IRNA BD A (ok)

APRIL8.1. Kepatuhan pengisian pemantauan suhu penyimpanan obat di lemari es.

1 2 3 4 5Numerator 3 3 3 3 3Denominator 3 3 3 3 3Hasil 100.00 100.00 100.00 100.00 100.00

8.2. Ketepatan melakukan asesmen nyeri pada pasien dewasa pot operasi.1 2 3 4 5

Numerator 0 0 0 0 0Denominator 0 0 0 0 0Hasil 0.00 0.00 0.00 0.00 0.00

8.3. Kepatuhan perawat melakukan identifikasi pasien sebelum melakukan tindakan bagi obat.1 2 3 4 5


8.4. Ketepatan pasien pulang < 2 jam.1 2 3 4 5


8.5. Ketepatan pemasangan tanda resiko jatuh.1 2 3 4 5

NumeratorDenominatorHasil #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

PEBRUARI8.1. Kepatuhan pengisian pemantauan suhu penyimpanan obat di lemari es.

1 2 3 4 5NumeratorDenominatorHasil #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!



8.3. Kepatuhan perawat melakukan identifikasi pasien sebelum melakukan tindakan bagi obat.






MARET8.1. Kepatuhan pengisian pemantauan suhu penyimpanan obat di lemari es.









Numerator

DenominatorHasil #DIV/0! #DIV/0! #DIV/0! #DIV/0!

APRIL8.1. Kepatuhan pengisian pemantauan suhu penyimpanan obat di lemari es.










MEI8.1. Kepatuhan pengisian pemantauan suhu penyimpanan obat di lemari es.



Numerator 2 0 0 0 0Denominator 2 0 0 0 0

Hasil 100.00 0.00 0 0 0


Numerator 0 0 1 0 0Denominator 0 0 1 0 0Hasil 0.00 0 100.00 0 0





JUNI8.1. Kepatuhan pengisian pemantauan suhu penyimpanan obat di lemari es.



Numerator 0 0 0 0 0Denominator 0 0 0 0 0Hasil #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!


Numerator 0 0 0 0 4Denominator 0 0 0 1 4Hasil #DIV/0! #DIV/0! #DIV/0! 0.00 100.00


Numerator 1 0 0 0 1Denominator 1 0 0 3 2Hasil 100.00 #DIV/0! #DIV/0! 0.00 50.00


Numerator 0 0 1 1 3Denominator 0 0 1 1 3Hasil #DIV/0! #DIV/0! 100.00 100.00 100.00

JULI8.1. Kepatuhan pengisian pemantauan suhu penyimpanan obat di lemari es.





Numerator 0 0 0 0 0Denominator 0 0 0 0 0Hasil #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!


Numerator 0 2 2 3 0Denominator 0 5 2 3 1Hasil #DIV/0! 40.00 100.00 100.00 0.00


Numerator 4 0 0 0 2Denominator 4 0 0 0 2Hasil 100.00 #DIV/0! #DIV/0! #DIV/0! 100.00

AGUSTUS8.1. Kepatuhan pengisian pemantauan suhu penyimpanan obat di lemari es.


8.2. Ketepatan melakukan asesmen nyeri pada pasien dewasa pot operasi.

1 2 3 4 5Numerator 0 0 0 1 1Denominator 0 0 0 1 1Hasil #DIV/0! #DIV/0! 0.00 100.00 100.00




Numerator 0 2 1Denominator 1 4 2Hasil 0.00 50.00 #DIV/0! #DIV/0! 50.00


Numerator 2Denominator 2Hasil #DIV/0! #DIV/0! #DIV/0! 100.00 #DIV/0!

SEPTEMBER8.1. Kepatuhan pengisian pemantauan suhu penyimpanan obat di lemari es.



Numerator 2 0 0 0 1Denominator 2 0 0 0 1Hasil 100.00 #DIV/0! #DIV/0! #DIV/0! 100.00


Numerator 4 5 6 6 0Denominator 4 5 6 6 0Hasil 100.00 100.00 100.00 100.00 #DIV/0!


Numerator 1 1 1 0 0

Denominator 1 1 3 0 0Hasil 100.00 100.00 33.33 #DIV/0! #DIV/0!


Numerator 0 0 2 0 0Denominator 0 0 2 0 0Hasil #DIV/0! #DIV/0! 100.00 #DIV/0! #DIV/0!

OKTOBER8.1. Kepatuhan pengisian pemantauan suhu penyimpanan obat di lemari es.










NOPEMBER8.1. Kepatuhan pengisian pemantauan suhu penyimpanan obat di lemari es.

1 2 3 4 5NumeratorDenominator

Hasil #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!









DESEMBER8.1. Kepatuhan pengisian pemantauan suhu penyimpanan obat di lemari es.










6 7 8 9 10 11 12 133 3 3 3 3 3 3 33 3 3 3 3 3 3 3

100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00

6 7 8 9 10 11 12 130 0 0 0 0 0 0 00 0 0 0 0 0 0 0

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Kepatuhan perawat melakukan identifikasi pasien sebelum melakukan tindakan bagi obat.6 7 8 9 10 11 12 13

0 0 0 0 0 0 0 10 0 0 0 0 0 0 1

0.00 0.00 0.00 0.00 0.00 0.00 0.00 100.00

6 7 8 9 10 11 12 131 1 1 1 1 1 0 12 3 2 1 3 2 2 2

50.00 33.33 50.00 100.00 33.33 50.00 0.00 50.00

6 7 8 9 10 11 12 13

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

6 7 8 9 10 11 12 13


6 7 8 9 10 11 12 13


Kepatuhan perawat melakukan identifikasi pasien sebelum melakukan tindakan bagi obat.

6 7 8 9 10 11 12 13


6 7 8 9 10 11 12 13


6 7 8 9 10 11 12 13


6 7 8 9 10 11 12 13


6 7 8 9 10 11 12 13




6 7 8 9 10 11 12 13


6 7 8 9 10 11 12 13


6 7 8 9 10 11 12 13


6 7 8 9 10 11 12 13




6 7 8 9 10 11 12 13


6 7 8 9 10 11 12 13


6 7 8 9 10 11 12 131 1 1 1 1 1 0 01 1 1 1 1 1 1 1

100.00 100.00 100.00 100.00 100.00 100.00 0.00 0.00

6 7 8 9 10 11 12 130 0 0 0 0 1 1 10 0 0 0 0 1 1 1

0 0 0 0 0 100.00 100.00 100.00


0 0 0 3 1 0 0 00 0 0 4 1 0 0 00 0 0 75.00 100.00 0 0 0

6 7 8 9 10 11 12 131 1 0 0 0 0 0 02 1 2 1 3 2 2 4

50.00 100.00 0.00 0.00 0.00 0.00 0.00 0.00

6 7 8 9 10 11 12 130 0 0 0 0 3 7 00 0 0 0 0 3 8 0

0.00 0.00 0.00 0.00 0.00 100.00 0.00 0.00

6 7 8 9 10 11 12 131 0 0 0 0 0 0 01 0 0 0 0 0 0 0

100.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

6 7 8 9 10 11 12 130 0 0 0 0 0 0 00 0 0 0 0 0 0 0



0 0 0 0 0 0 0 01 0 0 0 0 0 3 0

0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.00 #DIV/0!

6 7 8 9 10 11 12 130 0 0 0 3 0 0 00 0 0 0 4 0 3 1

#DIV/0! #DIV/0! #DIV/0! #DIV/0! 75.00 #DIV/0! 0.00 0.00

6 7 8 9 10 11 12 130 0 4 2 0 0 2 15 1 4 2 0 0 4 3

0.00 0.00 100.00 100.00 #DIV/0! #DIV/0! 50.00 33.33

6 7 8 9 10 11 12 133 3 3 3 3 3 3 33 3 3 3 3 3 3 3

100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00

6 7 8 9 10 11 12 131 0 0 0 0 0 0 01 0 0 0 0 0 0 0

100.00 0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!


0 0 10 0 0 0 0 00 0 10 0 0 0 0 0

#DIV/0! #DIV/0! 100.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

6 7 8 9 10 11 12 132 0 0 3 2 2 0 33 0 0 3 3 2 1 3

66.67 #DIV/0! #DIV/0! 100.00 66.67 100.00 0.00 100.00

6 7 8 9 10 11 12 134 0 0 0 0 2 1 04 0 0 6 0 2 3 0

100.00 #DIV/0! #DIV/0! 0.00 #DIV/0! 100.00 33.33 #DIV/0!

6 7 8 9 10 11 12 133 3 3 3 3 3 3 33 3 3 3 3 3 3 3

100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00

6 7 8 9 10 11 12 131 0 0 0 0 0 0 01 0 0 0 0 0 0 0

100.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


4 3 3 0 4 0 0 34 3 3 0 4 0 0 3

100.00 100.00 100.00 0.00 100.00 0.00 0.00 100.00

6 7 8 9 10 11 12 131 1 2 0 0 3 22 3 3 2 1 3 5

50.00 33.33 66.67 0.00 0.00 #DIV/0! 100.00 40.00

6 7 8 9 10 11 12 138 1

10 1#DIV/0! #DIV/0! #DIV/0! #DIV/0! 80.00 #DIV/0! 100.00 #DIV/0!

6 7 8 9 10 11 12 133 3 3 3 3 3 3 33 3 3 3 3 3 3 3

100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00

6 7 8 9 10 11 12 131 0 1 0 0 0 0 01 0 1 0 0 0 0 0

100.00 #DIV/0! 100.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!


0 0 0 6 0 6 0 00 0 0 6 0 6 0 0

#DIV/0! #DIV/0! #DIV/0! 100.00 #DIV/0! 100.00 #DIV/0! #DIV/0!

6 7 8 9 10 11 12 131 2 1 0 0 0 0 1

2 3 1 0 0 0 2 150.00 66.67 100.00 #DIV/0! #DIV/0! #DIV/0! 0.00 100.00

6 7 8 9 10 11 12 134 0 3 0 0 2 0 04 0 3 0 0 2 0 0

100.00 #DIV/0! 100.00 #DIV/0! #DIV/0! 100.00 #DIV/0! #DIV/0!

6 7 8 9 10 11 12 13


6 7 8 9 10 11 12 13




6 7 8 9 10 11 12 13


6 7 8 9 10 11 12 13


6 7 8 9 10 11 12 13


6 7 8 9 10 11 12 13




6 7 8 9 10 11 12 13


6 7 8 9 10 11 12 13


6 7 8 9 10 11 12 13


6 7 8 9 10 11 12 13




6 7 8 9 10 11 12 13


6 7 8 9 10 11 12 13


14 15 16 17 18 19 20 213 0 3 3 3 3 3 33 3 3 3 3 3 3 3

100.00 0.00 100.00 100.00 100.00 100.00 100.00 100.00

14 15 16 17 18 19 20 210 0 0 2 1 1 1 00 0 0 2 1 1 1 0

0.00 0.00 0.00 100.00 100.00 100.00 100.00 0.00

14 15 16 17 18 19 20 211 2 1 1 1 0 1 11 2 2 1 1 0 1 2

100.00 100.00 50.00 100.00 100.00 0.00 100.00 50.00

14 15 16 17 18 19 20 210 1 1 1 1 0 0 10 7 5 2 1 3 0 2

0.00 14.29 20.00 50.00 100.00 0.00 0.00 50.00

14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 211 1 0 0 0 1 1 11 1 1 1 1 1 1 1

100.00 100.00 0.00 0.00 0.00 100.00 100.00 100.00

14 15 16 17 18 19 20 210 0 0 0 0 0 0 00 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0.00

14 15 16 17 18 19 20 212 1 0 0 0 0 0 15 2 0 0 2 0 5 2

40.00 50.00 0 0 0.00 0 0.00 50.00

14 15 16 17 18 19 20 210 0 0 0 0 0 0 01 0 0 0 0 0 0 0

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

14 15 16 17 18 19 20 212 3 5 0 3 0 0 04 3 5 0 3 0 0 0

50.00 100.00 100.00 0.00 100.00 0.00 0.00 0.00

14 15 16 17 18 19 20 210 0 0 0 1 1 1 10 0 0 0 1 1 1 1

#DIV/0! #DIV/0! #DIV/0! #DIV/0! 100.00 100.00 100.00 100.00

14 15 16 17 18 19 20 210 0 0 0 0 0 0 00 0 0 0 0 0 0 0


14 15 16 17 18 19 20 210 0 0 0 4 0 0 00 0 0 0 4 0 2 0

#DIV/0! #DIV/0! #DIV/0! #DIV/0! 100.00 #DIV/0! 0.00 #DIV/0!

14 15 16 17 18 19 20 211 0 4 0 1 1 0 04 3 4 1 2 2 0 0

25.00 0.00 100.00 0.00 50.00 50.00 #DIV/0! #DIV/0!

14 15 16 17 18 19 20 211 0 0 0 0 0 2 23 0 0 0 0 0 3 2

33.33 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 66.67 100.00

14 15 16 17 18 19 20 213 3 3 3 3 3 3 33 3 3 3 3 3 3 3

100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00

14 15 16 17 18 19 20 210 0 0 0 0 0 0 00 0 0 0 0 0 0 0


14 15 16 17 18 19 20 210 0 0 0 0 0 0 00 0 0 0 0 0 0 0


14 15 16 17 18 19 20 210 0 1 0 1 0 0 00 0 1 0 1 0 0 2

#DIV/0! #DIV/0! 100.00 #DIV/0! 100.00 #DIV/0! #DIV/0! 0.00

14 15 16 17 18 19 20 210 0 2 1 0 0 0 20 0 2 1 0 0 0 2

#DIV/0! #DIV/0! 100.00 100.00 #DIV/0! #DIV/0! #DIV/0! 100.00

14 15 16 17 18 19 20 213 3 3 3 3 3 3 33 3 3 3 3 3 3 3

100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00

14 15 16 17 18 19 20 210 0 0 0 0 1 2 00 0 0 0 0 1 2 0

0.00 0.00 0.00 0.00 0.00 100.00 100.00 0.00

14 15 16 17 18 19 20 210 0 2 0 12 6 0 00 0 2 0 12 6 0 0

0.00 0.00 100.00 0.00 100.00 100.00 0.00 0.00

14 15 16 17 18 19 20 211 1 0 11 1 2 3

100.00 100.00 #DIV/0! 0.00 #DIV/0! #DIV/0! #DIV/0! 33.33

14 15 16 17 18 19 20 217 27 2

#DIV/0! #DIV/0! #DIV/0! 100.00 #DIV/0! 100.00 #DIV/0! #DIV/0!

14 15 16 17 18 19 20 213 3 3 3 3 0 0 03 3 3 3 3 0 0 0

100.00 100.00 100.00 100.00 100.00 #DIV/0! #DIV/0! 0.00

14 15 16 17 18 19 20 210 1 0 1 0 1 0 10 1 0 1 0 1 0 1

#DIV/0! 100.00 #DIV/0! 100.00 #DIV/0! 100.00 #DIV/0! 100.00

14 15 16 17 18 19 20 215 5 0 0 0 0 0 05 5 0 0 0 0 0 0

100.00 100.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

14 15 16 17 18 19 20 213 0 0 0 1 0 0 0

4 0 0 0 1 0 0 075.00 #DIV/0! #DIV/0! #DIV/0! 100.00 #DIV/0! #DIV/0! #DIV/0!

14 15 16 17 18 19 20 210 0 4 2 0 0 0 00 0 4 2 0 0 0 0

#DIV/0! #DIV/0! 100.00 100.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0!

14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


14 15 16 17 18 19 20 21


22 23 24 25 26 27 28 290 0 3 3 3 3 3 33 3 3 3 3 3 3 3

0.00 0.00 100.00 100.00 100.00 100.00 100.00 100.00

22 23 24 25 26 27 28 290 0 0 0 0 0 0 00 0 0 0 0 0 0 0

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

22 23 24 25 26 27 28 290 0 1 0 1 0 1 00 0 2 0 1 0 1 0

0.00 0.00 50.00 0.00 100.00 0.00 100.00 0.00

22 23 24 25 26 27 28 291 3 1 1 0 1 0 11 3 3 1 2 5 3 3

100.00 100.00 33.33 100.00 0.00 20.00 0.00 33.33

22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 291 1 1 1 1 1 1 11 1 1 1 1 1 1 1

100.00 1.00 1.00 1.00 1.00 1.00 1.00 100.00

22 23 24 25 26 27 28 291 0 0 0 0 0 0 01 0 0 0 0 0 0 0

100.00 0 0 0 0 0 0 0

22 23 24 25 26 27 28 290 0 1 3 2 3 1 00 0 2 3 2 3 2 00 0 50.00 100.00 100.00 100.00 50.00 0

22 23 24 25 26 27 28 290 1 0 1 1 0 0 00 1 0 2 2 1 2 0

0.00 100.00 0.00 50.00 50.00 0.00 0.00 0.00

22 23 24 25 26 27 28 290 0 0 0 1 0 0 00 0 0 0 1 1 3 2

0.00 0.00 0.00 0.00 100.00 0.00 0.00 0.00

22 23 24 25 26 27 28 291 1 1 1 1 1 1 11 1 1 1 1 1 1 1

100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00

22 23 24 25 26 27 28 290 0 2 2 0 0 0 00 0 2 2 0 0 0 0


22 23 24 25 26 27 28 293 0 5 3 3 3 0 23 0 5 3 3 3 0 2

100.00 #DIV/0! 100.00 100.00 100.00 100.00 #DIV/0! 100.00

22 23 24 25 26 27 28 291 1 2 2 1 1 0 32 2 3 2 2 1 0 3

50.00 50.00 66.67 100.00 50.00 100.00 #DIV/0! 100.00

22 23 24 25 26 27 28 290 2 2 1 2 3 0 00 3 3 2 2 3 0 0

#DIV/0! 66.67 66.67 50.00 100.00 100.00 #DIV/0! #DIV/0!

22 23 24 25 26 27 28 293 3 3 3 3 3 3 33 3 3 3 3 3 3 3

100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00

22 23 24 25 26 27 28 290 0 0 0 0 0 0 00 0 0 0 0 0 0 0


22 23 24 25 26 27 28 290 0 13 0 0 12 0 00 0 13 0 0 12 0 0

#DIV/0! #DIV/0! 100.00 #DIV/0! #DIV/0! 100.00 #DIV/0! #DIV/0!

22 23 24 25 26 27 28 290 2 2 0 0 3 2 10 2 4 0 1 3 2 1

#DIV/0! 100.00 50.00 #DIV/0! 0.00 100.00 100.00 100.00

22 23 24 25 26 27 28 293 2 1 1 3 3 0 03 3 3 2 4 3 0 0

100.00 66.67 33.33 50.00 75.00 100.00 #DIV/0! #DIV/0!

22 23 24 25 26 27 28 293 3 3 3 3 3 3 33 3 3 3 3 3 3 3

100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00

22 23 24 25 26 27 28 290 0 0 0 0 0 0 00 0 0 0 0 0 0 0

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

22 23 24 25 26 27 28 290 0 4 0 0 5 0 00 0 4 0 0 5 0 0

0.00 0.00 100.00 #DIV/0! #DIV/0! 100.00 #DIV/0! #DIV/0!

22 23 24 25 26 27 28 291 2 1 3 0 0 01 2 1 4 1 4 3

100.00 100.00 100.00 75.00 #DIV/0! 0.00 0.00 0.00

22 23 24 25 26 27 28 290 64 6


22 23 24 25 26 27 28 290 0 0 0 0 3 3 00 0 0 0 0 3 3 0

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 100.00 100.00 #DIV/0!

22 23 24 25 26 27 28 290 0 0 0 0 0 0 00 0 0 0 0 0 0 0


22 23 24 25 26 27 28 290 0 0 4 0 0 0 00 0 0 4 0 0 0 0

#DIV/0! #DIV/0! #DIV/0! 100.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0!

22 23 24 25 26 27 28 290 0 1 0 0 0 0 0

0 2 1 1 1 0 0 0#DIV/0! 0.00 100.00 0.00 0.00 #DIV/0! #DIV/0! #DIV/0!

22 23 24 25 26 27 28 290 0 0 0 7 0 2 20 0 0 0 7 0 2 2

#DIV/0! #DIV/0! #DIV/0! #DIV/0! 100.00 #DIV/0! 100.00 100.00

22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


22 23 24 25 26 27 28 29


30 31 32 3333

100.00 #DIV/0! #DIV/0! #DIV/0!

30 31 32 3300

0.00 #DIV/0! #DIV/0! #DIV/0!

30 31 32 3311

100.00 #DIV/0! #DIV/0! #DIV/0!

30 31 32 3345

80.00 #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 331 11 1

100.00 100.00 #DIV/0! #DIV/0!

30 31 32 330 00 0

0 0

30 31 32 332 22 2

100.00 100.00 #DIV/0! #DIV/0!

30 31 32 330 00 1

0.00 0.00 #DIV/0! #DIV/0!

30 31 32 331 01 0

100.00 0.00 #DIV/0! #DIV/0!

30 31 32 3311

100.00 #DIV/0! #DIV/0! #DIV/0!

30 31 32 3300

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 3322

100.00 #DIV/0! #DIV/0! #DIV/0!

30 31 32 3300

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 3344

100.00 #DIV/0! #DIV/0! #DIV/0!

30 31 32 333 33 3

100.00 100.00 #DIV/0! #DIV/0!

30 31 32 330 00 0

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 336 06 0

100.00 #DIV/0! #DIV/0! #DIV/0!

30 31 32 330 11 4

0.00 25.00 #DIV/0! #DIV/0!

30 31 32 334 04 0

100.00 #DIV/0! #DIV/0! #DIV/0!

30 31 32 333 13 3

100.00 33.33 #DIV/0! #DIV/0!

30 31 32 330 00 0

0.00 0.00 #DIV/0! #DIV/0!

30 31 32 330 00 0

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 3302

#DIV/0! 0.00 #DIV/0! #DIV/0!

30 31 32 3301

#DIV/0! 0.00 #DIV/0! #DIV/0!

30 31 32 3300

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 3300

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 3300

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 331

250.00 #DIV/0! #DIV/0! #DIV/0!

30 31 32 3302

0.00 #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

30 31 32 33

#DIV/0! #DIV/0! #DIV/0! #DIV/0!

INDIKATOR & SPM-RSINSTALASI RAWAT INAP BEDAH DALAM A

TAHUN 20151. PENCAPAIAN PELAYANAN.1.1. BOR.

Jan Feb Mar Apr2013 41 42 54 482014 40 62 64 532015 49.8 58.8 53.6 60.8

1.2. Jumlah pasien MRS.Jan Feb Mar Apr

Target 123 129 138 1272013 65 68 105 982014 89 120 119 922015 160 153 140 145

1.3. Peningkatan jumlah haper.Jan Feb Mar Apr

Target 521 544 581 5382013 313 298 424 3602014 315 435 503 3892015 464 494 499 548

Jan Feb Mar Apr Mei Jun Jul Agust Sep Okt Nop Des0

10203040506070

2013

2014

2015


20406080

100120140160180

Target

2013

2014

2015


100200300400500600700

Target

2013

2014

2015

2. Pencapaian pasien MRS sesuai jenis ruangan.2.1. Krisan

Jan Feb Mar AprTarget 66 69 73 682014 67 63 52 502015 76 79 68 59

2.2. SeruniJan Feb Mar Apr

Target 16 17 18 17

2014 7 17 23 8

2015 22 21 20 21

2.3. CempakaJan Feb Mar Apr

Target 8 9 9 82014 5 15 12 42015 17 17 11 22


100200300400500600700

Target

2013

2014

2015


20

40

60

80

Target

2014

2015


5

10

15

20

25

30

Target

2014

2015


10

20

30

Target

2014

2015

2.4. KemuningJan Feb Mar Apr

Target 21 21 23 212014 23 20 25 152015 28 24 25 28

2.5. KenangaJan Feb Mar Apr

Target 12 13 14 132014 5 5 7 152015 17 12 16 15

3. Klasifikasi pembiayaan.Jan Feb Mar Apr

Umum 46 86 62 86JKN non PBI 75 81 75 56JKM 0 0 0 0JKD 0 0 0 0LAin2 6 5 2 3

Jan Feb Mar Apr Mei Jun Jul Agust Sep Okt Nop Des

46

86

62

8671

51 5063

50

75 81 75

5647

66 6271

41

0 0 0 0 0 0 0 0 0

6 5 2 3 3 3 1 3 1

Umum JKN non PBI JKM LAin2


10

20

30

Target

2014

2015


10

20

30

40

Target

2014

2015


10

20

30

Target

2014

2015

4. Klasifikasi Jenis Pelayanan.Jan Feb Mar Apr

P. Dalam 87 94 74 68Bedah 15 14 13 20Isolasi 31 23 25 28Syaraf 9 9 16 18Paru 4 6 3 1Orto 4 6 3 8Rehab Medis 0 0 0 0THT 0 0 1 1kes jiwa 1 0 0 0Mata 4 0 1 0Bedah Digestif 1 0Anakjantung 5 1 2 1

5. INDIKATOR PELAYANAN.5.1. STANDAR PELAYANAN MINIMAL (RAWAT INAP).5.1.1. Input

Jan Feb Mar Apr

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%

Pemberi pelayanan Dokter sesuai klasifikasi RS (100%).

Pemberi pelayanan perawat sesuai klasifikasi RS (100%).

Tempat tidur dengan pengaman (100%).

Kamar mandi dengan pengaman (100%).


46

86

62

8671

51 5063

50

75 81 75

5647

66 6271

41

0 0 0 0 0 0 0 0 0

6 5 2 3 3 3 1 3 1



20

40

60

80

100 8794

7468

55 53 5566

42

15 14 1320 18

2717 20 18

3123 25 28 25 27

2030

179 9

16 1810 6 8 6 24 6 3 1 2

0

4 5 1

P. Dalam

Bedah

Isolasi

Syaraf

Paru

jantung

5.1.2. ProsesJan Feb Mar Apr

DPJP (100%). 100.00% 100.00% 100.00% 100.00%

92.40% 95.00% 95.00% 73.00%

100.00% 100.00% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00%

5.1.3. OutputJan Feb Mar Apr

1.25% 1,3% 1,4% 1,3%

0,6% 1,9% 1,4% 0.00%

5.1.4. Outcome.Jan Feb Mar Apr

90,1%

6. PENGENDALIAN INFEKSI.Jan Feb Mar Apr

96,2% 96,9 79,5% 86,6%

100.00% 75% 100% 90%

ILI (5%). 5% 5% 3,06% 2,6%ILO (3%). 0% 0% 0% 0%IADP (3%). 0% 0% 0% 0%CaUTI (<10%). 0% 0% 2,4% 0%HAP 0% 0% 0% 0%

0% 0% 0% 0

7. KESELAMATAN PASIEN.Jan Feb Mar Apr

100.00% 100.00% 99.20% 99.30%

Jam visit (100%)

Penanganan pasien dengan TB DOTS (100%).

Decubitus (0%).

Kejadian pulang paksa (≤ 5).

Kematian pasien > 48 jam (≤ 0,24).

Kepuasan pasien (≥ 90%).

Kepatuhan cuci tangan (80%).

Kepatuhan pemakaian APD (80%).

Kejadian tertusuk benda tajam dan terpapar cairan tubuh.

Ketepatan identitas.

Digi:B24,ALO,CHF,ASTR

100.00% 100.00% 100.00% 100.00%

100.00% 90.00% 87.00% 75.00%(6/8)

98.00% 99.00% 97.00% 93.00%

100.00% 100.00% 100.00% 100.00%

Pasien Jatuh. 0.00% 0.00% 0,7 0,6%

Evaluasi:pemakaian SBAR belum mencapai target dikarenakan lemahnya read back8. INDIKATOR PMKP 2015.8.1. Kepatuhan pengisian pemantauan suhu penyimpanan obat di lemari es.

Jan Feb Mar AprNumerator 26Denominator 31Hasil 83.87

8.2. Ketepatan melakukan asesmen nyeri pada pasien dewasa post operasi.Jan Feb Mar Apr

Numerator 13Denominator 13Hasil 100.00

8.3. Kepatuhan perawat melakukan identifikasi pasien sebelum melakukan tindakan bagi obat.Jan Feb Mar Apr


8.4. Ketepatan pasien pulang < 2 jam.Jan Feb Mar Apr


8.5. Ketepatan pemasangan tanda resiko jatuh.Jan Feb Mar Apr

Numerator 26

Terpasang gelang identitas pasien rawat inap.

Pelaksanaan SBAR

Ketepatan pemberian obat.

Ketepatan tranfusi.

Jan Feb Mar Apr Mei Jun Jul Agust Sep Okt Nop Des0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%



Pelaksanaan SBAR


Ketepatan tranfusi.

Pasien Jatuh.

Denominator 35Hasil 74.29

9. PENDAPATAN.Jan Feb Mar Apr

Target 246,848,028 257,443,162 275,287,598 254,654,9692013 123,435,213 94,531,542 171,632,093 334,643,7142014 143,220,971 199,079,930 263,473,209 284,098,5812015 290,093,266 286,000,582 304,742,236 373,029,540

10. BIAYA.Jan Feb Mar Apr

Rata2/BlnGaji 56,353,234 53,093,050 61,979,975 55,357,961Operasional 2,089,404 17,545,036 10,336,660 20,705,945Total 58,442,638 70,638,086 72,316,635 76,063,906


20,000,000

40,000,000

60,000,000

80,000,000

100,000,000

Rata2/Bln

Gaji

Operasional

Total


100,000,000

200,000,000

300,000,000

400,000,000

Target

2013

2014

2015


20,000,000

40,000,000

60,000,000

80,000,000

100,000,000

Rata2/Bln

Total


Mei Jun Jul Agust Sep Okt43 42 40 34 49 51.3741 42 33 40 46 40.7

44.7 46 40 45 38,4

Mei Jun Jul Agust Sep Okt135 130 132 118 134 137

80 85 90 74 96 9691 114 79 99 115 107

121 120 113 141 92

Mei Jun Jul Agust Sep Okt571 548 556 500 566 580333 317 316 257 398 398322 319 247 317 349 316416 414 372 419 336


10203040506070

2013

2014

2015


20406080

100120140160180

Target

2013

2014

2015


100200300400500600700

Target

2013

2014

2015

Mei Jun Jul Agust Sep Okt72 69 70 63 71 7347 42 37 54 61 5453 60 51 62 42


8 12 16 13 15 22

16 21 19 16 14



100200300400500600700

Target

2013

2014

2015


20

40

60

80

Target

2014

2015


5

10

15

20

25

30

Target

2014

2015


10

20

30

Target

2014

2015



Mei Jun Jul Agust Sep Okt71 51 50 63 5047 66 62 71 41

0 0 0 0 00 0 0 0 03 3 1 3 1


46

86

62

8671

51 5063

50

75 81 75

5647

66 6271

41

0 0 0 0 0 0 0 0 0

6 5 2 3 3 3 1 3 1



10

20

30

Target

2014

2015


10

20

30

40

Target

2014

2015


10

20

30

Target

2014

2015

Mei Jun Jul Agust Sep Okt55 53 55 66 4218 27 17 20 1825 27 20 30 1710 6 8 6 2

2 0 4 5 16 3 5 5 40 0 0 0 02 2 2 0 10 0 0 1 00 0 0 0 00 0 1 o 0

1 13 1 1 3 1

Mei Jun Jul Agust Sep Okt

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%


46

86

62

8671

51 5063

50

75 81 75

5647

66 6271

41

0 0 0 0 0 0 0 0 0

6 5 2 3 3 3 1 3 1



20

40

60

80

100 8794

7468

55 53 5566

42

15 14 1320 18

2717 20 18

3123 25 28 25 27

2030

179 9

16 1810 6 8 6 24 6 3 1 2

0

4 5 1

P. Dalam

Bedah

Isolasi

Syaraf

Paru

jantung

Mei Jun Jul Agust Sep Okt100.00% 100.00% 100.00% 100.00% 100.00%

95.00% 96%(400/414) 97%(364/372) 96%(403/419) 91%(306/336)

100.00% 100.00% 100.00% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00% 0.00%


0,8% 0,8% 0,8% 1,4% 0.00%

3,3% 0.00% 0,8% 2,1% 2,1%


88.33% 93,3%


94,6% 50% 68,4% 64,58%

100% 98% 100% 100%

1,9% 2,5% 2,14% 2,8% 3,2%0.00 0.00 0.00 0.00 0.000.00 0.00 0.00 0.00 0.00

0% 0.00 0.00 0.00 0.000.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.00


99.17% 99,1% 99,1% 100.00% 100.00%

100.00% 100.00% 100.00% 100.00% 100.00%

75.00%(24/32) 93%(30/32) 100%(24/24) 91%(42/44) 100.00%

96.60% 100.00% 99,1% 98.00% 100.00%

100.00% 100.00% 100.00% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00% 0.00%

Evaluasi:pemakaian SBAR belum mencapai target dikarenakan lemahnya read back

Mei Jun Jul Agust Sep Okt24 18 31 28 20 031 30 31 31 30 0

77.42 60.00 100.00 90.32 66.67 #DIV/0!


85.71 100.00 100.00 100.00 100.00 #DIV/0!

Kepatuhan perawat melakukan identifikasi pasien sebelum melakukan tindakan bagi obat.Mei Jun Jul Agust Sep Okt

25 29 41 57 47 040 36 41 57 47 0

60.00 80.00 100.00 100.00 100.00 #DIV/0!


34.00 50.00 66.67 43.14 50.00 #DIV/0!



20.00%

40.00%

60.00%

80.00%

100.00%

120.00%



Pelaksanaan SBAR


Ketepatan tranfusi.

Pasien Jatuh.

34 48 36 33 30 073.00 66.67 77.78 78.79 100.00 #DIV/0!

Mei Jun Jul Agust Sep Okt270,268,850 259,487,837 263,205,428 236,624,654 268,038,296 274,544,080139,961,543 166,303,122 164,292,736 106,645,904 209,818,486 209,818,486221,792,820 299,125,018 146,774,168 184,775,920 191,655,209 174,904,214271,277,214 232,935,017 244,474,365 259,978,901 239,311,679


57,840,431 73,600,885 56,399,208 62,519,588 64,937,16719,100,770 445,000 8,283,702 11,313,919 10,368,23676,941,201 74,045,885 64,682,910 73,833,507 64,937,167 0


20,000,000

40,000,000

60,000,000

80,000,000

100,000,000

Rata2/Bln

Gaji

Operasional

Total


100,000,000

200,000,000

300,000,000

400,000,000

Target

2013

2014

2015


20,000,000

40,000,000

60,000,000

80,000,000

100,000,000

Rata2/Bln

Total


Nop Des49.6 44.253.4 40

Nop Des141 136

92 95126 125

Nop Des595 573361 343401 354


10203040506070

2013

2014

2015


20406080

100120140160180

Target

2013

2014

2015


100200300400500600700

Target

2013

2014

2015

Nop Des75 7264 65

Nop Des19 18

21 26

Nop Des9 98 7


100200300400500600700

Target

2013

2014

2015


20

40

60

80

Target

2014

2015


5

10

15

20

25

30

Target

2014

2015


10

20

30

Target

2014

2015

Nop Des23 2322 16

Nop Des14 1411 11

Nop Des


46

86

62

8671

51 5063

50

75 81 75

5647

66 6271

41

0 0 0 0 0 0 0 0 0

6 5 2 3 3 3 1 3 1



10

20

30

Target

2014

2015


10

20

30

40

Target

2014

2015


10

20

30

Target

2014

2015

Nop Des

Nop Des


46

86

62

8671

51 5063

50

75 81 75

5647

66 6271

41

0 0 0 0 0 0 0 0 0

6 5 2 3 3 3 1 3 1



20

40

60

80

100 8794

7468

55 53 5566

42

15 14 1320 18

2717 20 18

3123 25 28 25 27

2030

179 9

16 1810 6 8 6 24 6 3 1 2

0

4 5 1

P. Dalam

Bedah

Isolasi

Syaraf

Paru

jantung

Nop Des

Nop Des

Nop Des

Nop Des

Nop Des

Evaluasi:pemakaian SBAR belum mencapai target dikarenakan lemahnya read back

Nop Des0 00 0

#DIV/0! #DIV/0!

Nop Des0 00 0

#DIV/0! #DIV/0!

Nop Des0 00 0

#DIV/0! #DIV/0!

Nop Des0 00 0

#DIV/0! #DIV/0!

Nop Des0 0


20.00%

40.00%

60.00%

80.00%

100.00%

120.00%



Pelaksanaan SBAR


Ketepatan tranfusi.

Pasien Jatuh.

0 0#DIV/0! #DIV/0!

Nop Des281,607,502 271,570,007169,901,668 138,525,995271,164,774 192,529,175

Nop Des

0 0


20,000,000

40,000,000

60,000,000

80,000,000

100,000,000

Rata2/Bln

Gaji

Operasional

Total


100,000,000

200,000,000

300,000,000

400,000,000

Target

2013

2014

2015


20,000,000

40,000,000

60,000,000

80,000,000

100,000,000

Rata2/Bln

Total

PENINGKATAN MUTU UNIT / INSTALASI …KRISAN…No Indikator / Pengukuran hasil analisis

1 Pemantauan suhu penyimpanan obat 77,4%2 Ketepatan melakukan asesmen nyeri px post o 85,7%3 pemakaian APD 75.00% turun4 Pelaporan insiden 86.00% turun56789

PENINGKATAN MUTU UNIT / INSTALASI …KRISAN…penyebab masalah

kurang kesadaran personel terhadap pemantauan suhu penyimpanan obat

pembersihan badpan tanpa pakai apronperawat lupa melaporkan insiden

PENINGKATAN MUTU UNIT / INSTALASI …KRISAN…solusi

monevbekerja sama dgn PPImonevMonev

PENINGKATAN MUTU UNIT / INSTALASI …KRISAN…jadwal

junimaretmaretmaret

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