DEVELOPMENT MODEL OF QUALITY NURSING CARE

By: Dr.Nursalam, M.Nurs (Hons) Senior lectur, hospital nursing manager

Airlangga University

(*)

Nursalam-07

"This is the beginning of a new day. You have been given this day to use as you will.

You can waste it or use it for good. What you do today is important because you are

exchanging a day of your life for it.

When tomorrow comes, this day will be gone forever; in its place is something that you have left behind . . . let

it be something better"

[Anonymous]

Diambil dari – Softskill DIKTI

OUR FUTURE

3

2. Why?

1. What?

3. How?

WHY &

WHAT

World Class Healthcare Experience

EBN-M - PICOT

1. QUALITY

ETHIIC: JABVC

2. PATIENT SAFETY

3. LEGAL

KPRS-2011

1 QUALITY

World Class Healthcare Experience

UU 44/2009 Pasal 29 - QUALITY

Setiap Rumah Sakit mempunyai kewajiban :

b. memberi pelayanan kesehatan yang aman, bermutu (QUALITY), antidiskriminasi, dan efektif dengan mengutamakan kepentingan pasien sesuai dengan standar pelayanan Rumah Sakit;

g. membuat, melaksanakan, dan menjaga standar mutu pelayanan kesehatan di Rumah Sakit sebagai acuan dalam melayani pasien;

FOCUS INTERNATIONAL STANDARD :

JOINT COMMISSION INTERNATIONAL ACCREDITATION

(2012)

1. PATIENT CENTER (STANDAR PELAYANAN BERFOKUS

PADA PASIEN)

2. PATIENT SAFETY IS A KEY PROGRAM AND FOCUS

(KESELAMATAN PASIEN MENJADI PROGRAM DAN

SASARAN UTAMA)

3. EFFORT ON IMPLEMENTATION FOR ACHIEVEMENT OF

QUALITY (SURVEI AKREDITASI DITUJUKAN UNTUK

MENCARI BUKTI BUKTI PENERAPAN UPAYA

PENINGKATAN MUTU DAN KESELAMATAN PASIEN

4. MANAGEMENT STANDARD IS TO SUPPORT PATIENT

SERVICE (STANDAR MANAJEMEN RS DITUJUKAN

MENDUKUNG PELAYANAN PASIEN)

5. CONTINUITY OF THE SERVICE (KESINAMBUNGAN

PELAYANAN)

STANDARDS JCI

Patient-Centered Standards

1. International Patient Safety Goals (IPSG)

2. Access to Care and Continuity of Care ( ACC )

3. Patient and Family Rights ( PFR )

4. Assessment of Patients ( AOP )

5. Care of Patients ( COP )

6. Anesthesia and Surgical Care

( ASC )

7. Medication Management and Use (MMU )

8. Patient and Family Education (PFE)

Health Care Organization and

Management Standards

9. Quality Improvement and

Patient Safety ( QPS )

10. Prevention and Control of

Infections ( PCI )

11. Governance, Leadership, and

Direction ( GLD )

12. Facility Management and Safety

( FMS )

13. Staff Qualifications and

Education ( SQE )

14. Management of Communication

and Information ( MCI )

PATIENT-CENTERED STANDARDS

1. Access to Care and Continuity of Care

( ACC )

1. Patient and Family Rights ( PFR )

2. Assessment of Patients ( AOP )

3. Care of Patients ( COP )

4. Anesthesia and Surgical Care ( ASC )

5. Medication Management and Use ( MMU )

6. Patient and Family Education ( PFE )

Commite for

nurse clinical

practice

• Review & Revise Policy

and Procedur

• Training and Socialisation

• Obs sftaf obidience

• Clinical teaching

• Cross audit

NURSING CONTRIBUTION

PROGRAM

1. PREVENTION AND CONTROL OF INFECTION

2. FACILITY MANAGEMENT SYSTEM

3. GOVERNANCE, LEADERSHIP, AND DIRECTION

4. STAFF QUALIFICATION AND EDUCATION

5. MANAGEMENT OF COMMUNICATION AND INFORMATION

6. EVIDENCE BASED PRACITCE

11

Copyright ©2004 BMJ Publishing Group Ltd.

Thompson, C. et al. Evid Based Nurs 2004;7:68-72

EVIDENCE BASE IN NURSING

P-I-C-O-T

PATIENT

INTERVENTION

COMPARISON

OUTCOME

TIME

13

What ?

14

CATEGORIES OF RISK IN THE

HOSPITAL

Patient care-related risks

Medical staff-related risks

Employee-related risks

Property-related risks

Financial risks

Other risks

Nursalam-07

PATIENT SAFETY 1. MEDICATION ERROR

2. PATIENT FALLS

3. BED SORE

4. PLEBITIS

5. RESTRAINS

2

Hospital

Safety

of

The

Patient of

The

Health Care

Worker

of

The

Facilities

of

The

Environment

of

The

Business

Scope of Hospital Risk Management (revised) :

17

Quality in Healthcare

…. begins with ensuring patient safety

KPRS-2010

Prosces of Care

Error

Patient

Not Injury

Injury

Near Miss

Adverse Event

-Kesalahan proses

-Dpt dicegah

-Pelaks Plan action

tdk komplit

- Plan action yg salah

-commission & omission

(NM)

(AE)

Proces of Care (Non Error)

Adverse Event patient

injury

(KTD=Kejadian Tdk Diharapkan)/

Sentinel

- Dpt obat “c.i.”, tdk timbul (chance)

- Plan, diket, dibatalkan (prevention)

- Dpt obat “c.i.”, diket, beri anti-nya

(mitigation)

(KNC=Kejadian NYARIS CIDERA)

PATIENT SAFETY

nursalam -2006

INDICATORS - D4

Nurse had specific professional duty to patient

(D1-duty)

Nurse did not carry out his/her duty

(D2- direlection)

Nurse caused injury to his/her patient

(D3 – Damage)

The patient’s injury resulted from the nurse’s

negligent action (D4- Direct Causation)

PATIENT SAFETY STANARD - FOCUS

Focus I PATIENT IDENTITY (Ketepatan identifikasi pasien)

Focus II DEV. EFFECTIVENESS OF COMMUNICATION

(Peningkatan komunikasi yang efektif)

Focus III DEV. SAFETY DRUG (Peningkatan keamanan obat

yang perlu diwaspadai high-alert)

Focus lV 6 RIGHT IN MEDICATION (patient, time, dosage,

method, drug, documentation)

Focus V REDUCE RISK OF INFECTION (Pengurangan

risiko infeksi terkait pelayanan kesehatan)

Focus VI REDUCE RISK FOR PATIENT FALL

(Pengurangan risiko pasien jatuh)

PERATURAN MENTERI KESEHATAN REPUBLIK

INDONESIA NOMOR 1691/MENKES/PER/VIII/2011

Djoti A

FOCUS I : PATIENT IDENTIFICATION

Djoti A

ALLERGY : GELANG MERAH

22 Djoti A

FOCUS II : IMPROVE AN EFFECTIVENESS

OF COMMUNICATIONS

Djoti A

ATTENTION

Order by oral

Order via Telphone

Report from examination

So – order Via oral &

telephone Write back

Read Back

Repeat Back

(Reconfirm)

Djoti A

LASA (LOOK ALIKE SOUND ALIKE)

NORUM ( NAMA OBAT RUPA MIRIP) • hidraALAzine

• ceREBYx

• vinBLASTine

• chlorproPAMIDE

• glipiZIde

• DAUNOrubicine

hidrOXYzine

ceLEBRex

vinCRIStine

chlorproMAZINE

glYBURIde

dOXOrubicine

Djoti A

FOCUS III : HIGH-ALERT FOR DRUG)

Look alike

Djoti A

FOCUS IV : 6 RIGHT

PATIENT, DRUG,

DOSAGE,TIME ...........

DOCUMMENTATION

Djoti A

FOCUS V :

REDUCE RISK OF INFECTION

Djoti A

FOCUS VI :

REDUCE RISK PATIENT FALL

Djoti A

3 LAW

World Class Healthcare Experience

KPRS-2011

CODE ETHICS

PATIENT

PRACTICE

J-A-B-V-C

SUPPORT - KESMAS

GOOD RELATIONSHIP COLLEAGUES

NURSING ETHICS &

UU NO 44/2009 (HOSPITAL)

COMMUNITY

PROFESSION

R-A-A

COMMITMENT – VALUE

HOW

TO IMPROVE

QUALITY

World Class Healthcare Experience

“The world is a dangerous place to live; not because of the people who are evil, but

because of the people who don't

do anything about it.“

(Albert Einstein)

HOSPTAL

”OLD” CHANGE

FUTURE HOSPITAL

“DIFFERENT”

21 CENTURY

WORLD CLASS

INTERNATIONAL

ACREDITATION

EXTERNAL

INTERNAL

POOR ORGANIZATION - NEVER

CHANGE

GOOD ORGANIZATION - REACT

QUICKLY TO CHANGE

EXCELLENT ORGANIZATION -

CREATE CHANGE

VISSION &

MISSION

DIKMAN -5/14/2012 36

VISSION NOW

MAN METHOD MATERIAL

MONEY ENVIRONMENT

WHICH ONE SHOULD BE CHANGED FIRST?

MAN:

P: Permission

T: Thanks

E: Excuse

37

GOOD GENTLEMAN

1. High Integrity

2. For thier jobs:

a.Loyality

b. Dedication

c.Prestation

d. Good attitude

4. FINANCIAL

3.

CUSTOMER

2. SERVICE:

Internal Business

Process

1. SDM:

Learning and

Growth

HUMAN CAPITAL

- A: Attitude

- K: knowledge

- S: skill

- I: insight

INFORMATION CAPITAL

- System

- Database

- Information Technology

ORGANIZATION CAPITAL

- Culture

- Leadership

- Alignment

- Teamwork

- Mindset

Innovation

Processes Customer

Management

Processes

Operation

Management

Processes

Customer

Value

Proposition

BSC-RSPHC

4 NURSING CARE

DELIVERY (NCD)

World Class Healthcare Experience

DEVELOPMENT MODEL OF QUALITY

(Kopelman,1986) Organisational characteristic

-Reward system

Goal setting and MBO

Selection

Training and development

Leadership

Organization structure

Environment

Performance(P)= (Efforts (E) + Achievement (A)

Job Performance

caring

Nurse characteristic

Knowledge,

Skills,

Ability,

Motivation

Attitudes

Value & Norm

Patient satisfaction and loyality

Work behavior

NCD (MAKP)

Objective performance

Feedback

Correction

Job design

Work schedule

Work characteristic

Quality dimension-

RATER

1. RELIABILITY

2. ASSURANCE

3. TANGIBLES

4. EMPHATY

5. RESPONSIVENESS

-INDICATOR (Indonesia)

1.Patient safety

2. . Patient Satisfaction&

Loyality

3.Sellf care

4. Comfortability

5. Anxiety

6. Knowledge - DP

“ Act as a Leader, not a Manager,

Stop Managing, Start Leading !”

( Robert Flater : “Jack Welch and GE Way” )

LEADER, AS CHANGE AGENT, NOT LOOK FOR POSITION

BUT AN ACTION! (RSU Haji Surabaya)

GOOD LEADER : do the right things

GOOD MANAGER : do the things right

Type of Situasional Leadership

(Hersey dan Blanchard )

H1.NS,Koef 0,189

H2. S, Koef 0,889

H3.1.S, Koef 0,845

H3.2.S, Koef 0,818

H.4,NS, Koef 0.152 H3.3.S, Koef 0,833

H3.3.4 ,Koef 0,736

NURSE CHARACTERISTIC

(X3)

ORGANISATIONAL

CHARACTERISTIC

(X1)

WORK CHARACTERISTIC

(X2)

PATIENT

SATISFACTION

(Y3.2)

NURSE

SATISFACTION

(Y3.1)

STANADAR KINERJA

(Y2)

STANDAR ASKEP

(Y1)

CARE

(Y2)

NURSING

CARE -

DELIVERY

(Y1)

MODEL - RESEARCH

MUHITH (2012)

Aims

Improve quality of nursing care

Streamline and facilitate co-ordination of care

Facilitate effective discharge planning and patient

education

Manage and optimize patient length of stay

Improve communication process

MANAGING NURSING CARE

DELIVERY SYSTEM

MODEL MAKP

Ward-Based Case Management

45

“It’s easy gettin’ good players.

The hard part is gettin’ them to play

with each other”

(Casey Stengel)

(Casey

nursalam -2006

ELEMENTS OF NCD

Clinical decision making

Work allocation

Communication

Management

Coordination

(Huber, 2006: 317)

CONDITIONS OF NCD IMPLEMENTATION

SFF Matrix (Example) :

SUITABILITY FEASIBILITY FLEXIBILITY TOTAL

Alternative A 1 1 3 5

Alternative B 3 2 1 6

Alternative C 3 3 2

Alternative D 2 2 1 5

8

Rate each alternative on scale of 1 – 3 for its

Suitability: whether the alternative is ethical or pratical. Is it appropriate in

scale or importance? An adequate response? Too extreme?

Feasibility: how many resources will be needed to solve the problem, how

likely will it solve the problem, How likely will it solve the problem?

Flexibility: ability to respond to unintended consequences, or opennes to new

possibilities?

Nursalam-07

C-A-R-L C: CAPABILITY

A: ACCESSIBILITY

R: RELEVANCY

L: LEGALITY

1. NCD

2. HAND OVER

3. NURSING ROUND

4. LOGISTIC AND DRUG

5. DISCHARGE PLANNING & PATIENT

ADMISSION

6. SUPERVISION

7. DOCUMMENTATION

SCOPE of MAKP

PRIMARY MODEL

MD NUM

RESOURCES

Primary Nurse

PATIENT

ASSOCIATE

NURSE

ASSOCIATE

NURSE

ASSOCIATE

NURSE

WORK LOAD & ALLOCATION

(FORMULA???? TIME & MOTION!

MAN

Nursalam-07

QUALITY INDICATORS 1.Patient safety

2. Patient Satisfaction

3. Self care

4. Comfortability

5. Anxiety

6. Knowledge

Nursalam-07

a PATIENT SAFETY 1. MEDICATION ERROR

2. PATIENT FALLS

3. DICUBITUS

4. FLEBITIS

a. MEDICATION ERROR

① PRESCRIBING

② ADMINISTERING

③ MONITORING - SAVING

b. PATIENT FALL – MFS (Morse

Fall Scale)

NURSE NEGLIGENT

PATIENT AWARENESS

WORK LOAD (PENGHITUNGAN – TIME

MOTION STUDY, WORK SAMPLING, DAILY LOG)

MODEL - BED

c

BED SORE (SCALE NORTON)

PHYSICAL

MENTAL

ACTIVITY

MOBILITY

INCONTINENCE

d.

FLEBITIS –

VIP (VISUAL INFUSION PHLEBITIS)

-MECHANICAL

BACTERIAL

CHEMICAL - DRUG

CAUSES

Nursalam-07

2

PATIENT SATISFACTION R-A-T-E-R

RELIABILITY – ASSURANCE-

TANGIBLES – EMPHATY -

RESPONSIVENES (Parasuraman)

Nursalam-07

3

SELF – CARE (katz)

Nursalam-07

4 CONFORTABILITY

(Visual Aid Scale)

Nursalam-07

5

ANXIETY Zung Self-Rating Anxiety Scale ( SAS / SRAS (Ian mcdowell, 2006)

Rentang penilaian 20-80, dengan pengelompokan sbb:

Skor 20 - 44 normal/tidak cemas

Skor 45-59 Kecemasan ringan

Skor 60-74 Kecemasan sedang

Skor 75-80 kecemasan berat

Nursalam-07

6 PATIENT KNOWLEDGE

(HBM , DP, PPB)

Nursalam-07

CONCLUSION – why NCD

• Accredation

• ISO 9001 : 2000

• Up-date sciences

• Good Corporate Governance

• Clinical Governance

• Strategy allience

• Financial

• Service orientation

• Business orientation

• Ethical

Nursalam-Unair-2012

MODEL INTEGRATED QUALITY IMPROVEMENT PROGRAM

(IQIP) IN PATIENTCARE

NURSES

NURSING CARE

STANDAR

Level 1

PATIENT CARE

BY OTHER HEALTH TEAM

LITTLE THINGS

PATIENT &

FAMILY SATISFACTION

SOLUTION PROB. SOLVING

NURSING COMMITTEE . SAK; SISTEM; ETIK; KULITAS;

DIKLAT & LITBANG; SKF

NON-CONFORMANCE? INPUT DATA

SOLUTION

INSTITUTIONS –

NURSING DEPT.

QUALITY

MONITOR TEAM

PROB. SOLVING

Level 2