Dasar Kesehatan Masyarakat

Fakultas Kesehatan Masyarakat

Universitas Indonesia

INSTITUSI PELAYANAN KESEHATAN

CHAPTER 10– HEALTHCARE INSTITUTIONS

P ro g r a m S a r j a n a Ke s e h a t a n Ma s y a r a k a t , F K M U I , 2 0 1 3

Public Health 101, Richard Riegelman , 2010

 LEARNING OBJECTIVES

1. Me n g id e n t if ik a s i r u a n g l in g k u p f a s il it a s p e l a y a n a n ke s e h a t a n
inpatient

Mengident if ikas i r uang l ingkup f as il it as pel ayanan ke s e h a t a n

outpatient
2.
3. Mendeskripsikan pendekatan yang digunakan untuk mendefinisikan dan
m e n g u k u r k u a n tita s p e la y a n a n ke s e h a ta n

Me n d e s k r ip s ik a n t ip e - t ip e ko o rd in a s i d a l a m p e l a y a n a n d a n me t o d e
yang tersedia untuk memfasilitasinya 4.
5. M e n g i d e n t if ik a s i p e r a n - p e r a n y a n g d a p a t d i l a k u k a n d e n g a n c a t a t a n e l e k t r o n i k m e d i s
d a l a m m e n i n g k at ka n p e n y a mp ai a n p e l a y an an ke s e h a ta n

Me n g id e n t if ik a s i ko mp o n e n ma l p r a k t ik me d is d a n ke s a l a h a n me d is
( medical errors ) 6.

DA S A R K E S E H ATA N M A S YA R A K AT
P R O G R A M S 1 K E S E H ATA N M A S YA R A K AT
 P R E FAC E : D I S C U S S I O N

George didn’t have health insurance and went to the emergency

room whenever he needed care. They always treated him there,
but then tried to get him connected to a primary care facility.

1
He wasn’t eligible for care at the Veterans Administration
facilities. So, they sent him to the local community health center,
which they called the “safety net” provider. George did go
there and they not having insurance. When they got sick,
however, George went back to the emergency department. Even
George agreed that it wasn’t the best way to get care, but he
wondered:
what is needed to make the system work better?

H E A L T H C A R E I N S T I T U T I O N S -3-
P R E FAC E : D I S C U S S I O N

Laura had breast cancer and it had spread. Her medical

records were on file at hospital, at four doctor’s offices, in two
emergency rooms, and at an outpatient imaging facility. No one

2
seemed to know how to put the system together. Whenever her
old records were essential, they asked her to go get a copy of
them and bring to her next appointment. That worked for a
while but when she ended up in the emergency room her records
just weren’t available. There must be a better way. Laura
thought to herself.
Hasn’t the healthcare system discovered the Internet yet?

H E A L T H C A R E I N S T I T U T I O N S -4-
 INSTITUTIONS MAKE UP THE HEALTHCARE SYSTEM

Heathcare Institutions
1 Inpatient ▪ A healthcare facility in which an individual may
remain for more than 24 hours
▪ Include hospitals, skilled nursing and
Facilities rehabilitation facilities, nursing homes, and
institutional hospices

2 Outpatient ▪ A healthcare facility in which patients can

remain for less than 24 hours
▪ Include the offices of clinicians, general, and
Facilities specialty clinics, emergency departments and a
range of new types of community-based
diagnostic and treatment facilities

H E A L T H C A R E I N S T I T U T I O N S -5-
 I N PAT I E N T FAC I L I T I E S E X I S T I N I N D O N E S I A

1) Hospitals generally designed for

short-term stays by patients
Inpatient
Facilities 2) Long-term care facilities ( Skilled
nursing facilities, nursing homes,
assisted living and dementia care,
Rawat Inap hospice care)

H E A L T H C A R E I N S T I T U T I O N S -6-
 O U T PAT I E N T FAC I L I T I E S E X I S T I N I N D O N E S I A

1) Clinical Facilities and Diagnostic

Testing
Outpatient
Facilities
2) Therapeutic Facilities
Rawat Jalan

H E A L T H C A R E I N S T I T U T I O N S -7-
 Institusi Pelayanan Kesehatan
• Fasilitas Pelayanan Kesehatan merupakan tempat
yang digunakan untuk menyelenggarakan
pelayanan kesehatan, baik peningkatan,
pencegahan, pengobatan, maupun pemulihan
yang dilakukan oleh pemerintah dan atau
masyarakat termasuk swasta.
• Fasyankes meliputi fasyankes perorangan dan
fasyankes masyarakat
• Fasyankes: tingkat pertama/primer, tingkat
kedua/sekunder, tingkat ketiga/tersier.
 Fasyankes Perorangan
• Tingkat Primer: Puskesmas dan jejaringnya, pos
kesehatan desa (poskesdes), fasyankes lain
seperti klinik (pemerintah/swasta/masyarakat),
dokter/bidan praktek swasta, dll
• Tingkat sekunder: RS setara kelas C, fasyankes
lainnya (pemerintah/swasta/masyarakat)
• Tingkat tersier: RS setara kelas A dan B, klinik
khusus (seperti pusat radioterapi)
 Fasyankes Masyarakat
• Tingkat primer: puskesmas dan jejaringnya,
fasyankes lain (pemerintah/swasta/masyarakat)
• Tingkat sekunder: Dinas Kesehatan
Kabupaten/Kota, Laboratorium kesehatan, Balai
Teknik Kesehatan Lingkungan (BTKL), Balai
Pengamanan Fasilitas Kesehatan (BPFK), dll
• Tingkat tersier: Dinas Kesehatan Propinsi, Kemkes,
dan unit kerja terkait di tinkkat nasional.
 THE QUALITY OF HEALTHCARE SERVICES

Quality Assessment of Healthcare Services

Structure Process Outcome

Focused on the Concentrates on Focus on the result
physical and the procedures of care from
organizational and formal rates of infection
infrastructure in processes that go to readmissions
which care is into delivering with complications
delivered care

H E A L T H C A R E I N S T I T U T I O N S
-
 THE QUALITY OF HEALTHCARE SERVICES

Characteristics of Healthcare Quality

– National Committee for Quality Assurance (NCQA)
Characteristics Meaning Examples How Measured?
Enough primary care physicians Patients satisfaction
Access to needed care
Access and and specialists surveys, patient
and good costumer
Service Satisfaction of patients in terms grievances and follow-
service
of problems obtaining care up, interviews with staff
System for checking credentials, Presence of system for
Personnel licensed and
Qualified sanctions checking credentials
trained and patients
Providers Patient satisfaction with Patient satisfaction
satisfied with services
providers of care surveys
Presence of guidelines for
Review of
Quality of services that appropriate clinical
independently-verified
Staying help people maintain preventive services
clinical records
Healthy good health and avoid Evidence that patients are
Review of responses
illness receiving appropriate
from patients
screening test

H E A L T H C A R E I N S T I T U T I O N S
-
 THE QUALITY OF HEALTHCARE SERVICES

Characteristics of Healthcare Quality

– National Committee for Quality Assurance (NCQA)
Characteristics Meaning Examples How Measured?
Presence of method for
evaluating new procedures,
Review of
drugs, and devices to
Quality of services independently-
ensure that patients have
Getting Better that help people verified clinical
assess to the most up-to-
recover from illness records
date care
Interviews with staff
Providing specific services,
such as smoking cessation
Programs to assist patients to
Review of
Quality of services manage chronic condition
independently-
Living with that help people like asthma
verified clinical
Illness manage chronic Provision of specific services,
records
illness such as eye examinations
Interviews with staff
for diabetics

H E A L T H C A R E I N S T I T U T I O N S -13-
TYPE OF COORDINATION OF CARE

Traditional Approach
Clinician-Patient Relationship

Knowledge Trust Commitment

Continuity of Care

H E A L T H C A R E I N S T I T U T I O N S -14-
 TYPE OF COORDINATION OF CARE

Type of Coordination of Care, Intended

Functions, and Challenges with Implementation

Type of
Intended Function Challenges with Implementation
Coordination

Continuity as a mechanism
Multiple clinicians involved in care
for ensuring coordination
Team rather than individual concept of
Clinician-Patient Development of one-to-one
primary care
Relationship relationships built on
Frequent changes in insurance coverage
knowledge and trust over
require change in health professionals
extended periods of time

Coordination of individual’s
Different structures and governance
information between
often lead to lack of coordination
Institutional institutions needed to
between inpatient facilities and
Coordination inform individual clinical
between inpatient and outpatient
and administrative
facilities
decision making

H E A L T H C A R E I N S T I T U T I O N S -15-
 TYPE OF COORDINATION OF CARE

Type of Coordination of Care, Intended

Functions, and Challenges with Implementation

Type of Challenges with

Intended Function
Coordination Implementation
Implies that a patient has comprehensive
Lack of comprehensive
coverage for services provided by the
insurance coverage often
full range of institutions
Financial means that essential services
Maximize the efficiency of the care
Coordination received and minimize the
cannot be delivered at the
most efficient or effective
administrative effort required to
institutional site
manage the payment system
Coordination Lack of coordination of
between Coordination of services between clinical
services between public
care and public health requires
health care communication to ensure follow-up and
health services and clinical
and public care is often based on lack
to protect the health of others
Health of communication

H E A L T H C A R E I N S T I T U T I O N S -16-
C O O R D I N AT I O N B E T W E E N H E A LT H C A R E A N D I N S T I TU T I ON

Each type differs in its

Types of institutions that
governance, finance,
deliver health care continued
accreditation, and
to proliferate in recent years
organizational structure

Mo s t patie n ts, po licy make r s an d e ve n clin ician s

do n o t h ave a go o d o ve r v iew o f th e s y s te m

Co n n e cti n g th e i n s ti tu ti o n s to a c h i e ve a n o r ga n i z e d
sy ste m h a s b e co me a ma j o r c h a l l e n ge

H E A L T H C A R E I N S T I T U T I O N S -17-
COORDINATION BETWEEN HEALTH CARE AND INSTITUTION

Approaches to Integrated The System

1 2
The Development of The Use of
Integrated Integrated
Healthcare Delivery Electronic Medical
Systems Records

H E A L T H C A R E I N S T I T U T I O N S -18-
 1. THE DEVELOPMENT OF HEALTHCARE DELIVERY SYSTEM

Termi n o l o gy
▪ A linkage of institutions and healthcare professionals that
together take on the responsibility of delivering coordinated
care
▪ The delivery of healthcare services to a defined population

The Successful Example

▪ Care coordination challenges
▪ Coordination of routine health care

H E A L T H C A R E I N S T I T U T I O N S -19-
2. THE USE OF ELECTRONIC MEDICAL RECORDS

The Roles of Electronic Medical Records

He a l th I n fo r m a ti o n a n d Da ta
Re su l ts M a n a ge me n t
O r d e r E n tr y / M a n a gemen t
De ci s i o n S u p p o r t M a n a ge me n t
E l e ctro n i c Co m m u n i ca ti o n a n d Co n n e cti v i ty
Pa t i e n t S u p p o r t
Ad m i n i s tr a ti ve p ro ce s s e s
Repor ting and Population Health

H E A L T H C A R E I N S T I T U T I O N S -20-
2. THE USE OF ELECTRONIC MEDICAL RECORDS

The Way Electronic Medical Records Improving Quality and Efficiency of Patient Care

Improve Patient Safety

• Electronic records containing information on prescribed drugs and other treatments are expected to
improve patient safety

Support the Delivery of Effective Patient Care

• Effectiveness is providing services based on scientific knowledge to those who could benefit and at
the same time refraining from providing services to those not likely to benefit

Facilitate Management of Chronic Conditions

• Electronic records can help inform clinicians of other care (recommended care) being given to their
patients with chronic condition

Improve Efficiency

• Electronic records, if consistently and widely implemented in the healthcare arena, can be expected
to reduce costs as they have in many other fields

H E A L T H C A R E I N S T I T U T I O N S -21-
 M E C H A N I S M TO A D D R E S S I S S U E S O F Q UA L I T Y I N H E A LT H C A R E

Hospital Accreditation of Malpractice Disclosure of

privileges and additional liability, not only Medical Errors
approval to healthcare for physicians,
perform specific organization but increasingly
procedures including clinical for other health
practices professionals

H E A L T H C A R E I N S T I T U T I O N S -22-
 MALPRACTICE AND MEDICAL ERROR

Medical Malpractice
A body of state civil law designed to hold
practitioners accountable to patients for the
quality of health care

Medical Malpractice is hailed by its supporters

a s t h e u l t i m a t e g u a r a n t o r o f q u a l i t y. I t i s a t t a c k e d b y i t s
d e t r a c t o r a s l e a d i n g t o d e f e n s i v e m e d i c i n e , i n c r e a s e d c o s t s, a n d
s h o r t a g e s i n v u l n e r a b l e p r o f e s s i o n s, s u c h a s o b s t e t r i c s

H E A L T H C A R E I N S T I T U T I O N S -23-
 MALPRACTICE AND MEDICAL ERROR

Medical Error ma y b e d u e t o d e f ic ie n c ie s
in t h e d ia g n os t ic s or t h e r a p e u t ic p r oc e s s on t h e
p a r t of c lin ic ia n ( s ) .
I t m a y a l s o b e d u e t o w h a t a r e c a l l e d s y s t e m e r r o r s, p r o b l e m s
resulting from deficiencies in the system for delivering health
care
S y s t e m E r r o r problems resulting from deficiencies in
the system for delivering health care or other services

40.000 DEATHS /year because of medical errors

-IOM do cume ntatio n

H E A L T H C A R E I N S T I T U T I O N S -24-
 MALPRACTICE AND MEDICAL ERROR

Errors in judgment and unsuccessful efforts are only considered

medical malpractice if the patient can establish all four of the
following:

A duty was owed

• A healthcare provider undertook the care or treatment of a patient

A duty was breached

• A failure of the healthcare provider to meet a relevant standard of care

The breach caused the injury

• Responsibility for an injury lies with the last negligent act. Proximal cause asks whether
the injury or the other event would have occurred if the negligent act had not occurred
Damages occurred
• Direct damages: Lost earning, as well as current and future medical expenses
• Indirect damages: Pain and emotional distress
• Punitive Damages: when conduct is intentionally harmful or grossly negligent

H E A L T H C A R E I N S T I T U T I O N S -25-
MALPRACTICE AND MEDICAL ERROR

Patient be informs of all outcomes of care including

“unanticipated outcomes”. Recent efforts to develop a system
of disclosure have included a far more specific set of
expectations including conveying to the patient:

Facts about the event

Presence of error or system failure

Expression of regret

A formal apology

H E A L T H C A R E I N S T I T U T I O N S -26-
 Dasar Kesehatan Masyarakat
Fakultas Kesehatan Masyarakat
Universitas Indonesia

INSTITUSI PELAYANAN KESEHATAN

CHAPTER 10– HEALTHCARE INSTITUTIONS

S E K I A N D A N T E R I M A K A S I H

Re f e re n c e : P u b l ic He a l t h 1 0 1 , R ic h a rd R ie g e l ma n , 2 0 1 0