Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
TRAINER EXECUTIVE
TUJUAN AKTIFITAS
Penyamaan Persepsi
Konsep
FMEA
Penyamaan Persepsi
Teknik Pelatihan
FMEA
SISTIMATIKA PAPARAN
INTRODUKSI FMEA
KESIMPULAN
HERKUTANTO 3
INTRODUKSI FMEA
HERKUTANTO 4
KUALITAS PELAYANAN
(Donabedian)
OUTCOME
PROCESS
STRUCTURE
HERKUTANTO 5
HERKUTANTO 6
SUMBER
HERKUTANTO 7
Apakah itu FMEA ?
metode perbaikan proses kinerja dgn
mengidentifikasi dan mencegah potensi
kegagalan sebelum terjadi.
proses proaktif, dimana kesalahan dicegah &
diprediksi sebelum terjadi.
HERKUTANTO 8
FMEA Terminology
Process FMEA - Conduct an FMEA on a
process that is already in place
HERKUTANTO 11
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
14
Baru
TUJUAN & HASIL
Daftar Tim
HERKUTANTO 15
PEMILIHAN TOPIK FMEA
Proses spesifik di rumah sakit:
Highrisk
Highvolume
highcost
HERKUTANTO 16
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 17
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 19
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
22
Baru
TUJUAN & HASIL
HERKUTANTO 23
HERKUTANTO 24
HERKUTANTO 25
HERKUTANTO 26
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 28
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 29
DIFFERENCES BETWEEN RISKS vs COMPLICATIONS
RISKS COMPLICATIONS
Allergy Anaphylactic Rx
Leucocytosis Sepsis
High
Dog Fence Child
HERKUTANTO 32
HERKUTANTO 33
HERKUTANTO 34
HERKUTANTO 35
HERKUTANTO 36
HERKUTANTO 37
Hazard, Barrier, Target Analysis
Medical Policies
Procedures Patient
Mishaps
HERKUTANTO 38
PENERAPAN HBA PADA FMEA
Prinsip: the DEVILS are in the DETAILS
HERKUTANTO 39
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 40
Hazard analysis: What is it?
becoming reality.
Hazard analysis: What is it?
Identify Hazards
Assess Risks
Reduce Risks
Verify Effectiveness
HERKUTANTO 42
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 50
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 51
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 52
TUJUAN & HASIL
HERKUTANTO 53
HERKUTANTO 54
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 55
Terjadi pada 1-2 staf Kehilangan waktu kecelakaan kerja pada
ANALISIS HAZARD ”LEVEL PROBABILITAS”
HERKUTANTO 56
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 57
HERKUTANTO 58
HERKUTANTO 59
Laboratory Test Ordering Process
HERKUTANTO 60
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
61
Baru
TUJUAN & HASIL
HERKUTANTO 62
Possible Characteristics of Root
Causes
HERKUTANTO 64
PROBING
to uncover root causes and their relationships
Equipment factors
nonfunctional paging system that delays
communication with the individual’s physician
HERKUTANTO 66
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 67
What could happen?
HERKUTANTO
68
Contributory Factors to Suicide
What could happen?
HERKUTANTO 69
DIABETES SCREENING
What could happen?
HERKUTANTO 70
Laboratory Test
Ordering Process
HERKUTANTO 71
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
72
Baru
TUJUAN & HASIL
HERKUTANTO 73
Decision Tree
Gunakan Decision Tree utk menentukan apakah modus perlu tindakan lanjut di“Proceed”
HERKUTANTO 75
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 76
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 77
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 78
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
80
Baru
TUJUAN & HASIL
Le
HERKUTANTO 81
SIKLUS PDSA
HERKUTANTO 82
SIKLUS PDSA
HERKUTANTO 83
LEMBAR KERJA
UJI COBA
HERKUTANTO
84
LEMBAR KERJA
UJI COBA
HERKUTANTO
85
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 86
Proses Baru
TUJUAN & HASIL
HERKUTANTO 87
Strategies for Creating and Managing
the Change Process
HERKUTANTO 89
LEMBAR MONITOR PROSES BARU
HERKUTANTO 90
KESIMPULAN
HERKUTANTO 91
HERKUTANTO 92
HERKUTANTO 93