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 tugas
0 : Tidak ada struktur organisasi
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
1.
2.
3.
Std Pelayanan Radiologi kelas C&D
(1993)
Std Pelayanan Radiologi kelas A&B
(1995)
Ijin BATAN
S.4.P.2 : Tipe Ruangan
0:
1:
2:
3:
4:
5:
Ruang a: R.Periksa+kamar gelap
Ruang a + R.TungguPasien
+ R. Petugas
+ R.R.Adm
+ R.Ekspertise
+ > 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
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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
reformat
Curved multiplanar
Case 2
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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
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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
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


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 Scan)

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
Chest Protocols

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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
Neuro Protocols
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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
Orthopedic Protocols

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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

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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
1.
2.
SOP PENANGANAN ORAL & RECTAL
CONTRAS AGENT OLEH RADIOGRAPH
SOP PENANGANAN ANTI AXIETY,
NAUSEA,ANTI EMETIC,ANTI COAGULAN
BY GP/RN
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
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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
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

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
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
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10
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MEDICATION RECONCILIATION
IN RADIOLOGY (2)
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Medication Reconciliation
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
Medication Reconciliation
Our Challenge
(Tantangan)
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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
1
3
2
2
3
4
4
4
5
2
6
1
7
2
18
REKOMENDASI
RANGKUMAN REKOMENDASI
PELAYANAN RADIOLOGI
STANDAR
PARAMETER
1
3
5
15
2
2
5
10
3
4
5
20
4
4
5
20
5
2
5
10
6
1
5
5
7
2
5
10
18
90
RANGKMAN PENILAIAN
NO
STD
5
4
3
2
1
0
JML
JML P
%
PERSENTASE PENCAPAIAN
STANDAR
JUMLAH NILAI
% = -------------------------- X 100
JUMLAH PARAMETER