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SISTEMATIKA IRAD. SISTEMATIKA 1. Falsafah dan Tujuan 2. Administrasi & Pengelolaan 3. Staf dan Pimpinan 4. Fasilitas & Peralatan 5. Kebijakan & Prosedur.

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Presentasi berjudul: "SISTEMATIKA IRAD. SISTEMATIKA 1. Falsafah dan Tujuan 2. Administrasi & Pengelolaan 3. Staf dan Pimpinan 4. Fasilitas & Peralatan 5. Kebijakan & Prosedur."— Transcript presentasi:

1 SISTEMATIKA IRAD

2 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

3 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

4 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

5 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 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

8 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

9 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

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: 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 1 : Ada tapi lisan, dibuat Ka.Inst. 2 : Ada tertulis,tapi tdk mengacu visi & misi,by Ka.Inst 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

13 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 Std pelay profesi tertulis tidak ada 2 : sda, tak ada std SMF Radiologi & SK Direktur 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 1 : Rutin &UGD ad tapi jam kerja saja,petugas on call on call 2: sda, petugas on site 3 : sda plus petugas on call, ekspertise di luar jam kerja by non DrSpR 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 site,ekspertise oleh Dr.SpR di luar jam kerja kerja

15 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

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

17 DO D: 1. Buku Register pasien atau data komputer komputer 2. Arsip 2. Arsip 3. Standar/pola ketenagaan 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 Pimpinan unit pelayanan Radiologi sebaiknya oleh dokter spesialis Radiologi terdaftar dibantu staf yang berkompeten dan profesional Kebutuhan SDM proporsional dengan aktivitas pelayanan Kebutuhan SDM proporsional dengan aktivitas pelayanan

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

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

21 DO Sub Spesialisasi Radiologi: 1. Radiologi anak 2. Radiologi neuro 3. Radiologi intervensional 4. Kedokteran nuklir

22 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

23 S.3.P.3 STAF PELAKSANA RADIOGRAPHER 0: Operator non nakes, non training : Operator adalah Radiographer purna waktu, sesuai kebutuhan

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

25 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 : Std ruang memenuhi syarat: ada prasarana penunjang, nyaman, sistem prasarana penunjang, nyaman, sistem komunikasi komunikasi

31 DO 1. Std Pelayanan Radiologi kelas C&D (1993) 2. Std Pelayanan Radiologi kelas A&B (1995) 3. 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 : Jumlah, jenis, ability peratan cukup,terawat, ikuti iptek cukup,terawat, ikuti iptek

34 DO R/F Table: u/ fluroscopy R/F Table: u/ fluroscopy Image intensifer : zooming gambar Image intensifer : zooming gambar Buckystand : kaset film u/ zooming foto Buckystand : kaset film u/ zooming foto thorax thorax Mobile unit Mobile unit Iptek : 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. 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 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 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. 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 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. 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. 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. 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. 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 3D rendering

45 Case 3 HISTORY: 49 YR M, STATUS POST ASCENDING/DESCENDING AORTA DISSECTION REPAIR/BENTALL PROCEDURE. RULE OUT DISSECTION. 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. 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. 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 3D rendering

47 Case 4 HISTORY: 42 Y/O M. RIGHT TIBIAL PLATEAU CT WITH THIN CUTS ASSESS FRACTURE. 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. 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. IMPRESSION : COMMINUTED SCHATZKER TYPE V BICONDYLAR FRACTURE. SCANNING PARAMETERS: 2 X 2IMAGE THICKNESS WITH A 1MM RECONSTRUCTION AT 3.5 PITCH. SCANNING PARAMETERS: 2 X 2IMAGE THICKNESS WITH A 1MM RECONSTRUCTION AT 3.5 PITCH.

48 3D rendering of AP tibia 3D rendering of AP tibia

49 Case 5 n HISTORY: 29 Y/O M. FRACTURE. EVALUATE. n FINDINGS: THERE IS POSTERIOR FRACTURE DISLOCATION OF THE RIGHT SHOULDER. THERE IS A FRACTURE THROUGH THE NECK OF THE GLENOID n 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. n 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. 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 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. 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 Lt. and Rt. carotid arteries

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

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

55 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)

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

57 PROTAP ATAU SOP PROTOKOL

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

59 Chest Protocols Abdominal Aortic Aneurysm (AAA) Abdominal Aortic Aneurysm (AAA) Abdominal Aortic Aneurysm (AAA) Abdominal Aortic Aneurysm (AAA) Aortic Dissection Aortic Dissection Aortic Dissection Aortic Dissection Coronary Calcification on EBCT revision Coronary Calcification on EBCT revision Coronary Calcification on EBCT revision Coronary Calcification on EBCT revision Coronary Calcification on Multislice Coronary Calcification on Multislice Coronary Calcification on Multislice Coronary Calcification on Multislice Interstitial Lung Disease (HRCT) Interstitial Lung Disease (HRCT) Interstitial Lung Disease (HRCT) Interstitial Lung Disease (HRCT) Airway Study McLennan Airway Study McLennan Airway Study McLennan Airway Study McLennan Pulmonary Embolism (PE) Chest only Pulmonary Embolism (PE) Chest only Pulmonary Embolism (PE) Chest only Pulmonary Embolism (PE) Chest only Pulmonary Embolism (PE) with Deep Venous Thrombosis (DVT) Pulmonary Embolism (PE) with Deep Venous Thrombosis (DVT) Pulmonary Embolism (PE) with Deep Venous Thrombosis (DVT) Pulmonary Embolism (PE) with Deep Venous Thrombosis (DVT) Pulmonary Nodule Pulmonary Nodule Pulmonary Nodule Pulmonary Nodule Standard Chest CT Standard Chest CT Standard Chest CT Standard Chest CT

60 Neuro Protocols Adult Head CT Adult Head CT Adult Head CT Adult Head CT Adult Sinus CT Adult Sinus CT Adult Sinus CT Adult Sinus CT Adult Orbit CT Adult Orbit CT Adult Orbit CT Adult Orbit CT Adult Neck CT Adult Neck CT Adult Neck CT Adult Neck CT Salivary Gland CT Salivary Gland CT Salivary Gland CT Salivary Gland CT Functional Larynx CT Functional Larynx CT Functional Larynx CT Functional Larynx CT CTA Circle of Willis CTA Circle of Willis CTA Circle of Willis CTA Circle of Willis CTA Carotids CTA Carotids CTA Carotids CTA Carotids Lumbar Myelogram Lumbar Myelogram Lumbar Myelogram Lumbar Myelogram Thoracic Myelogram Thoracic Myelogram Thoracic Myelogram Thoracic Myelogram Cervical Myelogram Cervical Myelogram Cervical Myelogram Cervical Myelogram Adult Trauma Face and Trauma Orbit CT (for patients who cannot have direct coronals) Adult Trauma Face and Trauma Orbit CT (for patients who cannot have direct coronals) Adult Trauma Face and Trauma Orbit CT (for patients who cannot have direct coronals) 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 - Axial with coronal reconstructions (Direct coronals should be done if possible, using other protocol) Adult IAC CT - Axial with coronal reconstructions (Direct coronals should be done if possible, using other protocol) Adult IAC CT - Axial with coronal reconstructions (Direct coronals should be done if possible, using other protocol) Adult IAC CT Adult IAC CT Adult IAC CT Adult IAC CT Adult TMJ CT Adult TMJ CT Adult TMJ CT Adult TMJ CT

61 Orthopedic Protocols Trauma Pelvis CT Protocol Trauma Pelvis CT Protocol Trauma Pelvis CT Protocol Trauma Pelvis CT Protocol Ankle CT Protocol Ankle CT Protocol Ankle CT Protocol Ankle CT Protocol Cervical Spine Cervical Spine Cervical Spine Cervical Spine Thoracic Spine Thoracic Spine Thoracic Spine Thoracic Spine Lumbar Spine CT Protocol Lumbar Spine CT Protocol Lumbar Spine CT Protocol Lumbar Spine CT Protocol Shoulder CT Shoulder CT Shoulder CT Shoulder CT Sacro-Iliac Joint CT Sacro-Iliac Joint CT Sacro-Iliac Joint CT Sacro-Iliac Joint CT Wrist CT Protocol Wrist CT Protocol Wrist CT Protocol Wrist CT Protocol Single Cut Hip CT Single Cut Hip CT Single Cut Hip CT Single Cut Hip CT

62 Pediatric Protocols Routine Head CT Routine Head CT Routine Head CT Routine Head CT Craniosynatosis Craniosynatosis Craniosynatosis Neck/Larynx Neck/Larynx Neck/Larynx Sinus/Maxillofacial CT Sinus/Maxillofacial CT Sinus/Maxillofacial CT Sinus/Maxillofacial CT Orbit/Sella CT Orbit/Sella CT Orbit/Sella CT Orbit/Sella CT IAC or TMJ CT IAC or TMJ CT IAC or TMJ CT IAC or TMJ CT C-Spine Trauma CT C-Spine Trauma CT C-Spine Trauma CT C-Spine Trauma CT Chest CT and/or Abdomen CT and/or Pelvis CT Chest CT and/or Abdomen CT and/or Pelvis CT Chest CT and/or Abdomen CT and/or Pelvis CT Chest CT and/or Abdomen CT and/or Pelvis CT High-Resolution Chest CT High-Resolution Chest CT High-Resolution Chest CT High-Resolution Chest CT Dynamic Airway Study (on Imatron) Dynamic Airway Study (on Imatron) Dynamic Airway Study (on Imatron) Dynamic Airway Study (on Imatron) EBCT Scanning Protocol for CF Subjects Who Have Signed Consent Form EBCT Scanning Protocol for CF Subjects Who Have Signed Consent Form EBCT Scanning Protocol for CF Subjects Who Have Signed Consent Form EBCT Scanning Protocol for CF Subjects Who Have Signed Consent Form CT Protocol for Cystic Fibrosis in Children CT Protocol for Cystic Fibrosis in Children CT Protocol for Cystic Fibrosis in Children CT Protocol for Cystic Fibrosis in Children

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

64 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

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

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

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

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

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

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

71 DO Contoh Evaluasi: 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 : 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, Non-anaphylactoid reactions (nausea, vomiting, cardiac arrhythmia, pulmonary edema, seizure, cardiac arrhythmia, pulmonary edema, seizure, renal failure) renal failure) Anaphylactoid reactions (urticaria, laryngeal Anaphylactoid reactions (urticaria, laryngeal edema, bronchospasm, circulatory collapse) edema, bronchospasm, circulatory collapse)

73 Medication Errors in Radiology Wrong time 17 3 Wrong time 17 3 Wrong route 19 3 Wrong route 19 3 Extra dose 20 3 Extra dose 20 3 Wrong patient 33 5 Wrong patient 33 5 Wrong drug preparation 33 5 Wrong drug preparation 33 5 Prescribing error 52 8 Prescribing error 52 8 Wrong administration technique Wrong administration technique Omission error Omission error Unauthorized/wrong drug Unauthorized/wrong drug Improper dose/quantity Improper dose/quantity

74 PROPERLY AND SAFELY STORED Medications are stored and secured under conditions suitable for product stability and safety Medications are stored and secured under conditions suitable for product stability and safety safe storage safe storage safe handling safe handling security 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 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 access? What medications can radiology technicians administer? What medications can radiology technicians administer?

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

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

78 CONTOH RESPON TIME 1. Breast Ultrasound: Patient Preparation: No preparation Patient Preparation: No preparation Duration of this procedure: about 15 minutes 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 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 lesions

79 2.Chest (Thorax) ultrasound Patient Preparation: No preparation Patient Preparation: No preparation Duration of this procedure: about 15 minutes 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. 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 What is Required by the Joint Commission? Commission? Three Required Steps to the Process Three Required Steps to the Process 1. Obtain and document a complete list of 1. Obtain and document a complete list of patient’s current medications on entry to the patient’s current medications on entry to the organization (with involvement of the patient) organization (with involvement of the patient) 2. Compare the medications the organization 2. Compare the medications the organization provides to those on the list to identify and provides to those on the list to identify and resolve discrepancies resolve discrepancies 10 10

81 MEDICATION RECONCILIATION IN RADIOLOGY (2) Medication Reconciliation Medication Reconciliation What is Required by the Joint What is Required by the Joint Commission? Commission? Three Required Steps to the Process Three Required Steps to the Process 3. Communicate the patient’s current medication list 3. Communicate the patient’s current medication list to the next provider on patient transfer or discharge to the next provider on patient transfer or discharge Medication Reconciliation Medication Reconciliation

82 Our Challenge (Tantangan) Improve medication process and medication Improve medication process and medication safety in Radiology safety in Radiology Meet regulatory standards established by Joint Commission Meet regulatory standards established by Joint Commission Decision to use or not use contrast is not always 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. 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

84 RANGKUMAN REKOMENDASI PELAYANAN RADIOLOGI STANDARPARAMETERREKOMENDASI

85 STANDARPARAMETER

86 RANGKMAN PENILAIAN NOSTD543210JML JML P %

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


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