DAFTAR ISI

Halaman
SAMPUL DEPAN .............................................................................................

DAFTAR ISI ......................................................................................................

BAB I PENDAHULUAN ........................................................................... 1

I.1. Latar Belakang ........................................................................ 2
I.2. Tujuan ..................................................................................... 2
I.3. Ruang Lingkup ....................................................................... 3
I.4. Batasan Operasional ............................................................... 3
I.5. Landasan Hukum .................................................................... 4
BAB II GAMBARAN UMUM RUMAH SAKIT ..................................... 5
II.1. Sejarah RSUD Kudungga ...................................................... 5
BAB III VISI DAN MISI RUMAH SAKIT ................................................ 8
III.1. Visi…………………………….. .......................................... 8
III.2. Misi………………………………………. .......................... 8
III.3. Nilai………………………. .................................................. 8
III.4. Motto……………………….. ............................................... 9
III.5. Falsafah…………………………… ..................................... 9
III.6. Tujuan RSUD Kudungga………………. ............................. 9
BAB IV STRUKTUR ORGANISASI RUMAH SAKIT ..... 11
BAB V STRUKTUR ORGANISASI PMKP ............................................ 12
BAB VI URAIAN JABATAN PMKP ......................................................... 13
VI.1. Ketua Komite Mutu dan Manajemen Risiko ........................ 13
VI.2. Koordinator Peningkatan Mutu............................................. 15
VI.3. Koordinator Manajemen Resiko dan Keselamatan Pasien ... 17
VI.4. Sekretaris Komite Mutu dan Manajemen Risiko .................. 19
BAB VII TATA HUBUNGAN KERJA ........................................................ 21
BAB VIII KONSEP DASAR PENINGKATAN MUTU DAN
KESELAMATAN PASIEN ........................................................... 22
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 VIII.1. Peningkatan Mutu RSUD Kudungga ..................................................... 22
VIII.2. Keselamatan Pasien ..................................................................................... 27
VIII.3. Pelaksanaan Program ......................................................... 35
BAB IX KEGIATAN .................................................................................... 68
X.1. Peningkatan Mutu ............................................................... 68
BAB X METODE PENINGKATAN MUTU ............................................ 95
BAB XI PENCATATAN DAN PELAPORAN .......................................... 100
BAB XII MONITORING DAN EVALUASI ............................................... 101
XIII.1. Monitoring ........................................................................................... 101
XIII.2. Evaluasi........................................................................................... ..... 101
XIII.3. Bukti Dokumen................................................................................... 101
BAB XIV PENUTUP ....................................................................................... 102

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