < 30 MNT
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
jan feb mar apr mei jun jul agust sept okt nov des
100%
95.83%
100% 100% 100% 100% 100% 100%
50%
100% 100% 100% 100% 100%

9. 2% 2%
0.8%
6.9%
0 0 0
11.1%
2.7%
9.6%
1%
2%
0%
0%
2%
4%
6%
8%
10%
12%
TARGET JAN FEB MAR APR MAI JUN JUL AGUST SEP OKT NOV DES
IAK-3 Kejadian Kegagalan Pelayanan Rontgen max 2%

10. • IAK-5
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
TARGET JAN FEB MAR APR MAI JUN JULI AGU SEP OKT NOV DES
100% 100% 100% 99.86% 99.64% 99.84% 99.89% 100% 100% 100% 100% 100% 100%
Penulisan resep sesuai formularium

11. • IAK-6
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
TARGET JAN FEB MAR APR MAI JUN JULI AGU SEP OKT NOV DES
100% 99.84% 99.94% 99.96% 99.93% 99.95% 100% 99.87% 100% 100% 100% 100% 99.74%
Tidak adanya kesalahan penyerahan obat dari farmasi ke
rawat inap

12. • IAK-9
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
target JAN FEB MAR APR MAI JUN JUL AGU SEP OKT NOV DES
100% 100% 100% 100% 100%
100%
100% 100% 100% 100%
100%
100%
100%
Waktu penyediaan dokumen rekam medis pelayanan rawat
jalan rerata < 10 mnt

13. • IAK-10
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
TARGET TW I TW II TW III TW IV
100%
81.58% 81.58%
81.6%
90%
Angka kepatuhan pemakaian tempat sampah infeksius
dan non infeksius

14. • IAK-11
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
TARGET JAN FEB MAR APR MAI JUN JUL AGU SEP OKT NOV DES
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Inform concent penelitian
target 100%

15. INDIKATOR MUTU AREA
MANAGEMEN

16. CAPAIAN INDIKATOR AREA MANAJEMEN 2017
99.9%
63.0%
100.0%
100.0%
83.0%
76.6%
127.0%
98.7%
0.0% 20.0% 40.0% 60.0% 80.0% 100.0% 120.0% 140.0%
IAM-1
IAM-2
IAM-3
IAM-4
IAM--5
IAM--6
IAM--8
IAM-9

17. • IAM-1
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
TARGET JAN FEB MAR APR MAI JUN JULI AGU SEP OKT NOV DES
100% 99.90% 100% 99.97% 99.27% 99.89% 99.93% 99.94% 99.95% 99.94% 99.95% 99.96% 100%
Ketersediaan obat sesuai formularium

18. • IAM-2
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
TARGET JAN FEB MAR APR MAI JUNI JULI SEP OKT NOV DES
100%
20% 20% 20%
50%
60%
70%
85% 85% 85% 85% 85%
Pemantauan maintenance APAR
target 100%

19. • IAM-3
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
TARGET JAN FEB MAR APR MAI JUN JUL AGUST SEP OKT NOV DES
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Ketepatan waktu kalibrasi alat medis

20. • IAM-4
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
TARGET JAN FEB MAR APR MAI JUN JUL AGUST SEP OKT NOV DES
80%
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Ketepatan waktu menanggapi kerusakan alat (maks 30 menit)

21. • IAM-5
83%
17%
Survey kepuasan pelanggan rumah sakit
target 80%
puas
kurang puas

22. • IAM-6
65%
70%
75%
80%
85%
90%
TARGET JAN FEB MAR APR MEI JUN JUL AGU SEP OKT NOV DES
90%
76.6% 76.6% 76.6% 76.6% 76.6% 76.6% 76.6% 76.6% 76.6% 76.6% 76.6% 76.6%
Angka survey kepuasan karyawan terhadap organisasi
(Target 90%)

23. • IAM-7
10 DIAGNOSA TERBANYAK TAHUN 2017
48.18%
30.03%
9.64%
4.05%
2.79%
2.58%
0.77%
0.70%
0.63% 0.63%
Skizofrenia paranoid
Skizofrenia tak terinci
kelainan psikotik akut mirip skizofrenia
kelainan psikotik akut
kelainan schizoafektif
kelainan jiwa akibat kerusakan otak
kelainan jiwa akibat penggunaan zat
psikoaktif
kelainan psikotis polimorf akut dengan gejala
schizofrenia
kelainan psikotik polimorf akut tanpa gejala
schizofenia
episode depresi berat dengan gejala psikotik

24. • IAM-8
0.00%
50.00%
100.00%
150.00%
200.00%
250.00%
JAN FEB MAR APR MAI JUN JULI AGUST SEPT OKT NOV DES
237.41%
151.70%
243.20%
65.38%
119%
83%
104%
87%
142%
87.00% 90%
117%
cost recovery
target 80%

25. • IAM-9
TIDAK ADA KEJADIAN PASIEN LARI
95.0%
95.5%
96.0%
96.5%
97.0%
97.5%
98.0%
98.5%
99.0%
99.5%
100.0%
98.5%
99.0%
99.5%
100.0%
98.3%
98.6%
99.0%
96.7%
98.1%
98.8%98.8%
99.0%

27. CAPAIAN AREA
SASARAN KESELAMATAN PASIEN 2017
96.1%
78.7%
100.0%
81.0%
98.3%
0.0% 20.0% 40.0% 60.0% 80.0% 100.0% 120.0%
SKP-1
SKP-2
SKP-3
SKP-5
SKP-6

28. • SKP-1
89.0%
90.0%
91.0%
92.0%
93.0%
94.0%
95.0%
96.0%
97.0%
98.0%
99.0% 98.6%
92.9%
95.3%
95.7%
96.8%
97.4%
98.2%
95.1%95.3%95.4%
96.9%
95.9%
Series 1
Kepatuhan identifikasi pasien dengan nama, tgl lahir, No RM dan
foto sebelum memberikan obat.

29. • SKP-2
Angka verifikasi oleh DPJP setelah komunikasi melalui telpon.
72.0%
74.0%
76.0%
78.0%
80.0%
82.0%
84.0%
86.0%
jan feb mar apr mei jun jul agust sept okt nov des
86.0%
78.0%
77.0%
78.0%78.0%78.0%
79.0%
78.0%
79.0%
77.0%
78.0%78.0%

30. • SKP-3
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
TARGET JAN FEB MAR APR MAI JUN JULI AGU SEP OKT NOV DES
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Ketepatan penyimpanan dan pemberian label LASA

31. • SKP-5
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
TARGET TW I TW II TW III TW IV
100.0%
66.0%
84.5% 86.0% 88.0%
ANGKA KEPATUHAN CUCI TANGAN

32. • SKP-6
Kelengkapan Assesmen resiko jatuh setiap pasien rawat inap
94.0%
95.0%
96.0%
97.0%
98.0%
99.0%
100.0%
jan feb mar apr mei jun jul agus sept okt nov des
98.0%
100.0%
97.0%
96.6%
97.6%
99.0%
98.2%98.0%
100.0%
98.2%98.0%
99.0%

34. • ILL-I
12:00:00 AM
2:24:00 AM
4:48:00 AM
7:12:00 AM
9:36:00 AM
12:00:00 PM
2:24:00 PM
4:48:00 PM
JAN FEB MAR APR MAI JUN JULI AGUST SEPT OKT NOV DES
7:29:00 AM
9:32:00 AM
7:45:00 AM
5:20:00 AM
7:45:00 AM
6:25:00 AM
8:32:00 AM
12:45:00 PM
12:06:00 PM
3:45:00 PM
10:35:00 AM
2:10:00 PM
Lama tindakan restrain pengikatan dalam jam pasien rawat inap
gangguan jiwa
(dalam jam)

35. • ILL-II
KEJADIAN PASIEN JATUH DENGAN ATAU TANPA CEDERA
0.0%
0.1%
0.1%
0.2%
0.2%
0.3%
0.3%
0.4%
0.2%
0.3%
0.3%
0.0% 0.0%
0.3%
0.2%
0.3%
0.0% 0.0% 0.0% 0.0%

36. • ILL-III
Angka pasien jatuh dengan cedera > level 2.
0.0%
0.1%
0.1%
0.2%
0.2%
0.3%
0.3%
0.4%
0.2%
0.3%
0.3%
0.0% 0.0%
0.3%
0.2%
0.3%
0.0% 0.0% 0.0% 0.0%