patient

DEVELOPMENT MODEL OF
(*)
QUALITY NURSING CARE
By: Dr.Nursalam, M.Nurs (Hons)
Senior lectur, hospital nursing manager
Airlangga University

"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]
Nursalam-07
OUR FUTURE
Diambil dari – Softskill DIKTI

1. What?
2. Why?
3. How?
3

WHY &
WHAT
World Class Healthcare Experience

ETHIIC:
JABVC
1. QUALITY
2. PATIENT
SAFETY
3. LEGAL
KPRS-2011
EBN-M - PICOT

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)

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)
STANDARDS JCI
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 )

NURSING CONTRIBUTION
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

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.
EVIDENCE BASE IN NURSING
P-I-C-O-T
PATIENT
INTERVENTION
COMPARISON
OUTCOME
TIME
Thompson, C. et al. Evid Based Nurs 2004;7:68-72

What ?
13

CATEGORIES OF RISK IN THE
HOSPITAL
Patient care-related risks
Medical staff-related risks
Employee-related risks
Property-related risks
Financial risks
Other risks
14

2
PATIENT SAFETY
1. MEDICATION ERROR
2. PATIENT FALLS
3. BED SORE
4. PLEBITIS
Nursalam-07
5. RESTRAINS

Scope of Hospital Risk Management (revised) :
of
The
Business
of
The
Environment
of
The
Patient
Hospital
Safety
of
The
Health Care
Worker
of
The
Facilities

Quality in Healthcare
…. begins with ensuring patient safety
17

Prosces of Care
Error
-Kesalahan proses
-Dpt dicegah
-Pelaks Plan action
tdk komplit
- Plan action yg salah
-commission & omission
Proces of Care
(Non Error)
PATIENT SAFETY
Patient
Not Injury
Injury
patient
injury
KPRS-2010
Near Miss
(NM)
(KNC=Kejadian NYARIS CIDERA)
- Dpt obat “c.i.”, tdk timbul (chance)
- Plan, diket, dibatalkan (prevention)
- Dpt obat “c.i.”, diket, beri anti-nya
(mitigation)
Adverse Event
Adverse Event
(AE)
(KTD=Kejadian Tdk Diharapkan)/
Sentinel

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)
nursalam -2006

PERATURAN MENTERI KESEHATAN REPUBLIK
INDONESIA NOMOR 1691/MENKES/PER/VIII/2011
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)
Djoti A

FOCUS I : PATIENT IDENTIFICATION
Djoti A

ALLERGY : GELANG MERAH
Djoti 22 A

FOCUS II : IMPROVE AN EFFECTIVENESS
OF COMMUNICATIONS
ATTENTION
Order by oral
Order via Telphone
Report from examination
Djoti A

Write back
Read Back
Repeat Back
So – order Via oral &
(Reconfirm)
telephone
Djoti A

FOCUS III : HIGH-ALERT FOR DRUG)
LASA (LOOK ALIKE SOUND ALIKE)
NORUM ( NAMA OBAT RUPA MIRIP)
• hidraALAzine hidrOXYzine
• ceREBYx
• vinBLASTine
• chlorproPAMIDE
• glipiZIde
• DAUNOrubicine
ceLEBRex
vinCRIStine
chlorproMAZINE
glYBURIde
dOXOrubicine
Djoti A

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
World Class Healthcare Experience
LAW

CODE ETHICS
NURSING ETHICS &
UU NO 44/2009 (HOSPITAL)
PATIENT
PRACTICE
COMMUNITY
COLLEAGUES
PROFESSION
J-A-B-V-C
R-A-A
SUPPORT - KESMAS
KPRS-2011
GOOD RELATIONSHIP
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”
VISSION &
MISSION
EXTERNAL
CHANGE
INTERNAL
POOR ORGANIZATION - NEVER
CHANGE
GOOD ORGANIZATION - REACT
QUICKLY TO CHANGE
EXCELLENT ORGANIZATION -
CREATE CHANGE
FUTURE HOSPITAL
“DIFFERENT”
21 CENTURY
WORLD CLASS
INTERNATIONAL
ACREDITATION
DIKMAN -5/14/2012 36

NOW
WHICH ONE SHOULD BE CHANGED FIRST?
MAN METHOD MATERIAL
MONEY ENVIRONMENT
MAN:
P: Permission
T: Thanks
E: Excuse
VISSION
GOOD GENTLEMAN
1. High Integrity
2. For thier jobs:
a.Loyality
b. Dedication
c.Prestation
d. Good attitude
37

Customer
Value
Proposition
HUMAN CAPITAL
- A: Attitude
- K: knowledge
- S: skill
- I: insight
Operation
Management
Processes
Customer
Management
Processes
3.
CUSTOMER
4. FINANCIAL
2. SERVICE:
Internal Business
Process
1. SDM:
Learning and
Growth
INFORMATION CAPITAL
- System
- Database
- Information Technology
Innovation
Processes
ORGANIZATION CAPITAL
- Culture
- Leadership
- Alignment
- Teamwork
- Mindset
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
Work characteristic
Objective performance
Feedback
Correction
Job design
Work schedule
Nurse characteristic
Knowledge,
Skills,
Ability,
Motivation
Attitudes
Value & Norm
Work behavior
NCD (MAKP)
Environment
Performance(P)= (Efforts (E) + Achievement (A)
Job Performance
caring
Patient satisfaction and
loyality
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

“ Act as a Leader, not a Manager,
Stop Managing, Start Leading !”
GOOD LEADER : do the right things
GOOD MANAGER : do the things right
( Robert Flater : “Jack Welch and GE Way” )
LEADER, AS CHANGE AGENT, NOT LOOK FOR POSITION
BUT AN ACTION! (RSU Haji Surabaya)

Type of Situasional Leadership
(Hersey dan Blanchard )

ORGANISATIONAL
CHARACTERISTIC
(X1)
NURSE
CHARACTERISTIC
(X3)
WORK
CHARACTERISTIC
(X2)
H1.NS,Koef 0,189
H2. S, Koef 0,889
MODEL - RESEARCH
H3.1.S,
Koef 0,845
STANDAR NURSING
CARE -
ASKEP
(Y1)
DELIVERY
(Y1)
H3.2.S, Koef 0,818
H3.3.S, Koef 0,833
STANADAR CARE
KINERJA (Y2)
(Y2)
H3.3.4 ,Koef 0,736
H.4,NS, Koef 0.152
NURSE
SATISFACTION
(Y3.1)
PATIENT
SATISFACTION
(Y3.2)
MUHITH (2012)

MANAGING NURSING CARE
Aims
Improve quality of nursing care
Streamline and facilitate co-ordination of care
Facilitate effective discharge planning and patient
education
DELIVERY SYSTEM
MODEL MAKP
Ward-Based Case Management
Manage and optimize patient length of stay
Improve communication process

“It’s easy gettin’ good players.
The hard part is gettin’ them to play
with each other”
(Casey Stengel)
(Casey
45

ELEMENTS OF NCD
Clinical decision making
Work allocation
Communication
Management
Coordination
(Huber, 2006: 317)
nursalam -2006

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
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?
8

C-A-R-L
C: CAPABILITY
A: ACCESSIBILITY
R: RELEVANCY
L: LEGALITY
Nursalam-07

SCOPE of MAKP
1. NCD
2. HAND OVER
3. NURSING ROUND
4. LOGISTIC AND DRUG
5. DISCHARGE PLANNING & PATIENT
ADMISSION
6. SUPERVISION
7. DOCUMMENTATION

MD
ASSOCIATE
NURSE
PRIMARY MODEL
NUM
Primary Nurse
PATIENT
ASSOCIATE
NURSE
RESOURCES
ASSOCIATE
NURSE

MAN
WORK LOAD & ALLOCATION
(FORMULA???? TIME & MOTION!

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
Nursalam-07

a. MEDICATION ERROR
① PRESCRIBING
② ADMINISTERING
③ MONITORING - SAVING

. 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)
CAUSES
-MECHANICAL
BACTERIAL
CHEMICAL - DRUG

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-07

MODEL INTEGRATED QUALITY IMPROVEMENT PROGRAM
Level 1
NURSES
SOLUTION
Nursalam-Unair-2012
NURSING CARE
STANDAR
(IQIP) IN PATIENTCARE
LITTLE THINGS
NURSING COMMITTEE
. SAK; SISTEM; ETIK; KULITAS;
DIKLAT & LITBANG; SKF
PROB. SOLVING
PATIENT CARE
BY OTHER HEALTH TEAM
PATIENT &
FAMILY SATISFACTION
NON-CONFORMANCE? INPUT DATA
SOLUTION
INSTITUTIONS –
NURSING DEPT.
Level 2
QUALITY
MONITOR TEAM
PROB. SOLVING