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SISTEMATIKA IRAD

SISTEMATIKA IRAD. SISTEMATIKA. Falsafah dan Tujuan Administrasi & Pengelolaan Staf dan Pimpinan Fasilitas & Peralatan Kebijakan & Prosedur Pengembangan & Program Pendidikan Evaluasi & Pengendalian Mutu. SISTEMATIKA. Falsafah dan Tujuan ( 3 Parameter) Administrasi & Pengelolaan ( 2 )

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SISTEMATIKA IRAD

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  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. 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 & 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 RATEWAS 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

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