clinical pathway merita
DESCRIPTION
ghchkgjcvbTRANSCRIPT
![Page 1: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/1.jpg)
Clinical Pathway
dr. Merita Arini, MMR
![Page 2: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/2.jpg)
Learning Objectives
![Page 3: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/3.jpg)
Topik
![Page 4: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/4.jpg)
Clinical Pathway in Hospital
Ronie Rivany
![Page 5: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/5.jpg)
UU 40/2004 tentang SJSNBab 24 ayat 3 menetapkan bahwa BPJS harus mengembangkan:
![Page 6: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/6.jpg)
PPres 12/ 2013 tentang Jaminan Kesehatan
Pasal 20 ayat 1 menetapkan produk: pelayanan kesehatan perorangan (promotif,
preventif, kuratif, dan rehabilitatif), obat dan bahan medis habis pakai
Pasal 39 mengatur Sistem pembayaran: Kapitasi untuk tingkat pertama, INA-CBGs
untuk tingkat lanjutan
![Page 7: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/7.jpg)
Cont’ • Pasal 42 mengatur Sistem Kendali
Mutu: – Memenuhi standar mutu fasilitas kesehatan
(input); – Memastikan proses pelayanan sesuai standar
(proses), – Memantau luaran kesehatan peserta (output)
![Page 8: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/8.jpg)
Input - Proses - OutputStandar input:
• Perijinan fasilitas kesehatan (standar bangunan, SDM, peralatan, SDM, dsb).
Standar output: • Kinerja di level pasien dan di level sarana
yankes: SPM RS*
Standar proses:• Manajemen:
• Standar akreditasi (RS, Lab.), standar pelayanan prima, dsb
• Pelayanan klinik (clinial care): • PPK/clinical guidelines oleh organisasi
profesi.
![Page 9: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/9.jpg)
Pedoman Pelayanan
Input Proses Output/Outcome
S P O
Kebijakanpelayanan
Pedoman Pengorganisasia
n
Tatalaksana
Survei kepuasan Indikator Mutu :
Indikator KlinikIndikator Mutu Yan
I K P :K T D : Sentinel EventK N C
•Standar SDM
•Standar Fasilitas
Peraturan dan perundanganPedoman
Djoto Atmodjo, KARS
![Page 10: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/10.jpg)
CP vs CGClinical Pathway Clinical Guideline
Lebih customize & user friendly:•Template seragam RS (locally agreed)• Disusun berdasarkan best practice (available) & kondisi RS•ownership lebih tinggi: multidisipliner
• Bentuk sangat bervariasi• Disusun melalui proses
rumit & butuh sumber daya & waktu >>.
• Sering << efektif karena <<nya perhatian & support
![Page 11: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/11.jpg)
Mengapa perlu menyusun CP?
Tarif INA CBGs Mutu Pelayanan Dianggap kecil, RS merasa
rugi:o Berdasarkan perbandingan
dg tarif RS o Berdasarkan perbandingan
dg cost RSo Berdasarkan kasus per kasus Efisiensi vs Fraud
Pedoman Nasional Praktek Kedokteran (PNPK), Pedoman Praktek Klinis (PPK), CP
o Bisa dihitung cost of careo Bisa dibandingkan dg tarif
INA-CBGso Bisa menjadi dasar u/
pengambilan keputusano Bisa sebagai alat kendali
mutu (audit medis, surveilans HAIs, penggunaan fornas, dsb.)
(Djasri, 2014)
![Page 12: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/12.jpg)
“ HOSPITAL GOVERNANCE “
STRUCTURE
PROFESSIONALCOMPT & CPD
PROCESS OUTPUT OUTCOME
CLINICAL PERFORMANCE& EVALUATION
CONSUMERVALUE
CLINICALRISK
MANAGEMENTINTEGRATED
CLINICALPATHWAY & GUIDELINE
PATIENT SAFETY, EQUITY, QUALITY
CLINICAL GOVERNANCE
CLINICALLEADERS
ICD 10ICD 9 CM
INSTITUTIONAL (HOSPITAL) GOVERNANCE
POLICYRESOURCES: 5 M
(2 M)
VISIONHOSP LEADERS
PROSES REALISASI GROWTH
HOSPITAL PERFORMANCE ?
SPMCONSUMER VALUES
BEST PRACTISEBASIC : VBMTOOLS : EBM
CASEMIX
Patientsafety
HOSPITAL
BYLAWS
![Page 13: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/13.jpg)
Clinical Pathway
![Page 14: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/14.jpg)
Alternative Names
• Clinical Pathway• Critical care pathway, • Integrated care pathway, • Coordinated care pathway, • Caremaps®, atau• Anticipated recovery pathway
(Djasri, 2014)
![Page 15: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/15.jpg)
DEFINISI • ICP is a matrix which places
interventions (tasks) on one axis & time (hours, days, weeks) & milestones (specific stages of recovery).
(Midleton & Roberts, 2000)
• CP serve as collaborative plans of patients care requiring cooperation from physician, nurses, clinical staff, & support staf .
(Guinane, 1997)
![Page 16: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/16.jpg)
Form Generik Clinical Pathway
Identitas PasienHari I Hari II Hari III
AssessmentIntervensi/ pelayananOutcomeVariasi
(Midleton & Roberts, 2000; Djasri, 2014)
![Page 17: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/17.jpg)
Karakteristik CP• Menggabungkan:
– Current evidence based– Budaya - Tradisi– Etika– Resources yg tersedia– Preferensi– Kebutuhan & keinginan konsumen– Sistem pengukuran melekat
• Easily audited• Transferable kepada area klinis lain dlm
RS sama(Rahma, Djasri, 2014)
(Midleton & Roberts, 2000)
Mendokumentasi-kan clinical practice terbaik bukan hanya clinical practice sekarang
![Page 18: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/18.jpg)
Elemen CP• Patients group• Scope• Multidisciplinary collaboration• Sequential & appropriate care/
intervention• Patient-focused care• Single record of care• Analysis of variations
(Middleton & Roberts, 2000)
![Page 19: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/19.jpg)
Struktur CP
SPO
![Page 20: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/20.jpg)
Langkah Penyusunan CP
(Rahma & Djasri, 2014)
![Page 21: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/21.jpg)
Cont’
![Page 22: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/22.jpg)
Teknis Pembuatan CP 1. Profesi Medis
• Mempersiapkan SPM/ SPO• bila belum ada dapat menyusun dulu SPM/
SPOnya sesuai kesepakatan.
2. Profesi Perawat• mempersiapkan SPO/ SAK
3. Profesi Rekam Medis/ Koder • mempersiapkan buku ICD 10 dan ICD 9CM, • Laporan RL1 sampai dengan 6 (terutama RL2). • Menyajikan daftar 5 - 10 penyakit utama & tersering
dari setiap divisi SMF/Instalasi dg kode ICD 10 & mean LoS berdasarkan data laporan morbiditas RL2.
Djoti Atmodjo, KARS
![Page 23: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/23.jpg)
Cont’ 4. Profesi Gizi• menyiapkan assesment nutrisi, asuhan
gizi
5. Profesi Farmasi• mempersiapkan Daftar Formularium, sistem
unit dose dan stop ordering
6. Profesi Akuntasi/ Keuangan• mempersiapkan Daftar Tarif rumah sakit
![Page 24: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/24.jpg)
![Page 25: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/25.jpg)
Contoh Form CP
![Page 26: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/26.jpg)
![Page 27: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/27.jpg)
Efektivitas/ Manfaat CP• Efektivitas CP debatable• Pada umumnya di RS hanya 30%
pasien yg dirawat dg CP. Selebihnya pasien dirawat dg prosedur biasa (usual care).
• ± 80% RS USA menggunakan CP u/ beberapa indikator
• Standar Akreditasi KARS 2012 5 CP/ RS/ tahun
(Benny, 2014)(Djasri, 2014)
![Page 28: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/28.jpg)
![Page 29: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/29.jpg)
Implemented for over 20 years and well established in hospitals - 80% of hospitals in USA (Saint 2003)
![Page 30: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/30.jpg)
VFM Unit (NHS Wales) Project
Clinical Resource Utilitation Group
• Sept 1995 - March 1997, UK• 700 clinical, managerial, operational staf• Aimed to:
– Identify the critical succes factors & potential bariers to adoption of ICPs
– Developt framework/ structured approach to support succesful implementation
(Midleton & Roberts, 2000)
![Page 31: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/31.jpg)
Cont’• Key result 5 distinct & sequential stages used
by organizations with evidence of succesful programmes of ICP activity:
![Page 32: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/32.jpg)
Awarenes Raising & Gaining Commitment
• A strategic approach: a vision of future– Shared vision– ICP
• change management tool • integral component of bussiness & quality • clinical governance
– Goverment papers & other related documents outline strategy for a defined period of time
1.
LEADERSHI
P
![Page 33: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/33.jpg)
Awarenes Raising & Gaining Commitment
• Reasons for developing ICPs– Reinforce aims of ICP ~ organizational
objectives• Improve quality of care trough consistent
management– Encourage patient involvement– Identify & measure outcomes of patient care
• Promote efficient without compromising quality– Reduce unnecessary documentation– Documenting variations from the predicted plan– Facilitate a plan of care & improve links & between
community services
1.
![Page 34: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/34.jpg)
Cont’
• Increase collaboration of multidisciplinary team
–Reduce unnecessary variations–Ensure that no critical aspects of care are
forgotten & that all intervention are planned appropiately & performed on time
–Providing a framework for effective clinical audit
–Educational/ training tool esp. New staff/ short rotation
![Page 35: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/35.jpg)
Awarenes Raising & Gaining Commitment
• ICP facilitator (Stephens, 1997)
– Solve problems of limited resources/ high workload
1.Key
factor
Facilitator’s role:• awareness• Provide initial training, ongoing education, & support• Act as a link between all professional goups involved• Set up & manage individual ICP projects• Attend & facilitate ICP development & meetings• Prepare ICP documentation• Provide ongoing evaluation, feedback, & review
![Page 36: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/36.jpg)
ICP facilitator: Skills Checklist(Stephens, 1997)
Presentation & training communication & negotiation project management/ change management Team building & group facilitation computer literate/ IT Skills ability to motivate/ lead ability to work to tight deadlines under pressure Sound knowledge of ICPs & related initiatives Confidence, credibility, & self motivation
Key task “awareness session” : encouraging staff involvement
![Page 37: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/37.jpg)
Putting System into Place• Selecting patient groups
– Common condition ( high % of patients) biggest impact on our organization
– Simple condition (not multi-pathology) quick wins/ motivator !!!
– Specific problem areas
2.
• High volume• High cost• High risk• Problem prone• Memiliki gap besar dg tarif INA CBGs
![Page 38: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/38.jpg)
Cont’
– Staff expressed preferences Ensure staff commitment
– Monitoring & comparing clinical outcome– Meeting health gain targets (national/
international)– Availability of evidence/ guidelines– Managing clinical risk
![Page 39: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/39.jpg)
Putting System into Place
• Agreeing the scope of ICP
– The development team
2.
Boundary
![Page 40: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/40.jpg)
• Defining the desired objectives of care– Patient outcome - Patient satisfaction– Service quality - Cost effetiveness &
efficiency
Putting System into Place2.
![Page 41: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/41.jpg)
Cont’
• Defining the desired objectives of careGained from:– Available evidence– Clinical audit– Benchmarking data– Accreditation standards– Health gain targets– National service framework, etc
![Page 42: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/42.jpg)
• Mapping the current process of care
• Moving from the process map to the ICP document
Putting System into Place2.
![Page 43: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/43.jpg)
• Lay-out Design• Process based or outcome?
– Depends on the skills of user
• ICP as the legal record of care – as a single record of care debatable– Flexibility review
Documentation3.
Check wound vs Wound dry
![Page 44: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/44.jpg)
• Variation analysis– Essential succes factor of ICP
implementation– “expected variations as professional
judgement for patient focused of care”– Code:
• By clinicians/ nurse manager/ clinical nurse specialist/ audit staff
• Explain in CP guidance asignment
Documentation3.
![Page 45: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/45.jpg)
Patient Pathway
![Page 46: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/46.jpg)
Patient Pathway (PP)Should include:• An introduction to PP• Guidance for using PP• Description of the natur of CPs & their use• Information on patient’s condition & their
threatment• Information to describe variations from the
expected & how care is individualized to suit patient needs
![Page 47: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/47.jpg)
• Requires careful planning & Effective project management
• Preparing the main players– Facilitator– Clinical staff– Managerial staff
• Learning from failure & communicating success throughout the organization
Implementation 4.
LEADERSHI
P
![Page 48: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/48.jpg)
Critical Success Factors• “top-down” support of senior
management tangible commitment• CP is a leader driven process• At the very least need:
– A full-time or designated facilitator– Office space– IT & reproduction facilities– Time for clinical staff to participate in
designing & reviewing CP
![Page 49: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/49.jpg)
The Full Time Job
• Base-lines audit of documentation of practices• Discussions with all key staff• Education session • Production & continuing refinement of the
documentation
![Page 50: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/50.jpg)
Barriers to success
• Professional cultures• Lack of organisational support• Care Pathway design• Inadequate time & resources• Ad-hoc approach
![Page 51: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/51.jpg)
Mengapa CP gagal?• Ownership rendah akibat keterlibatan/
dukungan staf yg disproporsional• CP ≠ universal panacea:
– perjalanan alami penyakit– Intoleransi obat– Resistensi antibiotik,– Penatalaksanaan tdk sesuai ketentuan, etc– CP seringkali lebih mudah digunakan pada:
• pasien bedah• Pasien dg single pathology (non-complicated, no-
comorbidities)
![Page 52: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/52.jpg)
Evaluasi CP“If you can measure, you can
manage it”
• purpose of evaluation
• Objects of evaluation
□ personal judgement
□ full research project
□ development process
□ operational aspects
□ single pathway
□ multiple pathways
5.
![Page 53: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/53.jpg)
Operational Aspects
“Apakah CP sukses diimplementasikan di semua area?”
• Contoh kriteria evaluasi:– Persetujuan staf klinis multidisiplin
menerapkan CP– Kelengkapan dokumentasi– Pendataan varians
![Page 54: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/54.jpg)
cont’
• outcome yang akan diukur
□ patient centered
□ (individual) clinical staff
□ clinical team
□ organizational
□ other
![Page 55: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/55.jpg)
Patient Centered • shortening time delay in process• clinical outcomes
– LoS– QoL– complication/ adverse events
• cost of care• satisfaction levels• patient education/ knowledge about the
condition & self management
![Page 56: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/56.jpg)
Individual Clinical Staff
• job satisfaction• staff turn-over• morale & stress levels• error in delivery of care
![Page 57: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/57.jpg)
Clinical Team
• multidisciplinary working• building teamwork• communication improvements• risk managemet• development of local guideline &
protocols
![Page 58: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/58.jpg)
Others
• documentation of delivery of care• effect of computerization of
pathways• effect of variance reporting
![Page 59: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/59.jpg)
Djasri, 2010
![Page 60: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/60.jpg)
Djasri, 2010
![Page 61: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/61.jpg)
Djasri, 2010
![Page 62: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/62.jpg)
Leadership for clinical system
• Quality is never an accident ; it’s always the result of:–high intention ; –sincere effort ;– intelligent direction–skillful executions ; – it represent the wise choice of many
alternatives
![Page 63: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/63.jpg)
![Page 64: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/64.jpg)
dr. Djoti Atmodjo, Sp.B.Dr. drg. Ronie Rivany, MARS
Lampiran
![Page 65: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/65.jpg)
![Page 66: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/66.jpg)
BENTUK SPO
Panduan praktik klinis (Clinical Practice Guideline)Alur klinis (Clinical Pathways)AlgoritmeProsedurProtokolStanding Orders
![Page 67: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/67.jpg)
Djoti - Atmodjo
PENDEKATAN PENGELOLAAN PASIEN•Diagnosis kerja•Gejala
Standar pelayanan :
Panduan Praktik Klinis•Definisi•Anamnesis•Pemeriksaan fisis•Kriteria diagnosis•Diagnosis banding•Pemeriksaan penunjang•Terapi•Edukasi•Prognosis•Kepustakaan
Alur klinisAlgoritmeProtokolProsedurStanding order
S P O
dapat dilengkapi dengan
![Page 68: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/68.jpg)
![Page 69: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/69.jpg)
![Page 70: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/70.jpg)
![Page 71: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/71.jpg)
• RS wajib memp.CP, Diagnosis mengacu pada ICD-10,Prosedur mengacu pd ICD-9CM Flowchart penyusunan CP
SPM Profesi Model Dummy
SPM RS
SOP Aktivitas
ICD
Surgical Medical
DRG
Case Mix
Clinical PathwayTerukur(admission to discharge) contoh :-Diare anak-Sectio Caesaria
![Page 72: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/72.jpg)
![Page 73: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/73.jpg)
CLINICAL PATHWAYCLINICAL PATHWAY & Cost of Care& Cost of Care
SYMPTOM DIAGNOSIS THERAPY FOLLOW UP
1
Activities ABC
ActivitiesABC
ActivitiesABC
ActivitiesABC
ActivitiesABC
2 3 4 5Admission Diagnosis Pre Therapy Therapy Follow up
![Page 74: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/74.jpg)
INDONESIAN DRG’s
![Page 75: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/75.jpg)
![Page 76: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/76.jpg)
International Classification of Disease (ICD)
Major Diagnostic Categories (MDC)
Surgical / Other / Medical
Diagnosis Related Groups (DRG’s)
Casemix
Clinical Pathway
Pengembangan Konsep Clinical Pathway
![Page 77: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/77.jpg)
INDONESIAN DRG’s• Pola pikir
– ICD tetap– MDC untuk sementara tetap– Clinical Pathway bisa dibuat– DRG di konfirmasi + bisa dibuat– Casemix di konfirmasi + bisa dibuat– Costing dilakukan dengan
pendekatan Activity Based Costing + Simple Distribution
![Page 78: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/78.jpg)
POLA PIKIR INDONESIAN DRG’s (1)
INA - DRG
1.Konfirmasi DRG 2.Hitung Cost/DRG
Clinical Pathway & Casemix
Activity Based Costing
![Page 79: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/79.jpg)
POLA PIKIR INDONESIAN DRG’s (2)
ICD
MDC
DRG DRG
CASEMIX
COST
COST
DRG
TARIF
TARIF
1
2
![Page 80: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/80.jpg)
![Page 81: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/81.jpg)
Sistem Casemix
• Sistem Casemix adalah suatu cara mengelola sumber daya rumah sakit seefektif mungkin dalam memberikan layanan kesehatan yang terjangkau kepada masyarakat berdasarkan pengelompokkan spektrum diagnosis penyakit yang homogen dan prosedur tindakan yang diberikan
• Secara ringkasnya sistem casemix terdiri dari 3 komponen utama – yakni kodefikasi diagnosis(ICD 10) dan prosedur tindakan (ICD 9 CM), pembiayaan (costing ) yang dapat berupa top-down approach, activity based costing dan atau kombinasi keduanya, dan clinical pathways
![Page 82: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/82.jpg)
INA DRG
• INA DRG adalah variasi sistem casemix untuk Indonesia yang disusun berdasarkan data dari15 rumah sakit vertikal, mempergunakan ICD 10 untuk diagnosis dan ICD 9CM untuk prosedur tindakan serta biaya berdasarkan tarif yang berlaku padawaktu tersebut. Dengan berakhirnya lisensi grouper INA-DRG terhitungtanggal 30 September 2010, maka nama sitem Casemix INA-DRG berubahmenjadi INA-CBG
• Untuk saat ini INA-DRG yang disusun berdasarkan data dari 15 rumah sakit vertikal Depkes RI (tipe A, B danrumah sakit khusus) telah berhasil membuat 23 MDC (Major Diagnostic Criteria
![Page 83: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/83.jpg)
Manfaat CP
• Sebagai instrumen pelayanan berfokus kepada pasien (patient-focused care) terintegrasi, berkesinambungan dari pasien masuk dirawat sampai pulangsembuh (continuous care), jelas akan dokter/perawat penanggung jawab pasien (duty of care)
• Utilitas pemeriksaan penunjang, penggunaan obat obatan
termasuk antibiotika, prosedur tindakan operasi,
• Antisipasi kemungkinan terjadinya medical errors (laten dan aktif, nyaris terjadi maupun kejadian tidak diharapkan/KTD) dan pencegahan kemungkinan cedera (harms) serta infeksi nosokomial dalam rangka keselamatan pasien(patient safety)
![Page 84: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/84.jpg)
• Mendeteksi dini titik titik potensial berisiko selama proses layanan perawatan pasien (tracers methodology) dalam rangka manajemen risiko (risks management),
• Rencana pemulangan pasien (patient discharge)
• Upayapeningkatan mutu layanan berkesinambungan (continuous quality improvement)
• Penulusuran kinerja(performance) individu profesi maupun kelompok (team-work )
![Page 85: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/85.jpg)
![Page 86: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/86.jpg)
![Page 87: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/87.jpg)
![Page 88: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/88.jpg)
Peran Dokter• Di Indonesia pengertian klinisi masih diberikan kepada
kelompok dokter yang langsung menangani pasien (staf medik fungsional/ SMF).
• Sedangkan tim keseluruhan dokter dan profesi lain sering disebut sebagai pelaksana pelayanan klinis (PPK)
• Persamaan/kesetaraan profesi ini merupakan suatu perubahan yang dapat memberikan dampak kepada pasien ataupun kepada para dokter sebagai profesi yang tertua.
• Diperlukan suatu perubahan persepsi bagi para dokter tentang hubungan baru dengan para profesional lainnya.
![Page 89: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/89.jpg)
• Namun demikian dokter akan tetap sebagai pemimpin bukan dalam bentuk hirarchical tetapi sebagai ketua tim (playing captain) di antara sesama profesi yang sederajat (the clinician)
![Page 90: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/90.jpg)
Seorang dokter harus bersikap dan bertindak sebagai orang pertama diantara profesional yang sederajat, dengan demikian dituntut suatu kepemimpinan yang demokratik di dalam suatu tim profesional.
PRIMUS INTER PARESFirst Among Equals
![Page 91: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/91.jpg)
Untuk itu diperlukan:1. Kompetensi2. Etika3. Karakter4. Empati5. Inspiring ability6. Membangun semangat dan
kerjasama tim7. Conflict resolution
Sifat-sifat diatas tentunya juga harus dimiliki oleh seluruh anggota-anggota tim, sehingga terbangun sebuah kerja sama tim (team work) yang efisien.
![Page 92: Clinical Pathway Merita](https://reader033.vdocuments.mx/reader033/viewer/2022061412/577c815e1a28abe054ac9142/html5/thumbnails/92.jpg)
Maturnuwun