case examples hfmeca (amkdp).pdf

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  • 7/27/2019 Case Examples HFMECA (AMKDP).pdf

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    LANGKAH ANALISIS MODUS KEGAGALAN, DAMPAK & PENYEBAB

    (AMKDP)/HEALTHCARE FAILURE MODE EFFECT & CAUSES ANALYSYS

    (HFMECA)

    1. Pilih Proses yang berisiko tinggi dan Bentuk Tim

    2. Gambarkan Alur Proses

    3. Diskusikan & Prioritaskan Modus Kegagalan

    4. Brainstorming Dampak Modus Kegagalan5. Identifikasi Penyebab Modus Kegagalan

    6. Hitung Total NPR (Nilai Prioritas Risiko)

    7. Disain ulang proses / Re-disain Proses

    8. Analisa & uji Proses baru9. Implementasi & Monitor Proses baru

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    LANGKAH 1 : PILIH PROSES YANG BERISIKO TINGGI

    Pilih Proses berisiko tinggi yang akan dianalisa.

    Judul Proses :

    BENTUK TIM

    Ketua : ____________________________________________________________

    Anggota 1. _______________ 4. ________________________________________2. _______________ 5. ________________________________________

    3. _______________ 6. ________________________________________

    Notulen _________________________________________

    Apakah semua Unit yang terkait dalam Proses sudah terwakili ? YA / TIDAK

    Tanggal dimulai ____________________ Tanggal selesai ______________________________

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    LANGKAH 2A DIAGRAM PROSES

    LANGKAH PROSES :

    Gambarkan proses secara grafis,sesuai kebijakan & prosedur untuk setiap tindakan dan nomor dibawah ini.Jika proses terlalu kompleks,anda memilih satu langkah proses atau sub proses untuk ditindak lanjuti

    Catat Sub proses untuk setiap langkah proses

    Sub Proses Sub Proses Sub Proses Sub Proses Sub Proses

    -------------------- --- - ----------------------- - - ------------------------- - --------------------------- - ------------------------------

    ------------------------ - ------------------------ - -------------------------- - -------------------------- -------------------------------

    - ----------------------- - ------------------------ - - ------------------------- - -------------------------- - ------------------------------

    - ----------------------- - ----------------------- - - ------------------------- - -------------------------- - ------------------------------

    - ----------------------- - ----------------------- - - ------------------------- - -------------------------- - ------------------------------

    ------------------------ - ----------------------- - ------------------------- - -------------------------- -------------------------------

    - ----------------------- - ----------------------- - - ------------------------ - -------------------------- - ------------------------------

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    LANGAKAH 2B DIAGRAM SUB PROSES

    LANGKAH SUB PROSES :

    Gambarkan Subproses secara grafis,sesuai kebijakan & prosedur untuk setiap tindakan dan nomor dibawah ini.Jika proses terlalu kompleks,anda memilih satu langkah Subproses untuk ditindak lanjuti

    Catat Modus Kegagalan untuk setiap langkah Sub proses

    Modus Kegagalan Modus Kegagalan Modus Kegagalan Modus Kegagalan Modus Kegagalan

    -------------------- --- - ----------------------- - - ------------------------- - --------------------------- - ------------------------------

    ------------------------ - ------------------------ - -------------------------- - -------------------------- -------------------------------

    - ----------------------- - ------------------------ - - ------------------------- - -------------------------- - ------------------------------

    - ----------------------- - ----------------------- - - ------------------------- - -------------------------- - ------------------------------

    - ----------------------- - ----------------------- - - ------------------------- - -------------------------- - ------------------------------

    ------------------------ - ----------------------- - ------------------------- - -------------------------- -------------------------------

    - ----------------------- - ----------------------- - - ------------------------ - -------------------------- - ------------------------------

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    LANGKAH 3

    BRAINSTORMING POTENSIAL MODUS KEGAGALAN & BUATPRIORITAS MODUS KEGAGALAN

    543214321EHML1-255432154321

    10987654321

    Ranking

    Modus

    Kegagalan

    NPR

    (5X7

    X8

    DeteksiKontrolBandsSkor

    Risi

    ko

    (3X

    4)

    ProbabilitasBahayaModus KegagalanProses

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    543214321EHML1-255432154321

    987654321

    NPR

    (5X7X8)DeteksiKontrolBandsSkor

    Risiko

    (3X4)

    ProbabilitasBahayaDampakModus Kegagalan

    LANGKAH 4

    BRAINSTORMING DAMPAK MODUS KEGAGALAN

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    2

    Dampak

    543214321EHML1-255432154321

    1098765431

    NPR

    (6X8X9)

    DeteksiKontrolBandsSkorRisiko

    (4X5)

    ProbabilitasBahayaPenyebabModus

    Kegagalan

    LANGKAH 5

    IDENTIFIKASI PENYEBAB MODUS KEGAGALAN

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    LANGKAH 6

    HITUNG TOTAL NPR

    3

    NPR

    Modus

    Kegagalan

    98765421

    RankingTotal NPRNPR

    Penyebab

    PenyebabNPR

    Dampak

    DampakModus

    Kegagalan

    No

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    LANGKAH 7

    PROSES DISAIN ULANG

    Ukuran

    Outcome /

    Pengawasan

    Kinerja

    Tanggal Dilaksanakan

    Proses Baru

    Tanggal

    Diselesaikan

    Penanggung

    jawab

    Rekomendasi

    Redisain

    Proses

    PenyebabDampakModus

    Kegagalan

    Proses

    987654321

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    No injuryFirst aid

    treatment

    only with no

    lost time, nor

    restricted

    duty injuries

    nor illnesses

    Medical expenses,

    lost time or

    restricted duty

    injuries or

    illness for 1 or

    2 staff

    Hospitalization

    of 1 or 2 staff or

    3 or more staff

    experiencing lost

    time or restricted

    duty

    injuries or

    illnesses

    Death or

    hospitalization

    of 3 or more

    staff

    Staff

    Outcome

    Evaluated &

    First aid

    treatment

    No injury but

    increased

    LOS to

    monitor

    effects

    MINOR

    2

    No injuryInjury with no

    permanent loss of

    function or

    Evaluation &

    treatment for

    1 or 2 visitors(less than

    hospitalizatin)

    Injury with

    permanent loss of

    function

    Or Hospitalization

    of 1 or 2

    visitors

    Death,

    hospitalization

    of 3 or more

    Visitor

    Outcome

    No injuryInjury with no

    permanent loss of

    function

    Injury with

    permanent

    loss of

    function

    DeathPatient

    Outcome

    INSIGNICANT

    1

    MODERATE

    3

    MAJOR

    4

    CATASTROPHIC

    5

    SEVERITY RATINGSEVERITY RATING(Modified by IMRK)(Modified by IMRK)

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    PROBABILITY(Modified by IMRK)

    Very likely to occur every monthAlmost certain5

    Likely to occur immediately or within a short period

    (may happen several times in one year )

    Likely4

    Possible will occur

    (may happen several times in 1 to 2 years)

    Possible3

    Unlikely to occur

    (may happen sometimes in 2 to 5 years)

    Unlikely)2

    Very Unlikely to occur

    (may happen sometime in 5 to 30 years)

    Rare1

    DefinitionDescriptionRating

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    RISK GRADING MATRIX

    ExtremeHighModerateLowLowRare1

    ExtremeHighModerateLowLowUnlikely2

    ExtremeExtremeHighModerateLowPossible3

    ExtremeExtremeHighModerateModerateLikely4

    ExtremeExtremeHighModerateModerateAlmost certain5

    Catastrophic5

    Major4

    Moderate3

    Minor2

    Insignificant1

    Potencial ConcequencesProbability

    /Likelihood

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    Sample Detectability Scale(Modified by IMRK)

    0 out of 10

    2 out 0f 10

    5 out of 10

    7 out of 10

    10 out to 10

    Probability of

    Detection

    Detection not possible at any pointAlmost certainnot to detect

    5

    Unlikely to be detectedLow likelihood4

    Moderate likelihood of detectionModerate

    likelihood3

    Likely to be detectedHigh likelihood2

    Almost always detected immediatelyCertain to detect1

    DefinitionDescriptionRating

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    CONTROLLABILITY

    Controls and Status are unknown or Residual riskDifficult4

    Controls are either not practically in place not effective, not

    communicated and or not complied with no reviews undertaken or

    Controls can be introduced to reduce risk to an acceptable level but

    will take longer than 1 year or entail significant effort or expensive

    Moderate

    difficult

    3

    Sufficient effective controls procedures are substantially in place

    for specific circumstances, communicated & are complied with

    periodic reviews are conducted or

    Controls can be introduced to reduce risk to an acceptable level

    within 1 year or at cost

    Moderate

    easy

    2

    Comprehensive effective controls fully in place, communicated,

    complied with, maintained, monitored, reviewed & tested

    regularly. All that is practicable to be done is being done orRisk can be introduced 1 month / or low cost or

    Easy1

    DefinitionDesriptionRating