petunjuk 2 materi identifikasi resiko

7/25/2019 Petunjuk 2 Materi Identifikasi Resiko

1/19

HERKUTANTO, FMEA 2013 1

Failure Mode and Effect Analysis

Herkutanto

Arjaty/ IMRK 2

STRATEGI REDUKSI RISIKO

HAZARD AND VULNERABILITYASSESSMENT

Infection control rsik assesment

REDISAIN PROSES :

- FMEA

TUJUAN PAPARAN

Strategi Pengendalian

Risiko melalui HVA,ICRA, FMEA

Mengenal langkah2

Failure Mode andEffect Analysis

Herkutanto 2009
http://www.docu-track.com/buy/http://www.docu-track.com/buy/


2/19


STRATEGI PENGENDALIAN RISIKO DI

RUMAH SAKIT

1

OSHA Training Institute 6

Hazard and

Vulnerability

Assessment

OSHA Training Institute Region IX

University of California, San Diego (UCSD) - Extension


The Purpose of the HVA

The purpose is a prioritization process that willresult in a risk assessment for all hazards

The tool includes consideration of multiplefactors

The focus is on organization planning andresources and /or the determine that no action

may be required. This is an organization

decision


Is this required?

The Joint Commission, previously called theJoint Commission of Accreditation of Healthcare

Organizations (JCAHO), requests an HVA for

organizations to determine the focus of their

emergency planning

There is no specific tool nor method defined


3/19



Preparedness

Preparedness of the organizations abilityto manage risks, can include items suchas:

Status of current plans

Training

Insurance

Back up systems

Community resources


Models

There are a number of models for an HVA.

Two well known models are fromAmerican Society of Healthcare Engineering (ASHE)

Kaiser Foundation

Both models can be adjusted to fit the

organization Security organizations and other vendors also

market HVA tools


Medical Center HVA Model

Kaiser model also includes:

Probability

Response factors

Human, property and business impacts, each

considered as a separate issue


A Comparison of Threat Events

Considered in HVA Models

ASHE Model 2001

Human Events

Natural Events Technological Events

Kaiser Foundation

Model 2001

Human Events

Natural Events Technological Events

Hazmat Events
http://www.docu-track.com/buy/http://www.docu-track.com/buy/http://www.docu-track.com/buy/http://www.docu-track.com/buy/


4/19



References American Society of Healthcare Engineering 2001

WWW.ashe.org

FEMA. Emergency Management Institute Hazardvulnerability analysis and risk assessment. Unit 2

http://www.training.fema.gov/emiweb/EMICourses/E464

CM/02%20Unit%202.pdf

Joint Commission Resources Hazard vulnerability

analysis (HVA), May/Jun 2002, 2-3



http://www.ashe.org/http://www.training.fema.gov/emiweb/EMICourses/E464http://www.docu-track.com/buy/http://www.docu-track.com/buy/http://www.training.fema.gov/emiweb/EMICourses/E464http://www.ashe.org/http://www.docu-track.com/buy/http://www.docu-track.com/buy/


5/19



Arjaty/ IMRK 18

RISK REDUCTION STRATEGIES DIFFICULTY &LONG TERM EFFECTIVENESS

Types of actions Degree of Long term

difficulty effectiveness

Easy Low1. Punitive2. Retraining / counseling

3. Process redesign4. Paper vs practice5. Technical system enhance6. Culture change

Difficult High

Arjaty/ IMRK 19


Identifikasi risiko dgn bertanya 3 pertanyaan dasar :

1. Apa prosesnya ?

2. Dimana risk points / cause?3. Apa yg dapat dimitigate pada dampak

risk points ?

Definisi ProsesTransformasi input menjadi output yg berkaitan dgn

Kejadian, aktivitas dan mekanisme yg terstruktur

Arjaty/ IMRK 20


RENCANAREDUKSI RISIKO

Design Proses u/Meminimalkan

risikokegagalan

Design Proses u/Mengurangi

DampakKegagalan terjadi

pada pasien

Design Proses u/Meminimalkan

risikoKegagalan terjadi

Pada pasien

RISK

POINTS /

COMMON CAUSES


6/19


Arjaty/ IMRK 21

IDENTIFYING RISK PRONE SYSTEM

Variable input

Complex systems Non standardized systems

Tightly coupled systems

Systems with tight time constraints

Systems with hierarchical

Arjaty/ IMRK 22

ariable input

Pasien Penyakit berat Penyakit penyerta Pernah mendapatkan pengobatan Usia

Pemberi Pelayanan

Tingkat keterampilan

Cara pendekatan

Proses Pelayanan harus dapat mengakomodasivariabilitas yang tdk dapat dihindarkan dan tidak dapatdikontrol ini.

Arjaty/ IMRK 23

Complexitas

Pelayanan rumah sakit sangat kompleks

Memerlukan beragam langkah yang sangat

mungkin berhadapan dengan kegagalan Semakin banyak langkah semakin besar

kemungkinan gagal

Donald Berwick :

1 langkah -- error 1 %

25 langkah -- error 22%

100 langkah -- error 63%

Arjaty/ IMRK 24

Lack of Standardization

Standard - -- proses tidak dapat berjalan

sesuai dengan harapan

Individu yang menjalankan proses harus

melaksanakan langkah langkah yang telah

ditetapkan secara konsisten

Variabilitas individual sangat tinggi -

perlu standard mis : SPO, Parameter, Protokol,Clinical Pathways dapat membatasi pengaruh

dari variabel yang ada.


7/19


Arjaty/ IMRK 25

Heavily dependent on human Intervention

Ketergantungan yang tinggi akan intervensiseseorang dalam proses dapat menimbulkanvariasi penyimpangan.

Tidak semua improvisasi bersifat buruk, dikenal creating safety at the sharp end

Pelayanan kesehatan sangat tergantung padaintervensi manusia

Petugas harus mampu mengendalikan situasiyang tidak terduga demi keselamatan pasien

Sangat tergantung pada pendidikan dan pelatihanyang memadai sesuai dengan tugas & fungsinya

Arjaty/ IMRK 26

Tightly Coupled

Perpindahan langkah dari suatu proses sering sangatketat, kadang baru disadari terjadi penyimpanganpada langkah yang telah lanjut.

Keterlambatan dalam suatu langkah akanmengakibatkan gangguan pada seluruh proses

Kekeliruan dalam suatu langkah akan mengakibatkan

penyimpangan pada langkah berikut ( cascade offaillure )

Kesalahan biasanya terjadi pada saat perpindahanlangkah atau adanya langkah yang terabaikan

Arjaty/ IMRK 27

Hierarchical culture

Suatu proses akan menghadapi risiko kegagalan lebihtinggi dalam unit kerja dengan budaya hirarki dibandingkandengan unit kerja yang budayanya berorientasi pada team

Staf enggan berkomunikasi & berkolaborasi satu denganyang lain

Perawat enggan bertanya kepada dokter atau petugasfarmasi tentang medikasi, dosis, serta element perawatanlainnya

Budaya hirarki sering tercipta misalnya dalam menentukanpenggunaan obat, verifikasi lokasi pembedahan oleh timbedah.

Tata cara berkomunikasi antar staf dalam prosespelayanan kesehatan sangat menentukan hasilnya.

Arjaty/ IMRK 28

Implementing Safety Cultures in Medic ine:What We Learn by Watching Physic ians

Timothy J . Hoff Henry Pohl J oel Bartfield

Residendi Kamar Bedah : ~Commission

~Suasanahierarki tinggi

~KesalahanTeknis

Residendi MICU : ~Ommission

Suasanahierarkilebihdatar

~ KesalahanPengambilan

Keputusan


8/19


PENDEKATAN MELALUI FMEA

2

Arjaty/ IMRK 30

What is FMEA ? Adalah metode perbaikan kinerja dgn

mengidentifikasi dan mencegah potensi

kegagalan sebelum terjadi. Hal tersebut

didesain untuk meningkatkan keselamatan

pasien.

Adalah proses proaktif, dimana kesalahan

dpt dicegah & diprediksi. Mengantisipasi

kesalahan akan meminimalkan dampak buruk

Arjaty/ IMRK 31

FMEA Terminology

Process FMEA - Conduct an FMEA on aprocess that is already in place

Design FMEA Conduct an FMEA beforea process is put into place Implementing an electronic medical records or

other automated systems

Purchasing new equipment

Redesigning Emergency Room, OperatingRoom, Floor, etc.

Arjaty/ IMRK 32

FAILURE MODE AND EFFECTS ANALYSIS

FAILURE (F) : When asystem orpart of a system

performs in a way that isnot

intended or desirable

MODE (M) : Theway or manner in which

something such asa failure can

happen. Failure mode is the

manner in which something can

fail.

EFFECTS (E) : The results orc onsequences of a

failure mode

Anal ysi s (A) : The detailedexamination of the

elements or structure of aprocess


9/19


Arjaty/ IMRK 33

Can prevent errors & nearmisses protectingpatients from harm.

Can increase the effectiveness & efficiency ofprocess

Taking a proactive approach to patient safetyalso makes good business sense in a health

care environment that is increasingly facing

demands from consumers, regulators & payers

to create culture focused on reducing risk &increasing accountability

Why should my organizationconduct an FMEA ?

Arjaty/ IMRK 34

FMEA has been around for over 30 years

Recently gained widespread appeal

outside of safety area

New to healthcare

Frequently used reliability & system safety

analysis techniques

Long industry track record

Where did FMEA come from ?

Arjaty/ IMRK 35

FMEA

Original

HFMEA

By : VA NCPS

HFMECA

By IMRK

1 Select a high risk process &

assemble a team

Define the HFMEA

Topic

Select a high risk process &

assemble a team

2 Diagram the process Assemble the Team Diagram the process

3 Brainstorm potential failure

modes & determine their effects(P X Da X De)

Graphically describe

the Process

Brainstorm potential failure

modes & Prioritize failure modes(P X Da) x K X De, Bands

4 Prioritize failure modes Conduct a Hazard

Analysis

Brainstorm potential effects of

failure modes

(P X Da) x K X De, Bands

5 Id en ti fy root causes of failure

modes

(P X Da X De)

Actions & Outcome

Measures

Identify root causes of failure

modes

(P X Da) x K X De, Bands

6 REDESIGN THE PROCESS CALCUL ATE TOTAL RPN

7 Analyze & test the new process REDESIGN THE PROCESS

8 Implement & monitor the

redesigned process

Analyze & test the new process

9 Implement & monitor the

redesi ned rocess

LANGKAH2 FMEA, HFMEA, HFMECA

Arjaty/ IMRK 36

What is HFMEA ?Modified by VA NCPS

Focus on preventing defects, enhancing safety, increasepositive outcome and increase patient satisfaction

The objective is to look for all ways for process or productcan fail

The famous question : What is could happen? Not Whatdoes happen ?

Hybrid prospective analysis model combines concepts :FMEA (Failure Mode and Effects Analysis)

HACCP (Hazard Analysis Critical Control Points)

RCA (Root Cause Analysis)


10/19


1. Tetapkan Topik AMKD2. Bentuk Tim3. Gambarkan Alur Proses

4. Buat Hazard Analysis

5. Tindakan dan Pengukuran Outcome

LANGKAH-LANGKAH

ANALISIS MODUS KEGAGALAN & DAMPAK (AMKD)

(HEALTHCARE FAILURE MODE EFFECT AND ANALYSIS)

(HFMEA)

By : VA NCPS

Arjaty/ IMRK 38

TIME LINE AND TEAM ACTIVITIES

P re me et in g Id en ti fy To pi c a nd no ti vy th e t ea m(Step 1 & 2)

1st team meeting Diagram the process, identify subprocess, verify the scope

2rd team meeting Visit the worksite to observe the process, verify that all process &

subprocess steps are correct (Step 3)

3 rd team meeting Brainstorming failure modes, assign individual team members to

consult with process users (Step 3)

4rd team meeting Identify failure modes causes, assign individual team members to

consult with process users for additional input (Step 3)

5th team meeting Transfer FM & Causes to the HFMEA Worksheet (Step3). Begin the

hazard analysis (Step 4)

Identify corrective actios and assign follow up responsibilities (Step 5)

6th

,7th

, 8th

. teammeeting plus 1 Assign team members to follow up individual charged with takingcorrective action

team meeting plus 2 Refine corrective actions based on feedback

team meeting plus 3 Test the proposed changes

team meeting plus 4 Meet with Top Management to obtain approval for all actions

Postteam meeting The advisor or his/ her designee follow up until all actions are

completed

39

LANGKAH -LANGKAH

FAILURE MODE & EFFECT ANALYSIS

1. Pilih Proses yang berisiko tinggi dan Bentuk Tim

2. GambarkanAlu r Pros es

3. DiskusikanModus Kegagalan potensial dan Dampak

nya

4. Buat prioritas Modus Kegagalan yang akan

diintervensi

5. Identi fikasiAkar Penyebab Modus Kegagalan

6. Disainulangproses / Re-disain Proses

7. Analisa & uji Proses baru

8. Implementasi & MonitorProses baru

Arjaty/ IMRK 40

LANGKAH 1 : PILIH PROSES YANG BERISIKO TINGGI

Pilih Proses berisiko tinggi yang akan dianalisa.

Judul Proses :

__________________________________________________________________________

_________________________________________________________

_________________________________________________________LANGKAH 2 : 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 ___________________


11/19


Arjaty/ IMRK 41

Arjaty/ IMRK 42

Arjaty/ IMRK 43

Arjaty/ IMRK 44

ANALISIS HAZARD LEVEL DAMPAKDAMPA

K

MINOR

1

MODERAT

2

MAYOR

3

KATASTROPIK

4

Kegagalan yang tidak

mengganggu Proses

pelayanan kepada

Pasien

Kegagalan dapat

mempengaruhi p roses

dan menimbulkan

kerugian ringan

Kegagalan menyebabkan

kerugian berat

Kegagalan menyebabkan

kerugian besar

Pasien Tidak ada cedera,

Tidak ada

perpanjangan

hari rawat

Cedera ringan

Ada Perpanjangan

hari rawat

Cedera luas / berat

Perpanjangan hari rawat

lebih lama (+> 1 bln)

Berkurangnya fungsi

permanen organ tubuh

(sensorik / motorik /

psikcologik / intelektual)

Kematian

Kehilangan fungsi tubuh

secara permanent (sensorik,

motorik, psikologik atau

intelektual) mis :

Operasi pada bagian atau

pada pasien yang salah,

Tertukarnya bayi

Pengunju

ng

Tidak ada cedera

Tidak ada penanganan

Terjadi pada 1-2 orgpengunjung

Cedera ringan

Ada Penanganan

ringan Terjadi pada 2 -4

pengunjung

Cedera luas / berat

Perlu dirawat

Terjadi pada 4 -6orang

pengunjung

Kematian

Terjadi pada > 6 orang

pengunjung

Staf: Tidak ada cedera

Tidak ada penanganan

Terjadi pada 1-2 staf

Tidak ada kerugian

waktu / keckerja

Cedera ringan

Ada Penanganan /

Tindakan

Kehilangan waktu /

kec kerja : 2-4 staf

Cedera luas / berat

Perlu dirawat

Kehilangan waktu /

kecelakaan kerja pada

4-6 staf

Kematian

Perawatan > 6 staf

Fasilitas

Kes

Kerugian < 1 000,,000

atau tanpa menimbulkan

dampak terhadap pasien

Kerugian

1,000,000 -

10,000,000

Kerugian

10,000,000 - 50,000,000

Kerugian > 50,000,000


12/19


Arjaty/ IMRK 45

ANALISIS HAZARD LEVEL PROBABILITAS

LEVEL DESKRIPSI CONTOH

4 Sering (Frequent) Hampir sering muncul dalam waktu yang

relative singkat (mungkin terjadi

beberapa kali dalam 1 tahun)

3 Kadang-kadang

(Occasional)

Kemungkinan akan muncul

(dapat terjadi bebearapa kali dalam 1

sampai 2 tahun)

2 Jarang (Uncommon) Kemungkinan akan muncul

(dapat terjadi dalam >2 sampai 5 tahun)

1 Hampir Tidak Pernah

(Remote)

Jarang sekali terjadi (dapat terjadi dalam

> 5 sampai 30 tahun)

Arjaty/ IMRK 46

TINGKAT B AHAYA

KATASTROPIK

4

MAYOR

3

MODERAT

2

MINOR

1

SERING

416 12 8 4

KADANG

312 9 6 3

JARANG

28 6 4 2

HAMPIR TIDAK

PERNAH

1

4 3 2 1

HAZARD SCORE

Arjaty/ IMRK 47

Does this hazard involve a

sufficient likelihood of

occurrence and severity to

warrant that it be

controlled?

(Hazard score of 8 or

higher) Is this a single point weakness in

the process? (Criticality failure

results in a system failure?)

CRITICALY

Does an effective control measure

already exist for the identified hazard?

CONTROL

Is this hazard so obvious and readily

apparent that a control measure is not

warranted?

DETECTABILITY

STOP

NO

NO

NO

NO

YES

YES

YES

YES

Proceed to

Potential

Causes for

this failure

mode

Do not proceed

to find potential

causes for this

failure mode

Decision TreeGunakan Decision Tree utk menentukan apakah modus perlu tindakan lanjut

diProceed..

Arjaty/ IMRK 48


13/19


Arjaty/ IMRK 49

50

LANGKAH -LANGKAH

FAILURE MODE & EFFECT ANALYSIS

1. Pilih Proses yang berisiko tinggi dan Bentuk Tim

2. GambarkanAlu r Pros es

3. Diskusikan Modus Kegagalan potensial dan Dampak

nya

4. Buat prioritas Modus Kegagalan yang akan

diintervensi

5. Identi fikasiAkar Penyebab Modus Kegagalan

6. Disainulangproses / Re-disain Proses

7. Analisa & uji Proses baru

8. Implementasi & MonitorProses baru

Arjaty/ IMRK 51

LANGKAH 1 :PILIH PROSES YANG BERISIKO TINGGI & BENTUK TIM

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 __________ _____________

Arjaty/ IMRK 52

STEP 2 DIAGRAM THE PROCESS

PROCESS STEPS :Describe the process graphically, according to your policy & procedure for the activity and number each one

If the process is complex you may want to select one process step or sub process to work on

1 2 3 4 5

Failure Mode Failure Mode Failure Mode Failure Mode Failure Mode

P em es anan ob at P enyi mp anan P enul is an o bat P er ac ikan o bat W ro ng d rug

Berlebihan (tdk vaksin tdk dlm R/ tdk jls tdk sesuai dosis

S es ua i ke bt hn) s es ua i s uh un ya Wrong dosage

PenulisanObat R/tdk R/

Dlm formularium Wrong frequence

Wrong route

administration

Selection &

Procurement

StoragePrescribing,

Ordering,

Trancribing

Preparing

&

Dispensing

Admin istr ation


14/19


Arjaty/ IMRK 53

Arjaty/ IMRK 54

Proses lama

yg high risk

DesainProses baru

Alur

Proses Potential Cause

Failure

Mode HS

Efek /

Dampak

Decision

Tree

K

K

DT

K

E

Tindakan

HFMEA

Kontrol

Eliminasi

Terima

Kritis

Kontrol

Deteksi

Hazard

Score

Herkutanto 2009

Arjaty/ IMRK 56

RATING SYSTEM

(Modified b y IMRK)

Rat ing Probabil itas

(P)

DAMPAK

(D)

Kontrol

(K)

Deteksi

(D)

1 Remote Minor effect Easy Certain to detect

2 Low likelihood Moderate effect Mpderate

Easy

High likelihood

3 Moderate

likelihood

Minor injury Moderate

difficult

Moderate

likelihood

4 High likelihood Major injury Difficult Low likelihood

5 Certain to

occur

Catastrophic effect

/ terminal injury,

death

Alm ost cer tain

not to detect

Risk Priori ty Numb er (RPN) / Critic aly Index (CI) = (Da x P) x K x De


15/19


Arjaty/ IMRK 57

Sample Severity Scale(Modified by IMRK)

Rating Description Definition

1 Minor effect or No effect May affect the individual served & w ouldresult in some effect on the proc ess or

Would not be noticeable to individual served

& would not affect the process

2 M od er at e ef fe ct M ay af fe ct th e i nd iv id ua l s er ved & w ou ldresult in a major effect on the process

3 M ino r i nj ur y Wo ul d af fec t t he i nd iv idu al and resu lt in amajor effect on the process

4 Major injury Would result i n a m ajor inj ury for theindividual served and have major effect on

the process

5 Catastrophic effect, aterminal injury or death

Extremely dangerous, failure would result

death of the individual served and have a

major effect on the process

Source : JCR : Joint Commision Resources

Arjaty/ IMRK 58

Rating Description Probability Definition

1 Remote tonon existent

1 in 10,000 No or l i tt le known occurrence h ighly

unlikely that condition will ever occur

2 LowLikelihood

1 in 5000 Poss ib l e, bu t no known data, t he

condition occurs in isolated cases, but

chances are low

3 Moderatelikelihood

1 in 200 Do cu men ted , b ut i nf re qu en tl y, th e

condition has a reasonable chance to

occur

4 Highlikelihood

1 i n 1 00 Do cu men ted a nd f re qu en t, t he

condition occurs very regularly and / or

during a reasonable amount of time

5 Certain tooccur

1 in 20 Do cum en ted , al mo st cer tai n, th e

condition will inevitably occur during

long periods typical for the step or link

Sample Probability of Occurrence Scale(Modified by IMRK)

Arjaty/ IMRK 59

Sample Detectability Scale(Modified by IMRK)

Rat in g Desc ri pt io n Pr ob ab il ity

of

Detection

Definition

1 Certain todetect

10 out to 10 Almost always detected

immediately

2 High likel ihood 7 out of 10 Likely to be detected

3 Moderatelikelihood

5 out of 10 Moderate l ikel ihood of detect ion

4 Low l i ke li hood 2 out 0 f 10 Un l ikel y to be de tected

5 Alm ost cer tainnot to detect

0 out of 10 Detection not possible at any point

Arjaty/ IMRK 60


16/19


Arjaty/ IMRK 61

STEP 5 IDENTIFY ROOT CAUSES OF FAILURE MODES

Failure Mode Potential

effect

Potenti

alcauses

Severity Probabi li t

y

Ri

skSc

or

e

(3

X4

)

Risk

Categories /

Bands

C on tr ol D et ec tion R PN

(5X8X9)

1 2 3 4 5 1 2 3 4 5 1-25

L M H E 1 2 3 4 1 2 3 4 5

1 2 3 4 5 6 7 8 9 10

Wrong route

administration

Death No

Training

X X 10 E X X 40

Wrong

frequency

Injury with

permanent loss offunction >

No

recordinChart

X X 12 E X X 24

Wrong

dosage

No injury

with nopermanen

t loss of

function

Miss

readinstruct

ion

X X 8 H X X 32

Wro ng d ru g N o injur y

but LOS >

Miss

identification

X X 4 H X X 16

Arjaty/ IMRK 62

STEP 6 CALCULA TE TOTAL RPN

No Failure

Mode

RPN

FailureMode

Potential

effect

RPN

effect

Potential

Causes

RPN

Causes

Total

RPN

Rank

1 2 3 4 5 6 7 8 9

1 Wro ng rou te

administrati

on

60 Death 40 No

Traini

ng

40 140 1

2 Wrong

frequency

48 Injury with

permane

nt lossof

function

12 No record

in

Chart

24 84 3

3 Wrong dosage 36 No injury

with nopermanent loss

offunction

36 Miss read

instruction

32 104 2

4 Wrong drug 36 No injury but

LOS > >

16 Miss

identificati

on

16 68 4

Arjaty/ IMRK 63

STEP 7 REDESIGN PROCESS

Pro ce ss F ai lu re

Mode

Potential

Effect

Potential

Causes

Redesign

Recommendatio

ns

PIC Targ et

Completio

n

date

for test

New

ProcessImplementa

tion

date &

Actions

Outcome

Measure /Monitoring

mechanism

1 2 3 4 5 6 7 8 9

Arjaty/ IMRK 64

TAKE A DEEP BREATH

Conduct a literature search to gather

relevant information from the professional

literature. Do not reinvent the wheel

Network with colleagues

Recommit to out of the box thinking

PREPARING TO REDESIGN

(step 6)


17/19


REDESIGN STRATEGIES

Prevent the failure from happening

(decrease likelihood of occurrence) Prevent the failure from reaching the

individual (increase detectability)

Protect individuals if a failure occurs

(decrease the severty of the efects)

Arjaty/ IMRK 65


18/19


Arjaty/ IMRK 71

REDISAIN PROSES

Variable input Complex

Nonstandarized

Tightly Coupled

Dependent on humanintervention

Time constraints

Hierarchical culture

Decreasing variability Simplify

Standardizing

Loosen coupling of process

Use technology

Optimise Redundancy

Built in fail safe mechanism

Documentation

Establishing a culture of

teamwork

Arjaty/ IMRK 72

LANGKAH 8

ANALISIS DAN UJI PROSES BARU

The team again completes steps 2 (diagram theprocess), step 3 (brainstorm potential failuremodes & determine their effect) and step 4(prioritize failure modes) of the FMEA process

Then the team should calculate a new criticalityindex (CI) or RPN.

Design improvements should bring reduction inthe CI / RPN.

Ex: 30 50% reduction ?


19/19


Arjaty/ IMRK 73

LANGKAH 9

IMPLEMENTASI DAN MONITORING PROSES

Strategies for Creating & Managing the Change Process :

1. Establish a sense of urgency2. Create a guiding coalition

3. Develop a vision and strategy

4. Communicate the changed vision

5. Empower broad based action

6. Generate short term wins

7. Consolidate gains and produce more change

8. Anchor new approaches in the culture

Arjaty/ IMRK 74

Proses lama

yg high risk

DesainProses baru

Alur

Proses Potential Cause

Failure

Mode HS

Efek /

Dampak

Decision

Tree

K

K

DT

K

E

Tindakan

AMKD / HFMEA

Kontrol

Eliminasi

Terima

Kritis

Kontrol

Deteksi

Hazard

Score

Arjaty/ IMRK 75

AMKDP / HFMECA

Prioritas

risiko

Total RPN

PROSES

LAMA

Failure

Mode,

Dampak,

Penyebab

RedisignProses

Analisis &

Uji Proses BaruTotal RPNPROSESBARU

Failure

Mode,

Dampak,

Penyebab

Implementasi

PROSES BARU

Total RPN

30-50%?

Arjaty/ IMRK 76

KESIMPULANBuilding a safe healthcaresystem

L E A D E R S H I P

petunjuk 2 materi identifikasi resiko

Documents