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Variasi proses

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. Mortality. Quality Problems. Morbidity. Disability. Unsatisfactory achievement of clinical outcome.

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Variasi proses

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  1. Variasi proses

  2. It is all about patients

  3. First do no harmSecond achieve best clinical outcomeThird make the people “fly”

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

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

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

  7. System approach to patient safety Structure – Process – Outcome Adverse event Incident & Critical Incident Contributing factors RCA, FMEA Accident: Complication Standard of care Hazard Latent Condition • Active Failure: • Unsafe acts • Errors • Violation • Sabotage • Errors: • Human (slips, lapses, mistakes) • Medical • Medication Notes: Term to be avoided: Blame, Fault, Negligence, Recklessness Sumber: The Canadian Patient SafetyDictionary, October 2003

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

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

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

  11. Quality improvement processModel 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? Aims Measurements Planned change P A C D

  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 • Susun ringkasan dari artikel tsb • Bagaimana pendapat saudara apakah model Nolan dapat diterapkan di rumahsakit di Indonesia

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