16 AU Kerangka kerja 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
What resources do you use:
Personnel, Equipment, drugs,
finance etc.
Resources
Process
How to use the resources:
Standards, Guidelines, SOP
Outcome
Result of care: Disability,
death, dissatisfaction, clinical
What is the result? Result
indicators
Care processes
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 co
it e t 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
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
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)
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
effectiven
ess 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
expectati
ons
• 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 syste 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, dll)
• 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
• Ujicoba Kerangka Kerja
Mutu
• Ujicoba indikator
• Sistem pemantauan
indikator
Penyusunan Panduan
• Panduan pengembangan
lanjutan kerangka kerja
mutu di tingkat propinsi,
kabupaten, faskes dll
• Guideline penerapan
kerangka kerja
• Guideline pengukuran
indikator
Quality Improvement
We ha e t o jobs: our job a d the
job of i pro i g our job
Donald Berwick
It is challe gi g, please do ’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
What resources do you use:
Personnel, Equipment, drugs,
finance etc.
Resources
Process
How to use the resources:
Standards, Guidelines, SOP
Outcome
Result of care: Disability,
death, dissatisfaction, clinical
What is the result? Result
indicators
Care processes
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 co
it e t 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
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
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)
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
effectiven
ess 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
expectati
ons
• 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 syste 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, dll)
• 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
• Ujicoba Kerangka Kerja
Mutu
• Ujicoba indikator
• Sistem pemantauan
indikator
Penyusunan Panduan
• Panduan pengembangan
lanjutan kerangka kerja
mutu di tingkat propinsi,
kabupaten, faskes dll
• Guideline penerapan
kerangka kerja
• Guideline pengukuran
indikator
Quality Improvement
We ha e t o jobs: our job a d the
job of i pro i g our job
Donald Berwick
It is challe gi g, please do ’t give up..