HOSPITAL QUALITY MANAGEMENT 19 02 2016

COURSE
THE STUDY PROGRAM COMPETENCY
 Leadership

Knowledge of
Hospital System

Research &
Communication Knowledge
Management
Hospital
Business Skill

Professionalism
 DESKRIPSI KOMPETENSI NASIONAL
Rumusan Kompetensi
Mampu menganalisis dan merespon dinamika faktor eksternal yang meliputi sistem dan
Knowledge of organisasi rumah sakit, perspektif pasien dan komunitas, kebijakan dan lingkungan
hospital system dengan menggunakan pendekatan Evidence Based Management Practice (EBMP) dan
knowledge management guna meningkatkan mutu pelayanan, keunggulan kompetitif
serta keberlangsungan organisasi rumah sakit dan pengembangan ilmu
Mampu melakukan advokasi, negosiasi (mediasi) dan lobby secara interpersonal, massa
Communication dan media sehingga berhasil membangun kemitraan secara berkesinambungan dengan
pemangku kepentingan (stakeholder).
Mampu menghasilkan nilai tambah dalam proses pengelolaan rumah sakit berdasarkan
Hospital penguasaan teori dan penerapan fungsi administrasi / manajemen serta prinsip bisnis
sehingga dapat meningkatkan mutu, aksesibilitas, keterjangkauan, ekuitas, efektfitas
business skill dan efisiensi rumah sakit serta pengembangan program strategis.
 DESKRIPSI KOMPETENSI NASIONAL
Rumusan Kompetensi

Mampu membangun iklim dan budaya organisasi rumah sakit untuk beradaptasi dan
Leadership
mentransformasi seluruh elemen organisai melalui kepemimpinan yang efekif (team
leadership dan drive result), serta bertanggung jawab terhadap hasil kerja mandiri
maupun institusi dan organisasi.
Research & Mampu mengelola riset, data riset, dan berkontribusi dalam pengembangan keilmuan
Knowledge administrasi atau manajemen rumah sakit serta mendiseminasikan hasil riset tersebut
sehingga mendapat pengakuan nasional dan internasional dalam bentuk publikasi
Management
ilmiah.
Mampu menyelaraskan antara individu dan organisasi rumah sakit (person
organizational fit) sesuai dengan standar etika dan profesi, meliputi akuntabilitas,
Professionalism
Professionalism orientasi pelayanan, komitmen pada pengembangan profesionalisme dan pembelajaran
seumur hidup dengan cara membangun karakter profesional dan kompetensi individu.
THE COURSE COMPETENCY
Quality Manager:
 Able to manage the implementation of quality management system
 Able to use quality management tools in order to implement continuous
quality improvement

Quality Leader:
 Able to lead the organizational change for quality
 Able to direct the organizational quality culture
LEARNING OBJECTIVES
1. Mampu menjelaskan konsep mutu dalam pelayanan kesehatan
2. Mampu menjelaskan filosofi sistem manajemen mutu serta strategi implementasi
sistem manajemen mutu dalam pelayanan rumah sakit
3. Mampu menjelaskan penerapan sistem keselamatan pasien dalam rumah sakit
4. Mampu menggunakan metode dan pendekatan manajemen dalam menganalisis
permasalahan keselamatan pasien dan menyusun rencana aksi program
keselamatan pasien
5. Mampu menjelaskan konsep, filosofi, fungsi dan metode akreditasi organisasi
pelayanan kesehatan (rumah sakit), yaitu JCI-KARS dan ISO
LEARNING OBJECTIVES
6. Mampu mengembangkan dokumen sistem manajemen mutu : Manual Mutu-
Prosedur- Instruksi Kerja, dengan contoh pada satu unit kerja.
7. Mampu menjelaskan peran sistem manajemen mutu dalam membangun kepuasan
pasien dan service excellence
8. Mampu menerapkan pengembangan mutu berkelanjutan dengan pendekatan
peningkatan mutu berkelanjutan pada contoh kasus di rumah sakit
9. Mampu menyusun strategi implementasi sistem manajemen mutu dan keselamatan
pasien
COURSE STRUCTURE
Lecture
Case: Hospital observation and benchmark
Task application
Individual assignment
Group assignment
GROUP ASSIGNMENT
Class is divided in four groups:
1. Group 1: Emergency Department
2. Group 2: Intensive Care Unit
3. Group 3: Operation Room
4. Group 4: Inpatient Ward
GROUP ASSIGNMENT
Task 1: Root cause analysis and Healthcare Failure Mode and Effect Analysis
Task 2: Evaluating the KARS Standard (Tracer Study in One Unit)
Task 3: Quality problem identification and Improvement plan (based on tracer
study finding)
Task 4: Designing the quality management document (based on ISO standard
and JCI) ..in one unit
Task 5: Hospital strategic plan to implement Quality and Patient Safety
management…in one unit
TASK 1: RCA & HFMEA
Group 1 and 2: RCA
 Every group choose 1 patient safety incident report or case
Group 3 and 4: HFMEA
 Group 3 : surgery procedure
 Group 4 : medication procedure
EVALUATION
In Class Observation:
 Individual participation
 Discussion

Structured Task Assignment:

 Presentation
 Group performance
 Written report

Individual Assignment
 Scientific paper

Final Examination
DEFINING QUALITY IN HEALTH CARE
SESSION OBJECTIVE
DEFINE AND DESCRIBE THE MEANING AND IMPACT OF QUALITY IN HEALTH
(HOSPITAL CARE)
DEFINE AND DESCRIBE THE QUALITY DIMENSION AND INDICATOR IN HEALTH CARE
DEFINE AND DESCRIBE THE PHYLOSOPHY OF QUALITY MANAGEMENT AND
CULTURE
QUESTIONS
1. What is quality in hospital care
2. How you can measure it
3. How we should maintain it
SEVERAL DEFINITION OF QUALITY
General: quality is the standard of a product or service which meets the
customers’ (reasonable) expectations.
Juran (1999) defines quality as fitness for use which encompasses quality of
design, quality of conformance, the availability and adequacy of service.
Feigenbaum (1983) defines quality as the total composite product and service
characteristics of marketing, engineering, manufacture, and maintenance
through which the product and service in use will meet the expectations of the
customer.
The International Organization for Standardization, ISO (1994), defines
quality as the totality of characteristics of an entity that bears on its ability to
satisfy stated and implied needs.
THE MULTIPLE VIEW OF QUALITY
(YOU CAN NOT MANAGE SOMETHING THAT YOU CAN NOT MEASURE)
Product based
(characteristic)

Value based User based

(quality & gain) (need & demand)

Q ?

Transcendent Manufacturing
(innate) based
 THE MULTIPLE VIEW OF QUALITY
Patient
what client and carriers want from
the services individuals and
Professional
population
whether the service meets
need as defined by
Management professional, provider and
the most efficient and productivity referrers and whether it
use of resources within limit and correctly carried out
directives set by higher
authorities/purchaser
Q H
“fully meeting requirement or the need
techniques and procedure
which are believe to be
necessary to meet client needs

of those who need the service most

at the lowest cost”
 WHAT IS QUALITY IN HEALTH
Quality as level of excellence produced and
documented in the process of patient care based on the
best knowledge available and achievable at a
particular facility
(IOM) “degree to which health services for individuals and
population increase the likelihood of desired health
oucomes and are consistent with current professional
knowledge”.
THE QUALITY DIMENSION
QUALITY PRISM
Patient

efficacy
relevancy adequacy

Effects

effectiveness efficiency

Activities productivity Resources

 1

The degree to which health care processes avoid,

Safety prevent, and ameliorate adverse outcomes or injuries
that stem from the processes of health care itself
(National Patient Safety Foundation, 2000).

The extent to which a system deals fairly with all

Equity
concerned. Equity, in this context, deals with the
distribution of healthcare and its benefits among a
people.
The degree to which healthcare services are
Access to unrestricted by geographic, economic, social,
services organizational, or linguistic barriers

Most commonly used

 2

Conformity to the realistic wishes, desires & expectations

Acceptability
of healthcare users and their families (Donabedian, 2003)

The degree to which provided healthcare is relevant to

Appropriateness the clinical needs, given the current best evidence.

Competency or The degree to which health system personnel have the

Capability training and abilities to assess, treat and communicate
with their clients.

Less commonly used

 3

Continuity The extent to which healthcare for specified users, over

time, is coordinated across providers and institutions.

The degree to which patients are able to obtain care

promptly (IOM, 2001). It includes both timely access to
care (people can get care when needed) (Aday and
Timeliness
Anderson, 1975) and coordination of care (once under
care, the system facilitates moving people across
providers and through the stages of care) (Shortell, 76).

Less commonly used

 Definition Function Type Criteria

QUALITY INDICATOR
DEFINITION

Kazandjian (1995): indicator is an observation

expected to indicate
indicate a certain aspect of
performance.
Measures are defined as
Boyce (1997): Indicator is statistics or others
seek to directly
directly quantify
quantify
unit of information which reflect
reflect , directly or
quality of care or health
indirectly the performance of the healthcare
outcomes
system in maintaining or increasing the well
being of its target population.
 Quality indicator will point to or indicate quality, or a
particular indicator will be indicating good or bad
quality.

The indicator could play as a ‘flags’ to draw attention

to issues that need closer look.

FUNCTION
TYPE
OUTCOME (such as rates of hospital-acquired infections or rates of 1 year
survival following acute myocardial infarction) seek to represent measures of
health improvements (or deterioration) attributable to medical care.

PROCESS (such as whether children are immunised appropriately,

whether, for those at risk, patients’ blood pressure is checked regularly by a
physician) represent measures of the delivery of appropriate (or inappropriate)
health care to the relevant population at risk – where appropriateness should
be based on clinical evidence of the effectiveness of the process concerned and
‘consistent with current professional knowledge’ (IOM, 2001).

STRUCTURE (such as whether doctors are suitably qualified and whether

hospitals are appropriately equipped) represent indicators of the
characteristics of, or inputs to, health care. They may represent necessary
conditions for the delivery of a given quality of health care but they are not
sufficient.
EXAMPLE
Structure:
 Proportion of specialist to other doctors
 Access to specific therapy
 Clinical guideline revised every 2nd year

Process:
 Proportion of patients with diabetes given regular foot care
 Proportion of patient with MI who received thrombolysis
 Proportion of patients assessed by doctor within 24 hours of referral

Outcome:
 Intermediate: Lipid profile result for patients with hyperlidemia
 End result: mortality, morbidity, functional status, work status, quality of life
TYPE
GENERIC measures aspects of care that are relevant to most patients
Example:
Registered patients in the emergency department>6 hours
Unscheduled return to operating room
In patient mortality

DISEASE-SPESIFIC diagnosis-specific and measure particular aspects of care

related to specific disease
Example:
Proportion of patient with hip fracture who need second operation
Proportion patient with lung cancer who are alive 30 days after surgery
Proportion of vaginal delivery after sectio caesaria
 IMPORTANCE SCIENTIFIC FEASIBILITY
Impact of disease or risk
SOUNDNESS Existence of prototypes.
on health and on health Validity Availability of
expenditure.
Reliability internationally-
Policy importance. comparable data across
Explicitness of evidence countries.
Susceptibility to being based.
influenced by the health Cost or burden of
care system. measurement.

CRITERIA
TASK TO DISCUSS
A patient satisfaction survey has reported that patients are
leaving the ED at your hospital without being seen and have
complained about the ED to the media.
The CEO has asked you to investigate:
QUESTIONS?
 How would you determine the cause of the problem
 How would you determine the extent of the problems
 How would you evaluate the impact of the problem on patient safety and
organization
 Whom would you work to improve the situation
 How could you conclude the improvement have been made
 What data would you used
 How you get this data
 How would you evaluate the cost of improvement process in relation to
benefit
THE CULTURE FOR QUALITY
 CONTINUOUS QUALITY IMPROVEMENT
Menyusun Rencana
Melakukan tindakan Peningkatan Mutu
koreksi terhadap hasil berdasar Identifikasi
Monev Masalah (Capaian
Indikator Mutu)

Melakukan Monev
berdasar Indikator Menerapkan Program
Program (Input, Proses, Peningkatan Mutu
Output)
OUR NATURE ACCREDITATION CYCLE
Notification Panic

De commit Over haul

Commit Site visit

BETTER ACCREDITATION CYCLE

Notification Tidy up

Carry on Site visit

 Plan-Do-Check-Act

Error detection-
remediation-correction

Maintain document and

document control

Set and meet goals and

objective
ORGANIZATIONAL CULTURE IS
The pattern, value, belief that shared by the organization
member’s
or
A pervasive or common organizational philosophy
or
How we do what we do
or
The glue that bind the organization together
EMBEDDING THE QUALITY IN THE ORGANIZATION

Quality Continuous
Management Improvement Total Quality
System Efficiency Culture
Sustainability
CULTURE OF QUALITY
Quality is in front of mind and part of the organization discussion
Internal audit is pat of the normal routine
Focus on Continuous Improvement
Collective contribution to the new idea to make the organization and its service better
Try to do some of preventive action measure at least one a year
Top management review is part of the normal routine
COMPETING VALUE FRAMEWORK (SCHEIN-
ZAMMUTO)
THE CHARACTERISTICS
 C A
Increase More internal More external Increase
community discretion differentiation Development

More
Increase management
leadership engagement

H M
THE HR FUNCTION
CULTURE TYPOLOGY AND QMS APPROACH
 QUALITY CULTURE ADOPTION

Communication Structure
Information Culture Adoption Action
Structure of of Improvement
Process quality Quality Continuity
 QUALITY AND CULTURE ARE ORGANIC
Quality Quality

ACTION

STRUCTURE

VISION
QUALITY AND CULTURE BOTH ARE ORGANIC
oFragile at beginning
oOnce it beginning both growth and flourish
oNourish by vision
oStrengthening by structure
oManifest by action
oOnce mature can take a lot of battering
oRevitalized itself ( to a point)
HOW TO MOVE
Determine what “quality” means for your organization
Embed the quality with your organization mission and core value
Provide quality training for all employee
Create opportunity to all employee to align with quality program
Promote and encourage quality as part of the common philosophy
Make quality as a central component in every key decision process