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RISK MANAGEMENT

Dr ARJATY W DAUD MARS

Arjaty Daud/ IMRK/ Risk Management 7/26/14

What ?

RISIKO ADALAH :
POTENSI TERJADINYA KERUGIAN YANG DAPAT TIMBUL DARI
PROSES KEGIATAN SAAT INI ATAU KEJADIAN DIMASA DATANG.
ERM, Risk Management Handbook for Health Care Organization
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RISIKO DI RUMAH SAKIT

Arjaty Daud/ IMRK/ Risk Management 7/26/14

RISIKO KLINIS / Clinical Risk :

Semua isu yang dapat berdampak terhadap

pencapaian pelayanan pasien yang bermutu
tinggi, aman dan efektif.
RISIKO NONKLINIS/ Corporate Risk :

Semua issu yang dapat berdampak terhadap

tercapainya tugas pokok dan kewajiban
hukum dari rumah sakit sebagai korporasi.
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KATEGORI RISIKO DI RUMAH SAKIT :

( CATEGORIES OF RISK )

Patient care-related risks

Medical staff-related risks
Employee-related risks
Property-related risks
Financial risks
Other risks

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RISK VS. MEDICAL ERROR

Potential Failure

Actual Failure

Medical
Errors

Risks

What is going wrong

With this process?

What could go wrong

With this process?

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Actual SE

Incident report

SE
Policy

"reviewable"

Adverse events

Examples

Patient death from medication

misadministration
Significant
misadministration
-- patient survives

"Important single events"

Full range of
Near Miss events,

Majority of
medication
errors

High Risk
Processes
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Pasien
tidak terpapar

Near Miss
(KNC=Kejadian NYARIS CIDERA)
- ERROR, diket, dibatalkan (prevention)

Medical Error
Procces of care error

Tidak
cidera

No Harm Event

(KTC=Kejadian TIDAK CIDERA)

Kesalahan proses yg
dpt dicegah :
Error in planning
Error in Execution

Pasien
terpapar

Krn berbuat : commission

Krn tidak berbuat : omission

- Dpt obat c.i., tdk timbul (chance)

- Dpt obat c.i., diket, beri anti-nya
(mitigation)

Pasien
cidera

Adverse Event

(KTD=Kejadian Tdk Diharapkan)

Dpt dicegah

significant
potential for harm
situation

reportable
circumstance

Tidak
cidera

(KPC=Kondisi Potensi Cedera)

Proses of Care
Non Error

Pasien
terpapar

Pasien
cidera

Adverse Event

(KTD=Kejadian Tdk Diharapkan)

-TIDAK Dpt dicegah

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JENIIS INSIDEN YG HARUS

DILAPORKAN
1. KEJADIAN SENTINEL
2. KEJADIAN TIDAK DIHARAPKAN (KTD)
Insiden yang mengakibatkan cedera pada pasien
3. KEJADIAN TIDAK CEDERA (KTC)
Insiden yang sudah terpapar kepada pasien tapi tidak
menimbulkan cedera
4. KEJADIAN NYARIS CEDERA (KNC)
Insiden yang belum terpapar kepada pasien
KONDISI POTENSIAL RISIKO / CEDERA YANG HARUS DILAPORKAN
KONDISI POTENSIAL CEDERA (KPC)
Kondisi yang berpotensial menimbulkan cedera tapi belum terjadi insiden
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JCI Sentinel Event Policy

Sentinel Events

JCI reviews organization activities in response to sentinel events in its

accreditation process.

This includes all initial accreditation surveys, triennial accreditation

surveys, and, as appropriate, focused surveys.

The following apply:

A sentinel event is an unanticipated occurrence involving death or major
permanent
loss of function unrelated to the natural course of the patients
illness or underlying condition.
Such events are called sentinel because they signal a need for immediate
investigation and response.
The terms sentinel event and medical error are not synonymous; not all
sentinel events occur because of an error, and not all errors result in
sentinel events.

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QPS 6

JCI Sentinel Event Policy

The following sentinel events are subject to review by JCI and include
any occurrence that meets the following criteria:
The event has resulted in an unanticipated death unrelated to
the
natural course of the patients illness or underlying
condition (for example, suicide).
The event has resulted in major permanent loss of function
unrelated to the natural course of the patients illness or
underlying condition.
The event resulted from wrong-site, wrong-patient, wrongprocedure surgery.
The event has resulted in an infant abduction or infant who
was sent home with the wrong parents.

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SENTINEL EVENT QPS 7 (JCI 5TH EDITION)

death, including, but not limited to,
1.an unanticipated
Death
that
is
unrelated to the natural course of the patients illness or

underlying condition (for example, death from a post operative

infection or a hospital-acquired pulmonary embolism);
Death of a full-terminfant ;and
suicide;
Major permanent loss off unction unrelated to the patients natural course
2.of
illness or underlying condition;
wrong-site,
wrong-procedure, wrong-patient surgery;
3.

4.Transmission of a chronic or fatal disease or illnessas as a result of

blood or blood products or transplanting contaminated organs or tissues;

5. infant abduction or an infant sent home with the wrong parents; and
rape, workplace violence such as assault (leading to death or
permanent loss of function); or homicide (willful killing) of a patient,
staff member, practitioner, medical student, trainee, visitor, or vendor
while on hospital property. (Also see SQE.8.2)
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HOW ?

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MANAJEMEN RISIKO RUMAH SAKIT

Kegiatan berupa identifikasi dan evaluasi
untuk mengurangi risiko cedera dan kerugian
pada pasien, karyawan rumah sakit, pengunjung
dan organisasinya sendiri (The Joint Commission on Accreditation of
Healthcare Organizations / JCAHO).

Kegiatan meminimalkan bahaya terhadap

pasien,
kegiatan untuk menciptakan
lingkungan yang aman bagi karyawan, pasien
dan pengunjung (ASHRM)
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Patient care
Related
Risks

Medical Staff
Related Risks

Hosp
Risk
Mgt

Other
Risks

Financial
Risks

Employee
Related
Risks
Property
Related
Risks

Roberta Caroll, editor : Risk Management Handbook for Health

Care Organizations, 4th edition, Jossey Bass, 2004

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PROSES MANAJEMEN RISIKO

TEGAKKAN KONTEKS

IDENTIFIKASI RISIKO
Reaktif & Proaktif)

ANALISA RISIKO
(Risk Grading, RCA, FMEA)
ASESMEN RISIKO

EVALUASI RISIKO

MONITOR DAN REVIEW

KOMUNIKASI DAN KONSULTASI

(Rencana Strategis)

(CBA)

KELOLA RISIKO
(Kontrol,, Transfer,
RISK REGISTER
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IDENTIFIKASI RISIKO

Incident reporting (Laporan Insiden)

n Case Report
n Complaint
n Claim data
n Clinical care review
n Audit Medis
Proaktif
n Occurrence Screening /
Medical Record Review
n Survey / Self Assesment
Reaktif

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ANALISA RISIKO
RISK ASSESSMENT TOOLS
Dalam Proses manajemen risiko terdapat
beberapa tools yang digunakan untuk analisa
risiko yaitu :
Risk

Matrix Grading
Root Cause Analysis (RCA)
Failure Mode Effect Analysis (FMEA)
Hazard Vulnerability Assessment (HVA)
Infection Control Risk assessment (ICRA)
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RISK MATRIX
RISIKO SEBAGAI SUATU FUNGSI DARI PROBABILITAS (CHANCE,LIKELIHOOD) DARI
SUATU KEJADIAN YANG TIDAK DIINGINKAN,DAN TINGKAT KEPARAHAN ATAU
BESARNYA DAMPAK DARI KEJADIAN TERSEBUT.

Skor risiko :
Probability X Consequence
Dampak (Consequences)
Penilaian dampak / akibat suatu insiden adalah seberapa berat akibat
yang dialami pasien mulai dari tidak ada cedera sampai meninggal
Probabilitas / Frekuensi / /Likelihood
Penilaian tingkat probabilitas / frekuensi risiko adalah seberapa seringnya
insiden tersebut terjadi

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RISK MATRIX GRADING

PROBABILITAS /FREKUENSI / LIKELIHOOD

Level
1
2

Frekuensi
Sangat jarang
Jarang

3
4

Mungkin
Sering

Sangat sering

Kejadian aktual
Dapat terjadi dalam lebih dari 5 tahun
Dapat terjadi dalam 2 5 tahun
Dapat terjadi tiap 1 2 tahun
Dapat terjadi beberapa kali dalam
setahun
Terjadi dalam minggu / bulan

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DAMPAK KLINIS / CONSEQUENCES / SEVERITY

Level

DESKRIPSI

Insignificant

Minor

Moderate

Major

Cathastropic

CONTOH DESKRIPSI
Tidak ada cedera, kerugian keuangan kecil
Dapat diatasi dengan pertolongan
kerugian keuangan sedang

pertama,

Berkurangnya

fungsi motorik / sensorik /

psikologis atau intelektual secara
semipermanent / reversibel / tidak
berhubungan dengan penyakit
S e t i a p k a s u s y a n g m e m p e r p a n j a n g
perawatan
Cedera luas
K ehilangan

fungsi utama
permanent
(motorik,
sensorik, psikologis,
intelektual), permanen / irreversibel/ tidak
berhubungan dengan penyakit
Kerugian keuangan besar
Kematian

yang tidak berhubungan dengan

perjalanan penyakit.
Kerugian keuangan sangat besar.

RISK GRADING MATRIX

Potencial Concequences
Frekuensi/
Likelihood

Insignificant
1

Minor
2

Moderate
3

Major
4

Catastropic
5

Sangat Sering Terjadi

(Tiap mgg /bln)
5

Moderate

Moderate

High

Extreme

Extreme

Sering terjadi
(Bebrp x /thn)
4

Moderate

Moderate

High

Extreme

Extreme

Mungkin terjadi
(1-2 thn/x)
3

Low

Moderate

High

Extreme

Extreme

Jarang terjadi
(2-5 thn/x)
2

Low

Low

Moderate

High

Extreme

Sangat jarang sekali (>5

thn/x)
1

Low

Low

Moderate

High

Extreme

Can be manage
by procedure

Clinical Manager / Lead

Clinician should assess the
consequences againts cost
of treating the risk

Detailed review &

urgent treatment should
be undertaken by senior
management

Immediate review &

action required at
Board level. Director
must be informed

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RISK MAPPING

IMPACT VS. PROBABILITY

High
I
M
P
A
C
T

Medium Risk

Share

High Risk

Mitigate & Control

Low Risk

Accept

Medium Risk

Control

Low

PROBABILITY

High
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Daud/ IMRK/ Risk Management
SKOR

CIDERA
PASIEN

7/26/14

INSGNIFICANT

MINOR

MODERATE

MAJOR

CATASTROPHIC

Tidak ada cedera

Dapat diatasi
dengan
pertolongan
pertama

B e r k u r a n g n y a

Cedera luas
K e h i l a n g a n

Kematian

fungsi motorik /
sensorik
Setiap kasus yang
memperpanjang
perawatan

fungsi utama
permanent

PELAYANAN/
OPERASIO
NAL

TERHENTI LEBIH
DARI 1 JAM

TERHENTI LEBIH
DARI 8 JAM

TERHENTI
LEBIH DARI 1
HARI

TERHENTI LEBIH
DARI 1 MINGGU

TERHENTI
PERMANEN

BIAYA /
KEUANGAN

KERUGIAN KECIL

KERUGIAN LEBIH
DARI 0,1%
ANGGARAN

KERUGIAN LEBIH
DARI 0,25 %
ANGGARAN

KERUGIAN LEBIH
DARI 0,5%
ANGGARAN

KERUGIAN LEBIH
DARI 1%
ANGGARAN

PUBLIKASI

RUMOR

- MEDIA LOKAL
- WAKTU
SINGKAT

- MEDIA LOKAL

MEDIA
NASIONAL
KURANG DARI 3
HARI

MEDIA NASIONAL
LEBIH DARI 3 HARI

DAMPAK KECIL
THD MORIL
KARYAWAN DAN
KEPERCAYAAN
MASYARAKAT

DAMPAK
BERMAKNA THD
MORIL KARYAWAN
DAN
KEPERCAYAAN
MASYARAKAT

DAMPAK SERIUS
THD MORIL
KARYAWAN DAN
KEPERCAYAAN
MASYARAKAT

MENJADI
MASALAH
BERAT BAGI PR

REPUTASI

RUMOR

- WAKTU LAMA

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EVALUASI RISIKO
1.

Risk Ranking

2. Prioritize the risk

3. Cost Benefit Analysis (setelah diranking,
biaya unt mengurangi resiko dibandingkan
dengan biaya kalau terjadi resiko)
4. Determine is the risk to be accepted or not

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PENGELOLAAN RISIKO
q

Dihindari (Avoid)
tidak melaksanakan kegiatan yang menimbulkan risiko
Direduksi (Reduction)
mengurangi atau mengandalikan dampak yang mungkin terjadi

Dipindahkan (Transfer)
mengatur agar pihak lain ikut menanggung atau
berbagi sebagian risiko, melalui kontrak,kerjasama, joint venture

Diterima: (Accept)
beberapa risiko sangat ringan sehingga dapat diterima /
dikelola sendiri
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RISK REGISTER
RS membuat Rekapitulasi risiko Tahunan Risk
Register
Risk Register :

Risiko yg teridentifikasi dalam 1 tahun

2. Informasi Insiden keselamatan pasien, klaim litigasi dan
komplain, investigasi eksternal & internal, exernal
assessments
1.

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Arjaty Daud, IMRK

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RISK REGISTER

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RISK REGISTER
TAHUN ..

PRIORITAS RISIKO

Tipe
Insid
en

Risk Score

Efek /
Dampak

Probabilitas

Sumber
Insiden/
Lok
Akar
identifika
Kejadia
asi
Masalah
si
n
Keteg
Jenis
ori 1.
Insiden
Risiko Laporan
mis. Insiden
Kes 2.
Pasien Komplain
( Mengapa
/ K3 / 3. Litigasi
Hal itu bisa
Inf 4. Rapat
terjadi )
Contr Unit
ol dll) Kerja
5. Survey
6. Ronde

Dampak

No
.

EVALU
ASI
RISIKO

ANALISIS
RISIKO

IDENTIFIKASI RISIKO

PENGELOL
Risk
AAN
Owner / PIC
RISIKO

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T
K
A
O
PR

1.
2.

3.
4.
5.
6.
7.
8.

IF

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RISK MANAGEMENT STEPS

Understand Risk Establish Risk Management Program

Identify High Risk Processes (Get input from
stakeholders)
Conduct a Risk Assessment
Conduct Proactive Risk Analysis
Develop Mitigating Strategies
Develop Contingency Plans
Implement Strategies and Plans
Reassess Risks
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IDENTIFY AND REDUCE

UNANTICIPATED ADVERSE EVENTS

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Risk Management
Framework

Leaders adopt a framework that:

1. Risk identification
2. Risk prioritization,
3. Risk reporting
4. Risk management
5. Investigation of adverse events
6. Management of related claims
Conducts and documents a proactive risk reduction annually
Take action to redesign high-risk
processes based on analysis

Arjaty Daud/ IMRK/ Risk Management

Risk
Iden=ca=on

Risk
Assessment

Risk
Reduc=on

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STEP 1: ESTABLISH RISK MANAGEMENT PROGRAM

Examples:
Sub-committee

of the overall QIPS

program
A risk management coordinator
integrated into the QIPS program
Need

to ensure organization-wide,
interdisciplinary representation.

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STEP 2: IDENTIFY ORGANIZATION-WIDE HIGH RISKS

PROCESSES
Sources

of information:

Patient

complaints
Incident reports (QPS)
Medication error reports (MMU.7.1)
Adverse event (medical error) monitoring
(QPS.6-8)
Environmental assessments (FMS.3.1)
INfection control assessments (PCI.5)
Insurance or legal claims
Safety walks or tracers
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CATEGORIES OF HIGH RISK PROCESSES

Types of infections, including organisms of

epidemiological significance
At-risk patient or resident populations
Supplies and equipment risks
Emergency preparedness
Environmental issues
Geographic considerations
Community considerations
Identify specific risk process
In each category
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IS THIS A HIGH RISK PROCESS?

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STEP 3: PREPARE A PRIORITIZED LIST OF HIGH

RISK PROCESSES
Have

leaders use prioritization criteria to

prepare list
List should reflect high risk process
processes for which failure has or will result
in harm to patients, staff, visitors, or contract
workers
You need standardized numerical values or criteria
to assess risks!!!
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RISK RANKING AND PRIORITIZATION METHODS

List

each high risk process

For each high risk process, assign a
score (H,M,L) for each prioritization
criteria
Create a ranked prioritize list of high risk
processes

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RISK RANKING AND PRIORITIZATION CRITERIA

Usual prioriKzaKon criteria are:

Probability or likelihood of occurrence
Risk of harm (criKcality) or impact
System capacity or preparedness

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RISK RANKING AND PRIORITIZATION CRITERIA

Sometimes

criteria given numerical

weight of 1-5 or 1-10 (refer to prioritization tool)
Each criteria scored as low, medium, or
high which is 1,3,5 or 1,5,9, or scored
from 1-10
Assigning numbers to ordinal scales

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PRIORITIZATION TOOL

Rangking

Probability :
4 = Sering Terjadi
3 = Mungkin terjadi
2 = Jarang terjadi
1 = Sangat jarang
0 = Tidak mungkin terjadi

Criteria Score



Sistem
Kontrol
saat
ini /
Dampak terhadap risiko
Preparedness
5 = Meninggal
5 = Kuat / Solid
4 = Cedera permanen
3 = Cedera reversibel / LOS>> 4 = Baik / Good
3 = Cukup / Fair
2 = Cedera ringan
2 = Kurang
1 = Tidak Cedera
1 = Tidak ada / None

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IDENTIFIKASI PROSES RISIKO TINGGI

NO

IDENTIFIKASI PROSES RISIKO TINGGI

Komponen Program

Situasi

RANGKING
PRIORITAS
RISIKO

RISK ASSESSMENT
Probability /
likelihood
(0-4)

Impact
(1-5)

Preparedness Total Score risk

(1-5)

ANALISA
RISIKO
PROAKTIF
FMEA / HVA

Dampak terhadap risiko

Probability :
4 = Sering Terjadi
3 = Mungkin terjadi
2 = Jarang terjadi
1 = Sangat jarang
0 = Tidak mungkin terjadi

5 = Meninggal
4 = Cedera permanen
3 = Cedera reversibel / LOS memanjang
2 = Cedera ringan
1 = Tidak Cedera

Arjaty Daud/ IMRK/ Risk Management

Sistem Kontrol saat ini

5 = Kuat / Solid
4 = Baik / Good
3 = Cukup / Fair
2 = Kurang
1 = Tidak ada / None

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STEP 4: USE PROACTIVE RISK REDUCTION TOOL

FOR ANALYSIS AND PRIORITIZATION

Tools:
Failure

Mode Effect Analysis- FMEA

Healthcare Failure Mode Effect Analysis
HFMEA
Hazard Vulnerability Analysis - HVA
Apply

analysis tool to a list of high risk

processes, starting with the highest
priority
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STEP 5: DEVELOP AND IMPLEMENT SOLUTIONS

It

is the job of management not only to

assess risk, but also to identify effective
courses of action to eliminate or mitigate
that risk
This commitment to implementing risk
reduction methods transforms risk
assessment into risk management
Use a FMEA/RCA method to identify root
causes and potential solutions
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