Praktek Bermutu dan

Manajemen Risiko

Gulardi H. Wiknjosastro
Bagian Obstetri Ginekologi
FKUI RS Dr. Cipto Mangunkusumo
Jakarta

Kematian BAYI
Ibu

X, ketuban pecah, hamil aterm

Induksi partus, janin hidup
Jam 22.00 dokter : hentikan induksi
Jam 7.00 seksio sesarea
Lahir bayi menangis sesak
Meninggal 2 jam kemudian
Pasien tak puas

Kredensial
SIKAP
AD/Statuta
RS
Akreditasi
Komite
Medik

Ijin Praktek

Standar
Profesi

MASALAH-TUNTUTAN
Kematian ibu bayi
Asfiksia
kelumpuhan otak
Kecacatan
permanen
Trauma
Kelainan bawaan

Kenapa ada tuntutan ?

PENYIMPANGAN

PRAKTEK-KLINIK

OR

=5.76
290 kasus malpraktek vs 262
kontrol (1988-1998)

Reduced medicolegal risk by compliance with obstetric

clinical pathways : a case control study
Ransom et al Obstet Gynecol 2003;101:751

Seksio sesarea

Risiko besar pada

ibu : perdarahan,
infeksi, anestesi
Risiko bayi : RDS,
preterm, tersayat
Persalinan pada
bekas SS
Peran : bidan,
perawat, dr. Anak ,
Anestetist

Definisi

Kecelakaan
(incident): kejadian
kesakitan/efek
samping akibat
tidak sesuai dengan
pelayanan RS.

Nama baik RS !!

LAPORAN KEJADIAN
Obyektif
Kerahasiaan
Segera -24 jam,
bila gawat pertelepon

MUTU >< RISIKO

Manajemen

mutu
Semakin baik semakin kecil
risiko
KOMUNIKASI !!
Hargai hak pasien tunjukkan
sikap menolong kunjungan > 1
kali /hari
INFORMED CONSENT

Komite Medik
Memegang teguh AD-Statuta RS
Terdiri multidisiplin
Menelaah Kredensial calon pegawai
Menilai luaran pelayanan
Proaktif thd keluhan
pasien/keluarga
Membina informasi dari unit
pelayanan keluhan- KESEDIHAN
pasien dan efek samping

PENERIMAAN DOKTER

Sesuai dengan
kebutuhan RS
kemampuan dokter ?
Dokter patuh dengan
AD-Statuta
Rincian tugas
Dokter Ob-Gin
kompetensi ??
Rekomendasi dari POGI
Ijin praktek dari
DepKes

Akreditasi

Kompetensi
Sikap buku LOG :
isi : luaran, jumlah
tindakan
ALARM (advances in
labor and risk
management)
Kredit CME
Kemampuan :
pendidikan dan
penelitian

Standar pelayanan
Ada dokter konsultan Fetomaternal
Multidisiplin : dr-OB, anestesi-OB,
bidan-kompeten OB+kompl, dsb
Purna waktu

FASILITAS : Km. Bersalin 02,

peghisap, oksimeter, tensi, alat
resusitasi
1 Km Operasi 3000 partus
Monitor CTG, AGD, Mikroskop +LAB ,
Transfusi

Manajemen Risiko

Prinsip : mengurangi
Manajer
Program

STANDAR - protap

SIKAP profesional
Persyaratan : Ijin
praktek
Kompetensi:
pelatihan
Audit

Manajemen Risiko Klinik

Struktur

: dokter, bidan, perawat dll

Tujuan : memperbaiki mutu,
menghindari kecelakaan
Langkah : 1. Identifikasi masalah
2. Analisa masalah
3. Lokalisasi masalah perbaiki
4. pendanaan bila terjadi tuntutan
Pertemuan dilakukan 1x/minggu.

Maternity clinical incident report

Events that could result in important short- or long-term adverse effects for the mother or
baby should be based on local consensus but would probably include:
Maternal/delivery incident

loss >1500 ml
Cord accident
Deep venous thrombosis
Duration 2nd stage >3hrs
(prim)
Duration 2nd stage >1hr
(parous)
Duration established labour
>18 hrs
Eclampsia
Hb <8g/dl postpartum
Hysterectomy/laparotomy

Fetal/neonatal incident

APGAR <7 at 5 minutes

Birth trauma
Cord pH <7.2
Neonatal death
Neonatal seizures
Stillbirth >500g
Shoulder dystocia
Small for gestational age
Term baby admitted to
paediatric unit
Unsuspected fetal anomaly

Organisational incident
Blood-Anaesthetic complications
ITU admission
Maternal death
Pulmonary embolism
Third degree tear
Unsuccessful forceps/ventouse
Uterine rupture
Delay >30mins for emergency
CS
Delay following call for
assistance
Delivery outwith labour suite
Faulty equipment
Interpersonal conflict over case
management
Potential service user complaint
Prescribing/administration error
Retained swab/instrument
Violation of local
protocol/guideline

Kompetensi

Analisa , contoh :
Memakai Partogram
Pengawasan janin
EFM- CTG
Bekerja sesuai
standar + etika
profesi
Membuat rekam
medik lengkap

Program
Pendidikan berkelanjutan bagi :
dokter dan perawat/bidan
Evidence based medicine practice
Menerapkan manajemen risiko
Perbaikan protokol- protap
Perbaikan rekam medik
Telaah unit perawatan intensif- gawat
darurat
Perhatian pada allergi-efek samping
KOmunikasi dokter-pasien >>>>

Perbaikan pelayanan ?
60% Ob-Gyn di Australia pernah
mengalami tuntutan dlm Obstetrik
Uang ganti A$ 35.515 (median)
44% akan berhenti praktek obstetri
dalam 5 tahun mendatang

MacLennan AH, Spencer MK. Projections of Australian

obstetricians ceasing practice and the reasons. Med J Aust
2002;176:425.

Kredensial
SIKAP
AD/Statuta
RS
Akreditasi
-Buku LOG
-ALARM
-Pelatihan

Komite
Medik

Ijin Praktek

Standar
Profesi
Panduan Etik

POGI

CLINICAL
GOVERNANCE

A Working Definition
It

is a framework through which NHS

organisations are accountable for
continuously improving the quality of their
services and safeguarding high standards
of care by creating an environment in
which excellence in clinical care will
flourish.

Why do we need Clinical

Governance?
to

give coherence to local quality

improvement activities
to promote the importance of clinical
quality
to restore public confidence in quality of
clinical care
to ensure public confidence in professional
self-regulation

Partnership for quality

all

professions and NHS managers

provides

framework for local

professional self - regulation

underpinned

development

by continuing professional

Accountability for quality

statutory responsibility for quality

Chief Executive ultimately responsible for

assuring quality of services (through the
Board)

formal local arrangements to assure clinical

quality (eg Board sub-committee)

Echoes Principles of Corporate

Governance
gives

clinical quality equal status to

financial management

gives

Boards responsibilities for clinical

governance

clear

standards and quality systems

openness

and accountability

To whom does it apply?

principles

of good clinical governance

will apply to all NHS organisations and
those engaged in NHS clinical practice

arrangements

must be proportionate to
the size of the organisation

Accountability locally
senior

clinician responsible for clinical

governance

regular

reports to the Board

annual

report on clinical governance

Coherent programme for quality

improvement

integrated quality improvement processes eg clinical

audit

evidence based practice

innovations and good practice systematically

disseminated

adverse events openly investigated and lessons

applied

What should it mean for

patients?
clearer

accountability for quality

increased

confidence in quality of
clinical services

How can Clinical Governance help

you?

by helping redress the balance between financial

performance and quality

by harnessing the commitment of clinicians and

managers to the delivery of quality patient services

by providing a coherent framework for disparate

local quality improvement

by reducing clinical risk and disseminating good

practice.

NHSE Clinical Governance

Key Steps Year 1

establish leadership, accountability and working

arrangements

carry out a baseline assessment of capacity and

capability

formulate and agree a development plan in light of

the assessment

clarify
reporting
arrangements
for
Clinical
Governance within board and annual reports

Baseline Assessment of Capability and

Capacity (1)

a searching and honest analysis of organisations strengths

and weaknesses in relation to current performance on quality.

the identification of any particularly problematic services

drawing where possible on objective data or feedback from
users of services or referring agencies).

an assessment of the extent to which data is in place for

quality surveillance.

Baseline Assessment of Capability and

Capacity (2)

establishing whether there are any deficits in key

mechanisms (eg for risk management etc)

making sure that there is integration of quality

activities and systems

establishing explicit links to HiMPs NSF and

PCG/PCTs

6. Gynaecology clinical incident report

Events that could result in important short- or long-term

adverse effects for the woman should again be based on
local consensus but would probably include:

Clinical incidents
Damage to structures (e.g. ureter, bowel, vessel)
Delayed or missed diagnosis (e.g. ectopic)
Deep venous thrombosis
Failed procedures (e.g. abortion, sterilisation, laparoscopy)
ITU admission
Omission of planned procedures (removal of IUCD at
sterilisation, sterilisation at abortion)
Operative blood loss >500ml
Ovarian hyperstimulation (assisted conception)
Performance of unplanned, unconsented procedures (e.g.
removal of ovaries at hysterectomy)
Pulmonary embolism
Unplanned return to theatre

Organisational incidents
Complications

of anaesthesia
Delay following call for assistance
Faulty equipment
Interpersonal conflict over case
management
Potential service user complaint
Prescribing/administration error
Retained swab/instrument
Violation of local protocol/guideline

Organisasi
POGI

Rumah Sakit
AD
Audit M - P

POGI JAYA

Ko-POGI

Dewan Pertimbangan Cabang

Tim Manajemen Risiko

-Dokter
-Bidan/Paramedik

Sikap dan kinerja

Buku LOG
Rekam Medik