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Clinical

Pathway
dr. Merita Arini, MMR

Learning Objectives

Topik

Clinical Pathway in Hospital


Ronie Rivany

UU 40/2004 tentang SJSN


Bab 24 ayat 3 menetapkan bahwa
BPJS harus mengembangkan:

PPres 12/ 2013 tentang


Jaminan Kesehatan
Pasal 20 ayat 1 menetapkan produk:
pelayanan kesehatan perorangan (promotif,
preventif, kuratif, dan rehabilitatif), obat dan
bahan medis habis pakai

Pasal 39 mengatur Sistem pembayaran:


Kapitasi untuk tingkat pertama, INA-CBGs
untuk tingkat lanjutan

Cont
Pasal 42 mengatur Sistem Kendali
Mutu:
Memenuhi standar mutu fasilitas kesehatan
(input);
Memastikan proses pelayanan sesuai standar
(proses),
Memantau luaran kesehatan peserta (output)

Input - Proses - Output


Standar input:
Perijinan fasilitas kesehatan (standar
bangunan, SDM, peralatan, SDM, dsb).
Standar proses:
Manajemen:
Standar akreditasi (RS, Lab.), standar
pelayanan prima, dsb
Pelayanan klinik (clinial care):
PPK/clinical guidelines oleh organisasi
profesi.
Standar
output:

Kinerja di level pasien dan di level sarana


yankes: SPM RS*

Djoto Atmodjo, KARS

Input

Kebijakan
pelayanan

Output/
Outcome

Proses

Tatalaksana

Pedoman
Pedoman
Pengorganisasia Pelayanan
n
Standar
SDM
Standar
Fasilitas

SPO

Peraturan dan perundangan


Pedoman

Survei kepuasan
Indikator Mutu :
Indikator Klinik
Indikator Mutu Yan
IKP:
K T D : Sentinel
Event

CP vs CG
Clinical Pathway

Clinical Guideline

Lebih customize & user Bentuk sangat bervariasi


Disusun melalui proses
friendly:
rumit & butuh sumber
Template seragam RS
daya & waktu >>.
(locally agreed)
Disusun berdasarkan best Sering << efektif karena
<<nya perhatian &
practice (available) &
support
kondisi RS
ownership lebih tinggi:
multidisipliner

Mengapa perlu menyusun CP?


Tarif INA CBGs
Dianggap kecil, RS
merasa rugi:
o Berdasarkan
perbandingan dg tarif
RS
o Berdasarkan
perbandingan dg cost
RS
o Berdasarkan kasus per
kasus
Efisiensi vs Fraud

Mutu Pelayanan
Pedoman Nasional
Praktek Kedokteran
(PNPK), Pedoman
Praktek Klinis (PPK), CP
o Bisa dihitung cost of
care
o Bisa dibandingkan dg
tarif INA-CBGs
o Bisa menjadi dasar u/
pengambilan
keputusan
o Bisa sebagai alat
kendali mutu (audit
medis, surveilans
HAIs,
(Djasri, 2014)
penggunaan fornas,

HOSPITAL GOVERNANCE
VISION
HOSP LEADERS
H
O
S
P
I
T
A
L
B
Y
L
A
W
S

POLICY
RESOURCES: 5 M
(2 M)

PROSES REALISASI

HOSPITAL
PERFORMANCE ?
SPM
CONSUMER VALUES

GROWTH

INSTITUTIONAL (HOSPITAL) GOVERNANCE


STRUCTURE

PROCESS

OUTPUT

OUTCOME

CLINICAL GOVERNANCE
PROFESSIONAL
COMPT & CPD

CLINICAL PERFORMANCE
& EVALUATION

CLINICAL
RISK
MANAGEMENT

Patient
safety
CLINICAL

LEADERS

INTEGRATED
CLINICAL
PATHWAY & GUIDELINE

BEST PRACTISE
BASIC : VBM
TOOLS : EBM

CONSUMER
VALUE
PATIENT
SAFETY, EQUITY, QUALITY
ICD 10
ICD 9 CM

CASEMIX

Clinical
Pathway

Alternative Names
Clinical Pathway
Critical care pathway,
Integrated care pathway,
Coordinated care pathway,
Caremaps, atau
Anticipated recovery pathway
(Djasri, 2014)

DEFINISI
ICP is a matrix which places
interventions (tasks) on one axis & time
(hours, days, weeks) & milestones
(specific stages of recovery).
(Midleton & Roberts, 2000)

CP serve as collaborative plans of


patients care requiring cooperation from
physician, nurses, clinical staff, & support
staf .
(Guinane, 1997)

Form Generik Clinical


Pathway
Identitas Pasien
Hari I
Assessment
Intervensi/
pelayanan

Hari II

Hari III

Outcome
Variasi
(Midleton & Roberts, 2000; Djasri, 2014)

Karakteristik CP
Menggabungkan:

Current evidence based


Mendokumentasi
Budaya - Tradisi
-kan clinical
practice terbaik
Etika
bukan hanya
Resources yg tersedia
clinical practice
Preferensi
sekarang
Kebutuhan & keinginan konsumen
Sistem pengukuran melekat

Easily audited
Transferable kepada area klinis lain dlm
RS sama
(Rahma, Djasri, 2014)
(Midleton & Roberts, 2000)

Elemen CP
Patients group
Scope
Multidisciplinary collaboration
Sequential & appropriate care/
intervention
Patient-focused care
Single record of care
Analysis of variations
(Middleton & Roberts, 2000)

Struktur CP

SPO

Langkah Penyusunan
CP

(Rahma & Djasri, 2014)

Cont

Teknis Pembuatan CP
1. Profesi Medis

Mempersiapkan SPM/ SPO


bila belum ada dapat menyusun dulu SPM/ SPOnya
sesuai kesepakatan.

2. Profesi Perawat

mempersiapkan SPO/ SAK

3. Profesi Rekam Medis/ Koder

mempersiapkan buku ICD 10 dan ICD 9CM,


Laporan RL1 sampai dengan 6 (terutama RL2).
Menyajikan daftar 5 - 10 penyakit utama & tersering
dari setiap divisi SMF/Instalasi dg kode ICD 10 &
mean LoS berdasarkan data laporan morbiditas RL2.
Djoti Atmodjo, KARS

Cont
4. Profesi Gizi

menyiapkan assesment nutrisi, asuhan


gizi

5. Profesi Farmasi
mempersiapkan Daftar Formularium, sistem
unit dose dan stop ordering

6. Profesi Akuntasi/ Keuangan


mempersiapkan Daftar Tarif rumah sakit

Contoh Form CP

Efektivitas/ Manfaat CP
Efektivitas CP debatable
Pada umumnya di RS hanya 30%
pasien yg dirawat dg CP. Selebihnya
pasien dirawat dg prosedur biasa
(usual care).
80% RS USA menggunakan CP u/
beberapa indikator
Standar Akreditasi KARS 2012
5 CP/ RS/ tahun
(Benny, 2014)
(Djasri, 2014)

Implemented for over 20 years and well


established in hospitals - 80% of hospitals
in USA (Saint 2003)

VFM Unit (NHS Wales)


Project
Clinical Resource Utilitation
Group

Sept 1995 - March 1997, UK


700 clinical, managerial, operational staf
Aimed to:
Identify the critical succes factors &
potential bariers to adoption of ICPs
Developt framework/ structured approach
to support succesful implementation
(Midleton & Roberts, 2000)

Cont
Key result 5 distinct & sequential stages used
by organizations with evidence of succesful
programmes of ICP activity:

1.

Awarenes Raising &


Gaining Commitment

A strategic approach: a vision of


future
Shared vision
ICP

HI
S
R
DE
A
E
L
P

change management tool


integral component of bussiness & quality
clinical governance

Goverment papers & other related


documents outline strategy for a
defined period of time

1.

Awarenes Raising &


Gaining Commitment

Reasons for developing ICPs


Reinforce aims of ICP ~ organizational
objectives
Improve quality of care trough consistent
management
Encourage patient involvement
Identify & measure outcomes of patient care
Promote efficient without compromising quality
Reduce unnecessary documentation
Documenting variations from the predicted plan
Facilitate a plan of care & improve links & between
community services

Cont
Increase collaboration of
multidisciplinary team
Reduce unnecessary variations
Ensure that no critical aspects of care are
forgotten & that all intervention are planned
appropiately & performed on time
Providing a framework for effective clinical
audit
Educational/ training tool esp. New staff/
short rotation

1.

Awarenes Raising &


Gaining Commitment

ICP facilitator (Stephens, 1997)


Solve problems of limited resources/
high workload

y
e
K or
t
c
fa

Facilitators role:

awareness
Provide initial training, ongoing education, & support
Act as a link between all professional goups involved
Set up & manage individual ICP projects
Attend & facilitate ICP development & meetings
Prepare ICP documentation
Provide ongoing evaluation, feedback, & review

ICP facilitator: Skills Checklist


(Stephens,
1997)
Presentation
& training
communication & negotiation

project
management/
change
management
Team building & group facilitation
computer literate/ IT Skills
ability to motivate/ lead
ability to work to tight deadlines under
pressure
Sound knowledge of ICPs & related
initiatives
Confidence, credibility, & self motivation
Key task awareness session :
encouraging staff involvement

2.

Putting System into Place

Selecting patient groups


Common condition ( high % of patients)
biggest impact on our organization

High volume
High cost
High risk
Problem prone
Memiliki gap besar dg tarif INA CBGs

Simple condition (not multi-pathology)


quick wins/ motivator !!!

Specific problem areas

Cont
Staff expressed preferences Ensure
staff commitment

Monitoring & comparing clinical outcome


Meeting health gain targets (national/
international)
Availability of evidence/ guidelines
Managing clinical risk

2.

Putting System into Place

Agreeing the scope of ICP

Boundary

The development team

2.

Putting System into Place

Defining the desired objectives of care


Patient outcome - Patient satisfaction
Service quality - Cost effetiveness & efficiency

Cont
Defining the desired objectives of care
Gained from:
Available evidence
Clinical audit
Benchmarking data
Accreditation standards
Health gain targets
National service framework, etc

2.

Putting System into Place

Mapping the current process of care

Moving from the process map to the


ICP document

3.

Documentation

Lay-out Design
Process based or outcome?
Depends on the skills of user
Check wound

vs

Wound dry

ICP as the legal record of care


as a single record of care debatable
Flexibility review

3.

Documentation

Variation analysis
Essential succes factor of ICP
implementation
expected variations as professional
judgement for patient focused of care
Code:
By clinicians/ nurse manager/ clinical nurse
specialist/ audit staff
Explain in CP guidance asignment

Patient Pathway

Patient Pathway (PP)


Should include:

An introduction to PP
Guidance for using PP
Description of the natur of CPs & their use
Information on patients condition & their
threatment
Information to describe variations from the
expected & how care is individualized to suit
patient needs

4.

Implementation

Requires careful planning & Effective


project management
Preparing the main players
Facilitator
Clinical staff
Managerial staff

I
H
S
R
E
D
LE A P

Learning from failure & communicating


success throughout the organization

Critical Success Factors


top-down support of senior
management tangible commitment
CP is a leader driven process
At the very least need:
A full-time or designated facilitator
Office space
IT & reproduction facilities
Time for clinical staff to participate in
designing & reviewing CP

The Full Time Job

Base-lines audit of documentation of practices


Discussions with all key staff
Education session
Production & continuing refinement of the
documentation

Barriers to success

Professional cultures
Lack of organisational support
Care Pathway design
Inadequate time & resources
Ad-hoc approach

Mengapa CP gagal?
Ownership rendah akibat keterlibatan/
dukungan staf yg disproporsional
CP universal panacea:
perjalanan alami penyakit
Intoleransi obat
Resistensi antibiotik,
Penatalaksanaan tdk sesuai ketentuan, etc
CP seringkali lebih mudah digunakan pada:
pasien bedah
Pasien dg single pathology (non-complicated, nocomorbidities)

5. Evaluasi CP
If you can measure, you can
manage it
purpose of evaluation
personal judgement
full research project

Objects of evaluation
development process

single pathway

operational aspects

multiple pathways

Operational Aspects
Apakah CP sukses
diimplementasikan di semua area?
Contoh kriteria evaluasi:
Persetujuan staf klinis multidisiplin
menerapkan CP
Kelengkapan dokumentasi
Pendataan varians

cont
outcome yang akan diukur
patient centered
(individual) clinical staff
clinical team
organizational
other

Patient Centered
shortening time delay in process
clinical outcomes
LoS
QoL
complication/ adverse events

cost of care
satisfaction levels
patient education/ knowledge about the
condition & self management

Individual Clinical Staff

job satisfaction
staff turn-over
morale & stress levels
error in delivery of care

Clinical Team

multidisciplinary working
building teamwork
communication improvements
risk managemet
development of local guideline &
protocols

Others
documentation of delivery of care
effect of computerization of
pathways
effect of variance reporting

Djasri, 2010

Djasri, 2010

Djasri, 2010

Leadership for clinical


system
Quality is never an accident ; its
always the result of:
high intention ;
sincere effort ;
intelligent direction
skillful executions ;
it represent the wise choice of many
alternatives

Lampiran

dr. Djoti Atmodjo, Sp.B.


Dr. drg. Ronie Rivany, MARS

BENTUK SPO
Panduan praktik klinis
(Clinical Practice
Guideline)
Alur klinis
(Clinical Pathways)
Algoritme
Prosedur
Protokol
Standing Orders

PENDEKATAN PENGELOLAAN PASIEN


Diagnosis kerja
Gejala

Standar pelayanan :
Panduan Praktik Klinis
Definisi
Anamnesis
Pemeriksaan fisis
Kriteria diagnosis
Diagnosis banding
Pemeriksaan penunjang
Terapi
Edukasi
Prognosis
Kepustakaan

Djoti - Atmodjo

O
P
S

dapat dilengkapi
dengan

Alur klinis
Algoritme
Protokol
Prosedur
Standing order

RS wajib memp.CP, Diagnosis


mengacu pada ICD-10,Prosedur
mengacu pd
ICD-9CM
Flowchart
penyusunan CP
ICD
SPM Profesi

Model Dummy
Surgical

SPM RS

SOP Aktivitas

Clinical Pathway
Terukur(admissi
on to discharge)
contoh :
-Diare anak
-Sectio Caesaria

Medical

DRG

Case Mix

CLINICAL PATHWAY
& Cost of Care
SYMPTOM

1
Admission

Activities

ABC

DIAGNOSIS

THERAPY

Diagnosis

Activities
ABC

4
Pre Therapy

Activities
ABC

FOLLOW UP

5
Therapy

Activities
ABC

Follow up

Activities
ABC

INDONESIAN DRGs

Pengembangan Konsep
Clinical Pathway
International Classification of Disease (ICD)
Major Diagnostic Categories (MDC)
Clinical
Pathway

Surgical / Other / Medical


Diagnosis Related Groups (DRGs)
Casemix

INDONESIAN DRGs
Pola pikir
ICD tetap
MDC untuk sementara tetap
Clinical Pathway bisa dibuat
DRG di konfirmasi + bisa dibuat
Casemix di konfirmasi + bisa dibuat
Costing dilakukan dengan
pendekatan Activity Based Costing +
Simple Distribution

POLA PIKIR INDONESIAN DRGs (1)

INA - DRG
1.Konfirmasi DRG

2.Hitung Cost/DRG

Clinical Pathway & Casemix

Activity Based Costing

POLA PIKIR INDONESIAN DRGs (2)


ICD
MDC

1
DRG

DRG
COST

DRG
CASEMIX

TARIF

COST
TARIF

Sistem Casemix
Sistem Casemix adalah suatu cara mengelola
sumber daya rumah sakit seefektif mungkin dalam
memberikan layanan kesehatan yang terjangkau
kepada masyarakat berdasarkan pengelompokkan
spektrum diagnosis penyakit yang homogen dan
prosedur tindakan yang diberikan
Secara ringkasnya sistem casemix terdiri dari 3
komponen utama yakni kodefikasi diagnosis(ICD
10) dan prosedur tindakan (ICD 9 CM), pembiayaan
(costing ) yang dapat berupa top-down approach,
activity based costing dan atau kombinasi
keduanya, dan clinical pathways

INA DRG
INA DRG adalah variasi sistem casemix untuk
Indonesia yang disusun berdasarkan data dari15
rumah sakit vertikal, mempergunakan ICD 10 untuk
diagnosis dan ICD 9CM untuk prosedur tindakan
serta biaya berdasarkan tarif yang berlaku
padawaktu tersebut. Dengan berakhirnya lisensi
grouper INA-DRG terhitungtanggal 30 September
2010, maka nama sitem Casemix INA-DRG
berubahmenjadi INA-CBG
Untuk saat ini INA-DRG yang disusun berdasarkan
data dari 15 rumah sakit vertikal Depkes RI (tipe A, B
danrumah sakit khusus) telah berhasil membuat 23
MDC (Major Diagnostic Criteria

Manfaat CP
Sebagai instrumen pelayanan berfokus kepada pasien
(patient-focused care) terintegrasi, berkesinambungan dari
pasien masuk dirawat sampai pulangsembuh (continuous
care), jelas akan dokter/perawat penanggung jawab pasien
(duty of care)
Utilitas pemeriksaan penunjang, penggunaan obat obatan
termasuk antibiotika, prosedur tindakan operasi,
Antisipasi kemungkinan terjadinya medical errors (laten
dan aktif, nyaris terjadi maupun kejadian tidak
diharapkan/KTD) dan pencegahan kemungkinan cedera
(harms) serta infeksi nosokomial dalam rangka
keselamatan pasien(patient safety)

Mendeteksi dini titik titik potensial berisiko


selama proses layanan perawatan pasien
(tracers methodology) dalam rangka
manajemen risiko (risks management),
Rencana pemulangan pasien (patient
discharge)
Upayapeningkatan mutu layanan
berkesinambungan (continuous
quality improvement)
Penulusuran kinerja(performance) individu
profesi maupun kelompok (team-work )

Peran Dokter
Di Indonesia pengertian klinisi masih diberikan kepada
kelompok dokter yang langsung menangani pasien (staf
medik fungsional/ SMF).
Sedangkan tim keseluruhan dokter dan profesi lain
sering disebut sebagai pelaksana pelayanan klinis (PPK)
Persamaan/kesetaraan profesi ini merupakan suatu
perubahan yang dapat memberikan dampak kepada
pasien ataupun kepada para dokter sebagai profesi yang
tertua.
Diperlukan suatu perubahan persepsi bagi para dokter
tentang hubungan baru dengan para profesional lainnya.

Namun demikian dokter akan tetap


sebagai pemimpin bukan dalam
bentuk hirarchical tetapi sebagai
ketua tim (playing captain) di
antara sesama profesi yang
sederajat (the clinician)

PRIMUS INTER PARES


First Among Equals

Seorang dokter harus bersikap dan


bertindak sebagai orang pertama
diantara profesional yang sederajat,
dengan demikian dituntut suatu
kepemimpinan yang demokratik di
dalam suatu tim profesional.

Untuk itu diperlukan:


1. Kompetensi
2. Etika
3. Karakter
4. Empati
5. Inspiring ability
6. Membangun semangat dan
kerjasama tim
7. Conflict resolution
Sifat-sifat diatas tentunya juga harus dimiliki
oleh seluruh anggota-anggota tim, sehingga
terbangun sebuah kerja sama tim (team
work) yang efisien.

Maturnuwun