Clinical Pathway

dr. Merita Arini, MMR

Learning Objectives

Topik

Clinical Pathway in Hospital

Ronie Rivany

UU 40/2004 tentang SJSNBab 24 ayat 3 menetapkan bahwa BPJS harus mengembangkan:

PPres 12/ 2013 tentang Jaminan Kesehatan

Pasal 20 ayat 1 menetapkan produk: pelayanan kesehatan perorangan (promotif,

preventif, kuratif, dan rehabilitatif), obat dan bahan medis habis pakai

Pasal 39 mengatur Sistem pembayaran: Kapitasi untuk tingkat pertama, INA-CBGs

untuk tingkat lanjutan

Cont’ • Pasal 42 mengatur Sistem Kendali

Mutu: – Memenuhi standar mutu fasilitas kesehatan

(input); – Memastikan proses pelayanan sesuai standar

(proses), – Memantau luaran kesehatan peserta (output)

Input - Proses - OutputStandar input:

• Perijinan fasilitas kesehatan (standar bangunan, SDM, peralatan, SDM, dsb).

Standar output: • Kinerja di level pasien dan di level sarana

yankes: SPM RS*

Standar proses:• Manajemen:

• Standar akreditasi (RS, Lab.), standar pelayanan prima, dsb

• Pelayanan klinik (clinial care): • PPK/clinical guidelines oleh organisasi

profesi.

Pedoman Pelayanan

Input Proses Output/Outcome

S P O

Kebijakanpelayanan

Pedoman Pengorganisasia

n

Tatalaksana

Survei kepuasan Indikator Mutu :

Indikator KlinikIndikator Mutu Yan

I K P :K T D : Sentinel EventK N C

•Standar SDM

•Standar Fasilitas

Peraturan dan perundanganPedoman

Djoto Atmodjo, KARS

CP vs CGClinical Pathway Clinical Guideline

Lebih customize & user friendly:•Template seragam RS (locally agreed)• Disusun berdasarkan best practice (available) & kondisi RS•ownership lebih tinggi: multidisipliner

• Bentuk sangat bervariasi• Disusun melalui proses

rumit & butuh sumber daya & waktu >>.

• Sering << efektif karena <<nya perhatian & support

Mengapa perlu menyusun CP?

Tarif INA CBGs Mutu Pelayanan Dianggap kecil, RS merasa

rugi:o Berdasarkan perbandingan

dg tarif RS o Berdasarkan perbandingan

dg cost RSo Berdasarkan kasus per kasus Efisiensi vs Fraud

Pedoman Nasional Praktek Kedokteran (PNPK), Pedoman Praktek Klinis (PPK), CP

o Bisa dihitung cost of careo Bisa dibandingkan dg tarif

INA-CBGso Bisa menjadi dasar u/

pengambilan keputusano Bisa sebagai alat kendali

mutu (audit medis, surveilans HAIs, penggunaan fornas, dsb.)

(Djasri, 2014)

“ HOSPITAL GOVERNANCE “

STRUCTURE

PROFESSIONALCOMPT & CPD

PROCESS OUTPUT OUTCOME

CLINICAL PERFORMANCE& EVALUATION

CONSUMERVALUE

CLINICALRISK

MANAGEMENTINTEGRATED

CLINICALPATHWAY & GUIDELINE

PATIENT SAFETY, EQUITY, QUALITY

CLINICAL GOVERNANCE

CLINICALLEADERS

ICD 10ICD 9 CM

INSTITUTIONAL (HOSPITAL) GOVERNANCE

POLICYRESOURCES: 5 M

(2 M)

VISIONHOSP LEADERS

PROSES REALISASI GROWTH

HOSPITAL PERFORMANCE ?

SPMCONSUMER VALUES

BEST PRACTISEBASIC : VBMTOOLS : EBM

CASEMIX

Patientsafety

HOSPITAL

BYLAWS

Clinical Pathway

Alternative Names

• Clinical Pathway• Critical care pathway, • Integrated care pathway, • Coordinated care pathway, • Caremaps®, atau• Anticipated recovery pathway

(Djasri, 2014)

DEFINISI • ICP is a matrix which places

interventions (tasks) on one axis & time (hours, days, weeks) & milestones (specific stages of recovery).

(Midleton & Roberts, 2000)

• CP serve as collaborative plans of patients care requiring cooperation from physician, nurses, clinical staff, & support staf .

(Guinane, 1997)

Form Generik Clinical Pathway

Identitas PasienHari I Hari II Hari III

AssessmentIntervensi/ pelayananOutcomeVariasi

(Midleton & Roberts, 2000; Djasri, 2014)

Karakteristik CP• Menggabungkan:

– Current evidence based– Budaya - Tradisi– Etika– Resources yg tersedia– Preferensi– Kebutuhan & keinginan konsumen– Sistem pengukuran melekat

• Easily audited• Transferable kepada area klinis lain dlm

RS sama(Rahma, Djasri, 2014)

(Midleton & Roberts, 2000)

Mendokumentasi-kan clinical practice terbaik bukan hanya clinical practice sekarang

Elemen CP• Patients group• Scope• Multidisciplinary collaboration• Sequential & appropriate care/

intervention• Patient-focused care• Single record of care• Analysis of variations

(Middleton & Roberts, 2000)

Struktur CP

SPO

Langkah Penyusunan CP

(Rahma & Djasri, 2014)

Cont’

Teknis Pembuatan CP 1. Profesi Medis

• Mempersiapkan SPM/ SPO• bila belum ada dapat menyusun dulu SPM/

SPOnya sesuai kesepakatan.

2. Profesi Perawat• mempersiapkan SPO/ SAK

3. Profesi Rekam Medis/ Koder • mempersiapkan buku ICD 10 dan ICD 9CM, • Laporan RL1 sampai dengan 6 (terutama RL2). • Menyajikan daftar 5 - 10 penyakit utama & tersering

dari setiap divisi SMF/Instalasi dg kode ICD 10 & mean LoS berdasarkan data laporan morbiditas RL2.

Djoti Atmodjo, KARS

Cont’ 4. Profesi Gizi• menyiapkan assesment nutrisi, asuhan

gizi

5. Profesi Farmasi• mempersiapkan Daftar Formularium, sistem

unit dose dan stop ordering 

6. Profesi Akuntasi/ Keuangan• mempersiapkan Daftar Tarif rumah sakit

Contoh Form CP

Efektivitas/ Manfaat CP• Efektivitas CP debatable• Pada umumnya di RS hanya 30%

pasien yg dirawat dg CP. Selebihnya pasien dirawat dg prosedur biasa (usual care).

• ± 80% RS USA menggunakan CP u/ beberapa indikator

• Standar Akreditasi KARS 2012 5 CP/ RS/ tahun

(Benny, 2014)(Djasri, 2014)

Implemented for over 20 years and well established in hospitals - 80% of hospitals in USA (Saint 2003)

VFM Unit (NHS Wales) Project

Clinical Resource Utilitation Group

• Sept 1995 - March 1997, UK• 700 clinical, managerial, operational staf• Aimed to:

– Identify the critical succes factors & potential bariers to adoption of ICPs

– Developt framework/ structured approach to support succesful implementation

(Midleton & Roberts, 2000)

Cont’• Key result 5 distinct & sequential stages used

by organizations with evidence of succesful programmes of ICP activity:

Awarenes Raising & Gaining Commitment

• A strategic approach: a vision of future– Shared vision– ICP

• change management tool • integral component of bussiness & quality • clinical governance

– Goverment papers & other related documents outline strategy for a defined period of time

1.

LEADERSHI

P

Awarenes Raising & Gaining Commitment

• Reasons for developing ICPs– Reinforce aims of ICP ~ organizational

objectives• Improve quality of care trough consistent

management– Encourage patient involvement– Identify & measure outcomes of patient care

• Promote efficient without compromising quality– Reduce unnecessary documentation– Documenting variations from the predicted plan– Facilitate a plan of care & improve links & between

community services

1.

Cont’

• Increase collaboration of multidisciplinary team

–Reduce unnecessary variations–Ensure that no critical aspects of care are

forgotten & that all intervention are planned appropiately & performed on time

–Providing a framework for effective clinical audit

–Educational/ training tool esp. New staff/ short rotation

Awarenes Raising & Gaining Commitment

• ICP facilitator (Stephens, 1997)

– Solve problems of limited resources/ high workload

1.Key

factor

Facilitator’s role:• awareness• Provide initial training, ongoing education, & support• Act as a link between all professional goups involved• Set up & manage individual ICP projects• Attend & facilitate ICP development & meetings• Prepare ICP documentation• Provide ongoing evaluation, feedback, & review

ICP facilitator: Skills Checklist(Stephens, 1997)

Presentation & training communication & negotiation project management/ change management Team building & group facilitation computer literate/ IT Skills ability to motivate/ lead ability to work to tight deadlines under pressure Sound knowledge of ICPs & related initiatives Confidence, credibility, & self motivation

Key task “awareness session” : encouraging staff involvement

Putting System into Place• Selecting patient groups

– Common condition ( high % of patients) biggest impact on our organization

– Simple condition (not multi-pathology) quick wins/ motivator !!!

– Specific problem areas

2.

• High volume• High cost• High risk• Problem prone• Memiliki gap besar dg tarif INA CBGs

Cont’

– Staff expressed preferences Ensure staff commitment

– Monitoring & comparing clinical outcome– Meeting health gain targets (national/

international)– Availability of evidence/ guidelines– Managing clinical risk

Putting System into Place

• Agreeing the scope of ICP

– The development team

2.

Boundary

• Defining the desired objectives of care– Patient outcome - Patient satisfaction– Service quality - Cost effetiveness &

efficiency

Putting System into Place2.

Cont’

• Defining the desired objectives of careGained from:– Available evidence– Clinical audit– Benchmarking data– Accreditation standards– Health gain targets– National service framework, etc

• Mapping the current process of care

• Moving from the process map to the ICP document

Putting System into Place2.

• Lay-out Design• Process based or outcome?

– Depends on the skills of user

• ICP as the legal record of care – as a single record of care debatable– Flexibility review

Documentation3.

Check wound vs Wound dry

• Variation analysis– Essential succes factor of ICP

implementation– “expected variations as professional

judgement for patient focused of care”– Code:

• By clinicians/ nurse manager/ clinical nurse specialist/ audit staff

• Explain in CP guidance asignment

Documentation3.

Patient Pathway

Patient Pathway (PP)Should include:• An introduction to PP• Guidance for using PP• Description of the natur of CPs & their use• Information on patient’s condition & their

threatment• Information to describe variations from the

expected & how care is individualized to suit patient needs

• Requires careful planning & Effective project management

• Preparing the main players– Facilitator– Clinical staff– Managerial staff

• Learning from failure & communicating success throughout the organization

Implementation 4.

LEADERSHI

P

Critical Success Factors• “top-down” support of senior

management tangible commitment• CP is a leader driven process• At the very least need:

– A full-time or designated facilitator– Office space– IT & reproduction facilities– Time for clinical staff to participate in

designing & reviewing CP

The Full Time Job

• Base-lines audit of documentation of practices• Discussions with all key staff• Education session • Production & continuing refinement of the

documentation

Barriers to success

• Professional cultures• Lack of organisational support• Care Pathway design• Inadequate time & resources• Ad-hoc approach

Mengapa CP gagal?• Ownership rendah akibat keterlibatan/

dukungan staf yg disproporsional• CP ≠ universal panacea:

– perjalanan alami penyakit– Intoleransi obat– Resistensi antibiotik,– Penatalaksanaan tdk sesuai ketentuan, etc– CP seringkali lebih mudah digunakan pada:

• pasien bedah• Pasien dg single pathology (non-complicated, no-

comorbidities)

Evaluasi CP“If you can measure, you can

manage it”

• purpose of evaluation

• Objects of evaluation

□ personal judgement

□ full research project

□ development process

□ operational aspects

□ single pathway

□ multiple pathways

5.

Operational Aspects

“Apakah CP sukses diimplementasikan di semua area?”

• Contoh kriteria evaluasi:– Persetujuan staf klinis multidisiplin

menerapkan CP– Kelengkapan dokumentasi– Pendataan varians

cont’

• outcome yang akan diukur

□ patient centered

□ (individual) clinical staff

□ clinical team

□ organizational

□ other

Patient Centered • shortening time delay in process• clinical outcomes

– LoS– QoL– complication/ adverse events

• cost of care• satisfaction levels• patient education/ knowledge about the

condition & self management

Individual Clinical Staff

• job satisfaction• staff turn-over• morale & stress levels• error in delivery of care

Clinical Team

• multidisciplinary working• building teamwork• communication improvements• risk managemet• development of local guideline &

protocols

Others

• documentation of delivery of care• effect of computerization of

pathways• effect of variance reporting

Djasri, 2010

Djasri, 2010

Djasri, 2010

Leadership for clinical system

• Quality is never an accident ; it’s always the result of:–high intention ; –sincere effort ;– intelligent direction–skillful executions ; – it represent the wise choice of many

alternatives

dr. Djoti Atmodjo, Sp.B.Dr. drg. Ronie Rivany, MARS

Lampiran

BENTUK SPO

Panduan praktik klinis (Clinical Practice Guideline)Alur klinis (Clinical Pathways)AlgoritmeProsedurProtokolStanding Orders

Djoti - Atmodjo

PENDEKATAN PENGELOLAAN PASIEN•Diagnosis kerja•Gejala

Standar pelayanan :

Panduan Praktik Klinis•Definisi•Anamnesis•Pemeriksaan fisis•Kriteria diagnosis•Diagnosis banding•Pemeriksaan penunjang•Terapi•Edukasi•Prognosis•Kepustakaan

Alur klinisAlgoritmeProtokolProsedurStanding order

S P O

dapat dilengkapi dengan

• RS wajib memp.CP, Diagnosis mengacu pada ICD-10,Prosedur mengacu pd ICD-9CM Flowchart penyusunan CP

SPM Profesi Model Dummy

SPM RS

SOP Aktivitas

ICD

Surgical Medical

DRG

Case Mix

Clinical PathwayTerukur(admission to discharge) contoh :-Diare anak-Sectio Caesaria

CLINICAL PATHWAYCLINICAL PATHWAY & Cost of Care& Cost of Care

SYMPTOM DIAGNOSIS THERAPY FOLLOW UP

1

Activities ABC

ActivitiesABC

ActivitiesABC

ActivitiesABC

ActivitiesABC

2 3 4 5Admission Diagnosis Pre Therapy Therapy Follow up

INDONESIAN DRG’s

International Classification of Disease (ICD)

Major Diagnostic Categories (MDC)

Surgical / Other / Medical

Diagnosis Related Groups (DRG’s)

Casemix

Clinical Pathway

Pengembangan Konsep Clinical Pathway

INDONESIAN DRG’s• Pola pikir

– ICD tetap– MDC untuk sementara tetap– Clinical Pathway bisa dibuat– DRG di konfirmasi + bisa dibuat– Casemix di konfirmasi + bisa dibuat– Costing dilakukan dengan

pendekatan Activity Based Costing + Simple Distribution

POLA PIKIR INDONESIAN DRG’s (1)

INA - DRG

1.Konfirmasi DRG 2.Hitung Cost/DRG

Clinical Pathway & Casemix

Activity Based Costing

POLA PIKIR INDONESIAN DRG’s (2)

ICD

MDC

DRG DRG

CASEMIX

COST

COST

DRG

TARIF

TARIF

1

2

Sistem Casemix

• Sistem Casemix adalah suatu cara mengelola sumber daya rumah sakit seefektif mungkin dalam memberikan layanan kesehatan yang terjangkau kepada masyarakat berdasarkan pengelompokkan spektrum diagnosis penyakit yang homogen dan prosedur tindakan yang diberikan

• Secara ringkasnya sistem casemix terdiri dari 3 komponen utama – yakni kodefikasi diagnosis(ICD 10) dan prosedur tindakan (ICD 9 CM), pembiayaan (costing ) yang dapat berupa top-down approach, activity based costing dan atau kombinasi keduanya, dan clinical pathways

INA DRG

• INA DRG adalah variasi sistem casemix untuk Indonesia yang disusun berdasarkan data dari15 rumah sakit vertikal, mempergunakan ICD 10 untuk diagnosis dan ICD 9CM untuk prosedur tindakan serta biaya berdasarkan tarif yang berlaku padawaktu tersebut. Dengan berakhirnya lisensi grouper INA-DRG terhitungtanggal 30 September 2010, maka nama sitem Casemix INA-DRG berubahmenjadi INA-CBG

• Untuk saat ini INA-DRG yang disusun berdasarkan data dari 15 rumah sakit vertikal Depkes RI (tipe A, B danrumah sakit khusus) telah berhasil membuat 23 MDC (Major Diagnostic Criteria

Manfaat CP

• Sebagai instrumen pelayanan berfokus kepada pasien (patient-focused care) terintegrasi, berkesinambungan dari pasien masuk dirawat sampai pulangsembuh (continuous care), jelas akan dokter/perawat penanggung jawab pasien (duty of care)

 • Utilitas pemeriksaan penunjang, penggunaan obat obatan

termasuk antibiotika, prosedur tindakan operasi,

• Antisipasi kemungkinan terjadinya medical errors  (laten dan aktif, nyaris terjadi maupun kejadian tidak diharapkan/KTD) dan pencegahan kemungkinan cedera (harms) serta infeksi nosokomial dalam rangka keselamatan pasien(patient safety)

• Mendeteksi dini titik titik potensial berisiko selama proses layanan perawatan pasien (tracers methodology)  dalam rangka manajemen risiko (risks management),

• Rencana pemulangan pasien (patient discharge) 

• Upayapeningkatan mutu layanan berkesinambungan (continuous quality improvement) 

• Penulusuran kinerja(performance) individu profesi maupun kelompok (team-work )

Peran Dokter• Di Indonesia pengertian klinisi masih diberikan kepada

kelompok dokter yang langsung menangani pasien (staf medik fungsional/ SMF).

• Sedangkan tim keseluruhan dokter dan profesi lain sering disebut sebagai pelaksana pelayanan klinis (PPK)

• Persamaan/kesetaraan profesi ini merupakan suatu perubahan yang dapat memberikan dampak kepada pasien ataupun kepada para dokter sebagai profesi yang tertua.

• Diperlukan suatu perubahan persepsi bagi para dokter tentang hubungan baru dengan para profesional lainnya.

• Namun demikian dokter akan tetap sebagai pemimpin bukan dalam bentuk hirarchical tetapi sebagai ketua tim (playing captain) di antara sesama profesi yang sederajat (the clinician)

Seorang dokter harus bersikap dan bertindak sebagai orang pertama diantara profesional yang sederajat, dengan demikian dituntut suatu kepemimpinan yang demokratik di dalam suatu tim profesional.

PRIMUS INTER PARESFirst Among Equals

Untuk itu diperlukan:1. Kompetensi2. Etika3. Karakter4. Empati5. Inspiring ability6. Membangun semangat dan

kerjasama tim7. Conflict resolution

Sifat-sifat diatas tentunya juga harus dimiliki oleh seluruh anggota-anggota tim, sehingga terbangun sebuah kerja sama tim (team work) yang efisien.

Maturnuwun