Dr. Sejal JaykarB.H.M.S, MHM, PMP

Pentingnya data Indikator untuk monitor

dan meningkatkandan meningkatkanPerformance RS

Q lit I di t D fQuality Indicators Defn Peningkatan mutu adalah pendekatan formal untuk analisis

ki j d i t ti t k i k tkkinerja dan upaya-upaya sistematis untuk meningkatkan kualitas indikator bertujuan untuk mendeteksi suboptimal

perawatan baik dalam struktur, proses, atau hasil, dan dapatdigunakan sebagai alat untuk memandu proses kualitasdigunakan sebagai alat untuk memandu proses kualitas

QI melibatkan Prospective dan retrospektif reviews. Ini bertujuan untuk perbaikanWhere are You ? dan mencari

tahu cara untuk membuat segalanya lebih baik.tahu cara untuk membuat segalanya lebih baik. Khusus upaya untuk Avoid Blame, dan untuk menciptakan

sistem untuk mencegah kesalahan terjadi.

Q A / Q I tQ Assurance v/s Q Improvement Quality Assurance Was reactive, retrospective, policing,

and in many ways punitive It often involved determiningand in many ways punitive. It often involved determining who was at fault after something went wrong. This term is older and not as likely to be used today.

Quality Improvement QI involves both prospective and t ti i Ai d t i t iretrospective reviews. Aimed at improvement -- measuring

where you are, and figuring out ways to make things better. It specifically attempts to avoid attributing blame, and to create systems to prevent errors from happening.

QI activities can be very helpful in improving how things work. Trying to find where the defect in the system is, and figuring out new ways to do things can be challenging and fun. Its a great opportunity to think outside the box.g pp y

An effective QI program can really help make your life better.

St k h ld i H lthStake holders in Healthcare Providers- Tend to view quality in a technical

sense accuracy of diagnosis, appropriateness of therapy, resulting health outcomeoutcome.

Payers - Focus on cost-effectiveness. Employers - Want both to keep their costsEmployers Want both to keep their costs

down, and to get their employees back to work quickly.

Patients - Want compassion as well as skill with clear communication.

Tipe Pengukuran Indikator

StrukturM il i k lit l k h t b k it Menilai kualitas layanan kesehatan yang berkaitan dengan kemampuan RS utk memenuhi kebutuhan pasien/ masyarakat (eg rasio perawat : tt)

Proses Menilai apa yg dikerjakan provider dan bagaimana

pelaksanaan pekerjaannya (Are e doing the rightpelaksanaan pekerjaannya. (Are we doing the right things?)

Outcome Menilai pengaruh proses layanan yg diberikan

terhadap kesehatan pasien, eg mortalitas, morbiditas.(Are we doing the right things well?)( Are we doing the right things well? )

3 t f i Q lit3 types of measure in Quality Structure: Physical equipment andStructure: Physical equipment and

facilities Availability of physicians and/or midwives

providing obstetrical careproviding obstetrical care. Process: How the system works?

Percent of mothers receiving prenatal care prior t 12 k t tito 12 weeks gestation.

Percent of mothers taking prenatal vitamins. Percent of smoking mothers counseled to quit.

Outcome: The final product, or results Neonatal mortality rate Pre-maturity rate Pre-maturity rate.

C t h STRUCTURE INDICATORSContoh STRUCTURE INDICATORS

Jumlah dokter spesialis dibandingkan dokter non-spesialisp

Akses terhadap pemeriksaan penunjang Ketersediaan unit khusus (eg stroke unit,Ketersediaan unit khusus (eg stroke unit,

unit geriatri) PPM direvisi setiap dua tahunp

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C t h PROCESS INDICATORSContoh PROCESS INDICATORS Pengelolaan pasien sesuai PPMg p Pasien infark miokard yang menerima tx

trombolisis Door to needle time for MI patients Door to needle-time for MI patients Pasien Ca mammae < 75 tahun, yg dilakukan

reseksi kgb aksila Waktu tunggu antara kontak dokter dengan

pasien akut di rawat inap Persentase pasien yg melakukan pemantauanPersentase pasien yg melakukan pemantauan

mandiri terhadap GD-nya Rates of dilated opthtahlmoscopic examination

R t f f t i ti Rates of foot examination

OUTCOMES of DISEASESOUTCOMES of DISEASES (Clinical Outcome Indicators)

THE FIVE Ds :THEFIVED s : DeathAbadoutcomeifuntimely Disease A set of symptoms physical signs andDisease Asetofsymptoms,physicalsignsand

laboratoryabnormalities Discomfort Symptomssuchaspain,nausea,dyspnoea

etc. Disability Impairedabilityconnectedtousualactivities

athome,workorinrecreation DissatisfactionEmotionalreactionstodiseaseandits

care such as sadness or angercare,suchassadnessoranger

6/14/2013

zrjaty/ JCI/2012 9

M th d F Q lit I tMethods For Quality Improvement FADEFADE PDSA/ PDCA

Si Si Six Sigma CQI- Deming Way TQM

FADEFADE FocusFocus Analyze

D l Develop Execute

Six SigmaSix Sigma

Patient SatisfactionPatient Satisfaction

Q lit f CQuality of CareTingkat pelayanan kesehatan untuk pasien dan masyarakat

i k t i t dih k d k i tmeningkat sesuai outcome yang diharapkan dan konsistendengan pengetahuan profesional terkini.(The degree to which health services for individuals and populations increase the likelihood of desired health outcomespopulations increase the likelihood of desired health outcomes and are consistent with current professional knowledge)

Dimensi Mutu :1. Efficacyy2. Appropriateness 3. Availability4. Timeliness5. Effectiveness6. Continuity7. Safety8. Efficiency9. Respect and caring

Dimensi Mutu1 Efficacy1. Efficacy

Tingkat perawatan dan pelayanan telah memenuhiharapan atau outcome yang diinginkanp y g g

2. Appropriateness Tingkat perawatan dan pelayanan yang diberikanrelevan dengan kebutuhan, diberikan sesuaipengetahuan saat ini

3 Availiblity3. AvailiblityTingkat perawatan dan pelayanan tepat tersediasesuai kebutuhan

4. TimelinessTingkat perawatan dan pelayanan diberikan sesuaiwaktu yang diperlukanwaktu yang diperlukan

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Dimensi Mutu5. Effectiveness

Tingkat perawatan dan pelayanan diberikan sesuaig p p ypengetahuan untuk mencapai outcome yang diinginkan.Pencapaian / penilaian hasil sesuai t ujuan yangPencapaian / penilaian hasil sesuai t.ujuan yang ditetapkan

6. ContinuityyTingkat perawatan dan pelayanan dikoordinasi antardisiplin ilmu, antar organisasi sepanjang waktu

7. SafetyTingkat perawatan dan pelayanan dimana risikointervensi dan risiko di lingkungan direduksi untukintervensi dan risiko di lingkungan direduksi untukpasien, klien, residen dll, termasuk petugaskesehatan 18

Dimensi Mutu8. Efficiency

Hubungan antara outcome (hasil perawatan dang ( ppelayanan) dan sumberdaya yang digunakan untukmemberikan perawatan dan pelayanan. Sumberdaya minimum dan hasil optimumdaya minimum dan hasil optimum.

9. Respect and caringp gTingkat dimana perawatan dan pelayanan diberikandengan menghargai kebutuhan, harapan, dank i i i di id d ti k t di i di idkeinginan individu, dan tingkat dimana individudilibatkan dalam keputusan perawatan danpelayanan mereka

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HIGH RISK, HIGH VOLUME, PROBLEM PRONEPRONE

HIGH RISKRefers to areas that are particularly vulnerable, fragile or unstable. Consider the risks involved in caring for such populations and the potentialthe risks involved in caring for such populations and the potential consequences of failing to provide correct treatment. This category may also include individuals who undergo new, experimental, or especially risky interventions.

HIGH VOLUMEMeans services that are offered frequently or to large a large population. Demographics play a part in this category. What population does your organization serve most frequently ? Do you target a particular age group ? Do g q y y g p g g pyou specialize in a particular type of care (Pediatric, surgery )?

PROBLEM PRONEThose where procedures or processes have historically producedThose where procedures or processes have historically produced unsatisfactory results. The incidents falls in Alzheimer unit twice. Pay special attention to areas where processes break down or where outcome are inconsistent.

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High Risk High Volume Problem Prone Populations and ProcesssesHigh Risk, High Volume, ProblemProne Populations and Processses

High Risk High Volume ProblemProne

Acute myocardial infarction patients Dementia Patients Continuum of care planning betweensettings or organizations

Geriataric patients (the frail elderly andthose with dementia)

Emergency triage services Delays in physical therapy

Highrisk obstetrical patients Endoscopy Home use of oxygenHIV/AIDS patients Heart failure patients Medication prescribing for pediatric

patients Neonates, especially lowbirthweightinfants

Hospice patients Posttransplant care

Oncology patients Obstetrical patients and newborns Surgicalsite infections and wound care Organ donation and transplatatation Patients receiving enteral or parenteral

nutrition Timeliness if diagnostic testing results

Substance abuse patients Patients with chronic conditions (diabetes, ashma, hypertension)

Treatment of bipolar or attentiondeficit disorders

Suicidal Patients Patients with flu or pneumonia Use of highalert medicationsSurgery and other invasive procedures Postsurgical rehabilitation services Verbal and telephone ordersTrauma care Substance abuse treatment Wait times for home visits,ambulatory

care, or ED treatment Use of antipsychotic medications Waived testingUse of restraint on violent individuals Wound care

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Xrays

Kriteria untuk menentukan prioritas area te a u tu e e tu a p o tas a ea

1. Impactonpatients.p p2. Areathatneedstoimproveperformance.3. Levelofimportanceoftheneedforimprovement.4. Relationtothestrategicplan(strategicplan)RS.5. Frequencyofevents/issues.6. Chances of success.6. Chancesofsuccess.7. Impactonfinancial.8. RSleadershipfocus.9. Theeffectoftheresultsofthepatient10. Satisfactionofhealthworkers/medical.11 Statutory requirements11. Statutoryrequirements.

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Alat untuk Menentukan Prioritas Perbaikan Kinerja

BrainstormingP t Ch t Pareto Chart

Prioritization Matrixes Cause and Effect Diagram Concept Mapping p pp g Causal Loop Diagrams Affinity DiagramAffinity Diagram Mock Tracers Multi-voting Multi-voting

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St f P i iti ti M t iSteps for Prioritization Matrix L- shaped MatrixL shaped Matrix 1. Set goal2 Set Criteria eg cost resources etc2. Set Criteria eg cost, resources etc3. Weigh Criteria for Each option 4 W i h O ti i t C it i4. Weigh Options against Criteria5. Compare Options 6. Choose the best option across all

criteria

Prioritization MatrixCriteria Relation to

St t iFinancial I t

Positive ti t

Support of Mi i

Probabilitf

Total

IssueStrategic plan(x10)

Impact(x10)

patient Impact(x10)

Mission(x5)

y of success(x5)

score

Pain 2 2 5 5 3management process 20 20 50 25 15 130Restraint & seclusion

3 2 5 5 4seclusion process 30 20 50 25 20 145Network access process

2

20

4

40

4

40

3

15

4

20 13520 40 40 15 20 135Retention of employees

2

20

4

40

4

40

3

15

4

20 135Cross continuum transfer process

4

40

5

50

5

50

4

20

4

20 1800 1 2 3 4 5

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0-----------------1----------- 2 ------------ 3 ---------- 4 -------------- 5No impact Moderate impact Major impact

Prioritization Matrix ExamplePrioritization Matrix- Example

Checklist Identifying Processes needingChecklist Identifying Processes needing Measurement or Improvement

Process / part of process Relates to organization mission / vision / goals Involves a high risk population or process Involves a high volume population or process Involves a high volume population or process Involves a problem prone process Relates to regulatory requirements Has been the cause of patient / client / resident

/ staff or other complaints Has shown poor performance in ongoing p p g g

measurement results Is necessary to address a special project (ex

redesign of facility)g y)

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EvaluatingMeasurement&ImprovementProjectsg p j

No PertanyaanNamaProyek

NamaProyek

1Apakah sesuai dengan misi/visi/sasaran organisasi?2Apakah arearisiko tinggi?3Apakah areavolumetinggi?4Apakah arearawan masalah?5Apa dimensi performance yang dituju?5Apa dimensi performanceyangdituju?6Apakah terkait pengukuran yangdiminta Pemerintah?7Apakah terkait pegukuran yangdiminta Akreditasi?8Apakah terkait Sasaran Keselamatan Pasien?p9Pernahkah menerima komplain dari pasien atau staf dalam areaini?10Sudahkah aktifitas ukuran menunjukkan penurunan performa?

Apakah pernah teridentifikasi adanya potensial masalah dalaml f b l ?11literatur atau asosiasi profesiatau sumber lain?

12Apakah perlu kejadian khusus?13Apa sumber daya yangdiperlukn (keuangan,SDM,dll)?14Apakah proyek ini dapat menghemat biaya?14Apakah proyek ini dapat menghemat biaya?

Clearlydefinedgoalsforeach

QPS 3 3 F E h MQPS 3.3 - For Each Measure theprocess,procedure,oroutcometobee p ocess, p ocedu e, o ou co e o be

measured; theavailabilityofscienceorevidence

supportingthemeasure; howmeasurementwillbeaccomplished; howthemeasuresfitintotheorganizations

overallplanforqualitymeasurementandpatientsafety; andsafety;and

thefrequencyofmeasurement.

QPS 3 3 Cli i l A MQPS 3.3- Clinical Area Measures1. patient assessments;2. laboratory services;3. radiology and diagnostic imaging services;4 surgical procedures;4. surgical procedures;5. antibiotic and other medication use;6. medication errors and near misses;7. anesthesia and sedation use;8. use of blood and blood products;9. availability, content, and use of patient records;9. availability, content, and use of patient records;10. infection prevention and control, surveillance,

and reporting; and11 clinical research11. clinical research.

M i l A MManagerial Area Measures 1 h f i l i d li1. theprocurementofroutinelyrequiredsupplies

andmedicationessentialtomeetpatientneeds;2. reportingofactivitiesasrequiredbylawsand

l iregulations;3. riskmanagement;4. utilizationmanagement;g ;5. patientandfamilyexpectationsandsatisfaction;6. staffexpectationsandsatisfaction;7 patient demographics and clinical diagnoses7. patientdemographicsandclinicaldiagnoses;8. financialmanagement;and9. preventionandcontrolofeventsthatjeopardize

thesafetyofpatients,families,andstaff.

Indicator Development Form 1). What Key Quality Characteristic (KQC).

2). What is the specific name of this indicator?

3). What is the rationale for this indicator? 4). Identify the literature / guidelines / references used to support your CQI project. ) y g pp y Q p j5). Data source:Medical Record Data Logs

System Reports, please specify:_______

Patient Satisfaction Report

Other _____________6) l d f 6). Operational definition 7). Numerator statement: (if applicable) 8). Denominator statement: (if applicable)9). What is this indicator measuring?Rate Days Time Percentage Other

MOS:

Percentage Other ________ 10). Who will receive the results? 11). How often?12). This indicator will satisfy the following objective(s):

Physician Partnership Customer Satisfaction Regulatory Requirement Physician Partnership Culture Transformation Value EnhancementMarket Development

Customer Satisfaction Clinical Excellence Operational Excellence Cost Reduction

Regulatory RequirementRisk ManagementSafety Requirement

13). This indicator is designed to measure the following dimension(s) of excellence:AppropriatenessAvailabilityContinuity

Effectiveness EfficiencyTimeliness

Safety EfficacyRespect and Dignity

Other, specify:_________

The Performance Indicator Dictionary of JCI High Alert Medications IPSG 31 Name of Indicator Noncompliance storage of concentrated electrolyte2 Program Compliance with the standards of JCI IPSG3 Dimension

Feasibility Efficiency Respectability and Dignity

Availability Timeliness y Others, Mentioned :

Sustainability Advantage Effectivity Safety

4 Objective Preventing medication errors due to storage of concentrated electrolyte that does not follow the rulesthat does not follow the rules.related to Physician Partnership Patient Satisfaction Policy and Regulation Cultural Transformation Clinical Excellence

Risk ManagementV l I t O ti l E ll Value Improvement Operational Excellence

Safety Market development Cost Reduction

5 R ti l d Lit t

Accordance with JCI standards IPSG 3 on high alert drugs, concentrated electrolyte (KCl 7.45%, Bicnat 8.4%, Magnesium sulfate 20% and 40%, 3%

5 Rationale and Literature NaCl) should not be kept in the treatment room except certain clinical areas as per predecided indications.

6 DefinitionConcentrated electrolyte (KCl 7.45% and NaCl 3%) not kept in the treatment room except in cardiac surgery and in the intensive care unit (ICU)(ICU).

7 Criteriaa. Inclusion All patient care areasb. Exclusion Cardiac operating room, intensive care unit (ICU)

8 Types of Indicator Structure Process Outcome Process and

Outcome9 Ki d f I di t9 Kind of Indicator

Rate based Sentinel event Percentage Others : 10 Numerator Number of treatment rooms that keep concentrated electrolytes11 Denominator The number of rooms that should not keep concentrated electrolytesp y

12 Measurement / Formulation Numerator/Denominator X 100%

13Standard of Measurement / Indicator Measurement Target and/or threshold :

0%

and/or threshold :

14 Data Source : Reporting System, explain : Supervisor monitoring reports / Satellite pharmacy PIC

D t b Oth Database Others : Patient Safety Report 15 Sample Target &Sample Size (n) :

Observation Ares : All patient care areas16 Data Collection Methodology : (Select one)

Retrospective Concurrent17 Data Collector : Supervisor/ PIC of Satellite pharmacy18 Data Assesment Frequency : (Select one)

Daily Weekly Monthly thers, Mentioned : on the spot19 Reporting Period :

Monthly 6 monthly Quarterly Others :

20 Explain the analysis plan Treatment rooms in addition to cardiac surgery and ICU20 Explain the analysis plan Treatment rooms in addition to cardiac surgery and ICU rooms that still keep concentrated electrolyte analyzed the root causes of why they keep.

21 Explain data dissemation to the staff

Name of treatment rooms in addition to the cardiac surgery rooms and ICU that still keep concentrated electrolytes will be published in the rapimtas and every department of Medical / UPT / Installation which is responsible for theMedical / UPT / Installation which is responsible for the maintenance area sent a warning letter by the Director of Medical and Nursing

22 Name of Instrument or audit file:

Monitoring sheet of Supervisor/ PJ satellite pharmacy.

I dik t Cli i l Contoh ContohIndikator- Clinical Contoh Contoh

Patient Assessment Medical& NursingAssessmentwithin24hrs

Pre-anesthesia assessment completion Laboratory Services TAT: Urgent Urine samples (1/2 hr)Laboratory Services TAT: Urgent Urine samples (1/2 hr)

QC: % of control cholesterolRadiology & Diagnostic Imaging Turnaround time X Ray results

Surgical Procedures Unplanned return to the OR within 48hoursSurgical Procedures p

Time- out Policy compliance Antibiotic & other Medication Use Antibiotic and other medication use: Chemotherapy

Prophylactic Antibiotic usage in Clean Surgeries Medication Errors & Near Misses Adverse Drug reaction reporting

Anesthesia & Sedation Use Pre-sedation assessment

Arrival and discharge times for post-anesthesia careU f Bl d d Bl d d t Number of Blood units issuedUse of Blood and Blood products Number of Blood units issued

Availability, Content & Use of Patient Medical Records

Medical Record Audit Analysis

Infection Prevention Control Surveillance and HandHygiene ComplianceInfection Prevention, Control, Surveillance and Reporting

yg p

HospitalAcquiredinfections VAPClinical Research NumberofSuccessfullycompletedResearches

Indikator Managerial Contoh Contoh

Medical Suppliesprocurementandmanagement

Noof Outofstockmedications

f k f hmanagement %ofzerostockvs 100%of3monthsRegulatory Requirements KARS

ReportingofInfectiousdiseasestoGovernmentRi k M t Incident Report and Near Miss analysisRiskManagement IncidentReportandNearMissanalysis

Utilizationmanagement DailyaverageInpatientscensus

Average lengthofStay

NoofLaboratorytestsPatientAndfamilyExpectationsandSatisfaction

Inpatientsatisfactionsurvey

PatientComplaintsSt ff S ti f ti SStaff ExpectationsandSatisfaction StaffSatisfactionSurvey

ExitInterviewandturnoverratePatientDemographicsandClinicalDiagnosis Top5clinicalDiagnosis

l l iMale:FemaleRatio

FinancialManagement %ofpaymentsmadeontimeaspercontractterms

Credit CollectionPrevention &ControlOfEventsThatjeopardizepatientandfamilysafety

Incidentreporting /SentinelEvents

Indikator- International Patient Safety Goals

Contoh Contoh

Safety Goals PatientIdentification NoofPatients WithoutIdentityBracelets

SpecimensNotlabeledasperpolicyof2identifiersidentifiers

EffectiveCommunication VerbalOrderssignedby Physicianswithin24hrs

T l h l b t lt d b kTelephonelaboratoryresultsarereadbackSafetyOfHigh AlertMedications %ofHighalertmedicationfoundstoredin

generalnursingunits

%ofhighalertmedicationfoundwithouthighalertlabel

EnsureCorrect site,CorrectProcedured C t ti t S

TimeoutcompletedpriortosurgeryandCorrectpatientSurgery

Reduce theriskofHealthcareAssociatedInfections

Handhygienecompliancerate

R d h i k f i h d N b f ti t f llReduce theriskofpatientharmduetofalls

Numberofpatientfalls

Patientsfoundtobeatriskhavefallriskinterventiondocumented

Questions ??Questions ??