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DEVELOPMENT MODEL OF QUALITY NURSING CARE
By: Dr.Nursalam, M.Nurs (Hons) Senior lectur, hospital nursing manager
Airlangga University
(*)
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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
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3
2. Why?
1. What?
3. How?
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WHY &
WHAT
World Class Healthcare Experience
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EBN-M - PICOT
1. QUALITY
ETHIIC: JABVC
2. PATIENT SAFETY
3. LEGAL
KPRS-2011
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1 QUALITY
World Class Healthcare Experience
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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;
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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)
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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 )
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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
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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
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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
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13
What ?
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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
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Nursalam-07
PATIENT SAFETY 1. MEDICATION ERROR
2. PATIENT FALLS
3. BED SORE
4. PLEBITIS
5. RESTRAINS
2
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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) :
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17
Quality in Healthcare
…. begins with ensuring patient safety
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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
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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)
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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
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FOCUS I : PATIENT IDENTIFICATION
Djoti A
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ALLERGY : GELANG MERAH
22 Djoti A
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FOCUS II : IMPROVE AN EFFECTIVENESS
OF COMMUNICATIONS
Djoti A
ATTENTION
Order by oral
Order via Telphone
Report from examination
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So – order Via oral &
telephone Write back
Read Back
Repeat Back
(Reconfirm)
Djoti A
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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)
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Look alike
Djoti A
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FOCUS IV : 6 RIGHT
PATIENT, DRUG,
DOSAGE,TIME ...........
DOCUMMENTATION
Djoti A
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FOCUS V :
REDUCE RISK OF INFECTION
Djoti A
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FOCUS VI :
REDUCE RISK PATIENT FALL
Djoti A
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3 LAW
World Class Healthcare Experience
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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
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HOW
TO IMPROVE
QUALITY
World Class Healthcare Experience
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“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)
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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
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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
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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
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4 NURSING CARE
DELIVERY (NCD)
World Class Healthcare Experience
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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
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“ 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
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Type of Situasional Leadership
(Hersey dan Blanchard )
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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)
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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
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45
“It’s easy gettin’ good players.
The hard part is gettin’ them to play
with each other”
(Casey Stengel)
(Casey
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nursalam -2006
ELEMENTS OF NCD
Clinical decision making
Work allocation
Communication
Management
Coordination
(Huber, 2006: 317)
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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?
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C-A-R-L C: CAPABILITY
A: ACCESSIBILITY
R: RELEVANCY
L: LEGALITY
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1. NCD
2. HAND OVER
3. NURSING ROUND
4. LOGISTIC AND DRUG
5. DISCHARGE PLANNING & PATIENT
ADMISSION
6. SUPERVISION
7. DOCUMMENTATION
SCOPE of MAKP
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PRIMARY MODEL
MD NUM
RESOURCES
Primary Nurse
PATIENT
ASSOCIATE
NURSE
ASSOCIATE
NURSE
ASSOCIATE
NURSE
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WORK LOAD & ALLOCATION
(FORMULA???? TIME & MOTION!
MAN
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QUALITY INDICATORS 1.Patient safety
2. Patient Satisfaction
3. Self care
4. Comfortability
5. Anxiety
6. Knowledge
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a PATIENT SAFETY 1. MEDICATION ERROR
2. PATIENT FALLS
3. DICUBITUS
4. FLEBITIS
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a. MEDICATION ERROR
① PRESCRIBING
② ADMINISTERING
③ MONITORING - SAVING
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b. PATIENT FALL – MFS (Morse
Fall Scale)
NURSE NEGLIGENT
PATIENT AWARENESS
WORK LOAD (PENGHITUNGAN – TIME
MOTION STUDY, WORK SAMPLING, DAILY LOG)
MODEL - BED
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c
BED SORE (SCALE NORTON)
PHYSICAL
MENTAL
ACTIVITY
MOBILITY
INCONTINENCE
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d.
FLEBITIS –
VIP (VISUAL INFUSION PHLEBITIS)
-MECHANICAL
BACTERIAL
CHEMICAL - DRUG
CAUSES
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2
PATIENT SATISFACTION R-A-T-E-R
RELIABILITY – ASSURANCE-
TANGIBLES – EMPHATY -
RESPONSIVENES (Parasuraman)
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3
SELF – CARE (katz)
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4 CONFORTABILITY
(Visual Aid Scale)
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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
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6 PATIENT KNOWLEDGE
(HBM , DP, PPB)
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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
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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
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