Pemberdayaan Profesi Rumah Sakit dalam rangka persiapan Pelaksanaan BPJS Kesehatan

Dody Firmanda Ketua Komite Medik RSUP Fatmawati, Jakarta

Disampaikan pada Acara Workshop dan Seminar Nasional Pembiayaan Kesehatan Berbasis INA-CBGs Dalam mendukung pelaksanaan Universal Coverage di Indonesia Tahun 2014, Hotel Mercure Padang 23-24 November 2012

Managed Care
P M D 6 1 / 2 0 0 7 B L U D P P 2 3 / 2 0 0 5 B L U P P 7 4 / 2 0 1 2 B L U

Peraturan Pelaksanaan BPJS Kesehatan 25-11-2012 (UU 24/2011 Psl 70a)

SJSN KESEHATAN

UU 40/2004 SJSN UU 24/2011 BPJS

PMK 147/2010 PMK 012/2012 PMK 001/2012 PMK 1691/2011 PMK 755/2011 PMK 1438/2010
U U 2 9 / 2 0 0 4 U U 4 4 / 2 0 0 9

Pathways

Guidelines
SPK PNPK/PPK

USA

ObamaCare

USA

5 Nov 2011

5 Mei 2011
5 November 2011

259

No. 1438/Menkes/Per/IX/2010

RINGKASAN PERATURAN MENTERI KESEHATAN

SPK PNPK SPO

Dibuat : Profesi Disahkan: Menkes Dibuat & ditetapkan: Pimpinan RS

Dikoordinasikan: Komite Medis Disusun: SMF

UU No. 29/2004 Praktik Kedokteran Psl 44 ayat 3 Standar Pelayanan Kedokteran

PerMenKes No 1438/IX/2010 Standar Pelayanan Kedokteran (SPK) Berita Negara Tahun 2010 No 464 24 Sept 2010

Panduan Praktik Klinis Clinical Pathways 1. Pengertian (Definisi) Algoritme 2. Anamnesis Protokol 3. Pemeriksaan Fisik Prosedur 4. Kriteria Diagnosis Standing Order 5. Diagnosis 6. Diagnosis Banding 7. Pemeriksaan Penunjang 8. Terapi 9. Edukasi 10.Prognosis 11. Kepustakaan DF2010

PMK 755/Menkes/PER/IV/2011 Medical Staf Bylaws (MSBL) dan Hospital Bylaws (HBL) RS
Struktur dan Organisasi Tata Kelola (SOTK) (Corporate Governance) Rumah Sakit

Clinical Governance RS

1
3

Healthcare Systems: 1. Policy 2. Provision (Provider) 3. Financing (Purchaser)

1. Donabedian 2. Maxwell 3. Don-Max

1. Efficient 2. Effective 3. Benefits (Value)

DALY QALY
Value = Quality / Cost

MUTU (QUALITY) dan KESELAMATAN PASIEN (PATIENT SAFETY)

What is Quality?
Quality of care must be defined in the light of the
providers technical expectations. standards and patients

While no single definition of health service quality applies in all situations, the following definitions are helpful guides:

SPK: Professional PNPK Standards PPK

Patients Quality Expectations.

Donabedian:

What is Quality?

The quality of technical care consists in the application of medical science and technology in a way that maximizes its benefits to health without correspondingly increasing its risks. The degree of quality is, therefore, the extent to which the care provided is expected to achieve the most favorable balance of risks and benefits.

BENEFITS
RISKS

Odds NNT 95% CI Ratio NNH

Donabedian A. Explorations in Quality Assessment and Monitoring, Ann Arbor, MI:Health Administration Press, 1980, 5-6.

What is Quality?
Roemer MI, Montoya-Aguilar C:
.proper performance (according to standards) of interventions that are known to be safe, that are affordable to the society in question, and that have the ability to produce an impact on mortality, morbidity, disability, and malnutrition.

P(erformance) = M(otivation)XC(ompetency)XB(arriers)
SAFETY = 1 /RISKS Insured vs Uninsured Prevalence and Burden of Disease(s)
Roemer MI, Montoya-Aguilar C. Quality Assessment and Assurance in Primary Health Care,. WHO Offset Publication No., 105, World Health Organization, Geneva, Switzerland, 1988.

The most comprehensive and perhaps the simplest definition of quality is that used by advocates of total quality management: Doing the right thing right, right away..

Wants

Demands
Needs
PNPK PPK CP
Health Needs Assessment

Insiden Keselamatan Pasien adalah: 1. setiap kejadian yang tidak disengaja dan 2. kondisi yang mengakibatkan atau berpotensi mengakibatkan cedera yang dapat dicegah pada pasien terdiri dari: a. Kejadian Tidak Diharapkan (KTD) , b. Kejadian Nyaris Cedera (KNC), c. KejadianTidak Cedera (KTC) dan d. Kejadian Potensi Cedera (KPC)

UU RI No. 24 Tahun 2011 BPJS 25-11-2011

UU RI No. 29 Tahun 2004 Pasal 44(3) Pasal 45 PMK 1438/2010 SPK

Peraturan Pelaksanaan BPJS Kesehatan 25-11-2012 (UU 24/2011 Psl 70a)

PNPK

PPK
BPJS Kesehatan mulai beroperasi 01-01-2014 (UU 24/2011 Psl 60(1)

INA CBG DRG

PT Askes Koding Costing PT Inhealth

ICD 10 ICD 9 CM

Clinical Pathways

SJSN (Kesehatan) When

PNPK/PPK What

Who Whose Whom How How much

PMK 1438/2010

3 Dimensi Universal Coverage

3. Financial (Cost) Coverage

1. Population Coverage

Catastrophic Expenditure

DAFTAR KEWENANGAN KLINIS DOKTER

360 Degree (Mini-PAT)

KEWENANGAN KLINIS INDIVIDU DOKTER

PROMOSI KESEHATAN TINGKAT RUMAH SAKIT

PROMOSI KESEHATAN TINGKAT RUMAH SAKIT

INTEGRATED HEALTH PROMOTION INTO CLINICAL PATHWAYS

UPAYA RUJUKAN

KEMKES RI INA -CBG SPK UPAYA RUJUKAN

PNPK/PPK

PT CLINICAL PATHWAYS

ASKES

UU RI No. 24 Tahun 2011 BPJS

Kesimpulan:
1.

2.
3. 4.

5. 6.

Peran Profesi di Rumah Sakit Komite Medik: membuat dan menetapkan format umum Panduan Praktik Klinis menetapkan kesepakatan tingkat evidens yang akan dipergunakan di RS mengkompilasi PPK yang telah selesai merekomendasikan PPK kepada direktur untuk pengesahan penggunaan PPK tersebut di rumah sakit melaksanakan audit medis dengan mempergunakan PPK menetapkan kewenangan klinis profesi medis

7. Perubahan dari price maker ke risk-taker