A to Z Manajemen Mutu di RS

Manajemen Mutu RS
Lecture # 5
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 propinsi
and 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 :

I. Non operative indicator

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

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,
preeclampsia, eclampsia, sepsis)



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 services
2. services  12 services
3. 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
0

medical services standard is not available (no standard)

Few unwritten standard in medical services

There are unwritten standard describe all medical
services
There are written standard describe all medical services
but have not approved by management
There are written standard describe all medical services
and approved by management
There are written standard describe all medical services,
and conducted the evaluation and follow up the result
by management

2
3
4

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 6575%. Note: no services get score < 60 %.

3. Full accreditation
hospital meets the standar
total score > 75%
No services get score < 60%
 3 years

4. Special accreditation
hospital meets full standard for 3 periode
 5 years.

Thank you

See you in next presentation..