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Komite Mutu dan Kesalamatan Pasien
| Indikator Nasional 2026 | |||||||||||||
| Daftar Indikator | Target | Jan | Feb | Mar | Apr | Mei | Jun | Jul | Agu | Sep | Okt | Nov | Des |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Kepatuhan Kebersihan Tangan | ≥ 85% | 100% | 99,73% | 99,93% | 100% | 99,79% | 100% | 99,99% | - | - | - | - | - |
| Kepatuhan Penggunaan Alat Pelindung Diri (APD) | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | - | - | - | - | - |
| Kepatuhan Identifikasi Pasien | 100% | 100% | 97,45% | 100% | 100% | 100% | 100% | 100% | - | - | - | - | - |
| Waktu Tanggap Operasi Seksio Sesarea Emergensi | ≥ 80% | N/A | N/A | N/A | N/A | N/A | N/A | N/A | - | - | - | - | - |
| Waktu Tunggu Rawat Jalan | ≥ 80% | 76,09% | 70,54% | 79,33% | 69,41% | 73,97% | 50,13% | 70,18% | - | - | - | - | - |
| Penundaan Operasi Elektif | ≤ 5% | 0,48% | 0,00% | 0% | 0,49% | 0,51% | 0% | 0,46% | - | - | - | - | - |
| Kepatuhan Waktu Visite Dokter | ≥ 80% | 58,82% | 60,70% | 57,41% | 57,71% | 57,03% | 58,98% | 63,20% | - | - | - | - | - |
| Pelaporan Hasil Kritis Laboratorium | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | - | - | - | - | - |
| Kepatuhan Penggunaan Formularium Nasional | ≥ 80% | 99,75% | 99,50% | 99,25% | 99% | 99,75% | 99,50% | 100% | - | - | - | - | - |
| Kepatuhan Staf Medis Terhadap Alur Klinis Clinical Pathway | ≥ 80% | 100% | 91,43% | 88,57% | 80% | 67,57% | 84,96% | 84,38% | - | - | - | - | - |
| Kepatuhan Upaya Pencegahan Risiko Pasien Jatuh | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | - | - | - | - | - |
| Kecepatan waktu Tanggap Komplain | ≥ 80% | 84,62% | 84,21% | 100% | 80% | 81,82% | 80% | 100% | - | - | - | - | - |
| Kepuasan Pasien | ≥ 76,61 | 94,15 | 94,41 | 95,04 | 94,46 | 92,55 | 93,44 | 91,57 | - | - | - | - | - |
| Indikator Prioritas RS 2026 | |||||||||||||
| Daftar Indikator | Target | Jan | Feb | Mar | Apr | Mei | Jun | Jul | Agu | Sep | Okt | Nov | Des |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Kejadian Insiden Pada Pasien Akibat Ketidaktepatan Dalam Pelaksanaan Identifikasi Pasien | 0. | 0. | 0. | 0. | 0. | 0. | 0. | - | - | - | - | - | - |
| Kepatuhan Pelaksanaan Serah Terima Pasien Yang Pindah Dari IGD ke Ruang Rawatan | 100% | 99,49% | 100% | 99,70% | 100% | 99,95% | 99,95% | - | - | - | - | - | - |
| Angka Kepatuhan Melakukan Pengawasan Terhadap Pemberian Obat High Alert | 100% | 100% | 100% | 97,01% | 95,48% | 95,24% | 96,49% | - | - | - | - | - | - |
| Kepatuhan Penandaan Lokasi Operasi (Site Marking) | 100% | 92,86% | 96,88% | 97% | 95,78% | 99,60% | 96,45% | - | - | - | - | - | - |
| Ketersediaan Fasilitas Hand Rub di Unit Pelayanan | 100% | 95,12% | 100% | 97,67% | 100% | 100% | 100% | - | - | - | - | - | - |
| Persentase Kejadian Pasien Jatuh | 0% | 0% | 0,06% | 0% | 0% | 0% | 0% | - | - | - | - | - | - |
| Ketepatan Pemberian Aspirin dan Clopidrogel pada pasien akut coronary syndrome di IGD | 100% | 72% | 95,65% | 94,29% | 97,50% | 97,96% | 85,00% | - | - | - | - | - | - |
| Respontime Pemeriksaan Troponin T | ≥ 95 % | - | - | 100% | 100% | 100% | 92,86% | - | - | - | - | - | - |
| Kejadian Penundaan atau Pembatalan Tindakan Kateterisasi Angiography/PCI Akibat Tidak Tersedianya Sediaan Farmasi dan Bahan Medis Habis Pakai | 0. | 0. | 0. | 0. | 0. | 0. | 0. | - | - | - | - | - | - |
| Persentase Kejadian Salah Penempatan Limbah Medis | 0% | 0,40% | 0,11% | 0% | 0% | 0% | 0,10% | - | - | - | - | - | - |
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