materi 10 indicator dan kriteria rs

A to Z Manajemen Risiko di RS

Manajemen Risiko di RS

Lecture # 10

by: Hafizurrachman

Fakultas Kesehatan Masyarakat

Universitas Indonesia

2008

Hospital performance indicator

• Definisi

• Penting-nya Indikator

• Kedudukan dalam Mutu

• Contoh-2 Indikator

• Cara mengukurnya

• Cara Interpretasinya

• Definisi

• Penting-nya Indikator

• Kedudukan dalam Mutu

• Contoh-2 Indikator

• Cara mengukurnya

• Cara Interpretasinya

Hospital health system

• Complex curative services

• Emergency care

• Referral center

Donabedian said :

hospital quality services improvement � important �hospital give the most critical services involves human life

Hence hospital should be delivered All services with highest quality

� Quality assurance concept, accreditation, ISO etc

New paradigm :

Old New Quality approach based on

Input & process � output/impact

indicator :

patient satisfaction

clinical aspect

eficiency

Indonesia Health office creates 2 indicators for hospital quality :

• Clinical indicator

• Performance indicator

Indicator ���� the way to assess activity performance by instrument

• WHO ideal indicator must have criteria :

1. valid

2. reliable

3. sensitive

4. specific

Control Mechanism

• Monitoring extension & Regulation hospital ( by Dinas Kesehatan propinsiand kabupaten/kota)

• Hospital accreditation committee (KARS)

• Hospital benchmark ( hospital network organisation )

Measurement method

• Inspection

• Customer survey (patient satisfaction, employee satisfaction, and performance indicator as BOR, LOS, DR)

• Assessment by third party : ISO, accreditation

• Statistical indicator

• Internal assessment

NHS Proposed 4 areas as hospital performance indicator

• 1. clinical effectiveness and outcomes

• 2. efficiency

• 3. Patient experience

• 4. capacity & capability

� Quality services indicator for hospital � 4 categories :

1. number of patient with decubitus

2. Number of infection caused by infusion /abocath

3. Number of complication/infection caused by blood transfusion

4. Number medical record completeness

5. Number of delayed in EMG care

I. Non operative indicator

II. Operative indicator

• 1. number of operative infection

• 2. number complication postoperative

• 3. Waiting time before elective operative

III. Mother care, delivery care and baby care

• 1. MMR caused by eclampsia

• 2. MMR caused by bleeding

• 3. MMR caused by sepsis

• 4. Extend LOS caused by delivery

• 5. PMR caused by BBLR

IV. Additional Indicator

• 1. MMR caused by referred eclampsia

• 2. MMR caused by referred bleeding

• 3. MMR caused by referred sepsis

• 4. Extension LOS caused by referred delivery

• 5. PMR caused by referred BBLR

• 6. Number of sectio caessarian

• 7. Number of appendectomi

NHS indicator � 4 area

• 1. Human resources improvement

• 2. Quality of services process

• 3. Customer satisfaction

• 4. Financing

12 indicator

12 indicators for hospital performance:

• 1. Average annual employee training (Hours)

• 2. Skill employee percentage in special unit

• 3. Responsiveness patient services in EMG

• 4. Waiting time before elective operation

• 5. MMR caused by delivery (bleeding,

• 6. number of nosocomial infection

• 7. number of medical record completeness

• 8. % patient satisfaction (survey)

• 9. % employee satisfaction (survey)

• 10. Hazardous liquid material Quality treatment

• 11. hospital financial status

• 12. % generic medicine in hospital

Accreditation

• Assessment method by third party : KARS

• Accreditation should be conducted every three years

Purpose :To improve quality of hospital services

Accreditation level :1. Basic services ���� 5 services2. services ���� 12 services3. Completed level ���� 16 services

scoring

Basic level � 5 services

• 1. management and administration

• 2. Medical services

• 3. Nursery services

• 4. EMG services

• 5. Medical records

Example : medical services ���� S.1 P.1 : medical services is given based on profession standard which stated by hospital management

There are written standard describe all medical services, and conducted the evaluation and follow up the result by management5

There are written standard describe all medical services and approved by management4

There are written standard describe all medical services but have not approved by management3

There are unwritten standard describe all medical services2

Few unwritten standard in medical services1

medical services standard is not available (no standard)0

Result : Accreditation status

1. Unaccreditated (FAILED)•Have not meet the standard•1 or more services get score less than 60 % or average total score 65% or <

2. Accreditation with notice• get minimum standard but not enough

to get full accreditation

• Average score from total services 65-75%. Note: no services get score < 60 %.

• hospital meets the standar• total score > 75%• No services get score < 60%���� 3 years

3. Full accreditation

4. Special accreditation

• hospital meets full standard for 3 periode

���� 5 years.

T h a n k y o u

See you in next presentation……..