2017 Mutu Sesi 16 AU Kerangka Mutu Kebutuhan Pengembangan di Indonesia
Kerangka Kerja Mutu:
Penguatan Proses Pengembangan di Indonesia
Adi Utarini
1
Struktur
• Mengapa dibutuhkan Kerangka
kerja mutu?
• Kerangka kerja mutu:
Indonesian National Quality
Framework
• Pemikiran mengenai langkah
pengembangan
Mutu: Perubahan Paradigma
Service Excellence
Clinical Excellence
Patient Safety
Global Burden of Unsafe Care (Jha et al., 2013)
• In every 100
hospitalisations, there
were approximately
14.2 of these adverse
events in HICs and 12.7
in LMICs.
Studi Patient Safety di beberapa negara
Is Safety-Quality important?
Lit review (Sandars & Esmail 2003)
• Medical errors: 5 80x in
100,000 consultations
• Prescribing error: 11% of total
prescriptions
Primary care clinics, Malaysia (Khoo et al, 2012):
• 3.6% diagnostic errors
• 41.1% medication errors
• 39.9% of errors had the potential to cause serious harm.
• 98.0% illegible handwriting
• 93.5% of errors detected were preventable.
Donabedian’s framework of quality care
Structure
Process
Outcome
What resources
do you use:
Resources
How to use the
resources: Care
processes
What is the
result? Result
Personnel,
Equipment,
drugs, finance
etc.
Standards, Guidel
ines, SOP
Result of care:
Disability, death,
dissatisfaction, cli
nical indicators
Apa yang perlu dimiliki Indonesia
untuk membangun Mutu?
Struktur
Direktorat Mutu dan
Akreditasi
Regulasi Mutu dan
Keselamatan Pasien
Kerangka Kerja Mutu
Komite nasional
Proses
Perijinan
Akreditasi
Sistem manajemen mutu
Panduan Praktek Klinis
Standar, prosedur, norma
dll.
Outcome
Indikator
Peningkatan mutu
Pengalaman pasien
Quality Framework
Quality framework
• Quality framework is a framework that is
applied as a foundation for improving quality
of services (at geographical level, institutional
level, service level, professional level etc)
• Quality framework represents the
stakeholder s commitment toward quality
dimensions and their priorities,
measurements, regulations and quality
management system
Quality Framework
A. How do we
achieve Quality?
Kerangka kerja
nasional
Tata kelola Klinis
Sistem
manajemen
mutu
Akreditasi RS
Akreditasi Pkm
Dll.
B. What level of quality are
we committed to provide
to our patients, families
and communities?
Akses
Keselamatan
Keadilan
Dsb.
Komitmen Mutu: Dimensi yang mana?
•
•
•
•
•
•
Effectiveness
Equity
Efficiency
Safety
Access
Patient
centeredness
• Timeliness
• Consumer
engagement
• Community
engagement
• Technical
competence
Six quality aims (Institute of Medicine, USA)
• Safe
• Effective
• Patient centered
• Timely
• Efficient
• Equitable
National Strategy for Quality
Improvement in Health Care (US)
3 Aims
• Better Care: Improve the overall
quality, by making health care
more patientcentered, reliable, accessible, and
safe.
• Healthy People/Healthy
Communities: Improve the health
of the U.S. population by
supporting proven interventions
to address behavioral, social
and, environmental determinants
of health in addition to delivering
higher-quality care.
• Affordable Care: Reduce the cost
of quality health care for
individuals, families, employers, a
nd government.
6 Priorities
• Making care safer by reducing harm
caused in the delivery of care.
• Ensuring that each person and family are
engaged as partners in their care.
• Promoting effective communication and
coordination of care.
• Promoting the most effective prevention
and treatment practices for the leading
causes of mortality, starting with
cardiovascular disease.
• Working with communities to promote
wide use of best practices to enable
healthy living.
• Making quality care more affordable for
individuals, families, employers, and
governments by developing and
spreading new health care delivery
models.
Tanzania: 2011-2016
•
•
•
•
•
•
•
•
•
•
•
Acceptability/patient centeredness
Technical competence
Access
Interpersonal relations
Effectiveness
Equity
Efficiency
Safety
Continuity of care
Choice of service
Physical infrastructure & Amenities
OECD Countries: 23 negara
Berbagai negara, berbagai dimensi mutu
Dimensi Mutu:
Indonesia
•
•
•
•
•
•
Dari beberapa dokumen
kebijakan:
Akses
Continuity of care
Cost of care
Infrastruktur fisik
Ketersediaan obat-alkes
Kompetensi teknis SDM
Quality Framework Victoria (Australia)
New South Wales, Australia
Dari Kerangka Kerja Mutu ke Indikator:
Menyusun Benang Merah
Contoh: Performance Assessment Tool for quality
improvement in Hospital (PATH model, WHO)
Example of PATH indicators
Clinical
effective
ness and
safety
Efficiency
SC
Prophylactic
antibiotics use
Readmission
LOS
Surgical
theatre use
Staff
orientation
and safety
Needle
injuries
Staff smoking
prevalence
Training
expenditure
Responsive
governance
Breastfeeding
at discharge
Patientcentered
ness
Patient
expectat
ions
• Clinical indicators
• Patient safety indicators
• Quality indicators
Indikator
Kinerja
Individu
Indikator
Mutu
Indikator Mutu
Pelayanan RS
Indeks
Kepuasan
Masyarakat
Indikator Klinis
Indikator dari
beberapa
lembaga:
KARS, BPJS,
Kemenkes
Indikator Keselamatan
Pasien
Indikator Mutu Pelayanan di Indonesia
Quality Improvement
– We need to improve
and a system to
improve
– Every system is
perfectly designed to
achieve exactly the
results it gets.
– The first law of
improvement
Global growth of Accred Org: 1951-2009
Akreditasi di negara-negara lain
•
•
•
•
•
•
•
•
•
•
•
•
Kyrgyztan
India
Mongolia
Philippines
Albania
Jordan
Thailand
Bosnia (AAQI, AKAZ)
Colombia
Serbia
South Africa
Germany
•
•
•
•
•
•
•
•
•
Brazil
Lithuania
Poland
Croatia
Saudi Arabia
Czech republic
South Korea
Portugal
Taiwan
England
Japan
France
Denmark
Switzerland
New Zealand
Spain
Canada
Australia
USA
Netherlands
Perbandingan antar lembaga akreditasi
menurut:
•
•
•
•
•
•
•
•
•
Fokus organisasi
Struktur organisasi
Jumlah RS terakreditasi
Histori
Tata kelola dan
kepemimpinan
Persyaratan akreditasi
Proses survei
Frekuensi survei
Surveyor
•
•
•
•
•
•
•
•
•
Proses skoring
Kategori akreditasi
Biaya akreditasi
Proses keputusan
akreditasi
Support akreditasi
Advokasi
Keselamatan pasien
Peningkatan mutu
Dll.
Apa dampak akreditasi?
•
Brubakk et al., Systematic review of hospital accreditation: the challenges of measuring
complex intervention effects. BMC Health service research, 2015, 15:280
• Dorongan terus menerus untuk akreditasi, akan tetapi
bukti yang menunjukkan efektivitas dan efisiensinya
minimal, sehingga tidak dapat ditarik kesimpulan
tentang dampaknya.
• Sebagian besar studi tidak melaporkan konteks
intervensi, implementasi ataupun biaya
• Tantangan dalam menilai dampak Akreditasi dan
sertifikasi yang merupakan contoh intervensi yang
kompleks dan beragam
• Diperlukan studi untuk menjawab: Apa aspek
akreditasi yang dapat bermanfaat untuk
meningkatkan keselamatan pasien dan kinerja
organisasi?
Remaining questions on accreditation
•
•
•
•
•
•
Improving clinical outcomes?
Improving participation of clinician?
Improving patient satisfaction?
Improving patient experience?
Improving patient safety?
Improving departmental quality
improvement initiatives?
• Efficient quality improvement strategy?
Quality Framework
A. How do we
achieve Quality?
Kerangka kerja
nasional
Tata kelola Klinis
Sistem
manajemen
mutu
Akreditasi
RS, Pkm
Dll.
B. What level of quality are
we committed to provide
to our patients, families
and communities?
Akses
Keselamatan
Keadilan
Dsb.
Usulan: Lima Tahap Pengembangan
Kerangka Kerja Mutu (KKM)
Desk review
Eksploratori
Formulasi
Berbagai dokumen
kebijakan
Dari berbagai lembaga
(Kemenkes, KARS, BPJS, d
ll)
Output: Kompilasi
dimensi mutu
Menggali dimensi
prioritas
Memetakan berbagai
peran lembaga
Mengidentifikasi
indikator dan strategi
Output: Usulan kerangka
kerja
Merumuskan Quality
Framework
Menyusun indikator dan
strategi QI
Output: Kerangka Kerja
Mutu Pelayanan
Kesehatan Indonesia
Usulan Tahap Pengembangan
Kerangka Kerja Mutu (KKM)
Implementasi Pilot
Penyusunan Panduan
Ujicoba Kerangka Kerja
Mutu
Ujicoba indikator
Sistem pemantauan
indikator
Panduan pengembangan
lanjutan kerangka kerja
mutu di tingkat
propinsi, kabupaten, fask
es dll
Guideline penerapan
kerangka kerja
Guideline pengukuran
indikator
Quality Improvement
We have two jobs: our job and the
job of improving our job
Donald Berwick
It is challenging, please don’t give up..
Penguatan Proses Pengembangan di Indonesia
Adi Utarini
1
Struktur
• Mengapa dibutuhkan Kerangka
kerja mutu?
• Kerangka kerja mutu:
Indonesian National Quality
Framework
• Pemikiran mengenai langkah
pengembangan
Mutu: Perubahan Paradigma
Service Excellence
Clinical Excellence
Patient Safety
Global Burden of Unsafe Care (Jha et al., 2013)
• In every 100
hospitalisations, there
were approximately
14.2 of these adverse
events in HICs and 12.7
in LMICs.
Studi Patient Safety di beberapa negara
Is Safety-Quality important?
Lit review (Sandars & Esmail 2003)
• Medical errors: 5 80x in
100,000 consultations
• Prescribing error: 11% of total
prescriptions
Primary care clinics, Malaysia (Khoo et al, 2012):
• 3.6% diagnostic errors
• 41.1% medication errors
• 39.9% of errors had the potential to cause serious harm.
• 98.0% illegible handwriting
• 93.5% of errors detected were preventable.
Donabedian’s framework of quality care
Structure
Process
Outcome
What resources
do you use:
Resources
How to use the
resources: Care
processes
What is the
result? Result
Personnel,
Equipment,
drugs, finance
etc.
Standards, Guidel
ines, SOP
Result of care:
Disability, death,
dissatisfaction, cli
nical indicators
Apa yang perlu dimiliki Indonesia
untuk membangun Mutu?
Struktur
Direktorat Mutu dan
Akreditasi
Regulasi Mutu dan
Keselamatan Pasien
Kerangka Kerja Mutu
Komite nasional
Proses
Perijinan
Akreditasi
Sistem manajemen mutu
Panduan Praktek Klinis
Standar, prosedur, norma
dll.
Outcome
Indikator
Peningkatan mutu
Pengalaman pasien
Quality Framework
Quality framework
• Quality framework is a framework that is
applied as a foundation for improving quality
of services (at geographical level, institutional
level, service level, professional level etc)
• Quality framework represents the
stakeholder s commitment toward quality
dimensions and their priorities,
measurements, regulations and quality
management system
Quality Framework
A. How do we
achieve Quality?
Kerangka kerja
nasional
Tata kelola Klinis
Sistem
manajemen
mutu
Akreditasi RS
Akreditasi Pkm
Dll.
B. What level of quality are
we committed to provide
to our patients, families
and communities?
Akses
Keselamatan
Keadilan
Dsb.
Komitmen Mutu: Dimensi yang mana?
•
•
•
•
•
•
Effectiveness
Equity
Efficiency
Safety
Access
Patient
centeredness
• Timeliness
• Consumer
engagement
• Community
engagement
• Technical
competence
Six quality aims (Institute of Medicine, USA)
• Safe
• Effective
• Patient centered
• Timely
• Efficient
• Equitable
National Strategy for Quality
Improvement in Health Care (US)
3 Aims
• Better Care: Improve the overall
quality, by making health care
more patientcentered, reliable, accessible, and
safe.
• Healthy People/Healthy
Communities: Improve the health
of the U.S. population by
supporting proven interventions
to address behavioral, social
and, environmental determinants
of health in addition to delivering
higher-quality care.
• Affordable Care: Reduce the cost
of quality health care for
individuals, families, employers, a
nd government.
6 Priorities
• Making care safer by reducing harm
caused in the delivery of care.
• Ensuring that each person and family are
engaged as partners in their care.
• Promoting effective communication and
coordination of care.
• Promoting the most effective prevention
and treatment practices for the leading
causes of mortality, starting with
cardiovascular disease.
• Working with communities to promote
wide use of best practices to enable
healthy living.
• Making quality care more affordable for
individuals, families, employers, and
governments by developing and
spreading new health care delivery
models.
Tanzania: 2011-2016
•
•
•
•
•
•
•
•
•
•
•
Acceptability/patient centeredness
Technical competence
Access
Interpersonal relations
Effectiveness
Equity
Efficiency
Safety
Continuity of care
Choice of service
Physical infrastructure & Amenities
OECD Countries: 23 negara
Berbagai negara, berbagai dimensi mutu
Dimensi Mutu:
Indonesia
•
•
•
•
•
•
Dari beberapa dokumen
kebijakan:
Akses
Continuity of care
Cost of care
Infrastruktur fisik
Ketersediaan obat-alkes
Kompetensi teknis SDM
Quality Framework Victoria (Australia)
New South Wales, Australia
Dari Kerangka Kerja Mutu ke Indikator:
Menyusun Benang Merah
Contoh: Performance Assessment Tool for quality
improvement in Hospital (PATH model, WHO)
Example of PATH indicators
Clinical
effective
ness and
safety
Efficiency
SC
Prophylactic
antibiotics use
Readmission
LOS
Surgical
theatre use
Staff
orientation
and safety
Needle
injuries
Staff smoking
prevalence
Training
expenditure
Responsive
governance
Breastfeeding
at discharge
Patientcentered
ness
Patient
expectat
ions
• Clinical indicators
• Patient safety indicators
• Quality indicators
Indikator
Kinerja
Individu
Indikator
Mutu
Indikator Mutu
Pelayanan RS
Indeks
Kepuasan
Masyarakat
Indikator Klinis
Indikator dari
beberapa
lembaga:
KARS, BPJS,
Kemenkes
Indikator Keselamatan
Pasien
Indikator Mutu Pelayanan di Indonesia
Quality Improvement
– We need to improve
and a system to
improve
– Every system is
perfectly designed to
achieve exactly the
results it gets.
– The first law of
improvement
Global growth of Accred Org: 1951-2009
Akreditasi di negara-negara lain
•
•
•
•
•
•
•
•
•
•
•
•
Kyrgyztan
India
Mongolia
Philippines
Albania
Jordan
Thailand
Bosnia (AAQI, AKAZ)
Colombia
Serbia
South Africa
Germany
•
•
•
•
•
•
•
•
•
Brazil
Lithuania
Poland
Croatia
Saudi Arabia
Czech republic
South Korea
Portugal
Taiwan
England
Japan
France
Denmark
Switzerland
New Zealand
Spain
Canada
Australia
USA
Netherlands
Perbandingan antar lembaga akreditasi
menurut:
•
•
•
•
•
•
•
•
•
Fokus organisasi
Struktur organisasi
Jumlah RS terakreditasi
Histori
Tata kelola dan
kepemimpinan
Persyaratan akreditasi
Proses survei
Frekuensi survei
Surveyor
•
•
•
•
•
•
•
•
•
Proses skoring
Kategori akreditasi
Biaya akreditasi
Proses keputusan
akreditasi
Support akreditasi
Advokasi
Keselamatan pasien
Peningkatan mutu
Dll.
Apa dampak akreditasi?
•
Brubakk et al., Systematic review of hospital accreditation: the challenges of measuring
complex intervention effects. BMC Health service research, 2015, 15:280
• Dorongan terus menerus untuk akreditasi, akan tetapi
bukti yang menunjukkan efektivitas dan efisiensinya
minimal, sehingga tidak dapat ditarik kesimpulan
tentang dampaknya.
• Sebagian besar studi tidak melaporkan konteks
intervensi, implementasi ataupun biaya
• Tantangan dalam menilai dampak Akreditasi dan
sertifikasi yang merupakan contoh intervensi yang
kompleks dan beragam
• Diperlukan studi untuk menjawab: Apa aspek
akreditasi yang dapat bermanfaat untuk
meningkatkan keselamatan pasien dan kinerja
organisasi?
Remaining questions on accreditation
•
•
•
•
•
•
Improving clinical outcomes?
Improving participation of clinician?
Improving patient satisfaction?
Improving patient experience?
Improving patient safety?
Improving departmental quality
improvement initiatives?
• Efficient quality improvement strategy?
Quality Framework
A. How do we
achieve Quality?
Kerangka kerja
nasional
Tata kelola Klinis
Sistem
manajemen
mutu
Akreditasi
RS, Pkm
Dll.
B. What level of quality are
we committed to provide
to our patients, families
and communities?
Akses
Keselamatan
Keadilan
Dsb.
Usulan: Lima Tahap Pengembangan
Kerangka Kerja Mutu (KKM)
Desk review
Eksploratori
Formulasi
Berbagai dokumen
kebijakan
Dari berbagai lembaga
(Kemenkes, KARS, BPJS, d
ll)
Output: Kompilasi
dimensi mutu
Menggali dimensi
prioritas
Memetakan berbagai
peran lembaga
Mengidentifikasi
indikator dan strategi
Output: Usulan kerangka
kerja
Merumuskan Quality
Framework
Menyusun indikator dan
strategi QI
Output: Kerangka Kerja
Mutu Pelayanan
Kesehatan Indonesia
Usulan Tahap Pengembangan
Kerangka Kerja Mutu (KKM)
Implementasi Pilot
Penyusunan Panduan
Ujicoba Kerangka Kerja
Mutu
Ujicoba indikator
Sistem pemantauan
indikator
Panduan pengembangan
lanjutan kerangka kerja
mutu di tingkat
propinsi, kabupaten, fask
es dll
Guideline penerapan
kerangka kerja
Guideline pengukuran
indikator
Quality Improvement
We have two jobs: our job and the
job of improving our job
Donald Berwick
It is challenging, please don’t give up..