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DINAS KESEHATAN

UPT PUSKESMAS KROMENGAN


Jalan Nailun Utara No. 104 Karangrejo Kecamatan Kromengan
Telp. 0341 – 4342036 / 085100532160
Email : puskesmaskromengan@gmail.com
Malang 65191

MM PUSKESMAS KROMENGAN |
PEMERINTAH KABUPATEN MALANG
DINAS KESEHATAN
UPTD PUSKESMAS KROMENGAN
Jalan Nailun Utara No. 104 Karangrejo
Kecamatan Kromengan
Telp. 0341 – 4342036 / 085100532160
Email : puskesmaskromengan@gmail.com
KodePos 65191

Lembar Pengesahan

MANUAL MUTU
Kode Dokumen Revisi Tanggal Terbit

MM 00 1 Desember 2016

Dibuat oleh :

SEKRETARIS TIM MUTU

Diperiksa oleh :

WAKIL MANAJEMEN MUTU

Disetujui oleh :

KEPALA UPTD PUSKESMAS


Drg. Herawati
NIP.19790310 200604 2 028

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DAFTAR ISI
Halaman
LEMBAR PENGESAHAN.......................................................................................... i
DAFTAR ISI............................................................................................................... ii
KATA PENGANTAR.................................................................................................. 1
BAB I. PENDAHULUAN
a. Latar Belakang
1. Profil Organisasi
a. Gambaran umum organisasi ............................................................... 2
b. Peta wilayah kerja ............................................................................... 3
c. Wilayah kerja puskesmas .................................................................... 4
d. Karakteristik wilayah ............................................................................ 4
e. Jarak Puskesmas dari Kab. ................................................................. 4
f. Piramida penduduk .............................................................................. 5
g. Penduduk per kelompok ...................................................................... 5
h. Data sarana dan prasarana ................................................................. 6
i. Data ketenagaan ................................................................................. 7
j. Sturktur Organisasi Puskesmas .......................................................... 8
k. Visi dan Misi ........................................................................................ 10
2. Kebijakan Mutu ......................................................................................... 11
3. Proses Layanan ........................................................................................ 11
b. Ruang Lingkup ............................................................................................... 20
c. Tujuan ............................................................................................................ 21
d. Landasan Hukum ........................................................................................... 21
BAB II. SISTEM MANAJEMEN
a. Persyaratan Umum ........................................................................................ 24
b. Pengedalian Dokumen ................................................................................... 24
c. Manual Mutu ................................................................................................. 29
d. Rencana Limata hunan .................................................................................. 32
e. Perencanaan Tingkat Puskesmas ................................................................. 34
f. Pedoman / Panduan ...................................................................................... 35
g. Standar SOP .................................................................................................. 42
BAB III. TANGGUNG JAWAB MANAJEMEN
a. Komitmen Manajemen ................................................................................... 55
b. Fokus pada Pelanggan .................................................................................. 55
c. Kebijakan Mutu .............................................................................................. 55
d. Perencanaan Sistem Manajemen Mutu .................................................................... 56
Sasaran Mutu ................................................................................................ 56

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INDIKATOR DAN TARGET KINERJA PROGRAM UKM ......................................... 58
INDIKATOR MUTU LAYANAN KLINIS ................................................................... 123
e. Tanggung Jawab, Wewenang dan Komunikasi ........................................... 129
f. Struktur Tim Mutu Puskesmas ..................................................................... 135
BAB IV. TINJAUAN MANAJEMEN
a. Umum ...................................................................................................................... 144
b. Masukan dari Tinjauan ............................................................................................ 144
c. Keluaran dari Tinjauan ............................................................................................ 144
BAB V. MANAJEMEN SUMBER DAYA
a. Penyediaan Sumber Daya ........................................................................... 146
b. Manajemen Sumber Daya Manusia ............................................................. 146
c. Infrastuktur ................................................................................................... 146
d. Linkungan Kerja .......................................................................................... 146
BAB VI. PENYELENGGARAAN KERJA
a. Upaya Kesehatan Masyarakat UKM ............................................................ 150
b. Upaya Kesehatan Perseorangan UKP ......................................................... 155
PERHITUNGAN AREA PRIORITAS ....................................................................... 170
BAB VII. PENUTUP ................................................................................................. 175

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