SUMBER

HERKUTANTO 7
SISTIMATIKA PAPARAN

8
INTRODUKSI FMEA & HFME A

HERKUTANTO 9
 What is FMEA ?
Adalah metode perbaikan kinerja dgn
mengidentifikasi dan mencegah potensi
kegagalan sebelum terjadi. Hal tersebut
didesain untuk meningkatkan keselamatan
pasien.

Mengantisipasi
Adalah prosesproaktif, dimana
Kesalahan dpt dicegah & diprediksi.
kesalahan akan meminimalkan dampak
buruk
HERKUTANTO 10
 What is HFMEA ?
Modified by VA NCPS

Focus on preventing defects, enhancing safety, increase

positive outcome and increase patient satisfaction

The objective is to look for all ways for process can fail

The famous question : What is could happen?

Not What does happen ?

Hybrid prospective analysis model combines concepts :

FMEA (Failure Mode and Effects Analysis)
HACCP (Hazard Analysis Critical Control Points)
RCA (Root Cause Analysis)

HERKUTANTO 11
 FMEA Terminology
Process FMEA - Conduct an FMEA on a
process that is already in place

Design FMEA Conduct an FMEA before

a process is put into place
Implementing an electronic medical records or
other automated systems
Purchasing new equipment
Redesigning Emergency Room, Operating
Room, Floor, etc.
12
FAILURE MODE AND EFFECTS ANALYSIS

FAILURE (F) : When a system or part of a system

performs in a way that is not
intended or desirable
MODE (M) : The way or manner in which
something such as a failure can
happen. Failure mode is the
manner in which something can
fail.
EFFECTS (E) : The results or consequences of a
failure mode
Analysis (A) : The detailed examination of the
elements or structure of a process
13
 Can prevent errors & nearmisses protecting
patients from harm.
Can increase the effectiveness & efficiency of
process
Taking a proactive approach to patient safety
also makes good business sense in a health
care environment that is increasingly facing
demands from consumers, regulators & payers
to create culture focused on reducing risk &
increasing accountability
 DELAPAN LANGKAH FMEA
1. Tetapkan Topik FMEA dan Bentuk Tim
2. Gambarkan Alur Proses
3. Identifikas Modus Kegagalan & Dampaknya (Hazard
4. Identifikas Prioritas Modus Kegagalan
5. Identifikasi Akar Penyebab Modus Kegagalan
6. Disain ulang Proses
7. Analisis dan Test Proses Baru
8. Implementasi dan Monitor Proses Baru
 LANGKAH OUTPUT
1 Tetapkan Topik FMEA dan Bentuk Tim Topik dan Tim
2 Gambarkan Alur Proses Alur Proses tergambar
3 Identifikasi Modus Kegagalan & Modus Kegagalan &
Dampaknya Dampaknya

4 Tetapkan Prioritas Modus Kegagalan Daftar Prioritas Modus

Kegagalan
5 Identifikasi Akar Penyebab Modus Akar Penyebab
Kegagalan Modus Kegagalan

6 Disain ulang Proses Proses Baru

7 Analisis dan Uji Coba Proses Baru Hasil Uji COba
8 Implementasi dan Monitor Proses Baru Penerapan Proses Baru

HERKUTANTO 18
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus

1 Kegagalan &
Dampaknya
4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang
Proses
TETAPKAN TOPI K & TIM 7 Analisis dan Uji
Coba Proses
Baru
8 Implementasi dan
HERKUTANTO Monitor Proses
19

Baru
 TUJUAN & HASIL

Terpilihnya Topik FMEA

Terpilihnya TIM Pelaksana untuk topik

tersebut

Daftar Tim

HERKUTANTO 20
21
 TUJUAN PEMILIHAN TOPIK
Fokus pada proses spesifik yang dianggap
prioritas (hospital specific)
Melakukan tindakan korektif pada proses
melalui redesign proses
Contoh:
Proses pelayanan Transfusi darah
Proses pemberian obat kepada pasien

HERKUTANTO 22
 LANGKAH 1 : PILIH PROSES YANG BERISIKO TINGGI

Pilih Proses berisiko tinggi yang akan dianalisa.

Judul Proses :

LANGKAH 2 : BENTUK TIM

Ketua :

Anggota 1. 4.

2. 5.

3. 6.

Notulen?
Apakah semua Unit yang terkait dalam Proses sudah terwakili ? YA / TIDAK
Tanggal dimulai Tanggal selesai

HERKUTANTO 24
 TIME LINE AND TEAM ACTIVITIES
Premeeting Identify Topic and notivy the team (Step 1 & 2)
1st team meeting Diagram the process, identify subprocess, verify the scope
2rd team meeting Visit the worksite to observe the process, verify that all process &
subprocess steps are correct (Step 3)
3 rd team meeting Brainstorming failure modes, assign individual team members to
consult with process users (Step 3)
4rd team meeting Identify failure modes causes, assign individual team members to
consult with process users for additional input (Step 3)
5th team meeting Transfer FM & Causes to the HFMEA Worksheet (Step3). Begin the
hazard analysis (Step 4)
Identify corrective actios and assign follow up responsibilities (Step 5)
6th,7th , 8th. team Assign team members to follow up individual charged with taking
meeting plus 1 corrective action
team meeting plus 2 Refine corrective actions based on feedback
team meeting plus 3 Test the proposed changes
team meeting plus 4 Meet with Top Management to obtain approval for all actions
Postteam meeting The advisor or his/ her designee follow up until all actions are
completed
HERKUTANTO 25
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus

2 Kegagalan &
Dampaknya
4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang
Proses
Gambarkan Alur Proses 7 Analisis dan Uji
Coba Proses
Baru
8 Implementasi dan
HERKUTANTO Monitor Proses
26

Baru
 TUJUAN & HASIL

Tergambarnya alur / langkah2 PROSES

dan SUBPROSES pelayanan yang dipilih
dalam suatu bagan yang jelas
LEMBAR ALUR
PROSES dan SUBPROSES PELAYANAN

HERKUTANTO 27
HERKUTANTO 28
HERKUTANTO 29
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus
Kegagalan &
3 Dampaknya

4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan

Identifikasi 6 Disain ulang Proses

7 Analisis dan Uji Coba

Modus Kegagalan & Proses Baru

Dampaknya 8 Implementasi dan

HERKUTANTO Monitor Proses30Baru
 TUJUAN & HASIL

1. Teridentifikasinya MODUS KEGAGALAN

pada setiap langkah proses pelayanan

2. Teridentifikasinya DAMPAK KEGAGALAN

pada setiap langkah proses pelayanan

HERKUTANTO 31
 HAZARD vs RISK vs.
COMPLICATIONS
1. A hazard is something that can cause harm, e.g. electricity, chemicals,
working up a ladder, noise, a keyboard, a bully at work, stress, etc. [...
tindakan medik ...??]
2. Complications are things that happen as a result of a disease or a
treatment that you prefer didn't happen [stroke from hypertension, or
bleeding following surgery]
A complication may be described as an adverse event caused by pre-
existing factors that were outside the doctors control. Patients are not the
same in health, habits, immunity or healing power, and have varying susceptibility
to complications
3. A risk is the chance, high or low, that any hazard will actually cause
somebody harm.
Risk factors are things that make it more likely that you will develop a
disease or condition. They may be things you can't do anything about,
like gender, family history, or race, or things you can control, like smoking
and diet. HERKUTANTO 32
DIFFERENCES BETWEEN RISKS vs COMPLICATIONS

RISKS COMPLICATIONS
Allergy Anaphylactic Rx

Leucocytosis Sepsis

Bleeding Hypovolemic shock

Fragile tissues Tissue damage

Naucea / vomit Hyponatraemia

HERKUTANTO 33
 Hazard analysis: What is it?

Hazard: Potentially dangerous condition,

which is triggered by an event,
called the cause of the hazard.

Risk: hazard that is associated with a

severity and a probability of
occurrence.
HERKUTANTO 34
Hazard, Barrier, Target Analysis

Hazard Barrier Target

High
Dog Fence Child

HERKUTANTO 35
HERKUTANTO 36
HERKUTANTO 37
HERKUTANTO 38
HERKUTANTO 39
HERKUTANTO 40
Hazard, Barrier, Target Analysis

Hazard Barrier Target

Medical Policies
Procedures Patient
Mishaps

HERKUTANTO 41
 PENERAPAN HBA PADA FMEA
Prinsip: the DEVILS are in the DETAILS

Cari modus / cara suatu langkah dalam

suatu subproses dapat gagal

HERKUTANTO 42
 DIAGRAM THE PROCESS

PROCESS STEPS :
Describe the process graphically, according to your policy & procedure for the activity and number each one
If the process is complex you may want to select one process step or sub process to work on

1 2 3 4 5

Storage Prescribing, Preparing

Selection &
Ordering, &
Procurement Administration
Trancribing Dispensin
g

Failure Mode Failure Mode Failure Mode Failure Mode Failure Mode

Pemesanan obat Penyimpanan Penulisan obat Peracikan obat Wrong drug

Berlebihan (tdk vaksin tdk dlm R/ tdk jls tdk sesuai dosis
Sesuai kebthn) sesuai suhunya
Wrong dosage

Penulisan Obat R/
tdk R/
Dlm formularium Wrong frequence

Wrong route
administration

HERKUTANTO 43
 Hazard analysis: What is it?

Hazard analysis: Identify all possible

hazards potentially created by a
product, process or application.

Risk assessment: It is the next step

after the collection of potential
hazards. Risk in this context is the
probability and severity of the hazard
HERKUTANTO 44

becoming reality.
 Hazard analysis: What is it?

General risk assessment

protocol : Establish Analysis
Parameters

Identify Hazards

Assess Risks

Derive Risk Rating

Reduce Risks

Verify
Effectiveness
HERKUTANTO
HE 45
Docum nt Results
e
 Hazard analysis: What is it?

Establish Analysis Parameters

Identify Hazards These parameters can

be limits of the
Assess Risks
machine or design,
Derive Risk Rating limits on uses, limits
Reduce Risks
on the scope of the
analysis, or other
Verify Effectiveness limits.
Document Results HERKUTANTO 46
 Hazard analysis: What is it?

Establish Analysis Parameters

Identify Hazards The nature of this

step lends itself to a
Assess Risks
team approach such
Derive Risk Rating as brainstorming.
Reduce Risks

Verify Effectiveness

Document Results HERKUTANTO 47

 Hazard analysis: What is it?

Establish Analysis Parameters

Identify Hazards
Two risk factors are used:
Assess Risks
severity of injury
Derive Risk Rating
probability of occurrenc
Reduce Risks

Verify Effectiveness

Document Results HERKUTANTO 48

 Hazard analysis: What is it?

Establish Analysis Parameters

Risk matrix:
Identify Hazards Severity Category
Pr
Probability Catastrop Critical Marginal Negligible
Assess Risks Level
Fr
Frequent hic
High High Serious Serious
Pr
Probable High High Serious Low
Derive Risk Rating O casional High Serious Low Low
c
Re
Remote Serious Low Low Low
Reduce Risks Im
Improbable Serious Low Low Low

If the risk is determined to not be acceptable, it

Verify Effectiveness
is necessary to reduce that risk by
implementing protective measures.
Document Results HERKUTANTO 49
 Hazard analysis: What is it?

Establish Analysis Parameters

Remedy actions are taken to
Identify Hazards reduce risks following the
hazard hierarchy:
Assess Risks
Eliminate hazards through the design
Derive Risk Rating Protect
Warn the user
Reduce Risks
Train the user(s)
Personal protective equipment
Verify Effectiveness

Document Results HERKUTANTO 50

 Hazard analysis: What is it?

Establish Analysis Parameters

Identify Hazards This assessment

verifies that the
Assess Risks
remedy actions have
Derive Risk Rating reduced the risks to an
Reduce Risks
acceptable level.

Verify Effectiveness

Document Results HERKUTANTO 51

 Hazard analysis: What is it?

Establish Analysis Parameters

Identify Hazards

Assess Risks

Derive Risk Rating

Reduce Risks
The documentation can be added to a
technical file for future use.

Verify Effectiveness

Document Results HERKUTANTO 52

 Full Hazard Analysis
Proactive Controls Reactive Controls

Recovery
Threat Barrier Barrier People
Measures

Recovery Asset
Threat Barrier Barrier Measures Damage
Hazard Top Event
(Incident)
Recovery
Threat Barrier Barrier Environment
Measures

Recovery
Measures Reputation
Escalation
controls

HERKUTANTO 53
 Completed Hazards & Effects Register

HAZARDS & EFFECTS REGISTER

Risk Remedial
Hazard ThreatsBarriers Top Recovery Consequences Rating Initial Final
Event Measures Risk Risk Action
P A E R Required

C5
X X X X X X X X X X D4,5 X
E3,4,5

X X X X X X X X

C5
X X X X X X X X X X D4,5
E3,4,5
E3,4

X X X X X X X X X
HERKUTANTO 54
Step 4A. Hazard Ente
r
Analysis: failur mod for
List result
(CPRS

potential
proces ste e es each )

s Rev
p. Verify Run Rn Repor
cal brat QC Sampl t
ew
Centrifug on e resu t
order
e
3A 38
specime 3C 3 3 3f
Faillure nFailure Failure Failure e lfai lure
Mode: Mode: Mode: V Mo : Mode:
lfai l1.1re
1.Wrong 1 .. Equiip. 1.lnstr 1.QCMode 1.Mecha 1 Computer
test broken not results ni crash
ordered 2..Wrong calibrate unacceptab error 2 Res1.1lt
speed d le 2.Te,ch ,ente ed
2.0rde:r
3.. 2.Bad err for wrong pt.
not
Specime1111 ca I ibra i 3 Computer
received ot
o1n l1nerface
c!lotted error
st.oired HHEERRKKUUTTAAN
4.. No power NTTOO 4 Res1.1lt
5..Wrong not
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim

2 Gambarkan Alur
Proses

3 Identifikasi Modus

4 Kegagalan &
Dampaknya

4 Tetapkan Prioritas
Modus Kegagalan

5 Identifikasi Akar
Penyebab Modus
Kegagalan

6 Disain ulang Proses

Tetapkan Prioritas 7 Analisis dan Uji Coba
Modus Kegagalan Proses Baru

8 Implementasi dan
Monitor Proses Baru
HERKUTANTO 56
 TUJUAN & HASIL

Tersedianya urutan prioritas

DAFTAR PRIORITAS MODUS

KEGAGALAN

HERKUTANTO 57
 Decoding I.he HFM EA"' Wotl<sl\e,et

faibemode Always e'o\illuate the failure Suoprocess Subprocess

number mods 1-st lo determins i Step number description
(eg, 1AI) causes need ID be ide.ntified.

Sccrir1g Decision lree Analysis

allure Modec
g .. .,
0 " E" U
Fht evalJate
:-. "c ... c- 8""E Actions ix
.
c ;; "'
E c:
a . "e Out<Jome Q

..
i::;
re moo,, Potential C uses .. :J:! " .. iii Ratiicmale fa
I a
;ZI "' i!!u'
r
la E ..:,

oerore B w " '-

OJ @
.. Measme c:
.. ""'c: 6S;
. c,e .."'. " !:i Stopping1
"'
"' M ; !l.
r . "'
<I}
-"'
delermm.'11

I
.


u.J 5 e
'" .
-e .
'
i
nl::Bcll
t 0
causes.

List lia.ilure mode.

sud, as 'Mong
speed fix equgiment

Subprocess number Failure Made Tihis space should be rett blank, unless your
+ Fai'lure Mode num hazard analys5 determined a slop aclior1. In llhat
ber + Cause identifier case, yau v.oukl fist llhe rationa!e la stopping.
HHEERRKKUUTTAAN 58
NTTOO
 ANALISIS HAZARD LEVEL DAMPAK
DAMPA MINOR MODERAT MAYOR KATASTROPIK
K 1 2 3 4
Kegagalan yang tidak Kegagalan dapat Kegagalan Kegagalan menyebabkan
mengganggu Proses mempengaruhi menyebabkan kerugian kerugian besar
pelayanan kepada proses dan berat
Pasien menimbulkan
kerugian ringan
Pasien Tidak ada cedera, Cedera ringan Cedera luas / berat Kematian
Tidak ada Ada Perpanjangan Perpanjangan hari Kehilangan fungsi tubuh
perpanjangan hari rawat rawat secara permanent (sensorik,
hari rawat lebih lama (+> 1 bln) motorik, psikologik atau
Berkurangnya fungsi intelektual) mis :
permanen organ tubuh Operasi pada bagian atau
(sensorik / motorik / pada pasien yang salah,
psikcologik / Tertukarnya bayi
intelektual)

Pengunj Tidak ada cedera Cedera ringan Cedera luas / berat Kematian
ung Tidak ada Ada Penanganan Perlu dirawat Terjadi
pada > 6 orang
penanganan ringan Terjadi pada 4 -6 pengunjung
Terjadi pada 1-2 org Terjadi pada 2 -4 orang
pengunjung pengunjung pengunjung
Staf: Tidak ada cedera Cedera ringan Cedera luas / berat Kematian
Tidak ada Ada Penanganan / Perlu dirawat Perawatan > 6 staf
penanganan Tindakan HERKUT ANTO ilangan waktu /
Keh 59
Terjadi pada 1-2 staf Kehilangan waktu kecelakaan kerja pada
 ANALISIS HAZARD LEVEL PROBABILITAS

LEVEL DESKRIPSI CONTOH

4 Sering (Frequent) Hampir sering muncul dalam waktu yang
relative singkat (mungkin terjadi
beberapa kali dalam 1 tahun)

3 Kadang-kadang Kemungkinan akan muncul

(Occasional) (dapat terjadi bebearapa kali dalam 1
sampai 2 tahun)

2 Jarang (Uncommon) Kemungkinan akan muncul

(dapat terjadi dalam >2 sampai 5 tahun)
1 Hampir Tidak Pernah Jarang sekali terjadi (dapat terjadi dalam
(Remote) > 5 sampai 30 tahun)

HERKUTANTO 60
 HAZARD SCORE
TINGKAT BAHAYA
KATASTROPIK MAYOR MODERAT MINOR
4 3 2 1

SERING 16 12 8 4
4
KADANG 12 9 6 3
3
JARANG 8 6 4 2
2
HAMPIR TIDAK 4 3 2 1
PERNAH
1

HERKUTANTO 61
HERKUTANTO 62
HERKUTANTO 63
Laboratory Test Ordering Process

HERKUTANTO 64
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus

5 Kegagalan &
Dampaknya
4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang
Identifikasi Akar Penyebab Proses
7 Analisis dan Uji
Modus Kegagalan Coba Proses
Baru
8 Implementasi dan
HERKUTANTO Monitor Proses
65

Baru
 TUJUAN & HASIL

Teridentifikasinya AKAR PENYEBAB

modus kegagalan yang telah teridentifikasi

Lembar AKAR PENYEBAB

HERKUTANTO 66
 Possible Characteristics of Root
Causes

Root causes are systemic.

Root causes appear far from the origin of

the failure.

The origins of root causes lie in common-

cause variation of organization systems
HERKUTANTO 67
 many of the failure modes
had the same root causes
Omission errors secondary to automatic stop order
Suboptimal patient involvement in medication histories
Suboptimal medication reconciliation by clinicians
Confusing epidural and patient-controlled analgesia
order sets
Lack of electronic medication administration record
Lack of computerized order entry

HERKUTANTO 68
 PROBING
to uncover root causes and their relationships

What could happen? (the failure mode)

Why could this happen?
That is, what are the most proximate causes? These
typically involve special-cause variations.

Why could these proximate causes happen?

That is, what systems and processes underlie those
proximate causes?
Common-cause variation here may lead to special-
cause variation in dependent processes.
HERKUTANTO 69
What could happen? - FACTORS
Human factors
failure to follow policieson precaution orders or failure
to conduct appropriate staff education/training

Assessment process factors

faulty initial assessment process

Equipment factors
nonfunctional paging system that delays
communication with the individuals physician
HERKUTANTO 70
 Questions to Uncover Causes
What safeguards are missing in the process?
If the process already contains safeguards (for
example, double checks), why might they not work to
prevent the failure every time?

What would have to go wrong for a failure like

this to happen?

If this failure occurred, why would the problem

not be identified before it affected an individual?

HERKUTANTO 71
 What could
happen?

HERKUTANTO
72
 Contributory Factors to Suicide
happen?
What could

HERKUTANTO 73
 DIABETES SCREENING
happen?
What could

HERKUTANTO 74
 Laboratory Test
Ordering Process

HERKUTANTO 75
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus

6 Kegagalan &
Dampaknya
4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang
Proses
Disain Ulang Proses 7 Analisis dan Uji
Coba Proses
Baru
8 Implementasi dan
HERKUTANTO Monitor Proses
76

Baru
 TUJUAN & HASIL

Teridentifikasinya PROSES BARU yang

bebas dari modus kegagalan

Lembar langkah2 PROSES BARU

HERKUTANTO 77
 Decision Tree
Gunakan Decision Tree utk menentukan apakah modus perlu tindakan lanjut diProceed

Does this hazard involve a

sufficient likelihood of
occurrence and severity to NO
warrant that it be controlled?
(Hazard score of 8 or
higher)
Is this a single point weakness in NO
YES the process? (Criticality failure
results in a system failure?)
CRITICALITY
YES
Does an effective control measure already exist YES
for the identified hazard? STOP
CONTROL THE HAZARD (=BARRIER) Do not proceed
NO to find potential
causes for this
Is this hazard so obvious and readily failure mode
apparent that a control measure is not YES
warranted? DETECTABILITY
(FORESEEABILITY) NO
Proceed to Potential
HERKUTANTO
Causes for this 78
failure mode
 PREPARING TO REDESIGN

Conduct a literature search to gather

relevant information from the professional
literature. Do not reinvent the wheel

Network with colleagues

Recommit to out of the box thinking

HERKUTANTO 79
 REDESIGN STRATEGIES
Prevent the failure from happening
(decrease likelihood of occurrence)
Prevent the failure from reaching the
individual (increase detectability)
Protect individuals if a failure occurs
(decrease the severty of the efects)

HERKUTANTO 80
 PROSES METODE
RISIKO TINGGI REDESIGN

Variable input
Decreasing variability
Complex Simplify
Nonstandarized Standardizin
Tightly Coupled g
Loosen coupling of process
Dependent on Use technology
human intervention Optimise Redundancy
Built in fail safe mechanism
Time constraints
Documentatio
Hierarchical culture n
Establishing a culture of
teamwork

HERKUTANTO 81
 REDESIGN PROCESS
Process Failure Potential Potential Redesign PIC Target New Outcome
Mode Effect Causes Recommend Completi Process Measure /
ations on Implementat Monitoring
date ion mechanism
for test date &
Actions

1 2 3 4 5 6 7 8 9

HERKUTANTO 82
 Proses
Redesign

Bandingkan :

Analisis & Ranking Analisis & Ranking

Failure Failure
Effect Causes Effect Causes
Mode Mode

Proses Lama Proses Baru

HERKUTANTO 83
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus

7 Kegagalan &
Dampaknya
4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang
Analisis dan Uji Coba Proses
7 Analisis dan Uji
Proses Baru Coba Proses
Baru
8 Implementasi dan
HERKUTANTO Monitor Proses
84

Baru
 TUJUAN & HASIL

Terujinya PROSES BARU dilapangan

Le

HERKUTANTO 85
SIKLUS PDSA

HERKUTANTO 86
SIKLUS PDSA

ERKUTANTO 87
 LEMBAR KERJA
UJI COBA

HERKUTANTO
88
 LEMBAR KERJA
UJI COBA

HERKUTANTO
89
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus

8 Kegagalan &
Dampaknya
4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang
Implementasi & Monitor Proses
7 Analisis dan Uji
Proses Baru Coba Proses
Baru
8 Implementasi
HERKUTANTO dan Monitor 90
Proses Baru
 TUJUAN & HASIL

PENERAPAN PROSES BARU

Manajemen Perubahan

Lembar MONITORING PROSES BARU

HERKUTANTO 91
 Strategies for Creating and Managing
the Change Process

Establish a sense of urgency

Create a guiding coalition

Develop a vision and strategy

Communicate the changed vision

Empower broad-based action

Generate short-term wins

Consolidate gains and produce more change

Anchor new approaches HERKUTANTO

in the culture 92
LEMBAR MONITOR PROSES BARU

HERKUTANTO 93
LEMBAR MONITOR PROSES BARU

HERKUTANTO 94
 KESIMPULAN

PROSES BARU YANG LEBIH AMAN

KEBIJAKAN & SOP LEBIH BAIK

RUMAH SAKIT YANG AMAN

HERKUTANTO 95
HERKUTANTO 96