Variasi proses. It is all about patients First do no harm Second achieve best clinical outcome Third make the people “fly”

Presentasi berjudul: "Variasi proses. It is all about patients First do no harm Second achieve best clinical outcome Third make the people “fly”"— Transcript presentasi:

1 Variasi proses

2 It is all about patients

3 First do no harm Second achieve best clinical outcome Third make the people “fly”

4 Quality problems in hospital services Quality Problems Mortality Morbidity Disability Unsatisfactory achievement of clinical outcome Patient dissatisfaction

5 Quality Problems Mortality Morbidity Disability Unsatisfactory achievement of clinical outcome Patient dissatisfaction ? Preventable vs non preventable

6 Quality Problems ? Severity of the disease Individual biovariability Service delivery process Accident Incident Adverse event Unsafe act:: Clinical Error Violation Sabotage Complication

7 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

8 ? Severity of the disease Individual biovariability Service delivery process Human factor Process variation Latent conditions

9 Service delivery process Human factor Process variation Latent conditions Special cause Common cause

10 Intervensi perbaikan Standardisasi Standardisasi Process improvement: Process improvement: – step by step improvement – radical improvement (reengineering)

11 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

12 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: www.ihi.org atau yang lain, cari satu contoh penerapan model Nolan untuk perbaikan www.ihi.org –Susun ringkasan dari artikel tsb –Bagaimana pendapat saudara apakah model Nolan dapat diterapkan di rumahsakit di Indonesia