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SISTEMATIKA IRAD.

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Presentasi berjudul: "SISTEMATIKA IRAD."— Transcript presentasi:

1 SISTEMATIKA IRAD

2 SISTEMATIKA Falsafah dan Tujuan Administrasi & Pengelolaan
Staf dan Pimpinan Fasilitas & Peralatan Kebijakan & Prosedur Pengembangan & Program Pendidikan Evaluasi & Pengendalian Mutu

3 SISTEMATIKA Falsafah dan Tujuan ( 3 Parameter)
Administrasi & Pengelolaan ( 2 ) Staf dan Pimpinan ( 4 ) Fasilitas & Peralatan ( 4 ) Kebijakan & Prosedur ( 2 ) Pengembangan & Prog Pendidikan (1) Evaluasi & Pengendalian Mutu ( 2 ) Total : 18 Parameter

4 SISTEMATIKA (FAS FKPE)
Falsafah dan Tujuan ( 3 Parameter) Administrasi & Pengelolaan ( 2 ) Staf dan Pimpinan ( 4 ) Fasilitas & Peralatan ( 4 ) Kebijakan & Prosedur ( 2 ) Pengembangan & Prog Pendidikan (1) Evaluasi & Pengendalian Mutu ( 2 ) Total : 18 Parameter

5 DINAS KESEHATAN PROPINSI JAWA TIMUR
BIMBINGAN AKREDITASI DI RUMAH SAKIT MOJOSARI 10 MARET 2008 OLEH TIM DINAS KESEHATAN PROPINSI JAWA TIMUR

6 SISTEMATIKA PENILAIAN PELAYANAN RADIOLOGI RUMAH SAKIT

7 SISTEMATIKA Falsafah dan Tujuan Administrasi & Pengelolaan
Staf dan Pimpinan Fasilitas & Peralatan Kebijakan & Prosedur Pengembangan & Program Pendidikan Evaluasi & Pengendalian Mutu

8 SISTEMATIKA Falsafah dan Tujuan ( 3 Parameter)
Administrasi & Pengelolaan ( 2 ) Staf dan Pimpinan ( 4 ) Fasilitas & Peralatan ( 4 ) Kebijakan & Prosedur ( 2 ) Pengembangan & Prog Pendidikan (1) Evaluasi & Pengendalian Mutu ( 2 ) Total : 18 Parameter

9 SISTEMATIKA (FASFKPE)
Falsafah dan Tujuan ( 3 Parameter) Administrasi & Pengelolaan ( 2 ) Staf dan Pimpinan ( 4 ) Fasilitas & Peralatan ( 4 ) Kebijakan & Prosedur ( 2 ) Pengembangan & Prog Pendidikan (1) Evaluasi & Pengendalian Mutu ( 2 ) Total : 18 Parameter

10 AKREDITASI PELAYANAN RADIOLOGI
TIM AKREDITASI DINKES PROPINSI JAWA TIMUR MOJOSARI 2008

11 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

12 S.1.P1 0 : Tak ada falsafah & tuj instalasi
: Ada tapi lisan, dibuat Ka.Inst. : Ada tertulis,tapi tdk mengacu visi & misi,by Ka.Inst : Ada tertulis,blm mengacu,by Ka.Inst & staf : Ada tertulis,mengacu,by Ka.Inst & Staf : sda 4 plus diberlakukan by pimpinan

13 S.1.P.2 : Yan Rad=Yan RS=Yan Profesi
0 : Tidak ada standar pelayanan : Ada std pelay sesuai Depkes,tertulis, Std pelay profesi tertulis tidak ada : 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

14 S.1.P.3. YAN RAD 24 JAM 0 : Pel Emergensy tidak ada,hanya on call
: Rutin &UGD ad tapi jam kerja saja,petugas on call 2 : sda, petugas on site : sda plus petugas on call, ekspertise di luar jam kerja by non DrSpR 4 : sda,petugas on site dan expertise by DrSpR : Ada rutin 24 jam,petugas on site,ekspertise oleh Dr.SpR di luar jam kerja

15 Std.2.ADMINSTRASI &PENGELOLAAN: Bagan Organisasi & uraian tugas
0 : Tidak ada struktur organisasi : 2 : 3 : 4 : 5 : Ada + uraian tugas lengkap by Dir RS

16 S.2.P.2 : 0 : Tidak ada petugas khusus pencatatan 1 2 3 4
5 : Ada, sesuai kebutuhan,evaluasi

17 DO D : 1. Buku Register pasien atau data komputer 2. Arsip
3. Standar/pola ketenagaan

18 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

19 S.3.P.1: Kepala SpRD 0 : Pimpinan bukan nakes 1 2 3 4
5 : Pimpinan Dr Sp Radiologi purna waktu

20 S.3.P.2 Staf Medik Fungsional Radiologi
0 : Pelaksana GP/ Spesialis non radiologi 1 2 3 4 5 :Pelaksana Dr SpRad

21 DO Sub Spesialisasi Radiologi: Radiologi anak Radiologi neuro
Radiologi intervensional Kedokteran nuklir

22 Bidang Kekhususan : Multi Slice CT Helical CT MRI Angiografi USG Dopler : USG plus visualisasi pembuluh darah Mammografi : Khusus payudara

23 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

24 S.3.P.4 Rapat Berkala 0 : Tidak ada rapat 1 2 3 4
: Ada jadwal rapat,hadir lengkap,notulen dan RTL

25 Std. 4. Fasilitas & Peralatan Standar Ruangan Imaging(aman,luas &
Std.4.Fasilitas & Peralatan Standar Ruangan Imaging(aman,luas & nyaman)

26 Ruang Kabinet

27 Ruang Baca

28 RUANG SCREENING

29 RUANG TUNGGU

30 S.4.P1 0 : Ruang tidak memenuhi standar 1 2 3 4
: Std ruang memenuhi syarat: ada prasarana penunjang, nyaman, sistem komunikasi

31 DO Std Pelayanan Radiologi kelas C&D (1993)
Std Pelayanan Radiologi kelas A&B (1995) Ijin BATAN

32 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

33 S.4.P.3. Kualitas Peralatan 0 : Jumlah minim,tak terawat 1 2 3 4
: Jumlah , jenis, ability peratan cukup,terawat, ikuti iptek

34 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

35 CT SCAN

36 MEDICAL SONOGRAPHY

37 MAMOGRAPHY

38 IMAGE TRANSFER

39 BUCKY STAND

40 Case Studies Multislice CT

41 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.

42 3D rendering Curved multiplanar reformat

43 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.

44 3D rendering

45 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.

46 3D rendering

47 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.

48 3D rendering of AP tibia

49 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.

50 3D rendering of AP scapula

51 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 CC CONTRAST WAS INJECTED AT 3 CC PER SECOND WITH 18 SECOND SCAN DELAY.

52 Lt. and Rt. carotid arteries

53 S.4.P.4. OBAT & PERALATAN BASIC LIFE SUPPORT FOR ALERGI BAHAN KONTRAS
0 : Tak ada 1 2 3 4 : Ada lengkap obat,cairan infus,02 dan peralatan

54 DAFTAR OBAT & PERALATAN
- adrenalin inj - anti histamin - Kortison - Dopamin Daftar Peralatan - alkes: needle,spuit - infus set dan standar infus - suction pump

55 DAFTAR MEDIA KONTRAS – Iohexol (Omnipaque®, GE Healthcare)
• 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)

56 Std.5 KEBIJAKAN DAN PROSEDUR
PERLU PROTAP (SOP) WRITTEN SOP

57 PROTAP ATAU SOP PROTOKOL

58 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)

59 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

60 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

61 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

62 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

63 S.5.P.1. SOP PERSIAPAN PEMERIKSAAN TEKNIS & ADMINISTRASI
0 :Tidak ada 1 2 3 4 5 : Lengkap,diketahui direktur

64 CONTOH SOP TEKNIS SOP PENANGANAN ORAL & RECTAL CONTRAS AGENT OLEH RADIOGRAPH SOP PENANGANAN ANTI AXIETY, NAUSEA,ANTI EMETIC,ANTI COAGULAN BY GP/RN

65 Std.6. PENGEMBANGAN STAF DAN PROGRAM PENDIDIKAN
SEMUA STAF INSTALASI PELATIHAN SEMINAR DLL

66 S.6.P.1. PLANNING SDM 0 : TIDAK ADA PLAN & ANALISIS 1 2 3 4
5 : WRITTEN PLANNING

67 DO PROTAP TEKNIS - Jadwal pemeriksaan khusus - protap :
a. Pemeriksaan lambung & usus b. Pemeriksaan ginjal c. USG Abdomen d. CT Scan Abdomen

68 PROTAP ADMINISTRATIP - Prosedur pendaftaran - Prosedur pembayaran - Prosedur Pengambilan pemeriksaan - Prosedur penyimpanan dokumen - dll

69 Std.7. EVALUASI DAN PENGENDALIAN MUTU
ADA PROSEDUR EVALUASI METODE : GKM,QA,TQC SELF ASSESTMENT

70 S.7.P.1. Ada evaluasi provider
0 :tidak ada 1 2 3 4 5 :Ada analisa darievaluasi tertulis,RTL

71 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

72 Adverse Reactions Non-anaphylactoid reactions (nausea, vomiting,
cardiac arrhythmia, pulmonary edema, seizure, renal failure) Anaphylactoid reactions (urticaria, laryngeal edema, bronchospasm, circulatory collapse)

73 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 Improper dose/quantity

74 PROPERLY AND SAFELY STORED
Medications are stored and secured under conditions suitable for product stability and safety safe storage safe handling security

75 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?

76 S.7.P.2. PROGRAM MUTU 0 : TIDAK ADA 1 2 3 4
: ADA, MIS : GKM, QA, PEER REVIEW PRINSIP : PDCA (PLAN,DO,CHEK,ACTION)

77 DO PROGRAM MELIPUTI : - MUTU ADMINISTARTIP - RESPON TIME PELAYANAN
- MUTU FILM ,RADIOGRAFER, PENCUCIAN - REVISI SOP ( KE-BERAPA) - PROG. PENINGKATAN SKILL (TRAINING,WORKSHOP)

78 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

79 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.

80 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

81 MEDICATION RECONCILIATION IN RADIOLOGY (2)
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

82 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.

83 matur nuwun

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

85 RANGKUMAN REKOMENDASI PELAYANAN RADIOLOGI
STANDAR PARAMETER 1 3 15 2 10 4 20 5 6 7 18 90

86 RANGKMAN PENILAIAN NO STD 5 4 3 2 1 JML JML P %

87 PERSENTASE PENCAPAIAN STANDAR
JUMLAH NILAI % = X 100 JUMLAH PARAMETER


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