9.1.1. TENAGA TENAGA KLINIS KLINIS BERPERAN AKTIF AKTIF DALAM PROSES PROSES PENINGKAT PENINGKATAN MUTU LAYANAN KLINIS DAN UPAYA KESELAMATAN PASIEN DAFTAR DOKUMEN BAB IX PENINGKATAN MUTU KLINIS DAN KESELAMATAN PASIEN (PMKP) TANGGUNG JAWAB JAWAB TENAGA TEN AGA KLINIS
STANDAR 9.1. 9.1.
KRITERIA
Peren erenca cana naan an,, 9.1.1. !n"#!r"n$, %an Tena$a +'"n" er/eran a+#"0 %a'a e&a'a" # /r!e /en"n$+a#an # 'a*anan 'a*anan +'"n" +'"n" %an /a*a +ee'aa#an /a"en %an +ee'aa#an P!+!+ /"+"ran ena%" #an$$n$ a-a ⁻ U/a*a /en"n$+a#an # 'a*anan +'"n", %an +ee'aa#an /a"en #ena$a *an$ ena%" #an$$n$ a-a e'r2 e+era %" #ena$a +'"n" *an$ eer"+an /e'a*anan +'"n" a2an /a"en. ⁻ Tena$a +'"n" -a" er/eran a+#"0 'a" %ar" "%en#"0"+a" /eraa'a2an # 'a*anan +'"n", e'a++an ana'"", en*n rencana /era"+an, e'a+ana+an, %an en"n%a+'an#". ⁻ I%en#"0"+a" /eraa'a2an # 'a*anan +'"n", /!#en" #era%"n*a r""+! %"'a++an %en$an en$$na+an "n%"+a#!r3"n%"+a#!r /e'a*anan +'"n" *an$ %"#e#a/+an !'e2 P+ea %en$an acan *an$ e'a. ⁻ U/a*a +ee'aa#an /a"en %"'a++an n#+ ence$a2 #era%"n*a (KTD), *a"# ce%era a#a 2a"' *an$ #"%a+ ea" %en$an 2ara/an, 2ara/an, *an$ #era%" #era%" +an +arena +!n%"" /a"en #e#a/" !'e2 +arena /enan$anan +'"n". Penan$anan +'"n" *an$ #"%a+ ea" +a%an$ #"%a+ en"'+an ce%era, a+a +ea%"#an "n" %"e# %en$an Kea%"an T"%a+ 4e%era (KT4).
⁻
ELEMEN
DOKUMEN YANG DISIAPKAN
9.1.1.1. ⁻ SK #en#an$ +e-a"an #ena$a +'"n" %a'a /en"n$+a#an # +'"n" %an +ee'aa#an /a"en. ⁻ La/"ran SK T" M# K'"n" 5 T/!+"
9.1.1.6. ⁻ "n%"+a#!r # +'"n" %" P+ea enr# +r"#er"a P+ea er%aar+an +e#ere%"aan er %a*a *an$ #ere%"a %an #an%ar /enca/a"an
9.1.1.7. ⁻ 8a"' /en$/'an %a#a, ⁻ +#" ana'"", ⁻ /e'a/!ran er+a'a "n%"+a#!r # +'"n"
9.1.1.. ⁻ B+#" !n"#!r"n$ 'a*anan +'"n", ⁻ +#" e&a'a", ⁻ +#" ana'"", ⁻ +#" #"n%a+ 'an#
9.1.1.:. ⁻ Pe'a+anaan "%en#"0"+a", ⁻ %!+en#a" %an /e'a/!ran KTD, KP4, KN4
9.1.1.;. ⁻ SK SOP /enan$anan KTD, KT4, KP4, KN4. ⁻ SOP /enan$anan KTD, KT4, KP4, KN4.
9.1.1.<.
⁻ B+#" ana'"", /enan$anan KTD, KT4, KP4, KN4. ⁻ #"n%a+ 'an# /enan$anan KTD, KT4, KP4, KN4
STANDAR 9.1. 9.1.
KRITERIA
Peren erenca cana naan an,, ⁻ (KN4) #era%" "+a 2a/"r aa !n"#!r"n$, %an %"'a++an +ea'a2an %a'a e&a'a" # /enan$anan +"n", #e#a/" 'a*anan +'"n" +ea'a2an #ere# #"%a+ a%" %an %"'a++an. ⁻ Kea%aan3+ea%aan #er#en# %a'a +ee'aa#an /e'a*anan +'"n", "a'n*a #e/a# ena%" #"%r *an$ #"%a+ %"'en$+a/" #an$$n$ a-a %en$an /en$aan, 'an#a" *an$ #ena$a *an$ '"c"n *an$ er""+! #era%" /a"en e+era %" #era#2, er/!#en" en"'+an /e'a*anan +'"n" ce%era. Kea%aan "n" %"e# (KP4)
ELEMEN
DOKUMEN YANG DISIAPKAN
9.1.1.=. ⁻ Pan%an Manaeen r""+! +'"n", ⁻ +#" "%en#"0"+a" r""+!, ⁻ ana'"", %an #"n%a+ 'an# r""+! /e'a*anan +'"n" ("n"a' %"'a++an FMEA n#+ a# +a)
9.1.1.9. ⁻ B+#" ana'"" %an /a*a e"n"a'+an r""+!
9.1.1.1>. ⁻ Keran$+a acan, Perencanaan Pr!$ra +ee'aa#an /a"en, ⁻ B+#" Pe'a+anaan, ⁻ B+#" e&a'a", %an #"n%a+ 'an#
DOKUMEN NO
?ENIS DOKUMEN LENG KAP 9.1.1
⁻ SK #en#an$ +e-a"an #ena$a +'"n" %a'a /en"n$+a#an # 1
+'"n" %an +ee'aa#an /a"en. (La/"ran SK T" M# K'"n" 5 T/!+")
⁻ In%"+a#!r # +'"n" %" P+ea ( er%aar+an 6
+e#ere%"aan er %a*a *an$ #ere%"a %an #an%ar /enca/a"an)
7 ⁻ 8a"' /en$/'an %a#a, ⁻ Pe'a/!ran er+a'a "n%"+a#!r # +'"n" : ⁻ B+#" ana'"" "n%"+a#!r *an$ %"e&a'a" ; ⁻ B+#" !n"#!r"n$ # 'a*anan +'"n", <
⁻ B+#" e&a'a", +#" ana'"", +#" #"n%a+ 'an# 2a"'
!n"#!r"n$ %an /en"'a"an # +'"n" ⁻ B+#" "%en#"0"+a", %!+en#a" %an /e'a/!ran KTD, KP4, = KN4 9 ⁻ SK SOP /enan$anan KTD, KT4, KP4, KN4. 1> ⁻ SOP /enan$anan KTD, KT4, KP4, KN4. 11 ⁻ B+#" ana'"", /enan$anan KTD, KT4, KP4, KN4. 16 ⁻ #"n%a+ 'an# /enan$anan KTD, KT4, KP4, KN4 17 ⁻ B+#" "%en#"0"+a" r""+! /e'a*anan +'"n" 1 ⁻ Ana'"", %an #"n%a+ 'an# r""+! /e'a*anan +'"n" ("n"a'
IMPLEMENTASI
ADA TIDAK
TIDAK
SUDA8
BELUM
%"'a++an 0ea n#+ a# +a) 1: ⁻ B+#" ana'"" %an /a*a e"n"a'+an r""+! 1;
⁻ Keran$+a acan, Perencanaan Pr!$ra +ee'aa#an /a"en,
1< ⁻ B+#" Pe'a+anaan, e&a'a", %an #"n%a+ 'an#