Variasi proses
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Transcript of Variasi proses
Variasi prosesVariasi proses
It is all about patientsIt is all about patients
First do no harmFirst do no harmSecond achieve best clinical Second achieve best clinical
outcomeoutcomeThird make the people “fly”Third make the people “fly”
Quality problems in hospital Quality problems in hospital servicesservices
Quality Problems
Mortality
Morbidity
Disability
Unsatisfactory achievement of clinical outcome
Patient dissatisfaction
Quality Problems
Mortality
Morbidity
Disability
Unsatisfactory achievement of clinical outcome
Patient dissatisfaction
?Preventable vs non preventable
Quality Problems
?Severity of the disease
Individual biovariability
Service delivery process
Accident
Incident
Adverse event
Unsafe act::Clinical ErrorViolationSabotage
Complication
System approach to patient System approach to patient safetysafety
Structure – Process – OutcomeStandard of careHazardLatent Condition
Active Failure:• Unsafe acts
• Errors• Violation• Sabotage
• Errors:• Human (slips, lapses, mistakes)• Medical• Medication
Accident:Complication
Contributing factorsRCA, FMEA
Adverse eventIncident & Critical Incident
Notes:Term to be avoided:Blame, Fault, Negligence,Recklessness
Sumber:The Canadian Patient SafetyDictionary, October 2003
?Severity of the disease
Individual biovariability
Service delivery process
Human factor
Process variation
Latent conditions
Service delivery process
Human factor
Process variation
Latent conditions
Special cause
Common cause
Intervensi perbaikanIntervensi perbaikan
StandardisasiStandardisasi Process improvement:Process improvement:– step by step improvementstep by step improvement– radical improvement radical improvement
(reengineering)(reengineering)
Quality improvement processQuality improvement processModel NolanModel Nolan
Apa yang ingin kita capai?
Bagaimana kita tahu bahwa perubahanyang dilakukan adalah perbaikan ?
Perubahan apa yang dapat kita lakukanyang hasilnya adalah perbaikan?
P
DC
A
Aims
Measurements
Planned change
Tugas untuk variasi prosesTugas untuk variasi proses
Terkait dengan process variation, cari artikel tentang Terkait dengan process variation, cari artikel tentang Indeks Kemampuan Proses (Process capability)Indeks Kemampuan Proses (Process capability)– Berikan ringkasan ttg artikel tersebutBerikan ringkasan ttg artikel tersebut– Bagaimana pendapat saudara apakah pengukuran indeks Bagaimana pendapat saudara apakah pengukuran indeks
kemampuan proses dapat diterapkan di rumahsakitkemampuan proses dapat diterapkan di rumahsakit
Masuk ke website: Masuk ke website: www.ihi.orgwww.ihi.org atau yang lain, cari satu atau yang lain, cari satu contoh penerapan model Nolan untuk perbaikancontoh penerapan model Nolan untuk perbaikan– Susun ringkasan dari artikel tsbSusun ringkasan dari artikel tsb– Bagaimana pendapat saudara apakah model Nolan dapat Bagaimana pendapat saudara apakah model Nolan dapat
diterapkan di rumahsakit di Indonesia diterapkan di rumahsakit di Indonesia