Implementasi Clinical Governance dalam Sistem Pelayanan kesehatan
Iwan Dwiprahasto MMR/CE&BU FK UGM/RSUP Dr. Sardjito
April 1 2004
Hospital condemned over deaths after 'appalling' failures in care Health secretary apologises over damning report on Mid Staffordshire NHS trust
17 March 2009
“Between 400 and 1,200 more people died than would have been expected at Mid Staffordshire NHS foundation trust over three years…. Although it is not clear how many of these deaths could have been avoided, the Healthcare Commission said patients undoubtedly suffered as a result of lapses in the standard of care.”
www.jcaho.org
The VA's studies 2003:
50% 50% rumah sakit tidak memenuhi standard cleanliness dan sanitasi sanita si
Lebih dari 1/3 rumah sakit yang diinspeksi tidak memenuhi standard infection control Dept. Veterinary Affiars, 2003
Sun Herald, Sydney September 14, 2003
70 System Factors Contributed to 3 Preventable Deaths average age = 39 years Patient 4%
9%
Organisational 10%
43% 14%
Task Work Environment Staff
20%
Communication & Team
System analysis (RCA) detected flaws not found by medical record review or unstructured staff interviews
Shifting paradigm in health care services
Equity
What is Clinical Governance? Governance?
Quality
Safety
“corporate responsibility for clinical performance”
Galbraith, 1999
Clinical Governance - What Aims to improve patient:
safety
overall quality of care by a ÂJustÊ Culture
reporting
outcome
open disclosure
„To support clinicians and managers in facilitating continuous, sustainable improvement in patient outcomes and the minimisation of adverse events via: • Research & development • Facilitating the implementation of effective & efficient clinical governance • Collecting, consolidating, disseminating information • providing feedback to clinicians and managers‰
Clinical governance Is a part of new approach to assuring quality health care
Definisi: "A framework through which halth care institutions are accountable for continuously improving the quality of their services, and safeguarding high standards of care by creating an environment in which excelence in clinical care can flourish"
4 PILAR UTAMA CLINICAL GOVERNANCE
Accountability
Evidencebased Practice
High standard s of care
• Standard-2 • Performance
menjamin pelaksana an excelence in clinical care • Professional development • Indikator-2 mutu
Peningkatan mutu berkelanjutan (CQI)
• RS memfasilitasi • Outcome optimal
“clinical governance is a way of making sure that everyone who passes through health system is well cared for” or System that enable staff to work in the best possible way
+ Staff performing to the highest possible standards
Perspektif dalam tataran Praktek Utamakan pasien/klien/customer Perbaiki standar kerja Belajar dari pengalaman buruk Memampukan staf dan tim Menggunakan informasi secara efektif
The following components have been identified as necessary
Clear national standards
Mekanisme untuk menjamin dilaksanakannya standar melalui local delivery
Identify standards
Apply standards
Monitor standards
Manpower planning
Clinical audit
CPD & Lifelong learning
National inquiries
Job plan
Complaints
Risk management
Monitoring & evaluation
1. EBM 2. Clinical Standard ..
Mekanisme untuk memonitor diterapkannya standar
Whistle-blowing 3. Research & Development
Fakta tentang Safety di bidang Bedah
• Di AS: tiap tahun terjadi 1500-2500 wrong site surgery.¹ • Survey terhadap 1050 hand surgeons, 21% melaporkan riwayat wrong-site surgery paling tidak sekali
Correct patient, operation and operative site 1. Seiden, Archives of Surgery, 2006. 2. Joint Commission, Sentinel Event Statistics, 2006.
What problems does this checklist address? (cont.)
Minimizing risk of infection
Antibiotika profilaksi 1 jam sebelum insisi mengurangi risiko SSI hingga 50%¹, ²
Hampir 50% antibiotika profilaksi diberikan tidak sesuai dengan waktu yang dipersyaratkan
Bratzler, The American Journal of Surgery, 2005. Classen, New England Journal of Medicine, 1992.
Fakta tentang Safety di bidang Bedah
Effective Teamwork Masalah komunikasi merupakan root cause pada 70% 70% events yang dilaporkan ke Joint Commission antara 199519952005..¹ 2005
Preoperative team briefing meningkatkan pemilihan dan timing pemberian antibiotika profilaksi, profilaksi, & pengendalian intraoperative temperature dan glycemia.² glycemia.², ³
Joint Commission, Sentinel Event Statistics, 2006. Makary, Joint Commission Journal on Quality and Patient Safety, 2006. Altpeter, Journal of the American College of Surgeons, 2007.
The ideal surgical outcome Persiapan pre operasi
Pelaksanaan operasi
Outcome baik
Persiapan operasi
Pelaksanaan operasi
Outcome buruk
Not always ideal Outcome baik Persiapan pre operasi
Pelaksanan operasi
The big black box Unexpected Outcome
Not always ideal Antibiotika profilaksi
Desinfektan
Cukur
Kateter
Puasa
Nurse
Infus Outcome baik
Persiapan pre operasi
Pelaksanan operasi
The big black box Unexpected Outcome
Not always ideal Perbaikan KU
Konsul
CT Scan
MRI
Radiologi Penunja ng
Persiapan pre operasi
Lab Outcome baik Pelaksanan operasi
The big black box Unexpected Outcome
Not always ideal Glycaemic control
Breakfast
Restriksi
Diet
Informasi
Gizi
Timing Outcome baik
Persiapan pre operasi
The big black box
Pelaksanan operasi
Unexpected Outcome
Not always ideal Ahli Bedah Ahli anestesi Nurse CSSD Konsultan
Persiapan pre operasi
Pelaksanan operasi
Outcome baik
The big black box Unexpected Outcome
Circulus Vitiosus Penundaa n operasi Sistem penjadwa lan
Dampak thd sistem
HAI
Utilisasi OK
aLOS panjang
Inefisiensi SDM
Biaya pasien
Inefisiensi fasilitas
Biaya operasion al
TUJUAN CLINICAL GOVERNANCE Untuk menjamin akses yang memadai dan high quality The best care untuk semua pasien melindungi pasien dari risiko yang tidak diharapkan
Akuntabilitas Tenaga Profesional Kesehatan Berorientasi pada standard
Menilai risiko dan mencegah failure Menerapkan konsep governance: team work, delivering corporate goals, running an accessible service Selalu berusaha untuk meningkatkan mutu secara berkelanjutan
Clinical Governance – What
„corporate responsibility for clinical performance‰
Galbraith MO, Scotland, 1999
Accountable Concensus oriented
Participat ory
Follows the rule of law
Transpar ent
Good Governance
Respons ive
Equitable inclusive Effective & Efficient
Komponen clinical governance 1. Clinical Audit 2. Risk management 3. Evidence-based practice 4. Mechanism to monitor the outcome of care 5. System for managing poor performance 6. Professional development 7. Hospital accreditation 8. Good quality of clinical data 9. Managing complaints 10 10.. Clinical leadership
1. CLINICAL AUDIT Apa tujuan Audit Klinik? Mengidentifikasi „GAP‰ antara yang „seharusnya‰ vs. yang „sesungguhnya‰ dilakukan Melakukan perbaikan atas dasar bukti yang secara ilmiah dapat dipertanggungjawabkan
SeharusSeharusnya dilakukan
GAP
Audit klinik
SesungguhSesungguhnya dilakukan
1. CLINICAL AUDIT Blaming culture
No blame culture
Mencari kesalahan
Mengidentifikasi gap
Mengadili
profesionalisme
Menyudutkan profesi
Accountability
2. CLINICAL RISK MANAGEMENT?
2. Clinical Risk Management Risk Management is doing it wrong less often Quality assurance is getting it right more often
It is a process, not a person,
not a framework.
It should be core to what we do in healthcare, not an extra,
not an addon
2. Clinical Risk Management
.
.
.
Profil kadar gentamisin dalam serum vs waktu
C.inc
C.clos
ANTIBIOTIC PHARMACODYNAMICS IN SURGICAL PROPHYLAXIS, Antimicrob Agent Chemother, Chemother, 2002; 2002;46:: 46::3026 ::30263026-30
Importance of Timing of Surgical Antimicrobial Prophylaxis (AP) Prospective study of 2,847 elective clean and clean clean-contaminated procedures Early AP (2(2-24 hrs before incision)
3.8% Postop AP (3 (3--24 hrs after incision)
3.3% Periop AP (< 3 hrs after incision)
1.4% Preop AP (<2 hrs before incision)
0.6% Classen, 1992 (NEJM 326:281-286)
Pre Pre--operative Shaving/Hair Removal Seropian, 2001
Method of hair removal
Razor = 5.6%
Timing of hair removal
Depilatory = 0.6%
immediately before = 3.1%
No hair removal = 0.6%
24 hours before = 7.1%
>24 hours before = 20 20% %
Risk management
Meminimalkan biaya akibat risiko
Improving quality
Perlindungan terhadap pasien
Perlindungan thd organisasi
Penggunaan Clopidogrel Dahulu
Seumur hidup
Rekomendasi saat ini NSTEMI ACS
• Aspirin + clopidogrel maksimal 12 bulan • Dilanjutkan aspirin monoterapi
STEMI
• Aspirin + clopidogrel + fibrinolitik 28 hari • Dilanjutkan aspirin monoterapi
Drug eluting stent
• Aspirin + clopidogrel selama 12 bulan • Dilanjutkan aspirin monoterapi
Drug efficacy is too low Therapeutic area
The effectiveness rate (%)
Spears et al. TRENDS in Molecular Medicine Vol. 7 No. 5 May 2001
Major Drugs Ineffective for Many...... Many......… … Hypertension Drugs 10-30% ACE Inhibitors Heart Failure Drugs 15-25% Beta Blockers Anti Depressants 20-50% Cholesterol Drugs 30-70% Statins Asthma Drugs 40-70% Beta-2-agonists
Good Clinical leaders Provide direction, make everybody accountable Protect their people from danger and expose them to reality Make change and stand for values that don’t change Lead by example: they use small gestures to send big messages Don’t blame – they learn Look for and network with other leaders To make more leaders at all levels to help their organisations change and move into the future
LIMA PILAR KEPEMIMPINAN KLINIK YANG EFEKTIF
encourage the heart
model the way enable others to act inspire a shared vision challenge the process
MAINTAINING GOOD PRACTICE put patients first show leadership have clear values collectively committed to sustaining & improving quality encourage learning through personal & team development care for each member foster a nono-blame culture committed to the principle of external review open about their performance
Clear records Sound evidence
Personal development programmes Team development programmes
Reliable data Efficient systems Explicit clinical guidelines
Appropriate clinical audit
Effective team use:
Mutual and external appraisal
Proses dalam pengembangan clincal governance Kejelasan bentuk tugas dan tanggungjawab pelayanan kesehatan dalam menjamin mutu pelayanan klinik Program pengembangan mutu secara komprehensif
Tujuan kebijakan dalam mengelola risiko Prosedur bagi seluruh kelompok profesional untuk mengidentifikasi dan menghindari kinerja yang buruk
Pendekatan terpadu clinical governance Poor performance • Early recognition • Decisive intervention • Effective self regulation • Feedback on performance
Quality Method • Access to evidence • Time allowed to plan • Training and development strategies • Information technology support practice
Risk avoidance • Well trained staff • Clear procedures • Safe environment
Culture • Open & participative • Good leadership • Patient partnership • Education & research value
Coherence • Goals of individual, team & organization alligned • Excellent communication • External partnership •
Infrastructure • Good practice spread • Evidence-based • Learned from failure • Improvement process integrated
Jangan menutup mata, banyak masalah di sekitar kita
