Variasi proses
It is all about patients
First do no harm Second achieve best clinical outcome Third make the people “fly”
Quality problems in hospital services Quality Problems Mortality Morbidity Disability Unsatisfactory achievement of clinical outcome Patient dissatisfaction
Quality Problems Mortality Morbidity Disability Unsatisfactory achievement of clinical outcome Patient dissatisfaction ? Preventable vs non preventable
Quality Problems ? Severity of the disease Individual biovariability Service delivery process Accident Incident Adverse event Unsafe act:: Clinical Error Violation Sabotage Complication
System approach to patient safety S tructure – P rocess – O utcome Standard of care Hazard Latent Condition Active Failure: Unsafe acts Errors Violation Sabotage Errors: Human (slips, lapses, mistakes) Medical Medication Accident: Complication Contributing factors RCA, FMEA Adverse event Incident & Critical Incident Notes: Term to be avoided: Blame, Fault, Negligence, Recklessness Sumber: The Canadian Patient SafetyDictionary, October 2003
? Severity of the disease Individual biovariability Service delivery process Human factor Process variation Latent conditions
Service delivery process Human factor Process variation Latent conditions Special cause Common cause
Intervensi perbaikan Standardisasi Standardisasi Process improvement: Process improvement: – step by step improvement – radical improvement (reengineering)
Quality improvement process Model Nolan Apa yang ingin kita capai? Bagaimana kita tahu bahwa perubahan yang dilakukan adalah perbaikan ? Perubahan apa yang dapat kita lakukan yang hasilnya adalah perbaikan? P DC A Aims Measurements Planned change
Tugas untuk variasi proses Terkait dengan process variation, cari artikel tentang Indeks Kemampuan Proses (Process capability) –Berikan ringkasan ttg artikel tersebut –Bagaimana pendapat saudara apakah pengukuran indeks kemampuan proses dapat diterapkan di rumahsakit Masuk ke website: atau yang lain, cari satu contoh penerapan model Nolan untuk perbaikan –Susun ringkasan dari artikel tsb –Bagaimana pendapat saudara apakah model Nolan dapat diterapkan di rumahsakit di Indonesia