2017 Mutu Sesi 1 AU Pengantar Mata Kuliah
Pengantar Mata Kuliah
Kuliah::
Kebijakan dan Manajemen Mutu (Safety and Quality)
Peminatan HPMHPM-2017
Adi Utarini ([email protected])
Sekretaris: [email protected]; Asisten:
Tujuan pembelajaran umum:
Menggunakan kerangka berpikir untuk
menganalisis masalah keselamatan
pasien, kebijakan dan mutu pelayanan kesehatan
serta mengidentifikasi intervensi perbaikan
keselamatan pasien dan mutu pelayanan
Memahami sistem manajemen mutu dan memilih
pendekatan-piranti peningkatan mutu
Menyusun program kegiatan untuk melakukan
perbaikan mutu yang berkesinambungan
Tujuan pembelajaran khusus
Menganalisis masalah keselamatan pasien dan mutu
pelayanan menggunakan kerangka Berwick
Melakukan analisis risiko dalam pemberian pelayanan
kesehatan
Menganalisis kerangka kerja mutu dan indikator mutu
pelayanan kesehatan
Memahami sistem manajemen mutu dalam pelayanan
kesehatan
Merencanakan peningkatan mutu yang berkesinambungan
dalam pelayanan kesehatan
Melakukan analisis kebijakan mutu dan fraud dalam era
jaminan kesehatan nasional
Struktur Sesi Perkuliahan
Pasien dan masyarakat
Sistem mikro pelayanan
Sistem makro organisasi
Lingkungan
Pengantar: Safety and Quality serta
Model Berwick
Pemberdayaan pasien dan
masyarakat
Sistem manajemen mutu
Kepemimpinan mutu
Komitmen dan budaya mutu
CQI, UR
Model-piranti QI dan metode statistik
Program Safety and Quality
Manajemen risiko dan safety
FMEA, RCA
Standar dan indikator mutu
Kebijakan Kemenkes
Mutu dan fraud di era JKN
Kerangka kerja mutu
Kebijakan -regulasi layanan primer
dan sekunder
Akreditasi fasyankes
Evaluasi Mata Kuliah
Penugasan: @ 10%
1. Menemukan artikel yang terkait dengan masalah safety dan
mutu pelayanan kesehatan: lessons learnt dan analisis dengan
Kerangka Berwick (Individu)
2. Berpartisipasi dalam pembelajaran mutu yang diselenggarakan
oleh pihak internasional (kelompok)
3. Menyusun rangkuman bab dalam buku (kelompok)
4. Berpartisipasi menulis di website mutupelayanankesehatan
(individu)
Ujian: 60%
Tengah semester: 20% (bentuk tertulis)
Akhir semester: 40% (penugasan utama)
Presensi:
Memenuhi 75% sebagai syarat mata kuliah
How do you choose a warung ?
Which one is safer?
It was later revealed that a chain of errors before the surgery culminated in
the wrong leg being prepped for the procedure. While the surgeon’s team
realized in the middle of the procedure that they were operating on the
wrong leg, it was already too late, and the leg was removed. As a result of
the error, the surgeon’s medical license was suspended for six months and
he was fined $10,000. University Community Hospital in Tampa, paid
$900,000 to King and the surgeon involved in the case paid an additional
$250,000 to King.
John Hawley had surgery in late January of 1998
New Jersey. Seorang pasien telah menjalani operasi paru kanan yang
tidak diperlukan. Dr. Perera, menyampaikan ke pasiennya bahwa paru
kanannya ditemukan tumor yang life-threatening, meskipun sama sekali
tidak ada. Ia juga mengubah Catatan Medik pasien yang memberi kesan
bahwa operasi pada paru kanan memang diperlukan. Komite
memutuskan bahwa dr. Parera telah melakukan gross negligence.
Surgical site infections (SSI) di RS
Insidensi: 49,1%
Widodo & Dwiprahasto, 2006
Ernest A. Codman (1869(1869-1940)
5 tahun (1911-1916), 337 pasien
Error 36%
No Error 64%
Studi Prevalensi Kejadian yang Tidak Diharapkan
Amerika Latin
10,5
USA-2011
2010 – 2011
32
USA-2010
25
Canada
7,5
Australia
1980 - 2005
16,6
Inggris
11,7
USA-2
2,7
USA-1
3,9
0
10
20
%
30
40
Harvard School of Public HealthHealth-Survey
(2002)
1 dari 3 dokter mengaku
Pernah mengalami KTD
Pada keluarga atau pribadi
Patient safety, definition
The
IOM
the
AHRQ
• “the prevention of harm to patients
• “freedom from accidental or preventable
injuries produced by medical care.
Emphasis is placed on the system of care delivery
that
• (1) prevents errors;
• (2) learns from the errors that do occur;
• (3) is built on a culture of safety that involves health
care professionals, organizations, and patients.
The origins of the patient safety problem are
classified in terms of
type of error
communication
patient
management
clinical
performance
(failures between patient
or patient proxy &
practitioners, practitioner
& nonmedical staff, or
among practitioners),
(improper
delegation, failure in
tracking, wrong
referral, or wrong
use of
resources), and
(before, during,
and after
intervention).
Untoward incidents, therapeutic misadventures, iatrogenic
injuries or other adverse occurrences directly associated
with care or services provided within the jurisdiction of a
medical center, outpatient clinic or other facility.
May result from acts of commission or omission
(e.g., administration of the wrong medication, failure to
make a timely diagnosis or institute the appropriate
therapeutic intervention, adverse reactions or negative
outcomes of treatment, etc.)
Adverse drug events in inp
inpatient
(Classen et al., 1997).
Extra cost
$8.4 million/year for
teaching hospital
with 700-beds
(Bates et al., 1997)
Prolong
hospitalization
Increase
mortality
1983-1993: 2x fold
(7.391 death 1993)
(Phillips, Christenfeld, and
McGlynn, 1998)
ERROR, Definition (IOM, 1999)
the use of a wrong
plan to achieve an
aim
Failure of a planned
action to be completed
as intended
ERROR OF PLANNING
ERROR OF EXECUTION
Errors include product, procedures, system
ERROR
Omission
Commission
error which occurs as a
result of an action not
taken
Eror which occurs as
a result of an action
taken incorrectly
• misdiagnosis
• delayed evaluation
• failure to prescribe
• Incorrect action
• wrong medication
• wrong administration
Near Misses
Death
1
Severe
0s
Minor – Moderate
00s
Prevented/No harm incidents
000s
SLIP is observeable
observeable,, LAPSE is not
Slip
Lapse
• turning the wrong knob on a
piece of equipment
• not being able to recall
something from memory
Active error:
An error that occurs at the level of the frontline
operator and whose effects are felt almost
immediately.
Latent error:
Errors in the design organization, training, or
maintenance that lead to operator errors and whose
effects typically lie dormant in the system for lengthy
periods of time
Defining, Identifying, and Measuring Error in Emergency Medicine
A
• The capacity to cause error
B
• Did not reach the patient
C
• Did not cause the patient harm
D
• Required monitoring to confirm it resulted in no harm to the patient
and/or required intervention to preclude harm
E
• Required Intervention
F
• Required Hospitalization
G
• Permanent Patient Harm
H
• Sustain Life
I
• Patient’s Death
Adverse event in Health Care System
Australia
%
18
New Zealand
Japan
Britain
Denmark
Canada
16,6
16
14
12
10
8
12,9
11
10,8
9
7,5
6
4
3,7
2
0
The IOM, 1999
USA
Multi-Causal Theory Swiss Cheese Diagram
(Reason, 1991)
Human error is a symptom of trouble deeper
in the system (it is the starting point, not the
end)
To explain failure, do NOT try to find where
people went wrong
Find how people’s assessment and action
made sense at the time, given the
circumstances that surrounded them
Patient safety
Freedom from accidental injury
avoiding injuries or harm to patients from care that is
intended to help them
1. Build a SAFETY CULTURE
2. Build a comm
ommitment
itment & foc
focus on patient safety
3. Develop integrated risk management programme
4. Develop record and report on patient safety
5. Actively involve patients in communicating safety issues
6. Learn from error and set up a more safety procedure
7. Prevent injury or harm through Patient Safety programme
Jadi...............................
o
Think Safety
o
Talk Safety
o
Work Safety
o
BREATHE … SAFETY
… everyday
Is Quality important?
Is Quality important?
In Hospital 6, less than 5% of TB suspects receive
sputum smear examination according to standards
(Ref)
In Medan, less than 20% of private practitioners
have heard of International Standards for TB Care
(ISTC) (Ref)
1 dissatisfied patient will tell their experiences to
more than 3 persons
I have to sell the only piece of land I have for TB
treatment [which is free at the health centre]
Indikator SPM
dll..
UU Praktek
Kedokteran
SJSN
Perijinan
UU
Konsumen
UU
Kesehatan
Permenkes
UU Rumah sakit
Akreditasi
QUALITY: Definitions
The degree or grade of excellence
The Oxford English Dictionary (1988)
the degree to which health care services for
individuals and populations increase the
likelihood of desired health outcomes and are
consistent with current professional
knowledge.
Agency for health care research and quality
QUALITY: Definitions
Carrying out interventions correctly
according to pre-established standards and
procedures, with an aim of satisfying the
customers of the health system and
maximizing results without generating
health risks or unnecessary costs.
Conformance to specification
QUALITY: Definitions
degree to which health services for
individuals and populations increase the
likelihood of desired health outcomes and
are consistent with current
professional knowledge
IOM, 1990
Definitions
National Association of Quality Assurance
Professionals described quality as “the level of
excellence produced and documented in the
process of patient care, based on the best
knowledge available and achievable at a particular
facility.”
the Community Health Accreditation Program
defined quality as “the degree to which consumers
progress toward a desired outcome”
QUALITY: Definitions
Conformance to standards ….
Exceeding customer expectations ….
Consists of
structure, process, outcomes
Defining Quality: Quality Dimensions:
Effectiveness
Equity
Efficiency
Safety
Access
Patient
centeredness
Timeliness
Consumer
engagement
Community
engagement
Technical
competence
Whose
perspectives?
Patients
and
families
Physician
Quality
Regulator
Payers
1. Quality
Awareness
2. Quality
Measurement
3. Quality
Improvement
Chain of effect in Improving Healthcare
Quality (Berwick model, 2001)
Suara pasien
“Dua jam sebelum operasi saya
tidak melihat adanya penanda
operasi pada ekstremitas yang
akan dioperasi. Terdapat
perbedaan informasi mengenai
jenis tindakan anestesi antara
dokter bedah dan dokter
anestesi. Padahal pasien adalah
dokter spesialis, dirawat di VVIP.
Alhamdulillah operasi berhasil
baik dan pasien terhindari dari
KTD”
Foto: Koleksi IHI
Penugasan 1: Individu (10%)
Menemukan artikel (empirical research atau systematic
review) tentang safety dan quality di jurnal internasional
Artikel harus berbeda antar mahasiswa
Dari artikel tersebut ditulis:
Artikel tersebut terkait dengan rantai peningkatan mutu
Berwick yang mana
Apa pembelajaran penting atau hal menarik dari artikel tersebut
Deadline: Rabu, 1 Maret, dikumpulkan file menggunakan
Gamel (fasilitas Forum)
Kuliah::
Kebijakan dan Manajemen Mutu (Safety and Quality)
Peminatan HPMHPM-2017
Adi Utarini ([email protected])
Sekretaris: [email protected]; Asisten:
Tujuan pembelajaran umum:
Menggunakan kerangka berpikir untuk
menganalisis masalah keselamatan
pasien, kebijakan dan mutu pelayanan kesehatan
serta mengidentifikasi intervensi perbaikan
keselamatan pasien dan mutu pelayanan
Memahami sistem manajemen mutu dan memilih
pendekatan-piranti peningkatan mutu
Menyusun program kegiatan untuk melakukan
perbaikan mutu yang berkesinambungan
Tujuan pembelajaran khusus
Menganalisis masalah keselamatan pasien dan mutu
pelayanan menggunakan kerangka Berwick
Melakukan analisis risiko dalam pemberian pelayanan
kesehatan
Menganalisis kerangka kerja mutu dan indikator mutu
pelayanan kesehatan
Memahami sistem manajemen mutu dalam pelayanan
kesehatan
Merencanakan peningkatan mutu yang berkesinambungan
dalam pelayanan kesehatan
Melakukan analisis kebijakan mutu dan fraud dalam era
jaminan kesehatan nasional
Struktur Sesi Perkuliahan
Pasien dan masyarakat
Sistem mikro pelayanan
Sistem makro organisasi
Lingkungan
Pengantar: Safety and Quality serta
Model Berwick
Pemberdayaan pasien dan
masyarakat
Sistem manajemen mutu
Kepemimpinan mutu
Komitmen dan budaya mutu
CQI, UR
Model-piranti QI dan metode statistik
Program Safety and Quality
Manajemen risiko dan safety
FMEA, RCA
Standar dan indikator mutu
Kebijakan Kemenkes
Mutu dan fraud di era JKN
Kerangka kerja mutu
Kebijakan -regulasi layanan primer
dan sekunder
Akreditasi fasyankes
Evaluasi Mata Kuliah
Penugasan: @ 10%
1. Menemukan artikel yang terkait dengan masalah safety dan
mutu pelayanan kesehatan: lessons learnt dan analisis dengan
Kerangka Berwick (Individu)
2. Berpartisipasi dalam pembelajaran mutu yang diselenggarakan
oleh pihak internasional (kelompok)
3. Menyusun rangkuman bab dalam buku (kelompok)
4. Berpartisipasi menulis di website mutupelayanankesehatan
(individu)
Ujian: 60%
Tengah semester: 20% (bentuk tertulis)
Akhir semester: 40% (penugasan utama)
Presensi:
Memenuhi 75% sebagai syarat mata kuliah
How do you choose a warung ?
Which one is safer?
It was later revealed that a chain of errors before the surgery culminated in
the wrong leg being prepped for the procedure. While the surgeon’s team
realized in the middle of the procedure that they were operating on the
wrong leg, it was already too late, and the leg was removed. As a result of
the error, the surgeon’s medical license was suspended for six months and
he was fined $10,000. University Community Hospital in Tampa, paid
$900,000 to King and the surgeon involved in the case paid an additional
$250,000 to King.
John Hawley had surgery in late January of 1998
New Jersey. Seorang pasien telah menjalani operasi paru kanan yang
tidak diperlukan. Dr. Perera, menyampaikan ke pasiennya bahwa paru
kanannya ditemukan tumor yang life-threatening, meskipun sama sekali
tidak ada. Ia juga mengubah Catatan Medik pasien yang memberi kesan
bahwa operasi pada paru kanan memang diperlukan. Komite
memutuskan bahwa dr. Parera telah melakukan gross negligence.
Surgical site infections (SSI) di RS
Insidensi: 49,1%
Widodo & Dwiprahasto, 2006
Ernest A. Codman (1869(1869-1940)
5 tahun (1911-1916), 337 pasien
Error 36%
No Error 64%
Studi Prevalensi Kejadian yang Tidak Diharapkan
Amerika Latin
10,5
USA-2011
2010 – 2011
32
USA-2010
25
Canada
7,5
Australia
1980 - 2005
16,6
Inggris
11,7
USA-2
2,7
USA-1
3,9
0
10
20
%
30
40
Harvard School of Public HealthHealth-Survey
(2002)
1 dari 3 dokter mengaku
Pernah mengalami KTD
Pada keluarga atau pribadi
Patient safety, definition
The
IOM
the
AHRQ
• “the prevention of harm to patients
• “freedom from accidental or preventable
injuries produced by medical care.
Emphasis is placed on the system of care delivery
that
• (1) prevents errors;
• (2) learns from the errors that do occur;
• (3) is built on a culture of safety that involves health
care professionals, organizations, and patients.
The origins of the patient safety problem are
classified in terms of
type of error
communication
patient
management
clinical
performance
(failures between patient
or patient proxy &
practitioners, practitioner
& nonmedical staff, or
among practitioners),
(improper
delegation, failure in
tracking, wrong
referral, or wrong
use of
resources), and
(before, during,
and after
intervention).
Untoward incidents, therapeutic misadventures, iatrogenic
injuries or other adverse occurrences directly associated
with care or services provided within the jurisdiction of a
medical center, outpatient clinic or other facility.
May result from acts of commission or omission
(e.g., administration of the wrong medication, failure to
make a timely diagnosis or institute the appropriate
therapeutic intervention, adverse reactions or negative
outcomes of treatment, etc.)
Adverse drug events in inp
inpatient
(Classen et al., 1997).
Extra cost
$8.4 million/year for
teaching hospital
with 700-beds
(Bates et al., 1997)
Prolong
hospitalization
Increase
mortality
1983-1993: 2x fold
(7.391 death 1993)
(Phillips, Christenfeld, and
McGlynn, 1998)
ERROR, Definition (IOM, 1999)
the use of a wrong
plan to achieve an
aim
Failure of a planned
action to be completed
as intended
ERROR OF PLANNING
ERROR OF EXECUTION
Errors include product, procedures, system
ERROR
Omission
Commission
error which occurs as a
result of an action not
taken
Eror which occurs as
a result of an action
taken incorrectly
• misdiagnosis
• delayed evaluation
• failure to prescribe
• Incorrect action
• wrong medication
• wrong administration
Near Misses
Death
1
Severe
0s
Minor – Moderate
00s
Prevented/No harm incidents
000s
SLIP is observeable
observeable,, LAPSE is not
Slip
Lapse
• turning the wrong knob on a
piece of equipment
• not being able to recall
something from memory
Active error:
An error that occurs at the level of the frontline
operator and whose effects are felt almost
immediately.
Latent error:
Errors in the design organization, training, or
maintenance that lead to operator errors and whose
effects typically lie dormant in the system for lengthy
periods of time
Defining, Identifying, and Measuring Error in Emergency Medicine
A
• The capacity to cause error
B
• Did not reach the patient
C
• Did not cause the patient harm
D
• Required monitoring to confirm it resulted in no harm to the patient
and/or required intervention to preclude harm
E
• Required Intervention
F
• Required Hospitalization
G
• Permanent Patient Harm
H
• Sustain Life
I
• Patient’s Death
Adverse event in Health Care System
Australia
%
18
New Zealand
Japan
Britain
Denmark
Canada
16,6
16
14
12
10
8
12,9
11
10,8
9
7,5
6
4
3,7
2
0
The IOM, 1999
USA
Multi-Causal Theory Swiss Cheese Diagram
(Reason, 1991)
Human error is a symptom of trouble deeper
in the system (it is the starting point, not the
end)
To explain failure, do NOT try to find where
people went wrong
Find how people’s assessment and action
made sense at the time, given the
circumstances that surrounded them
Patient safety
Freedom from accidental injury
avoiding injuries or harm to patients from care that is
intended to help them
1. Build a SAFETY CULTURE
2. Build a comm
ommitment
itment & foc
focus on patient safety
3. Develop integrated risk management programme
4. Develop record and report on patient safety
5. Actively involve patients in communicating safety issues
6. Learn from error and set up a more safety procedure
7. Prevent injury or harm through Patient Safety programme
Jadi...............................
o
Think Safety
o
Talk Safety
o
Work Safety
o
BREATHE … SAFETY
… everyday
Is Quality important?
Is Quality important?
In Hospital 6, less than 5% of TB suspects receive
sputum smear examination according to standards
(Ref)
In Medan, less than 20% of private practitioners
have heard of International Standards for TB Care
(ISTC) (Ref)
1 dissatisfied patient will tell their experiences to
more than 3 persons
I have to sell the only piece of land I have for TB
treatment [which is free at the health centre]
Indikator SPM
dll..
UU Praktek
Kedokteran
SJSN
Perijinan
UU
Konsumen
UU
Kesehatan
Permenkes
UU Rumah sakit
Akreditasi
QUALITY: Definitions
The degree or grade of excellence
The Oxford English Dictionary (1988)
the degree to which health care services for
individuals and populations increase the
likelihood of desired health outcomes and are
consistent with current professional
knowledge.
Agency for health care research and quality
QUALITY: Definitions
Carrying out interventions correctly
according to pre-established standards and
procedures, with an aim of satisfying the
customers of the health system and
maximizing results without generating
health risks or unnecessary costs.
Conformance to specification
QUALITY: Definitions
degree to which health services for
individuals and populations increase the
likelihood of desired health outcomes and
are consistent with current
professional knowledge
IOM, 1990
Definitions
National Association of Quality Assurance
Professionals described quality as “the level of
excellence produced and documented in the
process of patient care, based on the best
knowledge available and achievable at a particular
facility.”
the Community Health Accreditation Program
defined quality as “the degree to which consumers
progress toward a desired outcome”
QUALITY: Definitions
Conformance to standards ….
Exceeding customer expectations ….
Consists of
structure, process, outcomes
Defining Quality: Quality Dimensions:
Effectiveness
Equity
Efficiency
Safety
Access
Patient
centeredness
Timeliness
Consumer
engagement
Community
engagement
Technical
competence
Whose
perspectives?
Patients
and
families
Physician
Quality
Regulator
Payers
1. Quality
Awareness
2. Quality
Measurement
3. Quality
Improvement
Chain of effect in Improving Healthcare
Quality (Berwick model, 2001)
Suara pasien
“Dua jam sebelum operasi saya
tidak melihat adanya penanda
operasi pada ekstremitas yang
akan dioperasi. Terdapat
perbedaan informasi mengenai
jenis tindakan anestesi antara
dokter bedah dan dokter
anestesi. Padahal pasien adalah
dokter spesialis, dirawat di VVIP.
Alhamdulillah operasi berhasil
baik dan pasien terhindari dari
KTD”
Foto: Koleksi IHI
Penugasan 1: Individu (10%)
Menemukan artikel (empirical research atau systematic
review) tentang safety dan quality di jurnal internasional
Artikel harus berbeda antar mahasiswa
Dari artikel tersebut ditulis:
Artikel tersebut terkait dengan rantai peningkatan mutu
Berwick yang mana
Apa pembelajaran penting atau hal menarik dari artikel tersebut
Deadline: Rabu, 1 Maret, dikumpulkan file menggunakan
Gamel (fasilitas Forum)