Pmkp 12.Panduan Manajemen Resiko

DAFTAR ISI

BAB I.

PENDAHULUAN………………………………………… PENDAHULUAN……………… ……………………………………...3 …………...3

BAB II.

PENGERTIAN………………………………………… PENGERTIAN……………… ………………………………………….6 ……………….6

BAB III.

PERAN DAN TANGGUNG JAWAB DALAM MANAJEMEN RISIKO…………………… RISIKO……………………………………7 ………………7

BAB IV.

PROSES MANAJEMEN RISIKO……………………… RISIKO…………………………………..8 …………..8

BAB V.

SISTEM PELAPORAN………………… PELAPORAN……………………………………………… ……………………………15 15

BAB VI.

PENDIDIKAN DAN PELATIHAN………………… PELATIHAN………………………………..16 ……………..16

BAB VII.

INDIKATOR KEBERHASILAN…………… KEBERHASILAN…………………………………..17 ……………………..17

BAB VIII VIII.. RENCAN NCANA A KEGIA EGIAT TAN

………… ………………… ……………… ……… …………… …………18 18

BAB I.

MONITORING DAN EVALUASI…………………………… EVALUASI…………………………………1! ……1!

BAB .

PENUTUP…………………………………………… PENUTUP……………… ……………………………………………"# ………………"#

LAMPIRAN……………………………………………… LAMPIRAN………………… …………………………………………………….."1 ……………………….."1

1

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KATA PENGANTAR

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#euangan

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masyarakat

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)ATRI#6 )ATRI#6 GRA+ING RI6I#7 2ntuk menentukan skor risiko digunakan matriks grading risiko : a! Tetapkan %rekuensi %rekuensi pada kolom kiri kiri b! Tetapkan dampak dampak pada baris ke arah arah kanan c! Tetapkan 'arna 'arna bands>nya bands>nya berdasarkan berdasarkan pertemuan pertemuan antara %rekuensi dan dampak Skor Skor risik risiko o akan akan menen menentuk tukan an priori prioritas tas risik risiko. o. Jika Jika pada pada asesme asesmen n risik risiko o

berat

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Institus R6!

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;beberapa /thn< ( )ungkin terjadi ;>" thn/< & 3arang terjadi ;">* thn/< " 6angat jarang terjadi ;* thn/< 

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d! E.al E.alua uasi si risi risiko ko i! Risk ranking ii! Prior ioriti9 iti9e e th the ris risk k ;m ;mempr mprior ioritas itask kan ris risiiko< ko< iii! 0ost Bene%it Analysis ;membandingkan

biaya

pengura penguranga ngan n risiko risiko dengan dengan biaya biaya yang yang timbul timbul apabila apabila i.! i.!

terjadi riskor ah>ringa ingan n akan akan dikelola dikelola 2) Risiko oleh #omite )utu dan #eselamatan Pasien bersama #epala unit kerjaInstalasi kerjaInstalasi untuk membuat rencana tindak lanjut dan penga'asan! Tindakan sesuai tingkat dan Bands Resiko

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kelola risiko Risiko Risiko rendah$ rendah$ dilakuk dilakukan an in.esti in.estigasi gasi sederha sederhana na 5o' ;rendah<

pali paling ng

lama lama

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ming minggu gu

disel iseles esai aika kan n

den dengan gan

prosedur rutin

"! Pena Penang ngan anan an Risk Risko o#e #elo lola la kasu kasus s

risi risiko ko untu untuk k

memi memini nima malk lkan an

kerugian ;Risk 0ontrol< Perlakuan risiko adalah upaya untuk menyeleksi pilihan yang dapat mengu menguran rangi gi atau atau eniad eniadak akan an dampa dampak k sert sert kemun kemungki gkina nan n terja terjasi si risiko! Perlakuan yang dapat dipilih adalah: a! Peng Pengen enda dali lian an 2paya untuk mengubah risko yang merupakan langkah>langkah antiipati% yang direncanakan dan dilakukan secara rutin untuk mengurangi risiko! b! Penan enanga gana nan n 5angka 5angkah h yang yang dambil dambil untuk untuk mengur mengurangi angi risko risko jika tindaka tindakan n pegendalian belum memadai! +apat juga bermakna langkah> langkah yang telah direncanakan dan akan dilakukan apabila risiko ben>benar terjadi! 7psi Perlakuan Risiko

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)engurangi risiko

 "

prosedur dan persyarata!  Asuransi  Asuransi  Alih dayakan dayakan pekerjaan pekerjaan

)enerima resiko

BAB 8 6I6TE) PE5AP7RAN ! 6eti 6etiap ap unit unit pela pelaya yana nan n mela melaku kuka kan n iden identi ti%i %ika kasi si risi risiko ko seta setahu hun n seka sekali li kemudia dikompilasikan oleh 6ub #omite )anajemen Resiko! "! +ata +ata risik risiko o dike dikelo lola la lebih lebih lanju lanjutt oleh oleh #omi #omite te )utu )utu dan dan #ese #esele lema mata tan n Pasien &! +ata +ata risiko risiko terka terkait it in%eks in%eksii diserah diserahkan kan ke #omit #omite e PPI PPI (! +ata +ata risiko risiko non non klinis klinis diserahk diserahkan an kepad kepada a Tim Tim #& R6! *! Tim )anage )anagemen men risiko risiko menen menenuk ukan an Priorit Prioritas as risiko risiko yang yang ada ada di rumah rumah sakit sakit$$ dan dan melaku melakukan kan analis analisis is 1)EA! 1)EA!

)enyu )enyusu sun n desa desain in baru baru dan

memberikan rekomendasi kepada #epala! ,! Pela Pelaksa ksanak nakan an desig design n dipan dipanta tau u dengan dengan pengu pengumpu mpulan lan indik indikato atorr resiko resiko oleh PI0 data dari masing>masing umit pelayanan! -! +ata +ata die.a die.aluas luasii setia setiap p tiga tiga bulan bulan sekali! sekali! =! +ata +ata tahun tahunan an direk direkap apit itul ulas asii dan dan dian dianal alis isa a untu untuk k dila dilapo pork rkan an kepad kepada a

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BAB 8I PEN+I+I#AN +AN PE5ATIAN PE5ATIAN ! )ana )anaje jerr Resi Resiko ko meng mengko koor ordi dina nask skan an pend pendid idik ikan an dan dan pela pelati tiha han n bagi bagi manager ruangan dan sta% terkait! "! )en )ensosia osiallisas isasik ika an kepad pada selur luruh

sta%

tentang tang

manajemen risiko dalam pelayanan di rumah sakit!

imp implement menta asi

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2ntuk menilai bah'a penurunan risiko bisa dijalankan$ ditetapkan beberapa indikator yaitu :  A! Indikator #linis ! Angka Angka kejad kejadia ian n salah salah pemb pemberi erian an obat obat "! Angka Angka keja kejadia dian n in%ek in%eksi si daer daerah ah oper operas asii &! Angka Angka keja kejadian dian Phlebiti Phlebitis s pada pada pasie pasien n ra'at ra'at Inap Inap (! Angka Angka kejad kejadia ian n rese resep p tidak tidak terbac terbaca a *! Angka Angka kejadian kejadian kesalah kesalahan an hasil hasil labo laborato ratorium rium ,! Angka Angka keja kejadia dian n salah salah pros prosedu edurr operas operasii -! Angk Angka a keja kejadi dian an pas pasie ien n jatu jatuh h =! Angka Angka kepatu kepatuha han n pemb pemberi erian an antib antibiot iotik ik prop prophil hilaks aksis is pada pada opera operasi si bersih terkontaminasi D! Angk Angka a res respo pon n tim time e di di IG+ IG+ ?! ?! 4aktu 4aktu tunggu tunggu hasil pemeriksaan pemeriksaan penunjang penunjang B! Indi Indika kato torr Non Non #li #lini nis s ! Insid Insiden en petu petugas gas tertus tertusuk uk jarum jarum "! Insid Insiden en pasie pasien n terke terkena na seng sengata atan n listri listrik k &! Insid Insiden en karya karya'a 'an n atau atau pengun pengunjun jung g jatuh jatuh!! (! Tuntutan untutan hukum hukum oleh pasien pasien berka berkaitan itan denga dengan n prosedur prosedur pelaya pelayanan nan *! Penund Penundaan aan pelayan pelayanan an terkait terkait kerusak kerusakan an alat! alat! ,! #etepa #etepatan tan 'akt 'aktu u pengaju pengajuan an klaim klaim pela pelayana yanan n kesehat kesehatan an -! #etepa #etepatan tan 'aktu 'aktu penang penanganan anan aduan aduan masyara masyarakat kat

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sbg

bagian kebijakan

inte integr gral al

)anajemen Risiko

dari dari strategis

R6

R6

tentang

Pembentukan Tim

)anajemen

)anajemen Risiko R6

)embangun

risiko 6osialisasi

kesadaran

manajemen

tentang

dan

resiko

manajeme manajemen n risiko risiko risiko<

kepedulian

kepada

dan

sta% sta%

tent tentan ang g seluruh sta% 

manajemen resiko Pembelajara n

lalu

%aham Tim

P)#P 3anuari

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implementasinya 5aporan #P0

Identi%ikasi

dan risiko

pengalaman risi risiko ko

6ta%

set setiap iap

Risk register  di  Analisa

unit untuk

tahu tahun n pelayanan

risiko

Tim P)#P

1)EA ;manajemen prioritas risiko<

3anuari "?,

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E.aluasi dilakukan dengan cara: ! Audit untuk menelusuri menelusuri risiko yang terjdi terjdi berkaitan berkaitan dengan pelayanan pelayanan menyangkut dokter maupun pera'at! "! Re.ie Re.ie' ' dilak dilakuk ukan an pada pada kasus kasus sent sentine inell denga dengan n menge mengemb mbang angka kan n analisis 0ause Root Analysis! 5aporan e.aluasi pencapaian indikator risiko disusun setiap tri 'ulan dan K$$'! tahunan$ dilaporkan kepada #epala R$-/ S-)& K-*&)- H$'-- K$$'!

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prasaran prasarana a yang yang tersedia tersedia!! Apabila Apabila dipanda dipandang ng perlu perlu dapat dapat dilakuk dilakukan an re.isi re.isi #omite )utu dan #eselamatan Pasien dengan persetujuan #epala!