Audit Program Ppi ( Mariani,Skm,Mha )
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Transcript of Audit Program Ppi ( Mariani,Skm,Mha )
7/23/2019 Audit Program Ppi ( Mariani,Skm,Mha )
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Audit Program
Pencegahan &Pengendalin Infeksi *
Mariani Situmorang, SKM,MHA
PP PERDALIN
* Disampaikan pada Kursus Dasar KE-5 PPI – Perdain, !akarta, "#-$" Agustus$%%#
7/23/2019 Audit Program Ppi ( Mariani,Skm,Mha )
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mar's/PP-Perdalin KD-5 PPI, 18-21 Aug 2008 2
Mema&ami tu'uan utamaprogram Pen(ega&an danPengendaian In)eksi *PPI+
Mema&ami komponenprogram PPI di RS
Mema&ami konsep dasar
audit daam pen(apaiantu'uan PPPIMeningkatkan komitmen
mengaudit program PPI
Mutu RS
Mutu PPPI
Compliant ICPs
Objectives
PatientSafety
7/23/2019 Audit Program Ppi ( Mariani,Skm,Mha )
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mar's/PP-Perdalin KD-5 PPI, 18-21 Aug 2008 3
Outline" Penda&uuan
$ u'uan program PPI
. Komponen program PPI
/ Konsep Audit daamprogram PPI
5 Kesimpuan
7/23/2019 Audit Program Ppi ( Mariani,Skm,Mha )
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Hasil studi:
Pet RS0PK kurang patu&
Mutu PPPI
Mutu RS
Pt Safety ?
1.
PendahuluanHAIs dapat dicegah
kepatuhan PRS/PKmelaksanakan program PPI
Pasien, pengunung RS,petugas RS/pela!anankesehatan "PRS/PK# $erisikomendapat HAIs (healthcare-associated infections)
Audit program PPI keterlaksa%naan program PPI"sesuai standar#
pencapaian tuuan program PPI
mutu RS
Patient sa&et!
7/23/2019 Audit Program Ppi ( Mariani,Skm,Mha )
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'. (uuan Program
PPI "+ Meindungi pasien
$+ Meindungi petugas RS0pea1anan kese&atan*PRS0PK+, pengun'ung RS
.+ Men(apai kedua tu'uan diatas se(ara e)ekti)
7/23/2019 Audit Program Ppi ( Mariani,Skm,Mha )
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). Komponen *tama
Program PPI "1# "+ S2P0indakan
PPI
$+ Sur3eians .+ Penggunaan A4
/+ Kese&atanKar1aan
5+ Pendidikan 6Lati&an
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7/23/2019 Audit Program Ppi ( Mariani,Skm,Mha )
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mar's/PP-Perdalin KD-5 PPI, 18-21 Aug 2008 7
). Komponen *tama
Program PPI "'# 1# S+P/(indakan PPI, a.l:Isolation precautions
tandard Precautions!and !"giene (!#$ !%$ !)
PP ('ask$ face shields$ gloves$ gon$ etc)P (instruments$ linen$ etc)
ransmission-+ased Precautions (AP$,P$P)!ospital environment sanitation
#aste management afe handling and disposal of sharps '# Sur3eians)# 7
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). Komponen *tama Program
PPI ")# 1# S+P/(indakan PPI
'# Sur-eillance
Sur-eillance design, a.o: Planning/Scoping: goal o$ecti-es, method,
tm t$l Standardiing conceptual operational
de0nitions "numerator, denominator, etc# Recruiting/(raining sta
Sur-eillance acti-it!:
2ollecting data 3ntering Presenting data Interpreting/Anal!ing data Reporting disseminating result
)# Penggunaan A4
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mar's/PP-Perdalin KD-5 PPI, 18-21 Aug 2008
4. Konsep Auditdalam PPIa Pengertian audit
8 u'uan audit
( 9akupan auditd Auditor 6 Perann1a
e Instrumen audit * Audittools+
) indak an'ut audit
P ti
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1. Audit: pemeriksaan &ormalaccount suatu institusi/orgns
'. Audit dalam PPI: pemantauan/penga5asan secara terad5al konsisten keterlaksanaanprogram PPI sesuai standar
4.a. Pengertian
Audit
Pre Requisite !
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4.$. (uuan
Audit "1# "+ Dengan menggunakan instrumen audit ,menentukan apaka& 0 memastikan8a&a semua komponen program PPIsedang 6 se(ara konsisten diaksanakansesuai dgn pedoman0standar benchmarking di semua unit terkait di RS
$+ Audit PPI 8erperan se(ara 8ermaknadaam upa1a pen(apaian tu'uan clinicalgovernance
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4.$. (uuan
Audit "'# .+ Meningkatkan kepatu&an petugasRS0PK meaksanakan program PPI
/+ Audit 8erperan se(ara 8ermaknadaam pen(apaian tu'uan programrisk management
5+ Meningkatkan kaitas programPPI0Mutu RS Patient Safety
k
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4.c. 2akupan
Audit1# S+P/(indakanPPI
'# Sur-eillans )# Penggunaan A6
4# KesehatanKar!a5an
7# Pendidikan 8atihan
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A U D I T
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4.d. Auditor
Perann!a "1# Auditor: I22/I2(9 (im khusus Peran auditor, a.l:
1# engem$angkan program audit PPI tuuan, angka kepatuhan,cakupan
'# em$uat/mengem$angkan
instrumen Audit)# elaksanakan pelatihan menggu%
nakan instrumen audit "audit tools#
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4.d. Auditor
Perann!a "'# Peran auditor, a.l:
4# enad5alkan memastikan
pelaksanaan audit7# engaudit seluruh kegiatan audit
coring s"stem
;# elaporkan hasil audit ke pihakterkait
<# erekomendasi "alternati&#tindakan per$aikan, etc
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= IA: Instrumen standar !g digunakan memonitor konsistensi kepatuhan:
% manaemen/sta& RS/PK
% pasien/pengunung
melaksanakan program/S+P/
tindakan PPI secara akurat/
sesuai standar tepat 5aktu
4.e. Instrumen
Audit "1# Pengertian
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4.e. Instrumen
Audit "'# 2akupan= IA: mencakup:
Aspek manaerial: >alsa&ah, isi,
isi, (uuan, Ke$iakan, S+P, dll Keterlaksanaan S+P
Ketersediaan/kelengkapan tataletak &asilitas peralatan
Perilaku petugas RS/PK"mematuhi/tidak mematuhi S+P #
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4.e. Instrumen
Audit "'#
Kategori Struktur
= Struktur IA: @udul Alinea pengantar/Ke$iakan 6agian Isi
Penutup
= Kategori IA: % Sta& RS "man plk
% pasien
% pengunung
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4.e. Instrumen Audit: coring "4#
= coring Kategori kepatuhan,misaln!a: ;B C : (idak patuh
;B D <4 C : Kepatuhan
rendah <7 D E7 C : Kepatuhan
sedang F E7C : Kepatuhan
tinggi= coring .ormula
@umlah total a5a$an Ga%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% J1BB .. C
@umlah total a5a$an Ga L G(idak
4e
Reaisti(
: gn u
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. . : gn u
Scoring "7#
No. Aspek !ang Miaudit a(dk
2atatan
1. Ada kebijakan & SOP lengkap KTX
2. Pelatihan KT diberikan kepada semua stafX
. Tersedia fasilitas lengkap KT di setiapruang X
" #
S$%re& '''''''''''''''''''''''' ( '''' X )) ( **.*+ ,
" " T -
K e
p a t u h
a n
r e n d a h
(8: Analisa rekomendasi tindakan koreksi
Instrumen Audit Kebersihan Tangan
Kebijakan: Tangan didekontaminasi secara benar, memakai sabun anti-
setik untuk menekan risiko !AIs
Tangga": ###$$ Ruangan: ###$ Auditor: ###$$
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4.&. (indak 8anut
Audit etapkan
kategori kepatu&an
AnaisaAngka kepatu&an
Peaksanaan
audit 8erikutn1a
Pelaporan Rekomendasi(ind. per$aikan
(indakanPer$aikan oleh
unit terkait
PeningkatanMutu program PPI
PeningkatanMutu RS0PK
Patient Sa)et1
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7. Kesimpulan
Pasien, pengunung RS, petugas RS/pela!anankesehatan $erisiko mendapat HAIs
HAIs dapat dicegah apa$ila petugas RS/PKpatuh melaksanakan program PPI
Hasil studi menunukkan tingkat keatuhan Audit program PPI diperlukan untuk memantau
dan memastikan keterlaksanaan program PPI"sesuai standar#
Audit dapat dikem$angkan/dilaksanakan oleh
I22/I2( atau tim khusus !ang di$entuk untukitu Ke$erhasilan audit meningkatkan mutu
program PPI/mutu RS Patient sa&et!
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