Dody Firmanda

Not just being pass the Accreditation and paperwork but beyond that

Quality is a never ending journey

Clinical Pathways as an integrated services plan in hospital quality and finance. Dody Firmanda Chairman of Medical Committee Fatmawati Hospital Jakarta.
Introduction Quality is different things to different people based on their belief and norms, their perspective as medical doctors, managers, nurses, pharmacists, allied professions, patients and stakeholders etc. But, one thing for sure that quality is a never ending journey and quality is everyones responsibility not just merely entitle to the institution or unit only. The latest impact of quality itself nowadays is safety Patient Safety safe and cure to the patient and clean care for the providers. On the other part financial constraints and budget allocation are limited just put it simply that resources high qualified and quality people, time, facilities, equipment and knowledge are scarce and even if there are available- it will definitely very costly. Therefore, it will need a well tailored design tool that integrated and combine all aspects of professionals care involvement, resources usage and finance inclusively as it is already stated in Indonesian Law No 29/2004 (paragraph: kendali mutu dan kendali biaya) through a manageable professional quality system (Clinical Governance) and financial system within a hospital. The critical and important junction is what we named it as Clinical Pathways bridging the quality and financial systems that will reflects transparency, fairness and accountability as required in Good Corporate (Hospital) Governances principles (Diagram 1).

High Impact Intervention (HII)

Diagram 1. Fatmawati Hospitals Medical Committee strategy in implementing Clinical Governance (including patient safety) and Financial System (DRG Casemix System). Fatmawati Hospital Medical Committee has designed a general format for Clinical Pathways and it has been revised for three times prior approval in Medical Committee Plenary Session (as the highest decision making meeting) to be implemented to all 20 Departments in our hospital.

Definition of Clinical Pathways (CP) Clinical Pathways (CP) is a concept of integrated services plan to the patients which are time framed, predictive and measurable results based on evidence of medical, nurse and pharmaceutical guidelines.1,2, 3 Principles in developing Clinical Pathways A well developed Clinical Pathways means: a. All the services should be integrated, patient focused and continuous care. b. Involving all professions (doctors, nurses, pharmacists and allied professionals) c. In time limited (either days or hours) based on diseases progressiveness for inpatients and or in emergency unit. d. All activities to the patients should be written in CP document and as part of Medical Records. e. All deviations from the planned should be written as variance(s). f. Variance(s) might occur either caused by disease progressiveness, comorbid, complication or medical errors and should be analysed in the form of either as first and second medical audits or managerial audit. g. Variance(s) might use as an entry point to improve the quality of the services, revised the guidelines and setting new standards. Therefore the Clinical Pathways might be as a tool for: a. Medical Profession: setting clinical standards, guidelines, and evaluating department and individual performance. As an entry point
1

Firmanda D. Pedoman Penyusunan Clinical Pathways dalam rangka implementasi Sistem DRGs Casemix di rumah sakit. Disampaikan dalam Sidang Pleno Komite Medik RS Fatmawati, Jakarta 7 Oktober 2005. 2 Firmanda D. Clinical Pathways: Peran profesi medis dalam rangka menyusun Sistem DRGs Casemix di rumah sakit. Disampakan pada kunjungan lapangan ke RSUP Adam Malik Medan 22 Desember 2005, RSUP Hasan Sadikin Bandung 23 Desember 2005 dan Evaluasi Penyusunan Clinical Pathways dalam rangka penyempurnaan Pedoman DRGs Casemix Depkes RI, Hotel Grand Cempaka Jakarta 29 Desember 2005. 3 Firmanda D, Pratiwi Andayani, Nuraini Irma Susanti, Srie Enggar KD dkk. Clinical Pathways Kesehatan Anak dalam rangka implementasi Sistem DRGs Casemix di RS Fatmawati, Jakarta 2006.

for medical audits, clinical riks management and assessment for patient safety. b. Nurse Profession: setting clinical standards in nursing care (Asuhan Keperawatan) and improvement of PSBH (Problem Solving for Better Health). c. Pharmacists: Unit Dose Daily and Stop Ordering d. Managerial improvement such as billing systems and IT systems. Steps in developing Clinical Pathways There are steps to consider in developing Clinical Pathways Format as: 1. The components that are should be covered as the definition of Clinical Pathways itself 2. Use all the available and reliable hospital data based on local conditions such as RL2 report for patient morbidity and daily sensus 4 and MOH guidelines5 in: a. Selecting the topic for developing Clinical Pathways b. Deciding average inpatient lenght of stay in hospital (ALOS. 3. Use the local hospital medical and pharmaceutical guidelines. 2,5,7 4. Use ICD 10 for diagnostic and ICD 9 CM procedures properly.26

Firmanda D. Kodefikasi ICD 10 dan ICD 9 CM: indikator mutu rekam medik dalam rangka meningkatkan mutu pelayanan rumah sakit. Disampaikan pada Sosialisasi Pola Sistem Informasi Manajemen Rumah Sakit. Diselenggarakan oleh Direktorat Jenderal Bina Pelayanan Medik Depkes RI di Hotel Panghegar Bandung 1-3 Juni 2006. 5 Departemen Kesehatan RI. Buku Petunjuk Pengisian, Pengolahan dan Penyajian Data Rumah Sakit. Direktorat Jenderal Bina Pelayanan Medik Depkes RI, Jakarta 2005.

General Format of Fatmawati Hospitals Medical Committee for Clinical Pathways Our first design Clinical Pathways as in Diagram 2.

Diagram 2. General format of Clinical Pathways (in Indonesian language)

Diagram 3. Pediatrics Clinical Pathways for Dengue Hemorrhagic Fever (in Indonesian language).

Firmanda D, Pratiwi Andayani, Nuraini Irma Susanti, Srie Enggar KD dkk. Clinical Pathways Kesehatan Anak dalam rangka implementasi Sistem DRGs Casemix di RS Fatmawati, Jakarta 2006.

There are 62 Clinical Pathways from 8 specialist department and had been implemented in the hospital and other 106 Clinical Pathways in printing from the rest of departments (Diagram 4).

Diagram 4. Summary of Clinical Pathways in Fatmawati Hospital.

The Clinical Pathways as a tool for entry point for medical audits, clinical risks management/patient safety, cost efficiency, teaching medical students/residents and even for conducting research in hospital as shown in next diagram for examples.

Diagram 5. Implementation of Orthopedics Clinical Pathways for Tibia Fracture and its relationship with medical audit, clinical risks management, patient safety, practice guidelines, drugs formulary, HAI Surveillance and hospital cost-analysis.

Diagram 6. A research result for evidence-based practice - Implementation of Pediatrics Clinical Pathways for Newborn - with medical audit, clinical risks management, patient safety, practice guidelines, drugs formulary, HAI Surveillance and hospital cost-analysis.

Fatmawati Hospitals Medical Committee version for the implementation of Patient Safety Medical Committee has designed a patient safety framework which involving multi professions and as a bottom-up approach. (Diagram 7)

4 5

6 2

Diagram 7. Framework of Fatmawati Hospital Medical Committee for Patient Safety. For the structures (Box 1), Medical Committee developed medical profession quality systems (Clinical Governance) known as Sistem Komite Medik (Medical Committee System) and Sistem SMF (for all 20 specialist departments) as rules and regulations that bind to all medical professional in hospital from the first and early recruitment medical staff, medical practice guidelines, drugs formulary, HAI surveillance forms, medical audit 10

forms, high impact interventions (HII) forms, clinical pathways, maintain and improve their professional competences, monitoring their performances and individual risks medical assessment (portfolio). If any of these not available, means that there is a potential prone and flaw to patient safety and categorize as latent-type of medical errors. All those Medical Committee products are approved in Medical Committee Plenary Session (as the highest medical decision making meeting) to be implemented to all 20 Departments in our hospital as public hospital and teaching hospital (Diagram 8 and 9).

Diagram 8. Medical Committee book guidelines for Clinical Governance, Clinical Risks Management, Patient Safety, High Impact Intervention, HAI Surveillance, Hospital Drugs Formulary and Clinical Pathways. 11

Diagram 9. The structures of Medical Committee for Teaching Hospital in the implementation of patient safety (in Indonesian language).

12

In the process (Box 2) as implementation for patient safety, Medical Committee designed a mechanism of jobs flow chart as in Diagram 10.

Diagram 10. Medical Committees flowchart for the implementation of patient safety. Failure to conform (or compliance) to these processes mean there is a potential prone and flaw to patient safety and categorize as active-type of medical errors that might occurs as in either system failure or individual tasks.

13

The Infection Control Team of Medical Committee (ICT-MC) There are 16 clinical teams in Medical Committee, one of them is Infection Control Team of Medical Committee (ICT-MC) which it members come from multidisciplinary professions such as specialist doctors, nurses, pharmacists, and administrators. The ICT-MC has 5 pillars and clear objectives in infection control as: 1. Isolation of patients and barrier precautions : ICT-MC work together with managers and other teams (i.e. Avian Flu Team, HIV/AIDS Team etc) 2. Decontamination of items and equipment: ICT-MC advocating other hospital support services. 3. Prudent use of antibiotics: ICT-MC work together with Drugs and Therapeutics Team of Medical Committee (DTT-MC) in suggesting the rational use of antibiotics and classification usage of antibiotics in hospital. 4. Handwashing: designing, campaigning and training to all health professionals, and making recommendation of the infrastructure for hand hygiene. 5. Decontamination of environment: ICT-MC advocating other hospital support services and hospital environment department. Hand Hygiene Program Infection Control Team of Medical Committee (ICT-MC) has set-up regular time table training in Prevention of HAI (including hand hygiene such as hand washing) to all health professionals (including residents and medical students), food and catering staff, linen and laundry service staff, housekeepers, security staff and patients and their family (Diagram 11 and 12). To improve members of ICT-MC of their skills and knowledge in HAI, we do regular and training schedule as in Diagram 13. The ICT-MC do make their report of activities and future plan to Medical Committee regularly (monthly and annually) as in Diagram 14 and 15.

14

Diagram 11. ICT-MCs report training in Prevention of HAI including hand hygiene for housekeeper/cleaning service in 2005 for example (in Indonesian language)

15

Diagram 12. Time table of ICT-MC training in Prevention of HAI and hygiene for all hospital professionals in 2006 (in Indonesian language)

16

Diagram 13. ICT-MCs 2006 schedule for it members to improve their skills and knowledge in HAI.

17

Diagram 14. Year 2006 Annual report of ICT-MC to Medical Committee and Head Medical Committee recommendation for Year 2007 ICT-MC activities.

18

Diagram 15. ICT-MC Plan of Action for 2007 which been approved by Medical Committee. 19

The Infection Control Team of Medical Committee (ICT-MC) did socialize the program through group discussion/lectures and printing material as leaflet and stickers (Diagram 16).

Diagram 16. Printing and sticker materials for Hand Washing campaign from Infection Control Team of Medical Committee (ICT-MC). 20

As for monitoring and data collections for HAI surveillance, Infection Control Team of Medical Committee use the surveillance forms that attach to patients Medical Records (Diagram 13),

Diagram 17. HAI Surveillance form from ICT-MC (in Indonesian language).

21

Results of ICT-MC HAI Surveillance Trends analysis results of ICT-MC HAI Surveillance for the year of 2003 to 2005 as in Diagram 14 to 16.

Diagram 18. ICT-MCs trend analysis for IV associated infection for 2003 to 2005.

Diagram 19. ICT-MCs trend analysis for surgical sites associated infection for 2003 to 2005.

22

Diagram 20. ICT-MCs trend analysis for urinary catheterizations associated infection for 2003 to 2005. There is an enormous significant increase from the trends above in October to December 2005. Therefore ICT-MC and Medical Audit Team conducting a joint investigation for in-depth study. Results of those in-depth study as in Diagram 21.

23

Diagram 21. Results of in-depth study of HAI Surveillance for October to December 2005. Based on those results, Medical Committee recommended the implementation of High Impact Interventions to all departments (see Page 30). Other ICT-MC activities are hospital bacterial mapping and do antibiotics sensitivity as in Diagram 22a and 22b.

24

Diagram 22a. ICT-MCs Sensitivity for 2005.

Hospital

Bacterial

Mapping

and

Antibiotics

25

Diagram 22b. ICT-MCs Sensitivity for 2005.

Hospital

Bacterial

Mapping

and

Antibiotics

26

The output of ICT-MCs HAI surveillance results as inputs for Drugs and Therapeutics Team of Medical Committee (DTT-MC) in making drugs decision to be used and listed in Hospital Drugs Formulary (Diagram 20); especially for rational drugs and classified antibiotics into first line, second line or reserved (that are very potent but easily resistance) antibiotics as a strategy to combat the emergence and spread of antimicrobial resistant bacteria. DTT-MC has a system for hospital pharmaceutical care which involving doctors, nurses and pharmacists and known as Lingkaran 5 Langkah 12 Kegiatan (Circle of Five Steps and Twelve Activities) from selecting drugs, prescribing, dispensing, adverse events monitoring to summative audit (Diagram 23).

Diagram 23. Hospital Drugs Formulary from Drugs and Therapeutics Team of Medical Committee (DTT-MC).

27

Diagram 24. The Circle of Five Steps and Twelve Activities from Drugs and Therapeutics Team of Medical Committee (DTT-MC) (in Indonesian language).

28

Medical Committee has designed a Clinical Risks Management approached to assess the risks or medical errors (latent, active or near-miss) that might occur (Diagram 25). For monitoring and assessing individual medical ethics and risks, Medical Committee designed forms for every medical doctor as in Diagram 26.

Diagram 25. Steps of Clinical Risk Management (in Indonesian language).

29

Diagram 26. Medical Committee form for Individual Medical Risks Assessment (in Indonesian language). As a continuous quality improvement in patient safety, Medical Committee designed and there are 9 forms of High Impact Interventions (HII) that necessary to be taken action following the results of HAI Surveillance and Risks Assessment. Those 9 High Impact Interventions (HII) are: 1. HHI1: Preventing the risk of microbial contamination in medical and nursing care. 2. HII2: Preventing intravenous associated infection 3. HII-3: Preventing surgical site infection 4. HII-4: Preventing ventilator associated pneumonia 5. HII-5: Preventing urinary catheter associated infection 6. HII-6: Preventing inpatient associated diarrhea 7. HII-7: Preventing operation instruments associated injury 30

8. HII-8: Preventing anesthetics drugs and gases associated injury/harm 9. HII-9: Preventing drugs adverse events

Diagram 27. As an example one of nine High Impact Interventions (HII) HHI1: Preventing the risk of microbial contamination in medical and nursing care (in Indonesian language).

31

Conclusion
Clinical Pathways is a very powerful tool and useful for integrated services plan in health care (hospital) which is time framed, predictive and measurable results based on evidence, budget-based performance, and reliable for audits (both medical and financial audits), risks assessment and patient safety evaluation. It is a bridging between professional quality system (Clinical Governance) and Financial System (DRG Casemix System) through a well organized corporate governance that are transparency, fairness and accountable to all providers, purchasers and patients. Clinical Pathways can be useful as an entry point for: 1. Policy maker in allocating budget (RBA) based on cost weight and casemix index which are derived from Hospital Clinical Pathwayss column of cost. 2. Public Health Officers as a tool for decision making in diseases surveillance and point of prevalence. 3. Hospital CEO as a tool for assessing the hospital quality services and economic/financial evaluation of resources usage and plan. 4. Professional as a tool and entry point for revising guidelines, evaluating individual and teamworks performance. 5. Patients and purchasers ensuring the procedures and treatment that are given and clear financial costs. 6. Teaching and research as a tool and guidelines in daily evidencebased practice for medical/nursing education.

32

Empowering medical professions toward patient safety through professional quality system (Clinical Governance) and Clinical Pathways in Fatmawati Hospital.
Dody Firmanda, M.D, MA Head of Medical Committee Fatmawati Hospital Jakarta, Indonesia. Introduction In mid 1999 Fatmawati Hospitals Medical Committee as the highest medical professional organization in hospital did realize that we, especially mostly specialist physicians instead of being respectable and even eminent medical professors noticed our medical professionals weaknesses and lack of knowledge in management and leadership. Therefore, Medical Committee began to work as a team not as a solo practice as usual anymore but through a system. In pursue of this quality excellence, we had to review and start all-over right from the scratched and bottom. Medical Committee did re-positioning its existence in hospital by empowering the medical professions toward quality. So, what is quality? Quality is different things to different people based on their belief and norms, their perspective as medical doctors, managers, nurses, pharmacists, allied professions, patients and stakeholders etc. But, one thing for sure that quality is a never ending journey and quality is everyones responsible not just merely entitle to the institution or unit only. Therefore, Medical Committee set-up an embryo that consist of 8 physicians as a quality leader teams for all 20 specialist departments in hospital. Medical Committee trained at least 3 key physicians from each department about quality and designed a quality training package as in Diagram 1. The quality syllabus consists of (box 1): 1. Introduction of Quality: definitions, scope and principles. 2. Total Quality Management/Services: components, principles and implementation.

Presented as Country Presentation at Regional Patient Safety Workshop on Clean Care is Safer Care, WHO SEARO Bangkok Thailand 20-22 June 2007.

3. Quality Systems: how to develop a workable quality system 4. Professional continuous quality improvement: evidence-based medicine, medical audits. 5. Quality assurance: setting standards, conform to standards and maintaining/improving the standards. 6. Quality Control 7. Assignments on respective departments. After completing the training, those three key physicians have to train the rest of their colleagues in the department and begin to build their own departments quality system that integrated as one system into Medical Committees quality system for the organization, roles, rules and regulations in medical services, teaching and education; and medical research (box 2).

2 1

Diagram 1. Fatmawati Hospitals Medical Committee; Strategy in introducing and empowering medical professions toward quality in mid 1999. 2

Medical Committees Governance)

Medical

Profession

Quality

Systems

(Clinical

Fatmawati Hospitals Medical Committee has designed a concept for medical profession quality systems - Clinical Governance - known as Sistem Komite Medik (Medical Committee System) and Sistem SMF (for Department level) which is a written rules and regulations for doctors (Medical Staff Bylaws), description of how to organize/governance themselves, job descriptions, and duty of care. Medical Committee combined those systems with case-mix financial, ICD 10 and ICD 9 CM coding system through Clinical 1,2,3,4,5, 6 Pathways (Diagram 2). Those combination as a conceptual framework for the anticipation of Indonesian Law Number 29/2004 on Medical Practices, The law stated 3 main objectives which are ensuring and protecting the patients ( Patient Safety), guiding and empowering the medical professions towards quality (Good Doctors) , and ensuring the law, rules and regulations for community and doctors.

Firmanda D. Professional continuous quality improvement in health care: standard of procedures, clinical guidelines, pathways of care and evidence-based medicine. What are they? J Manajemen & Administrasi Rumah Sakit Indonesia 1999; 1(3): 139-144. 2 Firmanda D. Total quality management in health care (Part One). Indones J Cardiol Pediatr 1999; 1(1):43-9. 2 Firmanda D. Key to success of quality care programs: empowering medical professional. Global Health Journal 2000; 1(1) http://www.interloq.com/a26.htm 3 Firmanda D. The pursuit of excellence in quality care: a review of its meaning, elements, and implementation. Global Health Journal 2000;1(2) http://www.interloq.com/a39vlis2.htm 4 Firmanda D. Total quality management in health care (Part One). Indones J Cardiol Pediatr 1999; 1(1):43-9. 5 Firmanda D. Professional Continuous Quality Improvement: from Evidence -based Medicine towards Clinical Governance. Presented in World Pediatrics Congress of International Pediatric of Association, Beijing 2001. 6 Firmanda D. Discussion Forum on Evidence-based Medicine, Evidence-based Health Care, Evidence-based Policy and other health related disciplines. http://yahoogroups.com/group/ebm-f2000

Health Resources Groups (HRG)

High Impact Intervention (HII)

Diagram 2. Fatmawati Hospitals Medical Committee strategy in implementing Clinical Governance (including patient safety) and DRG Casemix System.

Fatmawati Hospitals Medical Committee version for the implementation of Patient Safety Medical Committee has designed a patient safety framework which involving multi professions and as a bottom-up approach. (Diagram 3)

4 5

6 2

Diagram 3. Framework of Fatmawati Hospital Medical Committee for Patient Safety. For the structures (Box 1), Medical Committee developed medical profession quality systems (Clinical Governance) known as Sistem Komite Medik (Medical Committee System) and Sistem SMF (for all 20 specialist departments) as rules and regulations that bind to all medical professional in hospital from the first and early recruitment medical staff, medical practice guidelines, drugs formulary, HAI surveillance forms, medical audit 5

forms, high impact interventions (HII) forms, clinical pathways, maintain and improve their professional competences, monitoring their performances and individual risks medical assessment (portfolio). If any of these not available, means that there is a potential prone and flaw to patient safety and categorize as latent-type of medical errors. All those Medical Committee products are approved in Medical Committee Plenary Session (as the highest medical decision making meeting) to be implemented to all 20 Departments in our hospital as public hospital and teaching hospital (Diagram 4 and 5).

Diagram 4. Medical Committee book guidelines for Clinical Governance, Clinical Risks Management, Patient Safety, High Impact Intervention, HAI Surveillance, Hospital Drugs Formulary and Clinical Pathways. 6

Diagram 5. The structures of Medical Committee for Teaching Hospital in the implementation of patient safety (in Indonesian language).

In the process (Box 2) as implementation for patient safety, Medical Committee designed a mechanism of jobs flow chart as in Diagram 6.

Diagram 6. Medical Committees flowchart for the implementation of patient safety. Failure to conform (or compliance) to these processes mean there is a potential prone and flaw to patient safety and categorize as active-type of medical errors that might occurs as in either system failure or individual tasks.

The Infection Control Team of Medical Committee (ICT-MC) There are 16 clinical teams in Medical Committee, one of them is Infection Control Team of Medical Committee (ICT-MC) which it members come from multidisciplinary professions such as specialist doctors, nurses, pharmacists, and administrators. The ICT-MC has 5 pillars and clear objectives in infection control as: 1. Isolation of patients and barrier precautions : ICT-MC work together with managers and other teams (i.e. Avian Flu Team, HIV/AIDS Team etc) 2. Decontamination of items and equipment: ICT-MC advocating other hospital support services. 3. Prudent use of antibiotics: ICT-MC work together with Drugs and Therapeutics Team of Medical Committee (DTT-MC) in suggesting the rational use of antibiotics and classification usage of antibiotics in hospital. 4. Handwashing: designing, campaigning and training to all health professionals, and making recommendation of the infrastructure for hand hygiene. 5. Decontamination of environment: ICT-MC advocating other hospital support services and hospital environment department. Hand Hygiene Program Infection Control Team of Medical Committee (ICT-MC) has set-up regular time table training in Prevention of HAI (including hand hygiene such as hand washing) to all health professionals (including residents and medical students), food and catering staff, linen and laundry service staff, housekeepers, security staff and patients and their family (Diagram 7 and 8). To improve members of ICT-MC of their skills and knowledge in HAI, we do regular and training schedule as in Diagram 9. The ICT-MC do make their report of activities and future plan to Medical Committee regularly (monthly and annually) as in Diagram 10 and 11.

Diagram 7. ICT-MCs report training in Prevention of HAI including hand hygiene for housekeeper/cleaning service in 2005 for example (in Indonesian language)

10

Diagram 8. Time table of ICT-MC training in Prevention of HAI and hygiene for all hospital professionals in 2006 (in Indonesian language)

11

Diagram 9. ICT-MCs 2006 schedule for it members to improve their skills and knowledge in HAI.

12

Diagram 10. Year 2006 Annual report of ICT-MC to Medical Committee and Head Medical Committee recommendation for Year 2007 ICT-MC activities.

13

Diagram 11. ICT-MC Plan of Action for 2007 which been approved by Medical Committee. 14

The Infection Control Team of Medical Committee (ICT-MC) did socialize the program through group discussion/lectures and printing material as leaflet and stickers (Diagram 12).

Diagram 12. Printing and sticker materials for Hand Washing campaign from Infection Control Team of Medical Committee (ICT-MC). 15

As for monitoring and data collections for HAI surveillance, Infection Control Team of Medical Committee use the surveillance forms that attach to patients Medical Records (Diagram 13),

Diagram 13. HAI Surveillance form from ICT-MC (in Indonesian language).

16

Results of ICT-MC HAI Surveillance Trends analysis results of ICT-MC HAI Surveillance for the year of 2003 to 2005 as in Diagram 14 to 16.

Diagram 14. ICT-MCs trend analysis for IV associated infection for 2003 to 2005.

Diagram 15. ICT-MCs trend analysis for surgical sites associated infection for 2003 to 2005.

17

Diagram 16. ICT-MCs trend analysis for urinary catheterizations associated infection for 2003 to 2005.

There is an enormous significant increase from the trends above in October to December 2005. Therefore ICT-MC and Medical Audit Team conducting a joint investigation for in-depth study. Results of those in-depth study as in Diagram 17.

18

Diagram 17. Results of in-depth study of HAI Surveillance for October to December 2005. Based on those results, Medical Committee recommended the implementation of High Impact Interventions to all departments (see Page 25). Other ICT-MC activities are hospital bacterial mapping and do antibiotics sensitivity as in Diagram 19a and 19b.

19

Diagram 19a. ICT-MCs Sensitivity for 2005.

Hospital

Bacterial

Mapping

and

Antibiotics

20

Diagram 19b. ICT-MCs Sensitivity for 2005.

Hospital

Bacterial

Mapping

and

Antibiotics

21

The output of ICT-MCs HAI surveillance results as inputs for Drugs and Therapeutics Team of Medical Committee (DTT-MC) in making drugs decision to be used and listed in Hospital Drugs Formulary (Diagram 20); especially for rational drugs and classified antibiotics into first line, second line or reserved (that are very potent but easily resistance) antibiotics as a strategy to combat the emergence and spread of antimicrobial resistant bacteria . DTT-MC has a system for hospital pharmaceutical care which involving doctors, nurses and pharmacists and known as Lingkaran 5 Langkah 12 Kegiatan (Circle of Five Steps and Twelve Activities) from selecting drugs, prescribing, dispensing, adverse events monitoring to summative audit (Diagram 21).

Diagram 20. Hospital Drugs Formulary from Drugs and Therapeutics Team of Medical Committee (DTT-MC).

22

Diagram 21. The Circle of Five Steps and Twelve Activities from Drugs and Therapeutics Team of Medical Committee (DTT-MC) (in Indonesian language).

23

Medical Committee has designed a Clinical Risks Management approached to assess the risks or medical errors (latent, active or near-miss) that might occur (Diagram 22). For monitoring and assessing individual medical ethics and risks, Medical Committee designed forms for every medical doctor as in Diagram 23.

Diagram 22. Steps of Clinical Risk Management (in Indonesian language).

24

Diagram 23. Medical Committee form for Individual Medical Risks Assessment (in Indonesian language). As a continuous quality improvement in patient safety, Medical Committee designed and there are 9 forms of High Impact Interventions (HII) that necessary to be taken action following the results of HAI Surveillance and Risks Assessment. Those 9 High Impact Interventions (HII) are: 1. HHI1: Preventing the risk of microbial contamination in medical and nursing care. 2. HII2: Preventing intravenous associated infection 3. HII-3: Preventing surgical site infection 4. HII-4: Preventing ventilator associated pneumonia 5. HII-5: Preventing urinary catheter associated infection 6. HII-6: Preventing inpatient associated diarrhea 7. HII-7: Preventing operation instruments associated injury 25

8. HII-8: Preventing anesthetics drugs and gases associated injury/harm 9. HII-9: Preventing drugs adverse events

Diagram 24. As an example one of nine High Impact Interventions (HII) HHI1: Preventing the risk of microbial contamination in medical and nursing care (in Indonesian language).

26

Fatmawati Hospitals Medical Committee version of Clinical Pathways Our hospitals medical committee has designed a general format for Clinical Pathways and it has been revised for three times prior approval in Medical Committee Plenary Session (as the highest decision making meeting) to be implemented to all 20 Departments in our hospital. Definition of our Clinical Pathways (CP) Clinical Pathways (CP) is a concept of integrated services plan to the patients which are time framed, predictive and measurable results based on evidence of medical, nurse and pharmaceutical guidelines.2,7,8,9 Principles in developing Clinical Pathways A well developed Clinical Pathways means: a. All the services should be integrated, patient focused and continuous care. b. Involving all professions (doctors, nurses, pharmacists and allied professionals) c. In time limited (either days or hours) based on diseases progressiveness for inpatients and or in emergency unit. d. All activities to the patients should be written in CP document and as part of Medical Records. e. All deviations from the planned should be written as variance(s).

Firmanda D. Pedoman Penyusunan Clinical Pathways dalam rangka implementasi Sistem DRGs Casemix di rumah sakit. Disampaikan dalam Sidang Pleno Komite Medik RS Fatmawati, Jakarta 7 Oktober 2005. 8 Firmanda D. Clinical Pathways: Peran profesi medis dalam rangka menyusun Sistem DRGs Casemix di rumah sakit. Disampakan pada kunjungan lapangan ke RSUP Adam Malik Medan 22 Desember 2005, RSUP Hasan Sadikin Bandung 23 Desember 2005 dan Evaluasi Penyusunan Clinical Pathways dalam rangka penyempurnaan Pedoman DRGs Casemix Depkes RI, Hotel Grand Cempaka Jakarta 29 Desember 2005. 9 Firmanda D, Pratiwi Andayani, Nuraini Irma Susanti, Srie Enggar KD dkk. Clinical Pathways Kesehatan Anak dalam rangka implementasi Sistem DRGs Casemix di RS Fatmawati, Jakarta 2006 (dalam pencetakan).

27

f. Variance(s) might occur either caused by disease progressiveness, comorbid, complication or medical errors and should be analysed in the form of either as first and second medical audits or managerial audit. g. Variance(s) might use as an entry point to improve the quality of the services, revised the guidelines and setting new standards. Therefore the Clinical Pathways might be as a tool for: a. Medical Profession: setting clinical standards, guidelines, and evaluating department and individual performance. As an entry point for medical audits, clinical riks management and assessment for patient safety. b. Nurse Profession: setting clinical standards in nursing care (Asuhan Keperawatan) and improvement of PSBH (Problem Solving for Better Health). c. Pharmacists: Unit Dose Daily and Stop Ordering d. Managerial improvement such as billing systems and IT systems. Steps in developing Clinical Pathways There are steps to consider in developing Clinical Pathways Format as: 1. The components that are should be covered as the definition of Clinical Pathways itself 2. Use all the available and reliable hospital data based on local 10 conditions such as RL2 report for patient morbidity and daily sensus 11 and MOH guidelines in: a. Selecting the topic for developing Clinical Pathways b. Deciding average inpatient lenght of stay in hospital (ALOS. 2,5,7 3. Use the local hospital medical and pharmaceutical guidelines. 4. Use ICD 10 for diagnostic and ICD 9 CM procedures properly.26

10

Firmanda D. Kodefikasi ICD 10 dan ICD 9 CM: indikator mutu rekam medik dalam rangka meningkatkan mutu pelayanan rumah sakit. Disampaikan pada Sosialisasi Pola Sistem Informasi Manajemen Rumah Sakit. Diselenggarakan oleh Direktorat Jenderal Bina Pelayanan Medik Depkes RI di Hotel Panghegar Bandung 1-3 Juni 2006. 11 Departemen Kesehatan RI. Buku Petunjuk Pengisian, Pengolahan dan Penyajian Data Rumah Sakit. Direktorat Jenderal Bina Pelayanan Medik Depkes RI, Jakarta 2005.

28

General Format of Fatmawati Hospitals Medical Committee for Clinical Pathways Our first design Clinical Pathways as shown in Diagram 25.

Diagram 25. General format of Clinical Pathways (in Indonesian language)

29

Diagram 26. Pediatrics Clinical Pathways for Dengue Hemorrhagic Fever Indonesian language).

12

(in

12

Firmanda D, Pratiwi Andayani, Nuraini Irma Susanti, Srie Enggar KD dkk. Clinical Pathways Kesehatan Anak dalam rangka implementasi Sistem DRGs Casemix di RS Fatmawati, Jakarta 2006.

30

There are 62 Clinical Pathways from 8 specialist department and had been implemented in the hospital and other 106 Clinical Pathways in printing from the rest of department (Diagram 27).

Diagram 27. Summary of Clinical Pathways in Fatmawati Hospital.

The Clinical Pathways as a tool for entry point for medical audits, clinical risks management/patient safety, cost efficiency, teaching medical students/residents and even for conducting research in hospital as shown in next diagram for examples.

31

Diagram 28. Implementation of Orthopedics Clinical Pathways for Tibia Fracture and its relationship with medical audit, clinical risks management, patient safety, practice guidelines, drugs formulary, HAI Surveillance and hospital cost-analysis.

32

Diagram 29. A research result for evidence-based practice - Implementation of Pediatrics Clinical Pathways for Newborn - with medical audit, clinical risks management, patient safety, practice guidelines, drugs formulary, HAI Surveillance and hospital cost-analysis.

33

What Next We are in Medical Committee is still working to design a workable and achievable that might suit to our hospital condition to patch-in the agenda of Nine Patient Safety Solutions Preamble May 2007 from WHO Collaborating Centre for Patient Safety Solutions, Joint Commission and Joint Commission International. Those nine patient safety solutions are:
1. 2. 3. 4. 5. 6. 7. 8. 9. Look-Alike, Sound-Alike Medication Names Patient Identification Communication During Patient Hand-Overs Performance of Correct Procedure at Correct Body Site Control of Concentrated Electrolyte Solutions Assuring Medication Accuracy at Transitions in Care Avoiding Catheter and Tubing Mis-Connections Single Use of Injection Devices Improved Hand Hygiene to Prevent Health Care-Associated Infection

To be integrated into our Medical Committees Quality System (Clinical Governance) as in Diagram 30

Diagram 30. Integrating and patch-in the agenda of Nine Patient Safety Solutions Preamble May 2007 into Fatmawati Hospital Medical Committees Quality System. .Dody Firmanda, Jakarta 13th June 2007. 34

TATA KELOLA KLINIS

(CLINICAL GOVERNANCE)

RSUP FATMAWATI JAKARTA 2012

RSUP FATMAWATI

Tata Kelola Klinis (Clinical Governance) RSUP Fatmawati Jakarta

Pendahuluan Dalam Peraturan Internal Rumah Sakit (Hospital Bylaws) RSUP Fatmawati dalam Bab XIV Peraturan Pelaksanaan Tata Kelola Klinis (clinical governance) Pasal 92 menerangkan bahwa guna melaksanakan tata kelola klinis (clinical governance) di rumah sakit maka setiap staf medis berkewajiban untuk: 1. melaksanakan keprofesian medis sesuai dengan Kewenangan Klinis dan Penugasan Klinis masing masing dalam Tata Kelola Klinis (Clinical Governance) rumah sakit dan kelompok staf medis (SMF), 2. memberikan pelayanan medis sesuai dengan standar profesi, standar pelayanan, dan standar prosedur operasional yang disesuaikan dengan kebutuhan medis pasien. 3. melakukan konsultasi sesuai kebutuhan pasien, 4. merujuk pasien apabila ditemukan keterbatasan kemampuan, sarana dan prasarana rumah sakit. Dengan terbitnya Undang Undang Republik Indonesia Nomor 24 Tahun 2011 tentang Badan Penyelenggara Jaminan Sosial (BJPS)1. Sesuai dengan amanat perundangan tersebut - peraturan mengenai pelaksanaan BPJS Kesehatan harus telah ada paling lama tanggal 25 November 2012 (1 tahun dari diundangkannya)2 dan sudah harus mulai beroperasi pada tanggal 1 Januari 20143 serta untuk BPJS Kesehatan4 tidak diselenggarakan lagi oleh Kementerian Kesehatan5. Pertanyaan yang timbul adalah bagaimana sistem BPJS Kesehatan tersebut? Dalam melakukan evaluasi kebijakan dan sistem layanan kesehatan (healthcare system and policies evaluation) ada 3 kriteria kunci yakni kriteria efektifitas, efisiensi, dan keberadilan/ekuiti (effectiveness, efficiency and equity)6 yang merupakan suatu rangkaian sistematik dalam suatu sistem. Melakukan suatu analisis ekonomi dalam pelayanan kedokteran profesi adalah tidak mudah, mengingat banyak faktor yang harus dipertimbangkan dari berbagai dimensi termasuk cara pendekatan dari jenis analisis ekonomi yang akan digunakan, batasan terminologi ekonomi itu sendiri mengenai utilization, productivity, benefit, efficiency, effectiveness, value for money, kebijakan fiskal dan tingkat inflation rate yang sering kali berubah. Disamping keterbatasan sumber daya dan kebijakan ekonomi yang dipengaruhi politis, sehingga tidak jarang 'resources' tersebut telah dipagu menjadi 'fixed'.7 Evolusi sistem layanan
1 2

Undang Undang RI Nomor 24 Tahun 2011 tentang Badan Penyelenggara Jaminan Sosial Undang Undang RI No.24 Tahun 2011 Pasal 70 ayat a. 3 Undang Undang RI No.24 Tahun 2011 Pasal 60 ayat (1). 4 Undang Undang RI No.24 Tahun 2011 Pasal 5 ayat (2)a. 5 Undang Undang RI No.24 Tahun 2011 Pasal 60 ayat (2)a. 6 Aday LA, Begley CE, Lairson DR. Evaluating the healthcare system: effectiveness, efficiency and equity. 3 rd ed. Washington DC: Health Administration Press, 2004. 7 Firmanda D. Aplikasi integrasi sinergis antara Evidenve-based Medicine, Evidence-based Healthcare dan Evidence-based Policy dalam satu sistem peningkatan mutu pelayanan kesehatan dan kedokteran

kesehatan di sarana kesehatan (rumah sakit) secara prinsipnya mulai dari yang bercirikan doing things cheaper dalam hal ini efficiency pada tahun 1970an pada waktu krisis keuangan dan gejolak OPEC, kemudian ekonomi mulai pulih dan masyarakat menuntut layanan kesehatan bercirikan doing things better dalam hal ini quality improvement. Selama dua dekade tersebut manajemen bercorak doing things right (dikenal sebagai increasing effectiveness) yang merupakan kombinasi doing things cheaper dan doing things better. Ternyata prinsip doing things right tidak memadai mengikuti perkembangan kemajuan teknologi maupun tuntutan masyarakat yang semakin kritis; dan prinsip manajemen doing things right tersebut telah ketinggalan zaman dan dianggap sebagai prinsip dan cara manajemen kuno. Pada abad 21 ini masa era globalisasi dibutuhkan tidak hanya doing things right, akan tetapi juga diperlukan prinsip manajemen doing the right things sehingga kombinasi keduanya disebut sebagai prinsip manajemen layanan modern doing the right things right. 8 Sedangkan di sisi dimensi lain profesi itu sendiri dituntut untuk meningkatkan mutu pelayanannya dan keprofesiannya dalam koridor etik-sosio-budaya serta berbagai peraturan dan perundangan hukum.7 Dalam Undang Undang RI Nomor 29 Tahun 2004 tentang Praktik Kedokteran pada pasal 45 menerangkan tentang kewajiban menyelenggarakan kendali mutu dan kendali biaya.9 Pada Undang Undang RI Nomor 44 Tahun 2010 tentang Rumah Sakit pada pasal 33 menerangkan tentang organisasi rumah sakit yang efektif, efisien, dan akuntabel. 10 Peraturan Pemerintah Nomor 23 Tahun 2005 tentang Pengelolaan Keuangan Badan Layanan Umum dan Peraturan Menteri Dalam Negeri Nomor 61 Tahun 2007 tentang Pedoman Teknis Pengelolaan Keuangan Badan Layanan Umum Daerah pada pasal 1 ayat 1 menyebutkan untuk memberikan pelayanan kepada masyarakat berupa penyediaan barang dan/atau jasa yang dijual tanpa mengutamakan mencari keuntungan dan dalam melakukan kegiatannya didasarkan pada prinsip efisiensi dan produktivitas.11,12 Sedangkan istilah, definisi dan dimensi akan efisiensi juga belum ada kesepakatan yang jelas dan eksplisit tergantung dari berbagai perspektif. Efisiensi dapat digolongkan kepada efisiensi
(Clinical Governance): suatu tantangan profesi IDAI di masa mendatang.II.Cost Effectiveness Analyses (CEA) Standar Pelayanan Medis (SPM) Kesehatan Anak IDAI Disampaikan pada Acara Pertemuan Perhimpunan Organisasi Profesi dengan Ditjen Yan Medik Depkes RI di Bogor September 2005. http://www.scribd.com/doc/12827936/Dody-Firmanda-2005-042-Aplikasi-integrasi-sinergis-EvidenvebasedMedicine-Evidencebased-Healthcare-dan-Evidencebased-Policy-dalam-Clinical-Gove 8 Firmanda D. Peran Efektifitas Klinis dalam rangka mewujudkan keselamatan/keamanan (safety) dan berorientasi kepada pasien (patient centredness).Disampaikan pada Hospital Management 3 diselenggarakan oleh Pusat Kajian Administrasi dan Kebijakan Kesehatan FKM UI di Grand Angkasa Hotel International, Medan 11 Agustus 2008. http://www.scribd.com/doc/9813111/Dody-Firmanda-2008-PeranEfektivitas-Klinis-Dalam-PATH 9 Undang Undang RI Nomor 29 Tahun 2004 tentang Praktik Kedokteran 10 Undang Undang RI Nomor 44 Tahun 2010 tentang Rumah Sakit 11 Peraturan Pemerintah RI Nomor 23 Tahun 2005 tentang Pengelolaan Keuangan Badan Layanan Umum 12 Peraturan Menteri Dalam Negeri Nomor 61 Tahun 2007 tentang Pedoman Teknis Pengelolaan Keuangan Badan Layanan Umum Daerah

tehnik (technical efficiency), efisiensi produksi/hasil (productive efficiency) dan efisiensi alokatif (allocative/societal efficiency) termasuk didalamnya bidang market dan kesehatan.6,13 Dalam pengambilan keputusan untuk tatakelola rumah sakit (corporate governance) dan tatakelola klinis (clinical governance) sebaiknya melalui strategi pendekatan berbasis bukti (evidence-based decision making) sebagaimana secara ringkasnya dapat dilihat pada Gambar 1 berikut.

Gambar 1. Strategi pendekatan dalam rangka implementasi pengambilan keputusun berbasis bukti (evidence-based decision making) dalam suatu sistem layanan kesehatan.

13

Firmanda D. Pengendalian mutu dan efisiensi pembiayaan layanan kesehatan. Disampaikan dalam rangka evaluasi Program Pelayanan Askes Terpadu Rumah Sakit (PPATRS) diselenggarakan oleh Kantor Pusat PT Askes (Persero) di Hotel Panorama Batam 10 Desember 2008. http://www.scribd.com/doc/9800878/Dody-Firmanda2008-Pengendalian-Mutu-Dan-Efisiensi-Biaya-RS-10-Desember-2008

Definisi Tata Kelola (Clinical Governance) di RSUP Fatmawati Jakarta: Tata Kelola Klinis (Clinical Governance) adalah sistem peningkatan mutu rumah sakit yang terdiri dari komponen quality assurance yakni setting standards, conform to standards dan continuous quality improvement (CQI). Kebijakan Tata Kelola Klinis (Clinical Governance) di RSUP Fatmawati Jakarta adalah: 1. Fokus pada pasien 2. Pelayanan secara terintegrasi dan berkesinambungan sesuai: a. Panduan Praktik Klinis (PPK) bagi staf medis b. Panduan Praktik Klinis (PPK) - Asuhan Keperawatan bagi staf keperawatan c. Panduan Praktik Klinis (PPK) (Sistem Unit Dosage Daily UDD) bagi staf farmasis d. Standar Prosedur Operasional dan Standing Orders bagi petugas laboratorium e. Standar Prosedur Operasional bagi jajaran manajemen struktural f. Standar Prosedural Operasional bagi manajemen fungsional 3. Tempat layanan meliputi: a. Rawat Jalan i. Instalasi Rawat Jalan ii. Instalasi Griya Husada b. Rawat Inap i. IRNA A ii. IRNA B iii. IRNA C iv. Gedung Prof dr. Soelarto(GPS) v. Instalasi Paviliun Anggrek vi. Instalasi Rawat Intensif c. Emergensi i. Instalasi Gawat Darurat d. Instalasi Bedah Sentral 4. Upaya Rujukan Kesehatan 5. Manajemen Risisko Klinis dan Keselamatan Pasien

Konsep Clinical Governance (Tata Kelola Klinis) RSUP Fatmawati Jakarta Konsep mendasar dari Tata Kelola Klinis (Clinical Governance) RSUP Fatmawati Jakarta (Gambar 2) adalah perpaduan: 1. Kebijakan (policy) tingkat makro dan mikro sesuai kebijakan dari Kementerian Kesehatan Republik Indonesia sehingga mampu laksana untuk diimplementasikan dengan secara sistematis dalam bentuk program dan kegiatan layanan pada tingkat organisasi RSUP Fatmawati dan institusi/unit di dalamnya. 2. Provisi layanan kesehatan berdasarkan layanan berjenjang dengan pola rujukan untuk Jakarta Selatan dan sekitarnya. 3. Pembiayaan dengan strategi peningkatan upaya efisiensi, realokasi sesuai prioritas dan peningkatan pendanaan net revenue generating.

SJSN BPJS 2014

Gambar 2. Konsep Clinical Governance (Tata Kelola Klinis) RSUP Fatmawati Jakarta

Struktur Clinical Governance (Tata Kelola Klinis) RSUP Fatmawati Standar Pelayanan Kedokteran14 adalah pedoman yang harus diikuti oleh dokter dalam menyelenggarakan praktik kedokteran15 dan salah satu tindak lanjut dari perundangan yang telah diterbitkan enam tahun yang lalu.16 Standar Pelayanan Kedokteran terdiri dari Pedoman Nasional Pelayanan Kedokteran (PNPK) dan Standar Prosedural Operasional (SPO). 17 Di RSUP Fatmawati pelayanan dilaksanakan secara terpadu oleh profesi medis, perawat, farmasis dan penunjang lainnya di instalasi layanan dibawah manajemen Kepala Instalasi terkait maka dengan demikian semua profesi terkait di atas di wajibkan untuk membuat Panduan Praktik Klinis masing masing sesuai bidang keprofesiannya (medis, perawat dan farmasi) serta penunjang dan manajemen instalasi dalam bentuk Standar Prosedur Operasional (SPO). Maka strukur Clinical Governance RSUP Fatmawati adalah sebagaimana dapat dilihat dalam Tabel 1 berikut. Tabel 1. Struktur Clinical Governance RSUP Fatmawati Jakarta. Standar Audit CQI Medis PPK Medis Audit Medis Revisi PPK Keperawatan Farmasi Penunjang Manajemen PPK PPK SPO SPO Keperawatan Kefarmasian SO Audit Audit Audit Audit Keperawatan Farmasi Manajemen Revisi Revisi Revisi SPO Revisi SPO PPK PPK dan SO Keperawatan Kefarmasian Integrasi Clinical Pathways Analisis Varians Revisi Clinical Pathways

Untuk penyusunan Panduan Praktik Klinis (PPK) staf medis18 dibuat mengacu kepada Pedoman Nasional Pelayanan Kedokteran (PNPK) yang dibuat oleh organisasi profesi19 dan disahkan oleh Menteri Kesehatan6. Secara ringkas tentang Peraturan Menteri Kesehatan RI Nomor 1438/IX/2010 tentang Standar Pelayanan Kedokteran tersebut sebagaimana dapat dilihat pada Gambar 3 berikut.

14

Permenkes RI Nomor 1438/IX/2010 tentang Standar Pelayanan Kedokteran. http://www.scribd.com/doc/43070763/Dody-Firmanda-2010-Permenkes-No-1438-MENKES-PER-IX2010-Standar-Pelayanan-Kedokteran 15 Permenkes RI Nomor 1438/IX/2010 tentang Standar Pelayanan Kedokteran Pasal 1 ayat 1. 16 Undang Undang RI Nomor 29 Tahun 2004 Pasal 44 ayat 3. 17 Peraturan Menteri Kesehatan RI Nomor 1438/IX/2010 tentang Standar Pelayanan Kedokteran Pasal 3 ayat 1. 18 Peraturan Menteri Kesehatan RI Nomor 1438/IX/2010 tentang Standar Pelayanan Kedokteran Pasal 11. 19 Peraturan Menteri Kesehatan RI Nomor 1438/IX/2010 tentang Standar Pelayanan Kedokteran Pasal 3 dan Pasal 6.

Gambar 3. Ringkasan Peraturan Menteri Kesehatan Nomor 1438/Menkes/Per/IX/2010 dan Lembaran Berita Negara Tahun 2010 Nomor 464 tertanggal 24 September 2010 tentang Standar Pelayanan Kedokteran Peraturan Menteri Kesehatan tersebut bertujuan untuk mengatur tata kelola klinis (clinical governance) yang baik agar mutu pelayanan medis dan keselamatan pasien dirumah sakit lebih terjamin dan terlindungi serta mengatur penyelenggaraan komite medik di setiap rumah sakit dalam rangka peningkatan profesionalisme staf medis.20 Dalam menyusun PPK untuk rumah sakit - profesi medis memberikan pelayanan keprofesiannya secara efektif (clinical effectiveness) dalam hal menegakkan diagnosis dan memberikan terapi berdasarkan pendekatan evidence-based medicine. Profesi perawat menyusun PPK Keperawatan berdasarkan pendekatan evidence-based nursing, sedangkan profesi farmasi dengan pendekatan evidence-based pharmacy. Panduan Praktik Klinis (PPK) berdasarkan pendekatan Evidencebased Medicine (EBM)21/Nursing (EBN)/Pharmacy(EBP) dan atau Health Technology Assessment (HTA)14 yang isinya terdiri sekurang kurangnya dari:22
20 21

Peraturan Menteri Kesehatan RI Nomor 755/Menkes/IV/2011 Pasal 2. Peraturan Menteri Kesehatan RI Nomor 1438/Menkes/Per/IX/2010 tentang Standar Pelayanan Kedokteran Pasal 4 ayat 3 22 Peraturan Menteri Kesehatan RI Nomor 1438/Menkes/Per/IX/2010 tentang Standar Pelayanan Kedokteran Pasal 10 ayat 4

1. Definisi/pengertian 2. Anamnesis 3. Pemeriksaan Fisik 4. Kriteria Diagnosis 5. Diagnosis Banding 6. Pemeriksaan Penunjang 7. Terapi 8. Edukasi 9. Prognosis 10. Kepustakaan Penyusunan Panduan Praktik Klinis (PPK) di atas dapat tentang:23 1. Tatalaksana penyakit pasien dalam kondisi tunggal dengan/tanpa komplikasi 2. Tatalaksana pasien berdasarkan kondisi Adapun langkah langkah dalam penyusunan Panduan Praktik Klinis secara ringkasnya dapat dilihat dalam Gambar 4 berikut.

23

Peraturan Menteri Kesehatan RI Nomor 1438/Menkes/Per/IX/2010 tentang Standar Pelayanan Kedokteran Pasal 4 ayat 1

PNPK/PPK

Gambar 4. Langkah umum dalam kajian literatur melalui pendekatan evidence-based medicine/nursing/pharmacy, tingkat evidens dan rekomendasi dalam proses penyusunan Panduan Praktik Klinis (PPK) medis, keperawatan dan farmasi.
9

Agar lebih mudah dan praktis dalam membantu profesi (medis, perawat dan farmasi) menyusun PPK, maka digunakan Tabel 2 berikut sebagai panduan dalam menentukan tingkat evidens dan rekomendasi sebagaimana langkah ke tiga dari evidence-based medicine (EBM) dalam telaah kritis (critical appraisal). Tabel 2 Ringkasan dalam telaah kritis (critical appraisal) VIA (Validity, Importancy dan Applicability)

Proses selanjutnya setelah menyusun Panduan Praktik Klinis (PPK) Rumah Sakit adalah membuat Clinical Pathways sebagai salah satu upaya dalam rangka kendali mutu dan biaya untuk dari Sistem Casemix (INA CBG) yang saat ini dipergunakan untuk Jaminan Pemeliharaan Kesehatan (Jamkesmas) maupun untuk Universal Coverage (BPJS) yang akan mulai berlaku 17 bulan lagi (1 Januari 2014) - maka INA CBG akan lebih disempurnakan dengan menghitung DRG Relative Weight dan Casemix Index serta Base Rate setiap pengelompokkan jenis penyakit dan selanjutnya dapat membandingkan (benchmarking) cost efficiency antar rumah sakit dalam memberikan layanan kesehatan berdasarkan keadaan sebenarnya diberikan melalui Clinical Pathways.

10

Model Clinical Governance (Tata Kelola Klinis) RSUP Fatmawati Setelah Konsep dan Struktur diatas maka Model Tata Kelola Klinis (Clinical Governance) RSUP Fatmawati yang berfokus pada paien (patient centrednes), terintegrasi, berkesinambungan (continuity of care) sebagaimana dapat dilihat pada Gambar 5 berikut yang terdiri dari: 1. Sistem Manajemen dengan subsistem Pelayanan, subsistem Pendidikan, Penelitian dan Pengembangan Sumber Daya Manusia dan subsistem Pembiayaan dan Keuangan 2. Sistem Staf Medis Fungsional (SMF) 3. Sistem Instalasi

1. Sistem Manajemen RS 2. Sistem SMF 3. Sistem Instalasi

Direktur RSF

Gambar 5. Model Tata Kelola Klinis (Clinical Governance) RSUP Fatmawati Jakarta

11

Sistem Manajemen RSUP Fatmawati Sistem Manajemen RSUP Fatmawati terdiri dari: 1. Sub Sistem Pelayanan 2. Sub Sistem Pendidikan, Penelitian dan Pengembangan Sumber Daya Manusia 3. Sub Sistem Pembiayaan dan Keuangan 1. Sub Sistem Pelayanan Terdiri dari: A. Kebijakan : Visi, Misi, Objektif dan Target Direktorat Medik dan Keperawatan 2 Sub sistem Pelayanan pada Direktorat Medik dan Keperawatan adalah terpadu dan terintegrasi serta tidak terpisahkan dari Sistem Manajemen Rumah Sakit 3 Struktur Organisasi dan Uraian Tugas (jobs description and duty of care) Direktorat Medik dan Keperawatan 4 Rencana Strategis dan Rencana Kerja Direktorat Medik dan Keperawatan (Plan of Action) 5 Standar Pelayanan Direktorat Medik dan Keperawatan: Alur Pelayanan Pasien dalam Rumah Sakit Alur Rujukan Pasien (secara vertikal dan horizontal) Identifikasi pasien Alur Keselamatan pasien Alur Deteksi Potensi Risiko Klinis Manajemen Risiko Klinis 6 Jadwal Kegiatan Direktorat Medik dan Keperawatan : Rawat Jalan Rawat Inap IGD Kamar Operasi Dinas Jaga (dengan on-site) Ruang Intensif Laporan Jaga Manajemen Audit Manajemen Kasus Potensi Bermasalah Rapat Koordinasi 9 Jadwal Laporan Berkala 10 Jadwal Cuti Tahunan 11 Jadwal Monitoring dan Evaluasi dalam rangka perbaikan dan peningkatan mutu (corrective, preventive and advancing actions) Direktorat Medik dan Keperawatan 1

B. Struktur :

C. Proses dan Hasil

12

2. Sub Sistem Pendidikan, Penelitian dan Pengembangan SDM Terdiri dari: A. Kebijakan : 1 2 Visi, Misi, Objektif dan Target Direktorat Umum, SDM dan Pendidikan Sub sistem Pendidikan, Penelitian dan Pengembangan Sumber Daya Manusia pada Direktorat Umum, SDM dan Pendidikan adalah terpadu dan terintegrasi serta tidak terpisahkan dari Sistem Manajemen Rumah Sakit Struktur Organisasi dan Uraian Tugas (jobs description and duty of care) Direktorat Umum, SDM dan Pendidikan Rencana Strategis dan Rencana Kerja Direktorat Umum, SDM dan Pendidikan (Plan of Action) Standar Direktorat Umum, SDM dan Pendidikan : Alur Administrasi dan Persuratan di Rumah Sakit Alur Rekrutmen staf Rumah Sakit Panduan Umum Pendidikan Dokter/Dokter Spesialis/Keperawatan/Kebidanan/Kefarmasian Panduan Umum Penelitian di Rumah ASakit Kerjasama (MOU) dengan Institusi Pendidikan Kinerja SDM Rumah Sakit Jadwal Kegiatan Direktorat Umum, SDM dan Pendidikan : Rapat Koordinasi Pengembangan Karier Staf Pegawai Potensi Bermasalah

B. Struktur :

3 4 5

C. Proses dan Hasil

9 Jadwal Laporan Berkala 10 Jadwal Cuti Tahunan 11 Jadwal Monitoring dan Evaluasi dalam rangka perbaikan dan peningkatan mutu (corrective, preventive and advancing actions) Direktorat Umum, SDM dan Pendidikan

13

3. Sub Sistem Pembiayaan dan Keuangan Terdiri dari: A. Kebijakan : 1 2 Visi, Misi, Objektif dan Target Direktorat Keuangan Sub sistem Pembiayaan dan Keuangan adalah terpadu dan terintegrasi serta tidak terpisahkan dari Sistem Manajemen Rumah Sakit Struktur Organisasi dan Uraian Tugas (jobs description and duty of care) Direktorat Keuangan Rencana Strategis dan Rencana Kerja Direktorat Keuangan (Plan of Action) Standar Direktorat Direktorat Keuangan : Alur Administrasi Keuangan dan Klaim RS Financial Statement Rumah Sakit Panduan Umum Penyusunan Biaya Rumah Sakit termasuk revenue center dan cost-center Panduan Penyusunan Pembayaran berdasarkan Renumerasi Jadwal Kegiatan Direktorat Keuangan : Rapat Koordinasi Jadwal Laporan Berkala Jadwal Cuti Tahunan Jadwal Monitoring dan Evaluasi dalam rangka perbaikan dan peningkatan mutu (corrective, preventive and advancing actions) Direktorat Keuangan

B. Struktur :

3 4 5

6 9 10 C. Proses dan Hasil 11

14

Sistem Staf Medis Fungsional (SMF) - Terdiri dari: A.Kebijakan : 1 Visi, Misi, Objektif dan Target SMF 2 Sub sistem Pelayanan, Pendidikan dan Penelitian pada tingkat SMF adalah terpadu dan terintegrasi serta tidak terpisahkan dari Sistem Manajemen Rumah Sakit B. Struktur : 3 Struktur Organisasi dan Uraian Tugas (jobs description and duty of care) setiap anggota SMF 4 Rencana Strategis Instalasi dan Rencana Kerja SMF (Plan of Action) 5 Standar Pelayanan Kedokteran: Panduan Praktik Klinis SMF berdasarkan Evidence-based Medicine (EBM) Clinical Pathways SMF 6 Jadwal Kegiatan Pelayanan Medis: Rawat Jalan Rawat Inap IGD Kamar Operasi Dinas Jaga (dengan on-site) Ruang Intensif Laporan Jaga Audit Medis Kasus Kematian/Kasus Sulit 7 Jadwal Kegiatan Ilmiah: Ronde Besar Journal reading 8 Jadwal Kegiatan Pendidikan a. Program Pendidikan Dokter i. Rotasi Mahasiswa ii. Bimbingan Fisik iii. Sajian Kasus iv. Referat i. Laporan Jaga v. Ujian Mingguan dan Ujian Akhir (Mini-Cex, CbD, DOPS, Mini-PAT) vi. Yudisium b. Program Pendidikan Dokter Spesialis (PPDS) ii. Rotasi PPDS iii. Journal Reading iv. Ronde Ruangan v. Asesmen: Mini-Cex, CbD, DOPS, Mini-PAT 9 Jadwal Rencana Pendidikan dan Penelitian Staf 10 Jadwal Laporan Berkala 11 Jadwal Cuti Tahunan dan Kepesertaan Kegiatan Ilmiah C. Proses dan 12 Jadwal Monitoring dan Evaluasi dalam rangka perbaikan dan peningkatan Hasil mutu (corrective, preventive and advancing actions) SMF
15

Sistem Instalasi RSUP Fatmawati Terdiri dari: A. Kebijakan : 1 2 Visi, Misi, Objektif dan Target Instalasi Sub sistem Pelayanan, Pendidikan dan Penelitian pada tingkat Instalasi adalah terpadu dan terintegrasi serta tidak terpisahkan dari Sistem Manajemen Rumah Sakit Struktur Organisasi dan Uraian Tugas (jobs description and duty of care) setiap anggota Instalasi Rencana Strategis dan Rencana Kerja Instalasi (Plan of Action) Standar Pelayanan Instalasi: Alur Layanan di Instalasi Perawat: Panduan Praktik Klinis Keperawatan berdasarkan Evidence-based Nursing (EBN) Farmasis: Panduan Praktik Klinis Kefarmasian berdasarkan Evidence-based Pharmacy dan Sistem UDD Keuangan: Panduan Billing dan Koding Jadwal Dinas Instalasi Jadwal Kegiatan Instalasi Jadwal Pemeriksaan Visitasi DPJP Jadwal Pemeriksaan Penunjang Jadwal Konsultasi Jadwal Pemberian Obat Jadwal Makanan Pasien Jadwal Pengembalian Rekam Medis Pertemuan rutin instalasi Jadwal Laporan Berkala Jadwal Cuti Tahunan dan Kepesertaan Kegiatan Ilmiah Jadwal Monitoring dan Evaluasi dalam rangka perbaikan dan peningkatan mutu (corrective, preventive and advancing actions) SMF

B. Struktur :

3 4 5

6 7

8 9 C. Proses dan Hasil 10

Jakarta, 30 Juni 2012

16

Dody Firmanda

Not just being pass the Accreditation and paperwork but beyond that

Quality is a never ending journey