EARLY

DESIMINATION
Inpatient 3rd floor ward RSUA

M1 = Man
Nurse workforce analysis includes the number of nursing and
non-nursing personnel, Inpatient 3rd Floor ward RSUA nurses
have 17 people with bachelor degree of nursing and 1 people
with magister of nursing background and several nursing
personnel who have been trained.

The number of nurses is on the Inpatient 3rd Floor

RSUA are 15 people plus 2 people in structural (Unit
Coordinator and Vice Unit Coordinator)

Structural Organization
Unit Coordinator 3rdrd Floor Ward
Rahmatul Fitriyah, S.Kep.,Ns

Vice Unit Coordinator 3rdrd Floor Ward

Zaenal Abidin, S.Kep.,Ns

Primary Nurse 1
Widyawati, S.Kep.,Ns

Associate Nurse
1. Nurul K, S.Kep., Ns
2. Dwi C. M, S.Kep., Ns
3. Eni P. L, S.Kep., Ns
4. Samsul H, S.Kep., Ns, M.Kep

Primary Nurse 2
Alwan Reval S.Kep.,Ns

1.
2.
3.
4.

Associate Nurse
Fauziah F, S.Kep., Ns
Nurya, S.Kep., Ns
Siti Nur I, S.Kep., Ns
Masfin M, S.Kep., Ns

Primary Nurse 3
Aulya Afifatur Rochmah, S.Kep.,Ns

Associate Nurse
1. Ahmad F, S.Kep., Ns
2. Pamela R. A, S.Kep., Ns
3. Shahtya D, S.Kep., Ns
4. Rio Yanuar, S.Kep., Ns

Medical and Nursing

Staffs
No
Qualificatiion
1
2

Total
33 peoples
17 peoples

Specialist Doctor
Nurses

Non Medical Staffs

No
1
2
3
4

Qualification
Nutrisionist
Cleaning Service
Heatlh Care Assistant
Administration
Jumlah

Total

Type

1 peoples
3 peoples
1 peoples
1 peoples
6 peoples

Central
Central
Honorer RSUA
Honorer RSUA

10 main cases of disease per AugustOktober 2014 in inpatient instalation 3rd

floor ward RSUA
N
o

Desease

1.
2.
3.
4.
5.
6.
7.
8.
9.
10

DM
CKD
TB
CVA
SH
HIV/AIDS
GEA
Hepatitis
Pneumonia
Efusi Pleura

August

Month
September

Oktober

7
4
10
5
2
5
6
4
7
6

18
13
9
7
8
4
3
3
2
2

16
17
5
7
6
2
2
3
1
0

Total
41
34
24
19
16
11
11
10
9
8

Precentage
23,03
19,10
13,48
10,67
8,99
6,18
6,18
5,46
5,06
4,49

The Need Of Nursing Staff Based On

Dependence Patient And Nurse
Recruitment On November 10th 2014
Nursing staff recruitment based on Douglas method
Clasification
Minimal care

Total
0

Nursing staff needed

Morning shift Afternoon shift
Night shift
0 x 0.17 = 0
0 x 0.14 = 0
0 x 0,10 = 0

Suggest nursing staff per day : 9 peoples

Nursing staff recruitment based on
Gillies method
Suggest nursing staff per day : 13 peoples

Nursing staff recruitment based on Health

Ministry
method
No
Category
Average
Average
patient per
day
1

Internal patient

13

treatments
hours per
pasien per day
3,5

2
3
4
5

Surgery patient
Emergency patient
Pediatric patient
Obstetric patient
Total

1
0
0
0
14

4
10
4,5
2,5
24,5

the number of
treatments per
day
45,5
4
0
0
0
49,5

Formula :

( total number of nurses + loss day) x 25%

(7 + 2) x 25 % = 2,25 = 2 nurses
Number of nurses = personnel available + Loss day + non nursing job
= 7 + 2+ 2
= 11 nurses

ses Work Load in 3rd floor ward RSUA per November 11th-12rd 2014
Work
Date

Shift

Produktif

Morning
95,9%
Shift
11-13 November
Afternoon
2014
92,5%
Shift
the average productive
of nurses
Night workload
shift
64,3%
criteria (84.2%)
Average per day
84,2%

NonProd
uktif
11,1%
15,9%

per day
49,2%
25,4%

in high

Percentage of work satisfaction of nurses

Nursing satisfaction working
Salary
Facility
Employment
Relationship
Suitability Of
Work
Supervision
Promotion

STP

TP

CP

SP

0%
3,6%

25%
24,3%

56,8%
38,2%

18,2%
30,9%

0%
0%

0%

0%

24,2%

60,6%

15,2%

0%

9,0%

45,5%

45,5%

0%

0%
0%

15,2%
30,3%

48,4%
48,5%

27,3%
21,2%

9,1%
0%

1. 56,8% said they felt quite satisfied for the salaries of nurses
2. 38,2% said they felt quite satisfied for the facilities available in the
hospital
3. 60,6% say they are satisfied for labor relations
4. 45,5% say they are quite satisfied and satisfied as to the suitability of
work
5. 48,4% said they felt quite satisfied for supervision in the workplace
6. 48,5% said they felt quite satisfied for promotion.

M1 Problem identification
Data

Problem

Etiologi

W: Nurses 3rd floor ward RSUA say MAKP has MAKP has been no training There are no
for nurses 3rd floor ward
not been trained.
planned training
RSUA
O: From the observations were carried out on
MAKP from the
11/12/2014 found that MAKP is not training.
D: There is no documentation of MAKP training
certificates

3rd floor ward

RSUA.

M1 Plan of Action
Problem
M1 MAN
Nurse 3rd floor
ward RSUA not
follow MAKP
training

Purpose
Improvin 1.
g the
quality of
human 2.
resource
s in
nursing
care
services

Plan

Goal Indicator

Time

Coordinator

Encourage
MAKP 1. The basic
Week
needs
of
training at all nurses in
3-5
patients are
3rd floor ward RSUA.
met
Support
refresher 2. The nurse
nursing by competent
said they
personnel periodically.
were
satisfied with
the work

Diah Susmiarti
Fawas Murtadho
Santoso

M2 = Materials
Facilities
Based on the results of the questionnaire infrastructure
100% of the nurses can use equipment
63% of nurses expressed need additional equipment,
45% of nurses stated inadequate administrative support.
Identify The Problem
Problem
1. Lack of support facilities and infrastructure such as kitchen, bell patients
who have not functioned and no kitchen on the 3rd floor RSUA.
Cause
2. There has been no opportunity to install and maximize the functionality of
equipment functions as a high workload and development planning should
be gradual.

M2 Plan of Action
Problem
Lack
of
support
facilities
and
infrastructure such as
kitchens, bell patients
who
have
not
functioned and no
kitchen on the 3rd
floor RSUA.

Purpose

Plan

Goal Indicators

time

coordinator

Kanisius
In order for the 1. Observe the availability 1.For
a Minggu Petrus
of
facilities
and
IV
Siga Tage, S.Kep
room
comparison
infrastructure
IRNA
infrastructure
between the
Level 3 and adjust the
Inpatient
3rd
availability of
MOH standards
floor can be
infrastructur
2.
Make
a
report
on
maximized its
es with a
unused tool and not
use to those
reference
available
to
the
officer
who have used,
standard in
in charge
plus for the
hospital
3.
Preparation
of
a
regular
less, and which
accreditation
schedule of activities
has not been
manuals
room inventory of
inventoried
2.The person in
facilities
and
charge of the
infrastructure
inventory of
4. Checking back post
infrastructur
Inventory of goods and
e
equipment
3.The absence
of
any
inventory
process

M3 = Methods
MAKP
W:
Nurses 3rd floor: 100% primary MAKP is applied 82% managed of job
description were clear, but in the working 45% isnt suitable with MAKP model.
Cord. Unit & O:
MAKP has been applied,special condition like PN helping AN in the nursing
implemetation was happened when the patient exceeds the capacity.
D:
distribution of patients managed , NP and AN in charge already written.
PROBLEM: Implementation of the primary MAKP has been already done, but if
the number of patients exceeds the capacity occurs, PN helping AN
in the nursing implemetation
CAUSE: High workload

ACCEPTED NEW PATIENTS

W:
Nurses 3rd floor: 82% nurses have been doing introduction, explaining the rules
and disease, and do documented. 73% no leaflets or brochures about disease
Coord. Unit &O :
Acceptance of new patients already well done, only if the patient exceeds the
capacity, a description of the disease is not always given directly. no visitor cards
and schedules visit card
D:
all formats acceptance of new patients has been completed and signed by the
nurse and the patient or family
PROBLEM: description of the disease and regulations have been implemented, but
not optimal yet
CAUSE: No leaflets and brochures about disease, there arent visiting
cards which given to the family.

DISCHARGE PLANNING
W:
Nurses 3rd floor: 82% do discharge planning when patients out from the hospital
and no distribution of leaflets in all patients.
Coord unit & O, D:
discharge planning doing good when patient out from hospital but in caring
process no documentation yet after educated, and no leaflets

PROBLEM: Health education were given to every patient and family when out
from hospital, but no leaflets / brochures given.
CAUSE: Unavailable of leaflets or brochures by the hospital and there is no
planning for maintenance dischare format

DRUG CENTRALIZATION
W:
45% said there isnt inform consent of drug centralization to patient /
family, 73% stated that centralization of existing drugs in the room already
implemented optimally
Coord. Unit, O, D:
centralization has been done for every drug, except syrup, medication
chart has documented well but no consent form drug centralization of patient /
family
PROBLEM: There is no specific format for the centralized drug approval, the type
of drug has not been centralized syrup.
CAUSE: There isnt inform consent of drug centralization to patient / family

NURSING ROUND
W:
82% of nurses said the implementation of nursing rounds is not optimal yet,.
Coord. Unit, O, D:
Nursing round has been done by profesion student and during this time for
prolong case, case study already done by medic &paramedic

team,

documentation of case study already done.

PROBLEM: Nursing rounds have been implemented but the implementation is
not maximized.
CAUSE: Limitless of nurse personnel make workload increase, so nurse have
more time use for caring.

DOCUMENTATION
W:
55% of nurses stated the documentation is not implemented on time (not
immediately after performing the action). 73% of nurses stated that the model
is time-consuming documentation nurses.
Coord Unit, O, D :
nursing documentation already well done but very time-consuming so that all
implementation that have been done are not immediately documented. Every
documentation writing in SBARs system.
PROBLEM: Filling of medical records do not immediately after nursing
implementation allowing forget to fill.
CAUSE: The increase in workload because of the limitations of nursing.

HAND OVER
W:
100% stated hand over done for 3 times, 18% hand over doesnt start on time.
Coord Unit, O, D:
Sometimes hand over not on time, some of nurse write the documentation
when hand over starting. the documentation hand over already well done.
PROBLEM: some of nurses are still completing documentation when hand over
starting, and sometimes hand over not on time
CAUSE: Time management isnt appropriate, and increase in workload.

SUPERVISION
W:
Nurses 3rd floor 36% nurses said there isnt form for supervision of
implementations, 55% there isnt feed back from supervisor, 64% want to
change for every implementation suitable like result.
Coord Unit, O:
supervision done any time and verbal feedback give direcly, supervision has
not been scheduled in assesment 10-14 November 2014
D:
There is no documentation result of implementation supervision

PROBLEM: supervision has not been scheduled, the documentation of

supervision result just give by verbal
CAUSE: Supervision has not been scheduled

M3 Plan of Action
Problem
Purpose
Plan
M3 Methode
1. Applying the model
MAKP
Expected
after MAKP planned in
Implementation of the management practices providing nursing care
primary MAKP has been by students FKP in of
patients
under
running well, but if the Space Inpatient Level management.
number of patients
3 is able to apply 2. Evaluate
the
exceeds the capacity
MAKP
primary implementation model
occurs penanambahan PPnursing
well. of MAKP has been
task concurrently PA
done in providing
nursing
care
of
patients
under
management.

Indicator

Time Coordinator
Minggu Evelin P, S.Kep
MAKP is applied either primary3-4
nursing

M4 = Money
Sources
1. Room financing and training: APBN and RKAT unair
2. Salary sorces:
PNS: APBN
Honorer: RKAT rektorat
contract: Airlangga university hospital
3.Patient Financing: general patients, personally, BPJS and jamkesmas
non-quota.

4. Based on the interview on September 11th 2014, to 3rd floor

nurses:
. There were 5 respondents (83.3%) who are contract workers
and honorary said that the payments made under the regional
minimum wage of Surabaya.
. All respondents (100%) said no remuneration.
. There are three respondents (27.3%) did not receive additional
income such as fees, transport and food allowances
5. Result of interview to clarify the results of the questionnaire under
the responsibility of the Remuneration found that the income
from the billing is divided into 40% for income together (all
employees), 55% returned to their respective units and 5% to
cash in nursing. Remuneration is divided every 3-4 months with
rapel system. Remuneration granted to civil servants and noncivil servants (contract and honorary), this remuneration for the
distribution by level of education, responsibility (coordinator, the
chief unit, PN and AN), workload, tenure and employment status
(as a civil servants and non-civil cervants).
24

6.

7.

Based on interviews with officers BPJS: AUH is not cooperate

with major insurance companies and the lack of public
patients. AUH parties cooperate with BPJS and a few
insurance companies such as Bangun Arti Insurance and
Cipta Dimensi Insurance.
According to the results of interviews with the patient's
family, there were 17 patients BPJS (100%) said they had no
difficulty in taking care of BPJS services, because they had
been given information by nurses and administration.

M4 Plan of Action
Problem

Purpose

The lack of a
common number of
general patients and
the patients with
insurance
from
major
insurance
companies.

To increase the
number of general
or private patients
who using large
insurance
companies.

Plan

Goal Indicator

Recommend
to 1. There is an
collaborate
with
enhancement in
major
insurance
the number of
companies such as
general patients.
Prudential, Alians 2. Theres an
and AXA insurance
enhancement of
company.
the number of
patients who use
the health
insurance from
major insurance
companies

M5 = Marketing
Main Point

1. Improved quality (assessment risk of falls, anxiety, selfcare, pain, plebitis, decubitus, UTI, SSI, and pneumonia)
2. Patient Safety
1) Patient identification correcly
2) Effective Communication
3) Drug Safety
4) Right Surgery (location, patient and procedure)
5) Reduction of risk Infection
6) Reduction of Patient Fall
3. ALOS (Average Length of Stay), BTO (Bed Turn Over)

Improved quality
N
o.
1.
2.
3

Risk of Fall

Morning
Shift
4
4
7
15 Patient

Afternoon
Shift
3
6
7
18 Patient

No
risk
assessment
of risk falls
Moderate Risk
High Risk
Total

Evening
Shift
1
9
7
17 Patient

Assesment risk fall using Morse Fall Scale on

11th November 2014, Patients at high risk of
fall in IRNA 3rd floor RSUA are elderly patients
and patients with loss awareness

Patient Satisfaction
No. Level of
Satisfaction
1.
very satisfied
2.
satisfied
3.
not satisfied
4.
very dissatisfied
Total

Total
1
13
14

percentag
e
7,15%
92,85%
0%
0%
100%

Assessment of patient satisfaction using satisfaction

questionnaire on 11th November 2014 about 92.85%
of patients satisfied with giving care of nurses

Patient Anxiety
No. Level of Anxiety Total
Percenta
Patient
ge
11
91,64%
1.
Normal
2.
Low
1
8,33%
3.
Moderate
0%
4.
High
0%
12 Self Rating
100%
Anxiety
assesment using Zung
Total
Anxiety Scale (SAS/SRAS) on 11th November
2015 about 8,33% (1 patient) has a Low
Anxiety

SELF CARE
Self Care assesment using KATZ index on
11-12th November 2014 about 4 patients
with G index because low awareness and
cannot do activity such as incontinent
urine/alvi, toileting, eating, etc

Restrain
Patient in IRNA 3rd Floor RSUA on 11th
November 2014, there was 1 patient with restrain
because low awareness.

Decubitus
Decubitus assesment using Norton Scale on 10-12th
November 2014, 4 patients have decubitus, but
decubitus were gotten before nursing care in 3rd Floor
RSUA.

Phlebitis
No. Phlebitis
1.
2.

Yes
No
Total

10/11/1 11/11/1 12/11/1 13/11/1 14/11/1 15/11/1

4
4
4
4
4
4
2
3
1
3
1
0
15
15
16
14
14
11
17
18
17
17
15
11

Phlebitis Assessment using Visual Infussion Score

(VIS) on 10-15th November 2014 for patient with IV
line, percentage phlebitis about 9,37% majority by
elderly patient because many factors.

UTI, SSI, Pneumonia

Using UTI assesment, Southampton Scoring
System , and Clinical Pulmonary Infection Score (CPIS)
No patient in 3rd floor RSUA suffer UTI, SSI,
and Pneumonia

Patient Safety
1. Patient identification correcly
1) Using pink or blue bracelet
2) Include name, age, address, birth date,
and medic record number
3) Assesment on November11th 2014,
about 53,3% (8 patient from15
patients) do not clearly about purpose
to put identification bracelet

Effective communication

Using SBAR method (Situation, Background,

Assesment, Recommendation)

Drug Safety
Labeling and double crosscheck for high

alert drug is available

No incident medication error
Right Surgery (location, patient and procedure)
include Correct-Site, Correct-Procedure,CorrectPatient Surgery, time in and time out system

Reduction of risk Infection

has special team for infection control

Socialiszation about hand hygiene has
not optimal from the nurses yet
10 patient or family (66,67%) do not
know about hand hygiene in 6 steps
correcly

Reduction of Patient Fall

Reduce of patient fall with close side rail

There is form for risk fall assesment
No sign risk fall or yellow bracelet

ALOS (Average Length of Stay)

From ALOS formula , on Agust October
2014 average value is 4,11 day

M5 Plan of Action
Proble purpose
m
M5Effort
to
Market improve the
ing
quality
of
service

plan
Propose explanation of
health education for
main purpose use
identity bracelet to the
patient and family.

goal

Every patient
using identity
bracelet and
know the
purpose of
identity bracelet
Propose to sign risk of IRNA 3rd floor
fall for IRNA 3rd Floor has a sign the
RSUA
risk of fall is
used according
to its function.
Propose to conduce
3. All patients
health education about and families
hand hygiene to
know how to
patient and family.
wash hands
correctly and
know the
benefits of using
handrub.

time coordinat
or
nd
2
Kusmanto,
week S.Kep

Eveline
Paskalia
Mea Mau,
S.Kep
Mardhiyah
Hayati,
S.Kep

Problem Priority
No.
1.
2.
3.
4.

Identification Persystem
(M1-M5)
M5-Mutu
Pasien Safety
M3
Discharge Planning
M3
Drug Centralization
M5-Mutu
Pasien Safety

5.

M3
Accepted new patient

6.

M1-Man
MAKP
M2 MATERIAL
infrastructur

7.

Problem
Socialization installation idenification bracelet
Unavailability of leaflets related to the patient's illness
There is no specific formafor the centralized drug approval.
Installation Risk fall to the risk patients is not optimal
A description of the disease and regulations have
been implemented but not optimal
No training MAKP

8.

M3
Supervision

Lack of support facilities and infrastructure (kitchen,

bell patients who have not functioned, and inventory
numbering).
There is no written documentation about the results
of supervision and scheduling regular supervision

9.

M5-Mutu
Pasien Safety

Socialization of Hand Hygine to family or patient is

not optimal

Diagram
O

TT
(0.4, 1.5)

M2
(0,7, 1.5)

M4
(-0.7,0)

M5
(1,1)

1.0
0.9

MAKP
(0.3,0.7)

0.8
0.7
0.6
0.5

SO
(1.0, 0.5)

0.4
0.3
0.2

0.1
- 1.0

- 0.9

- 0.8 - 0.7

- 0.6 - 0.5 - 0.4 - 0.3 - 0.2 - 0.1

0.1

- 0.1

PB

- 0.2

(0.1,-0.3)
DK

- 0.3

0.3

0.4 0.5

M1
(0.4, -0.2)
SV
(0.4, -0.3)

(0.2, -0.4)

- 0.4

RK

- 0.5

(0,-0,6) - 0.6
DP
(-1, -0.7)

0.2

M3
(0.3, -0.6)

- 0.7
-0.8
-0.9
-1.0

0.6

0.7

0.8

0.9

1.0