Failure Mode and Effect Analysis

Herkutanto
 Herkutanto

KETUA KOMITE KESELAMATAN PASIEN

KETUA KONSIL KEDOKTERAN, KKI
Guru Besar Fakultas Kedokteran Universitas Indonesia

HERKUTANTO 2
ALASAN UTAMA MELAKUKAN REGULASI

(Schellekens, W : Patient Safety Conference,

European Union Presidency Luxembourg, 4 5 April 2005)
TUJUAN PAPARAN
Strategi
Pengendalian Risiko
melalui FMEA

Mengenal langkah2
Failure Mode and
Effect Analysis
HERKUTANTO 4
 KUALITAS PELAYANAN
(Donabedian)

OUTCOME

PROCESS
PRO CESS

STRUCTURE

HERKUTANTO 5
HERKUTANTO 6
SUMBER

HERKUTANTO 7
 SISTIMATIKA PAPARAN

INTRODUKSI FMEA

DELAPAN LANGKAH FMEA

KESIMPULAN
HERKUTANTO 8
INTRODUKSI FMEA & HFMEA

HERKUTANTO 9
 What is FMEA ?
Adalah metode perbaikan kinerja dgn
mengidentifikasi dan mencegah potensi
kegagalan sebelum terjadi. Hal tersebut
didesain untuk meningkatkan keselamatan
pasien.

Adalah proses proaktif, dimana kesalahan

dpt dicegah & diprediksi. Mengantisipasi
kesalahan akan meminimalkan dampak buruk

HERKUTANTO 10
 What is HFMEA ?
Modified by VA NCPS

Focus on preventing defects, enhancing safety, increase

positive outcome and increase patient satisfaction

The objective is to look for all ways for process can fail

The famous question : What is could happen?

Not What does happen ?

Hybrid prospective analysis model combines concepts :

FMEA (Failure Mode and Effects Analysis)
HACCP (Hazard Analysis Critical Control Points)
RCA (Root Cause Analysis)

HERKUTANTO 11
 FMEA Terminology
Process FMEA - Conduct an FMEA on a
process that is already in place

Design FMEA Conduct an FMEA before

a process is put into place
Implementing an electronic medical records or
other automated systems
Purchasing new equipment
Redesigning Emergency Room, Operating
Room, Floor, etc.
HERKUTANTO 12
 FAILURE MODE AND EFFECTS ANALYSIS

FAILURE (F) : When a system or part of a system

performs in a way that is not
intended or desirable
MODE (M) : The way or manner in which
something such as a failure can
happen.. Failure mode is the
happen
manner in which something can
fail.
EFFECTS (E) : The results or consequences of a
failure mode
Analysis (A) : The detailed examination of the
elements or structure of a process
HERKUTANTO 13
 Why should my organization
conduct an FMEA ?
Can prevent errors & nearmisses protecting
patients from harm.
Can increase the effectiveness & efficiency of
process
Taking a proactive approach to patient safety
also makes good business sense in a health
care environment that is increasingly facing
demands from consumers, regulators & payers
to create culture focused on reducing risk &
increasing accountability
HERKUTANTO 14
 Where did FMEA come from ?
FMEA has been around for over 30 years
Recently gained widespread appeal
outside of safety area
New to healthcare
Frequently used reliability & system safety
analysis techniques
Long industry track record

HERKUTANTO 15
DELAPAN LANGKAH FMEA

HERKUTANTO 16
 LANGKAH-LANGKAH
LANGKAH-
ANALISIS MODUS KEGAGALAN & DAMPAKNYA
DAMPAKNYA
(JCI )

1. Tetapkan Topik FMEA dan Bentuk Tim

2. Gambarkan Alur Proses
3. Identifikas Modus Kegagalan & Dampak
Dampaknya
nya (Hazard Analysis)
4. Identifikas Prioritas Modus Kegagalan
Kegagalan
5. Identifikasi Akar Penyebab Modus Kegagalan
Kegagalan
6. Disain ulang Proses
7. Analisis dan Test Proses Baru
8. Implementasi dan Monitor Proses Baru
HERKUTANTO 17
 Output setiap langkah
LANGKAH OUTPUT
1 Tetapkan Topik FMEA dan Bentuk Tim Topik dan Tim
2 Gambarkan Alur Proses Alur Proses tergambar
3 Identifikasi Modus Kegagalan & Modus Kegagalan &
Dampaknya Dampaknya

4 Tetapkan Prioritas Modus Kegagalan Daftar Prioritas Modus

Kegagalan
5 Identifikasi Akar Penyebab Modus Akar Penyebab
Kegagalan Modus Kegagalan

6 Disain ulang Proses Proses Baru

7 Analisis dan Uji Coba Proses Baru Hasil Uji COba
8 Implementasi dan Monitor Proses Baru Penerapan Proses Baru
HERKUTANTO 18
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus

1 Kegagalan &
Dampaknya
4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang
Proses
TETAPKAN TOPIK & TIM 7 Analisis dan Uji
Coba Proses
Baru
8 Implementasi dan
HERKUTANTO
Monitor Proses
19

Baru
 TUJUAN & HASIL

Terpilihnya Topik FMEA

Terpilihnya TIM Pelaksana untuk topik

tersebut

Daftar Tim

HERKUTANTO 20
 PEMILIHAN TOPIK FMEA
Proses spesifik di rumah sakit:
Highrisk
Highvolume
highcost

Didasarkan pada data incident report

keselamatan pasien
Data rutin keselamatan pasien
Sentinel event

HERKUTANTO 21
 TUJUAN PEMILIHAN TOPIK
Fokus pada proses spesifik yang dianggap
prioritas (hospital
(hospital specific)
specific)
Melakukan tindakan korektif pada proses
melalui redesign proses
Contoh:
Proses pelayanan Transfusi darah
Proses pemberian obat kepada pasien

HERKUTANTO 22
 Characteristic of a high risk process
Variable team

Complex

Non standardized

Tightly coupled

Heavily dependent on human intervention

Hierarchical vs team

Tight time constraints

Loose time constraints HERKUTANTO 23

 LANGKAH 1 : PILIH PROSES YANG BERISIKO TINGGI

Pilih Proses berisiko tinggi yang akan dianalisa.

Judul Proses :
__________________________________________________________________________
_________________________________________________________
_________________________________________________________
LANGKAH 2 : BENTUK TIM

Ketua :
____________________________________________________________

Anggota 1. _______________ 4.
________________________________________
2. _______________ 5.
________________________________________
3. _______________ 6.
________________________________________

Notulen? _________________________________________
Apakah semua Unit yang terkait dalam Proses sudah terwakili ? YA / TIDAK
Tanggal dimulai ____________________ Tanggal selesai ___________________

HERKUTANTO 24
 TIME LINE AND TEAM ACTIVITIES

Premeeting Identify Topic and notivy the team (Step 1 & 2)

1st team meeting Diagram the process, identify subprocess, verify the scope
2rd team meeting Visit the worksite to observe the process, verify that all process &
subprocess steps are correct (Step 3)
3 rd team meeting Brainstorming failure modes, assign individual team members to
consult with process users (Step 3)
4rd team meeting Identify failure modes causes, assign individual team members to
consult with process users for additional input (Step 3)
5th team meeting Transfer FM & Causes to the HFMEA Worksheet (Step3). Begin the
hazard analysis (Step 4)
Identify corrective actios and assign follow up responsibilities (Step 5)
6th,7th , 8th. team Assign team members to follow up individual charged with taking
meeting plus 1 corrective action
team meeting plus 2 Refine corrective actions based on feedback
team meeting plus 3 Test the proposed changes
team meeting plus 4 Meet with Top Management to obtain approval for all actions
Postteam meeting The advisor or his/ her designee follow up until all actions are
completed
HERKUTANTO 25
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus

2 Kegagalan &
Dampaknya
4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang
Proses
Gambarkan Alur Proses 7 Analisis dan Uji
Coba Proses
Baru
8 Implementasi dan
HERKUTANTO
Monitor Proses
26

Baru
 TUJUAN & HASIL

Tergambarnya alur / langkah2 PROSES

dan SUBPROSES pelayanan yang dipilih
dalam suatu bagan yang jelas
LEMBAR ALUR
PROSES dan SUBPROSES PELAYANAN
ELAYANAN

HERKUTANTO 27
HERKUTANTO 28
HERKUTANTO 29
HERKUTANTO 30
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus
Kegagalan &
3 Dampaknya

4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan

Identifikasi 6 Disain ulang Proses

7 Analisis dan Uji Coba

Modus Kegagalan & Proses Baru

Dampaknya 8 Implementasi dan

HERKUTANTO Monitor Proses31Baru
 TUJUAN & HASIL

1. Teridentifikasinya MODUS KEGAGALAN

pada setiap langkah proses pelayanan

2. Teridentifikasinya DAMPAK KEGAGALAN

pada setiap langkah proses pelayanan

HERKUTANTO 32
 HAZARD vs RISK vs.
COMPLICATIONS
1. A hazard is something that can cause harm, e.g. electricity, chemicals,
working up a ladder, noise, a keyboard, a bully at work, stress, etc. [...
tindakan medik ...??]
...??]
2. Complication
Complicationss are things that happen as a result of a disease or a
treatment that you prefer didn't happen [stroke from hypertension,
hypertension, or
bleeding following surgery]
surgery]
A complication may be described as an adverse event caused by pre- pre-
existing factors that were outside the doctors control.
control. Patients are not the
same in health, habits, immunity or healing power, and have varying susceptibility
to complications
3. A risk is the chance, high or low, that any hazard will actually cause
somebody harm.
harm.
Risk factors are things that make it more likely that you will develop a
disease or condition. They may be things you can't do anything about,
about,
like gender, family history, or race, or things you can control,
control, like smoking
and diet. HERKUTANTO 33
DIFFERENCES BETWEEN RISKS vs COMPLICATIONS

RISKS COMPLICATIONS
Allergy Anaphylactic Rx

Leucocytosis Sepsis

Bleeding Hypovolemic shock

Fragile tissues Tissue damage

Naucea / vomit Hyponatraemia

HERKUTANTO 34
 Hazard analysis: What is it?

Hazard: Potentially dangerous condition,

which is triggered by an event,
event,
called the cause of the hazard.
hazard.

Risk: hazard that is associated with a

severity and a probability of
occurrence..
occurrence
HERKUTANTO 35
Hazard, Barrier, Target Analysis

Hazard Barrier Target

High
Dog Fence Child

HERKUTANTO 36
HERKUTANTO 37
HERKUTANTO 38
HERKUTANTO 39
HERKUTANTO 40
HERKUTANTO 41
Hazard, Barrier, Target Analysis

Hazard Barrier Target

Medical Policies
Procedures Patient
Mishaps

HERKUTANTO 42
 PENERAPAN HBA PADA FMEA
Prinsip:: the DEVILS are in the DETAILS
Prinsip

Cari modus / cara suatu langkah dalam

suatu subproses dapat gagal

HERKUTANTO 43
 DIAGRAM THE PROCESS

PROCESS STEPS :
Describe the process graphically, according to your policy & procedure for the activity and number each one
If the process is complex you may want to select one process step or sub process to work on

1 2 3 4 5

Prescribing, Preparing
Selection & Storage
Ordering, &
Procurement Administration
Trancribing Dispensin
g

Failure Mode Failure Mode Failure Mode Failure Mode Failure Mode

Pemesanan obat Penyimpanan Penulisan obat Peracikan obat Wrong drug

Berlebihan (tdk vaksin tdk dlm R/ tdk jls tdk sesuai dosis
Sesuai kebthn
kebthn)) sesuai suhunya
Wrong dosage

Penulisan Obat R/
tdk R/
Dlm formularium Wrong frequence

Wrong route
administration

HERKUTANTO 44
 Hazard analysis: What is it?

Hazard analysis
analysis:: Identify all possible
hazards potentially created by a
product, process or application
application..

Risk assessment
assessment:: It is the next step
after the collection of potential
hazards.. Risk in this context is the
hazards
probability and severity of the hazard
HERKUTANTO 45

becoming reality
reality..
 Hazard analysis: What is it?

General risk assessment

protocol : Establish Analysis Parameters

Identify Hazards

Assess Risks

Derive Risk Rating

Reduce Risks

Verify Effectiveness

HERKUTANTO 46
Document Results
 Hazard analysis: What is it?

Establish Analysis Parameters

Identify Hazards These parameters can

be limits of the
Assess Risks
machine or design,
Derive Risk Rating limits on uses, limits
Reduce Risks
on the scope of the
analysis, or other
Verify Effectiveness
limits.
Document Results HERKUTANTO 47
 Hazard analysis: What is it?

Establish Analysis Parameters

Identify Hazards The nature of this

step lends itself to a
Assess Risks
team approach such
Derive Risk Rating as brainstorming.
Reduce Risks

Verify Effectiveness

Document Results HERKUTANTO 48

 Hazard analysis: What is it?

Establish Analysis Parameters

Identify Hazards
Two risk factors are used:
Assess Risks
severity of injury
Derive Risk Rating
probability of occurrence
Reduce Risks

Verify Effectiveness

Document Results HERKUTANTO 49

 Hazard analysis: What is it?

Establish Analysis Parameters

Risk matrix:
Identify Hazards Severity Category
Probability Level Catastrophic Critical Marginal Negligible
Assess Risks Frequent High High Serious Serious
Probable High High Serious Low
Derive Risk Rating Occasional High Serious Low Low
Remote Serious Low Low Low
Reduce Risks Improbable Serious Low Low Low

If the risk is determined to not be acceptable, it

Verify Effectiveness
is necessary to reduce that risk by
implementing protective measures.
Document Results HERKUTANTO 50
 Hazard analysis: What is it?

Establish Analysis Parameters

Remedy actions are taken to
Identify Hazards reduce risks following the
hazard hierarchy:
Assess Risks
Eliminate hazards through the design
Derive Risk Rating Protect
Warn the user
Reduce Risks
Train the user(s)
Personal protective equipment
Verify Effectiveness

Document Results HERKUTANTO 51

 Hazard analysis: What is it?

Establish Analysis Parameters

Identify Hazards This assessment

verifies that the
Assess Risks
remedy actions have
Derive Risk Rating reduced the risks to an
Reduce Risks
acceptable level.

Verify Effectiveness

Document Results HERKUTANTO 52

 Hazard analysis: What is it?

Establish Analysis Parameters

Identify Hazards

Assess Risks

Derive Risk Rating

Reduce Risks The documentation can be added to a

technical file for future use.

Verify Effectiveness

Document Results HERKUTANTO 53

 Full Hazard Analysis
Proactive Controls Reactive Controls

Recovery People
Threat Barrier Barrier Measures

Recovery Asset
Threat Barrier Barrier Measures Damage
Hazard Top Event
(Incident)
Recovery Environment
Threat Barrier Barrier Measures

Recovery
Measures Reputation
Escalation
controls

HERKUTANTO 54
 Completed Hazards & Effects Register

HAZARDS & EFFECTS REGISTER

Risk
Hazard ThreatsBarriers Top Recovery Consequences Rating Initial Final Remedial
Event Measures Risk Risk Action
P A E R Required

C5
X X X X X X X X X X D4,5 X
E3,4,5

X X X X X X X X

C5
X X X X X X X X X X D4,5
E3,4,5

X X X X X X X X X
HERKUTANTO 55
HERKUTANTO 56
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim

2 Gambarkan Alur
Proses

3 Identifikasi Modus

4 Kegagalan &
Dampaknya

4 Tetapkan Prioritas
Modus Kegagalan

5 Identifikasi Akar
Penyebab Modus
Kegagalan

6 Disain ulang Proses

Tetapkan Prioritas 7 Analisis dan Uji Coba
Modus Kegagalan Proses Baru

8 Implementasi dan
Monitor Proses Baru
HERKUTANTO 57
 TUJUAN & HASIL

Tersedianya urutan prioritas

DAFTAR PRIORITAS MODUS

KEGAGALAN

HERKUTANTO 58
HERKUTANTO 59
 ANALISIS HAZARD LEVEL DAMPAK
DAMPA MINOR MODERAT MAYOR KATASTROPIK
K 1 2 3 4
Kegagalan yang tidak Kegagalan dapat Kegagalan Kegagalan menyebabkan
mengganggu Proses mempengaruhi menyebabkan kerugian kerugian besar
pelayanan kepada proses dan berat
Pasien menimbulkan
kerugian ringan
Pasien Tidak ada cedera, Cedera ringan Cedera luas / berat Kematian
Tidak ada Ada Perpanjangan Perpanjangan hari Kehilangan fungsi tubuh
perpanjangan hari rawat rawat secara permanent (sensorik,
hari rawat lebih lama (+> 1 bln) motorik, psikologik atau
Berkurangnya fungsi intelektual) mis :
permanen organ tubuh Operasi pada bagian atau
(sensorik / motorik / pada pasien yang salah,
psikcologik / Tertukarnya bayi
intelektual)

Pengunj Tidak ada cedera Cedera ringan Cedera luas / berat Kematian
ung Tidak ada Ada Penanganan Perlu dirawat Terjadipada > 6 orang
penanganan ringan Terjadi pada 4 -6 pengunjung
Terjadi pada 1-
1-2 org Terjadi pada 2 -4 orang
pengunjung pengunjung pengunjung
Staf: Tidak ada cedera Cedera ringan Cedera luas / berat Kematian
Tidak ada Ada Penanganan / Perlu dirawat Perawatan > 6 staf
penanganan Tindakan Kehilangan waktu /
HERKUTANTO 60
Terjadi pada 1-
1-2 staf Kehilangan waktu kecelakaan kerja pada
Tidak ada kerugian / kec kerja : 2-
2 -4 4-6 staf
waktu / keckerja staf
 ANALISIS HAZARD LEVEL PROBABILITAS

LEVEL DESKRIPSI CONTOH

4 Sering (Frequent) Hampir sering muncul dalam waktu yang
relative singkat (mungkin terjadi
beberapa kali dalam 1 tahun)

3 Kadang-kadang
Kadang- Kemungkinan akan muncul
(Occasional) (dapat terjadi bebearapa kali dalam 1
sampai 2 tahun)

2 Jarang (Uncommon) Kemungkinan akan muncul

(dapat terjadi dalam >2 sampai 5 tahun)
1 Hampir Tidak Pernah Jarang sekali terjadi (dapat terjadi dalam
(Remote) > 5 sampai 30 tahun)

HERKUTANTO 61
 HAZARD SCORE
TINGKAT BAHAYA
KATASTROPIK MAYOR MODERAT MINOR
4 3 2 1
SERING 16 12 8 4
4
KADANG 12 9 6 3
3
JARANG 8 6 4 2
2
HAMPIR TIDAK 4 3 2 1
PERNAH
1

HERKUTANTO 62
HERKUTANTO 63
HERKUTANTO 64
Laboratory Test Ordering Process

HERKUTANTO 65
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus

5 Kegagalan &
Dampaknya
4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang
Identifikasi Akar Penyebab Proses
7 Analisis dan Uji
Modus Kegagalan Coba Proses
Baru
8 Implementasi dan
HERKUTANTO
Monitor Proses
66

Baru
 TUJUAN & HASIL

Teridentifikasinya AKAR PENYEBAB

modus kegagalan yang telah teridentifikasi

Lembar AKAR PENYEBAB

HERKUTANTO 67
 Possible Characteristics of Root
Causes

Root causes are systemic

systemic..

Root causes appear far from the origin of

the failure.
failure.

The origins of root causes lie in common

common--
cause variation of organization systems
HERKUTANTO 68
 many of the failure modes
had the same root causes
Omission errors secondary to automatic stop order
Suboptimal patient involvement in medication histories
Suboptimal medication reconciliation by clinicians
Confusing epidural and patient-
patient-controlled analgesia
order sets
Lack of electronic medication administration record
Lack of computerized order entry

HERKUTANTO 69
 PROBING
to uncover root causes and their relationships

What could happen? (the failure mode)

mode)
Why could this happen?
That is, what are the most proximate causes?
causes? These
typically involve special-
special-cause variations.

Why could these proximate causes happen?

That is, what systems and processes underlie those
proximate causes?
causes?
Common--cause variation here may lead to special
Common special--
cause variation in dependent processes.
HERKUTANTO 70
What could happen? - FACTORS
Human factors
failure to follow policieson precaution orders or failure
to conduct appropriate staff education/training

Assessment process factors

faulty initial assessment process

Equipment factors
nonfunctional paging system that delays
communication with the individuals physician
HERKUTANTO 71
 Questions to Uncover Causes
What safeguards are missing in the process?
If the process already contains safeguards (for
example,, double checks), why might they not work to
example
prevent the failure every time?
time?

What would have to go wrong for a failure like

this to happen
happen??

If this failure occurred, why would the problem

not be identified before it affected an individual?

HERKUTANTO 72
 What could happen?

HERKUTANTO
73
 Contributory Factors to Suicide
What could happen?

HERKUTANTO 74
 DIABETES SCREENING
What could happen?

HERKUTANTO 75
 Laboratory Test
Ordering Process

HERKUTANTO 76
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus

6 Kegagalan &
Dampaknya
4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang
Proses
Disain Ulang Proses 7 Analisis dan Uji
Coba Proses
Baru
8 Implementasi dan
HERKUTANTO
Monitor Proses
77

Baru
 TUJUAN & HASIL

Teridentifikasinya PROSES BARU yang

bebas dari modus kegagalan

Lembar langkah2 PROSES BARU

HERKUTANTO 78
 Decision Tree
Gunakan Decision Tree utk menentukan apakah modus perlu tindakan lanjut diProceed..

Does this hazard involve a

sufficient likelihood of
occurrence and severity to NO
warrant that it be controlled?
(Hazard score of 8 or
higher)
Is this a single point weakness in
NO
YES the process? (Criticality failure
results in a system failure?)
CRITICALITY
YES
Does an effective control measure already exist YES
for the identified hazard? STOP
CONTROL THE HAZARD (=BARRIER) Do not proceed
NO to find potential
causes for this
Is this hazard so obvious and readily failure mode
apparent that a control measure is not YES
warranted?
DETECTABILITY NO
(FORESEEABILITY)
Proceed to Potential
HERKUTANTO
Causes for this 79
failure mode
 PREPARING TO REDESIGN

Conduct a literature search to gather

relevant information from the professional
literature. Do not reinvent the wheel

Network with colleagues

Recommit to out of the box thinking

HERKUTANTO 80
 REDESIGN STRATEGIES
Prevent the failure from happening
(decrease likelihood of occurrence)
occurrence)
Prevent the failure from reaching the
individual (increase
(increase detectability)
detectability)
Protect individuals if a failure occurs
(decrease the severty of the efects)

HERKUTANTO 81
 PROSES METODE
RISIKO TINGGI REDESIGN

Variable input
Decreasing variability
Complex Simplify
Nonstandarized Standardizing
Tightly Coupled Loosen coupling of process
Dependent on human Use technology
intervention Optimise Redundancy
Built in fail safe mechanism
Time constraints
Documentation
Hierarchical culture Establishing a culture of
teamwork

HERKUTANTO 82
 REDESIGN PROCESS
Process Failure Potential Potential Redesign PIC Target New Outcome
Mode Effect Causes Recommend Completi Process Measure /
ations on Implementat Monitoring
date ion mechanism
for test date &
Actions

1 2 3 4 5 6 7 8 9

HERKUTANTO 83
 Proses
Redesign

Bandingkan :

Analisis & Ranking Analisis & Ranking

Failure Failure
Effect Causes Effect Causes
Mode Mode

Proses Lama Proses Baru

HERKUTANTO 84
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus

7 Kegagalan &
Dampaknya
4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang
Analisis dan Uji Coba Proses
7 Analisis dan Uji
Proses Baru Coba Proses
Baru
8 Implementasi dan
HERKUTANTO
Monitor Proses
85

Baru
 TUJUAN & HASIL

Terujinya PROSES BARU dilapangan

Le

HERKUTANTO 86
SIKLUS PDSA

HERKUTANTO 87
SIKLUS PDSA

HERKUTANTO 88
 LEMBAR KERJA
UJI COBA

HERKUTANTO
89
 LEMBAR KERJA
UJI COBA

HERKUTANTO
90
 LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus

8 Kegagalan &
Dampaknya
4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang
Implementasi & Monitor Proses
7 Analisis dan Uji
Proses Baru Coba Proses
Baru
8 Implementasi
HERKUTANTO
dan Monitor 91
Proses Baru
 TUJUAN & HASIL

PENERAPAN PROSES BARU

Manajemen Perubahan

Lembar MONITORING PROSES BARU

HERKUTANTO 92
 Strategies for Creating and Managing
the Change Process

Establish a sense of urgency

Create a guiding coalition

Develop a vision and strategy

Communicate the changed vision

Empower broad
broad--based action

Generate short
short--term wins

Consolidate gains and produce more change

Anchor new approaches HERKUTANTO

in the culture 93
LEMBAR MONITOR PROSES BARU

HERKUTANTO 94
LEMBAR MONITOR PROSES BARU

HERKUTANTO 95
 KESIMPULAN

PROSES BARU YANG LEBIH AMAN

KEBIJAKAN & SOP LEBIH BAIK

RUMAH SAKIT YANG AMAN

HERKUTANTO 96
HERKUTANTO 97