ASPEK HUKUM DALAM

PRAKTIK KEDOKTERAN

MEIVY ISNOVIANA,MD disadur dari Dr.Sofwan

Dahlan

TUGAS & TANGGUNGJAWAN DOKTER

Melakukan trilogy of clinical case management !!!
Clinical case management is a dynamic process
where diagnosis and treatment often blend into one.
The essential factor is not analysis, but result, i,e.,
helping the patient.
The objectives :
1. To relieve his or her symptoms,
2. To make him or her comfortable again.
3. To restore his or her sense of well-being.
(Curran, W, J., 1982)
Oleh sebab itu diperlukan syarat kompetensi !!!

CLINICAL CASE MANAGEMENT

The trilogy of clinical case management is said
to be:
a.diagnosis (to identify the cause of symptom
and to decide on the natural of the illness);
b.treatment; and
c.prognosis (estimate of how long the patient
will be ill due to present condition with or
without treatment).
(Curran, W, J., 1982)

KOMPETENSI
+ The condition of being capable.
+ The capacity to perform task or role.

Aspek kompetensi yang harus dikuasai dokter:

1.
2.
3.
4.
5.

Medical knowledge.
Clinical skill.
Clinical judgment.
Humanistic quality.
Communication skill.

Peran (role) dokter adalah sebagai:

1. Medical expert. 2. Professional. 3. Communicator.
4. Health advocate. 5. Scholar.
6. Collaborator.
5. Manager.

DIAGNOSIS
Diagnosis merupakan pekerjaan Dr yang paling
sulit meski sudah dibantu peralatan hi-tech.
Hasil diagnosis bisa berupa:
a. Correct diagnosis (dikenali dengan benar);
b. Misdiagnosis (salah diagnosis); atau
c. Undiagnosis (tidak bisa dikenali penyakitnya).

Fakta di Amerika: kesalahan diagnosis mencapai

17 %, bahkan di UGD / ICU antara 20 % - 40 %.

NEW HIGH TECHNOLOGY

There are many fascinating, new testing
procedures available to todays diagnoticians.
The objective of these new techniques:
a. to increase accuracy.
b. to decrease patient discomfort and risk.
c. to broaden the diagnostic horizon available to the doctor.
(Gibbons, T, B, 1980)

SOME NOTES
It is important to be aware of the sensitivity
and specificity of the screening test.
1. A test with a high sensitivity will fewer
missed diagnosis.
2. A test with a high specificity will have
fewer alarms.
3. A positive test when there is a low possibility of the disease is more likely to be
false positive.
(Sandars, J, 2007)

MISDIAGNOSIS
Kesalahan diagnosis dapat disebabkan oleh:
a. error by doctors,
b. error by specialists,
c. error of laboratory tests, and
d. patient may contribute to an error in various ways.

(Curran, W, J, 1980)

Jadi, tidak setiap kesalahan diagnosis merupakan

MALPRAKTEK !!!
Malpraktek dalam mendiagnosis harus didasarkan pada
mutu upaya diagnosis, bukan temuan/hasil diagnosis !!!

DIAGNOSED

MISDIAGNOSIS
(sekitar 17%)

1.
2.
3.
4.

CORRECT
DIAGNOSIS
(the bonus)

Error by doctors,
Error by specialists,
Error of laboratory tests.
Patient may contribute to
an error in various ways.

UNDIAGNOSED

UNDIAGNOSIS

Medical science has

yet recognized the
syndrome, nor
named it, nor found
its cause,
explanation, or
cure.

TREATMENT
Proposed treatments depend on the particular disease.
Patients decisions about treatment will vary based on
their goals, and values.
A medical intervension may be burdensome or
nonburdensome.
Intervention may be curative, offering definitive
correction of condition, or supportive, offering relief of
symptoms and slowing the progerssion of diseases that
currently are incurable.
For other condition, intervensions are less effective
in delaying the progression of diseases, but still can be
used to palliate symptoms or to treat acute episodes.
(Johnson, Sigler, Winslade; 2006)

THE GOALS OF TREATMENT

1. Promotion of health and prevention of disease.
2. Maintenance or improvement quality of life through
relief of symptoms, pain, and suffering.
3. Cure of disease.
4. Prevention of untimely death.
5. Improvement of functional status or maintenance of
compromise status.
6. Education and counseling of patients regarding their
condition and prognosis.
7. Avoidance of harm to patient in their course of care.
8. Assisting in a peacefull death.
(Johnson, Sigler, Winslade; 2006)

SOME NOTES
Therapy without a diagnosis is like a shot in the
dark, and may be harmful.
Vain efforts to help the undiagnosed patient by
trying one treatment after an other could result in
loss of valuable time, drugs reactions or other
problems.
(Mencoba-coba terapi satu ke terapi lain terhadap pasien
yg tak terdiagnosis akan menghilangkan waktu berharga,
menimbulkan reaksi obat atau problem lain).
(Gibbons, T, B, 1980)

MORRIS & MORITZ

Every treatment by every physician on every patient is
in itself always a trial and error experimentation.
The simple reason seem to be that:
a. the patient is not quite the same physiologic
entity
today as he or she was yesterday or will be tomorrow.
b. his or her body is constantly changing, growing in
and out of such illnesses as allergies, diabetes, and
other diseases.
No physician knows, or can he know, how a given patient
will react to a given treatment untill that treatment is actually tried out on that patient and the physician observes

THE MAIN LATENT CONDITION

FOR FAILURE

1.
2.
3.
4.
5.
6.

Inadequate training.
Unworkable procedures.
Low standards of quality.
Poor or inadequate technology.
Unrealistic time pressures.
Understaffing.
(Firth-Cozens, J & Sandars, J, 2007)

PRACTICAL APPROACH
TO REDUCING ADVERSE EVENTS
1. Take a history that concentrates on the key
elements.
2. Asses the evidence and consider the possible
range of differential diagnoses.
3. Use diagnostic tests appropriately.
4. Carefully consider whether discharge from
care is appropriate.
5. Obtain a second opinion if the problem
remains unexplained.
(Sandars, J, 2007)

LISENSI
Lisensi adalah subject matter dari hukum publik yang
memberikan kewenangan kepada Dr untuk:
a. mewancarai pasien.
b. memeriksa fisik dan mental pasien.
c. menentukan pemeriksaan penunjang.
d. menegakkan diagnosis.
e. menentukan penatalaksanaan & pengobatan pasien.
f. melakukan tindakan kedokteran / kedokteran gigi.
g. menulis resep obat dan alat kesehatan.
h. menerbitkan surat keterangan Dr & Drg.
i. menyimpan obat dlm jumlah & jenis yang dijinkan.
j. meracik & menyerahkan obat bagi daerah terpencil.
k. kewenangan yg akan diatur dalam Peraturan Konsil.

PROFESSIONAL LIABILITY
Tanggung-gugat profesional (Dr) timbul karena
ia tidak melaksanakan trilogy of clinical case
managent dengan baik sehingga pasien menderita
kerugian.
Tanggunggugat tsb dapat dialihkan ke RS bila:
a. Dr bekerja sebagai employee (sub-ordinate).
b. Dr bekerja secara sukarela (sebagai voluntir).
c. Dr diundang oleh RS (visiting doctor).
Tanggunggugat dapat ditanggung bersama (joint
liability) jika Dr bekerja sebagai mitra.

CORPORATE LIABILITY

RS bertanggunggugat bila tidak melakukan langkah manajerial yang pantas terhadap:

a. hospital equipment, supplies, medication and
food.
b. hospital environment.
c. safety procedures.
d. selection and retention of employees & conferral of staff privileges (clinical privileges).

CLINICAL PRIVILEGES
Kewenangan yang diberikan kepada Dr,
Drg, perawat dan bidan oleh Direktur RS
atau oleh Hospital Governing Board untuk
memberikan layanan kepada pasien di RS.
Pemberian kewenangan tsb secara umum
dibatasi hanya pada tenaga kesehatan yang
memiliki lisensi, kompetensi, pengalaman,
dan lain-lain.

CLINICAL PRIVILEGES
Emergency privileges diberikan kepada
setiap tenaga kesehatan ketika ada kondisi
emergensi di RS, tanpa dikaitkan dengan
tugas layanan reguler ataupun statusnya.
Temporary privileges bisa diberikan kepada
tenaga kesehatan utk memberikan layanan
kesehatan dalam waktu terbatas atau kepada
pasien spesifik.

PEMBERIAN
CLINICAL PRIVILEGES
Ada banyak metoda pemberian Clinical Privilege.
Masing-masing metode punya kelebihan dan
kelemahan atau punya keuntungan dan kerugian.
Terdapat 4 metode pemberian CP, yaitu:
1. Laundry list method.
2. Categorical privilege delineation method.
3. Core privilege delineation method.
4. Combination approach.
RS perlu mengkaji metode mana yg paling sesuai.

THE ULTIMATE RESULT

The ultimate result of any method of clinical
privilege delineation is to insure the clinical
competency of the medical staff.
During the initial appointment process clinical competency validation is accomplished
by obtaining references related to requested
clinical privileges and by verifying education, training and experience.

MENILAI KOMPETENSI

1. Board certification.
2. Documentation of training and experience.
3. Physicians may gain this training through
supervised training programs.
4. Practitioner may also gain provisional
privileges allowing him or her to perform the
procedure under the supervision of another
practitioner skilled in the procedure
(proctoring).

5. Data from some new procedures have shown that

the complication rate decreases significantly and
competency increases significantly after a certain
number procedures are performed.
6. Guidelines for competency in new procedures or
treatment modalities must be developed on the basis
of a review of the literature and the technical aspects
of the procedure.
Once the guidelines are successfully met by the
practitioner, full privileges are granted.
7. As new procedures and treatment modalities
develop, guidelines for clinical privileges must also
develop.

CREDENTIALING ASPECTS
1. Kompetensi Akademik:
a. kognitif; dan
b. psikomotor.
2. Kesehatan:
a. kesehatan fisik; dan
b. kesehatan mental.

IMPAIRED PHYSICIANS
The one is unable to practice medicine
with reasonable skill and safety to patiens
because of a physical or mental illness,
including deterioration through the aging
process or motor skill, or excessive use or
abuse or drugs.

Joint Commission Credentialing, Privileging,

Competency, and Peer Review, 2003

CREDENTIALS REVIEW
1. Ensure that all information in included in the
packet for the credential committee and medical staff review.
2. Information in the packet includes quality
and peer review data to support the requested
clinical privileges.
3. Additional information is included to address
any red flags such as liability insurance
claims, discrepancies in information on the
reappointment form.

MASA BERLAKUNYA CP
Clinical privilege tidak bersifat permanen
sehingga CP dapat:
a. dipersempit;
b. diperluas, melalui permohonan yang
didukung oleh setifikat pendidikan atau
pelatihan tambahan; atau
c. dicabut karena Dr tidak menunjukkan
kompetensi (professional and ethical
performance) seperti yang diharapkan.

ASPEK HUKUM
CP merupakan subject matter dari hukum
privat, tetapi tidak boleh menafikan subject
matter dari hukum publik (STR & SIP).
CP memberikan legitimasi & perlindungan hukum.
CP tidak selalu harus identik dengan arahan
dari Kolegium.
Jika tidak setuju dengan CP dari Direktur,
maka dokter berhak memutuskan hubungan
kerja dengan RS.

ASPEK HUKUM (lanjutan)

Jika Dr melakukan tindakan diluar CP maka
Dr harus bertanggung-gugat penuh terhadap
kerugian pasien yang diakibatkan oleh
kesalahan/kelalaian, walau status Dr sebagai
sub-ordinate.
Jika RS ceroboh dalam memberikan clinical
privilege maka corporate liability dapat
diterapkan jika pasien mengalami kerugian
akibat kesalahan/kelalaian Dr.

MALPRACTICE PROPHYLAXIS
1. Refuse to take the case (when you suspect medicolegal
trouble may develop).
2. Never guarantee a cure.
3. Watch the time factor.
4. Watch the reverse time factor.
5. Keep up with the advance of medicine.
6. Do not be too advance.
7. Do not experiment.
8. Get the patients informed consent for all procedures.
9. Good housekeeping.
10. Employ at least ordinary skill and care at all times.
11. When in doubt, seek consultations.
12. Cooperate with your profession.
13. Watch your patient relations.
14. Watch your public relations.
(Morris, Moritz)