INM-1
Hand Hygiene Compliance
Analysis
This indicator improved from 80.32% in the first quarter to 89.81% in the second quarter and exceeded the national minimum target of 85%.
Standard
Achievement
Chart for INM-1
Quality & Patient Safety
National Quality Indicators
Second quarter 2026 quality report for RSK Bedah Lira Medika Bali, published as part of the hospital’s commitment to transparency, accountability, and patient safety.
Public Quality Report
All published indicators have gone through measurement, monitoring, evaluation, and validation by the relevant units in line with the hospital’s quality management standards. This publication helps patients, families, partners, and stakeholders understand the hospital’s ongoing quality improvement efforts.
Reporting Period
Q2 2026
Total Indicators
13 Indicators
Indicators Achieved
9/11
To deliver healthcare services that are high-quality, safe, and patient-centered, RSK Bedah Lira Medika Bali continuously measures and evaluates National Quality Indicators (INM) in accordance with the regulations of the Ministry of Health of the Republic of Indonesia.
Based on the measurement results for the second quarter of 2026 (April through June 2026), most quality indicators reached their targets and several indicators improved compared with the first quarter of 2026.
These results serve as a basis for continuous improvement so the hospital can continue delivering safe, high-quality, professional services oriented toward patient safety and satisfaction.
National Quality Indicator Achievement Table
The table below summarizes each indicator’s performance in April, May, and June 2026 along with the quarterly average and achievement status against the national standard.
| Code | Indicator | Standard | Apr 2026 | May 2026 | Jun 2026 | Average |
|---|---|---|---|---|---|---|
| INM-1 | Hand Hygiene Compliance | >= 85% | 86% | 91.27% | 91.98% | 89.81% |
| INM-2 | Personal Protective Equipment (PPE) Compliance | 100% | 87.19% | 92.08% | 93.07% | 90.78% |
| INM-3 | Patient Identification Compliance | 100% | 100% | 100% | 100% | 100% |
| INM-4 | Response Time for Cesarean Section Surgery | >= 80% | N/A | N/A | N/A | N/A |
| INM-5 | Outpatient Waiting Time | >= 80% | 99% | 100% | 100% | 99.77% |
| INM-6 | Elective Surgery Delay | <= 5% | 12.5% | 0% | 0% | 4.17% |
| INM-7 | Doctor Visit Time Compliance | >= 80% | 75.4% | 83.95% | 69.7% | 76.35% |
| INM-8 | Critical Laboratory Result Reporting | 100% | 100% | 100% | 100% | 100% |
| INM-9 | National Formulary Compliance | >= 80% | 99.4% | 99.4% | 99.4% | 99.4% |
| INM-10 | Compliance with Clinical Pathways | 100% | N/A | N/A | N/A | N/A |
| INM-11 | Fall Risk Prevention Compliance | 100% | 100% | 100% | 100% | 100% |
| INM-12 | Complaint Response Time | >= 80% | 92.59% | 94.12% | 100% | 95.57% |
| INM-13 | Patient Satisfaction | >= 76.61 | 85.19 | 87.5 | 91.56 | 88.08 |
Indicator Details
The summaries below are based on the second-quarter 2026 achievement narrative and grouped by indicator, analysis, recommendation, and special notes where applicable.
INM-2
Personal Protective Equipment (PPE) Compliance
Analysis
Performance improved from 82.88% in the first quarter to 90.78% in the second quarter. Although it has not yet reached the ideal 100% target, the upward trend shows better staff compliance with infection prevention, infection control, and workplace safety principles.
Standard
Achievement
Chart for INM-2
INM-3
Patient Identification Compliance
Analysis
Patient identification compliance in the second quarter of 2026 remained consistent at 100% and met the established target.
Standard
Achievement
Chart for INM-3
INM-4
Response Time for Cesarean Section Surgery
Note
Not applicable because there was no assessable service data for this indicator during April through June 2026.
INM-5
Outpatient Waiting Time
Analysis
Outpatient waiting time reached an average of 99.77% and exceeded the established minimum standard.
Standard
Achievement
Chart for INM-5
INM-6
Elective Surgery Delay
Analysis
This indicator showed a very significant improvement. In the first quarter the result was 23.81%, while in the second quarter it declined to 4.17%, meeting the national target of less than or equal to 5%.
Recommendation
Maintain coordination across units for patient preparation, operating room readiness, and the availability of supporting surgical resources.
Standard
Achievement
Chart for INM-6
INM-7
Doctor Visit Time Compliance
Analysis
Performance declined from 83.44% in the first quarter to 76.35% in the second quarter, so it did not meet the minimum 80% target. The evaluation found that delays were still influenced by dense physician schedules, surgical procedures, and coordination issues in several service units.
Recommendation
The hospital has set an improvement plan through stronger monitoring of visit schedules, better communication between attending physicians and inpatient units, and regular evaluations of physician visit compliance.
Standard
Achievement
Chart for INM-7
INM-8
Critical Laboratory Result Reporting
Analysis
The 100% result shows that all laboratory results categorized as critical values were reported to the responsible physician or authorized staff within the required standard time. This reflects the hospital’s commitment to patient safety through fast, accurate, and effective communication of supporting test results.
Standard
Achievement
Chart for INM-8
INM-9
National Formulary Compliance
Analysis
National Formulary compliance reached 99.40% and remained above the minimum 80% target.
Standard
Achievement
Chart for INM-9
INM-10
Compliance with Clinical Pathways
Note
Not applicable because there were no assessable cases for the Clinical Pathway indicator during the second quarter of 2026.
INM-11
Fall Risk Prevention Compliance
Analysis
Compliance with fall-risk prevention efforts in the second quarter of 2026 remained consistent at 100% and met the target.
Standard
Achievement
Chart for INM-11
INM-12
Complaint Response Time
Analysis
Complaint response time reached 95.57% and exceeded the minimum 80% target.
Standard
Achievement
Chart for INM-12
INM-13
Patient Satisfaction
Analysis
The patient satisfaction index reached 88.08 in the second quarter and remained above the national minimum standard of 76.61, although it declined slightly compared with the first quarter result of 92.22.
Standard
Achievement
Chart for INM-13
Note
This survey result is used as evaluation material for the hospital to continue improving service quality, communication, and the patient experience throughout care.