Académique Documents
Professionnel Documents
Culture Documents
Rumah Sakit
Executive Summary :
Patient Safety, Six Sigma & ISO 9000 Quality Management
(Audit/Akreditasi)
(Audit/Akreditasi)
c cMaintained
Maintained&&Improve
Improve
BSI 5751
EN/ISO 9000
Health MBNQA
Evidence-based
Clinical
Specialities
Evidence-based
Readers’ Users’ Guides Evidence-
Clinical Health Care Information
Guides to to Medical based
Epidemiology (EBHC): Mastery
Medical Literatures Medicine
• Policy
Literatures (EBM)
• Health
Technology
80an 90an Abad 21
Assessment
• Others
Understanding the
Benchmarking
business
Need Assessment
Understanding the
customers PIP (Investors in People)
Total
Quality
Quality QA Model:
System P ISO 9000
A D TQM Model:
S/C
CQI MBNQA
EQA
QA EFQM
Demands Aims
Value/
Needs Objectives Input Process Ouput Outcome Benefit
Relevance
Adequacy Efficiency Efficacy
Accessability Effectiveness
Impact Maxwell
Donabedian
1. Vision : futuristic mind-setting of the organisation
Systems/Standards Indicators
Criteria
ISO 9000: 2000
The ISO 9000 Core Standards
There are four Core Documents, as follows:
1. ISO 9000:2000 provides quality management principles and
fundamentals. It describes what the series is about and lists basic
definitions of terms for use by any organization.
2. ISO 9001:2000 states requirements for quality management
systems when it is necessary to demonstrate that an organization
is capable of effectively meeting customer and regulatory
requirements, such as JCAHO, NCQA, URAC or state and
federal requirements.
3. ISO 9004:2000 provides guidance for establishing a quality
management system that goes beyond ISO 9001 requirements to
meet and exceed customer expectations efficiently.
4. ISO 19011 provides guidance on planning and conducting
quality audits.
Model of a process-based quality management system
Clauses in the ISO 9001 Quality Systems Standard
1. General
8.1. Planning of monitoring and P 821 Customer satisfaction D 8201 Internal auditors
measurement P 822 Internal quality audits D 8202 Audit schedule
8.2. Monitoring and measurement P 823 Inspection and test procedure D 8203 Audit report
8.3. Control of non-conforming P 831 Control of non-conforming D 8401 Customer card
product product D 8402 Supplier card
8.4. Analysis of data P 851 Corrective and preventive actions D 8403 Internal problems since
8.5. Continual improveme one year
D 8501 Meeting schedule
D 8502 System meetings
D 8503 Specific meetings
D 8504 Project data
D 8505 Projects
D 8506 Corrective action request
D 8507 Executed actions
D 8508 Present actions
Basic Quality Performance Wheel
Program Performance
Cost Measurement
Customer
Satisfaction
Partial Wheel with Goals
% F ir e /S m o k e
C o n ta in m e n t
% B a c k I n ju r y D e f ic ie n c ie s % S to r a g e
R e d u c t io n R e d u c t io n D e f ic ie n c ie s
R a te R e d u c tio n
EC
100 O v e r a ll
C u sto m e r 100
5 S e r v ic e
S a tis fa c ti o n
P a r tic ip a t io n
95
95
T e le p h o n e 80 N o. of
80
C ascade 0 F a ls e F ire
N o tif ic a ti o n 80 A la rm s p e r
80 0
C o m p le tio n 100 m o n th
80 3
S a f e ty
S taff
M anagem ent S ta ff
K n o w le d g e
95 K n o w le d g e
L i fe 95
80 E m ergency
S a f e ty 80
P r e p . M g m t.
M g m t.
S e c u r ity
U ti lit y
13 M g m t.
M g m t. 13
H az/
U n s c h e d u le d 0 0 E n v ir o n . In s p e c t.
E q u ip t. M a t.
S h u td o w n s C ite d S m o k in g
M g m t. M g m t.
p e r m o n th V io la tio n s / 6 m o n th s
80 0
0 80
80 25
H o t/C o ld % C r im e
80 80
E n v ir o n . C a lls R a te p e r
p e r m o n th Y ear
R e d u c t io n
90
95
P e r s o n a l ly M SDS
90
O w n ed D e v ic e 95 P ro g ram
D e f ic ie n c ie s
S ta ff
M e d ic a l
K n o w le d g e
E q u ip . I n v e n to r y
D a t a A c c u ra c y
Hospital Based Performance Wheel
Im p le m en t
N ew C lin ic a l
In cr ea se d
P ra c tic e
R evenu e
G u id e lin es
$ 1 5 M il 12
% C o st
% In c r e a se d
R e d u c tio n
P r o d u c tiv ity
$ 1 2 M il 8
10 20
5 10
% D ec re a se
in In v e n to ry
15 10 P ro g ra m % D e c r e a se
C ost 20 35 in W a itin g
T im e
P e rfo rm a n c e
M e a s u re m e n t
and
Im p ro v e m e n t
40 C u s to m e r 15
S a tis fa c tio n
60 20 % D ec re a se
T im e lin e ss B ed D ays
o f A c c e ss of C are
85 20
95 5 30 30
% S a tisfa c tio n
% D ec re a se
per Survey
A b se n te eism
0 50
D ec re a se
C u sto m er
O p er a tin g B e d s
C o m p la in ts
Statistical Tools
Data/Check Sheets
C Statistical
Tools
A
Histograms Pareto Diagrams
U (Root Cause)
S
E Run Charts
S
Control Charts
Process
Capability
Analytical Tools
Data/Check Sheets
C Statistical
Tools
A Histograms Pareto Diagrams
U (Root Cause)
S
E Run Charts
S
Control Charts
Process
Capability
PQM OQM
Process Quality Management Outcome Quality Management
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