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INTEGRASI PROGRAM

MUTU PELAYANAN RUMAH SAKIT


DAN UPAYA KESELAMATAN PASIEN

Dr. ADIB A YAHYA, MARS

INSTITUT MANAJEMEN RISIKO KLINIS


WORKSHOP PENGUKURAN DAN ANALISA DATA INDIKATOR UNTUK MENINGKATKAN
MUTU DAN KESELAMATAN PASIEN
PERSI DAERAH JAWA TIMUR, SURABAYA 1 2 NOVEMBER 2013

Standar Pelayanan Pasien : Tujuan utama pelayanan kes RS adalah pelayanan pasien.
PATIENT-PATIENT
CENTERED
CARE

HOSPITAL
RISK
MANAGEMENT

(PELAYANAN FOKUS
PASIEN))

Safety
Safety is a fundamental principle
of patient care and a critical
component of Quality

Etik

Management.

4 Fondasi
Asuhan pasien

Asuhan Medis
Asuhan Keperawatan
Asuhan Gizi
Asuhan Obat

Kebutuhan
Pasien

Mutu
Patient
Safety

EBM
VBM

(World Alliance for Patient


Safety,
Sa
ety, Forward
o a d Programme
Programme,
og a e,
e,
WHO, 2004)

Evidence Based Medicine


Value Based Medicine

(Nico A Lumenta & Adib A Yahya, 2012)

IMPLEMENTASI PATIENT SAFETY


DI RUMAH SAKIT
DASAR HUKUM
UU.N0.44 TH.2009
Tentang Rumah Sakit :

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


PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA
NOMOR 1691/MENKES/PER/VIII/2011
TENTANG
KESELAMATAN PASIEN RUMAH SAKIT

STANDAR
KESELAMATAN PASIEN
PROGRAM
WHO PATIENT SAFETY
TUJUH LANGKAH
MENUJU
KESELAMATAN
PASIEN RUMAH SAKIT

9 SOLUTIONS

PENILAIAN

KARS

SASARAN
KESELAMATAN PASIEN
RUMAH SAKIT
IMPLEMENTASI PATIENT SAFETY
DI RUMAH SAKIT

STANDAR AKREDITASI RUMAH SAKIT 2012


I.

KELOMPOK STANDAR PELAYANAN BERFOKUS PADA PASIEN


1. AKSES KE PELAYANAN DAN KONTINUITAS PELAYANAN (APK)
2. HAK PASIEN DAN KELUARGA (HPK)
3. ASESMEN PASIEN (AP)
4. PELAYANAN PASIEN (PP)
5. PELAYANAN ANESTESI DAN BEDAH (PAB)
6. MANAJEMEN DAN PENGGUNAAN OBAT (MPO)
7 PENDIDIKAN PASIEN DAN KELUARGA (PPK)
7.

II.. KELOMPOK STANDAR MANAJEMEN RUMAH SAKIT


II
1. PENINGKATAN MUTU DAN KESELAMATAN PASIEN (PMKP)
2. PENCEGAHAN DAN PENGENDALIAN INFEKSI (PPI)
3. TATA KELOLA, KEPEMIMPINAN, DAN PENGARAHAN (TKP)
4. MANAJEMEN FASILITAS DAN KESELAMATAN (MFK)
5. KUALIFIKASI DAN PENDIDIKAN STAF (KPS)
6. MANAJEMEN KOMUNIKASI DAN INFORMASI (MKI)
III. SASARAN KESELAMATAN PASIEN RUMAH SAKIT
SASARAN I. KETEPATAN IDENTIFIKASI PASIEN
SASARAN II. PEN
PENINGKATAN KOMUNIKASI YANG EFEKTIF
SASARAN III. PENINGKATAN KEAMANAN OBAT YANG PERLU DIWASPADAI
SASARAN IV. KEPASTIKAN TEPAT LOKASI,TEPAT PROSEDUR,TEPAT PASIEN OPERASI
SASARAN V. PENGURANGAN RISIKO INFEKSI TERKAIT PELAYANAN KESEHATAN
SASARAN VI. PENGURANGAN RISIKO PASIEN JATUH
IV. Sasaran millennium development goals
(1) penurunan angka kematian bayi dan peningkatan kesehatan ibu;
(2) penurunan angka kesakitan HIV/AIDS; dan
(3) penurunan angka kesakitan tuberkulosis.

Essentials
Joint Commission Internationals
Essentials of Health Care Quality
y
and Patient Safety
by Joint Commission International (JCI)

Essentials

Quality and safety improvement framework


designed to help organizations focus on the
risk areas that have the greatest impact on
patient safety

Essentials can help to:


Determine levels of risk to patient safety in a health

care organization
Develop strategies to mitigate risks
Better allocate reso
resources
rces to improve
impro e q
quality
alit and
safety

How Essentials Is Applied


pp

Essentials will help an organization to:


Identify the risks that have the greatest impact on
safety
Design an approach for addressing these risks
Implement changes
Periodically reassess the impact of these
changes

Overview of
International Essentials for
Quality and Patient Safety

Essentials Address
Five Risk Areas / Focus Areas
Developed from extensive international
healthcare literature and experience
Ten Criteria for each Risk Area provide
clear and achievable risk reduction strategies
Progressive Levels
Levels of Effort
Effort are
identified for each Criterion

10

Overview of
Fi Risk
Five
Ri k Areas
A
/ Focus
F
Areas
A
Five widely recognized domains of risk :
1.
2.
3.
4.
5
5.

Leadership Process and Accountability


Competent and Capable Workforce
Safe Environment for Staff and Patients
Clinical Care of Patients
I
Improvement
t off Quality
Q lit and
d Safety
S f t

11

Risk Area / Focus Area 1:

Leadership Process and Accountability


CRITERION :
1. Leadership responsibilities and accountabilities are identified
2. Leadership for quality and patient safety
3.
3 Collaboration and cooperation at all levels
4. Quality requirements in clinical and managerial contracts
5. Quality, patient safety, and risk management are integrated.
6. Compliance with laws and regulations
7. Commitment to patient and family rights
8. Policies and procedures for highhigh-risk procedures and patients
9. Oversight of human subject research
10 O
10.
Oversight
i ht off organ and
d tissue
ti
donation
d
ti and
d transplantation
t
l t ti

12

Risk Area / Focus Area 2:

Competent and Capable Workforce


CRITERION :
1. Personnel files and job descriptions for all staff
2. Review of credentials of physicians
3.
3 Review of credentials of nurses
4. Review of credentials of other health professionals
5. Staff members are oriented to their jobs.
6. Oversight of students and those in training
7. Training in resuscitative techniques
8. Staff education on infection prevention and control
g those caring
g for the patient
p
9. Communication among
10 Staff health and safety program

13

Risk Area / Focus Area 3:

Safe Environment of Staff and Patients


CRITERION :
1. Regular inspection of buildings
2. Control of hazardous materials
3. Fire safety program
4. Biomedical equipment safety
5. Stable water and electricity sources
6 C
6.
Coordination
di ti off infection
i f ti prevention
ti and
d control
t l program
7. Reduction of health care
care--associated infections
8. Barrier techniques are used.
9 Proper disposal of sharps and needles
9.
10. Proper disposal of infectious medical waste

14

Risk Area / Focus Area 4:

Clinical Care of Patients


CRITERION :
1. Correct patient identification
2. Informed consent
3. Medical and nursing assessments for all patients
4 Laboratory services are available and reliable
4.
reliable.
5. Diagnostic imaging services available, safe, and reliable.
6. Planned and provided care is written.
pp p
y
7. Anesthesia and sedation are used appropriately.
8. Surgical services are appropriate to patient needs
9. Medication use is safely managed.
10. Patients are educated to participate in their care.

15

Risk Area / Focus Area 5:

Improvement of Quality and Safety


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

16

INTERNATIONAL ESSENTIALS OF HEALTH CARE QUALITY AND


PATIENT SAFETY (HOSPITAL ESSENTIALS)
Focus
Area
Criteria

Leadership
Process and
Accountability

Competent and
Capable
Workforce

Safe
Environment
for Staff and
Patients

Clinical Care
of
Patients

Patients
Improvement
of Quality and
Safety

Leadership
responsibilities
and
accountabilities
identified

Personnel files
and job
descriptions for
all staff

Regular
inspection of
buildings

Correct patient
identification

There is an
adverse event
reporting system

Leadership for
quality and safety

Review of
credentials of
physicians

Control of
hazardous
materials

Informed
consent

Adverse events
are analyzed.

Collaborative
management

Review of
credentials of
nurses

Fire safety
program

Medical and
nursing
assessments for
all patients

High-risk
processes and
high-risk patients
are monitored.

Oversight of
contracts

Review of
credentials of
other health
professionals

Biomedical
equipment safety

Laboratory
services are
available and
reliable.

Patient
satisfaction is
monitored.

17

Staff orientation
to their jobs

Stable water and


Electricity sources

Diagnostic
imaging services
are available,
safe, and reliable.

Staff satisfaction
is monitored

Integration of
quality and risk
management

Compliance with
laws and
regulations

Oversight of
students and
those in training

Coordination of
infection
prevention and
control program

Planned and
provided care is
written.

There is a
complaint
process.

Commitment to
patient and
family
rights

Training in
resuscitative
techniques

Reduction of
health care
associated
infections (hand
hygiene)

Anesthesia and
sedation are
used
appropriately.

Clinical
guidelines and
pathways are
available and
used.

Policies and
procedures for
care of high-risk
patients

Staff education
on infection
prevention and
control

Barrier
techniques are
used (gloves,
masks, and so
on).

Surgical services
are appropriate
to patient needs.

Staff understand
how to improve
processes.

Oversight of
human subject
research

Communication
among those
caring for the
patient

Proper disposal
of sharps and
needles

Medication use
is safely
managed.

Clinical
outcomes are
monitored.

Organ
procurement,
d
donation,
ti
and
d
transplantation

Staff health and


safety program

Proper disposal
of infectious
medical
di l waste
t

Patients are
educated to
participate
ti i t in
i
their care.

Communicating
quality and safety
i f
information
ti to
t
staff

10

INTERNATIONAL ESSENTIALS OF HEALTH CARE QUALITY AND PATIENT SAFETY Hospital Edition
Joint Commission International

18

TERIMAKASIH
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