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Clinical Pathway Cost of Treatment(Conceptual Thinking Application)
Ronnie Rivany Health Hospital Economics
Pusat Kajian Ekonomi & Kebijakan Kesehatan FKMUI
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JASTIFIKASI
Standarisasi tarif RS ?
Belum ada Clinical Pathway sebagai penjagamutu & sebagai basis layanan MUTU danbasis perencanaan/perhitungan biaya
Sistem, Kebijakan dan Prosedur yang tidak jelas dan tidak konsisten serta belumterintegrasi
Buku Tarif Departemen Kesehatan 2007 (?)
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1 Diseases and disorders of the nervous system
2 Disease and disorders of the eye
3 Disease and disorders of the ear, nose, and throat
4 Disease and disorders of the respiratory system
5 Disease and disorders of the circulatory system6 Disease and disorders of the digestive system
7 Disease and disorders of the hepatobiliiary system and pancreas
8 Disease and disorders of the musculoskeletal system and connective tissue
9 Disease and disorders of the skin, subcutaneous tissue, and breast
10 Endocrine, nutritional, and metabolic diseases and disorders
11 Disease and disorders of the kidney and the urinary tract
12 Disease and disorders of the male reproductive
13 Disease and disorders of the female reproductive system
14 Pregnancy, childbirth, and the purperium
15 Newborn and other neonates with conditions originating in the perinatal period
16 Disease and disorders of blood and blood forming organs and immunological disorders
17 Myeloproliferative disease and disorder, and poorly differentiated neoplasm
18 Infectious and parasitic disease (systemic or unspecified sites)
19 Mental diseases and disorders
20 Alcohol/drug use and alcohol/drug- induced organic mental disorders
21 Injuries, poisoning, and toxic effects of drugs
22 Burns
23 Factors influencing health status and other contact with health services
Major Diagnostic Categories (AR-DRG v 5,2, 2006)
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DRG Numbering The format = A DD S A = Pre MDC DRGs ; B = nervous system
DRG; O = Reproductive System ; Z = DRGsrelating to other health factors; 9 = the errorDRGs
DD = DRGs partition; Range 01 39 Surgical Partition Range 40 59 Other Partition
Range 60 99 Medical Partition S = split indicator A = highest resources DRG B = second highest resources
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General Logic,Diagnosis Related Groups All acute admited patien
Principal diagnosis
Major diagnostic category # 1
Significant secondary condition ?
Procedure cluster A over age X
What age groups
What procedure
ProcedureCuster A
Procedure cluster A
Over Age X, with CC
Surgical Partition of MDC # 1
Procedure cluster A
Over Age X, without CC
Procedure cluster A under age X
ProcedureCluster C
ProcedureCluster D
ProcedureCluster B
Medical Partition of MDC # 1
MDc # 4MDC # 3MDC # 2
Yes No
Over Under X
Yes No
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INDONESIAN DRGs
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INDONESIAN DRGs
Pola pikir ICD tetap MDC untuk sementara tetap Clinical Pathway bisa dibuat DRG di konfirmasi + bisa dibuat
Casemix di konfirmasi + bisa dibuat Costing dilakukan dengan pendekatan
Activity Based Costing + Simple
Distribution
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POLA PIKIR INDONESIAN DRGs (1)
INA - DRG
1.Konfirmasi DRG 2.Hitung Cost/DRG
Clinical Pathway & Casemix
Activity Based Costing
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POLA PIKIR INDONESIAN DRGs (2)
ICD
MDC
DRG DRG
CASEMIX
COST
COST
DRG
TARIF
TARIF
1
2
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Clinical Pathway
Anticipated Recovery Pathway (ARPs) Multidisciplinary Pathways of Care (MPCs)
Care Protocols Integrated Care Pathways Pathways of Care Care Packages
Collaborative Care Pathways Care Maps Care Profiles
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Konsep perencanaan pelayananterpadu yang merangkum setiap
langkah yg diberikan kepada pasienberdasarkan standar yanmed,standar asuhan keperawatan&
standar pelayanan tenaga kesehatan
lainnya , yg berbasis bukti dng hasilyg dpt diukur dan dalam jangka
waktu tertentu selama di rumah sakit
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1 Diseases and disorders of the nervous system
2 Disease and disorders of the eye
3 Disease and disorders of the ear, nose, and throat
4 Disease and disorders of the respiratory system
5 Disease and disorders of the circulatory system6 Disease and disorders of the digestive system
7 Disease and disorders of the hepatobiliiary system and pancreas
8 Disease and disorders of the musculoskeletal system and connective tissue
9 Disease and disorders of the skin, subcutaneous tissue, and breast
10 Endocrine, nutritional, and metabolic diseases and disorders
11 Disease and disorders of the kidney and the urinary tract
12 Disease and disorders of the male reproductive
13 Disease and disorders of the female reproductive system
14 Pregnancy, childbirth, and the purperium
15 Newborn and other neonates with conditions originating in the perinatal period
16 Disease and disorders of blood and blood forming organs and immunological disorders
17 Myeloproliferative disease and disorder, and poorly differentiated neoplasm
18 Infectious and parasitic disease (systemic or unspecified sites)
19 Mental diseases and disorders
20 Alcohol/drug use and alcohol/drug- induced organic mental disorders
21 Injuries, poisoning, and toxic effects of drugs
22 Factors influencing health status and other contact with health services
23 Medical Outpatient Visit
Major Diagnostic Categories (Pedoman Tarif ?? DEPKES,2007
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HUBUNGAN C.P & DRG/CASEMIX
ICD
MDC
TARIF
DRG DRG
CASEMIX
COST
COST
TARIF
DRG
Clinical Pathway
l l h l
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Clinical Pathway in Hospital
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International Classification of Disease (ICD)
Major Diagnostic Categories (MDC)
Surgical / Other / Medical
Diagnosis Related Groups (DRGs)
Casemix
ClinicalPathway
Pengembangan KonsepClinical Pathway
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Format dasar Clinical Pathway Aktivitas pelayanan Pra R.I
(Poliklinik/ UGD)
Rawat Inap (R.I)
Hari I Tgl
Hari 2 Tgl
Komplikasi /
Co- morbidity
1 2 3 4 5
Pendaftaran
Penetapan Diagnose
Pra-Perawatan
Perawatan
Tindak Lanjut
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Aktivitas pelayanan Pra R.I (Poliklinik/
UGD)
Rawat Inap (R.I)
Hari I Tgl
Hari 2 Tgl
Komplikasi /
Co- morbidity
1 2 3 4 5
Pra-Perawatan
Assessment klinis pemeriksaan/visite dokter konsultasi
Pemeriksaan penunjang laboratorium Radiologi
Dst sesuai SPM, SAK & SPO
Perawatan
Tindakan medis Pemberian obat
Dst-nya, sesuai SPM,SAK & SPO
CLINICAL PATHWAY DALAM
TAHAPAN PRA PERAWATAN & PERAWATAN
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No SOP Hari.1
Diag.Utama + Serta + Sulit +
Serta+ Sulit
1 A d m i s s i o n
2 Diagnost ic
3 Pra Therapy
4 Therapy
5 Fol low Up
6 Discharge
DUMMY TABLE (1)Clinical Pathw ay Uti l isas i
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DUMMY TABLE (2)Clinical Pathway Utilisasi
No Aktivitas SDM OBAT OVERHEAD
1 A d m i s s i o n
2 Diagnost ic
3 Pra Therapy
4 Therapy
5 Fol low Up
6 Discharge
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DUMMY TABLE (3)Clinical Pathway Utilisasi
No Aktivitas MinUtilisasi
MaxUtilisasi
Mean /MedianUtilisasi
1 A d m i s s i o n
2 Diagnost ic
3 Pra Therapy
4 Therapy
5 Fol low Up
6 Discharge
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CLINICAL PATHWAY
SYMPTOM DIAGNOSIS THERAPY FOLLOW UP
1
Activities ABC
ActivitiesABC
ActivitiesABC
ActivitiesABC
ActivitiesABC
2 3 4 5
Admission Diagnosis Pre Therapy Therapy Follow up
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Diawali dengan membuat template untukmendapatkan clinical pathway . Langkah-langkah dalam membuat clinical pathwayadalah sebagai berikut :
Membuat koding untuk memudahkan entry data.
Entry data karakteristik, identitas, tanggalmasuk dan keluar rumah sakit, lama harirawat, jenis pembayaran, diagnosa utama,penyakit penyerta, penyakit penyulit, caramasuk, status keluar dan kelas rawatan dari
masing-masing pasien. Entry data dilakukanberdasarkan kelom ok AR-DRG.
PEMBUATAN CLINICAL PATHWAY (1)
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Entry semua aktivitas yang diterima pasien dari masuksampai pulang dan pada waktu rawat jalan. Semuaaktivitas dekelompokkan berdasarkan tahap clinicalpathway.
Konfirmasi tahap clinical pathway dan variabelkegiatan dengan SPM IDI, SPM Profesi dan para
dokter dan paramedis di Rumah Sakit . Draft clinical pathway diisi berdasarkan frekuensimasing-masing kasus.
Berdasarkan nilai mean atau median didapatkan nilairata-rata masing-masing variabel dalam clinical
pathway perhari rawatan berdasarkan kelompok AR-DRG. Cleaning dan pengecekan ulang terhadap nilai
utilisasi berdasarkan tahap dalam clinical pathwaymasing-masing kelompok AR-DRG sehingga
didapatkan nilai utilisasi kelompok AR-DRGberdasarkan clinical athwa .
PEMBUATAN CLINICAL PATHWAY (2)
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Draft & Finalisasi Clinical Pathway
Setelah draft Clinical Pathway yangberbasis evidence tadi telah dibuat, makatahapan akhir dari penyusunan ClinicalPathway ini adalah Focus GroupDiscussion dengan Panel Expert ( paraspesialis ) dan Ikatan Profesi , untuk
bersama-sama menyepakati jenis dan jumlah tindakan/FORMULARIUMyang akan dipergunakan dalam Clinical
Pathway
PEMBUATAN CLINICAL PATHWAY (3)
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DUMMY TABLE (1)Clinical Pathway Cost of Treatment
Activities Day.1 Day.2 Day.3 Day..
Admission + + + +
Diagnosis + + + +
Pre Therapy + +
Therapy + + + +Follow Up
Discharge
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No Activities Day.1
PrincipalDiagnosis
Penyulit Penyerta PP
1 Nursing
2 Consultation
3 Doctor visits4 Medical Procedures
5 Nursing
6 Medical /DRUGS Treatment
7 Supporting exams
8 Nutrition
9 Physiotherapy
10 Etc
Clinical Pathway Cost of Treatment
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No Activities U DC IC TC UC U x UC
1 Admission
2 Diagnosis3 Pre Therapy
4 Therapy5 Follow Up6 Discharge
T O T A L C/DRG
DUMMY TABLE (3)Clinical Pathw ay Cos t of Treatm ent
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Cost of Treatment(Cost DRG/Casemix)
No Cost of Treatment / Activity BasedCosting
Direct Cost IndirectCostInvestasi Operasional Pemeliharaan
1 Admission
2 Diagnostic
3 Pra Therapy
4 Therapy5 Follow up
6. Discharge
INDEX
%
%
%
%
%
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Cost of Treatment Rawat Inap dan Rawat JalanNo AR-DRG KLS. III KLS. II KLS.I UTAMA VIP RAJ
1 B70A 5181485 5281384 5339924 5778045 5805053 80312 B70B 4075179 4153671 4199667 4543904 4565126 99513 B70C 1905273 1976629 2018443 2331386 2350678 987044 B70D 1848767 1863038 1871401 1933989 1937848
Perbandingan Biaya Rawat Inap KLS.IIINo AR-DRG KLS. III Tanpa Gaji Tanpa Obat Tanpa Gaji
Dan Obat1 B70A 5181485 4250350 2972007 20408722 B70B 4075179 3476706 2250808 16523343 B70C 1905273 1489521 1438879 10231274 B70D 1848767 1624600 1030735 806568
APLIKASI COST/DRG/Casemix dalam PK BLU(1)
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CLINICAL PATHWAY COST of TREATMENT
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TARIFF DETERMINANT per DRGS
TARIFF
UNIT COSTROOM & BOARD
UNIT COSTDRUGS
UNIT COSTOK
UNIT COSTMED SUPPLIES
UNIT COSTLAB
Total cost Q
COST/DRGs Margin
ACTIVITY BASED COSTING + SIMPLE DISTRIBUTION
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LAPORAN
Clinical Pathway & Cost of Treatment Diagnos is Related Group (DRGs)
Sectio Caesaria, Diare Anak & Katarak (2008)Apendictomy & Pneumonia Anak (2009 - 2010)
DINAS KESEHATANPemerintah Propinsi Daerah Khusus Ibukota Jakarta
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REKAM MEDIK DI RUMAH SAKIT
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LAPORAN
Clinical Pathway & Cost of Treatment Diagnos is Related Group (DRGs)
10 Dept International Wing2009 - 2010
RUMAH SAKITDr Cipto Mangunkusumo, Jakarta
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LAPORANClinical Pathway & Cost of Treatment
Diagnos i s Related Group (DRGs) Rumatan Methadon, 2010
RUMAH SAKIT KETERGANTUNGAN OBATCibubur - Jakarta
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DIREKTORAT JENDERAL BINA PELAYANAN MEDIKDEPARTEMEN KESEHATAN
2005
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RS wajib memp.CP, Diagnosis mengacupada ICD-10,Prosedur mengacu pd ICD-9CM Flowchart penyusunan CP
SPM Profesi Model Dummy
SPM RS
SOP Aktivitas
ICD
Surgical Medical
DRG
Case Mix
Clinical PathwayTerukur(admission to discharge)contoh :-Diare anak-Sectio Caesaria
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TUJUAN : utk meningkatkan mutu Yan pasien
memaksimalkan penggunaan sumber dayascr efisien dng mengurangi dokumentasi ygtdk diperlukan.
membantu identifikasi & klarifikasi prosesYan klinis
mendukung efektivitas klinik, audit medis &risk management
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Dalam menyusun c l in ica l pa thway (C.P) di RS peru
memadukan & menyesuaikan dng bbagai sistem ygtlh dibangun serta tlh bjalan sehingga stiap bagianyg ada di RS lebih mudah menyesuaikan & salingmendukung pd saat C.P. selesai dibuat &disosialisasikan.
Komite Medik sngt bperan dlm mbantu penyusunan& plaksanaan C.P. di RS.
Pedoman C.P. di RS diharapkan dpt mbantu RS dlmmenyusun C.P. dlm rangka mendukung plaksanaanpengembangan DRGs Casemix di RS.
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TERIMA KASIHatas perhatian & kesempatan
kerjasamanya
www.ina-drg-rr.net