CURRICULUM VITAE

DATA PRIBADI
Nama : dr.ADIB ABDULLAH YAHYA,MARS
Pangkat : Brigjen TNI (Purn)
Tempat/tanggal lahir : Magelang,16 Februari 1949
Jabatan : DIREKTUR UTAMA RUMAH SAKIT MMC
Agama : Islam
ALAMAT : Jl. Punai H-24,Kel.Tengah,Jakarta Timur – 13540
Telp : (021)8404580
Fax : (021) 8408047
HP : 08161803497
E-MAIL : adibabdullahyahya@yahoo.com

PENDIDIKAN UMUM
SMA Negeri Magelang 1966
S1 : Fakultas Kedokteran Universitas Gajah Mada (UGM),
Yogyakarta, 1973
S2 : Fakultas Kesehatan Masyarakat, Universitas Indonesia (UI), Jakarta,
Program Kajian Administrasi Rumah Sakit ( KARS )

PENDIDIKAN MILITER
Sekolah Staf dan Komando TNI Angkatan Darat (SESKOAD), 1987/1988

PELATIHAN
Combined Humanitarian Assistance Response Training, oleh Singapore Armed Forces (SAF), Singapura, 2000
Health as a Bridge for Peace Workshop, oleh World Health Organization (WHO), Yogyakarta, 2000
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PENGALAMAN JABATAN
Komandan Detasemen Kesehatan Pasukan Pengamanan Presiden (Paspampres), 1987-1991
Kepala Rumah Sakit “Muhammad Ridwan Meuraksa”, Jakarta, 1992
Kepala Kesehatan Daerah Militer (Kakesdam) Jaya, Jakarta, 1993
Komandan Pusat Pendidikan Kesehatan TNI – AD,1995 – 1999
Wakil Kepala Pusat Kesehatan TNI, 1999 – 2000
Kepala RSPAD Gatot Soebroto, 2000 – 2002
Dekan Fakultas Kedokteran UPN, Jakarta, 2000 – 2002
Wakil Ketua Tim Dokter Kepresidenan RI, 2000 – 2002
Direktur Kesehatan TNI Angkatan Darat (Dirkesad), 2002-2004
Wakil Ketua Tim Pemeriksaan kesehatan untuk calon Presiden dan calon Wakil Presiden RI Th.2004
DOSEN Pasca Sarjana FKM UI, Kajian Administrasi Rumah Sakit (KARS)
DOSEN Pasca Sarjana URINDO
DIREKTUR UTAMA RUMAH SAKIT MMC

ORGANISASI
Ketua Ikatan Rumah Sakit Jakarta Metropolitan (IRSJAM), 2000-2003
Ketua Umum Perhimpunan Rumah Sakit Seluruh Indonesia ( PERSI), 2003-2009
PRESIDENT OF ASIAN HOSPITAL FEDERATION ( AHF ) 2009 – 2011
Anggota Komnas FBPI.
Surveyor KARS
Ketua Umum PERMAPKIN
Ketua Komtap Bidang Kebijakan Kesehatan KADIN Indonesia
Angggota TNP2K.
Dewan Pakar Perhimpunan Rumah Sakit Seluruh Indonesia ( PERSI)
Dewan Pakar IDI
Anggota Majelis Kehormatan Etik Kedokteran (MKEK) IDI Pusat
Tim Konsultan Institut Manajemen Risiko Klinis ( IMRK )
Anggota KNKPRS
Koordinator Bidang 1 : KAJIAN KESELAMATAN PASIEN, IKPRS- PERSI
Instruktur HOPE ( Hospital Preparedness for Emergencies and Disasters} 2
 PENINGKATAN MUTU
MENUJU KESELAMATAN PASIEN

Dr. ADIB A YAHYA, MARS

INSTITUT MANAJEMEN RISIKO KLINIS

“ PELATIHAN MANJEMEN RISIKO DAN PENINGKATAN MUTU
MENUJU KESELAMATAN PASIEN “
 PENGERTIAN MUTU

MUTU (QUALITY) ADALAH KESESUAIAN

DENGAN STANDAR (CONFORMANCE TO
REQUIREMENTS)  (CROSBY)

MUTU ADALAH GAMBARAN DARI PRODUK

YANG MEMENUHI KEBUTUHAN
PELANGGAN DAN BEBAS DARI KECACATAN
 (JURAN)
 DONADEBIAN’S THREE WAYS TO
MEASURE QUALITY
STRUCTURE : THE RELATIVELY STABLE
CHARACTERISTICS OF THE PROVIDERS OF CARE, OF
THE TOOLS AND RESOURCES THEY HAVE AT THEIR
DISPOSAL, AND OF THE PHYSICAL AND
ORGANIZATIONAL SETTINGS IN WHICH THEY WORK.

PROCESS OF CARE : A SET OF ACTIVITIES THAT GO ON

WITHIN AND BETWEEN PRACTITIONERS AND PATIENTS.

OUTCOME : A CHANGE IN A PATIENT’S CURRENT AND

FUTURE HEALTH STATUS THAT CAN BE ATTRIBUTED TO
ANTECEDENT HEALTHCARE
Komponen pelayanan kesehatan di RS :

– Komponen struktur
menunjukkan aspek institusional fasilitas pelayanan kesehatan
seperti ukuran, kompleksitas, jumlah dan luasnya unit atau
departemen, jumlah dan kualifikasi staf, peralatan medis dan
non-medis, struktur organisasi, sistem keuangan dan sistem
informasi
– Komponen proses
menunjukkan apa yang sesungguhnya dilakukan terhadap
pasien untuk mendapatkan pelayanan.
- Komponen OUTPUT (hasil)
menunjukkan efek pelayanan yang diberikan terhadap tingkat
status kesehatan pasien atau masyarakat yang dapat berupa
perbaikan fungsi fisiologis, psikologis, pengurangan
penderitaan, sakit dan penyakit
- Komponen OUTCOME (dampak)
Tingkat kepuasan pasien (patient satisfaction)
 Masing – masing komponen memiliki standar tersendiri :

Standar Standar Standar Standar

Struktur Proses Output Outcome
= Standar-2 tentang Standar Tentang Proses Medis
sumberdaya (SDM, a. Melekat pd DOKTER Indikator Output:
fisik, finansial) dan
kondisinya, serta Stand. Perilaku / Etik Aspek pelayanan medis
bagaimana sistem-2 Stand. Kompetensi Aspek efisiensi
dioperasikan dan
dikendalikan Aspek kepuasan pasien
Standar Profesi Aspek cakupan pelayanan
Aspek keselamatan pasien
b. Terkait Dgn Asuhan PASIEN
Stand. Prosedur
Stand. Asuhan
Stand. Kinerja Good Medical Care /
Kewajiban Institusi QUALITY OF SERVICES /
INTERNATIONAL
untuk memenuhinya QUALITY OF CARE PATIENT
SATISFACTION
STANDARD OF A GOOD PRACTICE / INDEX
(IPSI)
STANDARD OF CONDUCT
MUTU VS CITRA
LOOK AT THE BUSINESS
THROUGH
THE CUSTOMER`S
EYES
Our Society’s Perception About Healthcare

Unsafe
Inaccessible
Increasing cost
Qualified workforce shortages
Lack of consumer involvement
 KOMPONEN PEMBENTUK CITRA

Struktur Proses Output Outcome

TANGIBLE : CEPAT/RESPONS TIME

•BANGUNAN KEMUDAHAN SEMBUH
•TAMAN TERKOORDINASI QUALITY OF LIFE
•PARKIR AMAN APRESIASI THD.UPAYA
•ALAT KOMUNIKATIF VALUE OF MONEY
•DOKTER/PERAWAT KETERLIBATAN PASIEN
KESINAMBUNGAN
PROSES

MANFAATKAN PATIENT SATISFACTION

PANCA INDERA

KESAN “PROFESIONAL”
TRUST & LOYALTY
MUTU DAN KEPUASAN PASIEN
 “PELAYANAN PRIMA” RUMAH SAKIT

“PELAYANAN PRIMA ADALAH PELAYANAN

KEPADA PASIEN YANG BERDASARKAN
STANDAR KUALITAS UNTUK MEMENUHI
KEBUTUHAN DAN KEINGINAN PASIEN
SEHINGGA PASIEN DAPAT MEMPEROLEH
KEPUASAN YANG AKHIRNYA DAPAT
MENINGKATKAN KEPERCAYAANNYA
KEPADA RUMAH SAKIT”
MENGKUKUR KEPUASAN PASIEN DENGAN
“SERVICE QUALITY PERCEPTION”

Reliability
Assurance
Tangible
Empathy
Responsiveness

Baksheesh
Crossing the Quality Chasm:
A New Health System for t
he 21st Century
   (2001)
   

IOM Study of Health Care Quality

 Crossing the Quality Chasm:

The chasm between what we know and what

we need to know to improve care

The chasm between care delivery and those

who do not fund, study, support, or publish
practical studies that address the real problems
of patients and care

The chasm between research and quality

improvement
IOM : Crossing the Quality Chasm
A New Health System for the 21st Century

Six Aims -- Health Care should be :

– Safe - No unintended injuries

– Effective - Based on evidence
– Patient-Centered
– Timely - No harmful delays
– Efficient - Waste avoided
– Equitable - No variance in quality
HUBUNGAN MANAJEMEN RISIKO,
KESELAMATAN PASIEN
DAN
MANAJEMEN MUTU
 FOREWORD

When a patient is harmed as a result of a medical error,

risk managers and quality managers have immediate interests in
identifying the circumstances that led to the error.

These interests, however, can be quite divergent :

Current perspectives

Risk managers Quality managers

concerns over potential for conduct a parallel investigation

future litigation
protect information
investigation to assess the
liability exposure
mitigate any future loss
only focused on financial
losses from organizational
liability.
to design formal process
improvement
target the underlying causes of
the event
to improve the quality of
patient care
focus on best possible
outcomes in patient care.
Over the years, these separate paths have contributed
to a silo mentality.
In many organizations, information is too rarely
exchanged between risk managers and quality
managers and collaboration is too often
minimal or nonexistent.
 THE NEED FOR A COLLABORATIVE MODEL

The ideal risk management and quality management collaborative

model allows the exchange of event-related information in a way that
does not jeopardize the defense of a potential malpractice claim.

Typically, risk managers are skilled investigators; they take care to

avoid any speculation or premature conclusions that could potentially
bias the analysis. With additional training, the risk manager will be
able to identify special causes and latent causes of the event under
analysis.

The risk manager will have the opportunity to recognize other risk
issues not directly related to process or quality of care, too.

Once the root causes are identified, the risk manager can forward this
information to quality management colleagues for design and
implementation of the corresponding action plan.
 Risk Management,
Quality Improvement, and
Patient Safety
the Institute of Medicine’s (IOM) 2001 report Crossing the Quality Chasm aptly
describes the evolving roles of healthcare risk management and quality
improvement* in healthcare organizations . In the past, the two functions often
operated separately and individuals responsible for each function had different
lines of reporting—an organizational structure that further divided risk
management and quality.

Today, as the quote from Crossing the Quality Chasm suggests, risk
management and quality improvement efforts in healthcare organizations are
rallying behind patient safety and finding ways to work together more effectively
and efficiently to ensure that their organizations deliver safe and high-quality
patient care.
Australian Patient Safety Foundation
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 HOW HAVE RISK MANAGEMENT AND QUALITY EVOLVED?

In the past, a typical organizational chart might have had risk management
reporting to a chief operating officer or a legal department and the quality and
patient safety activities reporting to a chief medical director.

The organization hierarchy did not allow for any overlap of risk management and
quality functions, nor did it allow for sharing of data.

This type of segregated structure, with the two functions operating in different silos
of the organization, evolved from quality and risk management’s historical roots.

CEO

COO CMD

X
RM QI
PS
 OVERLAPPING FUNCTIONS IN RISK MANAGEMENT AND
QUALITY IMPROVEMENT

As the risk management and quality improvement functions in hospitals focus

on patient safety initiatives , professionals from both fields indicate that their
activities overlap.

The Joint Commission’s patient safety standards suggest a framework for

overlapping risk and quality activities by requiring that, at least every 18 months,
organizations select a high-risk process and conduct a proactive risk
assessment of the process to correct process problems and prevent adverse
events.
- The quality manager will be able to identify high-risk processes based on
patient outcomes data, and
- the risk manager will be able to identify high-risk processes from event report
data.
Both the risk and quality managers will participate in the proactive risk assessment
because they bring their skills in identifying ways in which a process can break
down, redesigning the process, and testing the redesign to minimize risk to
patients.
 Risk Management and Quality Improvement Functions Overlap
in Patient Safety

RISK MANAGEMENT OVERLAPPING FUNCTIONS QUALITY IMPROVEMENT

Risk identification (e.g., near-miss
and adverse event reporting)
Risk control (e.g., loss prevention
and loss reduction)
Risk financing
Claims management
Contract/policy review
Patient relations and disclosure
Safety and security
Corporate and
regulatory compliance
Accreditation compliance
Mandatory event reporting
Workers’ Compensation
Bioethics
Analysis of adverse and
sentinel events and trends
Root-cause analysis
Proactive risk assessments
Patient complaint handling
Public reporting of quality data
Patient education
Patient safety initiatives
Board reports
Feedback to providers and staff
Provider credentialing
Accreditation issues
Staff education and training
Strategic planning
Quality methodology
Quality measures/indicators/
dashboards/core measures, etc.
Benchmarking
Best practices/clinical guidelines
Provider performance and
competency
Accreditation coordination
Patient satisfaction
Peer review
Quality-of-care reviews
Improvement projects
Utilization/resource/
case management
Different Roles, Same Goal:
Risk and Quality Management
Partnering for Patient Safety
 Approaches to align risk management and
quality improvement strategies with
a focus on patient safety.

Because each organization is unique, facilities must choose the

approaches that work best for them.

There is no single, best solution for all organizations.

 STEPS
Conduct an assessment of current approaches.

- What systems are currently in place for quality, risk, and patient
safety?
- Who is responsible for these areas? How are the risk and quality
functions of the organization perceived by those in the organization?
- Is coordination among the risk, quality, and patient safety
functions reliable and connected?
- Does the current system identify areas in need of improvement to
ensure safe patient care and reduce the organization’s risk for
exposure?
 To evaluate collaboration between risk management and quality
improvement, considers some of the following questions during
the assessment process:

• What process is used to ensure that quality initiatives are aligned with strategic
goals?
• Do hospital leaders take proactive steps to resolve potential problems?
• What is the perception of the roles of risk management, patient safety, and
quality improvement in the hospital?
• Is there a formal process of gathering and analyzing internal data to identify
potential areas of high organizational risk?
• Is peer review conducted when a pattern of poor quality is identified?
• Does an investigation take place when an adverse trend is identified that may
affect patient safety?
• How is accountability for recommendations from root-cause analyses assigned?
• How are overlapping issues between risk and quality management handled?
• How is implementation of National Patient Safety Goals monitored ?
Identify data and information collected by each function and how
the flow of information can enhance risk and quality efforts .

- How can information collected by one department enhance

the efforts of other departments?

- Data that might be conveyed from risk management to quality

improvement could include information on :
. specific claims brought against a particular service or for a
particular reason during a specified period of time,
. event and near-miss report data uncovering problems not
identified through other data sources, and
. safety management data related to preventing injury to patients,
visitors, or staff during the performance of clinically related activities.
Position departments close to each other.

- The offices of risk, quality, and patient safety functions should

be in proximity so that managers can facilitate an atmosphere of
sharing and identification of efforts that may require input from staff
from the various offices.

- Locating offices near each other will also foster more frequent
communication among staff involved in risk, quality, and patient
safety.
Learn from each other.

- Risk and quality managers can learn from each other.

- Claims data has been a rich source of information for risk

managers who want to focus on certain high-risk areas in an
organization but who find that information from these reporting
systems is insufficient to bring about change

- Conversely, risk managers can provide a unique perspective in

assisting quality managers with the public release of hospital-specific
quality data.
Leave egos at the door.

- Those who have realigned their risk, quality, and patient safety
functions have warned that fear of change can be a barrier to
integration
- Anticipate conflict, but identify the strengths that each individual
brings to the unified effort.
 SAMPLE APPROACHES

Approach One

- At small and medium-size hospitals, the responsibility for risk

management, patient safety, and quality improvement may be
assigned to one person
- Depending on the organization, this person may have additional
responsibilities such as infection control and corporate compliance
- As the organization grows, the manager of the one person risk and
quality department may need to add another individual to the
department to assist with risk management and quality improvement
responsibilities.
CEO

RM
QI
PS
Approach Two

- In medium-size to large hospitals and medical centers,

the functions of risk management and quality improvement
are often separate
- At minimum, the two departments should be sharing data
on adverse events, peer review, and quality-of-care
concerns
- Additionally, representatives from the two departments
should meet on a regular basis to address issues of mutual
concern CEO

RM QI
Approach Three

- Some larger organizations and healthcare systems have established a department in

the organization dedicated to risk, quality, and patient safety
- The groups in the department should participate in weekly team meetings to ensure
timely communication of important issues of mutual interest
- Topics covered during these meetings might include the following: accreditation
issues;
patient complaint data;
claims data;
sentinel event response and
opportunities for process improvements;
CEO
federal, state, and local regulatory issues; and
strategic planning.

DEPT

RM QI PS
 LEADERSHIP SUPPORT

To presenting the business case for aligned risk and quality structures, ways to gain
leadership’s support for the integrated efforts of risk and quality include the following:

 Ensure that the goals of the risk management and quality improvement plans are
aligned with the strategic goals of the organization.
 Cultivate boards of trustees’ increasing involvement in quality and patient safety
matters by presenting concise data summarizing important initiatives. Commonly
reported risk and patient safety measures include patient satisfaction, quality
improvement project results, hospital-acquired infection rates, adverse events, and
medication error rates
 Emphasize the importance of aligned risk and quality strategies in creating a
high-reliability organization.
Such an organization is able to reduce variability in patient care—and, thus, potential
errors—through standardization; to take information learned from errors and near
misses and provide feedback to staff to improve the delivery of care; and to support
leadership’s commitment to safety and excellence.
 Emphasize that aligned risk and quality structures in the organization will assist leaders
in meeting the standards in its hospital accreditation, which hold hospital leaders
responsible for creating and maintaining a culture of safety and quality.
 IN CONCLUSION

Improved collaboration between risk management and quality improvement

will contribute to an organization’s success in enhancing patient safety and
minimizing patient harm.

The organization will realize other benefits from this collaboration, such as
improved communication among groups, less duplication of effort, and
better coordination of activities.

Whether the coordinated activity is undertaken by one individual, by

outlining coordinated approaches through organizational policy, or by
aligning the quality, risk, and patient safety activities in one department,
organizations that adopt these approaches will be best positioned to find
system solutions to prevent and mitigate patient harm.
COLLABORATION ...... ???

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THANK
YOU