| Judul Indikator | Standar | Januari | Februari | Maret | April | Mei | Juni | Juli | Agustus | September | Oktober | November | Desember |
| Kepatuhan Identifikasi Pasien | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| Kepatuhan Penggunaan APD | 100% | 94,26% | 93,29% | 93,19% | 94,33% | 94,81% | 94,14% | 93,29% | 91,77% | 88,61% | 92,81% | 92,86% | 95,81% |
| Waktu Tunggu Rawat Jalan | ≥ 80% | 95,01% | 97,54% | 94,07% | 91,3% | 91,6% | 92,66% | 96,25% | 92,08% | 92,33% | 90,38% | 89,8% | 80,12% |
| Penundaan Operasi Elektif | ≤ 5% | 0% | 0% | – | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% |
| Kepatuhan Jam Visite Dokter Spesialis | ≥ 80% | – | 100% | 100% | 100% | 100% | 100% | 100% | 80% | 100% | 100% | 100% | 50% |
| Kepatuhan Penggunaan Formularium Nasional | ≥ 80% | 90,59% | 90,91% | 89,35% | 97,6% | 98% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| Kepatuhan Kebersihan Tangan (Hand Hygiene) | ≥ 85% | 88,57% | 89,68% | 89,68% | 90% | 89,23% | 89,34% | 89,70% | 86,24% | 88,69% | 90,03% | 93,68% | 89,22% |
| Kepatuhan Upaya Pencegahan Risiko Pasien Jatuh | 100% | – | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| Kepuasan Pasien dan Keluarga | ≥ 76,61 | – | – | – | – | – | 94,7% | – | – | – | – | – | 91,49% |
| Kecepatan Waktu Tanggap Komplain | >80% | 100% | 100% | – | 100% | – | 100% | 100% | – | 100% | – | – | 100% |
| Kepatuhan Terhadap Clinical Pathways | >80% | 83,3% | 92,3% | 90,2% | 92,1% | 84,2% | 78,9% | 81% | 82,6% | 88,4% | 92,1% | 84,2% | 78,9 % |
| Hasil Kritis Laboratorium | 100% ( ≤ 30 menit) | – | – | – | – | – | – | – | – | – | – | – | – |