Pathway
dr. Merita Arini, MMR
Learning Objectives
Topik
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
Kebijakan
pelayanan
Output/
Outcome
Proses
Tatalaksana
Pedoman
Pedoman
Pengorganisasia Pelayanan
n
Standar
SDM
Standar
Fasilitas
SPO
Survei kepuasan
Indikator Mutu :
Indikator Klinik
Indikator Mutu Yan
IKP:
K T D : Sentinel
Event
CP vs CG
Clinical Pathway
Clinical Guideline
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
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)
Hari II
Hari III
Outcome
Variasi
(Midleton & Roberts, 2000; Djasri, 2014)
Karakteristik CP
Menggabungkan:
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
Cont
Teknis Pembuatan CP
1. Profesi Medis
2. Profesi Perawat
Cont
4. Profesi Gizi
5. Profesi Farmasi
mempersiapkan Daftar Formularium, sistem
unit dose dan stop ordering
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)
Cont
Key result 5 distinct & sequential stages used
by organizations with evidence of succesful
programmes of ICP activity:
1.
HI
S
R
DE
A
E
L
P
1.
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.
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
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.
High volume
High cost
High risk
Problem prone
Memiliki gap besar dg tarif INA CBGs
Cont
Staff expressed preferences Ensure
staff commitment
2.
Boundary
2.
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.
3.
Documentation
Lay-out Design
Process based or outcome?
Depends on the skills of user
Check wound
vs
Wound dry
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
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
I
H
S
R
E
D
LE A P
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
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
Lampiran
BENTUK SPO
Panduan praktik klinis
(Clinical Practice
Guideline)
Alur klinis
(Clinical Pathways)
Algoritme
Prosedur
Protokol
Standing Orders
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
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
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
INA - DRG
1.Konfirmasi DRG
2.Hitung Cost/DRG
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)
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.
Maturnuwun