SISTEMATIKA IRAD

SISTEMATIKA
1.
2.
3.
4.
5.
6.
7.

Falsafah dan Tujuan

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

SISTEMATIKA
1.
2.
3.
4.
5.
6.
7.

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

SISTEMATIKA
(FAS FKPE)
1.
2.
3.
4.
5.
6.
7.

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

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

SISTEMATIKA
PENILAIAN PELAYANAN
RADIOLOGI RUMAH
SAKIT

SISTEMATIKA
1.
2.
3.
4.
5.
6.
7.

Falsafah dan Tujuan

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

SISTEMATIKA
1.
2.
3.
4.
5.
6.
7.

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

SISTEMATIKA
(FASFKPE)
1.
2.
3.
4.
5.
6.
7.

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

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
1

2
3

4
5

: Pel Emergensy tidak ada,hanya on call

: Rutin &UGD ad tapi jam kerja saja,petugas
on call
: sda, petugas on site
: sda plus petugas on call, ekspertise di luar
jam kerja by non DrSpR
: sda,petugas on site dan expertise by
DrSpR
: Ada rutin 24 jam,petugas on
site,ekspertise oleh Dr.SpR di luar jam
kerja

Std.2.ADMINSTRASI
&PENGELOLAAN:
Bagan Organisasi & uraian
0
: Tidak ada struktur organisasi
tugas
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
Std Pelayanan Radiologi kelas C&D
(1993)
2. Std Pelayanan Radiologi kelas A&B
(1995)
3. Ijin BATAN
1.

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 Sca
n)

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 Thro
mbosis (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 d
one 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

SOP PENANGANAN ORAL & RECTAL
CONTRAS AGENT OLEH
RADIOGRAPH
2. SOP PENANGANAN ANTI AXIETY,
NAUSEA,ANTI EMETIC,ANTI
COAGULAN BY GP/RN
1.

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
patients 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 patients 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

2
18

REKOMENDAS
I

RANGKUMAN REKOMENDASI
PELAYANAN RADIOLOGI

STANDAR

PARAMETER

15

10

20

20

10

10

18

90

RANGKMAN PENILAIAN
NO

STD

JML

JML P

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