PEMERINTAH KABUPATEN SIGI RUMAH SAKIT UMUM DAERAH TORA BELO Alamat: jalan Trans Palu-Palolo kr 14 Sidera Kec. Sigi Biromaru Kode Pos 94364 a [AGREGASI DATA INDIKATOR PRIORITAS MUTU UNIT (IMP-UNIT) RSUD TORA BELO TAHUN 2023 Poti Waktu Tunggu Rawat Jalan autan Ten [Feb [Maret [ape mtet [unto Sent [Nae [Numerator as_| ava] 129 | aa] 7a] a] ass_|_448 |_a7 [capaian 7a_| 726 | Fort | oer | 67.28 | 75.29 _|-w232_| #333_| 8698] FONTOT | FONTOT | ADIT Rekam Medi Pengembalian rekam medis awat inap ke filing < 28 jam setelah pasien pulang faut Ton [fen _[ Maret [Apc Mei_[ Jun [a] Agu] Sept [Ot Nove [Nomerator a0_| 366 | a? | an] aay aaa | ant |__| [Benumerstor =e so0 | 540] sx] a3] es | a7 | 6 [capsian %) Tesi] 7320 | was | 70a | —as66 | esas | saps 3503 | 7703 | aDNOT | wOIW/Or | wOW/OT Intalas Gist Kepatuhan pemakalan APD petugas di bagian produksi makanan uaa Ten_[_feb_]_Maret_[__Apal_[ Mel] Juni] su] Agust] Sept] Oo] Nov ]Des [Numerator rE] cy FE] 7 a 7 7 9 a7 [Denumerstor 20] 15 7 7 a 7 a 39 a7 [Gapaian 6) 5.0000 | 100,00 | Too00| “700,00 | “60,05 -| sno | F00,00 | Tooce | OTE | wOIWTOT | wOWTOT Instalal Laundry Kejadian linen hilang. alan Taree arate ear [Numerator ar _| 272 | 2m | sas | a 2a | as [Denumerator ao _9a2_| 93] 2 | 930] 907 | |__| [Capaian 6) a7] 9784 | 3526 | 971 | 9698 | 471 | 0780 | 9693 | 9430 | abwior | wbW/OT | AOW/T5 Instatasl Farmasi Kepatuhan Penggunaan Formularium Nasional aun Jon [_feb [Maret [Apa [Mel tun [sul] Agust [Sept [om [Nov [Des [Numerator | 103 | ~_52 | 109107 | 105 | a03_|~_77 | 106 [oenumerator si_| 108 | sa 32 | 109 | 108 | 308 | 81 | 308, [capsian (%) 3630 | 9537 | 9630 | s8oe | 98 | 9722 | 9537 | 95,08 | 985 | aoiol | wow/ol | eoW/ol instalai Sanitash Kepatuhan Pelaksanaan Perilahan Limbah 83 flan. tan_[ feb | Maret] Ap [Mel] Jun [_sul Aquat [Sept | om [nov] ber [Numerator 10 1S FT 1 a 20) v7 20 20) [benumerator 2 2 25 26 2 25 25 25 26 [Capaian (%) 4000] 7143_| 7600 | 3335 | 6190 | 80.00 | 6538 | 60.00 | 7692 | abwor | wbW/Or | aDW/OT Laboratorium Waktu tunggu hasi pelayanan laboratorium, Bulan dan [ feb [Maree [Apa [mel [sunt [sul Aguse [Sept [om [nov oer [Numerator 29 | 29 28 25 73 2 2 40) 29 [oenumerator 23 | 29) 28 25 23 28 2 40 29 [capaian (%) 300,00 | 100,00 | 100,06 | 10000_| “700.00 | 100,00 | 19000 | 100.00 | 100.00 | abw/or | wbW/Or | aIV/OT Radiologt Pengulangan foto rontgen [Buian Jon] Feb [Maret [Apa Mel [Jon [su Agus Sept [oat Nov [bes [Numerator 0 3 1 1 0 1 1 2 1 [benumerator 261 | 208 | 250_| 17 | 267 | 230_| 186 | 298 [207 [capaian (%) jo [14a | o40 | 053 | 000 | 043 | 058 | 057 | 048 | sonjoi | wowjor | wonjor Instalasl Gawat Darurat Emergency Respon Tme <5 Menit faulan Jen_[ feb [Maret [Apa [Mel [Juni [sui Aquat [Sept [oa [Nov] oer [Numerator 2 | 2 30 2. 30 25 25 | 28 28 [benumerator 29 | 21 30 21 30 3, 25 28 28 [capaian (%) 7700.00 | 100,00 | 100,00 | 10000 | 700,00 | 100,00 | 10000 | 100,00 | 100.00 | sow/or | wow/or | wOW/or10 u 2 B 4 168 Kebidanan ejadian kematlan tbu arena persalinan. fulan dn] feb [Maret [Apel [Mei [suns [| Agust [Sept [om [Now [Des Numerator o 0 0 0 0 0 0 1 0 [Denumerator 5 a a 10 i 9 10 3 8 [capaion (%) 300000000 [ano [000 [0.00 | a00 [7.65 [0.00 | -wowor | wow7or | eow7or ‘Ruanganicu Kejadian dekubitus Bulan Ta] _feb | Maret | ape] _Mel_[ sons] vol] Agust [Sept [om [Now [Des [Numerator ° 0 0 ° 0 0 1 © 0. [Denumerator 2 20 ar 25 19 3 26 2 2 [capaton 8) 09 | 900 | 0.00 | ano | 0.90 | 0.00 [38s | 000 | 0.00 | wowor | wpiw7or | wOW7Or {nstalas! Bedah Sentral Penundaan Operas! Elekt [Bulan fan] feb [Maret Api Mel[ sunt] aa] Aquat [Sept [om [Now [Des Numerator 1 2 1 2 0 5. 4 z 1 [Denumerator a | 27 | 93 sr | 115_[ 100 | _107_[ 368 [copaian %) 3 2 308220 | 000 | 435 | 400_| 196 | as9_| wowor | wpw7or | wow/or ‘Central Sterile Supply Departemen (CSSD) \Kesalahan Pads Protes Packing dan LabelingAlat Str Bulan tn | feb [| Maret_[ Apr Taal | Agust [sept [om [Nov [Des [Numerator 0 0 0 0 0 0 0 0 [Denumerator i2_| s00_| e05_| a79| sos_| ser_| s93 | can _| 1250 [eapaion (5 ‘900 | 9.00 [090 | a0 | 0.00 | 0.00 | a0 | 000 | 000 | wnwjor | wowyer | wow7or Ruangan NICU ‘Kemampuan menangani BBLR <2500 gr Bulan Jn [ feb | Maret | Apil [Mel [sun] ul] Aust [Sept [om [Wow [Des [Numerator 3 25 22 16 20 24 24 0 24 [Denumerator 6 23 26 8 25 26 25 Fy 28 [capaian (3) wi25_| a5 | #462 | ano | 80.00 | 92,31 | 9600 | a2.61 | 8571 | wbvio1 | wbI/or | ADIT16 1s ‘Ruangan Meranti “Angkainfeksi Luka Operas! Bersih (LO) [Bulan in| feb | Maret | Apel [Mel [sunt] ull] Agust [Sept [om [Now [Des INumerator 4 0. 0 D 0 3 0 1 0. [Denumerator ms _|y07 | an_| a Fa eC 7 38 [capaian (6) 320 | 000 | 000 | oc0 [000 [2.13 | 00 | 15 | 0.00 | -apwor | owror | sow7or ‘Ruangan Ebon! \Kepatuhan pelaksanaan Site marking pada pasien yang akan dlakukan tindakan operasi vlan tn [ feb [ Maret [Apel [ Mel_[ Juni [voll [Aquat [Sept] om [Now [Den Numerator 2 30, © 30 a4 29 2 20 7 [Denumerator 2 20, 6 10 1 23 3 20 7 [capaion (8) 300,00 _| 100,00 | 100,00 | 100,60 | 100,00] 100,00 | 169,60 | 100,00 | 100,00 | wBwor | wOW/Or | #OIV/OT Ruangan Akasa ‘Angka kejadian pasienjatuh vlan tn] feb [Maret [Apel [Mel [sunt [not Aguat Sept [om now ber Numerator 0 1 0 0 0 0 0 0. 0. [Denumerator 3 2. 6a a9 [uso es [a0 [capaian (6) 00 | 1.67 | 0.00 | e060 | 000 | 0.00 | 00 | 000 | a.00_| abot | wowioi | eow7oi ‘Ruangan Cemara 1 ‘etidak patuhan pendokumentasian assesmen nyerl secara kontinyu di status pasion foun yn] Fed | marer [ages [met [suns [ao agus [Sept [om now bes Numerator z 0 0 1 0 0 0 oO °. [Denumerator tor} mna_[ 37] 13827 a0 [5138 [a [capaion 3) 1a7_| 900 [000 | a7a_| 000 [000 | a00 | 000 | 0.00_| aow7or | wowjei | eow7or ‘Ruangan Mahon! ‘Propors! pasien TB paru terkontaminasi bakteriologsdiantaraterduga TB Bulan fn [ feb [Maret [apr [Mel [juni wall] Agust [Sept [om [Now [Des Numerator 7 20. i 7 19 2 1 5 3 [Denumerator © 2 2 10 19 26 13 20 10 [capaian 37s0_| #333 | 91.67 | 7000 | 100.00 | e462 | e462 | 75.00 | 3000 | ovo | woot | sowv/or20 Ruangan Cemara2 Kepatuhan Identfikasi Pasion Bulan tn] fFeb | Maret | Apa [Mel [sons] wo] Agust Sept [om [Wow [Des Numerator 2 39 19 15 20 15 14 14 a [Denumerator 2 19 39 35 20 a5 14 14 18 [capaion (6) 700,00 | 100,00 | 100,00 | 100.00 | 100,00 | 100,00 | 100,00 | 100,00 | 100,00 | wpvror | wowor | woWv/or Sih, 9 Oktober 2023, Ketua Komite Medlk SUD Tora Belo dr, Adety SilvanRUMAH SAKIT UMUM DAERAH TORA BELO Alomat: PEMERINTAH KABUPATEN SIGL S falan Trans Palu-Palolo km 14 Sidera Kee Sigh Biromaru Kode Pos 94364 [AGREGASI DATA INDIKATOR PRIORITAS MUTU UNIT (IMP-UNIT) RSUD TORA BELO TAHUN 2023 1 Pott Wold Tung Rawat san stestuney Raman Waktu TungguRawatJlonTahun 2023 a a 10000 fex——[“7176—| 20 2000 Warae [703 [0 . = Pt —| ee] ao 3 ae fie [e728 [0 & Sm fon [7525 | ao ao = Ey oe = fot —| “a3 | “a 2 bm a CE 200 =o Set —[-eos8— [60 a8 for 0 fa OC Nov 30 Capaionte)| 79.1 | 75,26 | 704% 6724 | 75,29 | 82,32 | 83,33 | 8658 i 5 Esoateteteteletete ets te2 Rekam Medik ‘Pengembalian rekam medi rawat nap ke filing <24 jam setelah pasien pulang ‘Bulan_[_Capaian_| Standar | Un 7401 [80 Pengembalian Rekam Medis <2x24 jamTahun 2023, Feb 73,20_| 20. IMaret_—| 81,85 | 20. [ape 70.21 | 80. Met 20) fru 20) fur 50) [agust 35,03_| 80 (Seer 77.03_| #0. [oxe 0 Now #0 ew. a ‘ust | Sept | OF 0 3 Intalasi ial {20D petugas dl bagian prodiuks! makanan a Kepatuhan Pemakaian AP Thun 2023 100, 1200 0 iar 1000 100. g me 100 2 18 i 090 100. 090 lent | 100,00 | roo ‘i fae 100 [Now 100) ie ont | Nov be i Se in rales mcitaeal | standart) 100 | 165 | 1694 Instalas! Laundry Keladan nen tang ‘Bulan_[_Capaian | Standar Kejadian Linen Hilang Tahun 2023 ban o731 [100 sgn: feo [784 “ion {030 fuaret [25.26] “i00] Ed tee] | 3 Be x zi fen —| “3874 —[ “io 5 ue [it 37,80 | 100 & 340 F : lage | “3553 | 00 Se La Best —] “3830 00] So Pa fox 700 tan] Feb Mort] | Mer oa [ne | be er Fc [=conaunna|anan |a7ee| 6 | ar s638 | is. im [peeStandar(%) | 100 100 | 100 | 100 100 | 100 | 100 5 instal Fara Kepatuhan Penggunaan Formularium Nasio ‘ulan_]_Capaian_J Standar lan | 9630 [80 ‘Kepatuhan Penggunaan Formularium Nasional Tahun 2023 Feb 3537 | 60 ange [Maret 9630_| 80 [apa 30 ae Mer 80 i 2000 bunt 30 bu 30 5 ae fagust 30 a) Seat 20, 2080 fox 0 Nov 20 ne Thai | al | Aeuit Des. #0 [== capaian(*|| 96,30 | 95,37 | 96,30 | 98,04 | 98,00 | 97,22 ai6 Instalasi Sanitasi ‘Kepatuhan PelaksanaanPemilahan Limbah 83 [Jan 40,00, 100 Kepatuhen Pelaksanaan Pemilahan Limbah 83 Tahun 2023 fe — [ee [ wie a i rae ler 6150_| 100} a Feat —[- soar fe bs a ko 00) dunt ‘gust | Sept be rc i |e | 400 |e ico | 16 | 1 | | 7 aterm Mia teggalpinann brn [peat | Spee [San Wats Trgn st Peaaron Tan 203 i 1010 fazer [nom [ [Apeil 100,00 100" tow hae [af g we — i oe [et — [en [—tar i [Agust 100,00 100 & 40K Esse — [|r 20 be 7 [Now 100, pm Feb | Maret | April bar a sea ic | 1 | ioSian Pengulanan Foto Rotgen Tahun 2023 3 5 5 s g s g 3] 5 5] é — S| O89 [Tan | Feb [Maret] Apri Wel | tun [ ul Sept | Om | Wow | bee | == topaanGal| an | see | oa | 059 | 000 | 043 | ose oat So} | seam] sts tstststs)/sts]~sls[s te 9 Instalas! Gawat Darurat Emergency Respon Tes Menit Buon [capstan stondar] Emergency Response Time Tohun 2023, ban: 709,00 —|__100 a Feo 300,00] “100 [Maret 100,00 100, as aC 3 mm ier 300,00] —i00 2 fiun "109,00 | 100] é ‘ohn [Jul 100,00 100, 2 4 [agust —| 100,00] —i00 sa [sent | 100,00 —i00 en [owt 100, “Agust] Sert | OF er | [= capaan | 10090 10.03 1000 10,0 1004 10,00! 00.09] 10000] 000) bes 700 a10 1GB Kebidanan Keladian kematian Ibu arena persalinan, Tulan_[-Capaian | Standar i aa Kejadian Kematian (bv karena Persainan Tahun 2023 eb 7300 [0 0 fMaret [000 —o 200 fae ea —| 9 io ter 300 —[ 0 2 6m Tl 300 | —o. £500 Tor 300] er JAgust 7.65, o é an [Sent 0.00 o = [Okt o a oo New 7 Tan | Feb [Maret] Re | Wel [To bes 2 Stmaanthd| 000 | 900 | e00 | 000 | 000 | oo [—sandats)] 0 | 0 |e | 0 | o | o 11 Ruangan cy jalan dekubitus Guan | Capatan [Sonar Kejadian Dekubitus Tahun 2023 an 300 [15 Fe a0 [ 415 [Maret —[ 000 [35 pe oo [ 4s z er oo [ 45 & har oor] ‘ bull 385 1S e jAgust_ 0,00 1s ae [Sept 0,00 1s a [Okt 1s (000 [Jan | Feb [Maret] Apri] Mei ] Juni | Juli | Agust | Sept | Om | Now | Des [Nov 15, [m= Capaian(%)| 0,00 | 0,00 | 0,00 | 0,00 | 0,00 | 0.00 0.00 [Des 1S [standart] as [25 [15 | 45 | a5 | 4s as | as | as [1s12 Instalas Bedah Sentral Penundaan OperasiElektit Sar ee | Saar Perundoan pra Ek Than 2023 feet [Maret 1,08 s so fers i & fs : ge fe : £ oe Fase : a bse : = fox 5 aS ‘uli [Agust] Sept | OW | Now | Des ie z —E iat Seta [Des s [sonar s 1s] s{stsi{si/si/si[s|sis]s 13 Central Sterile Supply Departemen (CSS0) ‘Kesalahan Pada Proses Packing dan Labeling Alat Steril ulan_[_Capaian J Standar kesalahan pada Proses Packing dan Labelling Alat Steril Tahun 2023, lan 000 | 0 Feo 000] 0 | 190 Maret | 000 0 aso fas 200] 0 949 [Mei 0,00 o a 2 fun 000] 0 £ x = oo bas too Boo fagust —[ 0 —[ —o € a0 sent 2.00 | 0 930 lor o oe Now ° Tan [ feb [woret| aor Met [ wont [ nll [Agus | Sem | Ow | wow | Om [Des ° = cspvantHi| co | 600 | 000 | 0.00 | 000 | 0.00 | 000 | 000 | 0.00 [—surasr) o | e [of oloelolelolojlojolo14 Ruangan NICU 15 Kemampuan menangal ‘Bulan_[_copaian lian 81,25 Kernampuan Menangani BBLR Tahun 2023 Fem 36,00 Iaaret | aa62 [Ape er hi bus fagust | ~a2.68 Sept 85,71 fox Nov = (Feb [Maret] Aprit | 1 dull_| Agus | Sept | Ok | Nov Des Copan i 81.25 | 26.00 | 38,62 00 | 82,33 | 8600 | #261 | 85.71 seandart3) 0 | #0 wo | a | oo) a0 | oo | a | oO Auangan Merantl Angka Infeks! Luka Operas! Bersih (ILO) ee om ie Angka Infeksi Luka Operasi Bersih (ILO)Tahun 2023 Feb 3,00 [a5 aso Maret 0,00] 0.15 300 aT 0,00 | 0.15 0 rar 0,00 | 015 i juni 213, 0,15 = ae hall 0.00 |_ os 2 1s jAgust 115, 0.15 é 100, Seat 000 | 0.15 030 fox O15 — EB Nov’ 0.15, O98 “Fe [aon | Mel [ tual | [bes 0,15 [= Capalan ti] 3,20 | 000 | 0,00 | 000 | 0,00 | 2.13 | a00 | 1:5 | 0.00 [—stondar(si] 05 | 935 | 05 | 015 | 015 | 035 | 045 | os | 0.3536 Ruangan Ebon! naansite marking pada pasien yang aan dllakukan tindakan operas! v Sar | apn | Sta beet rao Xepatuhan Peaksaran te Marling Thun 2023 eo iia iar 00 tan [Apel 100,00 100, = — cs gome Fee —t a.m} 0 (Tul 100,00. 100" ge [agust | 100.00] —r00 E1080 Fee — [ies —t08 fe is far it ba its puangan lai Se ‘AngkaKeladian Pasi Jatuh Tahun 2023 bet too to _— a oC iter —[ ao [Apel 0,00 o g icon —o a [Jun 6,00 o § ull 0,00 o é [Agust. 0,00, oO fest —[-es0—| 3 fo fer + ea [Des o [—Standar (9) c o olelolfo o ofoljo 048 Ruangan Ceara Ketidak patuhan pendohumentasian assesmen nyeri secara Kontinyu dl status paslen Bulan | Capalan_[ Standar ] fan af Ketidakpatuhan Pendokumentasian Assesment Nyerl Tahun 2023 Feo 000 | 0 200 IMaret—| 0.000. ua [Ana 078 0 1 2 oc 0.00 | 0 42 bun 0.00 | 0 g is [iu 0,00 0 i 040 agus 0.00] __0 240 seat a ou a0 fore = oa Now ° [Des a | mm Capaian (| standart) Ruangan Mahon! Proporsipaslen TB paruterkontaminasl bakteiologlsdiantaraterduga TB Bulan_[ Capaian_[ Standar | ba a im] ProporsiPasien TB Paru Terlontaminasi Bakteriologis Tahun 2023 Fem 3333 | 100] 22060 IMaret_——Si.67 | —a00 i [Apa 79,00 | _100- ar 700,00 | 100 g 200 bur een —| 100 | Sea bu 24,62 _| 100 g [agwst | —75,00__| 100 eg 10 [seat 29,00 | 1007 2080 fore i00—| 00 Nav 00 Now | oes be oe [—Sstanaar |20 Ruangan Cemara2 Kepatuhan Identifikas! Pasien ‘Bulan | Capaian_ | Standar (an 100,00 |__100 Feo 100,00 | 100 IMaret_—| 100,00_| 100. [Aon 300,00_| 100 Mer 700,00—|—100—} liu "100,00 | 100, ft 300,00—| —i00- [agust_—_[100,00_| 100 Iseot 100,00 | 100, foe 100- Now. 300 [Des 100- 12000 10900 2080 00 4000 2080 0 Persentase Kepatuhan Indertifikasi Pasien Tahun 2023, me Canaan |S standaei| [aut 100.0) 109, 100 | 308 oa | 300 Sigi,9 Oktober 2023, Ketua Komite Mutu SUD Tora Belo Ae dr Adetya Silvan