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    Audit Program Ppi (Mariani, SKM, Mha)

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    Dedy Hartantyo
    The document discusses the importance of auditing infection prevention and control programs in hospitals. It outlines the objectives of auditing as ensuring compliance with standard protocols, improving staff adherence, and enhancing quality of care and patient safety. The key components of an infection control program that should be audited include standard operating procedures, surveillance activities, antibiotic use, and employee health policies. An effective audit involves using standardized tools to monitor compliance, qualified auditors, and implementing corrective actions based on findings to strengthen the infection control program.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd

    Audit Program Ppi (Mariani, SKM, Mha)

    Uploaded by

    Dedy Hartantyo
    77 views23 pages
    The document discusses the importance of auditing infection prevention and control programs in hospitals. It outlines the objectives of auditing as ensuring compliance with standard protocols, improving staff adherence, and enhancing quality of care and patient safety. The key components of an infection control program that should be audited include standard operating procedures, surveillance activities, antibiotic use, and employee health policies. An effective audit involves using standardized tools to monitor compliance, qualified auditors, and implementing corrective actions based on findings to strengthen the infection control program.

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    audit program ppi ( Marini,Skm,Mha )

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    Audit Program Ppi ( Mariani,Skm,Mha )

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    The document discusses the importance of auditing infection prevention and control programs in hospitals. It outlines the objectives of auditing as ensuring compliance with standard protocols, improving staff adherence, and enhancing quality of care and patient safety. The key components of an infection control program that should be audited include standard operating procedures, surveillance activities, antibiotic use, and employee health policies. An effective audit involves using standardized tools to monitor compliance, qualified auditors, and implementing corrective actions based on findings to strengthen the infection control program.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    77 views23 pages

    Audit Program Ppi (Mariani, SKM, Mha)

    Uploaded by

    Dedy Hartantyo
    The document discusses the importance of auditing infection prevention and control programs in hospitals. It outlines the objectives of auditing as ensuring compliance with standard protocols, improving staff adherence, and enhancing quality of care and patient safety. The key components of an infection control program that should be audited include standard operating procedures, surveillance activities, antibiotic use, and employee health policies. An effective audit involves using standardized tools to monitor compliance, qualified auditors, and implementing corrective actions based on findings to strengthen the infection control program.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 23

    Audit

    Program
    Pencegahan &
    Pengendalin Infeksi *
    Mariani Situmorang, SKM,MHA
    PP PERDALIN
    * Disampaikan pada Kursus Dasar KE-5 PPI Perdalin, Jakarta, 18-21 Agustus
    2008

    Objectives
    Memahami

    tujuan utama
    program Pencegahan dan
    Pengendalian Infeksi (PPI)
    Memahami komponen
    program PPI di RS
    Memahami konsep dasar
    audit dalam pencapaian
    tujuan PPPI
    Meningkatkan komitmen
    mengaudit program PPI
    mar's/PP-Perdalin

    KD-5 PPI, 18-21 Aug 2008

    Patient
    Safety

    Mutu RS

    Mutu PPPI

    Compliant ICPs
    2

    Outline
    1.
    2.
    3.
    4.
    5.

    Pendahuluan
    Tujuan program PPI
    Komponen program PPI
    Konsep Audit dalam
    program PPI
    Kesimpulan

    mar's/PP-Perdalin

    KD-5 PPI, 18-21 Aug 2008

    1.
    Pendahuluan
    Hasil studi:

    HAIs

    dapat dicegah
    kepatuhan PRS/PK
    melaksanakan program PPI

    Pasien, pengunjung RS,


    Pet. RS/PK
    petugas RS/pelayanan
    kurang patuh
    kesehatan (PRS/PK) berisiko

    mendapat HAIs (healthcareMutu PPPI
    associated infections)
    Mutu RS Audit program PPI
    keterlaksa-naan program PPI

    (sesuai standar)
    Pt Safety ?
    pencapaian tujuan program PPI
    mutu RS Patient safety
    mar's/PP-Perdalin

    KD-5 PPI, 18-21 Aug 2008

    2. Tujuan Program

    PPI

    1)
    2)

    Melindungi pasien
    Melindungi petugas RS/
    pelayanan kesehatan
    (PRS/PK), pengunjung RS

    3)

    Mencapai kedua tujuan di


    atas secara efektif

    mar's/PP-Perdalin

    KD-5 PPI, 18-21 Aug 2008

    3. Komponen Utama

    Program PPI
    F
    A
    L
    S
    A
    F
    A
    H
    &

    K
    E
    B
    I
    J
    A
    K
    A
    N
    &

    Tu
    S.
    ju O.
    an P.

    mar's/PP-Perdalin

    1)
    P
    R
    O
    G
    R
    A
    M

    2)
    3)
    4)
    5)

    (1)

    SOP/Tindakan
    PPI
    Surveillans
    Penggunaan AB
    Kesehatan
    Karyawan
    Pendidikan &
    Latihan

    KD-5 PPI, 18-21 Aug 2008

    I
    M
    P
    L
    E
    M
    E
    N
    T
    A
    S
    I

    3. Komponen Utama
    (2)
    Program
    PPIPPI,
    1) SOP/Tindakan
    a.l:
    Isolation

    Standard Precautions
    Hand Hygiene (HW, HR, HS)
    PPE (Mask, face shields, gloves, gown, etc)
    PCE (instruments, linen, etc)
    Transmission-Based Precautions (AP,DP,CP)

    Hospital

    precautions

    environment sanitation:

    Waste management
    Safe handling and disposal of sharps

    2) Surveillans
    3)

    mar's/PP-Perdalin

    KD-5 PPI, 18-21 Aug 2008

    3. Komponen Utama Program


    1) SOP/Tindakan PPI

    PPI

    (3)

    2) Surveillance

    Surveillance design, a.o:

    Planning/Scoping: goal & objectives, method,


    tm tbl
    Standardizing conceptual & operational
    definitions (numerator, denominator, etc)
    Recruiting/Training staf

    Surveillance activity:

    Collecting data
    Entering Presenting data
    Interpreting/Analyzing data
    Reporting & disseminating result

    3) Penggunaan AB

    mar's/PP-Perdalin

    KD-5 PPI, 18-21 Aug 2008

    Audit
    a. Pengertian
    dalam
    PPI audit
    4. Konsep

    Tujuan audit
    Cakupan audit
    Auditor & Perannya
    Instrumen audit (Audit
    tools)
    f. Tindak lanjut audit
    b.
    c.
    d.
    e.

    mar's/PP-Perdalin

    KD-5 PPI, 18-21 Aug 2008

    4.a. Pengertian
    1.
    2.

    Audit

    Audit: pemeriksaan formal


    account suatu institusi/orgns
    Audit dalam PPI: pemantauan/
    pengawasan secara terjadwal
    & konsisten keterlaksanaan
    program PPI sesuai standar

    Pre Requisite !
    mar's/PP-Perdalin

    KD-5 PPI, 18-21 Aug 2008

    10

    4.b. Tujuan
    Audit

    (1)

    1)

    Dengan menggunakan instrumen audit ,


    menentukan apakah / memastikan
    bahwa semua komponen program PPI
    sedang & secara konsisten dilaksanakan
    sesuai dgn pedoman/standar
    benchmarking di semua unit terkait di RS

    2)

    Audit PPI berperan secara bermakna


    dalam upaya pencapaian tujuan clinical
    governance

    mar's/PP-Perdalin

    KD-5 PPI, 18-21 Aug 2008

    11

    4.b. Tujuan
    3)
    4)

    5)

    Audit

    (2)

    Meningkatkan kepatuhan petugas


    RS/PK melaksanakan program PPI
    Audit berperan secara bermakna
    dalam pencapaian tujuan program
    risk management

    Meningkatkan kwalitas program


    PPI/Mutu RS Patient Safety

    mar's/PP-Perdalin

    KD-5 PPI, 18-21 Aug 2008

    12

    4.c. Cakupan
    Audit
    F
    A
    L
    S
    A
    F
    A
    H
    &

    K
    E
    B
    I
    J
    A
    K
    A
    N
    &

    Tu
    S.
    ju O.
    an P.

    mar's/PP-Perdalin

    1)
    P
    R
    O
    G
    R
    A
    M

    2)
    3)

    SOP/Tindakan
    PPI
    Surveillans
    Penggunaan AB
    Kesehatan
    Karyawan
    Pendidikan &
    Latihan

    U
    A
    4)
    5)

    T
    I

    KD-5 PPI, 18-21 Aug 2008

    I
    M
    P
    L
    E
    M
    E
    N
    T
    A
    S
    I

    13

    4.d. Auditor &


    (1)
    Perannya

    Auditor:

    ICC/ICT; Tim khusus


    Peran auditor, a.l:
    1)

    2)
    3)

    Mengembangkan program audit PPI


    tujuan, angka kepatuhan,
    cakupan
    Membuat/mengembangkan
    instrumen Audit
    Melaksanakan pelatihan menggunakan instrumen audit (audit tools)

    mar's/PP-Perdalin

    KD-5 PPI, 18-21 Aug 2008

    14

    4.d. Auditor &


    (2)
    Perannya
    Peran
    4)
    5)
    6)
    7)

    auditor, a.l:

    Menjadwalkan & memastikan


    pelaksanaan audit
    Mengaudit seluruh kegiatan audit
    Scoring system
    Melaporkan hasil audit ke pihak
    terkait
    Merekomendasi (alternatif)
    tindakan perbaikan, etc

    mar's/PP-Perdalin

    KD-5 PPI, 18-21 Aug 2008

    15

    4.e. Instrumen
    (1)
    Audit Pengertian

    # IA: Instrumen standar yg digunakan memonitor konsistensi kepatuhan:

    - manajemen/staf RS/PK
    - pasien/pengunjung

    melaksanakan program/SOP/
    tindakan PPI secara akurat/
    sesuai standar & tepat waktu

    mar's/PP-Perdalin

    KD-5 PPI, 18-21 Aug 2008

    16

    4.e. Instrumen
    (2)
    Audit Cakupan

    # IA: mencakup:

    Aspek manajerial: Falsafah, Visi,


    Misi, Tujuan, Kebijakan, SOP, dll
    Keterlaksanaan SOP

    Ketersediaan/kelengkapan & tata


    letak fasilitas & peralatan
    Perilaku petugas RS/PK
    (mematuhi/tidak mematuhi SOP )

    mar's/PP-Perdalin

    KD-5 PPI, 18-21 Aug 2008

    17

    4.e. Instrumen

    Audit

    (2)

    Kategori &
    # Kategori Struktur
    IA: - Staf RS (manj & plks
    - pasien
    - pengunjung

    # Struktur IA:

    Judul
    Alinea pengantar/Kebijakan
    Bagian Isi
    Penutup

    mar's/PP-Perdalin

    KD-5 PPI, 18-21 Aug 2008

    18

    4.e. Instrumen Audit:


    #

    Scoring

    (4)

    Scoring Kategori kepatuhan,


    misalnya:
    Be
    < 60 %
    : Tidak patuh

    60 74 % : Kepatuhan
    Realistic
    rendah
    75 85 % : Kepatuhan
    sedang
    > 85%
    : Kepatuhan
    # Scoring Formula
    tinggi
    Jumlah
    total jawaban Ya
    ------------------------------------------------------------ X
    100 = .. %

    Jumlah
    total
    jawaban
    Ya
    +
    Tidak
    mar's/PP-Perdalin
    KD-5 PPI, 18-21 Aug 2008

    19

    4.e. IA: Contoh Sbgn Instrumen


    & Scoring

    (5)

    Instrumen Audit Kebersihan Tangan


    Kebijakan: Tangan didekontaminasi secara benar, memakai sabun antiseptik untuk menekan risiko HAIs

    No.

    Ruangan: .

    Aspek yang Diaudit

    Auditor: ..

    Ya

    1.

    Ada kebijakan & SOP lengkap KT

    2.

    Pelatihan KT diberikan kepada semua staf

    3.

    Td
    k

    Catata
    n

    Ke
    pa
    tu
    re han
    nd
    ah

    Tanggal: ..

    Tersedia fasilitas lengkap KT di setiap


    X
    ruang
    1 Y + 1Y
    2
    Score: ------------------------ = ---- X 100 = 66.67 %
    1Y+1Y+1T
    3

    TL: Analisa & rekomendasi tindakan koreksi

    4.f. Tindak Lanjut


    Patient Safety
    Peningkatan
    Mutu RS/PK

    Audit
    Tetapkan
    Pelaksanaan
    audit berikutnya kategori kepatuhan

    Peningkatan
    Mutu program PPI
    Tindakan
    Perbaikan oleh
    unit terkait
    mar's/PP-Perdalin

    Pelaporan &
    Rekomendasi
    Tind. perbaikan

    KD-5 PPI, 18-21 Aug 2008

    Analisa
    Angka kepatuhan

    21

    5. Kesimpulan
    Pasien, pengunjung RS, petugas RS/pelayanan
    kesehatan berisiko mendapat HAIs
    HAIs dapat dicegah apabila petugas RS/PK
    patuh melaksanakan program PPI
    Hasil studi menunjukkan tingkat keatuhan
    Audit program PPI diperlukan untuk memantau
    dan memastikan keterlaksanaan program PPI
    (sesuai standar)
    Audit dapat dikembangkan/dilaksanakan oleh
    ICC/ICT atau tim khusus yang dibentuk untuk
    itu
    Keberhasilan audit meningkatkan mutu
    program PPI/mutu RS Patient safety

    mar's/PP-Perdalin

    KD-5 PPI, 18-21 Aug 2008

    22

    mar's/PP-Perdalin

    KD-5 PPI, 18-21 Aug 2008

    23

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