03. PS is a Key Component of RM (Dr.adib 2012)

CURRICULUM VITAEDATA PRIBADI

Nama : dr.ADIB ABDULLAH YAHYA,MARSPangkat : Brigjen TNI (Purn)Tempat/tanggal lahir : Magelang,16 Februari 1949

Jabatan : President Asian Hospital Federation (AHF)Agama : IslamALAMAT : Jl. Punai H-24,Kel.Tengah,Jakarta Timur – 13540

Telp : (021)8404580Fax : (021) 8408047

HP : 08161803497 E-MAIL : [email protected]

PENDIDIKAN UMUM

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PENDIDIKAN UMUM

SMA Negeri Magelang 1966S1 : Fakultas Kedokteran Universitas Gajah Mada (UGM),

Yogyakarta, 1973S2 : Fakultas Kesehatan Masyarakat, Universitas Indonesia (UI), Jakarta,

Program Kajian Administrasi Rumah Sakit ( KARS )

PENDIDIKAN MILITER

Sekolah Staf dan Komando TNI Angkatan Darat (SESKOAD), 1987/1988

PELATIHAN

Combined Humanitarian Assistance Response Training, oleh Singapore Armed Forces (SAF), Singapura, 2000Health as a Bridge for Peace Workshop, oleh World Health Organization (WHO), Yogyakarta, 2000

PENGALAMAN JABATANKomandan Detasemen Kesehatan Pasukan Pengamanan Presiden (DanDenkes Paspampres), 1987-1991Kepala Rumah Sakit “Muhammad Ridwan Meuraksa”, Jakarta, 1992Kepala Kesehatan Daerah Militer (Kakesdam) Jaya, Jakarta, 1993Komandan Pusat Pendidikan Kesehatan TNI – AD,1995 – 1999Wakil Kepala Pusat Kesehatan TNI, 1999 – 2000Kepala RSPAD Gatot Soebroto, 2000 – 2002Dekan Fakultas Kedokteran UPN, Jakarta, 2000 – 2002Wakil Ketua Tim Dokter Kepresidenan RI, 2000 – 2002Direktur Kesehatan TNI Angkatan Darat (Dirkesad), 2002-2004Wakil Ketua Tim Pemeriksaan kesehatan untuk calon Presiden dan calon Wakil Presiden RI Th.2004DOSEN Pasca Sarjana FKM UI, Kajian Administrasi Rumah Sakit (KARS)

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DOSEN Pasca Sarjana FKM UI, Kajian Administrasi Rumah Sakit (KARS)DIREKTUR UTAMA RUMAH SAKIT MMC

ORGANISASIKetua Ikatan Rumah Sakit Jakarta Metropolitan (IRSJAM), 2000-2003Ketua Umum Perhimpunan Rumah Sakit Seluruh Indonesia ( PERSI), 2003-2009Anggota Komnas FBPI. Ketua Komtap Bidang Kebijakan Kesehatan KADIN IndonesiaAngggota TNP2K.Ketua Divisi Kemahkamahan Majelis Kehormatan Etik Kedokteran (MKEK) IDI Pusat Tim Konsultan Institut Manajemen Risiko Klinis ( IMRK )Koordinator Bidang 1 : KAJIAN KESELAMATAN PASIEN, KKPRSInstruktur HOPE ( Hospital Preparedness for Emergencies and Disasters}PRESIDENT OF ASIAN HOSPITAL FEDERATION ( AHF ) 2009 – 2011

PATIENT SAFETY IS A KEY COMPONENT OF PATIENT SAFETY IS A KEY COMPONENT OF RISK MANAGEMENTRISK MANAGEMENT

Dr. ADIB A YAHYA, MARSPRESIDENT

ASIAN HOSPITAL FEDERATION( AHF )

WORKSHOP KESELAMATAN PASIEN DAN MANAJEMEN RISIKO KLINIS DI RUMAH SAKIT

1. What?

3. How?

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2. Why?

3. How?

What ?What ?

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DEFINISI RISIKODEFINISI RISIKO

RISIKO ADALAHRISIKO ADALAH ::

“ “ POTENSI TERJADINYA KERUGIANPOTENSI TERJADINYA KERUGIANYANG DAPAT TIMBUL DARI PROSESYANG DAPAT TIMBUL DARI PROSES

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YANG DAPAT TIMBUL DARI PROSESYANG DAPAT TIMBUL DARI PROSESKEGIATAN SAATKEGIATAN SAAT SEKARANGSEKARANG ATAUATAUKEJADIANKEJADIAN DIMASA DATANGDIMASA DATANG.”.”

ERM, Risk Management Handbook for Health Care OrganizationERM, Risk Management Handbook for Health Care Organization

Risiko di Rumah SakitRisiko di Rumah Sakit

RISIKO KLINISRISIKO KLINIS ::SEMUA ISU YANG DAPAT BERDAMPAK SEMUA ISU YANG DAPAT BERDAMPAK

TERHADAP TERHADAP PENCAPAIAN PELAYANAN PASIENPENCAPAIAN PELAYANAN PASIENYANG BERMUTU TINGGI,AMAN DAN EFEKTIF.YANG BERMUTU TINGGI,AMAN DAN EFEKTIF.

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RISIKO NONKLINISRISIKO NONKLINIS/ Corporate Risk/ Corporate Risk ::

SEMUA ISSU YANG DAPAT BERDAMPAK SEMUA ISSU YANG DAPAT BERDAMPAK TERHADAP TERCAPAINYA TUGAS POKOKTERHADAP TERCAPAINYA TUGAS POKOK

DAN DAN KEWAJIBAN HUKUMKEWAJIBAN HUKUM DARI RUMAH SAKIT DARI RUMAH SAKIT SEBAGAI KORPORASISEBAGAI KORPORASI..

KATEGORI RISIKO DI RUMAH SAKITKATEGORI RISIKO DI RUMAH SAKIT ::( ( Categories of RiskCategories of Risk ))

Patient carePatient care--related risksrelated risks

Medical staffMedical staff--related risksrelated risks

EmployeeEmployee--related risksrelated risks

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EmployeeEmployee--related risksrelated risks

PropertyProperty--related risksrelated risks

Financial risksFinancial risks

Other risksOther risks

Risiko yang berhubungan dengan perawatan pasienRisiko yang berhubungan dengan perawatan pasien((Patient care related risksPatient care related risks))

Direct association with Direct association with patient carepatient careConsequences of inappropriate or incorrectly performed Consequences of inappropriate or incorrectly performed

medical treatmentsmedical treatmentsConfidentiality Confidentiality and appropriate release of informationand appropriate release of informationProtection from Protection from abuseabuse, , neglectneglect and assaultand assault

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Protection from Protection from abuseabuse, , neglectneglect and assaultand assaultWas patient Was patient informed of risksinformed of risks??NondiscriminatoryNondiscriminatory treatmenttreatmentAppropriate Appropriate triage and transfertriage and transfer of patients from ERof patients from ERPatient participation in Patient participation in research studiesresearch studies and use of experimental and use of experimental

drugs drugs -- was consent obtained?was consent obtained?Was Was patient dischargedpatient discharged appropriately?appropriately?

Risiko yang berhubungan dengan tenaga medisRisiko yang berhubungan dengan tenaga medis

((Medical staff Medical staff -- related risksrelated risks))

-- Credential Credential terhadap staf medis ?terhadap staf medis ?

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-- Tindakan medis sesuai Tindakan medis sesuai kompetensikompetensi dan dan prosedur bakuprosedur baku ??

-- Was patient Was patient properly managed properly managed ??

-- Do we have adequately Do we have adequately trained staff trained staff ??

Risiko yang berhubungan dengan karyawanRisiko yang berhubungan dengan karyawan

((Employee related risksEmployee related risks))

-- Risiko Risiko keselamatan dan kecelakaan kerjakeselamatan dan kecelakaan kerja

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-- Risiko Risiko keselamatan dan kecelakaan kerjakeselamatan dan kecelakaan kerja

-- Maintaining a Maintaining a safe environmentsafe environment -- Employee Health PolicyEmployee Health Policy ::

. reducing risk of . reducing risk of occupational illness and injuryoccupational illness and injury

. providing for the . providing for the treatment and compensationtreatment and compensation of of workers for workworkers for work--related illnesses or injuriesrelated illnesses or injuries

Risiko yang berhubungan dengan propertyRisiko yang berhubungan dengan property((Property related risksProperty related risks))

Protect assets from losses due to Protect assets from losses due to firesfires, , floodsfloods, etc, etc

Paper and/or electronic recordsPaper and/or electronic records -- patient, business patient, business

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Paper and/or electronic recordsPaper and/or electronic records -- patient, business patient, business and financial and financial -- protected from damage or protected from damage or destructiondestruction

Procedures for Procedures for handling cashhandling cash and safeguarding and safeguarding valuablesvaluables

Bonding and Bonding and insuranceinsurance to protect facility from to protect facility from losseslosses

Risiko keuanganRisiko keuangan((Financial risksFinancial risks))

–– Bad DebtBad Debt

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–– Meningkatnya suku bungaMeningkatnya suku bunga

–– Global Financial ” tsunami”Global Financial ” tsunami”

Risiko lainRisiko lain

((Other risksOther risks))

-- Hazardous materialHazardous material management :management :

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-- Hazardous materialHazardous material management :management :

chemical, radioactive, infectious biological chemical, radioactive, infectious biological waste managementwaste management

-- Legal & regulatoryLegal & regulatory risksrisks

-- Reputational RiskReputational Risk

WHY ?WHY ?

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HOSPITALHOSPITAL

System made up of thousands of System made up of thousands of

interinter--linked processeslinked processes……………..……………..

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things can go wrongthings can go wrong

Errors are inevitable

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Errors are inevitable

………….but most are preventable

HOW ?HOW ?

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DIDALAM SISTEM KITA YANG SANGAT KOMPEKS INI …..BAGAIMANA KITA AKAN MENDARAT DENGAN SELAMAT ?

BAHAYA / HAZARD / RISIKO YANG MANA YANG HARUS KITA TANGANI TERLEBIH DAHULU ?

MANJEMEN RISIKO

. . . ADALAH PENDEKATAN PROAKTIFUNTUK MENGIDENTIFIKASI,MENILAI

2020

UNTUK MENGIDENTIFIKASI,MENILAI DAN MENYUSUN PRIORITAS RISIKO,

DENGAN TUJUAN UNTUK MENGHILANGKAN ATAU

MEMINIMALKAN DAMPAKNYA.

RISK MANAGEMENT PROCESSRISK MANAGEMENT PROCESS

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RISK MANAGEMENT PROCESSRISK MANAGEMENT PROCESS

PROSES MANAJEMEN RISIKOPROSES MANAJEMEN RISIKO

KO

MU

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AS

I DA

N K

ON

SU

LTA

SI

MO

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OR

DA

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EV

IEW

TEGAKKAN KONTEKS

IDENTIFIKASI RISIKO

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KO

MU

NIK

AS

I DA

N K

ON

SU

LTA

SI

MO

NIT

OR

DA

N R

EV

IEW

ANALISA RISIKO

EVALUASI RISIKO

KELOLA RISIKO

ASESMEN RISIKOASESMEN RISIKO

RISK REGISTERRISK REGISTER

RISK MANAGEMENT TECHNIQUES/TREATMENTSRISK MANAGEMENT TECHNIQUES/TREATMENTS

RISK CONTROLRISK CONTROL ::

-- EXPOSURE AVOIDANCEEXPOSURE AVOIDANCE-- LOSS PREVENTIONLOSS PREVENTION-- LOSS REDUCTIONLOSS REDUCTION

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-- SEGREGATION (SEPARATION OR DUPLICATION)SEGREGATION (SEPARATION OR DUPLICATION)-- CONTRACTUAL TRANSFER FOR RISK CONTROLCONTRACTUAL TRANSFER FOR RISK CONTROL

RISK FINANCINGRISK FINANCING ::

-- RISK RETENTIONRISK RETENTION-- RISK TRANSFERRISK TRANSFER

IMPLEMENTASI IMPLEMENTASI

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IMPLEMENTASI IMPLEMENTASI MANAJEMEN RISIKO KLINIK MANAJEMEN RISIKO KLINIK

DI RUMAH SAKITDI RUMAH SAKIT

PRIMUM, NON NOCEREPRIMUM, NON NOCEREFIRST, DO NO HARMFIRST, DO NO HARM

HIPPOCRATES’S TENET HIPPOCRATES’S TENET (460(460--335 BC)335 BC)

RisikoRisiko SELALU MELEKATSELALU MELEKAT dengandengan

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RisikoRisiko SELALU MELEKATSELALU MELEKAT dengandenganproses pengobatan kepadaproses pengobatan kepada

pasien itu sendiripasien itu sendiri

RISIKO MENYATU DENGAN SEMUA ASPEK PELAYANAN KESEHATAN,TERMASUK :

• pengobatan dan perawatan kepada pasien;

• menentukan prioritas pelayanan ;

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• pengembangan proyek dan pelayanan ;

• pembelian obat dan produk kesehatan lain;

• instruksi dan follow up kepada pasien.

CRITICAL POINTS IN CLINICAL RISK MANAGEMENTCRITICAL POINTS IN CLINICAL RISK MANAGEMENT

PROVIDING CARE IN THE PROVIDING CARE IN THE EMERGENCY ROOMEMERGENCY ROOMMAKING A MAKING A DIAGNOSISDIAGNOSIS

ORDERING ORDERING INVESTIGATIONS AND INTERPRETINGINVESTIGATIONS AND INTERPRETINGTHE RESULTSTHE RESULTS

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THE RESULTSTHE RESULTSUNDERTAKING UNDERTAKING INVASIVE PROCEDURESINVASIVE PROCEDURES

DRUG DRUG TREATMENTTREATMENTWARDWARD MANAGEMENTMANAGEMENT

RISK MANAGEMENT IN RISK MANAGEMENT IN ERER

POTENTIAL ERRORSPOTENTIAL ERRORS

Assessment of emergencies Assessment of emergencies by by insufficiently experienced insufficiently experienced junior staffjunior staff

Inadequate use of Inadequate use of specialist specialist opinionopinion

REDUCING/MINIMISING RISKSREDUCING/MINIMISING RISKS

Experienced clinicians available Experienced clinicians available fullfull--timetime

Involvement of specialist in the Involvement of specialist in the training of stafftraining of staff

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opinionopinion

Inadequate reading of simple Inadequate reading of simple radiographsradiographs

Poor management of Poor management of standard standard situationsituation

Inadequate Inadequate assessment before assessment before dischargedischarge

training of stafftraining of staff

Training of staffTraining of staff

“on call” radiologist“on call” radiologist

Use protocols with sensitivityUse protocols with sensitivity

Senior staff to take responsibility Senior staff to take responsibility for dischargesfor discharges

REDUCING REDUCING DIAGNOSTIC DIAGNOSTIC ERRORERROR


Failure to take a wellFailure to take a well--focused focused case historycase history

Failure to assess the Failure to assess the


Concentrate on key elementsConcentrate on key elements

Better trainingBetter training

Write down conclusions before Write down conclusions before

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Failure to assess the Failure to assess the evidence & evidence & make a DDmake a DD

Inappropriate Inappropriate use of testsuse of tests

Leaving the problem Leaving the problem unexplainedunexplained

Write down conclusions before Write down conclusions before making a planmaking a plan

Define spesific quuestios to be Define spesific quuestios to be answered by chosen testsanswered by chosen tests

Get a second opinionGet a second opinion

REDUCING THE RISKS OF REDUCING THE RISKS OF INVESTIGATIONINVESTIGATION


Clinician Clinician misreadsmisreads visual visual evidence e.g. x ray; ECGevidence e.g. x ray; ECG

Clinician not aware of Clinician not aware of lab resultslab results


Fully trained staff to interpret and Fully trained staff to interpret and report on testsreport on tests

Clinically important results to be Clinically important results to be

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Clinician not aware of Clinician not aware of ward ward observationobservation

Clinician fails to Clinician fails to understand test understand test resultresult

Inappropriate Inappropriate use of testsuse of tests

relayed to clinician urgentlyrelayed to clinician urgently

Ward tests to be supervised and Ward tests to be supervised and results discussed with cliniciansresults discussed with clinicians

Aware of the limits of their Aware of the limits of their competencecompetence

Senior staff to check repeatedlySenior staff to check repeatedly

Careful supervisionCareful supervision

Reducing the risks of Reducing the risks of invasive proceduresinvasive procedures

Consider The Consider The risk : benefit ratiorisk : benefit ratio

Discuss theDiscuss the procedure with the patientprocedure with the patient

Carrying out the procedure including coping with Carrying out the procedure including coping with potential difficultiespotential difficulties

Ensure that the equipment is in good working order Ensure that the equipment is in good working order

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Ensure that the equipment is in good working order Ensure that the equipment is in good working order and that and that back up equipmentback up equipment is availableis available

If the procedure is not going well obtain If the procedure is not going well obtain help / be help / be prepared to give upprepared to give up

Ensure that the operator has Ensure that the operator has sufficient skillsufficient skill

Reducing the risks of Reducing the risks of invasive proceduresinvasive procedures

Consider The Consider The risk : benefit ratiorisk : benefit ratio

Discuss theDiscuss the procedure with the patientprocedure with the patient

Carrying out the procedure including coping with Carrying out the procedure including coping with potential difficultiespotential difficulties

Ensure that the equipment is in good working order Ensure that the equipment is in good working order

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Ensure that the equipment is in good working order Ensure that the equipment is in good working order and that and that back up equipmentback up equipment is availableis available

If the procedure is not going well obtain If the procedure is not going well obtain help / be help / be prepared to give upprepared to give up

Ensure that the operator has Ensure that the operator has sufficient skillsufficient skill

COMMON SPECIFIC FACTORS ASSOCIATED WITH COMMON SPECIFIC FACTORS ASSOCIATED WITH DRUG DRUG ADVERSE EVENTSADVERSE EVENTS

FAILURE TO TAKE ACCOUNT OF DECLINING FAILURE TO TAKE ACCOUNT OF DECLINING RENAL / HEPATIC FUNCTIONRENAL / HEPATIC FUNCTION

FAILURE TO CHECK FOR POSSIBLE FAILURE TO CHECK FOR POSSIBLE ALLERGIC ALLERGIC RESPONSESRESPONSES

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RESPONSESRESPONSES

USING THE USING THE WRONG DRUG NAMEWRONG DRUG NAME OR MEANS OF OR MEANS OF ADMINISTRATIONADMINISTRATION

MISCALCULATION OF MISCALCULATION OF DOSAGEDOSAGE

REDUCING THE RISKS OF ONGOING REDUCING THE RISKS OF ONGOING WARD CAREWARD CARE


Failure to Failure to monitormonitor clinical clinical progressprogress

Failure to recognise that a Failure to recognise that a patient is patient is not making not making satisfactory progresssatisfactory progress

REDUCING.MINIMISING RISKSREDUCING.MINIMISING RISKS

Joint education regarding Joint education regarding appropriate monitoringappropriate monitoring

Regular supervisionRegular supervision

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satisfactory progresssatisfactory progress

Failure to provide Failure to provide appropriate appropriate treatmenttreatment

ShiftShift workingworking

Use spesialist staff Use spesialist staff –– clinician clinician from appropriate unit, nurse from appropriate unit, nurse spesialist, physiotherapistspesialist, physiotherapist

Briefing & deBriefing & de--briefingbriefingSBARSBAR

PATIENT SAFETY,QUALITY OF CAREPATIENT SAFETY,QUALITY OF CARE

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PATIENT SAFETY,QUALITY OF CAREPATIENT SAFETY,QUALITY OF CARE

AND RISK MANAGEMENTAND RISK MANAGEMENT

The basic principles for safety The basic principles for safety and quality of careand quality of care

The basic principles for patient safety are The basic principles for patient safety are the the principles for quality of careprinciples for quality of care: :

-- to to do the right thingdo the right thing

for the for the right patientright patient

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for the for the right patientright patient

using the using the right methodright method and and

at the at the right timeright time, and , and

-- to to communicate wellcommunicate well with thewith the patient patient and the rest of the and the rest of the clinical teamclinical team

“It’s easy gettin’ good players.“It’s easy gettin’ good players.The hard part is gettin’ them to play The hard part is gettin’ them to play

with each other”with each other”

(Casey Stengel)

(Casey

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Communicating Team ???Communicating Team ???

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Quality in HealthcareQuality in Healthcare

…. begins with …. begins with ensuring patient safetyensuring patient safety

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Key reasonsKey reasons

Patients are Patients are more at riskmore at risk than nonthan non--patientspatients

Medical interventions are, by their nature, Medical interventions are, by their nature,

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highhigh--risk procedures risk procedures -- small error marginssmall error margins

Medicine remains an Medicine remains an inexactinexact, hands, hands--on on endeavourendeavour

Patient safety in contextPatient safety in context

Patient safetyPatient safety is an important component of is an important component of

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risk managementrisk management, , clinical governanceclinical governance, and , and quality improvementquality improvement. .

4343Australian Patient Safety Foundation

I. Risk management is not primarily about avoiding or mitigating claims; rather, it is a tool for

improving the quality of care.II. Incident reporting is only one aspect of the identification of

risk. Incident reporting is on the reactive side of risk management. More emphasis needs to be placed on

CONCLUSIONSCONCLUSIONS

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management. More emphasis needs to be placed on

the proactive side.III. Risk management is actually

the business of all stakeholders in the organisation, clinicians and nonclinicians.

IV. The primary focus of risk management should now be clinical governance and patient safety.

FINAL WORDFINAL WORD

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……Safe care is not an option.It is the right of every patient

who entrusts their care to our Healthcare systems…Sir Liam Donaldson,

Chair, WHO World Alliance for Patient Safety, Forward Programme, 2006–2007

4646TERIMAKASIHTERIMAKASIH

03. PS is a Key Component of RM (Dr.adib 2012)

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Transcript of 03. PS is a Key Component of RM (Dr.adib 2012)