Kerangka Kerja Mutu:Penguatan Proses Pengembangan di Indonesia

1Adi Utarini

Struktur

• Mengapa dibutuhkan Kerangkakerja mutu?

• Kerangka kerja mutu:Indonesian National QualityFramework

• Pemikiran mengenai langkahpengembangan

• Mengapa dibutuhkan Kerangkakerja mutu?

• Kerangka kerja mutu:Indonesian National QualityFramework

• Pemikiran mengenai langkahpengembangan

Mutu: Perubahan Paradigma

Service Excellence

Clinical Excellence

Patient Safety

Global Burden of Unsafe Care (Jha et al., 2013)

• In every 100hospitalisations, therewere approximately14.2 of these adverseevents in HICs and 12.7in LMICs.

• In every 100hospitalisations, therewere approximately14.2 of these adverseevents in HICs and 12.7in 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

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.

StructureWhat resources

do you use:Resources

Personnel,Equipment,

drugs, financeetc.

Donabedian’s framework of quality careDonabedian’s framework of quality care

ProcessHow to use the

resources: Careprocesses

Standards, Guidelines, SOP

Outcome What is theresult? Result

Result of care:Disability, death,dissatisfaction, cli

nical indicators

Apa yang perlu dimiliki Indonesiauntuk membangun Mutu?

Struktur

• Direktorat Mutu danAkreditasi

• Regulasi Mutu danKeselamatan 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• …

• Direktorat Mutu danAkreditasi

• Regulasi Mutu danKeselamatan Pasien

• Kerangka Kerja Mutu• Komite nasional• …

• Perijinan• Akreditasi• Sistem manajemen mutu• Panduan Praktek Klinis• Standar, prosedur, norma

dll.• …

• Indikator• Peningkatan mutu• Pengalaman pasien• …

Quality Framework

Quality framework• Quality framework is a framework that is

applied as a foundation for improving qualityof services (at geographical level, institutionallevel, service level, professional level etc)

• Quality framework represents thestakeholder’s commitment toward qualitydimensions and their priorities,measurements, regulations and qualitymanagement system

• Quality framework is a framework that isapplied as a foundation for improving qualityof services (at geographical level, institutionallevel, service level, professional level etc)

• Quality framework represents thestakeholder’s commitment toward qualitydimensions and their priorities,measurements, regulations and qualitymanagement system

Quality Framework

A. How do weachieve Quality?

• Kerangka kerjanasional

• Tata kelola Klinis• Sistem

manajemenmutu

• Akreditasi RS• Akreditasi Pkm• Dll.

B. What level of quality arewe committed to provideto our patients, familiesand communities?

• Kerangka kerjanasional

• Tata kelola Klinis• Sistem

manajemenmutu

• Akreditasi RS• Akreditasi Pkm• Dll.

• Akses• Keselamatan• Keadilan• Dsb.

Komitmen Mutu: Dimensi yang mana?

• Effectiveness• Equity• Efficiency• Safety• Access• Patient

centeredness

• Timeliness• Consumer

engagement• Community

engagement• Technical

competence

• 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

• Safe• Effective• Patient centered

• Timely• Efficient• Equitable

National Strategy for QualityImprovement in Health Care (US)

3 Aims

• Better Care: Improve the overallquality, by making health caremore patient-centered, reliable, accessible, andsafe.

• Healthy People/HealthyCommunities: Improve the healthof the U.S. population bysupporting proven interventionsto address behavioral, socialand, environmental determinantsof health in addition to deliveringhigher-quality care.

• Affordable Care: Reduce the costof quality health care forindividuals, families, employers, and government.

6 Priorities• Making care safer by reducing harm

caused in the delivery of care.• Ensuring that each person and family are

engaged as partners in their care.• Promoting effective communication and

coordination of care.• Promoting the most effective prevention

and treatment practices for the leadingcauses of mortality, starting withcardiovascular disease.

• Working with communities to promotewide use of best practices to enablehealthy living.

• Making quality care more affordable forindividuals, families, employers, andgovernments by developing andspreading new health care deliverymodels.

• Better Care: Improve the overallquality, by making health caremore patient-centered, reliable, accessible, andsafe.

• Healthy People/HealthyCommunities: Improve the healthof the U.S. population bysupporting proven interventionsto address behavioral, socialand, environmental determinantsof health in addition to deliveringhigher-quality care.

• Affordable Care: Reduce the costof quality health care forindividuals, families, employers, and government.

• Making care safer by reducing harmcaused in the delivery of care.

• Ensuring that each person and family areengaged as partners in their care.

• Promoting effective communication andcoordination of care.

• Promoting the most effective preventionand treatment practices for the leadingcauses of mortality, starting withcardiovascular disease.

• Working with communities to promotewide use of best practices to enablehealthy living.

• Making quality care more affordable forindividuals, families, employers, andgovernments by developing andspreading new health care deliverymodels.

Tanzania: 2011-2016

• Acceptability/patient centeredness• Technical competence• Access• Interpersonal relations• Effectiveness• Equity• Efficiency• Safety• Continuity of care• Choice of service• Physical infrastructure & Amenities

• 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

Berbagai negara, berbagai dimensi mutu…

Dimensi Mutu:Indonesia

Dari beberapa dokumenkebijakan:

• Akses• Continuity of care• Cost of care• Infrastruktur fisik• Ketersediaan obat-alkes• Kompetensi teknis SDM

Dari beberapa dokumenkebijakan:

• Akses• Continuity of care• Cost of care• Infrastruktur fisik• Ketersediaan obat-alkes• Kompetensi teknis SDM

Quality Framework Victoria (Australia)

New South Wales, Australia

Dari Kerangka Kerja Mutu ke Indikator:Menyusun Benang Merah

Contoh: Performance Assessment Tool for qualityimprovement in Hospital (PATH model, WHO)

Example of PATH indicators

Clinicaleffectiveness and

safety

Efficiency

LOS

Stafforientationand safety

Responsivegovernance

Breastfeedingat discharge

Patient-centered

ness

Patientexpectat

ions

Clinicaleffectiveness and

safety

SC

Prophylacticantibiotics use

Readmission

Surgicaltheatre use

Needleinjuries

Staff smokingprevalence

Trainingexpenditure

Breastfeedingat discharge

Patientexpectat

ions

• Clinical indicators• Patient safety indicators• Quality indicators

IndeksKepuasanMasyarakat Indikator Klinis

IndikatorMutu

Indikator daribeberapalembaga:KARS, BPJS,Kemenkes

IndikatorKinerjaIndividu

Indikator MutuPelayanan RS

IndikatorMutu

Indikator daribeberapalembaga:KARS, BPJS,Kemenkes

Indikator KeselamatanPasien

Indikator Mutu Pelayanan di Indonesia

Quality Improvement

– We need to improveand a system toimprove

– “Every system isperfectly designed toachieve exactly theresults it gets.”

– The first law ofimprovement

– We need to improveand a system toimprove

– “Every system isperfectly designed toachieve exactly theresults it gets.”

– The first law ofimprovement

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

EnglandJapanFranceDenmarkSwitzerlandNew ZealandSpainCanadaAustraliaUSANetherlands

• 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

EnglandJapanFranceDenmarkSwitzerlandNew ZealandSpainCanadaAustraliaUSANetherlands

Perbandingan antar lembaga akreditasimenurut:

• 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.

• 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 tetapibukti yang menunjukkan efektivitas dan efisiensinyaminimal, sehingga tidak dapat ditarik kesimpulantentang dampaknya.

• Sebagian besar studi tidak melaporkan konteksintervensi, implementasi ataupun biaya

• Tantangan dalam menilai dampak Akreditasi dansertifikasi yang merupakan contoh intervensi yangkompleks dan beragam

• Diperlukan studi untuk menjawab: Apa aspekakreditasi yang dapat bermanfaat untukmeningkatkan keselamatan pasien dan kinerjaorganisasi?

• Brubakk et al., Systematic review of hospital accreditation: the challenges of measuringcomplex intervention effects. BMC Health service research, 2015, 15:280

• Dorongan terus menerus untuk akreditasi, akan tetapibukti yang menunjukkan efektivitas dan efisiensinyaminimal, sehingga tidak dapat ditarik kesimpulantentang dampaknya.

• Sebagian besar studi tidak melaporkan konteksintervensi, implementasi ataupun biaya

• Tantangan dalam menilai dampak Akreditasi dansertifikasi yang merupakan contoh intervensi yangkompleks dan beragam

• Diperlukan studi untuk menjawab: Apa aspekakreditasi yang dapat bermanfaat untukmeningkatkan keselamatan pasien dan kinerjaorganisasi?

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?

• 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 weachieve Quality?

• Kerangka kerjanasional

• Tata kelola Klinis• Sistem

manajemenmutu

• AkreditasiRS, Pkm

• Dll.

B. What level of quality arewe committed to provideto our patients, familiesand communities?

• Kerangka kerjanasional

• Tata kelola Klinis• Sistem

manajemenmutu

• AkreditasiRS, Pkm

• Dll.

• Akses• Keselamatan• Keadilan• Dsb.

Usulan: Lima Tahap PengembanganKerangka Kerja Mutu (KKM)

Desk review• Berbagai dokumen

kebijakan• Dari berbagai lembaga

(Kemenkes, KARS, BPJS, dll)

• Output: Kompilasidimensi mutu

Eksploratori• Menggali dimensi

prioritas• Memetakan berbagai

peran lembaga• Mengidentifikasi

indikator dan strategi• Output: Usulan kerangka

kerja

Formulasi• Merumuskan Quality

Framework• Menyusun indikator dan

strategi QI• Output: Kerangka Kerja

Mutu PelayananKesehatan Indonesia

• Berbagai dokumenkebijakan

• Dari berbagai lembaga(Kemenkes, KARS, BPJS, dll)

• Output: Kompilasidimensi mutu

• Menggali dimensiprioritas

• Memetakan berbagaiperan lembaga

• Mengidentifikasiindikator dan strategi

• Output: Usulan kerangkakerja

• Merumuskan QualityFramework

• Menyusun indikator danstrategi QI

• Output: Kerangka KerjaMutu PelayananKesehatan Indonesia

Usulan Tahap PengembanganKerangka Kerja Mutu (KKM)

Implementasi Pilot

• Ujicoba Kerangka KerjaMutu

• Ujicoba indikator• Sistem pemantauan

indikator

Penyusunan Panduan

• Panduan pengembanganlanjutan kerangka kerjamutu di tingkatpropinsi, kabupaten, faskes dll

• Guideline penerapankerangka kerja

• Guideline pengukuranindikator

• Ujicoba Kerangka KerjaMutu

• Ujicoba indikator• Sistem pemantauan

indikator

• Panduan pengembanganlanjutan kerangka kerjamutu di tingkatpropinsi, kabupaten, faskes dll

• Guideline penerapankerangka kerja

• Guideline pengukuranindikator

Quality Improvement

“We have two jobs: our job and thejob of improving our job”

Donald Berwick

“We have two jobs: our job and thejob of improving our job”

Donald Berwick

It is challenging, please don’t give up..It is challenging, please don’t give up..