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HOSPITAL BUSINESS EXCELLENCE FRAMEWORK

Dr. Dody Firmanda, Sp.A, MA Ketua Komite Medik RSUP Fatmwati, Jakarta

Disampaikan pada Acara Round Table Discussion – Key Performance Indicators (KPIs) for Hospital diselenggarakan oleh PT Krakatau Medika di Hotel Permata Krakatau, Cilegon 6 Agustus 2009

Vision or guiding philosophy 1 Vision or guiding philosophy What What we we want want
Vision or guiding philosophy
1
Vision or guiding philosophy
What What we we want want to to be be
2
Core Core values values and and
Strategy
beliefs beliefs
Who Who we we want want to to be be
The way we are
going to achieve it
3
Mission Mission
Our Our purpose purpose and and the the
scope scope of of our our work work
4
Critical Critical Success Success Factors Factors
5
Key Key
(CSFs) (CSFs)
Performance Performance
Indicators Indicators (KPIs) (KPIs)
Target
What What success success will will look look like like – – a a
balanced balanced scorecard scorecard of of results results
6
Core Core processes processes
People
Resources
How How success success will will be be achieved achieved
Process management

RUMAH SAKIT : ………………………………………………………

1
1

Vision

2
2

Values

3
3

Mission

4
4

CSFs

5
5

KPIs

6
6

Core

Processes

EVOLUSI 1:

Pendahuluan

EVOLUSI 1: Pendahuluan

EVOLUSI 2:

EVOLUSI 2: Tahun 1970an Tahun 1980an Tahun 1990an Abad 21
EVOLUSI 2: Tahun 1970an Tahun 1980an Tahun 1990an Abad 21
EVOLUSI 2: Tahun 1970an Tahun 1980an Tahun 1990an Abad 21
EVOLUSI 2: Tahun 1970an Tahun 1980an Tahun 1990an Abad 21
EVOLUSI 2: Tahun 1970an Tahun 1980an Tahun 1990an Abad 21
EVOLUSI 2: Tahun 1970an Tahun 1980an Tahun 1990an Abad 21
EVOLUSI 2: Tahun 1970an Tahun 1980an Tahun 1990an Abad 21
EVOLUSI 2: Tahun 1970an Tahun 1980an Tahun 1990an Abad 21
EVOLUSI 2: Tahun 1970an Tahun 1980an Tahun 1990an Abad 21

Tahun 1970an

Tahun 1980an

Tahun 1990an

Abad 21

Quality Leadership

Conform Conform the the Standards Standards Maintain Maintain & & Improve Improve the the Standards
Conform Conform the the Standards Standards
Maintain Maintain & & Improve Improve the the Standards Standards
Audits
Continuous Continuous Quality Quality Improvement Improvement (CQI) (CQI)
Surveillance
Evidence-based Evidence-based Medicine Medicine (EBM) (EBM)
Health Health Technology Technology Assessments Assessments (HTA) (HTA)
System System & & Sub Sub Systems Systems
Ideas Ideas
Model/Paradigma Model/Paradigma
Theory Theory
Leadership, Values & Principles
Vision
Vision
Vision

Vision

Vision
Vision
Vision
Vision
Vision Mission 1 Mission 2 Mission 3 Needs Wants Demands Objective 1 Objective2 Objective 3 Objective
Vision Mission 1 Mission 2 Mission 3 Needs Wants Demands Objective 1 Objective2 Objective 3 Objective
Vision Mission 1 Mission 2 Mission 3 Needs Wants Demands Objective 1 Objective2 Objective 3 Objective

Mission 1

Mission 2 Mission 3 Needs
Mission 2
Mission 3
Needs

Wants

Vision Mission 1 Mission 2 Mission 3 Needs Wants Demands Objective 1 Objective2 Objective 3 Objective

Demands

Objective 1 Objective2 Objective 3 Objective 4
Objective 1
Objective2
Objective 3
Objective 4
Demands Objective 1 Objective2 Objective 3 Objective 4 Target 1 Target 2 Target 3 Target 4
Target 1 Target 2 Target 3 Target 4 Target 5
Target 1
Target 2
Target 3
Target 4
Target 5
Objective 4 Target 1 Target 2 Target 3 Target 4 Target 5 Measurable Target 1 Target

Measurable

Target 1 Target 2 Target 3 Target4 Target 4
Target 1
Target 2
Target 3
Target4
Target 4
5 Measurable Target 1 Target 2 Target 3 Target4 Target 4 Target 1 Target 1 Target
5 Measurable Target 1 Target 2 Target 3 Target4 Target 4 Target 1 Target 1 Target
5 Measurable Target 1 Target 2 Target 3 Target4 Target 4 Target 1 Target 1 Target

Target 1

Target 1

Target 2

Target 2

Time-frame

Target 3

Target 3

Target 4

Target 1 Target 2 Target 3 Target4 Target 4 Target 1 Target 1 Target 2 Target
Target 1 Target 2 Target 3 Target4 Target 4 Target 1 Target 1 Target 2 Target

WHO Europe :

Performance Assessment Tool for Quality Improvement in Hospitals (PATH)

WHO Europe : Performance Assessment Tool for Quality Improvement in Hospitals (PATH)
dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008

dodyfirmanda, 21 November 2008

WHOEurope PATH dengan model Sistem Komite Medik RSUP Fatmawati

WHOEurope PATH dengan model Sistem Komite Medik RSUP Fatmawati dodyfirmanda, 21 November 2008

dodyfirmanda, 21 November 2008

dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008

dodyfirmanda, 21 November 2008

dodyfirmanda, 21 November 2008
dodyfirmanda, 21 November 2008

PATIENT SAFETY =

1

RISIKO X ERRORS

RISIKO =

B A R R I E R S

KOMPETENSI X MOTIVASI

KINERJA = MOTIVASI X KOMPETENSI

BARRIERS

X ERRORS RISIKO = B A R R I E R S KOMPETENSI X MOTIVASI KINERJA
X ERRORS RISIKO = B A R R I E R S KOMPETENSI X MOTIVASI KINERJA

Knowledge-based

Mutu Profesi

Performance = Kompetensi X Motivasi Sarana

Kompetensi = Pelayanan, Pendidikan & Penelitian

Sarana Kompetensi = Pelayanan, Pendidikan & Penelitian Rawat Jalan Rawat Inap Operasi Emergensi Konsultasi Jaga

Rawat Jalan Rawat Inap Operasi Emergensi Konsultasi Jaga

Rawat Jalan Rawat Inap Operasi Emergensi Konsultasi Jaga Dokter Sp.1 Sp.2 Uji Klinis Deskriptif Standar/indikator

Dokter

Sp.1

Sp.2

Inap Operasi Emergensi Konsultasi Jaga Dokter Sp.1 Sp.2 Uji Klinis Deskriptif Standar/indikator Audit/Benchmarking

Uji Klinis Deskriptif

Standar/indikator

Audit/Benchmarking

CQI

1. Kolegium 2. STR dari Konsil Kedokteran 3. SIP Sertifikat Kompetensi Kewenangan Klinis Komite Medik
1. Kolegium 2. STR dari Konsil Kedokteran 3. SIP Sertifikat Kompetensi
1. Kolegium
2. STR dari Konsil Kedokteran
3. SIP
Sertifikat Kompetensi
1. Kolegium 2. STR dari Konsil Kedokteran 3. SIP Sertifikat Kompetensi Kewenangan Klinis Komite Medik
1. Kolegium 2. STR dari Konsil Kedokteran 3. SIP Sertifikat Kompetensi Kewenangan Klinis Komite Medik
Kewenangan Klinis

Kewenangan Klinis

Kewenangan Klinis Komite Medik

Komite Medik

Contoh Kewenangan Klinis

Contoh Kewenangan Klinis
Contoh Kewenangan Klinis
Sub Komite Kredensial 1. Tes Kepribadian 2. Tes MMPI-2 3. Wawancara
Sub Komite Kredensial 1. Tes Kepribadian 2. Tes MMPI-2 3. Wawancara

Sub Komite Kredensial

1. Tes Kepribadian

2. Tes MMPI-2

3. Wawancara

Pemeriksaan Penunjang Diagnostik Pemeriksaan Penunjang Terapeutik Obata obatan Peralatan Operasi Ruang Tindakan/Operasi

Pemeriksaan Penunjang Diagnostik Pemeriksaan Penunjang Terapeutik Obata obatan Peralatan Operasi Ruang Tindakan/Operasi SDM Penunjang

Keselamatan Pasien

Safetyness = Risks X Harms

Keselamatan Pasien Safetyness = Risks X Harms Likelihood Frekuensi Severity C e d e r a

Likelihood

Keselamatan Pasien Safetyness = Risks X Harms Likelihood Frekuensi Severity C e d e r a

Frekuensi

Pasien Safetyness = Risks X Harms Likelihood Frekuensi Severity C e d e r a Infeksi

Severity

Pasien Safetyness = Risks X Harms Likelihood Frekuensi Severity C e d e r a Infeksi

Cedera Infeksi Nosokomial Meninggal Litigasi

Audit Medis
Audit Medis

Surveilans Nosokomial

Audit Medis Surveilans Nosokomial PRA (Probability Risks Assessment) Portfolio Individu Audit Medis Audit Medis Audit

PRA (Probability Risks Assessment)

Surveilans Nosokomial PRA (Probability Risks Assessment) Portfolio Individu Audit Medis Audit Medis Audit Medis

Portfolio Individu

Audit Medis

Audit Medis

Audit Medis

Nosokomial PRA (Probability Risks Assessment) Portfolio Individu Audit Medis Audit Medis Audit Medis Komite Hukum RS

Komite Hukum RS

Implementasi

Implementasi

Implementasi

Implementasi

Implementasi

Implementasi

Implementasi

Implementasi Gambar 6. Kerangka Konsep Patient Safety Komite Medik RSUP Fatmawati

Gambar 6. Kerangka Konsep Patient Safety Komite Medik RSUP Fatmawati

Model Patient Safety
Model Patient Safety
(untuk RS pendidikan)
(untuk RS pendidikan)
KOMITE MEDIK: SISTEM CLINICAL GOVERNANCE, PATIENT SAFETY & CP
KOMITE MEDIK: SISTEM CLINICAL GOVERNANCE, PATIENT SAFETY & CP

KOMITE MEDIK: SISTEM CLINICAL GOVERNANCE, PATIENT SAFETY & CP

KOMITE MEDIK: SISTEM CLINICAL GOVERNANCE, PATIENT SAFETY & CP
/ Adverse Events
/ Adverse Events
/ Adverse Events