INTEGRASI INTEGRASI PROGRAM PROGRAM MUTU MUTU PELAYANAN PELAYANAN RRUMAH SAKITUMAH SAKIT

DAN UPAYA KESELAMATAN PASIEN DAN UPAYA KESELAMATAN PASIEN

Dr. ADIB A YAHYA, MARS

INSTITUT MANAJEMEN RISIKO KLINIS“ PELATIHAN MANJEMEN RISIKO DAN PENINGKATAN MUTU

MENUJU KESELAMATAN PASIEN “

4 Fondasi4 FondasiAsuhan pasienAsuhan pasien

PATIENTPATIENT--CENTEREDCENTERED

CARECARE

HOSPITALHOSPITALRISKRISK

MANAGEMENTMANAGEMENT

• Asuhan MedisAsuhan Medis• Asuhan KeperawatanAsuhan Keperawatan• Asuhan GiziAsuhan Gizi• Asuhan ObatAsuhan Obat

• Evidence Based Evidence Based MedicineMedicine

• Value Based MedicineValue Based Medicine

““Safety is a fundamental principle Safety is a fundamental principle of patient care and a critical of patient care and a critical component of Quality component of Quality

Management.” Management.”

(World Alliance for Patient (World Alliance for Patient Safety, Forward Programme, Safety, Forward Programme,

WHO, 2004)WHO, 2004)

(PELAYANAN(PELAYANAN FOKUSFOKUS PASIEN)PASIEN)

(Nico A Lumenta & Adib A Yahya, 2012)(Nico A Lumenta & Adib A Yahya, 2012)

Standar Pelayanan Pasien : Standar Pelayanan Pasien : Tujuan utama pelayanan kes RS adalah pelayanan pasien….

Konsep

Konsep FilosofiFilosofiss

Asuhan pasien

Asuhan pasien

(Patient care)

(Patient care)

EBMEBMVBMVBM

EtikEtik

KebutuhanKebutuhanPasienPasien

• MutuMutu• PatientPatientSafetySafety

IMPLEMENTASI PATIENT SAFETY IMPLEMENTASI PATIENT SAFETY DI RUMAH SAKITDI RUMAH SAKIT

UU.N0.44 TH.2009 Tentang Rumah Sakit :

Pasal 43 :(1) Rumah Sakit wajib menerapkan standar keselamatan pasien.

PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIANOMOR 1691/MENKES/PER/VIII/2011

TENTANGKESELAMATAN PASIEN RUMAH SAKIT

TUJUH LANGKAH MENUJU

KESELAMATAN PASIEN RUMAH SAKIT

STANDAR KESELAMATAN PASIEN

PROGRAMWHO PATIENT

SAFETY

KARSPENILAIANPENILAIAN

DASAR HUKUMDASAR HUKUM

SASARAN KESELAMATAN PASIEN

RUMAH SAKIT9 SOLUTIONS

IMPLEMENTASI PATIENT SAFETY DI RUMAH SAKIT

STANDAR AKREDITASI RUMAH SAKIT 2012STANDAR AKREDITASI RUMAH SAKIT 2012I.I. KELOMPOK STANDAR PELAYANAN BERFOKUS PADA PASIENKELOMPOK STANDAR PELAYANAN BERFOKUS PADA PASIEN

1. AKSES KE PELAYANAN DAN KONTINUITAS PELAYANAN (APK) 1. AKSES KE PELAYANAN DAN KONTINUITAS PELAYANAN (APK) 2. HAK PASIEN DAN KELUARGA (HPK) 2. HAK PASIEN DAN KELUARGA (HPK) 3. ASESMEN PASIEN (AP) 3. ASESMEN PASIEN (AP) 4. PELAYANAN PASIEN (PP) 4. PELAYANAN PASIEN (PP) 5. PELAYANAN ANESTESI DAN BEDAH (PAB) 5. PELAYANAN ANESTESI DAN BEDAH (PAB) 6. MANAJEMEN DAN PENGGUNAAN OBAT (MPO) 6. MANAJEMEN DAN PENGGUNAAN OBAT (MPO) 7. PENDIDIKAN PASIEN DAN KELUARGA (PPK) 7. PENDIDIKAN PASIEN DAN KELUARGA (PPK)

IIII. KELOMPOK STANDAR MANAJEMEN RUMAH SAKIT. KELOMPOK STANDAR MANAJEMEN RUMAH SAKIT 1. PENINGKATAN MUTU DAN KESELAMATAN PASIEN 1. PENINGKATAN MUTU DAN KESELAMATAN PASIEN (PMKP)(PMKP) 2. PENCEGAHAN DAN PENGENDALIAN INFEKSI (PPI) 2. PENCEGAHAN DAN PENGENDALIAN INFEKSI (PPI) 3. TATA KELOLA, KEPEMIMPINAN, DAN PENGARAHAN (TKP) 3. TATA KELOLA, KEPEMIMPINAN, DAN PENGARAHAN (TKP) 4. MANAJEMEN FASILITAS DAN KESELAMATAN (MFK) 4. MANAJEMEN FASILITAS DAN KESELAMATAN (MFK) 5. KUALIFIKASI DAN PENDIDIKAN STAF (KPS) 5. KUALIFIKASI DAN PENDIDIKAN STAF (KPS) 6. MANAJEMEN KOMUNIKASI DAN INFORMASI (MKI) 6. MANAJEMEN KOMUNIKASI DAN INFORMASI (MKI)

III. SASARAN KESELAMATAN PASIEN RUMAH SAKITIII. SASARAN KESELAMATAN PASIEN RUMAH SAKITSASARAN I. KETEPATAN IDENTIFIKASI PASIENSASARAN I. KETEPATAN IDENTIFIKASI PASIENSASARAN II. PESASARAN II. PENNINGKATAN KOMUNIKASI YANG EFEKTIFINGKATAN KOMUNIKASI YANG EFEKTIFSASARAN III. PENINGKATAN KEAMANAN OBAT YANG PERLU DIWASPADAISASARAN III. PENINGKATAN KEAMANAN OBAT YANG PERLU DIWASPADAISASARAN IV. KEPASTIKAN TEPAT LOKASI,TEPAT PROSEDUR,TEPAT PASIEN OPERASISASARAN IV. KEPASTIKAN TEPAT LOKASI,TEPAT PROSEDUR,TEPAT PASIEN OPERASISASARAN V. PENGURANGAN RISIKO INFEKSI TERKAIT PELAYANAN KESEHATANSASARAN V. PENGURANGAN RISIKO INFEKSI TERKAIT PELAYANAN KESEHATANSASARAN VI. PENGURANGAN RISIKO PASIEN JATUHSASARAN VI. PENGURANGAN RISIKO PASIEN JATUH

IV. IV. Sasaran Sasaran millennium development goalsmillennium development goals

(1) penurunan angka kematian bayi dan peningkatan kesehatan ibu; (1) penurunan angka kematian bayi dan peningkatan kesehatan ibu;

(2) penurunan angka kesakitan HIV/AIDS; dan (2) penurunan angka kesakitan HIV/AIDS; dan

(3) penurunan angka kesakitan tuberkulosis.(3) penurunan angka kesakitan tuberkulosis.

44

HOSPITAL COMPETITIVENESS HOSPITAL COMPETITIVENESS PERFORMANCEPERFORMANCE

HOSPITAL COMPETITIVENESS PERFORMANCEHOSPITAL COMPETITIVENESS PERFORMANCE

OBJECTIVES:OBJECTIVES:

CUSTOMER CUSTOMER AWARENESSAWARENESSCUSTOMER CUSTOMER IMAGEIMAGECUSTOMER CUSTOMER SATISFACTIONSATISFACTIONCUSTOMER CUSTOMER LOYALTYLOYALTY

MOMENTS OF TRUTHMOMENTS OF TRUTH

MOMENTS OF TRUTHMOMENTS OF TRUTH

HEALTHCARE QUALITY :HEALTHCARE QUALITY :

– NOT ONLY THE QUALITY OF PATIENT’S NOT ONLY THE QUALITY OF PATIENT’S CLINICAL CARECLINICAL CARE

– EVERYTHING THAT HAPPENS DURING EVERYTHING THAT HAPPENS DURING THE COURSE OF TREATMENTTHE COURSE OF TREATMENT

– ““SERVICE QUALITY”SERVICE QUALITY” INCLUDES ALL INCLUDES ALL ASPECTS OF A ASPECTS OF A PATIENT’S HEALTHCARE PATIENT’S HEALTHCARE EXPERIENCEEXPERIENCE

Pull into parking lot

Park

Walk from car

Enter facility

Ask direction

Approach receptionist

Sign in

Wait

Clinical examination

To the patient room

Doctor visit

Nurse care

Operating theater

Discharge

Payment

Leave facility

Get into car

Leave parking lot

Decide “Would I recommend this hospital ?”

To the hospitalMoments of truth : Hospital in patient

INTEGRASI INTEGRASI PROGRAM PROGRAM MUTU MUTU PELAYANAN PELAYANAN RRUMAH SAKITUMAH SAKIT, ,

MANAJEMEN RISIKO MANAJEMEN RISIKO DAN KESELAMATAN PASIEN DAN KESELAMATAN PASIEN

““Essentials”Essentials”

Joint Commission International’s Joint Commission International’s Essentials of Health Care Quality Essentials of Health Care Quality

and Patient Safetyand Patient Safety

by Joint Commission International (JCI)by Joint Commission International (JCI)

EssentialsEssentials

Quality and safety improvement framework Quality and safety improvement framework designed to help organizations designed to help organizations focus on the focus on the risk areasrisk areas that have the that have the greatest impact on greatest impact on patient safetypatient safety

Essentials can help to:Essentials can help to: Determine Determine levels of risk levels of risk to patient safety in a health to patient safety in a health

care organizationcare organization Develop strategies to Develop strategies to mitigate risks mitigate risks Better Better allocate resources allocate resources to improve quality and to improve quality and

safetysafety

How Essentials Is AppliedHow Essentials Is Applied

Essentials will help an organization to:Essentials will help an organization to:

Identify the risksIdentify the risks that have the greatest impact on that have the greatest impact on safetysafety

Design an approach Design an approach for addressing these risksfor addressing these risks

Implement changesImplement changes

Periodically reassess Periodically reassess the impact of these the impact of these changeschanges

Overview of Overview of International Essentials for International Essentials for Quality and Patient SafetyQuality and Patient Safety

Essentials AddressEssentials Address Five Risk Areas / Focus Areas Five Risk Areas / Focus Areas

Developed from extensive international Developed from extensive international healthcare healthcare literature and experienceliterature and experienceTen Criteria for each Risk Area provide Ten Criteria for each Risk Area provide clear and achievable clear and achievable risk reduction strategiesrisk reduction strategiesProgressive Progressive “Levels of Effort”“Levels of Effort” are are identified for each Criterionidentified for each Criterion

Overview ofOverview of Five Risk Areas / Focus Areas Five Risk Areas / Focus Areas

Five widely recognized Five widely recognized domains of risk domains of risk : :

1.1. LeadershipLeadership Process and Accountability Process and Accountability

2.2. Competent and Capable Competent and Capable WorkforceWorkforce

3.3. Safe Environment Safe Environment for Staff and Patientsfor Staff and Patients

4.4. Clinical Care Clinical Care of Patientsof Patients

5.5. Improvement of Improvement of Quality and Safety Quality and Safety

5 DOMAINS

OF RISK

Leadership Processand

Accountability

Competent and Capable Workforce

Safe Environment for

Staff and Patients

Clinical Care of PatientsImprovement of Quality and Safety

Joint Commission International’s Essentials of Health Care Quality

and Patient Safety

Risk Area / Focus Area 1:Risk Area / Focus Area 1: Leadership Process and Accountability Leadership Process and Accountability

CRITERION :CRITERION : 1. Leadership 1. Leadership responsibilities and accountabilities responsibilities and accountabilities are identified are identified 2. Leadership for 2. Leadership for quality and patient safetyquality and patient safety3. 3. Collaboration and cooperation Collaboration and cooperation at all levelsat all levels4. Quality requirements in 4. Quality requirements in clinical and managerial contractsclinical and managerial contracts5. Quality, patient safety, and risk management are 5. Quality, patient safety, and risk management are integratedintegrated..6. Compliance with 6. Compliance with laws and regulationslaws and regulations7. Commitment to 7. Commitment to patient and family rightspatient and family rights8. Policies and procedures for 8. Policies and procedures for high-risk procedures and patientshigh-risk procedures and patients9. Oversight of 9. Oversight of human subject researchhuman subject research10. Oversight of organ and tissue 10. Oversight of organ and tissue donation and transplantationdonation and transplantation

Risk Area / Focus Area 2: Risk Area / Focus Area 2: Competent and Capable WorkforceCompetent and Capable Workforce

CRITERION :CRITERION :

1. Personnel 1. Personnel files and job descriptions files and job descriptions for all stafffor all staff

2. Review of 2. Review of credentials of physicianscredentials of physicians

3. Review of 3. Review of credentials of nursescredentials of nurses

4. Review of credentials of 4. Review of credentials of other health professionalsother health professionals

5. Staff members are 5. Staff members are oriented oriented to their jobs.to their jobs.

6. Oversight of students and 6. Oversight of students and those in trainingthose in training

7. Training in 7. Training in resuscitative techniquesresuscitative techniques

8. Staff education on 8. Staff education on infection prevention infection prevention and controland control

9. 9. CommunicationCommunication among those caring for the patient among those caring for the patient

10 Staff 10 Staff health and safety programhealth and safety program

Risk Area / Focus Area 3: Risk Area / Focus Area 3: Safe Environment of Staff and PatientsSafe Environment of Staff and Patients

CRITERION :CRITERION :

1. Regular 1. Regular inspection of buildingsinspection of buildings

2. Control of 2. Control of hazardous materialshazardous materials

3. 3. Fire safety Fire safety programprogram

4. 4. Biomedical equipment Biomedical equipment safetysafety

5. Stable 5. Stable water and electricity water and electricity sourcessources

6. Coordination of 6. Coordination of infection prevention infection prevention and control programand control program

7. Reduction of 7. Reduction of health care-associated infectionshealth care-associated infections

8. 8. Barrier techniques Barrier techniques are used.are used.

9. 9. Proper Proper disposal of sharps and needlesdisposal of sharps and needles

10. Proper 10. Proper disposal of infectious medical wastedisposal of infectious medical waste

Risk Area / Focus Area 4: Risk Area / Focus Area 4: Clinical Care of Patients Clinical Care of Patients

CRITERION :CRITERION :

1. Correct patient 1. Correct patient identificationidentification2. 2. Informed consentInformed consent3. Medical and nursing 3. Medical and nursing assessmentsassessments for all patients for all patients4. 4. Laboratory services Laboratory services are available and reliable.are available and reliable.55. Diagnostic imaging . Diagnostic imaging services available, safe, and reliable.services available, safe, and reliable.6. Planned and provided care is 6. Planned and provided care is writtenwritten..7. 7. Anesthesia and sedation Anesthesia and sedation are used appropriately.are used appropriately.8. 8. Surgical services Surgical services are appropriate to patient needsare appropriate to patient needs9. 9. Medication use Medication use is safely managed.is safely managed.10. Patients are educated to 10. Patients are educated to participateparticipate in their care. in their care.

Risk Area / Focus Area 5: Risk Area / Focus Area 5: Improvement of Quality and SafetyImprovement of Quality and Safety

CRITERION :CRITERION :

1. There is an adverse event 1. There is an adverse event reporting systemreporting system..

2. Adverse events are 2. Adverse events are analyzed.analyzed.

3. 3. High-riskHigh-risk processes and high-risk patients are monitored. processes and high-risk patients are monitored.

44. Patient satisfaction . Patient satisfaction is monitored.is monitored.

5. 5. Staff satisfaction Staff satisfaction is monitored.is monitored.

6. There is a 6. There is a complaint processcomplaint process..

7. 7. Clinical guidelines Clinical guidelines and pathways are available and used.and pathways are available and used.

8. Staff understands how 8. Staff understands how to improve processesto improve processes..

9. 9. Clinical outcomes Clinical outcomes are monitored.are monitored.

10. Communicating quality and safety 10. Communicating quality and safety information to staffinformation to staff

FocusArea►

1 2 3 4 5

Criteria▼

LeadershipProcess and

Accountability

Competent andCapable

Workforce

SafeEnvironmentfor Staff and

Patients

Clinical Care of

Patients

PatientsImprovementof Quality and

Safety

1

Leadershipresponsibilities

andaccountabilities

identified

Personnel filesand job

descriptions forall staff

Regularinspection of

buildings

Correct patientidentification

There is anadverse event

reporting system

2Leadership for

quality and safetyReview of

credentials ofphysicians

Control ofhazardousmaterials

Informedconsent

Adverse eventsare analyzed.

3

Collaborativemanagement

Review ofcredentials of

nurses

Fire safetyprogram

Medical andnursing

assessments forall patients

High-riskprocesses and

high-risk patientsare monitored.

4

Oversight ofcontracts

Review ofcredentials ofother health

professionals

Biomedicalequipment safety

Laboratoryservices areavailable and

reliable.

Patientsatisfaction is

monitored.

INTERNATIONAL ESSENTIALS OF HEALTH CARE QUALITY ANDPATIENT SAFETY (HOSPITAL ESSENTIALS)

5

Integration ofquality and risk

management

Staff orientationto their jobs

Stable water andElectricity sources

Diagnosticimaging services

are available,safe, and reliable.

Staff satisfactionis monitored

6

Compliance withlaws and

regulations

Oversight ofstudents and

those in training

Coordination ofinfection

prevention andcontrol program

Planned andprovided care is

written.

There is acomplaintprocess.

7

Commitment topatient and

familyrights

Training inresuscitativetechniques

Reduction ofhealth care–associated

infections (handhygiene)

Anesthesia andsedation are

usedappropriately.

Clinicalguidelines andpathways areavailable and

used.

8

Policies andprocedures for

care of high-riskpatients

Staff educationon infection

prevention andcontrol

Barriertechniques areused (gloves,masks, and so

on).

Surgical servicesare appropriate

to patient needs.

Staff understandhow to improve

processes.

9

Oversight ofhuman subject

research

Communicationamong thosecaring for the

patient

Proper disposalof sharps and

needles

Medication useis safely

managed.

Clinicaloutcomes are

monitored.

10

Organprocurement,donation, and

transplantation

Staff health andsafety program

Proper disposalof infectious

medical waste

Patients areeducated to

participate intheir care.

Communicatingquality and safety

information tostaff

INTERNATIONAL ESSENTIALS OF HEALTH CARE QUALITY AND PATIENT SAFETY™ Hospital EditionJoint Commission International

" People don’t change when you tell them there is a better option. " People don’t change when you tell them there is a better option. They change when they conclude they have no other optionThey change when they conclude they have no other option ““

Michael MandelbaumMichael Mandelbaum

" It is not the strongest of the species that survives," It is not the strongest of the species that survives, not the most intelligent, not the most intelligent,

but the one most responsive to change “but the one most responsive to change “

Charles DarwinCharles Darwin

FINAL WORDS

TERIMAKASIHTERIMAKASIH