PROGRAM PENINGKAT PENINGKATAN MUTU M UTU UNIT KAMAR BERSALIN DAN RUANG BAYI
RUMAH SAKIT UMUM KARYA DHARMA HUSADA
JALAN YUDISTIRA NO 7 SINGARAJA BALI
2017
2
DAFTAR ISI
DAFTAR ISI............................................................................................................................. i 1. PENDAHULUAN ............................................................................................................... 1 2. LATAR BELAKANG ........................................................................................................ 2 3. TUJUAN ..............................................................................................................................3 a. Umum.............................................................................................................................. 3 b. Khusus............................................................................................................................. 3 4. KEGIATAN POKOK DAN RINCIAN KEGIATAN............................................................3 a. K!"a#a$ P%&%& ................................................................................................................ 3 b. R"$'"a$ K!"a#a$.............................................................................................................. 3 (. CARA )ELAKSANAKAN KEGIATAN ............................................................................4 a. Fas P*s"a+a$..................................................................................................................4 b. Fas P,a&sa$aa$..............................................................................................................4 '. Fas E-a,uas" ....................................................................................................................4 . SASARAN...........................................................................................................................4 a. P$"$!&a#a$ &%m+#$s" +#u!as ...................................................................................... 4 b. P$"$!&a#a$ +$'a+a"a$ "$/"'a#%* mu#u u$"# ....................................................................4 '. P$"$!&a#a$ +$'a+a"a$ "$/"&a#%* mu#u RS .....................................................................5 /. Pm$uha$ sa*a$a /a$ +*asa*a$a ssua" s#a$/a* PONEK ................................................5 0. JADAL PELAKSANAAN KEGIATAN ........................................................................... 5 . EALUASI PELAKSANAAN KEGIATAN DAN PELAPORAN ......................................6 . PENCATATAN5 PELAPORAN DAN EALUASI KEGIATAN .........................................6
i
1. PENDAHULUAN
P,a6a$a$ /"&ama* b*sa,"$ /a$ *ua$! ba6" a/a,ah sa,ah sa#u 7a&#%* 6a$! sa$!a# +$#"$! /a,am m$u$8a$! +,a6a$a$ /" sua#u Rumah Sa&"#. Da$ sa,ah sa#u 7a&#%* 6a$! 8u!a +$#"$! u$#u& m$/u&u$! ha, #*sbu# a/a,ah "m+,m$#as" +*%!*am +a#"$# sa7#6 6a$! 8u!a s,a*as /$!a$ -"s" RSU Ka*6a Dha*ma Husa/a. B"/a$ /"#u$#u# u$#u& m$"$!&a#&a$ &mam+ua$$6a /a,am mmb*"&a$ asuha$
&b"/a$a$ 6a$! %+#"ma,5 m,a,u" +$"$!&a#a$
SD) /$!a$ mmb*"&a$ +,a#"ha$ PONEK ba"& I$#*$a, mau+u$ E&s#*$a, U$"# Kama* B*sa,"$ /a$ *ua$! ba6" /"#u$#u# a/a$6a sua#u +,a6a$a$ &b"/a$a$ 6a$! +*"ma5 ba"& /a*" s!" sumb* /a6a ma$us"a5 sa*a$a /a$ +*asa*a$a 6a$! /"s/"a&a$. Sh"$!!a /a+a# mmb*"&a$ +,a6a$a$ 6a$! b*mu#u &+a/a +as"$. Dua /"a$#a*a #u8ua$ #*sbu# mm+u$6a" sasa*a$ /a$ "$/"&a#%* 6a$! #*&a"# /$!a$ &sha#a$ "bu5 ba6" /a$ a$a& s*#a m$"$!&a#&a$ +,a6a$a$ I)D 9I$"s"as" )$6usu" D"$" +a/a ba6" +a/a +*sa,"$a$ $%*ma, mau+u$ S&s"% 6a$! b*#u8ua$ u$#u& : ; P$u*u$a$ A$!&a Kma#"a$ Ibu 9AKI< /a*" 4=>1== === 9SKDI /a$ SKRT 1=< m$8a/" 1=2>1== === +a/a #ahu$ 2=1( /a$. ; A$!&a Kma#"a$ Ba6" 9AKB< /a*" >1=== &,ah"*a$ h"/u+ 9SKDI /a$ SKRT< 1=< m$8a/" 23>1=== &,ah"*a$ h"/u+ +a/a #ahu$ 2=1(. P,a6a$a$ %bs##*" /a$ $%$a#a, *!"%$a, m*u+a&a$ u+a6a +$6/"aa$ +,a6a$a$ ba!" "bu /a$ ba6" ba*u ,ah"* s'a*a #*+a/u /a,am b$#u& Pelayanan Obstetri Neonatal Emergensi Komprehensif PONEK! /" Rumah
Sa&"#.
1
2. LATAR BELAKANG
U$#u& m$"$!&a#&a$ &?a,"#as +,a6a$a$/a$ &+uasa$ +,a$!!a$ ma&a /"+*,u&a$ #$a!a 6a$! +*%7ss"%$a, /a$ 7as","#as 6a$! mma/a" s*#a &%m"#m$ /a*" s,u*uh s#a7 /"u$"# &ama* b*sa,"$ /a$ *ua$! ba6" u$#u& s,a,u m$"$!&a#&a$ &?a,"#as +,a6a$a$ /a$ m,a$8u#&a$ P*%!*am &*8a 6a$! b,um /"'a+a" +a/a #ahu$ 2=10. D"ma$a P*%!*am #*sbu# sa$!a# +$#"$! u$#u& /",a&sa$a&a$ &a*$a m*u+a&a$ s#a$/a* m"$"ma, +,a6a$a$ /"Rumah Sa&"#. Da,am *a$!&a m$!u*a$!" a$!&a &ma#"a$ Ibu /a$ Ba6" ma&a RSU Ka*6a Dha*ma Husa/a b*u+a6a : a. )$"$!&a#&a$ &?a,"#as +,a6a$a$ m*!$'6 %bs##*" /a$ $%$a#a, b. ),a&u&a$ #a#a &,%,a 6a$! ba"& #*&a"# &,a$!su$!a$ h"/u+ "bu /a$ ba6" /$!a$ m,a&u&a$ ANC b*7%&us '. )m+*&ua# s6s#m *u8u&a$ #"mba, ba,"& /. )$"$!&a#&a$ 7&#"7"#as /a$ 7s"$s" &!a?a#/a*u*a#a$
"bu
/a$
ba6"
/$!a$
/a,am
+,a6a$a$
mma&s"ma,&a$
/a$
m,a&u&a$ *-"s" s#a$/a* /a$ +*%s/u* ssua" /$!a$ +&mba$!a$ ",mu &/%&#*a$ P$6bab &ma#"a$
+a/a masa P*$a#a,>N%$a#a, +a/a umum$6a
b*&a"#a$ /$!a$ &sha#a$ "bu s,ama &ham",a$5 &sha#a$ 8a$"$ s,ama /"/a,am &a$/u$!a$ /a$ +*%ss +*#%,%$!a$ +*sa,"a$a$ 6a$! b*masa,ah5%,h &a*$a "#u +*,u a/a$6a s#*a#!" u$#u& m$u*u$&a$ a$!&a &ma#"a$ >&sa&"#a$ ma#*$a, /a$ +*"$a#a,. U$#u& m$u$8a$! +$"$!&a#a$ mu#u +,a6a$a$5 U$"# Kama* B*sa,"$ /a$ *ua$! ba6" mma$/a$! +*,u a/a$6a +*%!*am &*8a u$"# 6a$! a&a$ m$8a/" &*a$!&a a'ua$ /a,am m,a&sa$a&a$ u+a6a@u+a6a u$#u& m$"$!&a#&a$ mu#u +,a6a$a$. ". TUJUAN
2
a. Umum
1. T*,a&sa$a$6a +,a6a$a$ 6a$! b*&ua,"#as 2. T*,a&sa$a$6a P*%!*am K*8a 6a$! b*mu#u /a,am mmb*"&a$ +,a6a$a$
&b"/a$a$
/$!a$
mmb*"&a$
&ama$a$
/a$
&$6ama$$ &+a/a +as"$ /"&ama* b*sa,"$. b. Khusus
1. )$"$!&a#&a$ &%m+#$s" s#a7 /"u$"# &ama* b*sa,"$ /a$ *ua$! ba6" /$!a$
+*&mba$!a$ ",mu 6a$! #*&"$" m,a,u" +,a#"ha$
I$#*$a, /a$ &s#*$a,. 2. T*s,$!!a*a$6a *s+%$ #"m /a$ #*'a+a"$6a I$/"&a#%* mu#u /"u$"# Kama* b*sa,"$ /a$ *ua$! ba6" 3. )$6"a+&a$ *ua$!a$ /a$ #m+a# b*sa,"$ &usus u$#u& m$8a!a +*"-as" +as"$
#. KEGIATAN POKOK DAN RIN$IAN KEGIATAN
a. Pm","ha$ "$/"'a#%* )u#u
T"/a& a/a a$!&a &8a/"a$ +*/a*aha$ /a,am +*sa,"$a$ T"/a& a/a a$!&a &#*,amba#a$ SC '6#% T"/a& a/a &8a/"a$ ba6" #*#u&a* Smua "bu 6a$! m,ah"*&a$ s+%$#a$ /a$ SC5 ba6" m$/a+a#&a$
I)D Smua "bu ba6">&,ua*!a ba6" m$/a+a#&a$ /u&as" #$#a$! ASI
E&s,us"7 Smua ba6" +*ma#u* ba6"$6a m$/a+a#&a$ +*a?a#a$ m#%/
&a$!!u*u b. P$!a/aa$ 7as","#as5 sa*a$a /a$ +*a,a#a$ m/"s
Pm,"ha*aa$ Pm,"ha*aa$ /a$ +*a?a#a$ a,a# m/"s /" Kama* b*sa,"$ /a$ Rua$! ba6" m$!a'u /a*" -$/%* 6a$! /",a&u&a$ s'a*a b*&a,a
3
s#"a+ #ahu$ a#au #"a+ ha*" +a/a ?a&#u s*ah #*"ma %+*a$ S#a7 &
S#a7 b*"&u#$6a. Ka,"b*as" A,a# Smua P*a,a#a$ )/"s Kama* B*sa,"$ /a$ Rua$! Ba6" /" Rumah Sa&"# Ka*6a Dha*ma Husa/a /"&a,"b*as" s#"a+ 1 #ahu$ s&a," %,h
BPFK Su*aba6a . P$!a$#"a$ a#au +$ambaha$ S#"a+ a/a +$!a$#"a$ a#au +$ambaha$ a,a# &+a,a u$"# Kama* B*sa,"$ /a$ Rua$! Ba6" ha*us mmbua# +*$'a$aa$ +$!a/aa$ a,a# m/"s /a$ $%$ m/"s /a$ 8u!a bu/!# a$!!a*a$ & #ahu$ b*"&u#$6a ssua" /$!a$ s+s"7"&as" a,a# /a$ /",a+%*&a$ & ass. su+*-"s%* *a?a# &husus .
'. P*%!*am +,a#"ha$ &%m+#$s" b"/a$ &ama* b*sa,"$ /a$ *ua$! ba6" /. P*%!*am P,a#"ha$ PONEK . P*%!*am P,a#"ha$ ma$a!m$# "$#$s"7 7. P*%!*am P,a#"ha$ ma$a!m$# Ba$!sa, !. P*%!*am P,a#"ha$ Rsus"#as" Ba6" h. P*%!*am P,a#"ha$@P,a#"ha$ ,a"$ 6a$! m$!a'u +a/a u+/a# +*a?a#a$ NICU /a$ ba6" sha#
%. $ARA MELAKSANAKAN KEGIATAN a. Fase Persiapan
1. )$!a8u&a$ /a7#a* $ama@$ama u$#u& m$!"&u#"
+,a#"ha$ ba"&
"$#*$a, mau+u$ &s#*$a, 2. S%s"a,"sas" +*%!*am +$"$!&a#a$ &ua,"#as +,a6a$a$ /a$ *s+%$ #"m &+a/a s,u*uh s#a7 /"&ama* b*sa,"$ /a$ *ua$! ba6" 4
3. )mbua# +$!a8ua$ u$#u& m,$!&a+" sa*a$a /a$ +*asa*a$a *ua$!a$ b. Fase Pelaksanaan
a. Pengendalian Mutu
)mbua# "$/"&a#%* mu#u U$"# &am* b*sa,"$ /a$ *ua$! ba6" S%s"a,"sas" & s,u*uh s#a7 &am* b*sa,"$ /a$ *ua$! ba6" #$#a$! "$/"'a#%* mu#u 6a$! ha*us /" 'a+a" )mbua# bu&u +a$#au )$s%s"a,"sas"&a$ 'a*a 'u'" #a$!a$ ,a$!&ah /$!a$ ( m%m$# 'u'" #a$!a$ )$u$8u& +$a$!!u$! 8a?ab "$/"&a#%* mu#u Pma$#aua$ #*ha/a+ +mb*"a$ %ba# E-a,uas" /a$ +,a+%*a$ s#"a+ bu,a$ &+a/a su+*-"s%* &+*a?a#a$ /a$ UP)
b. Pengadaan Prasarana dan peralatan medis
)$!'& smua "$-$#a*"s m/"s /a$ $%$ m/"s )mbua# +$!a8ua$ +*m"$#aa$ a,a# ssua" bu/!# +a/a bu,a$ 6a$! #,ah /"#$#u&a$
c. Program pelatihan kompetensi
)$!"&u#" +,a#"ha$ "$#*$a, ssua" /$!a$ 8a/?a, 6a$! #,ah
/"#$#u&a$ /a*" D"&,a# HRD )$!"&u#" +,a#"ha$ &s#*$a, u$#u& s*#"7"&as" /" RSUP Sa$!,ah
c. Fase Evaluasi
E-a,uas" &"$*8a /a$ +,a+%*a$ & su+*-"s%* &+*a?a#a$ s#"a+ a?a, bu,a$
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&. SASARAN a. Peningkatan kompetensi petugas
- P,a#"ha$>Sm"$a* &s#*$a, 1== - S%s"a,"sas" has", +,a#"ha$>sm"$a* I$#*$a, u$"# 1== b. Peningkatan pencapaian indicator mutu unit
- T"/a& a/a$6a &ma#"a$ "bu &a*$a +*/a*aha$ = - A$!&a &#*,amba#a$ +*s"a+a$ SC '"#% 3= m$"# = - Smua ba6" ba*u ,ah"* s+%$#a$ /a$ SC #"/a& m$!a,am" as7"&s"a -
= T"/a& a/a &8a/"a$ ba6" #*#u&a* : 1== Smua ba6" ba*u ,ah"* SC m$/a+a# I)D : 1== Smua "bu ba6" m$/a+a#&a$ /u&as" #$#a$! ASI &s,us"7 : 1== Smua ba6" +*ma#u* /" "$#$s"7 ba6" m$/a+a#&a$ +*a?a#a$ m#%/ &a$!!u*u : 1==
'. Pemenuhan sarana dan prasarana
- P$!am+*aha$ a,a#@a,a# m/"s /a$ $%$ m/"s ssua" /$!a$ 6a$! #,ah /"a8u&a$ ssua" 8a/?a, d. Program pelatihan kompetensi bidan kamar bersalin dan ruang bayi
- S,u*uh b"/a$ &ama* b*sa,"$ /a$ *ua$! ba6" /a+a# m$!"&u#" +,a#"ha$ "$#*$a, ssua" 8a/?a, 6a$! #,ah /"#$#u&a$ - 3 %*a$! b"/a$ &ama* b*sa,"$ /a$ *ua$! ba6" /a+a# m$!"&u#" +,a#"ha$ s*#"7"&as" /" RSUP Sa$!,ah 6a"#u 2 %*a$! PJ Sh"7# /a$ 1 %*a$! +*a&#"s"
7. JAD(AL PELAKSANAAN KEGIATAN NO 1
KEGIATAN
BULAN & 7 )
* 10
11
12
P,a#"ha$>Sm"$a* E&s#*$a,
6
2 " # %
P,a#"ha$ I$#*$a, A$a,"sa &bu#uha$ Fas","#as P$!mba$!a$ *ua$!a$ /" K Pma$#aua$ *s+%$ #"m
&
+,a6a$a$ /"bu&u +a$#au E-a,uas" sasa*a$ mu#u La+%*a$
7 )
Bu,a$a$ P,a+%*a$ "$/"&a#%* mu#u E-a,uas" +*%!*am &*8a /a$ *s+%$ #"m +,a6a$a$ /"u$"#
). E+ALUASI PELAKSANAAN KEGIATAN DAN PELAPORAN
K+a,a u$"# a&a$ m,a&u&a$ -a,uas" +,a&sa$aa$ &!"a#a$ s#"a+ a&h"* bu,a$ /a$ /",a&u&a$ +$'a#a#a$ &!"a#a$ s#"a+ ha*".
*. PEN$ATATAN, PELAPORAN DAN E+ALUASI KEGIATAN
E-a,uas" /",a&u&a$ #*ha/a+ "$/"'a#%* mu#u s#"a+ bu,a$ /a$ P$'a#a#a$ /",a&u&a$ s#"a+ ha*"5 m&a$"sm +,a+%*a$ a&a$ /",a+%*&a$ s#"a+ bu,a$ ssua" /$!a$ 7%*ma# 6a$! #,ah /"##a+&a$. E-a,uas" s'a*a &s,u*uha$ a&a$ /",a&u&a$ +a/a a&h"* #ahu$. I$/"&a#%* 6a$! /"!u$a&a$ a/a,ah m$"$!&a#$6a &"$*8a /a$ &ua,"#as +,a6a$a$ /"&ama* b*sa,"$
)$!#ahu"5
S"$!a*a8a5 2=10
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Su+*-"s%* K+*a?a#a$
Ka. U$"# Kama* B*sa,"$
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D"s#u8u" O,h: )a$a8* )/"s P,a6a$a$ Rumah Sa&"#
9 /. De8a P9 Sa:-a !
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