STRATEGI

IMPLEMENTASI SISTEM
MANAJEMEN MUTU
Viera Wardhani
  Identifikasikan fungsi apa saja yang harus di rumah sakit untuk
menjalankan sistem manajemen mutu. Sebagai panduan perhatikan
persyaratan ISO, JCI dan skema akreditasi lain yang berlaku di rumah
sakit.
 Lakukan analisis :
 apakah fungsi tersebut sudah terakomodasi dalam struktur organisasi yang ada
 apakah fungsi tersebut sudah berjalan secara ”otomatis”

Task 5  Rancanglah satu struktur organisasi mutu pelayanan kesehatan

dirumah sakit secara skematis dilengkapi dengan tugas pokok dan
fungsi masing-masing struktur. Perhatikan bahwa struktur tersebut
tidak selalu harus merupakan struktur baru. Berikan juga penjelasan
persyaratan kemampuan (kualifikasi) dimasing-masing struktur
 Bagaimana langkah strategis dan rencana aksi anda untuk
menerapkan sistem manajemen mutu secara berkelanjutan dan
sebagai bagian dari program kerja organisasi.
 Notification Tidy up

Carry on Site visit

Notification Panic

De commit Over haul

Commit Site visit

The element of
Policy, planning, document
QMS maturity
leadership

structure

General QI activities

Specific QI activities

Patient involvement

Accountability
  proses manajemen yang meliputi struktur,
tanggungjawab, prosedur, proses, dan pengelolaan
sumberdaya yang diperlukan untuk menerapkan
prinsip dan upaya nyata yang diperlukan untuk
Batasan SMM menjamin pencapaian tujuan mutu sebuah organisasi.
 sistem manajemen (kebijakan, proses, prosedur,
standar) yang memungkinkan pencapaian tujuan mutu
suatu organisasi.
  Functions needed:
 Quality planning
Komponen  Quality improvement program
SMM  Information and Measurement: Monitoring
and evaluation
 Resource management
 Standard policy Managerial
and management Performance
system

Standard
Care process
of main
performance
process
The JCI Healthcare Organization
Standard Management Standards
Patient Centered
Care
Patient
Safety
Clinical & Disease
Goals Quality specific
Goals performance
Pressure Self Assessment: Policy ,
and standard-capability- Adjustment with current Structure of
intention Why philosophy condition and staging for responsibility
should we?
full and continuous and rule
implementation
Agreement and
Steps understanding the Activities
SOP
philosophy
Implementing Identification

QMS Increasing Human

Resources Capability
Process Process
Continuous
Initiation Implementation
education Providing standard
equipment, facility,
(substitute if necessary Mon-ev
and staging)
Performance &
reward
 Director

Carier path Quality

development Committee
program
Resource Unit Operational Unit Information
• Financial • Daily Unit
Resources & • Human program
Resources • Quality
Information • Facilities & Improvement
equipment program

Quality Quality
Indicator Indicator
 Stakeholder
• National Policy
• Patient Quality
• Owner Policy
• Payer

Quality Quality
Objective Plan
Policies and Quality
Procedures Indicators

Structure & Process Monitoring &

Responsibility Bisnis evaluation

Resource Standard
Management Procedure
 1. Align organisational processes with external pressure
2. Put quality high on the agenda
Seven ways to 3. Implement supportive organisation-wide systems for
improve quality improvement
quality and 4. Assure responsibilities and team expertise at
safety in your departmental level
hospital 5. Organise care pathways based on evidence of quality
and safety interventions
6. Implement pathway-oriented information systems
7. Conduct regular assessment and provide feedback
  Professional involvement
 Training and initiatives
 A legal requirement to implement QI
The enabler  Public demand
 Expectation and involvement
 Quality improvement project and politic
interest
  Under funding
 Lack of political leadership & strategic planning
 Lack of incentives/confused incentives/low
The barrier motivation
 Cultural barrier; professioal, bureaucratic, lack
of professional training/education