Variasi prosesVariasi proses

It is all about patientsIt is all about patients

First do no harmFirst do no harmSecond achieve best clinical Second achieve best clinical

outcomeoutcomeThird make the people “fly”Third make the people “fly”

Quality problems in hospital Quality problems in hospital servicesservices

Quality Problems

Mortality

Morbidity

Disability

Unsatisfactory achievement of clinical outcome

Patient dissatisfaction

Quality Problems

Mortality

Morbidity

Disability

Unsatisfactory achievement of clinical outcome

Patient dissatisfaction

?Preventable vs non preventable

Quality Problems

?Severity of the disease

Individual biovariability

Service delivery process

Accident

Incident

Adverse event

Unsafe act::Clinical ErrorViolationSabotage

Complication

System approach to patient System approach to patient safetysafety

Structure – Process – OutcomeStandard of careHazardLatent Condition

Active Failure:• Unsafe acts

• Errors• Violation• Sabotage

• Errors:• Human (slips, lapses, mistakes)• Medical• Medication

Accident:Complication

Contributing factorsRCA, FMEA

Adverse eventIncident & Critical Incident

Notes:Term to be avoided:Blame, Fault, Negligence,Recklessness

Sumber:The Canadian Patient SafetyDictionary, October 2003

?Severity of the disease

Individual biovariability

Service delivery process

Human factor

Process variation

Latent conditions

Service delivery process

Human factor

Process variation

Latent conditions

Special cause

Common cause

Intervensi perbaikanIntervensi perbaikan

StandardisasiStandardisasi Process improvement:Process improvement:– step by step improvementstep by step improvement– radical improvement radical improvement

(reengineering)(reengineering)

Quality improvement processQuality improvement processModel NolanModel Nolan

Apa yang ingin kita capai?

Bagaimana kita tahu bahwa perubahanyang dilakukan adalah perbaikan ?

Perubahan apa yang dapat kita lakukanyang hasilnya adalah perbaikan?

P

DC

A

Aims

Measurements

Planned change

Tugas untuk variasi prosesTugas untuk variasi proses

Terkait dengan process variation, cari artikel tentang Terkait dengan process variation, cari artikel tentang Indeks Kemampuan Proses (Process capability)Indeks Kemampuan Proses (Process capability)– Berikan ringkasan ttg artikel tersebutBerikan ringkasan ttg artikel tersebut– Bagaimana pendapat saudara apakah pengukuran indeks Bagaimana pendapat saudara apakah pengukuran indeks

kemampuan proses dapat diterapkan di rumahsakitkemampuan proses dapat diterapkan di rumahsakit

Masuk ke website: Masuk ke website: www.ihi.orgwww.ihi.org atau yang lain, cari satu atau yang lain, cari satu contoh penerapan model Nolan untuk perbaikancontoh penerapan model Nolan untuk perbaikan– Susun ringkasan dari artikel tsbSusun ringkasan dari artikel tsb– Bagaimana pendapat saudara apakah model Nolan dapat Bagaimana pendapat saudara apakah model Nolan dapat

diterapkan di rumahsakit di Indonesia diterapkan di rumahsakit di Indonesia