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METODE PELAPORAN

HASIL AUDIT CUCI


TANGAN

Oleh : Rosdelima Simarmata


Himpunan Perawat Pencegah dan Pengendali Infeksi Indonesia (HIPPII)
Cabang Banten
POKOK BAHASAN
I. ACUAN
II. TUJUAN PELAPORAN
III. LAPORAN KEPATUHAN CUCI TANGAN
1. OVERALL HAND HYGIENE COMPLIANCE
2. HAND HYGIENE COMPLIANCE BY MOMENTS
3. HAND HYGIENE COMPLIANCE BY HEALTHCARE
WORKER CATEGORY
IV. PENYAJIAN DATA
V. KESIMPULAN
I. ACUAN
1. WHO Guidelines on Hand Hygiene In Health Care
Provide Health Care (Revised Aug 2009).
2. Peraturan Menteri Kesehatan Republik Indonesia
Nomor 27 Tahun 2017 Tentang Pedoman Pencegahan
dan Pengendalian Infeksi di Fasilitas Pelayanan
Kesehatan
3. Peraturan Menteri Kesehatan Republik Indonesia
Nomor 34 Tahun 2017 Tentang Akreditasi Rumah Sakit
4. Standar Nasional Akreditasi Rumah Sakit Edisi 1,
Efektif 1 Januari 2018
PENDAHULUAN
 Hand washing
prevents the spread
of germs.
 CDC recommends
cleaning hands in a
specific way to avoid
getting sick and
spreading germs to
others.
1. Nose, mouth, or eyes
to hands to others
2. Hands to food
3. Food to hands to food
4. Infected child to
hands to other
children:
5. Animals to people
DISEASES AND HAND WASHING

Hands are the most


exposed part of the
body to germs.
Touching the eyes,
mouth, nose or
food transfers the
germs into the
body.
KEEPING UPDATE!

SAVE LIVES: Clean Your Hands


(SL:CYH) 5 May 2017 - 'Fight
antibiotic resistance - it's in your
hands'
STANDAR NASIONAL AKREDITASI
RUMAH SAKIT EDISI 1
II. TUJUAN PELAPORAN HASIL AUDIT

 Untuk Edukasi dan Umpan balik


 Evaluasi terhadap Keberhasilan /
Kegagalan suatu Kegiatan
 Sebagai bukti Kegiatan Kualitas
 Hasil pencapaian dapat
dipergunakan untuk publikasi
secara internal  Marketing
III. LAPORAN KEPATUHAN CUCI
TANGAN

1. OVERALL HAND HYGIENE


COMPLIANCE
Berdasarkan target/Pilot Area, seperti
 Rawat Inap
 Rawat Jalan
 Hospital Wide
 Intensive Care Unit
 Bagaimana Figur Kepatuhan?
 Periode Laporan  3 bulan, 6 bulan, 1
tahun, dst
2. Hand Hygiene Compliance by
Moments
The 5 Moments
1. Before touching
a patient
2. Before clean / aseptic
procedure

3. After body fluid exposure risk


4. After touching
a patient
5. After touching patient
surroundings
3. Hand Hygiene Compliance by Healthcare
Worker Category

1) Perawat & Bidan


2) Dokter Spesialis dan
dr Umum
3) Petugas Farmasi
4) Petugas Radiologi
5) Petugas
Laboratorium
6) Petugas Kesehatan
lainnya, misalnya:
 House Keeping
 Petugas Pelayanan
Makanan
 Nurse Aid
 Petugas
Administrasi
 dll
IV. PENYAJIAN DATA

Beberapa cara penyajian data Kepatuhan:


• Tabel
• Garis / Line Chart
• Batang / Bar Chart
• Pie Chart
• Control Chart
• dll
Compliance Rate by Moment - Tabel

Correct Total Compliance Lower 95% Upper 95%


Moment Moments Moments Rate CI CI
1 - Before Touching A 136,344 168,930 80.7% 80.5% 80.9%
Patient

2 - Before Procedure 51,621 58,782 87.8% 87.6% 88.1%

3 - After a Procedure 63,741 69,954 91.1% 90.9% 91.3%


or Body Fluid
Exposure Risk

4 - After Touching a 147,019 167,266 87.9% 87.7% 88.1%


Patient

5 - After Touching A 95,948 121,627 78.9% 78.7% 79.1%


Patient's
Surroundings

Source: http://www.hha.org.au/LatestNationalData.aspx - National Hand Hygiene Compliance Rate By Moment


- Australia
Compliance Rate by Moment –
Bar Chart

Source: http://www.hha.org.au/LatestNationalData.aspx - National Hand Hygiene Compliance Rate By Moment


- Australia
Hand Hygiene Compliance by
Profesi

Prosentasi Kategori Responden - Audit Cuci Tangan

25
35

Doctor
Nurse/Midwife
Otherhealcatre Workers
40
Overall Hand Hygiene Compliance
by Year
What is the WHO Multimodal Hand Hygiene
Improvement Strategy?

Based on the ONE System change


Alcohol-based handrubs at point of care
evidence and and access to safe continuous water supply, soap and towels

recommendations
from the WHO TWO Training and education
Guidelines on Providing regular training to all health-care workers

Hand Hygiene in
Health Care THREE Evaluation and feedback
(2009), Monitoring hand hygiene practices, infrastructure, perceptions, &
knowledge, while providing results feedback to health-care workers
made up of
5 core FOUR Reminders in the workplace
components, to Prompting and reminding health-care workers
improve hand
hygiene in health-
FIVE Institutional safety climate
care settings Individual active participation, institutional support, patient participation
Change Tap Water
Touch tap water Non touch/long handle tap water

Automatic tap water


Pelaporan Kegiatan Program HH

Kegiatan terkait Program Kebersihan Tangan,


termasuk:
 Edukasi  Pasien & Keluarga, Petugas, Pengunjung
 Audit - Kepatuhan Cuci Tangan
 Pemakaian Sabun, Hand rub, Tisu
 Audit Ketersediaan Sarana Cuci tangan 
poster, leaflet, baner, dll
 Kampanye Seputar Cuci  Global Campaign
5th May
LAPORAN DISAJIKAN KEPADA

 Petugas Kesehatan terkait dan Petugas


Kesehatan Lainnya
 Bagian Terkait
 Komite / Tim PPI RS
 Komite Mutu dan Keselamatan Kerja
RS
 Manajer dan Direktur RS
EVALUASI LAPORAN

 Evaluasi Laporan dapat dilakukan:


 Setiap 3 bulan
 Setiap 6 bulan
 Setiap 12 bulan
 Jika dibutuhkan  Evaluasi jika ada
Penurunan Trend yang significant
 Bersama dengan Evaluasi Program
Kerja PPI
V. KESIMPULAN

 Pelaporan data sangat penting dilakukan sebagai


bagian dari edukasi dan umpan balik bagi
petugas terkait
 Laporan audit dapat digunakan sebagai salah
indikator keberhasilan dan atau kegagalan yang
dapat digunakan sebagai bukti kegiatan mutu
internal RS.
 Pecapaian target audit dapat digunakan oleh
marketing dengan tujuan publikasi
 Penyajian data audit yang baik memudahkan
petugas dalam memahami data tersebut
Thank you

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