FMEA 2016-Penyuluhan Singkat
FMEA 2016-Penyuluhan Singkat
FMEA 2016-Penyuluhan Singkat
Herkutanto
Herkutanto
HERKUTANTO 2
ALASAN UTAMA MELAKUKAN REGULASI
Mengenal langkah2
Failure Mode and
Effect Analysis
HERKUTANTO 4
KUALITAS PELAYANAN
(Donabedian)
OUTCOME
PROCESS
STRUCTURE
HERKUTANTO 5
HERKUTANTO 6
SUMBER
HERKUTANTO 7
SISTIMATIKA PAPARAN
INTRODUKSI 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.
HERKUTANTO 10
What is HFMEA ?
Modified by VA NCPS
The objective is to look for all ways for process can fail
HERKUTANTO 11
FMEA Terminology
Process FMEA - Conduct an FMEA on a
process that is already in place
HERKUTANTO 15
DELAPAN LANGKAH FMEA
HERKUTANTO 16
LANGKAH-LANGKAH
ANALISIS MODUS KEGAGALAN & DAMPAKNYA
(JCI )
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
Daftar Tim
HERKUTANTO 20
PEMILIHAN TOPIK FMEA
Proses spesifik di rumah sakit:
Highrisk
Highvolume
highcost
HERKUTANTO 21
TUJUAN PEMILIHAN TOPIK
Fokus pada proses spesifik yang dianggap
prioritas (hospital 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
Hierarchical vs team
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
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
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
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. Complications are things that happen as a result of a disease or a
treatment that you prefer didn't happen [stroke from hypertension, or
bleeding following surgery]
A complication may be described as an adverse event caused by pre-
existing factors that were outside the doctor’s 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.
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,
like gender, family history, or race, or things you can control, like smoking
and diet. HERKUTANTO 33
DIFFERENCES BETWEEN RISKS vs COMPLICATIONS
RISKS COMPLICATIONS
Allergy Anaphylactic Rx
Leucocytosis Sepsis
High
Dog Fence Child
HERKUTANTO 36
HERKUTANTO 37
HERKUTANTO 38
HERKUTANTO 39
HERKUTANTO 40
HERKUTANTO 41
Hazard, Barrier, Target Analysis
Medical Policies
Procedures Patient
Mishaps
HERKUTANTO 42
PENERAPAN HBA PADA FMEA
Prinsip: the DEVILS are in the DETAILS
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
Penulisan Obat R/
tdk R/
Dlm formularium Wrong frequence
Wrong route
administration
HERKUTANTO 44
Hazard analysis: What is it?
becoming reality.
Hazard analysis: What is it?
Identify Hazards
Assess Risks
Reduce Risks
Verify Effectiveness
HERKUTANTO 46
Document Results
Hazard analysis: What is it?
Verify Effectiveness
Identify Hazards
Two risk factors are used:
Assess Risks
• severity of injury
Derive Risk Rating
• probability of occurrence
Reduce Risks
Verify Effectiveness
Verify Effectiveness
Identify Hazards
Assess Risks
Verify Effectiveness
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
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
8 Implementasi dan
Monitor Proses Baru
HERKUTANTO 57
TUJUAN & HASIL
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 1-2 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 1-2 staf Kehilangan waktu kecelakaan kerja pada
ANALISIS HAZARD ”LEVEL PROBABILITAS”
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
HERKUTANTO 67
Possible Characteristics of Root
Causes
HERKUTANTO 69
PROBING
to uncover root causes and their relationships
Equipment factors
nonfunctional paging system that delays
communication with the individual’s 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
prevent the failure every time?
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
HERKUTANTO 78
Decision Tree
Gunakan Decision Tree utk menentukan apakah modus perlu tindakan lanjut di“Proceed”
HERKUTANTO 80
REDESIGN STRATEGIES
Prevent the failure from happening
(decrease likelihood of occurrence)
Prevent the failure from reaching the
individual (increase 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 :
Failure Failure
Effect Causes Effect Causes
Mode Mode
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
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
HERKUTANTO 92
Strategies for Creating and Managing
the Change Process
HERKUTANTO 94
LEMBAR MONITOR PROSES BARU
HERKUTANTO 95
KESIMPULAN
HERKUTANTO 96
HERKUTANTO 97