| Jenis Indikator Mutu | Okt | Nov | Des | Rata-Rata | Standart | |
| Kepatuhan Identifikasi Pasien di Laboratorium | Num | 266 | 235 | 190 | 691 | 100% |
| Denum | 267 | 235 | 192 | 694 | ||
| Capaian | 99,63% | 100% | 98,95% | 99,6% | ||
| Jenis Indikator Mutu | Okt | Nov | Des | Rata-Rata | Standart | |
| Kelengkapan Formulir Serah Terima antar Unit | Num | 236 | 198 | 262 | 696 | 100% |
| Denum | 257 | 200 | 270 | 727 | ||
| Capaian | 91% | 99% | 97% | 95% | ||
| Jenis Indikator Mutu | Okt | Nov | Des | Rata-Rata | Standart | |
| Kepatuhan Pelabelan Obat High Alert | Num | 150 | 150 | 150 | 450 | 100% |
| Denum | 150 | 150 | 150 | 450 | ||
| Capaian | 100% | 100% | 100% | 100% | ||
| Jenis Indikator Mutu | Okt | Nov | Des | Rata-Rata | Standart | |
| Kelengkapan Pengisian Formulir SSC | Num | 146 | 130 | 109 | 385 | >85% |
| Denum | 166 | 140 | 120 | 426 | ||
| Capaian | 87.9% | 92.8% | 90% | 90% | ||
| Jenis Indikator Mutu | Okt | Nov | Des | Rata-Rata | Standart | |
| Kepatuhan Kebersihan Tangan Unit Intensif | Num | >85% | ||||
| Denum | ||||||
| Capaian | % | % | % | % | ||
| Jenis Indikator Mutu | Okt | Nov | Des | Rata-Rata | Standart | |
| Kepatuhan Upaya Pencegahan Risiko Pasien Jatuh di Perinatologi | Num | 100% | ||||
| Denum | ||||||
| Capaian | 100% | 100% | 100% | 100% | ||
| Jenis Indikator Mutu | Okt | Nov | Des | Rata-Rata | Standart | |
| Waktu Tanggap Kasus PE dan PEB < 30 Menit | Num | 4 | 3 | 3 | 34 | 80% |
| Denum | 4 | 3 | 3 | 34 | ||
| Capaian | 100% | 100% | 100% | 100% | ||
| Jenis Indikator Mutu | Okt | Nov | Des | Rata-Rata | Standart | |
| Skrinning Pemeriksaan Hepatitis, HIV, dan Sifilis pada Ibu Hamil | Num | 80% | ||||
| Denum | ||||||
| Capaian | % | % | % | % | ||
| Jenis Indikator Mutu | Okt | Nov | Des | Rata-Rata | Standart | |
| Kepatuhan Penggunaan Formularium Nasional di Ruang Rawat Inap | Num | 80% | ||||
| Denum | ||||||
| Capaian | 100% | 100% | 100% | 100% | ||
| Jenis Indikator Mutu | Okt | Nov | Des | Rata-Rata | Standart | |
| Angka Keterlambatan Transfer Pasien dari IGD ke Ruang Rawat Inap | Num | 80% | ||||
| Denum | ||||||
| Capaian | 100% | 100% | 100% | 100% | ||