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INTEGRASI INTEGRASI PROGRAM PROGRAM MUTUMUTU PELAYANANPELAYANAN RRUMAH SAKITUMAH SAKITMUTU MUTU PELAYANAN PELAYANAN RRUMAH SAKITUMAH SAKIT

DAN UPAYA KESELAMATAN PASIEN DAN UPAYA KESELAMATAN PASIEN

Dr. ADIB A YAHYA, MARSDr. ADIB A YAHYA, MARS

INSTITUT MANAJEMEN RISIKO KLINIS“ WORKSHOP PENGUKURAN DAN ANALISA DATA INDIKATOR UNTUK MENINGKATKAN WORKSHOP PENGUKURAN DAN ANALISA DATA INDIKATOR UNTUK MENINGKATKAN

MUTU DAN KESELAMATAN PASIEN “PERSI DAERAH JAWA TIMUR, SURABAYA 1 – 2 NOVEMBER 2013

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PATIENTPATIENT--HOSPITALHOSPITAL

StandarStandar PelayananPelayanan PasienPasien : : Tujuan utama pelayanan kes RS adalah pelayanan pasien….

PATIENTPATIENTCENTEREDCENTERED

CARECARE

HOSPITALHOSPITALRISKRISK

MANAGEMENTMANAGEMENT(PELAYANAN(PELAYANAN FOKUSFOKUS

PASIEN)PASIEN)

“Safety is a fundamental principle “Safety is a fundamental principle

))

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 Safety, Forward ProgrammeProgramme, ,

EtikEtik

•• MutuMutu4 4 FondasiFondasiAsuhan pasienAsuhan pasien

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

Sa ety, o a dSa ety, o a d og a eog a e,,WHO, 2004)WHO, 2004)

EBMEBM

KebutuhanKebutuhanPasienPasien

•• MutuMutu•• PatientPatientSafetySafety

Asuhan GiziAsuhan Gizi•• Asuhan ObatAsuhan Obat •• Evidence Based MedicineEvidence Based Medicine

•• Value Based MedicineValue Based Medicine

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

VBMVBM

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IMPLEMENTASI PATIENT SAFETY IMPLEMENTASI PATIENT SAFETY DI RUMAH SAKITDI RUMAH SAKIT

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

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

PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA

DASAR HUKUMDASAR HUKUM

NOMOR 1691/MENKES/PER/VIII/2011TENTANG

KESELAMATAN PASIEN RUMAH SAKIT

STANDARKESELAMATAN PASIEN

PROGRAMWHO PATIENT SAFETY

TUJUH LANGKAH MENUJU

KESELAMATAN PASIEN RUMAH SAKIT

KARSPENILAIANPENILAIAN

SASARANSASARAN KESELAMATAN PASIEN

RUMAH SAKIT9 SOLUTIONS

IMPLEMENTASI PATIENT SAFETY DI RUMAH SAKIT

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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)7. PENDIDIKAN PASIEN DAN KELUARGA (PPK)7. PENDIDIKAN PASIEN DAN KELUARGA (PPK)

IIII. KELOMPOK STANDAR MANAJEMEN RUMAH SAKIT. KELOMPOK STANDAR MANAJEMEN RUMAH SAKIT1. 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

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“Essentials”“Essentials”Joint Commission International’s Joint Commission International’s Essentials of Health Care Quality Essentials of Health Care Quality yy

and Patient Safetyand Patient Safety

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

6

EssentialsEssentials

Quality and safety improvement frameworkQuality and safety improvement frameworkQuality 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 safetypatient safetypatient safety

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Essentials can help to:Essentials can help to: DetermineDetermine levels of risklevels of risk to patient safety in a healthto patient safety in a healthDetermine 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

BetterBetter allocate reso rcesallocate reso rces to impro e q alit andto impro e q alit and Better Better allocate resources allocate resources to improve quality and to improve quality and safetysafety

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How Essentials Is AppliedHow Essentials Is Appliedpppp

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

Identify the risksIdentify the risks that have the greatest impact onthat have the greatest impact onIdentify the risksIdentify the risks that have the greatest impact on that have the greatest impact on safetysafetyDesign an approach Design an approach for addressing these risksfor addressing these risksImplement changesImplement changesPeriodically reassess Periodically reassess the impact of these the impact of these changeschanges

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

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Essentials AddressEssentials AddressFive Risk Areas / Focus AreasFive Risk Areas / Focus Areas

Developed from extensive international Developed from extensive international healthcare literature and experiencehealthcare literature and experienceTen Criteria for each Risk Area provideTen Criteria for each Risk Area provideTen Criteria for each Risk Area provide Ten Criteria for each Risk Area provide clear and achievable risk reduction strategiesclear and achievable risk reduction strategiesProgressiveProgressive “Levels of Effort”“Levels of Effort” areareProgressive Progressive Levels of EffortLevels of Effort are are identified for each Criterionidentified for each Criterion

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Overview ofOverview ofFi Ri k A / F AFi Ri k A / F AFive Risk Areas / Focus AreasFive Risk Areas / Focus Areas

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

1.1. Leadership Process and AccountabilityLeadership Process and Accountability2.2. Competent and Capable WorkforceCompetent and Capable Workforce3.3. Safe Environment for Staff and PatientsSafe Environment for Staff and Patients4.4. Clinical Care of PatientsClinical Care of Patients55 I t f Q lit d S f tI t f Q lit d S f t5.5. Improvement of Quality and Safety Improvement of Quality and Safety

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

CRITERION :CRITERION :

1. Leadership responsibilities and accountabilities are identified 1. Leadership responsibilities and accountabilities are identified 2. Leadership for quality and patient safety2. Leadership for quality and patient safety3 Collaboration and cooperation at all levels3 Collaboration and cooperation at all levels3. Collaboration and cooperation at all levels3. Collaboration and cooperation at all levels4. Quality requirements in clinical and managerial contracts4. Quality requirements in clinical and managerial contracts5. Quality, patient safety, and risk management are integrated.5. Quality, patient safety, and risk management are integrated.6. Compliance with laws and regulations6. Compliance with laws and regulations7. Commitment to patient and family rights7. Commitment to patient and family rights8. Policies and procedures for high8. Policies and procedures for high--risk procedures and patientsrisk procedures and patients9. Oversight of human subject research9. Oversight of human subject research10 O i ht f d ti d ti d t l t ti10 O i ht f d ti d ti d t l t ti10. Oversight of organ and tissue donation and transplantation10. Oversight of organ and tissue donation and transplantation

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

CRITERION :CRITERION :

1. Personnel files and job descriptions for all staff1. Personnel files and job descriptions for all staff2. Review of credentials of physicians2. Review of credentials of physicians3 Review of credentials of nurses3 Review of credentials of nurses3. Review of credentials of nurses3. Review of credentials of nurses4. Review of credentials of other health professionals4. Review of credentials of other health professionals5. Staff members are oriented to their jobs.5. Staff members are oriented to their jobs.6. Oversight of students and those in training6. Oversight of students and those in training6. Oversight of students and those in training6. Oversight of students and those in training7. Training in resuscitative techniques7. Training in resuscitative techniques8. Staff education on infection prevention and control8. Staff education on infection prevention and control9. Communication among those caring for the patient9. Communication among those caring for the patientg g pg g p10 Staff health and safety program10 Staff health and safety program

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

CRITERION :CRITERION :

1. Regular inspection of buildings1. Regular inspection of buildings2. Control of hazardous materials2. Control of hazardous materials3. Fire safety program3. Fire safety program4. Biomedical equipment safety4. Biomedical equipment safety5. Stable water and electricity sources5. Stable water and electricity sources6 C di ti f i f ti ti d t l6 C di ti f i f ti ti d t l6. Coordination of infection prevention and control program6. Coordination of infection prevention and control program7. Reduction of health care7. Reduction of health care--associated infectionsassociated infections8. Barrier techniques are used.8. Barrier techniques are used.9 Proper disposal of sharps and needles9 Proper disposal of sharps and needles9. Proper disposal of sharps and needles9. Proper disposal of sharps and needles10. Proper disposal of infectious medical waste10. Proper disposal of infectious medical waste

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

CRITERION :CRITERION :

1. Correct patient identification1. Correct patient identification2. Informed consent2. Informed consent3. Medical and nursing assessments for all patients3. Medical and nursing assessments for all patients4 Laboratory services are available and reliable4 Laboratory services are available and reliable4. Laboratory services are available and reliable.4. Laboratory services are available and reliable.5. Diagnostic imaging services available, safe, and reliable.5. Diagnostic imaging services available, safe, and reliable.6. Planned and provided care is written.6. Planned and provided care is written.7. Anesthesia and sedation are used appropriately.7. Anesthesia and sedation are used appropriately.pp p ypp p y8. Surgical services are appropriate to patient needs8. Surgical services are appropriate to patient needs9. Medication use is safely managed.9. Medication use is safely managed.10. Patients are educated to participate in their care.10. Patients are educated to participate in their care.

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

CRITERION :CRITERION :

1. There is an adverse event reporting system.1. There is an adverse event reporting system.2. Adverse events are analyzed.2. Adverse events are analyzed.3. High3. High--risk processes and highrisk processes and high--risk patients are monitored.risk patients are monitored.4. Patient satisfaction is monitored.4. Patient satisfaction is monitored.5. Staff satisfaction is monitored.5. Staff satisfaction is monitored.6. There is a complaint process.6. There is a complaint process.7. Clinical guidelines and pathways are available and used.7. Clinical guidelines and pathways are available and used.8. Staff understands how to improve processes.8. Staff understands how to improve processes.9. Clinical outcomes are monitored.9. Clinical outcomes are monitored.10. Communicating quality and safety information to staff10. Communicating quality and safety information to staff

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Focus 1 2 3 4 5

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

FocusArea►

1 2 3 4 5

Criteria▼

LeadershipProcess and

Accountability

Competent andCapable

Workforce

SafeEnvironmentfor Staff and

Clinical Care of

Patients

PatientsImprovementof Quality and

Patients Safety

1

Leadershipresponsibilities

andaccountabilities

Personnel filesand job

descriptions forall staff

Regularinspection of

buildings

Correct patientidentification

There is anadverse event

reporting systemaccountabilities

identifiedall staff

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.

Oversight of Review of Biomedical Laboratory Patient

4

Oversight ofcontracts

Review ofcredentials ofother health

professionals

Biomedicalequipment safety

Laboratoryservices areavailable and

reliable.

Patientsatisfaction is

monitored.

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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.

Policies and Staff education Barrier Surgical services Staff understand

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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.

Oversight ofhuman subject

Communicationamong those

Proper disposalof sharps and

Medication useis safely

Clinicaloutcomes are

9human subject

researchamong thosecaring for the

patient

of sharps andneedles

is safelymanaged.

outcomes aremonitored.

10

Organprocurement,d ti d

Staff health andsafety program

Proper disposalof infectious

di l t

Patients areeducated to

ti i t i

Communicatingquality and safety

i f ti t10 donation, andtransplantation

medical waste participate intheir care.

information tostaff

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

19

TERIMAKASIHTERIMAKASIHTERIMAKASIHTERIMAKASIH