HOSPITAL

BUSINESS EXCELLENCE
FRAMEWORK
Dr. Dody Firmanda, Sp.A, MA
Ketua Komite Medik
RSUP Fatmwati, Jakarta

Disampaikan pada Acara Round Table Discussion – Key Performance Indicators (KPIs) for Hospital
diselenggarakan oleh PT Krakatau Medika di Hotel Permata Krakatau, Cilegon 6 Agustus 2009
 Vision
Vision or
or guiding philosophy 1
guiding philosophy
What
Whatwe
wewant
wantto
tobe
be

Core 2
Core values
values and
and Strategy
beliefs
beliefs The way we are
Who
Whowe
wewant
wantto
tobe
be going to achieve it
Mission 3
Mission
Our
Ourpurpose
purposeand
andthe
the
scope of our work
scope of our work

Critical Success
Critical Factors 4
Success Factors
5 (CSFs)
Key
Key (CSFs)
Performance
Performance Whatsuccess
successwill
willlook
looklike
like––aa Target
What
Indicators
Indicators(KPIs)
(KPIs) balancedscorecard
balanced scorecardof ofresults
results

Core processes
processes 6
Core
People Howsuccess
successwill
willbe
beachieved
achieved Resources
How

Process management
 RUMAH SAKIT : ………………………………………………………
1 Vision ........................................................................................................................

Values
................................... .............................................
2 ................................... .............................................
................................... .............................................
................................... ............................................

Mission
................................... .............................................
3 ................................... .............................................
................................... .............................................
................................... .............................................

CSFs
................................... .............................................
4 ................................... .............................................
................................... .............................................
................................... .............................................
................................... .............................................
................................... .............................................
................................... .............................................

KPIs
................................... .............................................
5 ................................... .............................................
................................... .............................................
................................... .............................................
................................... .............................................
................................... ............................................

Core
................................... .............................................
6 ................................... .............................................
................................... .............................................
Processes ................................... .............................................
................................... ............................................
EVOLUSI 1: Pendahuluan
EVOLUSI 2:
Doing
Doingthings
things
cheaper
cheaper
(Efficiency)
(Efficiency)
Doing
Doingthings
things
right
right

Doing
Doingthe
the
right
rightthings
things
Doing
Doingthings
things right
better right
better(Quality
(Quality
Improvement)
Improvement)

Doing
Doingthe
theright
right
things
things
(Effectiveness)
(Effectiveness)

Tahun 1970an Tahun 1980an Tahun 1990an Abad 21

 Quality Leadership

Inspection
Inspection Quality
QualityControl
Control Quality
QualityAssurance
Assurance Total
TotalQuality
Quality

Criteria
Criteria Setting
SettingStandards
Standards
Structures
Structures
(Inputs) Indicators
Indicators
(Inputs) Conform
Conformthe
theStandards
Standards
Process
Process
Outcomes
Outcomes Maintain
Maintain&&Improve
Improvethe
theStandards
Standards

Outputs
Outputs Audits ContinuousQuality
QualityImprovement
Improvement(CQI)
(CQI)
Continuous
Impact
Impact Surveillance Evidence-basedMedicine
Evidence-based Medicine(EBM)
(EBM)
HealthTechnology
Health TechnologyAssessments
Assessments(HTA)
(HTA)

System&&Sub
System SubSystems
Systems

Ideas
Ideas Concepts
Concepts Constructions
Constructions Model/Paradigma
Model/Paradigma Theory
Theory

Leadership, Values & Principles

 Vision

Mission 1 Mission 2 Mission 3

Wants Demands Needs

Measurable Objective 1 Objective2 Objective 3 Objective 4

Target 1 Target 1 Target 1 Target 1

Target 2
Target 2 Target 2 Target 2
Time-frame Target 3
Target 3 Target 3 Target 3
Target 4
Target 4 Target4
Target 4 Target 5
 WHO Europe :
Performance Assessment Tool for Quality Improvement in
Hospitals (PATH)
dodyfirmanda, 21 November 2008
WHOEurope PATH dengan model Sistem
Komite Medik RSUP Fatmawati

dodyfirmanda, 21 November 2008

dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008
PATIENT SAFETY = 1
RISIKO X ERRORS

RISIKO = B A R R I E R S
KOMPETENSI X MOTIVASI

KINERJA = MOTIVASI X KOMPETENSI

BARRIERS

Knowledge-based
Mutu Profesi
Performance = Kompetensi X Motivasi
Sarana

Kompetensi = Pelayanan, Pendidikan & Penelitian

Standar/indikator Rawat Jalan Dokter Uji Klinis

Audit/Benchmarking Rawat Inap Sp.1 Deskriptif
CQI Operasi Sp.2
Emergensi
Konsultasi
Jaga
 1. Kolegium
2. STR dari Konsil Kedokteran
3. SIP

Sertifikat Kompetensi

Kewenangan Klinis
Komite Medik
Contoh Kewenangan Klinis
Sub Komite Kredensial
1. Tes Kepribadian
2. Tes MMPI-2
3. Wawancara
Pemeriksaan Penunjang Diagnostik
Pemeriksaan Penunjang Terapeutik
Obata obatan
Peralatan Operasi
Ruang Tindakan/Operasi
SDM Penunjang
Keselamatan Pasien

Safetyness = Risks X Harms

Likelihood Severity

Frekuensi Cedera
Infeksi Nosokomial
Meninggal
Litigasi
 Audit Medis

Audit Medis
Audit Medis

Surveilans Nosokomial
Audit Medis

PRA (Probability Risks Assessment)

Komite Hukum RS
Portfolio Individu
Implementasi
Implementasi
Implementasi
Implementasi

Gambar 6. Kerangka Konsep Patient Safety Komite Medik RSUP Fatmawati

Model Patient Safety
(untuk RS pendidikan)
KOMITE MEDIK: SISTEM CLINICAL GOVERNANCE, PATIENT SAFETY & CP
/ Adverse Events