Workshop Patient Safety ARSSaMa Malang, 12 s/d 14 November 2007

LANGKAH 1

MEMBANGUN BUDAYA KESELAMATAN PASIEN

Dr. ADIB A YAHYA, MARS

SISTEMATIKA
Pendahuluan Pengertian Budaya Keselamatan pasien Manfaat Budaya Keselamatan pasien Survei Keselamatan Pasien Langkah-langkah membangun budaya Fakta & pengalaman tentang manfaat PS

Safety is a fundamental principle of patient care and a critical component of quality management.
(World Alliance for Patient Safety, Forward Programme WHO,2004)

TUJUH LANGKAH MENUJU KESELAMATAN PASIEN RUMAH SAKIT

BANGUN KESADARAN AKAN NILAI KP, Ciptakan kepemimpinan & budaya yg terbuka & adil. PIMPIN DAN DUKUNG STAF ANDA, Bangunlah komitmen & fokus yang kuat & jelas tentang KP di RS Anda INTEGRASIKAN AKTIVITAS PENGELOLAAN RISIKO, Kembangkan sistem & proses pengelolaan risiko, serta lakukan identifikasi & asesmen hal yang potensial bermasalah KEMBANGKAN SISTEM PELAPORAN, Pastikan staf Anda agar dgn mudah dapat melaporkan kejadian / insiden, serta RS mengatur pelaporan kpd KKP-RS. LIBATKAN DAN BERKOMUNIKASI DENGAN PASIEN, Kembangkan cara-cara komunikasi yg terbuka dgn pasien BELAJAR & BERBAGI PENGALAMAN TTG KP, Dorong staf anda utk melakukan analisis akar masalah untuk belajar bagaimana & mengapa kejadian itu timbul CEGAH CEDERA MELALUI IMPLEMENTASI SISTEM KP, Gunakan informasi yang ada tentang kejadian / masalah untuk melakukan perubahan pada sistem pelayanan KKP RS

1. RS: Kebijakan : tindakan staf segera setetelah insiden, langkah kumpul fakta, dukungan kepada staf, pasien - keluarga Kebijakan : peran & akuntabilitas individual pada insiden Tumbuhkan budaya pelaporan & belajar dari insiden Lakukan asesmen dengan menggunakan survei penilaian KP.

BANGUN KESADARAN AKAN NILAI KP Ciptakan kepemimpinan & budaya yg terbuka & adil.

Tim: Anggota mampu berbicara, peduli & berani lapor bila ada insiden Laporan terbuka & terjadi proses pembelajaran serta pelaksanaan tindakan / solusi yg tepat.

BUDAYA SAFETY

A safety culture is where staff within an organisation have a constant and active awareness of the potential for things to go wrong. Both the staff and the organisation are able to acknowledge mistakes, learn from them, and take action to put things right.
Budaya keselamatan adalah dimana staf dalam suatu organisasi memiliki kesadaran yg konstan dan aktif tentang hal yg potensial menimbulkan kesalahan. Baik staf maupun organisasi mampu membicarakan kesalahan, belajar dari kesalahan tsb, dan mengambil tindakan perbaikan

BUDAYA SAFETY

Being open and fair means sharing information openly and freely, and fair treatment for staff when an incident happens. This is vital for both the safety of patients and the well-being of those who provide their care.
Bersikap terbuka dan adil / jujur berarti membagi informasi secara terbuka dan bebas, dan penanganan adil bagi staf bila insiden terjadi. Hal ini penting bagi keselamatan pasien dan ketenangan bagi pemberi layanan

BUDAYA SAFETY

The systems approach to safety acknowledges that the causes of a patient safety incident cannot simply be linked to the actions of the individual healthcare staff involved. All incidents are also linked to the system in which the individuals were working.
Pendekatan sistem pada keselamatan menerangkan bahwa penyebab insiden keselamatan pasien tidak dapat dihubungkan dengan sederhana ke staf yang terlibat. Semua insiden berkaitan juga dengan sistem tempat orang itu bekerja

BUDAYA SAFETY

Changing values, beliefs and attitudes is not easy . Developing a safety culture in an organisation needs strong leadership and careful planning and monitoring.

Mengubah nilai-nilai, keyakinan, dan perilaku tidaklah mudah. Pengembangan budaya keselamatan dalam suatu organisasi memerlukan kepemimpinan yang kuat dan perencanaan & pemantauan yang cermat

BUDAYA SAFETY

It is vital that not only clinical staff but all those who work in organisations, as well as patients and carers, ask themselves how they can help to improve the safety of patients.
Perubahan nilai, keyakinan dan perilaku tersebut penting bukan hanya bagi staf, melainkan juga semua orang yang bekerja di rumah sakit tersebut, serta pasien dan keluarganya. Tanyakan apa yang bisa mereka bantu untuk meningkatkan keselamatan pasien

KOMPONEN
Penjelasan / pemahaman tentang aktivitas 1) acknowledgment of the high risk, errororganisasi yang of bersifat risiko tinggi dan prone nature an organization's activities, rentan kesalahan

2) blame-free environment where Lingkungan yang individuals are bebas-menyalahkan, able to report errors or close sehingga orang punishment, dapat melapor kesalahan tanpa calls without penghukuman 3) expectation of collaboration across ranks to seek solutionslintas to vulnerabilities, and Harapan kerjasama tingkatan untuk mencari solusi atas on vulnerabilitas the part of the 4) willingness organization to direct resources to address Kemauan organisasi untuk mengarahkan safetydaya concerns. sumber untuk kepentingan keselamatan
AHRQ

Components of a Culture of Safety

Commitment to safety articulated at the highest levels of the organization and translated into shared values, beliefs, and behavioral norms at all levels. Necessary resources, incentives, and rewards provided by the organization to allow this commitment to occur. Safety is valued as the primary priority, even at the expense of production or efficiency; personnel are rewarded for erring on the side of safety even if they turn out to be wrong. Communication between workers and across organizational levels is frequent and candid. Unsafe acts are rare despite high levels of production. There is an openness about errors and problems; they are reported when they do occur. Organizational learning is valued; the response to a problem focuses on improving system performance rather than on individual blame.
Source: Singer SJ, Gaba DM, Geppert JJ, et al. The culture of safety: results of an organization-wide survey in 15 California hospitals. Qual Saf Health Care 2003 Apr;12(2):112-8. Reproduced with permission from the BMJ Publishing Group.

Commitment to safety articulated at the highest levels of the organization and translated into shared values, beliefs, and behavioral norms at all levels

Komitmen kepada keselamatan diartikulasikan pada tingkat tertinggi organisasi dan di-ejawantahkan ke dalam nilai, keyakinan, dan norma-norma perilaku pada semua tingkatan

Necessary resources, incentives, and rewards provided by the organization to allow this commitment to occur.

Sumber daya yang diperlukan, insentif, dan penghargaan disediakan oleh organisasi agar komitmen tersebut dapat terjadi

Safety is valued as the primary priority, even at the expense of production or efficiency; personnel are rewarded for erring on the side of safety even if they turn out to be wrong

Keselamatan diberi nilai sebagai suatu prioritas utama, bahkan dengan mengorbankan produksi atau efisiensi; personil rumah sakit diberi penghargaan atas pelaporan kesalahan di bidang safety, bahkan meskipun kemudian dinyatakan salah

Communication between workers and across organizational levels is frequent and candid. There is an openness about errors and problems; they are reported when they do occur Komunikasi antar karyawan dan antar tingkatan organisasi harus sering terjadi dan tulus Terdapat keterbukaan tentang kesalahan dan masalah; dilaporkan bila terjadi

Organizational learning is valued; the response to a problem focuses on improving system performance rather than on individual blame

Pembelajaran organisasi adalah penting / berharga. Tanggapan atas suatu masalah lebih difokuskan untuk meningkatkan kinerja sistem daripada untuk menyalahkan seseorang

BLAMING vs SAFETY

BLAMING:

ANALISIS BERAKHIR PADA HUMAN FACTORS TINDAKAN: MENYALAHKAN DAN MENGHUKUM (LESS) REWARD AND (MORE) PUNISHMENT SIKAP: SEMBUNYIKAN KESALAHAN REPORTING, ANALYSIS, LEARNING, (MORE) REWARD AND (LESS) PUNISHMENT TINDAKAN: CARI UPAYA PENCEGAHAN SIKAP: BERLOMBA BERBUAT BAIK DAN MENCEGAH YG BURUK (BUDAYA BELAJAR)

SAFETY:

BLAMING ?

SUPPORTING?

SIKAP RUMAH SAKIT

Pastikan RS memiliki kebijakan yg menjabarkan apa yg harus dilakukan staf segera setelah terjadi insiden, bagaimana langkah pengumpulan fakta harus dilakukan & dukungan apa yang harus diberikan kepada staf, pasien - keluarga Pastikan RS memiliki kebijakan yg menjabarkan peran & akuntabilitas individual bilamana ada insiden Tumbuhkan budaya pelaporan & belajar dari insiden yang terjadi di RS. Lakukan asesmen dengan menggunakan survei penilaian KP
KKP RS

SIKAP STAF DALAM TIM

Pastikan rekan sekerja anda merasa mampu untuk berbicara mengenai kepedulian mereka & berani melaporkan bilamana ada insiden Demonstrasikan kepada tim anda ukuran yang dipakai di RS anda utk memastikan semua laporan dibuat secara terbuka & terjadi proses pembelajaran serta pelaksanaan tindakan / solusi yg tepat

KKP RS

TERBUKA DAN JUJUR

staff are open about incidents they have been involved in; staff and organisations are accountable for their actions; staff feel able to talk to their colleagues and superiors about any incident; organisations are open with patients, the public and staff when things have gone wrong, and explain what lessons will be learned; staff are treated fairly and supported when an incident happens.
NHS

Being open and fair does not mean an absence of accountability.

Accountability for patient safety means being open with patients, explaining the actions taken and providing assurance that lessons will be learned.
NHS

SINGKIRKAN MITOS-MITOS: the perfection myth: bila orang bekerja keras maka mereka tidak akan membuat errors the punishment myth: bila kita menghukum orang yang melakukan errors maka akan semakin sedikit pembuat errors, atau bahwa tindakan pendisiplinan dapat memperbaiki melalui channelling atau meningkatkan motivasi.
NHS

Penanganan Insiden
Staff harus sama persepsinya tentang insiden Staff harus tahu apa yang harus dilakukan bila menemui insiden: mencatat, melapor, dianalisis, memperoleh feed-back, belajar dan mencegah pengulangan Staff harus akuntabel dan tahu bagaimana pendekatan sistem dan personil

MENGAPA BUDAYA SAFETY?

Bukti di industri lain menunjukkan bahwa budaya organisasi yang berorientasi ke keselamatan dan sikap karyawan yang berani bicara tentang terjadinya kesalahan telah meningkatkan keselamatan Di Rumah Sakit Wimmera - Australia:

Penurunan
Pd

Adverse Events

pasien rawat inap : 1,35% - 0,74% Pd pasien IGD : 3,26% - 0,48%

MANFAAT BUDAYA SAFETY

a potential reduction in the recurrence and in the severity of patient safety incidents through increased reporting and organisational learning;
Potensi mengurangi angka kejadian dan keparahan kejadian patient safety melalui peningkatan pelaporan dan pembelajaran organisasi

MANFAAT BUDAYA SAFETY

a reduction in the physical and psychological harm patients can suffer because people are more aware of patient safety concepts, are working to prevent errors and are speaking up when things go wrong;
Pengurangan derita fisik dan psikologis pasien, karena orang makin sadar tentang konsep patient safety akan bekerja mencegah kesalahan dan berbicara bila terjadi kesalahan

MANFAAT BUDAYA SAFETY

a lower number of staff suffering from distress, guilt, shame, loss of confidence and loss of morale because fewer incidents are occurring;
Penurunan jumlah staf yang menderita tertekan, merasa bersalah, malu, kehilangan percaya diri, dan kehilangan keberanian mental, karena berkurangnya insiden yang terjadi

MANFAAT BUDAYA SAFETY

an improvement in waiting times for treatment through a higher turnover of patients. This is because patients who experience a safety incident require, on average, an extra seven to eight days in hospital over and above the time their treatment would normally require ;
Peningkatan turnover pasien, mengingat pasien yg terkena insiden umumnya membutuhkan perawatan 7-8 hari lebih dari masa rawat normal

MANFAAT BUDAYA SAFETY

a reduction in the costs incurred for treatment and extra therapy; a reduction in resources required for managing complaints and claims;

Pengurangan biaya untuk pengobatan / penatalaksanaan ekstra akibat insiden Pengurangan kebutuhan sumber daya untuk menangani komplain dan klaim

MANFAAT BUDAYA SAFETY

a decrease in wider financial and social costs incurred through patient safety incidents including lost work time and disability benefits.
Penurunan biaya finansial dan sosial yang diperlukan untuk menangani insiden patient safety, termasuk kehilangan jam kerja dan pembayaran kecacatan

BAGAIMANA MEMULAI PENERAPAN BUDAYA KESELAMATAN PASIEN?

MULAILAH DENGAN SURVEI

TENTANG ISU :
Bagaimana

kemampuan managemen senior melihat ke depan dan berkomitmen ke arah keselamatan Bagaimana komunikasi antara staf dengan manager

TENTANG ISU: Bagaimana sikap dan perilaku dalam melaporkan suatu kejadian, blaming dan penghukumannya Bagaimana faktor-faktor dalam lingkungan kerja mempengaruhi kinerja, seperti kelelahan, pemecahan perhatian, desain peralatan dan ketersediaan/kesiapan alat.

TOOLS UNTUK SURVEI

TYPOLOGY:

Checklist for Assessing Institutional Resilience (CAIR ) Manchester Patient Safety Assessment Tool20 (MaPSaT) Advancing Health in America (AHA) and Veterans Health Association (VHA): Strategies for Leadership. An Organisational Approach to Patient Safety

DIMENSIONAL:

Safety Attitudes Questionnaire (SAQ) Stanford Patient Safety Centre of Inquiry Culture Survey

contoh

Isu apa saja yg dinilai?

Unit

tempat responden bekerja Variabel latar responden Ukuran keluaran tentang insiden dan pelaporannya Dimensi keselamatan pasien di tingkat Unit tsb Dimensi keselamatan pasien di tingkat RS

contoh

I. Background Variables
A. What is your primary work area or unit in this hospital? H1. How long have you worked in this hospital? H2. How long have you worked in your current hospital work area/unit? H3. Typically, how many hours per week do you work in this hospital? H4. What is your staff position in this hospital? H5. In your staff position, do you typically have direct interaction or contact with patients? H6. How long have you worked in your current specialty or profession?

contoh

II. Outcome measures

Frequency of Event Reporting Overall Perceptions of Safety Patient Safety Grade Number of Events Reported

contoh

Overall Perceptions of Safety:

Patient safety is never sacrificed to get A15. Keselamatan pasien tidak pernah dikorbankan untuk more work done. memperbanyak pekerjaan yang bisa dikerjakan
A18. procedures systems are good Prosedur dan Our sistem kita adalah and bagus dalam mencegah at preventing errors from happening. terjadinya kesalahan

A18.

Our procedures and systems are good

It is just by chance that more serious mistakes dont happen around here. (reverse worded) Hanyalah suatu kebetulan bahwa kesalahan yang lebih We have patient safety problems in this A17r. serius tidak terjadi disini (neg) unit (reverse worded)
Kita memiliki masalah keselamatan pasien di unit ini (neg)
Reliability of this dimensionCronbachs alpha (4 items) = .74

A10r.

III. Safety Culture Dimensions (Unit level)

contoh

Harapan dan tindakan supervisor dan manajer& dalam expectations actions Supervisor/manager mempromosikan promotingkeselamatan safety

Learning Continuous Organizational Pembelajaran organisasi perbaikan kontinyu

improvement Kerjasama tim di RS Teamwork Within Hospital Units Keterbukaan dalam berkomunikasi Openness Communication and Communication About Error Feedback Umpan balik dan komunikasi tentang Kesalahan Nonpunitive Response To Error Tanggapan yang tidak menghukum terhadap kesalahan Staffing Staff Hospital Management Support for Patient Safety RS mendukung Keselamatan Pasien Manajemen

contoh

Supervisor/manager expectations & actions promoting safety

Supervisor / Manajer: B1. My supervisor/manager says a good word when he/she sees a job done according to established Memuji bila staf melakukan prosedur PS patient safety procedures. B2. My supervisor/manager seriously considers staff Mempertimbangkan usulan staf untuk peningkatan PS suggestions for improving patient safety. Memerintahkan kerjaup, dengan melakukan jalan B3r. Wheneverpercepatan pressure builds my supervisor/manager pintas wants (neg) us to work faster, even if it means taking shortcuts. (reverse worded) Tidak memperhatikan masalah PS yg sudah terjadi B4r. My supervisor/manager overlooks patient safety problems berulang (neg) that happen over and over. (reverse worded)
Reliability of this dimensionCronbachs alpha (4 items) = .75

contoh

Teamwork Within Hospital Units

Orang People saling membantu unitanother ini A1. support di one in this unit. Bila banyak yg membutuhkan A3. terdapat Whenpekerjaan a lot of work needs to be done quickly, we work together asbekerja a team to get the work diselesaikan secepatnya, kita bersama dalam satu done. tim untuk menyelesaikannya A4. In this unit, people treat each other with Dalam unit ini orang memperlakukan orang lain dengan respect. hormat A11. When one area in this unit gets really busy, Bila salah satu help area di unit ini sibuk, maka yang lain akan others out. membantunya
Reliability of this dimensionCronbachs alpha (4 items) = .83

IV. Safety Culture Dimensions (Hospital-wide)

Teamwork Across Hospital Units Hospital Handoffs & Transitions

contoh

contoh

Teamwork Across Hospital Units kerjasama yg baik antar unit yg F4. Terdapat There is good cooperation among hospital harus bekerjasama units that need to work together. F10. Unit-unit Hospital bekerja units work well together to provide bersama untuk memberi the bestterbaik care for patients. layanan kepada pasien F2r. Unit-unit Hospital tidak units bekerjasama do not coordinate with satu well sama lain each other. (reverse worded) (neg) F6r. It is often unpleasant to work with staff from Sangat tidak menyebangkan other hospital units. (reverse bekerja worded) dengan staf dari unit lain (neg)
Reliability of this dimensionCronbachs alpha (4 items) = .8

MANFAAT SURVEI
Suatu organisasi perlu mengetahui budayanya yg sekarang sebelum bisa mengubah budaya tersebut Mengubah sikap dan perilaku itu sulit dan lama, perlu pemahaman tentang keselamatan pasien dan pendekatan sistem pada errors dan incidents Leadership penting dalam membentuk value dan belief dalam budaya

LEVEL OF MATURITY WITH RESPECT TO A SAFETY CULTURE

Why Why waste waste our our time time On safety? On safety?

We do Something when we Have an incident

We We have have systems systems in in Place Place to to Manage Manage all all Like Like risks risks

We We are are always always On On alert alert for for Risks Risks that that Might Might emerge emerge

Risk Risk management management Is Is an an integral integral Part Part of of Everything Everything That That we we do do

SELANJUTNYA BAGAIMANA?

Langkah-langkah
1. Assess the culture of safety. 2. Provide science-of-safety education. 3. Identify safety concerns. 4. Establish senior leader partnerships with units. 5. Learn from one defect per month. 6. Re-assess (re-measure) the culture of safety.
Membangun budaya adalah suatu siklus yg tak henti-henti

ACTION RECOMMENDATIONS 1
Seek leadership support for the creation of a culture of safety throughout the organization. Support can be gained by providing data demonstrating that communication problems are major causes of medical errors and information on how teamwork failures lead to malpractice claims and by sharing success stories of facilities that have affected patient safety by improving safety culture.

ACTION RECOMMENDATIONS 2
Partner with clinicians and managers in conducting an assessment of the existing safety climate in the organization. Appoint a project team, accountable to a senior executive, to carry out the assessment using surveys, interviews, or other techniques. Based on survey findings, formulate and execute an action plan to improve the culture of safety. Establish realistic measures to gauge the effectiveness of action plans.

ACTION RECOMMENDATIONS 3 Provide safety science education to frontline staff, managers, and physicians. Include teamwork training and education in communication techniques. Incorporate safety culture initiatives into the overall organizational patient safety plan. Ensure that patient safety initiatives, action plans, and results of interventions to improve safety are periodically reported to the board of directors.

ACTION RECOMMENDATIONS 4
Establish a nonpunitive system for reporting errors, events, and near misses. Consider implementing a reward-based reporting system, and ensure timely feedback to staff on how reports are used to improve patient safety. Ensure that disclosure policies are in keeping with current regulations and standards. Work toward using disclosure with apology as a claimavoidance strategy.

ACTION RECOMMENDATIONS 5 Share information on improvements and successes based on safety culture changes to maintain enthusiasm for participation and support. Communicate plans to address areas still in need of improvement and other opportunities to enhance patient safety.

FAKTA

Dengan sistem patient Safety, Sentara Norfolk General Hospital: 84 % pengurangan Pneumonia yg berkaitan dg ventilator dari 2001 s/d Juni 2004 Dengan Tim Tanggap Cepat di Missouri Baptist Medical Center telah menurunkan 60 % penurunan panggilan darurat henti nafas dan krisis serupa dan penurunan 15% henti jantung. Johns Hopkins Hospital mengalami peningkatan 49 - 91 % proporsi pelaporan staf ICU tentang iklim safety dan menghilangkan kasus infeksi pembuluh darah akibat kateterisasi, mencegah 8 kematian dan berhemat $2 juta pertahun. Kasus adverse drug events menurun 91 percent di OSF St. Joseph Medical Center.

KATA AKHIR
Keselamatan Pasien di Rumah Sakit hanya dapat dicapai dengan membangun budaya yang berorientasikan kepada keselamatan pasien Budaya keselamatan pasien harus dipahami, dihayati dan diamalkan oleh seluruh unsur rumah sakit Peran pimpinan, baik formil maupun non formil diperlukan dalam membentuk nilai dan memberi teladan.