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Praktek Bermutu dan Manajemen Risiko

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Kematian BAYI

• Ibu X, ketuban pecah, hamil aterm

• Induksi partus, janin hidup• Jam 22.00 dokter : hentikan

induksi• Jam 7.00 seksio sesarea• Lahir bayi menangis sesak• Meninggal 2 jam kemudian• Pasien tak puas

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Kredensial

SIKAP

Akreditasi

Standar Profesi

AD/StatutaRS

KomiteMedik

Ijin Praktek

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MASALAH-TUNTUTAN

• Kematian ibu –bayi

• Asfiksia – kelumpuhan otak

• Kecacatan permanen

• Trauma• Kelainan bawaan

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Kenapa ada tuntutan ?

•PENYIMPANGAN PRAKTEK-KLINIK

•OR =5.76•290 kasus malpraktek vs

262 kontrol (1988-1998)• Reduced medicolegal risk by compliance

with obstetric clinical pathways : a case –control study

• Ransom et al – Obstet Gynecol 2003;101:751

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Seksio sesarea

• Risiko besar pada ibu : perdarahan, infeksi, anestesi

• Risiko bayi : RDS, preterm, tersayat

• Persalinan pada bekas SS

• Peran : bidan, perawat, dr. Anak , Anestetist

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Definisi

• Kecelakaan (incident): kejadian kesakitan/efek samping akibat tidak sesuai dengan pelayanan RS.

• Nama baik RS !!

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LAPORAN KEJADIAN

• Obyektif• Kerahasiaan• Segera -24 jam,

bila gawat per-telepon

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MUTU >< RISIKO

• Manajemen mutu• Semakin baik semakin

kecil risiko• KOMUNIKASI !!• Hargai hak pasien – tunjukkan

sikap menolong – kunjungan > 1 kali /hari

• INFORMED CONSENT

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Komite Medik

• Memegang teguh AD-Statuta RS• Terdiri multidisiplin• Menelaah Kredensial calon

pegawai• Menilai luaran pelayanan• Proaktif – thd keluhan

pasien/keluarga• Membina informasi dari unit

pelayanan-keluhan- KESEDIHAN pasien dan efek samping

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PENERIMAAN DOKTER

• Sesuai dengan kebutuhan RS – kemampuan dokter ?

• Dokter patuh dengan AD-Statuta

• Rincian tugas

• Dokter Ob-Gin – kompetensi ??

• Rekomendasi dari POGI • Ijin praktek dari DepKes

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Akreditasi

• Kompetensi• Sikap buku

LOG : isi : luaran, jumlah tindakan

• ALARM (advances in labor and risk management)

• Kredit CME• Kemampuan :

pendidikan dan penelitian

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Standar pelayanan

• Ada dokter konsultan Fetomaternal• Multidisiplin : dr-OB, anestesi-OB,

bidan-kompeten – OB+kompl, dsb• Purna waktu

• FASILITAS : Km. Bersalin – 02, peghisap, oksimeter, tensi, alat resusitasi

• 1 Km Operasi – 3000 partus• Monitor CTG, AGD, Mikroskop +LAB

, Transfusi

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Manajemen Risiko• Prinsip : mengurangi• Manajer• Program

• STANDAR - protap

• SIKAP – profesional • Persyaratan : Ijin

praktek• Kompetensi:

pelatihan • Audit

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Manajemen Risiko Klinik

• Struktur : dokter, bidan, perawat dll

• Tujuan : memperbaiki mutu, menghindari kecelakaan

• Langkah : 1. Identifikasi masalah2. Analisa masalah3. Lokalisasi masalah perbaiki4. Pendanaan – bila terjadi tuntutan

• Pertemuan dilakukan 1x/minggu.

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Maternity clinical incident reportEvents that could result in important short- or long-term adverse effects for the mother or

baby should be based on local consensus but would probably include:

Maternal/delivery incident

loss >1500 ml

Cord accident

Deep venous thrombosis

Duration 2nd stage >3hrs (prim)

Duration 2nd stage >1hr (parous)Duration established labour >18 hrs

EclampsiaHb <8g/dl postpartum

Hysterectomy/laparotomy

Fetal/neonatal incident APGAR <7 at 5 minutesBirth traumaCord pH <7.2Neonatal deathNeonatal seizuresStillbirth >500gShoulder dystociaSmall for gestational ageTerm baby admitted to paediatric unit Unsuspected fetal anomaly

Organisational incident Blood-Anaesthetic complicationsITU admissionMaternal deathPulmonary embolismThird degree tearUnsuccessful forceps/ventouseUterine rupture

Delay >30mins for emergency CSDelay following call for assistanceDelivery outwith labour suiteFaulty equipmentInterpersonal conflict over case managementPotential service user complaintPrescribing/administration errorRetained swab/instrumentViolation of local protocol/guideline

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Kompetensi

• Analisa , contoh : Memakai Partogram

• Pengawasan janin – EFM- CTG

• Bekerja sesuai standar + etika profesi

• Membuat rekam medik lengkap

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Program

• Pendidikan berkelanjutan bagi : dokter dan perawat/bidan

• Evidence based medicine – practice

• Menerapkan manajemen risiko • Perbaikan protokol- protap• Perbaikan rekam medik• Telaah unit perawatan intensif-

gawat darurat• Perhatian pada allergi-efek

samping• Komunikasi dokter-pasien >>>>

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Perbaikan pelayanan ?

• 60% Ob-Gyn di Australia pernah mengalami tuntutan dlm Obstetrik

• Uang ganti A$ 35.515 (median)• 44% akan berhenti praktek obstetri

dalam 5 tahun mendatang

• MacLennan AH, Spencer MK. Projections of Australian obstetricians ceasing practice and the reasons. Med J Aust

2002;176:425.

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Kredensial

SIKAP

Akreditasi

-Buku LOG-ALARM-Pelatihan

Standar Profesi

AD/StatutaRS

KomiteMedik

Ijin PraktekPOGI

Panduan Etik

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CLINICAL GOVERNANCE

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A Working Definition

• It is a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.

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Why do we need Clinical Governance?

• to give coherence to local quality improvement activities

• to promote the importance of clinical quality

• to restore public confidence in quality of clinical care

• to ensure public confidence in professional self-regulation

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• all professions and NHS managers

• provides framework for local professional self - regulation

• underpinned by continuing professional development

Partnership for quality

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Accountability for quality

• statutory responsibility for quality

• Chief Executive ultimately responsible for assuring quality of services (through the Board)

• formal local arrangements to assure clinical quality (i.e., Board sub-committee)

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• gives clinical quality equal status to financial management

• gives Boards responsibilities for clinical governance

• clear standards and quality systems

• openness and accountability

Echoes Principles of Corporate Governance

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To whom does it apply?

• principles of good clinical governance will apply to all NHS organisations and those engaged in NHS clinical practice

• arrangements must be proportionate to the size of the organisation

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• senior clinician responsible for clinical governance

• regular reports to the Board

• annual report on clinical governance

Accountability locally

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Coherent programme for quality improvement

• integrated quality improvement processes i.e., clinical audit

• evidence based practice• innovations and good practice

systematically disseminated• adverse events openly

investigated and lessons applied

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What should it mean for patients?

•clearer accountability for quality

• increased confidence in quality of clinical services

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• by helping redress the balance between financial performance and quality

• by harnessing the commitment of clinicians and managers to the delivery of quality patient services

• by providing a coherent framework for disparate local quality improvement

• by reducing clinical risk and disseminating good practice.

How can Clinical Governance help you?

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NHSE Clinical Governance Key Steps Year 1

• establish leadership, accountability and working arrangements

• carry out a baseline assessment of capacity and capability

• formulate and agree a development plan in light of the assessment

• clarify reporting arrangements for Clinical Governance within board and annual reports

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Baseline Assessment of Capability and Capacity (1)

• a searching and honest analysis of organisations’ strengths and weaknesses in relation to current performance on quality.

• the identification of any particularly problematic services drawing where possible on objective data or feedback from users of services or referring agencies).

• an assessment of the extent to which data is in place for quality surveillance.

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Baseline Assessment of Capability and Capacity (2)

• establishing whether there are any deficits in key mechanisms (eg for risk management etc)

• making sure that there is integration of quality activities and systems

• establishing explicit links to HiMPs NSF and PCG/PCTs

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6. Gynaecology clinical incident report

• Events that could result in important short- or long-term adverse effects for the woman should again be based on local consensus but would probably include:

Clinical incidents Damage to structures (e.g. ureter, bowel, vessel)

Delayed or missed diagnosis (e.g. ectopic)Deep venous thrombosisFailed procedures (e.g. abortion, sterilisation, laparoscopy)ITU admissionOmission of planned procedures (removal of IUCD at sterilisation, sterilisation at abortion)Operative blood loss >500mlOvarian hyperstimulation (assisted conception)Performance of unplanned, unconsented procedures (e.g. removal of ovaries at hysterectomy)Pulmonary embolismUnplanned return to theatre

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Organisational incidents

• Complications of anaesthesiaDelay following call for assistanceFaulty equipmentInterpersonal conflict over case managementPotential service user complaintPrescribing/administration errorRetained swab/instrumentViolation of local protocol/guideline

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Organisasi

POGI

POGI JAYA

Tim Manajemen Risiko-Dokter-Bidan/Paramedik

Rumah Sakit

ADAudit M - P

Dewan Pertimbangan Cabang

Ko-POGI

• Sikap dan kinerja• Buku LOG• Rekam Medik

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