clinical pathway & cot selasa
DESCRIPTION
TRANSCRIPT
Clinical Pathway & Cost of Treatment
(Conceptual Thinking & Application)
Ronnie Rivany ® Health & Hospital Economics
Pusat Kajian Ekonomi & Kebijakan Kesehatan FKMUI
JASTIFIKASI
• Standarisasi tarif RS ?
• Belum ada Clinical Pathway sebagai penjaga mutu & sebagai basis layanan MUTU dan basis perencanaan/perhitungan biaya
• Sistem, Kebijakan dan Prosedur yang tidak jelas dan tidak konsisten serta belum terintegrasi
• Buku Tarif Departemen Kesehatan 2007 (?)
1 Diseases and disorders of the nervous system
2 Disease and disorders of the eye
3 Disease and disorders of the ear, nose, and throat
4 Disease and disorders of the respiratory system
5 Disease and disorders of the circulatory system
6 Disease and disorders of the digestive system
7 Disease and disorders of the hepatobiliiary system and pancreas
8 Disease and disorders of the musculoskeletal system and connective tissue
9 Disease and disorders of the skin, subcutaneous tissue, and breast
10 Endocrine, nutritional, and metabolic diseases and disorders
11 Disease and disorders of the kidney and the urinary tract
12 Disease and disorders of the male reproductive
13 Disease and disorders of the female reproductive system
14 Pregnancy, childbirth, and the purperium
15 Newborn and other neonates with conditions originating in the perinatal period
16 Disease and disorders of blood and blood forming organs and immunological disorders
17 Myeloproliferative disease and disorder, and poorly differentiated neoplasm
18 Infectious and parasitic disease (systemic or unspecified sites)
19 Mental diseases and disorders
20 Alcohol/drug use and alcohol/drug- induced organic mental disorders
21 Injuries, poisoning, and toxic effects of drugs
22 Burns
23 Factors influencing health status and other contact with health services
Major Diagnostic Categories (AR-DRG v 5,2, 2006)
DRG Numbering
• The format = A DD S• A = Pre MDC DRG’s ; B = nervous system
DRG; O = Reproductive System; Z = DRG’s relating to other health factors; 9 = the error DRG’s
• DD = DRG’s partition; – Range 01 – 39 Surgical Partition– Range 40 – 59 Other Partition– Range 60 – 99 Medical Partition
• S = split indicator– A = highest resources DRG– B = second highest resources
General Logic, Diagnosis Related Group’sAll acute admited patien
Principal diagnosis
Major diagnostic category # 1
Significant secondary condition ?
Procedure cluster A over age X
What age group’s
What procedure
ProcedureCuster A
Procedure cluster AOver Age X, with CC
Surgical Partition of MDC # 1
Procedure cluster AOver Age X, without CC
Procedure cluster A under age X
ProcedureCluster C
ProcedureCluster D
ProcedureCluster B
Medical Partition of MDC # 1
MDc # 4MDC # 3MDC # 2
Yes No
Over Under X
Yes No
INDONESIAN DRG’s
INDONESIAN DRG’s
• Pola pikir– ICD tetap
– MDC untuk sementara tetap
– Clinical Pathway bisa dibuat
– DRG di konfirmasi + bisa dibuat
– Casemix di konfirmasi + bisa dibuat
– Costing dilakukan dengan pendekatan Activity Based Costing + Simple Distribution
POLA PIKIR INDONESIAN DRG’s (1)
INA - DRG
1.Konfirmasi DRG 2.Hitung Cost/DRG
Clinical Pathway & Casemix
Activity Based Costing
POLA PIKIR INDONESIAN DRG’s (2)
ICD
MDC
DRG DRG
CASEMIX
COST
COST
DRG
TARIF
TARIF
1
2
Clinical Pathway
• Anticipated Recovery Pathway (ARPs)• Multidisciplinary Pathways of Care (MPCs)• Care Protocols• Integrated Care Pathways• Pathways of Care• Care Packages• Collaborative Care Pathways• Care Maps• Care Profiles
Konsep perencanaan pelayanan terpadu yang merangkum setiap
langkah yg diberikan kepada pasien berdasarkan standar yanmed, standar asuhan keperawatan&
standar pelayanan tenaga kesehatan lainnya , yg berbasis
bukti dng hasil yg dpt diukur dan dalam jangka waktu tertentu
selama di rumah sakit
1 Diseases and disorders of the nervous system
2 Disease and disorders of the eye
3 Disease and disorders of the ear, nose, and throat
4 Disease and disorders of the respiratory system
5 Disease and disorders of the circulatory system
6 Disease and disorders of the digestive system
7 Disease and disorders of the hepatobiliiary system and pancreas
8 Disease and disorders of the musculoskeletal system and connective tissue
9 Disease and disorders of the skin, subcutaneous tissue, and breast
10 Endocrine, nutritional, and metabolic diseases and disorders
11 Disease and disorders of the kidney and the urinary tract
12 Disease and disorders of the male reproductive
13 Disease and disorders of the female reproductive system
14 Pregnancy, childbirth, and the purperium
15 Newborn and other neonates with conditions originating in the perinatal period
16 Disease and disorders of blood and blood forming organs and immunological disorders
17 Myeloproliferative disease and disorder, and poorly differentiated neoplasm
18 Infectious and parasitic disease (systemic or unspecified sites)
19 Mental diseases and disorders
20 Alcohol/drug use and alcohol/drug- induced organic mental disorders
21 Injuries, poisoning, and toxic effects of drugs
22 Factors influencing health status and other contact with health services
23 Medical Outpatient Visit
Major Diagnostic Categories (Pedoman Tarif ?? DEPKES,2007)
HUBUNGAN C.P & DRG/CASEMIX
ICD
MDC
TARIF
DRG DRG
CASEMIX
COST
COST
TARIF
DRG
Clinical Pathway
Clinical Pathway in Hospital
International Classification of Disease (ICD)
Major Diagnostic Categories (MDC)
Surgical / Other / Medical
Diagnosis Related Groups (DRG’s)
Casemix
Clinical Pathway
Pengembangan Konsep Clinical Pathway
Format dasar Clinical PathwayAktivitas
pelayananPra R.I
(Poliklinik/
UGD)
Rawat Inap (R.I)
Hari ITgl
Hari 2Tgl
Komplikasi/Co-
morbidity
1 2 3 4 5
Pendaftaran
Penetapan Diagnose
Pra-Perawatan
Perawatan
Tindak Lanjut
Aktivitas pelayanan Pra R.I(Poliklinik/
UGD)
Rawat Inap (R.I)
Hari ITgl
Hari 2Tgl
Komplikasi/Co-
morbidity
1 2 3 4 5
Pra-Perawatan
Assessment klinis pemeriksaan/visite dokter konsultasi
Pemeriksaan penunjang laboratorium Radiologi Dst sesuai SPM, SAK & SPO
Perawatan
Tindakan medis Pemberian obat
Dst-nya, sesuai SPM,SAK & SPO
CLINICAL PATHWAY DALAM
TAHAPAN PRA PERAWATAN & PERAWATAN
No SOP Hari.1
Diag.Utama + Serta + Sulit + Serta
+ Sulit
1 Admission
2 Diagnostic
3 Pra Therapy
4 Therapy
5 Follow Up
6 Discharge
DUMMY TABLE (1)Clinical Pathway Utilisasi
DUMMY TABLE (2)Clinical Pathway Utilisasi
No Aktivitas SDM OBAT OVERHEAD
1 Admission
2 Diagnostic
3 Pra Therapy
4 Therapy
5 Follow Up
6 Discharge
DUMMY TABLE (3)Clinical Pathway Utilisasi
No Aktivitas Min
Utilisasi
Max
Utilisasi
Mean / Median
Utilisasi
1 Admission
2 Diagnostic
3 Pra Therapy
4 Therapy
5 Follow Up
6 Discharge
CLINICAL PATHWAYCLINICAL PATHWAY
SYMPTOM DIAGNOSIS THERAPY FOLLOW UP
1
Activities ABC
ActivitiesABC
ActivitiesABC
ActivitiesABC
ActivitiesABC
2 3 4 5
Admission Diagnosis Pre Therapy Therapy Follow up
• Diawali dengan membuat template untuk mendapatkan clinical pathway. Langkah- langkah dalam membuat clinical pathway adalah sebagai berikut :
• Membuat koding untuk memudahkan entry data.• Entry data karakteristik, identitas, tanggal
masuk dan keluar rumah sakit, lama hari rawat, jenis pembayaran, diagnosa utama, penyakit penyerta, penyakit penyulit, cara masuk, status keluar dan kelas rawatan dari masing-masing pasien. Entry data dilakukan berdasarkan kelompok AR-DRG.
PEMBUATAN CLINICAL PATHWAY (1)
• Entry semua aktivitas yang diterima pasien dari masuk sampai pulang dan pada waktu rawat jalan. Semua aktivitas dekelompokkan berdasarkan tahap clinical pathway.
• Konfirmasi tahap clinical pathway dan variabel kegiatan dengan SPM IDI, SPM Profesi dan para dokter dan paramedis di Rumah Sakit .
• Draft clinical pathway diisi berdasarkan frekuensi masing-masing kasus.
• Berdasarkan nilai mean atau median didapatkan nilai rata-rata masing-masing variabel dalam clinical pathway perhari rawatan berdasarkan kelompok AR-DRG.
• Cleaning dan pengecekan ulang terhadap nilai utilisasi berdasarkan tahap dalam clinical pathway masing-masing kelompok AR-DRG sehingga didapatkan nilai utilisasi kelompok AR-DRG berdasarkan clinical pathway.
PEMBUATAN CLINICAL PATHWAY (2)
Draft & Finalisasi Clinical Pathway
• Setelah draft Clinical Pathway yang berbasis evidence tadi telah dibuat, maka tahapan akhir dari penyusunan Clinical Pathway ini adalah Focus Group Discussion dengan Panel Expert ( para spesialis ) dan Ikatan Profesi , untuk bersama-sama menyepakati jenis dan jumlah tindakan/FORMULARIUM yang akan dipergunakan dalam Clinical Pathway
PEMBUATAN CLINICAL PATHWAY (3)
DUMMY TABLE (1)
Clinical Pathway Cost of Treatment Activities Day.1 Day.2 Day.3 Day
…..
Admission + + + +
Diagnosis + + + +
Pre Therapy + +
Therapy + + + +
Follow Up
Discharge
No Activities Day.1
Principal
Diagnosis
Penyulit Penyerta PP
1 Nursing
2 Consultation
3 Doctor visits
4 Medical Procedures
5 Nursing
6 Medical /DRUGS Treatment
7 Supporting exams
8 Nutrition
9 Physiotherapy
10 Etc
DUMMY TABLE (2)Clinical Pathway Cost of Treatment
No Activities U DC IC TC UC U x UC
1 Admission
2 Diagnosis
3 Pre Therapy
4 Therapy5 Follow Up
6 Discharge
T O T A L C/DRG
DUMMY TABLE (3)Clinical Pathway Cost of Treatment
Cost of Treatment (Cost DRG/Casemix)
No Cost of Treatment / Activity Based Costing
Direct Cost IndirectCostInvestasi Operasional Pemeliharaan
1 Admission
2 Diagnostic
3 Pra Therapy
4 Therapy5 Follow up
6. Discharge
INDEX
%
%
%
%
%
Cost of Treatment Rawat I nap dan Rawat J alan
No AR-DRG KLS. I I I KLS. I I KLS.I UTAMA VI P RAJ AL
1 B70A 5181485 5281384 5339924 5778045 5805053 803121
2 B70B 4075179 4153671 4199667 4543904 4565126 995167
3 B70C 1905273 1976629 2018443 2331386 2350678 987047
4 B70D 1848767 1863038 1871401 1933989 1937848
Perbandingan Biaya Rawat I nap KLS.I I I
No AR-DRG KLS. I I I Tanpa Gaj i Tanpa Obat Tanpa Gaj i
Dan Obat
1 B70A 5181485 4250350 2972007 2040872
2 B70B 4075179 3476706 2250808 1652334
3 B70C 1905273 1489521 1438879 1023127
4 B70D 1848767 1624600 1030735 806568
APLIKASI COST/DRG/Casemix dalam PK BLU(1)
CLINICAL PATHWAY COST of TREATMENT
TARIFF DETERMINANT per DRG’S
TARIFF
UNIT COSTROOM & BOARD
UNIT COSTDRUGS
UNIT COSTOK
UNIT COSTMED SUPPLIES
UNIT COST LAB
Total cost Q
COST/DRG’sMargin
ACTIVITY BASED COSTING + SIMPLE DISTRIBUTION
LAPORANClinical Pathway & Cost of Treatment
Diagnosis Related Group (DRG’s)Sectio Caesaria, Diare Anak & Katarak (2008)
Apendictomy & Pneumonia Anak (2009 - 2010)
DINAS KESEHATANPemerintah Propinsi Daerah Khusus Ibukota Jakarta
REKAM MEDIK DI RUMAH SAKIT
LAPORANClinical Pathway & Cost of Treatment
Diagnosis Related Group (DRG’s)10 Dept – International Wing
2009 - 2010
RUMAH SAKIT Dr Cipto Mangunkusumo, Jakarta
LAPORANClinical Pathway & Cost of Treatment
Diagnosis Related Group (DRG’s)Rumatan Methadon, 2010
RUMAH SAKIT KETERGANTUNGAN OBATCibubur - Jakarta
DIREKTORAT JENDERAL BINA PELAYANAN MEDIKDEPARTEMEN KESEHATAN
2005
• RS wajib memp.CP, Diagnosis mengacu pada ICD-10,Prosedur mengacu pd ICD-9CM Flowchart penyusunan CP
SPM Profesi Model Dummy
SPM RS
SOP Aktivitas
ICD
Surgical Medical
DRG
Case Mix
Clinical PathwayTerukur(admission to discharge) contoh :-Diare anak-Sectio Caesaria
TUJUAN :• utk meningkatkan mutu Yan pasien
• memaksimalkan penggunaan sumber daya scr efisien dng mengurangi dokumentasi yg tdk diperlukan.
• membantu identifikasi & klarifikasi proses Yan klinis
• mendukung efektivitas klinik, audit medis & risk management
Dalam menyusun clinical pathway (C.P) di RS peru memadukan & menyesuaikan dng b’bagai sistem yg tlh dibangun serta tlh b’jalan sehingga stiap bagian yg ada di RS lebih mudah menyesuaikan & saling mendukung pd saat C.P. selesai dibuat & disosialisasikan.
Komite Medik sngt bperan dlm m’bantu penyusunan & plaksanaan C.P. di RS.
Pedoman C.P. di RS diharapkan dpt m’bantu RS dlm menyusun C.P. dlm rangka mendukung plaksanaan pengembangan DRG’s Casemix di RS.
TERIMA KASIHatas perhatian & kesempatan
kerjasamanya
www.ina-drg-rr.net