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DR.DR. MELIANA ZAILANI CLINICAL GOVERNANCE AND CLINICAL AUDIT.

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Presentasi berjudul: "DR.DR. MELIANA ZAILANI CLINICAL GOVERNANCE AND CLINICAL AUDIT."— Transcript presentasi:

1 DR.DR. MELIANA ZAILANI CLINICAL GOVERNANCE AND CLINICAL AUDIT

2 IMPORTANT ELEMENTS OF CLINICAL GOVERNANCE Education & training Clinical audit Clinical effectiveness Risk management Research and development Openness

3 Clinical Governance Clinical Governance Clinical audit Clinical audit Education & Training Education & Training Risk management Risk management Account- ability Account- ability Research & development Research & development Clinical Effective- ness Clinical Effective- ness Important elemen of clinical governance

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5 TOPIK YANG PERLU DIAUDIT: Layanan klinis yang diterima oleh pasien Manajemen (atau organisasi) fasilitas kesehatan Aspek hak asasi manusia dari layanan medis

6 UNDANG UNDANG NOMOR RI NOMOR 44 TAHUN 2009 TENTANG RUMAH SAKIT Pasal 39. 1)Dalam penyelenggaraan RS harus dilakukan audit 2)Audit sebagaimana dimaksud dapat berupa audit kinerja dan audit klinis. (penjelasan: audit kinerja adalah pengukuran kinerja berkala yg meliputi kinerja pelayanan dan kinerja keuangan, audit medis adalah upaya evaluasi profesional thd mutu yan med yg diberikan kpd pasien dg menggunakan rekam medisnya yg dilaksanakan oleh profesi medis 3)Audit kinerja dan audit medis dapat dilakukan secara internal dan eksternal (Penjelasan : audit medik internal oleh Komite Medik, audit kinerja internal oleh SPI)

7 Analisis kritis yang sistematik dari kualitas pelayanan kesehatan, meliputi prosedur yang digunakan untuk diagnosis dan pengobatan, dalam rangka menyiapkan jaminan bahwa mutu pelayanan yang terbaik dapat tercapai, dengan memperhatikan sumber daya yang tersedia Audit Klinis: Assessment dari keseluruhan pelayanan klinik

8 AUDIT MEDIS Audit medis adalah upaya evaluasi secara profesional terhadap mutu pelayanan medis yang diberikan kepada pasien dengan menggunakan rekam medisnya yang dilaksanakan oleh profesi medis. Audit medis : Assessment dari pelayanan medis yang dilakukan oleh peer group (mitra bestari) Mitra bestari (peer group) adalah sekelompok staf medis dengan reputasi dan kompetensi profesi yang baik untuk menelaah segala hal yang terkait dengan profesi medis

9 AUDIT KLINIS Dapat mengakses: Structure - type of resources Process - what is done to patients Outcome - the result of clinical interventions

10 EXAMPLES OF CLINICAL INDICATORS Hospital death Unplanned re-admission Compliance to treatment regimen Admission for certain health problem Surgery for certain conditions Length of hospital stay CPR in non-ICU setting

11 Meliputi sistem organisasi dan dan proses untuk monitoring dan peningkatan pelayanan, antara lain: Konsultasi dan keterlibatan pasien Manajemen risiko klinis Audit Klinis Research and effectiveness Staffing and staff management Pendidikan, pelatihan dan pengembangan profesi berkelanjutan. Penggunaan informasi dari pengalaman, hasildan proses

12 AUDITS DEPEND ON THE PRESENCE OF TWO THINGS: 1. Standards (or protocols, or treatment guidelines) are essential to the audit process. Every practice or procedure in a medical facility should be governed by a standard from the treatment of life-threatening complications to cleaning the wards to respecting patients’ privacy. These standards are the source of the criteria on which criterion-based audits are based. Where standards do not exist, criterion-based audits cannot be accomplished.  This is not to say you should abandon the idea! Rather you should find and adopt standards, or – as a last resort – write your own. 2. Written records are essential to almost all audits of clinical practice most audits of administrative procedures such as management of pharmaceutical supplies. In fact, it would be a very good idea to audit the completeness of the records before any other audit is begun. A quick review of a sample of records may indicate that until records are better kept, a criterion-based audit will not be feasible.  Remember – if it is not written down, it did not happen !

13 HOW TO SELECT THE KIND OF AUDIT THAT WILL BE MOST USEFUL FOR YOUR MEDICAL FACILITY how to get started, who to involve, what criteria to use, how to analyze the data, how to identify the problems, how to make recommendations, and finally, how to evaluate whether the audit had any impact on the quality of the medical care

14 AUDIT BUKAN REVIEW  “Reviews” merupakan diskusi rutin, al. laporan kematian dan komplikasi kasus laporan pagi/laporan kasus laporan kematian bulanan  apabila dalam review teridentifikasi adanya suatu problem, staf harus memutuskan apakah hal tersebut merupakan suatu masalah yang umum (suatu audit dapat menjelaskan hal ini), apakah sudah tersedia standar (tetapi tidak selalu di ikuti) untuk mengatasi masalah ini atau apakah harus dibuat standar baru. bila dibuat Standar baru seluruh staf harus dilatih untuk implementasi dan diberlakukan masa transisi sebelum di lakukan audit

15 WHY CONDUCT AN AUDIT? Effective audit > Improves practice > Promotes efficient use of resources > Improves staff morale and motivation > Improves case fatality rates > Increases met need for Em C > Increases utilization of services

16 MEDICAL AUDIT Involves a systematic approach Highlights opportunities for improvement Provides mechanism for change Is different from case presentation, morbidity & mortality meetings

17 THE AUDIT CYCLE involves: Observation of existing practice The setting of standards Comparison between observed and set standards Implementation of change Reaudit of clinical practice

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19 High RiskHigh CostHigh Volume

20 R i s k S e v e r i t y Risk Frequency Insignificant Mild Moderate Severe Very severe Certain Very likely Possible Unlikely Rare

21 AUDIT TECHNIQUES Basic clinical audit - throughput, morbidity, mortality Incident review - critical incident reporting Clinical record review Criterion audit - retrospective analysis judged against chosen criteria Adverse occurrence screening Focused audit studies - specific outcome Global audit - comparison between units National studies - e.g. NCEPOD

22 COMPARATIVE AUDIT Hal yang harus diperhatikan High quality data collection Relevant and valid measure of outcome Appropriate and valid measures of case mix A representative population Appropriate statistical analysis

23  HAKEKAT AUDIT MEDIS Menjaga mutu Kepedulian terhadap keselamatan pasien Bukan untuk tujuan menilai performance dokter Bukan instrumen untuk menilai ada /tidaknya kesalahan dokter pada kasus dugaan malpraktek

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