Penggunaan Statistik untuk

Peningkatan Mutu

Trisasi Lestari
2016
Seandainya praktek klinis bisa
sesederhana ini

X Y
Pasien Pasien
konsultasi sembuh
dg Dokter dan puas
Banyak faktor yang mempengaruhi

X1 Usia X4 Koordinasi
pelayanan
kesehatan
Y Outcome
pasien (sembuh,
X2 Gender perbaikan
fungsional atau
kepuasan)
X3 Status
kesehatan X5 Komunikasi
Time 1 Time 2 Time 3
 Kenyataannya seperti ini
R1 R4

X1 Usia X4 Koordinasi
pelayanan
kesehatan
R2 Y Outcome
pasien (sembuh,
X2 Gender perbaikan
R3 fungsional atau
kepuasan)
X3 Status
kesehatan
R5
X5 Komunikasi
Time 1 Time 2 Time 3
 The Quality Gurus

W. Edwards Deming Walter Shewhart Joseph M. Juran

(1900-1993) (1891-1967) (1904 - 2008 )
W.Edwards Deming
Quality is reducing variation
Dr Walter Shewhart
Komponen Ilmu Terapan
 Pertanyaan 2: Bagaimana kita tahu
bahwa perubahan yang terjadi adalah
suatu perbaikan?
Sulitnya mengukur mutu
Manfaat Pengumpulan Data
Manfaat Pengumpulan Data (lanjutan)
 “The more effort you put into
understanding and utilizing data,
the more you will be rewarded in
terms of solving the right problem
in the right way”.
(The Victorian Quality Council Safety and Quality in Health)
 Peran data dalam QI
• Quality improvement bisa reactive dan
proactive.
– Reaktif terhadap masalah yang ditemukan dalam
data/laporan rutin.
– Proaktif dengan menganalisis data untuk mencari
celah untuk perbaikan.
Sumber data?
 Data Internal
• adverse events, incident reports
• sentinel events
• infection rates, isolates
• length of patient stay
• a range of clinical indicators
• service utilization data including diagnostics,
• pharmacy, specific procedures
• clinical outcomes from clinical registries
• waiting times for surgery
• waiting times for the emergency department
• customer complaints
• expenditure reports
• use of high-cost medication items.
 Eksternal Data
• Data nasional/provinsi
• Data surveillance
• Publikasi ilmiah
• Performance RS lain
Jenis data
Pengumpulan Data
Good Data
 Kunci pengumpulan data yg baik
Stratifikasi
• Pemisahan data
berdasarkan kategori yg
ditetapkan sebelumnya
• Untuk mengidentifikasi pola
tertentu dalam data
• Usia, gender, unit, waktu,
shift, hari, musim, prosedur,
ruang, dll.
Sampling
• Probability
– Simple random sampling
– Systematic random sampling
– Stratified random sampling
– Stratified proportional
random sampling
• Non-probability
– Quota sampling
– Convenience sampling
– Judgment sampling
– Total sampling
Bias Sampling
 Definisi operasional: Penting tapi
sering terlupakan
• Adalah deskripsi mengenai apa yang akan
diukur dan bagaimana mengukurnya secara
konsisten
• Menjelaskan konsep improvement
• Jelas dan tidak ambigu
• Menjelaskan metode dan alat ukur
Bagaimana definisi operasional dari:
 Contoh definisi operasional indikator
Subject Treating and caring for people in a safe environment; and
protecting them from avoidable harm
Topic Patient Safety
Detailed Descriptor The number of MRSA bloodstream infections
Reporting Frequency Quarterly, with monthly breakdowns
Data source Laboratory register
Data filter All reported data
Calculation None required, as the indicator is a single count
Reporting type Count
Coverage Hospital wide
Person in charge Microbiologist
Type of data
 Masalahnya
Data agregat yang disajikan dalam bentuk tabel
atau nilai statistik tidak akan membantu
menunjukkan dampak dari proses peningkatan
mutu.
Data agregat hanya memberikan ‘judgment”
tapi tidak menunjukkan ‘improvement’ yang
terjadi.
Veronika JW, Anahí D, Ralph G. Trends in antibiotic utilization in eight Latin American
countries, 1997–2007. Rev Panam Salud Publica: 27; 3; Mar. 2010
Line graph representing waiting times
in the emergency department
of two hospitals
Basic Tools for Improving Quality
 1. Basic Data Presentation

1. Deskriptif Statistik
 2. Percentage change

Prevalence of pressure ulcers before and after intervention

3. Measures of centre
Satisfaction survey (response rate)
Satisfaction Survey Results
4. Pie Chart
5. Using bar for comparison
6. Box Plots
 7. Measures of Variance
• Range : Maximum – Minimum
• Variance
• Standard Deviation
• Confidence interval
2. Histogram
 Histogram
• Shows relative frequencies
• Produced from grouped data
• Determine the number of classes
– 2a−1 < n ≤ 2a
– n=100, 26 < n ≤ 27 = 7 classes
• Get insight into the shape of of the
distribution of population
3. Pareto Chart
 Pareto Chart
• Bar chart
• bedanya dengan histogram: tersusun
menurun
• Penemu: Vilfredo Pareto (1848-1923)
• Diaplikasikan pertama kali oleh JM. Juran
• Menunjukan level non-conformity
• Coba dibuat dengan memasukkan kategori
lain jika pareto chart tidak terbentuk
 Pareto Chart

Vital Few
Trivial many
4. Check sheet
 Check Sheet
• A means of recording historical data
– on causes of nonconformities
– On nonconforming units
• Source of data for Pareto Chart
• no uniform design
• notes on raw materials, machine
performance, or operator changes.
 5. Scatter Plot
• Simplest: bivariate scatter plot
• Vertical axis: dependent variable
• Perhatikan scaling axis
• Ada dua jenis:
– a time sequence plot
• (minute, hours, days, weeks, years)
– A probability plot
• Horizontal Axis: observation
• Vertical axis: probability distribution
 A time sequence scatter plot
of patient priority score vs time waited for surgery (n=50)
A probability scatter plot
 6. Control Chart
• a time sequence plot with “decision lines”
added:
• to determine whether or not a process is in control
• can indicate when a process is “out of
control.”
• Similar to hipothesis testing (balance between
type 1 and type 2 error)
Basic form of a control chart
7. Cause and Effect Diagram
 Cause and Effect Diagram
• Introduced by Prof Ishikawa in 1943
• Ishikawa diagram/fishbone chart
• list as many possible or probable causes as we
can think of without making the diagram too
cluttered
• maintaining the correct relationship between
the causes.
 Cause and Effect Diagram
• When a relationship between the quality
characteristic and a cause can be shown
quantitatively using numerical information,
the cause should be enclosed in a box
• When it is known that a relationship between
a cause and an effect does exist, but the
relationship cannot be supported with data,
the cause should be underlined
• No relationship : only be labeled
Negative Ishikawa diagram
 8. Defect Concentration Diagram
• a schematic diagram that shows the various
sides of a unit of production
• the positions where nonconformities occur
pinpointed
• Defect location check sheet (Ishikawa)
• information about the potential causes
Control Chart
Control chart representing nosocomial
infections in the ED
Performance improvement Data
Chest Pain in Emergency
Department. Slide courtesy of IHI
 Average CABG Mortality
Before and After implementation of a new Protocol
(Slide courtesy of IHI)
A second look at the Data

7%

2%
Angka rata-rata tidak menggambarkan
situasi sesungguhnya

Χ (CL)

Waktu
 Bagaimana variasi dalam sebuah
sistem dengan berjalannya waktu?

Shewhart 1920: variasi terkontrol

dan tidak terkontrol (special cause)
 Jenis Variasi
• Terkontrol (common • Tidak terkontrol (special
cause) cause)
– Terkait dengan desain – Bukan disebabkan
proses karena desain proses
– Akibat proses regular, – Akibat proses ireguler
penyebab natural, atau atau tidak alami
biasa. – Mempengaruhi sebagian
– Mempengaruhi semua outcome tapi tidak
outcome proses seluruhnya
– Hasilnya stabil – Hasilnya tidak stabil
– Bisa diprediksikan – Tidak bisa diprediksikan
 Akibat variasi: apakah outcomenya
bisa diterima?
• Contoh:
– Seorang pasien dengan rata-rata tekanan darah
165 mmHg dan bervariasi antara 160 – 170
mmHg. Variasi ini stabil, dan bisa diprediksi, tetapi
tidak bisa diterima. Harus diturunkan.
– Waktu tunggu hasil laboratorium bervariasi antara
4-6 jam. Pada salah satu minggu, waktu
tunggunya hanya berkisar antara 30 menit – 1
jam.
Bagaimana menilai variasi dalam
proses perbaikan mutu?
 Run Chart
Run adalah satu atau
Plot the dots… lebih data points pada
salah satu sisi median
yang sama, tidak
termasuk data point yang
terletak pada median.

X (Median)

Waktu
Non-random rules for run chart
Shewhart’s Control Chart

Sigma Limit
UCL
Upper Control Limit

Χ (CL)
LCL
Lower Control Limit
Biasanya diperlukan 15-20 data points

Waktu
Pembagian Zona dalam Control Chart

Zone A +3 SL
UCL
Zone B +2 SL Upper Control Limit

Zone C +1 SL Χ (CL)
Zone C -1 SL
Zone B -2 SL
LCL
Lower Control Limit
Zone A -3 SL
 Aturan Control Chart untuk
mengidentifikasi penyebab variasi
 Time to surfactant
administration of premature infants
Jenis-jenis control chart
“If I had to reduce
my message for
management to just
a few words, I’d say
it all had to do with
reducing variation”.
(W.Edwards Deming)
 you don’t have to be a
statistician to be successful in
quality improvement.
Terima Kasih