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Jaminan kualitas & peningkatan kualitas pelayanan peserta didik di RSSA Syaifullah Asmiragani KPRS
22

quality improvement assurance

Dec 31, 2016

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Page 1: quality improvement assurance

Jaminan kualitas & peningkatan kualitaspelayanan peserta didik di RSSA

Syaifullah Asmiragani

KPRS

Page 2: quality improvement assurance

Patient safety incidentKejadian sentinel 2014

Px 1, rujukan dari RS Soedono

COB 1x5 + subdural hematome frontotemporal kiri + intracranialhemorage + contusional hemorage + edema cerebri + fr liniear ostemporal kiri + subgaleal hematome kanan kiri

KTD : trepanasi salah sisi

Follow up : px meninggal 2 hari post op

RTL : pembuatan dan penyempurnaan SPO , hukuman disiplin

Page 3: quality improvement assurance

Patient safety incidentKejadian sentinel 2014

Px 2,

Dx: OF tibia fibula grade IIIc (S), CF tibia (D) yg

KTD : pemasangan gips dan bivalve gips yg tidak sesuaiSPO

Follow up : kaki kanan pasien mengalami nekrosis,pasien mengalami sepsisi dan kedua kaki harusdiamputasi

RTL : pembuatan dan penyempurnaan SPO , hukumandisiplin

Page 4: quality improvement assurance

OF tibia fibula dextra grade 3C

Page 5: quality improvement assurance

CF tibia sinistra

Page 6: quality improvement assurance

Patient safety incidentKejadian sentinel 2015

Px 1, Rujukan dari RS Bangil

Dx : peritonitis generalisata ec appedicitis perforata

KTD : dilakukan pemasangan CVC, dan wire tertinggal danmasuk ke jantung.

Follow up : px meninggal pasca pengambilan wire

Kerugian : Rp 60 jt

RTL : pembuatan dan penyempurnaan SPO , hukumandisiplin

Page 7: quality improvement assurance

Patient safety incidentKejadian sentinel 2015Px 2

Dx : luka tembak senapan angin di pelvis

KTD : tidak ada indikasi operasi cito pengambilan operasi

Follow up : pasien mengalami komplikasi peritonitis akibat infeksiluka operasi dan pneumothorax. Total dilakukan 3 kali operasi.Penderita dirawat selama 3 bln dengan pembiayaan dari RSSA

Kerugian : Rp 128 jt

RTL : pembuatan dan penyempurnaan SPO , hukuman disiplin

Page 8: quality improvement assurance
Page 9: quality improvement assurance

Semua pasien belum tentu kita sembuhkan

Semua pasien beresiko kita cederai

Page 10: quality improvement assurance

BAD PRACTICE

Why adverse outcomes continue to happen?

No safety barriers

Page 11: quality improvement assurance

why ?

Page 12: quality improvement assurance

GOOD PRACTICE

Build safety barriers

Page 13: quality improvement assurance

When the safety barriers work

Page 14: quality improvement assurance

TOOLS

1. RCA

2. Procedure

3. Monitoring ?

Page 15: quality improvement assurance

Focus on the tail

The GUARDIANS

The GUARDIANS

IPM

KPRS

KOMITE MEDIK

KOMITE

KEPERAWATAN

SATKER

FK ?

AKPER ?

Page 16: quality improvement assurance

Focus on the tail

Pasif

Laporan patient safety

incident

- KTD

- KTC

- KNC

- KPC

Aktif

- Audit rekam medik

berkala

- Sidak

- Investigasi aktif

Page 17: quality improvement assurance

RTL : komunikasi efektif

Page 18: quality improvement assurance

WORSE BETTERQUALITY

GOOD

Σ

Quality Assurance maintenance

Page 19: quality improvement assurance

WORSE BETTER

QUALITY

Σ

Quality Improvement

GOOD

Page 20: quality improvement assurance

Quality Improvement

Quality improvement project:

1. Identify an issue

2. Build a team to address it

3. Define the problem

4. Choose a target

5. Test the change

6. Reconsider or extend the improvement efforts

Page 21: quality improvement assurance

Quality ImprovementPELAYANAN YANG BAIK ADALAH PENDIDIKAN

YANG BAIKPENDIDIKAN YANG

BAIK ADALAH PELAYANAN YANG BAIK

Page 22: quality improvement assurance

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