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Faculty of Medicine

Gadjah Mada University
Standards for Medical
Professional
Tjahjono Kuntjoro
Faculty of Medicine
Gadjah Mada University
OBJECTIVES
• 1. Understand and explain the definition of
standard for medical professional
• 2. Explain the importance of standards in
providing medical services
• 3. Explain types of standards being used in
medical professions
• 4. Understand the steps of developing
standards
• 5. Understand how to monitor and evaluate
the implementation of standards
Faculty of Medicine
Gadjah Mada University
Subtopics
• 1. Definition of standards in medical practice
• 2. The benefits of standards in medical
practice
• 3. Types of standards in medical practice
• 4. The steps of developing standards
• 5. Monitoring and evaluating the
implementation of standards
Faculty of Medicine
Gadjah Mada University
Definition of standards
• Oxford dictionary:
– standards are degrees of excellence,
standards serve as a basis of comparison
– standards are a minimum with which a
community may be reasonably content,
– a standard is recognized as a model for
imitation.
Faculty of Medicine
Gadjah Mada University
Definition of standards
• Donabedian:
– professionally developed expressions of
the range of acceptable variations from a
norm or criterion
– criteria are defined as predetermined
elements against which aspects of the
quality of medical services may be
compared, and norms as measures of
usual observed performance.
Faculty of Medicine
Gadjah Mada University
Definition of standards
• Katz & Green:
– Standard is defined as a written statement
that specifies expectations
– Standards in health care practices are
divided into three domains: standards of
governance, standards of practice, and
standard of service.
Faculty of Medicine
Gadjah Mada University
Definition of standards
• Meissenheimer:
– Any established measure of extent, quantity,
quality, or value; an agreed-upon or expected
level of performance;
– The expression of the range of acceptable
variations from a norm or criterion.
• WHO:
– A benchmark of achievement which is based
on a desired level of excellence.
– Standards become models to be imitated and may
serve as the basis for comparison.
Faculty of Medicine
Gadjah Mada University
Benefit of
standards
in medical
practice
Needs
Expectation
Customer
Focus
Requirement
Process Variation
Process Improvement
S D
A C
P D
A C
Re-engineering
Q S
P A
Evidence Based
8 dimensions:
•access
•effectiveness
•efficiency
•safety
•continuity of care
•technical competence
•amenities
•human relationship
Principles:
Customer focus
Process focus
Commitment
Empowerment
Vision, Mission, Values, Management System, Leadership
Change of Behavior
Faculty of Medicine
Gadjah Mada University
Why standard/practice guidelines
may be needed ?
• Problem in clinical decision making
related to:
– Size of health burden
– Cost
– Variations in practice
– Existence of available evidence
Faculty of Medicine
Gadjah Mada University
Benefits of standards in medical
practice
• Reducing process variations (Schroeder, 1994)
• Safety of the patients and the health workers: (Moss &
Barrach, 2002; Reason, 2002)
– Care can not be considered to be high quality unless it is safe
– Standards should be established in order to reduce patient harm
as well as workers harm
• Professional requirements:
– As a profession we have a duty to maintain good standards of
practice and care, and to show respect human life (Swage,
2000)
– Articulate what the professions do (Schroeder, 1994)
• A framework for measuring quality (Schroeder, 1994).
Faculty of Medicine
Gadjah Mada University
Use of guidelines by clinicians
(Feder et al, 1999)
• Guideline for practice
• Information source for continuing professional
education: overview of the management of a
condition or the use of an intervention
• Instrument for self assessmeent
• Answer specific clinical questions arising out
of day to day practice
• Allows the clinicians to identify what sort of
evidence to search for
Faculty of Medicine
Gadjah Mada University
Potential benefits for patients
• Improve health outcomes
• Reduce mortality and morbidity
• Improve quality of life
• Improve consistency of care
• Make more informed health care
choices, preferences in selecting the
best options
Faculty of Medicine
Gadjah Mada University
Potential limitations
• Scientific evidence about what to recommend
is often lacking, misleading, or misinterpreted
• Recommendations are influenced by the
opinions and clinical experience and
composition of the standard development
group
• Patient needs may not be the only priority in
making recommendations, other
considerations maybe: managerial, political,
economic, etc)
Faculty of Medicine
Gadjah Mada University
Potential harms to patients
• Recommendation that do not take due
account of evidence can result in suboptimal,
ineffective or harmful practices
• More consistent practice patterns and
reduced variation may come at the expense
of reducing individualized care for patients
with special needs
• Adversely may affect public policy (example:
displace limited resources)
Faculty of Medicine
Gadjah Mada University
Potential harm for
professionals
• Conflicting guidelines/standards
from different professional bodies
• Unfairly judgment the quality of care
based on invalid
standards/guidelines
• Ignoring complexity of medical care
Faculty of Medicine
Gadjah Mada University
Types of standards
• Donabedian:
– Structure standards: the things we use
( human, financial, physical resources)
– Process standards: what we do (activities
that constitute care, service, or
management)
– Outcome standards: address the results
Faculty of Medicine
Gadjah Mada University
Standard
•External Standards
•Internal Standards
Developed by people/organization outside the health care
facility
Developed by the health care facility itself based on evidence,
References, and the conditions of the organization
(Burrill & Ledolter, Achieving Quality through Continual Improvement)
Faculty of Medicine
Gadjah Mada University
Standard
•Minimal
•Optimal
•Achievable
No service should fall bellow
this standard
A “must”, bellow which lies the
unacceptable
The best level of service that
can be achieve
Represent a degree of excellence
The level of performance achieve
by the top quartile of service
(MuirGray, J.A., Evidence Based Health Care, 2001; WHO, 1993)
Faculty of Medicine
Gadjah Mada University
Focus of standards
• Organization and management of health
care: Standard Operating Procedures
• Clinical Practices: Clinical Practice
Guidelines/Standards or Clinical
Protocols, and Care Pathways
Faculty of Medicine
Gadjah Mada University
Standard developed
by
external organization:
MOH
Standard for Evaluating
The Quality system or
Assuring the service
quality
(optimal)
Developed by
Accreditation body
Accreditation
Licensing
Professional
Organizations
Clinical standards
Professional guideline
Clinical Procedures
Standard of care
Standard of practice
Standard of
governance
Standards for public
service
Standards for
clinical practices
Standards for
Administration &
management
Internal Standards
(achievable)
Health
Professions
Faculty of Medicine
Gadjah Mada University
Read this statement:
• The development of practice standards is not
without controversy: many physicians argue
that such standards are too restrictive and
impede exercise of their best judgement
when treating individual patients (WHO,
1993).
• So instead of using the term of “standard”, the
professional organizations tend to use the
term of “guideline” as a “softer standard”.
Faculty of Medicine
Gadjah Mada University
Organization and management
standards are easier to
develop, monitor and evaluate
but….
Clinical practice standards require
a great deal of consensus
building to achieve and to
interpret appropriately
Faculty of Medicine
Gadjah Mada University
How standards are set
Collective
professional
judgment
Evidence based Value based
Faculty of Medicine
Gadjah Mada University
Steps in developing standards
• Basic principles:(NHMRC,1998).
– should focus on outcomes,
– should be based on the best available evidence and should
include a statement about the strength of their
recommendations,
– the method used to synthesize the available evidence should be
the strongest applicable,
– the process of guideline development should be multi-
disciplinary and should include consumers,
– should be flexible and adaptable to varying local conditions
including the technology development and resources available,
– should be developed with resource constraints in mind,
– guidelines are developed to be disseminated and implemented
taking into account their target audiences,
– the implementation and impact of guidelines should be
evaluated,
– should be revised regularly
Faculty of Medicine
Gadjah Mada University
Steps in developing standards
• determining the need for and scope of the
guidelines, convene a multi-disciplinary panel to
oversee the development of the guidelines,
• define the purpose of and target audience for the
guidelines,
• identify health outcomes,
• review the scientific evidence,
• formulate the guidelines,
• formulate a dissemination and implementation
strategy,
Faculty of Medicine
Gadjah Mada University
Steps in developing standards
• formulate an evaluation and revision strategy,
• proceed to produce the guidelines,
• reporting on the guidelines development
process,
• assessing the guidelines document whether it
conforms to the principles of guideline
development, and
• consultation to wider group of interested parties
that may not have already been involved.
Faculty of Medicine
Gadjah Mada University
Should all activities or
processes be standardized ?
Faculty of Medicine
Gadjah Mada University
Criteria for prioritizing the need
for developing standards
• High risk
• High cost
• High volume
• Problem prone
Faculty of Medicine
Gadjah Mada University
Monitoring and evaluating the
implementation of standards
• Clinical micro-system: small organized
groups of providers and staff caring for
defined populations of patients,
assessing and monitoring the
performance.
• Self assessment: using a check list
• Peer-review: using a check-list.
Faculty of Medicine
Gadjah Mada University
Conclusions
• Standards for medical professional as written
statements that specifies expectations, degrees
of excellence, expressions of the range of
acceptable variations from criterion, are needed
for assuring quality, safety, and professional
medical care services.
• The standards can be divided into structure,
process, and outcome, as well as practice,
service, and governance. Concerning the levels
of standards, there are minimum and optimum
standards.
Faculty of Medicine
Gadjah Mada University
Conclusions
• The implementation of appropriate standard
will improve quality of care, assure patient
and provider safety by reducing patient and
worker harms.
• The development of standards or practice
guidelines should involve professionals as
well as customers, and should be based on
the best available evidence.
• Standards should be tested, implemented,
monitored, and continually revised based
on the best evidence, knowledge,
evaluation results, and medical technology
development.
Faculty of Medicine
Gadjah Mada University
References
• Bapelkes Gombong (2000), Laporan Evaluasi Pasca Pelatihan Jaminan Mutu, Gombong.
• Katz, J .M., Green, E.,(1997) Managing Quality: A Guide to System-Wide Performance
• Management in Health Care, 2
nd
ed, Mosby, St Louis: 24-32
• Meisenheimer, C.G., (1997) Improving Quality: A guide to Effective Programs, 2
nd
ed, Aspen,
• Maryland:33-44.
• Mohr, J .J ., Batalden, P.B., (2002), Improving Safety on the front lines: the role of clinical
• microsystems, Qual Saf Health Care: 11:45-50.
• Morris, A.H., Decision support and safety of clinical environment, Qual Saf Health Care. 11:69-
• 75.
• Moss, F., Barach, P., (2002), Quality and Safety in Health Care: a time of transition,
• Qual Saf Health Care, 11:1.
• NHMRC (National Health and Medical Research Council), 1998, A guide to development,
• implementation, and evaluation of clinical practice guidelines, Canberra.
• Pusdiklat DepKes RI, (1996) Modul Pelatihan Jaminan Mutu Pelayanan Kesehatan Dasar di
• Puskesmas, J akarta
• Reason, J ., Combating omission errors through task analysis and good reminders,
• Qual Saf Health Care, 11:40-44.
• Schroeder, P., (1994), Improving Quality and Performance: Concepts, Programs, and
• Technioques, Mosby, St Louis: 9-11
• Swage, T., (2000), Clinical Governance in Health Care Practice, Butterworth Heinemann,
• Oxford: 197.
• WHO, Division of Strengthening of Health Services District Health System, The Contemporary
• use of Standards in Health Care, 1993.