EVALUASI PELAYANAN HEMODIALISIS PADA PASIEN JKN DI UNIT HEMODIALISIS RS PANTI RAPIH

RITA KUSUMA D, Dr. dr. Andreas Meliala, DPH, MAS

2020 | Tesis | MAGISTER ILMU KESEHATAN MASYARAKAT

Latar belakang : Rumah Sakit Panti Rapih adalah Rumah Sakit Tipe B dan berdasarkan PMK No. 64 Tahun 2016 tentang Perubahan Atas Peraturan Menteri Kesehatan No. 52 Tahun 2016 Tentang Standar Tarif Pelayanan Kesehatan Dalam Penyelenggaraan Program Jaminan Kesehatan, tarif hemodialisis di RS tipe B sebesar Rp 923.100,00. Rumah Sakit Panti Rapih merupakan Pemberi Pelayanan Kesehatan Tingkat 3 (PPK 3) setara dengan RS tipe A, tetapi walaupun demikian RS Tipe A mempunyai tarif hemodialisis berdasarkan INA CBGs yang lebih tinggi, perbedaan perlakuan di dalam tarif pada Pemberi Pelayanan Kesehatan yang sama-sama tingkat 3 diharapkan tidak berdampak kepada penurunan kualitas. Dari data pelaporan klaim yang dilakukan oleh Tim Casemix terdapat fenomena penurunan persentase pemeriksaan laboratorium dan peningkatan pemberian obat di saat terjadi peningkatan jumlah pasien di Unit Hemodialisis yang menarik untuk dievaluasi dan diteliti untuk melihat dampaknya terhadap pelayanan di Unit Hemodialisis terutama pada pasien Jaminan Kesehatan Nasional (JKN), apakah pemeriksaan laboratorium dan pemberian obat di Unit Hemodialisis sesuai standar pelayanan di Rumah Sakit Panti Rapih. Tujuan penelitian: Mengidentifikasi peranan Clinical Reminder sebagai instrumen evaluasi pelayanan di Unit Hemodialisis pada pasien JKN dengan mengukur tingkat kepatuhan terhadap standar pelayanan. Metode penelitian: Jenis penelitian yang digunakan adalah quasi experimental dengan rancangan pre test dan post test. Populasi penelitian pasien Gagal Ginjal Kronik yang menjalani hemodialisis di Unit Hemodialisis RS Panti Rapih sebanyak 192 orang. Subyek penelitian kualitatif pasien rawat jalan dengan penjaminan JKN menjalani hemodialisis satu sampai dua kali seminggu. Metode pengambilan sampel total population sampling. Dilakukan pre post intervensi. Analisis data kuantitatif dilakukan menggunakan Uji Non Parametrik Beda Rerata Mann Whitney dan Uji Non Parametrik Fischer Exact Test. Hasil dan Pembahasan: Clinical Reminder didapatkan peningkatan rerata frekuensi hemodialisis, rerata pemberian obat dan rerata pemeriksaan laboratorium tidak bermakna secara statistik setelah dilakukan Uji Mann Whitney. Hasil penelitian post intervensi Clinical Reminder didapatkan peningkatan rerata pemberian obat bermakna secara statistik dengan Uji Mann Whitney. Peningkatan rerata jumlah obat dan peningkatan rerata pemeriksaan laboratorium saat dilakukan intervensi berdampak pada peningkatan tarif rumah sakit (real cost) dan selisih tarif antara tarif rumah sakit dengan tarif INA CBGs sehingga terjadi peningkatan rerata pada kedua komponen tersebut dibandingkan pada sebelum intervensi. Pada saat dilakukan intervensi dengan Clinical Reminder kepatuhan terhadap standar pelayanan berdasarkan variabel penyakit penyerta/komorbid, pemberian obat dan pemeriksaan laboratorium meningkat dan bermakna secara statistik setelah dilakukan Uji Fischer Exact Test, Clinical Reminder berfungsi sebagai kontrol dan evaluasi pelayanan sehingga lebih sesuai dengan standar pelayanan. Pada sub penelitian kondisi pelayanan selama pandemi Covid-19 didapatkan tidak ada perubahan dalam jumlah pasien maupun jumlah kunjungan pasien di Unit Hemodialisis. Kesimpulan dan Saran: Clinical Reminder sebagai solusi untuk evaluasi mutu pelayanan di Unit Hemodialisis belum efektif dan kurang sensitif karena Panduan Praktek Klinis (PPK) yang digunakan sebagai acuan standar kurang detil dan terlalu luas cakupannya walaupun terdapat hubungan antara Clinical Reminder dengan tingkat kepatuhan terhadap standar pelayanan. Peningkatan rerata pemberian obat dan rerata pemeriksaan laboratorium serta korelasinya dengan peningkatan kepatuhan terhadap standar pelayanan ini secara bermakna berdampak kepada peningkatan tarif Rumah Sakit dan selisih yang timbul antara tarif Rumah Sakit dengan tarif INA CBGs juga semakin besar. Hal tersebut menjadi tantangan bagi Rumah Sakit bahwa untuk pasien dengan pembiayaan JKN semakin ideal pelayanan yang diberikan sesuai dengan standar pelayanan maka tarif Rumah Sakit semakin besar melebihi paket pembiayaan INA CBGs sehingga menjadi beban Rumah Sakit dari segi finansial. Tujuan Clinical Reminder adalah melihat kesesuaian dengan Panduan Praktek Klinis yang dijadikan standar pelayanan di Unit Hemodialisis bukan naik turunnya jumlah pemberian obat maupun pemeriksaan laboratorium.

Background: Panti Rapih Hospital is a Type B Hospital and based on PMK No. 64 of 2016 concerning Amendments to the Minister of Health Regulation No. 52 2016 About the Standard Rates of Health Services in the Implementation of Health Insurance Program, Rates hemo dialysis in the RS Type B Rp 923,100.00. The Rapih Panti Hospital is a Level 3 Health Service Provider (PPK 3) equivalent to a Type A RS, but even so Type A Hospitals have higher hemodialysis rates based on INA CBGs, different treatments in the rates at Health Care Providers who are equally level 3 not expected to have an impact on quality degradation. From the claim reporting data conducted by the Casemix Team there is a phenomenon of a decrease in the percentage of laboratory examinations and an increase in drug administration when there is an increase in the number of patients in the Hemodialysis Unit which is interesting to be evaluated and examined to see the impact on the service in the Hemodialysis Unit, especially in National Health Insurance (JKN) patients ), whether the laboratory examination and drug administration in the Hemodialysis Unit are rational and in accordance with the service standards at the Rapih Panti Hospital. The purpose of this study : Seeing the role of Clinical Reminder as an instrument of service evaluation in the Hemodialysis Unit in JKN patients by measuring the level of compliance with service standards. Research methods : This type of research is a quasi experimental design with pre-test and post-test. The study population was patients with Chronic Kidney Failure who underwent hemodialysis in the Hemodialysis Unit of Panti Rapih Hospital as many as 192 people. Subjects for qualitative research are outpatients with JKN guarantees who undergo hemodialysis one to two times a week. The sampling method is total population sampling . The intervention was carried out using Clinical Remanding performed pre and post intervention. Quantitative data analysis was performed by statistical descriptive analysis using the Mann Whitney Non-Parametric Average Test and the Non-Parametric Fischer Exact Test . Results and Discussion : The results of the study with Clinical Reminder intervention found an increase in the average frequency of hemodialysis, the mean of drug administration and the mean of laboratory examination were not statistically significant after the Mann Whitney test. The results of the post-intervention study with Clinical Reminder showed a statistically significant increase in drug administration with the Mann Whitney Test. An increase in the average number of drugs and an increase in the average laboratory examination at the time of the intervention had an impact on increasing hospital rates ( real cost ) and the difference in rates between hospital rates with INA CBGs rates so that there was an increase in the average of the two components compared to before the intervention. At the time of intervention with Clinical Reminder adherence to service standards based on variable comorbidities / comorbidities, drug administration and laboratory examinations increased compared to the period before the intervention and statistically significant after the Fischer Exact Test, this showed that Clinical Reminder functions as a control and evaluation of services so that it is more in line with service standards. In the sub-study condition of service during the Covid-19 pandemic, there was no change in the number of patients or the number of patient visits in the Hemodialysis Unit . Conclusion and Recommendation : Clinical Reminder as a solution for evaluating the quality of services in the Hemodialysis Unit is not yet effective and less sensitive because the Clinical Practice Guidelines (PPK) used as a reference standard are less detailed and too broad in scope although there is a relationship between Clinical Reminder and the level of compliance with service standards. The increase in average drug administration and laboratory examination rates and their correlation with increased adherence to these service standards significantly impacts the increase in hospital rates and the difference arising between hospital rates and INA CBGs rates is also increasing. This is a challenge for the Hospital that for patients with JKN funding, the more ideal the services provided are in accordance with the service standards, the greater the Hospital rate exceeds the INA CBGs financing package so that it becomes a burden on the Hospital in financial terms.

Kata Kunci : Clinical Reminder, Evaluasi Hemodialisis, Pasien JKN, Clinical Reminder, Hemodialysis Evaluation, JKN Patients