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Evidence based practice 1
Evidence based practice 1
Evidence based practice 1
Evidence based practice 1
Evidence based practice 1
Evidence based practice
1
Mutu: kepatuhan pd standar kepuasan pelanggan
Mutu:
kepatuhan pd standar
kepuasan pelanggan
Akses thd pelayanan
Akses thd pelayanan
Keefektifan
Keefektifan
Efisiensi
Efisiensi
Keamanan
Keamanan
Kelangsungan layanan
Kelangsungan layanan
Kompetensi tehnis
Kompetensi tehnis
Kenyamanan
Kenyamanan
Hub. Antar manusia
Hub. Antar manusia
Keefektifan Efisiensi Keamanan Kelangsungan layanan Kompetensi tehnis Kenyamanan Hub. Antar manusia Dimensi Mutu 2
Dimensi Mutu 2
Dimensi Mutu
2
Keefektifan Efisiensi Keamanan Kelangsungan layanan Kompetensi tehnis Kenyamanan Hub. Antar manusia Dimensi Mutu 2
Pengambilan keputusan dalam pelayanan kesehatan Needs &Values Resources/ Evidence Opportunity Costs 3
Pengambilan keputusan dalam pelayanan kesehatan Needs &Values Resources/ Evidence Opportunity Costs 3
Pengambilan keputusan dalam pelayanan kesehatan Needs &Values Resources/ Evidence Opportunity Costs 3
Pengambilan keputusan
dalam pelayanan kesehatan
Needs &Values
Resources/
Evidence
Opportunity
Costs
3
Pengambilan keputusan dalam pelayanan kesehatan
Pengambilan keputusan
dalam pelayanan kesehatan
Pengambilan keputusan dalam pelayanan kesehatan Opinion bases decision making (pengambilan keputusan berbasis opini)
Pengambilan keputusan dalam pelayanan kesehatan Opinion bases decision making (pengambilan keputusan berbasis opini)
Pengambilan keputusan dalam pelayanan kesehatan Opinion bases decision making (pengambilan keputusan berbasis opini)
Opinion bases decision making (pengambilan keputusan berbasis opini) Evidence-based decision making (pengambilan
Opinion bases decision making
(pengambilan keputusan
berbasis opini)
Evidence-based decision
making
(pengambilan keputusan
berbasis evidens)

Increasing pressure

berbasis opini) Evidence-based decision making (pengambilan keputusan berbasis evidens) Increasing pressure 4
berbasis opini) Evidence-based decision making (pengambilan keputusan berbasis evidens) Increasing pressure 4
berbasis opini) Evidence-based decision making (pengambilan keputusan berbasis evidens) Increasing pressure 4
berbasis opini) Evidence-based decision making (pengambilan keputusan berbasis evidens) Increasing pressure 4

4

berbasis opini) Evidence-based decision making (pengambilan keputusan berbasis evidens) Increasing pressure 4
Evidence-based health care: a discipline centered upon evidence- based decision making about individual groups of
Evidence-based health care: a discipline centered upon evidence- based decision making about individual groups of
Evidence-based health care: a discipline centered upon evidence- based decision making about individual groups of
Evidence-based health care:
a discipline centered upon evidence-
based decision making about
individual groups of patients or
population, which may be manifest
as evidence-based purchasing or
evidence-based management
(Muir Gray, J.A, 1999)
5
EBHC: the Practice
EBHC: the Practice
asking an answerable question (questioning).
asking an answerable question
(questioning).
the Practice asking an answerable question (questioning). searching for the best evidence. critically-appraising the
searching for the best evidence.
searching for the best evidence.
critically-appraising the evidence.
critically-appraising the evidence.
performing (practicing) thru integrating the evidence with our expertise and our patient’s unique biology and
performing (practicing) thru integrating
the evidence with our expertise and our
patient’s unique biology and values, and
evaluating our performance
evaluating our performance
Pertanyaan yang diajukan dalam pengambilan keputusan Apa jenis metoda penelitian mrp yg terbaik untuk menjawab
Pertanyaan yang diajukan dalam pengambilan keputusan Apa jenis metoda penelitian mrp yg terbaik untuk menjawab
Pertanyaan yang diajukan dalam pengambilan keputusan Apa jenis metoda penelitian mrp yg terbaik untuk menjawab
Pertanyaan yang diajukan
dalam pengambilan keputusan
Apa jenis metoda penelitian mrp yg
terbaik untuk menjawab pertanyaan
Apakah penelitian masuk
kategori bermutu
Berapa besar manfaat dan efek
yang sebaliknya ?
Apakah hasil penelitian dapat
Digeneralisasikan ?
Apakah hasil penelitian dapat
diaplikasikan pd populasi lokal
Apakah hasil penelitian dapat
diaplikasikan untuk pasien tertentu?
7
Mengapa menerapkan pelayanan kesehatan berbasis evidens Population Patient (ageing) expectations Professional
Mengapa menerapkan pelayanan kesehatan berbasis evidens Population Patient (ageing) expectations Professional
Mengapa menerapkan pelayanan kesehatan berbasis evidens Population Patient (ageing) expectations Professional
Mengapa menerapkan
pelayanan kesehatan berbasis
evidens
Population
Patient
(ageing)
expectations
Professional
expectations
New knowledge
& technology
Industry
Research
8
Kinerja dalam menerapkan pelayanan berbasis evidens
Kinerja dalam menerapkan
pelayanan berbasis evidens
Kinerja dalam menerapkan pelayanan berbasis evidens K M x Kp = H K = Kinerja M
Kinerja dalam menerapkan pelayanan berbasis evidens K M x Kp = H K = Kinerja M
Kinerja dalam menerapkan pelayanan berbasis evidens K M x Kp = H K = Kinerja M

K

M x Kp

=

H

K = Kinerja M = Motivasi Kp= Kompetensi H = Hambatan

: Kinerja yankes yang berbasis evidens : Motivasi untuk menerapkan : Kompetensi untuk menerapkan : Hambatan dalam penerapan

yankes yang berbasis evidens : Motivasi untuk menerapkan : Kompetensi untuk menerapkan : Hambatan dalam penerapan
9
9
Lingkup Pelayanan Kesehatan Berbasis Evidens (PKBE)
Lingkup Pelayanan Kesehatan
Berbasis Evidens (PKBE)

Producing Evidence (menghasilkan evidens)

Keputusan:

(PKBE) Producing Evidence (menghasilkan evidens) Keputusan: Kebijakan Pembiayaan Menejemen Making evidence available
(PKBE) Producing Evidence (menghasilkan evidens) Keputusan: Kebijakan Pembiayaan Menejemen Making evidence available

Kebijakan

Pembiayaan

Menejemen

evidens) Keputusan: Kebijakan Pembiayaan Menejemen Making evidence available (Menyediakan evidens) Using

Making evidence available (Menyediakan evidens)

Menejemen Making evidence available (Menyediakan evidens) Using evidence: getting research into practice (menggunakan

Using evidence: getting research into practice (menggunakan evidens: praktek berbasis penelitian)

practice (menggunakan evidens: praktek berbasis penelitian) For individual patients (untuk pasien secara individu) For

For individual patients (untuk pasien secara individu)

For populations and groups of patients:

(untuk populasi atau kelompok pasien)

Evidence-based medicine Evidence-based public health and health or clinical practice (yan klinik/medik berbasis
Evidence-based medicine
Evidence-based public health and health
or clinical practice
(yan klinik/medik berbasis evidens)
service management
(manajemen yankes dan kesmas berbasis
Evidens)
10
10
Hubungan Manajemen Mutu dan Pelayanan Kesehatan Berbasis Evidens PKBE + QM = Kemanfaatan Maximum Kesehatan
Hubungan Manajemen Mutu dan Pelayanan Kesehatan Berbasis Evidens PKBE + QM = Kemanfaatan Maximum Kesehatan
Hubungan Manajemen Mutu dan Pelayanan Kesehatan Berbasis Evidens PKBE + QM = Kemanfaatan Maximum Kesehatan
Hubungan Manajemen Mutu dan Pelayanan Kesehatan Berbasis Evidens PKBE + QM = Kemanfaatan Maximum Kesehatan
Hubungan Manajemen Mutu dan Pelayanan Kesehatan Berbasis Evidens
Hubungan Manajemen Mutu dan
Pelayanan Kesehatan Berbasis
Evidens

PKBE + QM = Kemanfaatan Maximum Kesehatan dengan risiko dan biaya yang paling rendah

Kesehatan Berbasis Evidens PKBE + QM = Kemanfaatan Maximum Kesehatan dengan risiko dan biaya yang paling
Kesehatan Berbasis Evidens PKBE + QM = Kemanfaatan Maximum Kesehatan dengan risiko dan biaya yang paling
Kesehatan Berbasis Evidens PKBE + QM = Kemanfaatan Maximum Kesehatan dengan risiko dan biaya yang paling
Kesehatan Berbasis Evidens PKBE + QM = Kemanfaatan Maximum Kesehatan dengan risiko dan biaya yang paling
Kesehatan Berbasis Evidens PKBE + QM = Kemanfaatan Maximum Kesehatan dengan risiko dan biaya yang paling
Kesehatan Berbasis Evidens PKBE + QM = Kemanfaatan Maximum Kesehatan dengan risiko dan biaya yang paling
Kesehatan Berbasis Evidens PKBE + QM = Kemanfaatan Maximum Kesehatan dengan risiko dan biaya yang paling
11
11
Evolusi PKBE
Evolusi PKBE
Doing things cheaper (Efficiency)
Doing things
cheaper
(Efficiency)
Evolusi PKBE Doing things cheaper (Efficiency) Doing things better (Quality Improvement) Doing thing right Doing the
Doing things better (Quality Improvement)
Doing things
better
(Quality
Improvement)
Doing thing right
Doing thing right
things better (Quality Improvement) Doing thing right Doing the right things right Doing the right things
things better (Quality Improvement) Doing thing right Doing the right things right Doing the right things
things better (Quality Improvement) Doing thing right Doing the right things right Doing the right things
things better (Quality Improvement) Doing thing right Doing the right things right Doing the right things
things better (Quality Improvement) Doing thing right Doing the right things right Doing the right things
things better (Quality Improvement) Doing thing right Doing the right things right Doing the right things
things better (Quality Improvement) Doing thing right Doing the right things right Doing the right things
Doing the right things right
Doing the right
things right
Doing the right things (Increasing Effectiveness)
Doing the right things
(Increasing
Effectiveness)
Doing the right things right Doing the right things (Increasing Effectiveness) 1970s 1980s 1990s 21 s
Doing the right things right Doing the right things (Increasing Effectiveness) 1970s 1980s 1990s 21 s
Doing the right things right Doing the right things (Increasing Effectiveness) 1970s 1980s 1990s 21 s

1970s

1980s

1990s

Doing the right things right Doing the right things (Increasing Effectiveness) 1970s 1980s 1990s 21 s

21 st century

12
12
Siklus QSAP Raise Questions (dimensions and definitions) Searching for evidence Appraising the evidence Getting
Siklus QSAP Raise Questions (dimensions and definitions) Searching for evidence Appraising the evidence Getting
Siklus QSAP Raise Questions (dimensions and definitions) Searching for evidence Appraising the evidence Getting
Siklus QSAP
Siklus QSAP

Raise Questions (dimensions and definitions) Searching for evidence Appraising the evidence Getting Research into Practice

Q S P A
Q
S
P
A

Questioning

Searching

Appraising

Appraising the evidence Getting Research into Practice Q S P A Questioning Searching Appraising Practicing 13

Practicing

Appraising the evidence Getting Research into Practice Q S P A Questioning Searching Appraising Practicing 13
Appraising the evidence Getting Research into Practice Q S P A Questioning Searching Appraising Practicing 13
13
13
Q S Benchmarking P A P D A S S D Q S Re-engineering A
Q S Benchmarking P A P D A S S D Q S Re-engineering A
Q S Benchmarking P A P D A S S D Q S Re-engineering A
Q S Benchmarking P A P D A S S D Q S Re-engineering A
Q S Benchmarking P A P D A S S D Q S Re-engineering A
Q S Benchmarking P A P D A S S D Q S Re-engineering A
Q
S
Benchmarking
P
A
P D
A S
S
D
Q
S
Re-engineering
A
S
P
A
14
Evidence-driven audit cycle Evidence I d e n t i f y topic Identify areas
Evidence-driven audit cycle Evidence I d e n t i f y topic Identify areas
Evidence-driven audit cycle Evidence I d e n t i f y topic Identify areas
Evidence-driven audit cycle
Evidence-driven audit cycle
Evidence
Evidence

Identify

topic Identify areas
topic
Identify
areas

Re-audit to ensure change has been effective

areas Re-audit to ensure change has been effective Implement change into practice Set Standards/ guidelines

Implement change into practice

Set Standards/ guidelines

Implement change into practice Set Standards/ guidelines Measure practice against standards which need to be changed
Implement change into practice Set Standards/ guidelines Measure practice against standards which need to be changed

Measure practice against standards

Implement change into practice Set Standards/ guidelines Measure practice against standards which need to be changed

which need to be changed

15
15
Type of research Qualitative Case Cohort R C T Systemat Interventio Research ic Control n
Type of research Qualitative Case Cohort R C T Systemat Interventio Research ic Control n
Type of research Qualitative Case Cohort R C T Systemat Interventio Research ic Control n
Type of research
Qualitative
Case
Cohort
R C T
Systemat
Interventio
Research
ic
Control
n
Review
Diagnosis
v
vv
vvv
Treatment
v
vv
vvv
Screening
vv
vvv
Managerial
v
v
v
vv
vvv
Innovation
16
Type of research Qualitativ Survey Case Cohort RCT Systemati Outcome e c Review Control Research
Type of research
Qualitativ
Survey
Case
Cohort
RCT
Systemati
Outcome
e
c Review
Control
Research
Effectiveness of
vv
vvv
Intervention
Effectiveness of
Health Service
v
v
v
v
vv
vvv
delivery
Safety
v
v
vv
vvv
Acceptability
v
v
vv
vvv
Cost-
vv
vvv
effectiveness
Appropriatenes
v
v
vvv
s
Quality
v
v
v
v
vvv
17
Acceptability v v vv vvv Cost- vv vvv effectiveness Appropriatenes v v vvv s Quality v
Quality of evidence
Quality of evidence

I. At least one randomized controlled trial

of evidence I. At least one randomized controlled trial II-1. Controlled trials without randomization
of evidence I. At least one randomized controlled trial II-1. Controlled trials without randomization
of evidence I. At least one randomized controlled trial II-1. Controlled trials without randomization

II-1. Controlled trials without randomization

(quasi-experimental designs)

II-2. Cohort or case-control studies

II-3. Multiple time series (observational studies)

or dramatic results III. Agreement among respected authorities

(anecdote / expert opinion)

among respected authorities (anecdote / expert opinion) 18 Lawrence RS, Mickalide AD. Preventive services in
among respected authorities (anecdote / expert opinion) 18 Lawrence RS, Mickalide AD. Preventive services in
18
18

Lawrence RS, Mickalide AD. Preventive services in clinical practice: designing the periodic health examination. JAMA 1987; 257:2205-7.

Quality of evidence rating I : Evidence obtained from a systematic review of all relevant
Quality of evidence rating I : Evidence obtained from a systematic review of all relevant
Quality of evidence rating I : Evidence obtained from a systematic review of all relevant
Quality of evidence rating
Quality of evidence rating
I : Evidence obtained from a systematic review of all relevant RCTs II : Evidence
I : Evidence obtained from a systematic review of all
relevant RCTs
II : Evidence obtained from at least one properly-
designed RCT
III-1: Evidence obtained from well-designed CT w/o
randomization
III-2: Evidence obtained from well-designed cohort or
case control analytic studies preferably from more
than one center or research group
III-3: Evidence obtained from multiple time series with
or without the intervention. Dramatic results in
uncontrolled experiements
IV: Opinions of respected authorities, based on
clinical experience, descriptive studies, or reports of
expert committees
19
Grades of recommendation A : evidence levels Ia & Ib B : evidence levels IIa,
Grades of recommendation A : evidence levels Ia & Ib B : evidence levels IIa,
Grades of recommendation A : evidence levels Ia & Ib B : evidence levels IIa,
Grades of recommendation
Grades of recommendation
A : evidence levels Ia & Ib B : evidence levels IIa, IIb, III C
A : evidence levels Ia & Ib
B : evidence levels IIa, IIb, III
C : evidence levels IV
GPP: Good Practice Points
(recommended best practice based on the
clinical experience of the guideline
development group
20
Keterampilan yang diperlukan agar dapat mengambil keputusan berdasar evidens Kemampuan untuk menetapkan kriteria,
Keterampilan yang diperlukan agar dapat mengambil keputusan berdasar evidens Kemampuan untuk menetapkan kriteria,
Keterampilan yang diperlukan agar dapat mengambil keputusan berdasar evidens
Keterampilan yang diperlukan agar
dapat mengambil keputusan berdasar
evidens
Kemampuan untuk menetapkan kriteria, misalnya: effectiveness, safety, acceptability Kemampuan untuk mendapatkan artikel
Kemampuan untuk menetapkan kriteria,
misalnya: effectiveness, safety, acceptability
Kemampuan untuk mendapatkan artikel tentang
(effectiveness, safety, acceptability) dari tes,
diagnosis, atau perlakukan/treatment.
Kemampuan untuk menguji kualitas evidens
Kemampuan untuk menguji apakan hasil suatu
penelitian berlaku umum (generaliable)
Kemampuan untuk menguji apakah hasil
penelitian dapat diterapkan pada “local
population”
21
Ability to Data bases Access databases New form of organization for public health
Ability to
Data bases
Access
databases
New form
of organization
for public
health
databases New form of organization for public health SAS skills Searching Appraisal Storing & Retrieving 22
databases New form of organization for public health SAS skills Searching Appraisal Storing & Retrieving 22
databases New form of organization for public health SAS skills Searching Appraisal Storing & Retrieving 22
databases New form of organization for public health SAS skills Searching Appraisal Storing & Retrieving 22
databases New form of organization for public health SAS skills Searching Appraisal Storing & Retrieving 22
SAS skills
SAS
skills

Searching Appraisal Storing & Retrieving

databases New form of organization for public health SAS skills Searching Appraisal Storing & Retrieving 22
databases New form of organization for public health SAS skills Searching Appraisal Storing & Retrieving 22
databases New form of organization for public health SAS skills Searching Appraisal Storing & Retrieving 22
databases New form of organization for public health SAS skills Searching Appraisal Storing & Retrieving 22
databases New form of organization for public health SAS skills Searching Appraisal Storing & Retrieving 22
22
22
Quality improvement is the science of process management
Quality improvement
is the
science of process management
Quality improvement is the science of process management Its purpose is "close the gap" between practice
Quality improvement is the science of process management Its purpose is "close the gap" between practice
Quality improvement is the science of process management Its purpose is "close the gap" between practice
Quality improvement is the science of process management Its purpose is "close the gap" between practice

Its purpose is "close the gap" between practice and the best available evidence

science of process management Its purpose is "close the gap" between practice and the best available
science of process management Its purpose is "close the gap" between practice and the best available
science of process management Its purpose is "close the gap" between practice and the best available
science of process management Its purpose is "close the gap" between practice and the best available
science of process management Its purpose is "close the gap" between practice and the best available
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Research versus improvement
Research versus improvement
Research versus improvement synergy Publishing research Performance/execution Aim: new knowledge Aim: better practice

synergy

Research versus improvement synergy Publishing research Performance/execution Aim: new knowledge Aim: better practice
Research versus improvement synergy Publishing research Performance/execution Aim: new knowledge Aim: better practice
Research versus improvement synergy Publishing research Performance/execution Aim: new knowledge Aim: better practice
Research versus improvement synergy Publishing research Performance/execution Aim: new knowledge Aim: better practice

Publishing research

Performance/execution

Aim: new knowledge

Aim: better practice

Methods:

Methods:

tests blinded no bias all possible data, just in case fixed hypotheses -- one large test

tests observable (helps spread) stable bias just enough data changing hypotheses -- sequential tests

Emphasizes internal validity

Emphasizes external validity

tests Emphasizes internal validity Emphasizes external validity Plan-Do-Study- Publish vs. 24 Plan-Do-Study- Act

Plan-Do-Study- Publish vs.

tests Emphasizes internal validity Emphasizes external validity Plan-Do-Study- Publish vs. 24 Plan-Do-Study- Act
tests Emphasizes internal validity Emphasizes external validity Plan-Do-Study- Publish vs. 24 Plan-Do-Study- Act
24
24

Plan-Do-Study- Act

Achieving interpretable comparisons
Achieving interpretable comparisons
Achieving interpretable comparisons Internal validity: If measured outcomes changed, can that change be causally
Achieving interpretable comparisons Internal validity: If measured outcomes changed, can that change be causally
Achieving interpretable comparisons Internal validity: If measured outcomes changed, can that change be causally
Achieving interpretable comparisons Internal validity: If measured outcomes changed, can that change be causally

Internal validity: If measured outcomes changed, can that change be causally attributed to the intervention being tested?

External validity: Within which external populations and settings do the measured results apply?

being tested? External validity: Within which external populations and settings do the measured results apply? 25
being tested? External validity: Within which external populations and settings do the measured results apply? 25
being tested? External validity: Within which external populations and settings do the measured results apply? 25
being tested? External validity: Within which external populations and settings do the measured results apply? 25
being tested? External validity: Within which external populations and settings do the measured results apply? 25
being tested? External validity: Within which external populations and settings do the measured results apply? 25
being tested? External validity: Within which external populations and settings do the measured results apply? 25
being tested? External validity: Within which external populations and settings do the measured results apply? 25
being tested? External validity: Within which external populations and settings do the measured results apply? 25
25
25
Fundamental improvement questions
Fundamental improvement questions

What are we trying to accomplish?

A clear outcome target is essential to assign resources, garner collaboration, etc.

essential to assign resources, garner collaboration, etc. How will we know that a change is an
essential to assign resources, garner collaboration, etc. How will we know that a change is an
essential to assign resources, garner collaboration, etc. How will we know that a change is an
essential to assign resources, garner collaboration, etc. How will we know that a change is an

How will we know that a change is an improvement?

Without this step, innovation is impossible

"Truth is found more often

from mistakes than from confusion" -- Francis Bacon, 1561-1626

What

changes

can

improvement?

we

make

A hypothesis generation step

that

will

result

in

we make A hypothesis generation step that will result in modified from: The Foundation of Improvement
we make A hypothesis generation step that will result in modified from: The Foundation of Improvement
we make A hypothesis generation step that will result in modified from: The Foundation of Improvement
we make A hypothesis generation step that will result in modified from: The Foundation of Improvement
we make A hypothesis generation step that will result in modified from: The Foundation of Improvement

modified from: The Foundation of Improvement by Thomas W. Nolan et. al

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26
Using data to improve The minimum standard: an annotated time series 1. Start with a
Using data to improve The minimum standard: an annotated time series 1. Start with a
Using data to improve The minimum standard: an annotated time series 1. Start with a
Using data to improve
Using data to improve

The minimum standard: an annotated time series

1. Start with a run chart (80% of total value)

Run chart: a graph that tracks sequential instances of some measure

2. Add center and goal lines (anchors the eye - now 95% of total value)

3. Add control limits (in appropriate zones)

Add center and goal lines (anchors the eye - now 95% of total value) 3. Add
Add center and goal lines (anchors the eye - now 95% of total value) 3. Add
Add center and goal lines (anchors the eye - now 95% of total value) 3. Add
Add center and goal lines (anchors the eye - now 95% of total value) 3. Add
Add center and goal lines (anchors the eye - now 95% of total value) 3. Add
Add center and goal lines (anchors the eye - now 95% of total value) 3. Add
Add center and goal lines (anchors the eye - now 95% of total value) 3. Add
Add center and goal lines (anchors the eye - now 95% of total value) 3. Add
Add center and goal lines (anchors the eye - now 95% of total value) 3. Add
Add center and goal lines (anchors the eye - now 95% of total value) 3. Add
27
27
Why use level II-3 evidence? In many circumstances, level II-3 evidence is better than current
Why use level II-3 evidence? In many circumstances, level II-3 evidence is better than current
Why use level II-3 evidence? In many circumstances, level II-3 evidence is better than current
Why use level II-3 evidence?
Why use level II-3 evidence?

In many circumstances, level II-3 evidence is better than current practice

Level II-3 evidence can easily imbed in daily work

efficient data collection and analysis, without massive overhead contributes to holding the gains

efficient data collection and an alysis, without massive overhead contributes to holding the gains

Change is a temporal phenomenon

With some additional effort, can upgrade to level II-2 or level II-1 evidence

gains Change is a temporal phenomenon With some additional effort, can upgrade to level II-2 or
gains Change is a temporal phenomenon With some additional effort, can upgrade to level II-2 or
gains Change is a temporal phenomenon With some additional effort, can upgrade to level II-2 or
gains Change is a temporal phenomenon With some additional effort, can upgrade to level II-2 or
gains Change is a temporal phenomenon With some additional effort, can upgrade to level II-2 or
28
28
Use evidence higher than II-3 when:
Use evidence higher than II-3 when:
Use evidence higher than II-3 when: Scant evidence supporting the change exists, and failure carries significant
Use evidence higher than II-3 when: Scant evidence supporting the change exists, and failure carries significant
Use evidence higher than II-3 when: Scant evidence supporting the change exists, and failure carries significant

Scant evidence supporting the change exists, and failure carries significant potential risk for patients

No theory supports the change

The aim is to find causes of rare but important events

Outcomes are separated by a substantial amount of time from the changes under study (high potential that

extraneous, unrecognized causes will intrude)

The change proposes enforced standardization, with widespread, compulsory compliance

The change will result in significant cost increases

The change will result in significant cost increases It is easy to generate better evidence (existing

It is easy to generate better evidence (existing research

infrastructure; natural experiments)

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29
Model for improvement
Model for improvement
What are we trying to accomplish? How will we know that the change is an
What are we trying to accomplish?
How will we know that the change
is an improvement?
What changes can we make that
will result in improvement?
Act
Plan
a change
Study
Do
its effects
it in a
small test
Plan a change Study Do its effects it in a small test guidelines may contain too
Plan a change Study Do its effects it in a small test guidelines may contain too
Plan a change Study Do its effects it in a small test guidelines may contain too
Plan a change Study Do its effects it in a small test guidelines may contain too
Plan a change Study Do its effects it in a small test guidelines may contain too
Plan a change Study Do its effects it in a small test guidelines may contain too
Plan a change Study Do its effects it in a small test guidelines may contain too

guidelines may contain too many changes; therefore, select one or two to focus on at a time

30
30
Repeated use of the cycle A P S D A P S D Changes that
Repeated use of the cycle A P S D A P S D Changes that
Repeated use of the cycle A P S D A P S D Changes that
Repeated use of the cycle A P S D A P S D Changes that
Repeated use of the cycle A P S D A P S D Changes that
Repeated use of the cycle A P S D A P S D Changes that
Repeated use of the cycle
Repeated use of the cycle
Repeated use of the cycle A P S D A P S D Changes that result
A P S D A P S D
A
P
S
D
A
P
S
D

Changes that result in improvement

A P S D A P S D Changes that result in improvement Hunches Theories Ideas
A P S D A P S D Changes that result in improvement Hunches Theories Ideas

Hunches

Theories

Ideas

Changes that result in improvement Hunches Theories Ideas learn as you go small tests, not (necessarily)

learn as you go small tests, not (necessarily) small changes

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Seorang ibu akan disuntik oleh dokter, sebelum disuntik dokter mengoleskan alkohol pada pantat pasien Ibu
Seorang ibu akan disuntik oleh dokter, sebelum disuntik dokter mengoleskan alkohol pada pantat pasien Ibu
Seorang ibu akan disuntik oleh dokter, sebelum disuntik dokter mengoleskan alkohol pada pantat pasien Ibu
Seorang ibu akan disuntik oleh dokter, sebelum disuntik dokter mengoleskan alkohol pada pantat pasien Ibu
Seorang ibu akan disuntik oleh dokter, sebelum
disuntik dokter mengoleskan alkohol pada
pantat pasien
Ibu tersebut menanyakan: “Dok mengapa pantat
saya dioles alkohol”
Diskusikan:
– 1. apa sebenarnya yang ditanyakan oleh pasien
tersebut ?
– 2. apa jawaban saudara terhadap pertanyaan pasien
tersebut ?
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Apa sebenarnya yang ditanyakan oleh ibu tsb: – Manfaat alkohol – Apakah perlu dioles alkohol
Apa sebenarnya yang ditanyakan oleh ibu tsb: – Manfaat alkohol – Apakah perlu dioles alkohol
Apa sebenarnya yang ditanyakan oleh ibu tsb: – Manfaat alkohol – Apakah perlu dioles alkohol
Apa sebenarnya yang ditanyakan oleh ibu tsb: – Manfaat alkohol – Apakah perlu dioles alkohol
Apa sebenarnya yang ditanyakan oleh ibu tsb:
– Manfaat alkohol
– Apakah perlu dioles alkohol
– Kalau tidak dioles akibatnya apa
– Mengapa harus dipantat
– Mengapa harus alkohol
Jawaban bapak/ibu:
– Untuk membersihkan daerah yang akan disuntik
supaya tidak terjadi infeksi
– Untuk sedikit mengurangi rasa sakit
– Mencegah infeksi masuknya kuman ke dalam tempat
suntikan
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3. Apa dasarnya Saudara memberikan jawaban tersebut ?: – Teori yang saya pelajari pada waktu
3. Apa dasarnya Saudara memberikan jawaban tersebut ?: – Teori yang saya pelajari pada waktu
3. Apa dasarnya Saudara memberikan jawaban tersebut ?: – Teori yang saya pelajari pada waktu
3. Apa dasarnya Saudara memberikan jawaban tersebut ?: – Teori yang saya pelajari pada waktu
3. Apa dasarnya Saudara memberikan
jawaban tersebut ?:
– Teori yang saya pelajari pada waktu sekolah
– Kebiasaan kami melakukan hal tersebut
– Protap mengharuskan kami untuk melakukan
4. Baca artikel yang sudah dibagikan
5. Diskusikan apa kesimpulan dari artikel
tersebut.
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Kesimpulan dari artikel: – Alkohol tidak menunjukkan bukti yang signifikan untuk mengurangi terjadinya infeksi pada
Kesimpulan dari artikel: – Alkohol tidak menunjukkan bukti yang signifikan untuk mengurangi terjadinya infeksi pada
Kesimpulan dari artikel: – Alkohol tidak menunjukkan bukti yang signifikan untuk mengurangi terjadinya infeksi pada
Kesimpulan dari artikel: – Alkohol tidak menunjukkan bukti yang signifikan untuk mengurangi terjadinya infeksi pada
Kesimpulan dari artikel:
– Alkohol tidak menunjukkan bukti yang
signifikan untuk mengurangi terjadinya infeksi
pada luka suntikan
6. Apakah saudara sebagai dokter akan
mengubah cara praktik saudara pada
waktu memberikan suntikan pada pasien ?
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Kasus Saudara sebagai seorang kepala Dinas Kesehatan Kabupaten Karena di Kabupaten Saudara terdiri dari wilayah
Kasus Saudara sebagai seorang kepala Dinas Kesehatan Kabupaten Karena di Kabupaten Saudara terdiri dari wilayah
Kasus Saudara sebagai seorang kepala Dinas Kesehatan Kabupaten Karena di Kabupaten Saudara terdiri dari wilayah
Kasus
Kasus
Saudara sebagai seorang kepala Dinas Kesehatan Kabupaten Karena di Kabupaten Saudara terdiri dari wilayah pulau
Saudara sebagai seorang kepala Dinas Kesehatan Kabupaten
Karena di Kabupaten Saudara terdiri dari wilayah pulau dan transportasi
sulit, maka oleh Bupati disarankan agar memberdayakan perawat dan
bidan yang ada untuk dapat memberikan pelayanan medis dan gawat
darurat dan harus berkualitas. Saudara diminta untuk mempertimbangkan
usulan tersebut.
Saudara baru saja mempelajari tentang evidence based public health, dan
Saudara ingin mempraktikkan evidence based dalam setiap pengambilan
keputusan
Apa yang akan saudara lakukan ?
– A. pertanyaan apa yang harus saudara jawab agar dapat mengambil keputusan
yang tepat ?
– B. bagaimana saudara dapat memperoleh jawaban tersebut ? Apa yang akan
Saudara lakukan ?
– C. Evidens level yang mana yang akan saudara cari untuk dapat mengambil
keputusan tsb ? Dan bagaimana saudara dapat memperoleh evidens tsb ?
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Pertanyaan yang harus dijawab: – Jumlah perawat dan bidan yang ada – Kualitas bidan dan
Pertanyaan yang harus dijawab: – Jumlah perawat dan bidan yang ada – Kualitas bidan dan
Pertanyaan yang harus dijawab: – Jumlah perawat dan bidan yang ada – Kualitas bidan dan
Pertanyaan yang harus dijawab: – Jumlah perawat dan bidan yang ada – Kualitas bidan dan
Pertanyaan yang harus dijawab:
– Jumlah perawat dan bidan yang ada
– Kualitas bidan dan perawat yang ada
– Kajian terhadap saran bupati
– Seberapa sulit transportasi
– Kondisi kesehatan masyarakat dan pola penyakit
– Legalitas perawat dan bidan (expert opinion)
– Ketersediaan sarana kesehatan di tempat tsb
– Seberapa jauh dokter dapat menjangkau daerah tsb
– Demografi dan kebiasaan masyarakat
– Tingkat kepercayaan masyarakat thd bidan dan perawat
– Apakah penambahan kewenangan bidan dan perawat untuk
memberikan pelayanan medis dan gawat darurat efektif, efisiesn
dan berkualitas ? – dalam negeri, luar negeri ??
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Kasus Delapan puskesmas di kabupaten tetangga sudah memperoleh sertifikasi ISO 9001:2000. Bupati menghendaki Saudara
Kasus Delapan puskesmas di kabupaten tetangga sudah memperoleh sertifikasi ISO 9001:2000. Bupati menghendaki Saudara
Kasus Delapan puskesmas di kabupaten tetangga sudah memperoleh sertifikasi ISO 9001:2000. Bupati menghendaki Saudara
Kasus
Kasus
Delapan puskesmas di kabupaten tetangga sudah memperoleh sertifikasi ISO 9001:2000. Bupati menghendaki Saudara sebagai
Delapan puskesmas di kabupaten tetangga sudah memperoleh sertifikasi
ISO 9001:2000.
Bupati menghendaki Saudara sebagai kepala dinas untuk mengikuti
kabupaten tetanggan untuk membuat kebijakan agar semua puskesmas di
kabupaten saudara juga mendapatkan sertifikasi iso
Saudara merasa ragu-ragu untuk membuat keputusan apakah mengikuti
kata bupati atau tidak
Saudara baru saja mempelajari tentang evidence based public health, dan
Saudara ingin mempraktikkan evidence based dalam setiap pengambilan
keputusan
Apa yang akan saudara lakukan ?
– A. pertanyaan apa yang harus saudara jawab agar dapat mengambil keputusan
yang tepat ?
– B. bagaimana saudara dapat memperoleh jawaban tersebut ? Apa yang akan
Saudara lakukan ?
– C. Evidens level yang mana yang akan saudara cari untuk dapat mengambil
keputusan tsb ? Dan bagaimana saudara dapat memperoleh evidens tsb ?
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