PRAKTEK BERMUTU

DAN MANAJEMEN
RISIKO
 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 nafas
● Meninggal 2 jam kemudian
● Pasien tak puas
 KREDENSIAL

AD/
STATUTA RS SIKAP

KOMITE
MEDIK AKREDITASI

STANDAR
IJIN PRAKTEK
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 SC

● Peran : bidan, perawat, dr. Anak, Anestesi
 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 per-telepon
 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 – terhadap 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 Departemen Kesehatan
 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, penghisap,

oksimeter, tensi, alat resusitasi
● 1 Km Operasi – 3000 partus
● Monitor CTG, AGD, Mikroskop +LAB, Transfusi
 MANAJEMEN RISIKO
● Prinsip : mengurangi resiko
● Manajer (Direktur RS  Administratif &
Manajemen Badan Hukum)
● Petugas pelaksana  Teknis medis &
Medikolegal
● STANDAR dan Akreditasi
● SIKAP – profesional
● Persyaratan : Ijin praktek
● Kompetensi: pelatihan
● Audit Klinik & Confidential Enquiry
 MANAJEMEN RISIKO
KLINIK
● Struktur : dokter, bidan, perawat dll.
● Tujuan : memperbaiki mutu, menghindari
kecelakaan
● Langkah :
• Identifikasi masalah
• Analisa masalah
• Lokalisasi masalah  perbaiki
• 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
Fetal/neonatal incident Organisational incident
incident
• Blood loss >1500 • APGAR < 7 at 5 minutes • Blood-Anaesthetic complications
ml • Birth trauma • ITU admission
• Cord accident • Cord pH < 7.2 • Maternal death
• Deep venous • Pulmonary embolism
• Neonatal death • Third degree tear
thrombosis • Neonatal seizures • Unsuccessful forceps/ventouse
• Duration 2nd stage • Stillbirth > 500g • Uterine rupture
> 3 hrs (prim)
• Shoulder dystocia • Delay > 30mins for emergency CS
• Duration 2nd stage
> 1 hr (parous) • Small for gestational age • Delay following call for assistance
• Duration • Term baby admitted to • Delivery outwith labour suite
established labour paediatric unit • Faulty equipment
> 18 hrs • Unsuspected fetal anomaly • Interpersonal conflict over case
• Eclampsia management
• Hb < 8g/dl • Potential service user complaint
postpartum • Prescribing/administration error
• Hysterectomy / • Retained swab/instrument
laparotomy • Violation of local protocol / guideline
 KOMPETENSI
● Analisa, contoh : Memakai Partogram
● Pengawasan janin – Electronic Fetal
Monitoring- 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 – prosedur tetap (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 dalam bidang Obstetri
● 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
Komite -ALARM
Medik -Pelatihan

Standar
Ijin Praktek Profesi POGI

Panduan Etik
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 by continuing professional
development
 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 (i.e., 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
i.e., 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
 6. Gynaecology clinical
incident report
Clinical incidents
● 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 POGI JAYA Ko-POGI

AD
Audit M - P Dewan Pertimbangan Cabang

Tim Manajemen Risiko

-Dokter
-Bidan/Paramedik

• Sikap dan kinerja

• Buku LOG
• Rekam Medik