Kerangka Kerja Mutu:Penguatan Proses Pengembangan di Indonesia
1Adi Utarini
Struktur
• Mengapa dibutuhkan Kerangkakerja mutu?
• Kerangka kerja mutu:Indonesian National QualityFramework
• Pemikiran mengenai langkahpengembangan
• Mengapa dibutuhkan Kerangkakerja mutu?
• Kerangka kerja mutu:Indonesian National QualityFramework
• Pemikiran mengenai langkahpengembangan
Mutu: Perubahan Paradigma
Service Excellence
Clinical Excellence
Patient Safety
Global Burden of Unsafe Care (Jha et al., 2013)
• In every 100hospitalisations, therewere approximately14.2 of these adverseevents in HICs and 12.7in LMICs.
• In every 100hospitalisations, therewere approximately14.2 of these adverseevents in HICs and 12.7in LMICs.
Studi Patient Safety di beberapa negara
Is Safety-Quality important?
Lit review (Sandars & Esmail 2003)• Medical errors: 5 – 80x in
100,000 consultations• Prescribing error: 11% of total
prescriptions
Lit review (Sandars & Esmail 2003)• Medical errors: 5 – 80x in
100,000 consultations• Prescribing error: 11% of total
prescriptions
Primary care clinics, Malaysia (Khoo et al, 2012):• 3.6% diagnostic errors• 41.1% medication errors• 39.9% of errors had the potential to cause serious harm.• 98.0% illegible handwriting• 93.5% of errors detected were preventable.
StructureWhat resources
do you use:Resources
Personnel,Equipment,
drugs, financeetc.
Donabedian’s framework of quality careDonabedian’s framework of quality care
ProcessHow to use the
resources: Careprocesses
Standards, Guidelines, SOP
Outcome What is theresult? Result
Result of care:Disability, death,dissatisfaction, cli
nical indicators
Apa yang perlu dimiliki Indonesiauntuk membangun Mutu?
Struktur
• Direktorat Mutu danAkreditasi
• Regulasi Mutu danKeselamatan Pasien
• Kerangka Kerja Mutu• Komite nasional• …
Proses
• Perijinan• Akreditasi• Sistem manajemen mutu• Panduan Praktek Klinis• Standar, prosedur, norma
dll.• …
Outcome
• Indikator• Peningkatan mutu• Pengalaman pasien• …
• Direktorat Mutu danAkreditasi
• Regulasi Mutu danKeselamatan Pasien
• Kerangka Kerja Mutu• Komite nasional• …
• Perijinan• Akreditasi• Sistem manajemen mutu• Panduan Praktek Klinis• Standar, prosedur, norma
dll.• …
• Indikator• Peningkatan mutu• Pengalaman pasien• …
Quality Framework
Quality framework• Quality framework is a framework that is
applied as a foundation for improving qualityof services (at geographical level, institutionallevel, service level, professional level etc)
• Quality framework represents thestakeholder’s commitment toward qualitydimensions and their priorities,measurements, regulations and qualitymanagement system
• Quality framework is a framework that isapplied as a foundation for improving qualityof services (at geographical level, institutionallevel, service level, professional level etc)
• Quality framework represents thestakeholder’s commitment toward qualitydimensions and their priorities,measurements, regulations and qualitymanagement system
Quality Framework
A. How do weachieve Quality?
• Kerangka kerjanasional
• Tata kelola Klinis• Sistem
manajemenmutu
• Akreditasi RS• Akreditasi Pkm• Dll.
B. What level of quality arewe committed to provideto our patients, familiesand communities?
• Kerangka kerjanasional
• Tata kelola Klinis• Sistem
manajemenmutu
• Akreditasi RS• Akreditasi Pkm• Dll.
• Akses• Keselamatan• Keadilan• Dsb.
Komitmen Mutu: Dimensi yang mana?
• Effectiveness• Equity• Efficiency• Safety• Access• Patient
centeredness
• Timeliness• Consumer
engagement• Community
engagement• Technical
competence
• Effectiveness• Equity• Efficiency• Safety• Access• Patient
centeredness
• Timeliness• Consumer
engagement• Community
engagement• Technical
competence
Six quality aims (Institute of Medicine, USA)
• Safe• Effective• Patient centered
• Timely• Efficient• Equitable
• Safe• Effective• Patient centered
• Timely• Efficient• Equitable
National Strategy for QualityImprovement in Health Care (US)
3 Aims
• Better Care: Improve the overallquality, by making health caremore patient-centered, reliable, accessible, andsafe.
• Healthy People/HealthyCommunities: Improve the healthof the U.S. population bysupporting proven interventionsto address behavioral, socialand, environmental determinantsof health in addition to deliveringhigher-quality care.
• Affordable Care: Reduce the costof quality health care forindividuals, families, employers, and government.
6 Priorities• Making care safer by reducing harm
caused in the delivery of care.• Ensuring that each person and family are
engaged as partners in their care.• Promoting effective communication and
coordination of care.• Promoting the most effective prevention
and treatment practices for the leadingcauses of mortality, starting withcardiovascular disease.
• Working with communities to promotewide use of best practices to enablehealthy living.
• Making quality care more affordable forindividuals, families, employers, andgovernments by developing andspreading new health care deliverymodels.
• Better Care: Improve the overallquality, by making health caremore patient-centered, reliable, accessible, andsafe.
• Healthy People/HealthyCommunities: Improve the healthof the U.S. population bysupporting proven interventionsto address behavioral, socialand, environmental determinantsof health in addition to deliveringhigher-quality care.
• Affordable Care: Reduce the costof quality health care forindividuals, families, employers, and government.
• Making care safer by reducing harmcaused in the delivery of care.
• Ensuring that each person and family areengaged as partners in their care.
• Promoting effective communication andcoordination of care.
• Promoting the most effective preventionand treatment practices for the leadingcauses of mortality, starting withcardiovascular disease.
• Working with communities to promotewide use of best practices to enablehealthy living.
• Making quality care more affordable forindividuals, families, employers, andgovernments by developing andspreading new health care deliverymodels.
Tanzania: 2011-2016
• Acceptability/patient centeredness• Technical competence• Access• Interpersonal relations• Effectiveness• Equity• Efficiency• Safety• Continuity of care• Choice of service• Physical infrastructure & Amenities
• Acceptability/patient centeredness• Technical competence• Access• Interpersonal relations• Effectiveness• Equity• Efficiency• Safety• Continuity of care• Choice of service• Physical infrastructure & Amenities
OECD Countries: 23 negara
Berbagai negara, berbagai dimensi mutu…
Dimensi Mutu:Indonesia
Dari beberapa dokumenkebijakan:
• Akses• Continuity of care• Cost of care• Infrastruktur fisik• Ketersediaan obat-alkes• Kompetensi teknis SDM
Dari beberapa dokumenkebijakan:
• Akses• Continuity of care• Cost of care• Infrastruktur fisik• Ketersediaan obat-alkes• Kompetensi teknis SDM
Quality Framework Victoria (Australia)
New South Wales, Australia
Dari Kerangka Kerja Mutu ke Indikator:Menyusun Benang Merah
Contoh: Performance Assessment Tool for qualityimprovement in Hospital (PATH model, WHO)
Example of PATH indicators
Clinicaleffectiveness and
safety
Efficiency
LOS
Stafforientationand safety
Responsivegovernance
Breastfeedingat discharge
Patient-centered
ness
Patientexpectat
ions
Clinicaleffectiveness and
safety
SC
Prophylacticantibiotics use
Readmission
Surgicaltheatre use
Needleinjuries
Staff smokingprevalence
Trainingexpenditure
Breastfeedingat discharge
Patientexpectat
ions
• Clinical indicators• Patient safety indicators• Quality indicators
IndeksKepuasanMasyarakat Indikator Klinis
IndikatorMutu
Indikator daribeberapalembaga:KARS, BPJS,Kemenkes
IndikatorKinerjaIndividu
Indikator MutuPelayanan RS
IndikatorMutu
Indikator daribeberapalembaga:KARS, BPJS,Kemenkes
Indikator KeselamatanPasien
Indikator Mutu Pelayanan di Indonesia
Quality Improvement
– We need to improveand a system toimprove
– “Every system isperfectly designed toachieve exactly theresults it gets.”
– The first law ofimprovement
– We need to improveand a system toimprove
– “Every system isperfectly designed toachieve exactly theresults it gets.”
– The first law ofimprovement
Global growth of Accred Org: 1951-2009
Akreditasi di negara-negara lain
• Kyrgyztan• India• Mongolia• Philippines• Albania• Jordan• Thailand• Bosnia (AAQI, AKAZ)• Colombia• Serbia• South Africa• Germany
• Brazil• Lithuania• Poland• Croatia• Saudi Arabia• Czech republic• South Korea• Portugal• Taiwan
EnglandJapanFranceDenmarkSwitzerlandNew ZealandSpainCanadaAustraliaUSANetherlands
• Kyrgyztan• India• Mongolia• Philippines• Albania• Jordan• Thailand• Bosnia (AAQI, AKAZ)• Colombia• Serbia• South Africa• Germany
• Brazil• Lithuania• Poland• Croatia• Saudi Arabia• Czech republic• South Korea• Portugal• Taiwan
EnglandJapanFranceDenmarkSwitzerlandNew ZealandSpainCanadaAustraliaUSANetherlands
Perbandingan antar lembaga akreditasimenurut:
• Fokus organisasi• Struktur organisasi• Jumlah RS terakreditasi• Histori• Tata kelola dan
kepemimpinan• Persyaratan akreditasi• Proses survei• Frekuensi survei• Surveyor
• Proses skoring• Kategori akreditasi• Biaya akreditasi• Proses keputusan
akreditasi• Support akreditasi• Advokasi• Keselamatan pasien• Peningkatan mutu• Dll.
• Fokus organisasi• Struktur organisasi• Jumlah RS terakreditasi• Histori• Tata kelola dan
kepemimpinan• Persyaratan akreditasi• Proses survei• Frekuensi survei• Surveyor
• Proses skoring• Kategori akreditasi• Biaya akreditasi• Proses keputusan
akreditasi• Support akreditasi• Advokasi• Keselamatan pasien• Peningkatan mutu• Dll.
Apa dampak akreditasi?• Brubakk et al., Systematic review of hospital accreditation: the challenges of measuring
complex intervention effects. BMC Health service research, 2015, 15:280
• Dorongan terus menerus untuk akreditasi, akan tetapibukti yang menunjukkan efektivitas dan efisiensinyaminimal, sehingga tidak dapat ditarik kesimpulantentang dampaknya.
• Sebagian besar studi tidak melaporkan konteksintervensi, implementasi ataupun biaya
• Tantangan dalam menilai dampak Akreditasi dansertifikasi yang merupakan contoh intervensi yangkompleks dan beragam
• Diperlukan studi untuk menjawab: Apa aspekakreditasi yang dapat bermanfaat untukmeningkatkan keselamatan pasien dan kinerjaorganisasi?
• Brubakk et al., Systematic review of hospital accreditation: the challenges of measuringcomplex intervention effects. BMC Health service research, 2015, 15:280
• Dorongan terus menerus untuk akreditasi, akan tetapibukti yang menunjukkan efektivitas dan efisiensinyaminimal, sehingga tidak dapat ditarik kesimpulantentang dampaknya.
• Sebagian besar studi tidak melaporkan konteksintervensi, implementasi ataupun biaya
• Tantangan dalam menilai dampak Akreditasi dansertifikasi yang merupakan contoh intervensi yangkompleks dan beragam
• Diperlukan studi untuk menjawab: Apa aspekakreditasi yang dapat bermanfaat untukmeningkatkan keselamatan pasien dan kinerjaorganisasi?
Remaining questions on accreditation
• Improving clinical outcomes?• Improving participation of clinician?• Improving patient satisfaction?• Improving patient experience?• Improving patient safety?• Improving departmental quality
improvement initiatives?• Efficient quality improvement strategy?
• Improving clinical outcomes?• Improving participation of clinician?• Improving patient satisfaction?• Improving patient experience?• Improving patient safety?• Improving departmental quality
improvement initiatives?• Efficient quality improvement strategy?
Quality Framework
A. How do weachieve Quality?
• Kerangka kerjanasional
• Tata kelola Klinis• Sistem
manajemenmutu
• AkreditasiRS, Pkm
• Dll.
B. What level of quality arewe committed to provideto our patients, familiesand communities?
• Kerangka kerjanasional
• Tata kelola Klinis• Sistem
manajemenmutu
• AkreditasiRS, Pkm
• Dll.
• Akses• Keselamatan• Keadilan• Dsb.
Usulan: Lima Tahap PengembanganKerangka Kerja Mutu (KKM)
Desk review• Berbagai dokumen
kebijakan• Dari berbagai lembaga
(Kemenkes, KARS, BPJS, dll)
• Output: Kompilasidimensi mutu
Eksploratori• Menggali dimensi
prioritas• Memetakan berbagai
peran lembaga• Mengidentifikasi
indikator dan strategi• Output: Usulan kerangka
kerja
Formulasi• Merumuskan Quality
Framework• Menyusun indikator dan
strategi QI• Output: Kerangka Kerja
Mutu PelayananKesehatan Indonesia
• Berbagai dokumenkebijakan
• Dari berbagai lembaga(Kemenkes, KARS, BPJS, dll)
• Output: Kompilasidimensi mutu
• Menggali dimensiprioritas
• Memetakan berbagaiperan lembaga
• Mengidentifikasiindikator dan strategi
• Output: Usulan kerangkakerja
• Merumuskan QualityFramework
• Menyusun indikator danstrategi QI
• Output: Kerangka KerjaMutu PelayananKesehatan Indonesia
Usulan Tahap PengembanganKerangka Kerja Mutu (KKM)
Implementasi Pilot
• Ujicoba Kerangka KerjaMutu
• Ujicoba indikator• Sistem pemantauan
indikator
Penyusunan Panduan
• Panduan pengembanganlanjutan kerangka kerjamutu di tingkatpropinsi, kabupaten, faskes dll
• Guideline penerapankerangka kerja
• Guideline pengukuranindikator
• Ujicoba Kerangka KerjaMutu
• Ujicoba indikator• Sistem pemantauan
indikator
• Panduan pengembanganlanjutan kerangka kerjamutu di tingkatpropinsi, kabupaten, faskes dll
• Guideline penerapankerangka kerja
• Guideline pengukuranindikator
Quality Improvement
“We have two jobs: our job and thejob of improving our job”
Donald Berwick
“We have two jobs: our job and thejob of improving our job”
Donald Berwick
It is challenging, please don’t give up..It is challenging, please don’t give up..