AKREDITASI PELAYANAN RADIOLOGI by SqQ49p

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									SISTEMATIKA IRAD
             SISTEMATIKA
1.   Falsafah dan Tujuan
2.   Administrasi & Pengelolaan
3.   Staf dan Pimpinan
4.   Fasilitas & Peralatan
5.   Kebijakan & Prosedur
6.   Pengembangan & Program Pendidikan
7.   Evaluasi & Pengendalian Mutu
             SISTEMATIKA
1.   Falsafah dan Tujuan ( 3 Parameter)
2.   Administrasi & Pengelolaan ( 2 )
3.   Staf dan Pimpinan ( 4 )
4.   Fasilitas & Peralatan ( 4 )
5.   Kebijakan & Prosedur ( 2 )
6.   Pengembangan & Prog Pendidikan (1)
7.   Evaluasi & Pengendalian Mutu ( 2 )
     Total : 18 Parameter
              SISTEMATIKA
               (FAS FKPE)
1.   Falsafah dan Tujuan ( 3 Parameter)
2.   Administrasi & Pengelolaan ( 2 )
3.   Staf dan Pimpinan ( 4 )
4.   Fasilitas & Peralatan ( 4 )
5.   Kebijakan & Prosedur ( 2 )
6.   Pengembangan & Prog Pendidikan (1)
7.   Evaluasi & Pengendalian Mutu ( 2 )
     Total : 18 Parameter
   BIMBINGAN AKREDITASI
                 DI
       RUMAH SAKIT MOJOSARI
           10 MARET 2008
              OLEH TIM
DINAS KESEHATAN PROPINSI JAWA TIMUR
     SISTEMATIKA
 PENILAIAN PELAYANAN
RADIOLOGI RUMAH SAKIT
             SISTEMATIKA
1.   Falsafah dan Tujuan
2.   Administrasi & Pengelolaan
3.   Staf dan Pimpinan
4.   Fasilitas & Peralatan
5.   Kebijakan & Prosedur
6.   Pengembangan & Program Pendidikan
7.   Evaluasi & Pengendalian Mutu
             SISTEMATIKA
1.   Falsafah dan Tujuan ( 3 Parameter)
2.   Administrasi & Pengelolaan ( 2 )
3.   Staf dan Pimpinan ( 4 )
4.   Fasilitas & Peralatan ( 4 )
5.   Kebijakan & Prosedur ( 2 )
6.   Pengembangan & Prog Pendidikan (1)
7.   Evaluasi & Pengendalian Mutu ( 2 )
     Total : 18 Parameter
              SISTEMATIKA
               (FASFKPE)
1.   Falsafah dan Tujuan ( 3 Parameter)
2.   Administrasi & Pengelolaan ( 2 )
3.   Staf dan Pimpinan ( 4 )
4.   Fasilitas & Peralatan ( 4 )
5.   Kebijakan & Prosedur ( 2 )
6.   Pengembangan & Prog Pendidikan (1)
7.   Evaluasi & Pengendalian Mutu ( 2 )
     Total : 18 Parameter
     AKREDITASI
PELAYANAN RADIOLOGI
        TIM AKREDITASI
  DINKES PROPINSI JAWA TIMUR
        MOJOSARI 2008
     STD.1 FALSAFAH DAN TUJUAN
   Pelayanan Radiologi berupa
    radiodiagnostik & radioterapi dengan
    mempertimbangkan aspek:
    1. Bahaya radiasi
    2. Perkembangan Iptek
    3. Cost-benefit ratio
    4. Kemampuan SDM
S.1.P1
0 : Tak ada falsafah & tuj instalasi
1 : Ada tapi lisan, dibuat Ka.Inst.
2 : Ada tertulis,tapi tdk mengacu visi &
     misi,by Ka.Inst
1 : Ada tertulis,blm mengacu,by Ka.Inst &
    staf
2 : Ada tertulis,mengacu,by Ka.Inst & Staf
3 : sda 4 plus diberlakukan by pimpinan
S.1.P.2 : Yan Rad=Yan RS=Yan
           Profesi
0 : Tidak ada standar pelayanan
1 : Ada std pelay sesuai Depkes,tertulis,
    Std pelay profesi tertulis tidak ada
2 : sda, tak ada std SMF Radiologi & SK
    Direktur
3 : Ada Sk Dir, tidak ada Std SMF Rad RS
4 : lengkap
5 : semua std ada plus evaluasi iptek
     S.1.P.3. YAN RAD 24 JAM
0   : Pel Emergensy tidak ada,hanya on call
1   : Rutin &UGD ad tapi jam kerja saja,petugas
      on call
2   : sda, petugas on site
3   : sda plus petugas on call, ekspertise di luar
      jam kerja by non DrSpR
4   : sda,petugas on site dan expertise by DrSpR
5   : Ada rutin 24 jam,petugas on
       site,ekspertise oleh Dr.SpR di luar jam
       kerja
Std.2.ADMINSTRASI &PENGELOLAAN:
      Bagan Organisasi & uraian tugas
0 : Tidak ada struktur organisasi
1 :
2 :
3 :
4 :
5 : Ada + uraian tugas lengkap by Dir RS
S.2.P.2 :
0 : Tidak ada petugas khusus pencatatan
1
2
3
4
5 : Ada, sesuai kebutuhan,evaluasi
                    DO
D : 1. Buku Register pasien atau data
       komputer
    2. Arsip
    3. Standar/pola ketenagaan
     Std.3. STAF & PIMPINAN
 Pimpinan unit pelayanan Radiologi
  sebaiknya oleh dokter spesialis Radiologi
  terdaftar dibantu staf yang berkompeten
  dan profesional
 Kebutuhan SDM proporsional dengan
  aktivitas pelayanan
S.3.P.1: Kepala SpRD
0 : Pimpinan bukan nakes
1
2
3
4
5 : Pimpinan Dr Sp Radiologi purna waktu
   S.3.P.2 Staf Medik Fungsional
             Radiologi
0 : Pelaksana GP/ Spesialis non radiologi
1
2
3
4
5 :Pelaksana Dr SpRad
                    DO
Sub Spesialisasi Radiologi:
1. Radiologi anak
2. Radiologi neuro
3. Radiologi intervensional
4. Kedokteran nuklir
Bidang Kekhususan :
1. Multi Slice CT
2. Helical CT
3. MRI
4. Angiografi
5. USG Dopler : USG plus visualisasi
   pembuluh darah
6. Mammografi : Khusus payudara
 S.3.P.3 STAF PELAKSANA RADIOGRAPHER

0 : Operator non nakes, non training
1
2
3
4
5 : Operator adalah Radiographer purna
  waktu, sesuai kebutuhan
       S.3.P.4 Rapat Berkala
0 : Tidak ada rapat
1
2
3
4
5 : Ada jadwal rapat,hadir lengkap,notulen
    dan RTL
Std.4.Fasilitas & Peralatan
     Standar Ruangan Imaging(aman,luas &
     nyaman)
Ruang Kabinet
Ruang Baca
RUANG SCREENING
RUANG TUNGGU
                S.4.P1
0 : Ruang tidak memenuhi standar
1
2
3
4
5 : Std ruang memenuhi syarat: ada
     prasarana penunjang, nyaman, sistem
     komunikasi
                    DO
1.   Std Pelayanan Radiologi kelas C&D
     (1993)
2.   Std Pelayanan Radiologi kelas A&B
     (1995)
3.   Ijin BATAN
       S.4.P.2 : Tipe Ruangan
0:   Ruang a: R.Periksa+kamar gelap
1:   Ruang a + R.TungguPasien
2:   + R. Petugas
3:   + R.R.Adm
4:   + R.Ekspertise
5:   + > 1 R.Periksa
    S.4.P.3. Kualitas Peralatan
0 : Jumlah minim,tak terawat
1
2
3
4
5 : Jumlah , jenis, ability peratan
    cukup,terawat, ikuti iptek
                       DO
 R/F Table: u/ fluroscopy
 Image intensifer : zooming gambar
 Buckystand        : kaset film u/ zooming foto
                      thorax
 Mobile unit
 Iptek :
  - CT Scan helical,MRI
  - Color USG
  - Digital X-ray
  - Multi slice CT
CT SCAN
MEDICAL SONOGRAPHY
MAMOGRAPHY
IMAGE TRANSFER
BUCKY STAND
Case Studies
     Multislice CT
                               Case 1

   HISTORY: 83 Y/O M, EVALUATE INFRARENAL
    AORTIC ANEURYSM.
   FINDINGS: THERE IS EVIDENCE OF AN
    INFRARENAL AORTIC ANEURYSM WITH A
    MAXIMUM DIAMETER AT ITS MID PORTION OF
    5 CM AP X 5.2 CM
   ANEURYSM PROJECTS INFERIORLY TO JUST
    PROXIMAL TO THE BIFURCATION OF THE ILIAC
    ARTERIES
   SCANNING PARAMETERS: 3 X 3IMAGE
    THICKNESS WITH A 1.5 MM RECONSTRUCTION
    AT 3.5 PITCH. THE CONTRAST INJECTION RATE
    WAS 3CC/SEC. IT WAS MONITERED WITH
    SURESTART FOR TIMING OF THE SCAN.
   3D rendering   Curved multiplanar
    reformat
                            Case 2
   HISTORY: 68 Y/O M WITH AN INFRARENAL
    AAA 5 X 5 CM BY CT ON JULY 29. FOLLOW UP
    SIZE OF THE AAA.
   FINDINGS: IN THE ABDOMEN, THERE IS
    STABLE SIZE OF A 5 CM AP X 5 CM TRANS X 5.4
    CM CC INFRARENAL AAA.
   IMPRESSION: UNCHANGED SIZE AND
    LOCATION OF A AAA WHICH IS INFRARENAL IN
    LOCATION BUT INVOLVES THE IMA.
   SCANNING PARAMETERS: 3 X 3IMAGE
    THICKNESS WITH A 1.5 MM RECONSTRUCTION
    AT 3.5 PITCH. THE CONTRAST INJECTION RATE
    WAS 3CC/SEC. IT WAS MONITERED WITH
    SURESTART FOR TIMING OF THE SCAN.
   3D rendering
                     Case 3
   HISTORY: 49 YR M, STATUS POST
    ASCENDING/DESCENDING AORTA DISSECTION
    REPAIR/BENTALL PROCEDURE. RULE OUT
    DISSECTION.
   FINDINGS: THERE IS CONTINUED EVIDENCE
    OF AORTIC DISSECTION EXTENDING FROM THE
    AORTIC ROOT TO INCLUDE THE ARCH,
    DESCENDING AORTA, BIFURCATION INTO
    COMMON ILIACS, AND BIFURCATION INTO
    INTERNAL AND EXTERNAL ILIAC.
   SCANNING PARAMETERS: 5 X 5 IMAGE
    THICKNESS WITH A 3 MM RECONSTRUCTION
    AT 3.5 PITCH. THE CONTRAST INJECTION RATE
    WAS 3CC/SEC. IT WAS MONITERED WITH
    SURESTART FOR TIMING OF THE SCAN.
   3D rendering
                      Case 4
   HISTORY: 42 Y/O M. RIGHT TIBIAL PLATEAU CT WITH
    THIN CUTS ASSESS FRACTURE.
   FINDINGS: THERE IS A SCHATZKER TYPE V
    FRACTURE OF THE PROXIMAL TIBIA. IN ADDITION,
    THERE IS SOME COMMINUTION INVOLVING THE
    TIBIAL PLATEAU ANTERIORLY AND TIBIAL PLATEAU
    POSTERIORLY.
   IMPRESSION: COMMINUTED SCHATZKER TYPE V
    BICONDYLAR FRACTURE.
   SCANNING PARAMETERS: 2 X 2IMAGE THICKNESS
    WITH A 1MM RECONSTRUCTION AT 3.5 PITCH.
   3D rendering of AP tibia
            Case 5
   HISTORY: 29 Y/O M. FRACTURE. EVALUATE.
   FINDINGS: THERE IS POSTERIOR FRACTURE
    DISLOCATION OF THE RIGHT SHOULDER. THERE
    IS A FRACTURE THROUGH THE NECK OF THE
    GLENOID
   IMPRESSION: 1. POSTERIOR FRACTURE
    DISLOCATION OF THE RIGHT SHOULDER AND
    COMMINUTED FRACTURE OF THE SCAPULA
    MAINLY INVOLVING THE NECK OF THE GLENOID
    WITH INTERARTICULAR EXTENSION AT THE
    SUPERIOR ASPECT OF THE GLENOHUMERAL
    JOINT.
   SCANNING PARAMETERS: 3 X 3 X 1.5 MM
    HELICAL AXIAL CT IMAGES WERE OBTAINED
    THROUGH THE RIGHT SHOULDER.
 3D rendering of AP scapula
               Case 6
   HISTORY: 32 Y/O F WITH HIGH GRADE LEFT
    INTERNAL CAROTID ARTERY STENOSIS AND
    POOR IMAGING OF THE DISTAL INTERNAL
    CAROTID ARTERY.
   FINDINGS: THERE IS APPROXIMATELY 50%
    STENOSIS OF THE DISTAL RIGHT INTERNAL
    CAROTID ARTERY AT THE GENU OF THE
    CAROTID SIPHON. LEFT CAROTID ARTERY:
    THERE IS A TIGHT STENOSIS IN THE PROXIMAL
    LEFT INTERNAL CAROTID ARTERY
   SCANNING PARAMETERS: 1 x 1 SLICE
    THICKNESS WITH A .5MM RECONSTRUCTION,
    HELICAL PITCH WAS 3.5. 100 CC CONTRAST
    WAS INJECTED AT 3 CC PER SECOND WITH 18
    SECOND SCAN DELAY.
   Lt. and Rt. carotid arteries
S.4.P.4. OBAT & PERALATAN BASIC LIFE SUPPORT
          FOR ALERGI BAHAN KONTRAS

0 : Tak ada
1
2
3
4
5 : Ada lengkap obat,cairan infus,02 dan
    peralatan
    DAFTAR OBAT & PERALATAN
 Daftar obat
  - adrenalin inj
  - anti histamin
  - Kortison
  - Dopamin
 Daftar Peralatan
  - alkes: needle,spuit
  - infus set dan standar infus
  - suction pump
    DAFTAR MEDIA KONTRAS
•Iodinated agents
– Iohexol (Omnipaque®, GE Healthcare)
– Iodixanol (Visipaque®, GE Healthcare)
– Iopromide (Ultravist®, Bayer Healthcare)
– Ioversol (Optiray®, Tyco/Mallinckrodt)
– Iopamidol (Isovue®, Bracco Diagnostics)
• Gadolinium agents
– Gadobenate (MultiHance®, Bracco Diagnostics)
– Gadodiamide (Omniscan®, GE Healthcare)
– Gadoteridol (ProHance®, Bracco Diagnostics)
– Gadoversetamide (OptiMARK ®, Tyco/Mallinckrodt)
– Gadopentetate (Magnevist®, Berlex)
Std.5 KEBIJAKAN DAN PROSEDUR
 PERLU PROTAP (SOP)
 WRITTEN SOP
PROTAP ATAU SOP



  PROTOKOL
            Body Protocols


 Appendicitis Scan
 Biphasic CT of Liver
 Biphasic Pancreas (Pancreatic Protocol)
 Chest, Abdomen, Pelvis Scan
 Adrenal Mass (Pheochromocytoma IS
  suspected)
 Renal Mass Evaluation
 Routine Abdomen/Pelvis
 “I Think There Is a Stone Scan” (Stone Scan)
            Chest Protocols

 Abdominal Aortic Aneurysm (AAA)
 Aortic Dissection
 Coronary Calcification on EBCT revision
 Coronary Calcification on Multislice
 Interstitial Lung Disease (HRCT)
 Airway Study McLennan
 Pulmonary Embolism (PE) Chest only
 Pulmonary Embolism (PE) with Deep Venous Thrombosis
  (DVT)
 Pulmonary Nodule
 Standard Chest CT
                    Neuro Protocols
   Adult Head CT
   Adult Sinus CT
   Adult Orbit CT
   Adult Neck CT
   Salivary Gland CT
   Functional Larynx CT
   CTA Circle of Willis
   CTA Carotids
   Lumbar Myelogram
   Thoracic Myelogram
   Cervical Myelogram
   Adult Trauma Face and Trauma Orbit CT (for patients who cannot have direct
    coronals)
   Adult IAC CT - Axial with coronal reconstructions (Direct coronals should be done if
    possible, using other protocol)
   Adult IAC CT
   Adult TMJ CT
        Orthopedic Protocols

   Trauma Pelvis CT Protocol
   Ankle CT Protocol
   Cervical Spine
   Thoracic Spine
   Lumbar Spine CT Protocol
   Shoulder CT
   Sacro-Iliac Joint CT
   Wrist CT Protocol
   Single Cut Hip CT
            Pediatric Protocols
   Routine Head CT
   Craniosynatosis
   Neck/Larynx
   Sinus/Maxillofacial CT
   Orbit/Sella CT
   IAC or TMJ CT
   C-Spine Trauma CT
   Chest CT and/or Abdomen CT and/or Pelvis CT
   High-Resolution Chest CT
   Dynamic Airway Study (on Imatron)
   EBCT Scanning Protocol for CF Subjects Who Have Signed Consent
    Form
   CT Protocol for Cystic Fibrosis in Children
  S.5.P.1. SOP PERSIAPAN PEMERIKSAAN
           TEKNIS & ADMINISTRASI

0 :Tidak ada
1
2
3
4
5 : Lengkap,diketahui direktur
        CONTOH SOP TEKNIS
1.   SOP PENANGANAN ORAL & RECTAL
     CONTRAS AGENT OLEH RADIOGRAPH
2.   SOP PENANGANAN ANTI AXIETY,
     NAUSEA,ANTI EMETIC,ANTI COAGULAN
     BY GP/RN
Std.6. PENGEMBANGAN STAF DAN
       PROGRAM PENDIDIKAN
 SEMUA STAF INSTALASI
 PELATIHAN
 SEMINAR
 DLL
    S.6.P.1. PLANNING SDM
0 : TIDAK ADA PLAN & ANALISIS
1
2
3
4
5 : WRITTEN PLANNING
                     DO
   PROTAP TEKNIS
    - Jadwal pemeriksaan khusus
    - protap :
        a. Pemeriksaan lambung & usus
        b. Pemeriksaan ginjal
        c. USG Abdomen
        d. CT Scan Abdomen
   PROTAP ADMINISTRATIP
    - Prosedur pendaftaran
    - Prosedur pembayaran
    - Prosedur Pengambilan pemeriksaan
    - Prosedur penyimpanan dokumen
    - dll
Std.7. EVALUASI DAN PENGENDALIAN MUTU

 ADA PROSEDUR EVALUASI
 METODE : GKM,QA,TQC
 SELF ASSESTMENT
 S.7.P.1. Ada evaluasi provider
0 :tidak ada
1
2
3
4
5 :Ada analisa darievaluasi tertulis,RTL
                           DO
   Contoh Evaluasi:
    - Angket,Kotak saran
    - Aspek keamanan petugas
    - Aspek penyimpanan bahan radiologi
    - Efek samping dan Medical Error
    - Review pembuatan dan labeling iv contras
   Mekanisme evaluasi mutu & profesional provider :
    - evaluasi teknik
    - evaluasi teknik kualitas pencucian
    - evaluasi expertise
    - evaluasi kecepatan pelayanan/expertise
          Adverse Reactions

 Non-anaphylactoid reactions (nausea, vomiting,
 cardiac arrhythmia, pulmonary edema, seizure,
  renal failure)
 Anaphylactoid reactions (urticaria, laryngeal
  edema, bronchospasm, circulatory collapse)
    Medication Errors in Radiology

   Wrong time 17 3
   Wrong route 19 3
   Extra dose 20 3
   Wrong patient 33 5
   Wrong drug preparation 33 5
   Prescribing error 52 8
   Wrong administration technique 82 13
   Omission error 96 15
   Unauthorized/wrong drug 135 22
   Improper dose/quantity 166 27
    PROPERLY AND SAFELY STORED


Medications are stored and secured under
 conditions suitable for product stability
 and safety
 safe storage
 safe handling
 security
        Medications are Properly
          and Safely Stored

 Unauthorized persons, in accordance with
  hospital policy and applicable law or regulation
  cannot have access to medications
 What medications can radiology technicians
  access?
 What medications can radiology technicians
  administer?
    S.7.P.2. PROGRAM MUTU
0 : TIDAK ADA
1
2
3
4
5 : ADA, MIS : GKM, QA, PEER REVIEW
    PRINSIP : PDCA
              (PLAN,DO,CHEK,ACTION)
                  DO
   PROGRAM MELIPUTI :
    - MUTU ADMINISTARTIP
    - RESPON TIME PELAYANAN
    - MUTU FILM ,RADIOGRAFER, PENCUCIAN
    - REVISI SOP ( KE-BERAPA)
    - PROG. PENINGKATAN SKILL
      (TRAINING,WORKSHOP)
        CONTOH RESPON TIME
         1. Breast Ultrasound:
 Patient Preparation: No preparation
 Duration of this procedure: about    15 minutes
 Technical Details:
  This includes 2D and Doppler Ultrasound
  imaging of breasts.
  This study is useful in:
  * Detection of focal breast disease
  * Characterization of the lesions
  * Assessment of vascularity pattern of the
    lesions
        2.Chest (Thorax) ultrasound

   Patient Preparation: No preparation
   Duration of this procedure: about 15 minutes
   Technical Details:
    This test is done usually as secondary investigation to clarify the
    doubts in chest radiography.
    Chest ultrasound can image the structures which are not air filled
    and when there in no air filled structure between it and the
    ultrasound probe.
    Chest ultrasound is useful in:
    * Detecting pleural and pericardial effusion, even when they are
    minimal
    * Differentiation between consolidation of lung and pleural effusion
    * Assessment of pleural mass, pulmonary mass that is abutting the
    chest wall or heart. Point to be noted here that, if the mass is
    located deep inside the lung, there won't be any window for
    ultrasound beam, so assessment won't be possible.
    MEDICATION RECONCILIATION
          IN RADIOLOGY
   What is Required by the Joint
   Commission?
   Three Required Steps to the Process
   1. Obtain and document a complete list of
   patient’s current medications on entry to the
   organization (with involvement of the patient)
   2. Compare the medications the organization
   provides to those on the list to identify and
   resolve discrepancies

   10
    MEDICATION RECONCILIATION
         IN RADIOLOGY (2)

   Medication Reconciliation
   What is Required by the Joint
   Commission?
   Three Required Steps to the Process
   3. Communicate the patient’s current medication list
   to the next provider on patient transfer or discharge
   Medication Reconciliation
                   Our Challenge
                    (Tantangan)
 Improve medication process and medication
 safety in Radiology
 Meet regulatory standards established by Joint
  Commission
 Decision to use or not use contrast is not always
  determined at the time the procedure is ordered
 Failure to perceive contrast as a drug, belief that
  contrast is safe, inability to visualize a workable process,
  doubt that pharmacists can add safety or value to
  process, computerized prescriber order entry, the
  decision to use contrast is not always made when the
  procedure is ordered, and contrast media is purchased
  and stored in the radiology department.
    RANGKUMAN REKOMENDASI
      PELAYANAN RADIOLOGI
STANDAR   PARAMETER   REKOMENDASI

1         3
2         2
3         4
4         4
5         2
6         1
7         2
          18
              RANGKUMAN REKOMENDASI
                PELAYANAN RADIOLOGI

STANDAR   PARAMETER

1         3                5     15
2         2                5     10
3         4                5     20
4         4                5     20
5         2                5     10
6         1                5      5
7         2                5      10
          18                      90
           RANGKMAN PENILAIAN
NO   STD    5   4   3   2   1   0   JML   JML P   %
PERSENTASE PENCAPAIAN
      STANDAR

       JUMLAH NILAI
% = -------------------------- X 100
    JUMLAH PARAMETER

								
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