Pengembangan model manajer kasus dan dampaknya terhadap kepuasan dan mutu pelayanan klinik di rumah sakit :: Penataan struktur dan proses pemberdayaan manajer kasus di ruang rawat inap

KASIM, Felix, Promotor Prof.Dr. Mohammad Hakimi, SpOG(K).,Ph.D

2007 | Disertasi | S3 Ilmu Kedokteran

Latar belakang: Perubahan manajemen pelayanan kesehatan yang Cost effectiveness berorientasi pada patient safety dan quality assurance mendorong perubahan menyeluruh dari paradigma service exellence menjadi clinical exellence. Oleh karenanya penting dilakukan intervensi untuk meningkatkan mutu klinik. Tujuan penelitian: untuk mengetahui dampak penerapan disease case manager dengan integrated clinical pathway pada penanganan pasien TBC yang dirawat inap di RS.Immanuel Bandung Jawa Barat. Metode penelitian: Jenis penelitian adalah Action Research ,yang berlangsung selama 2 tahun. Pada tahap diagnosing action dilakukan penyamaan persepsi mengenai manajer kasus (MK) dan integrated clinical pathway (ICP) serta pengkajian pelayanan keperawatan dan penanganan TBC di RS. Dilakukan pengumpulan data dengan wawncara mendalam 24 responden kunci, 12 informan tambahan dan observasi partisipatif di RS.Immanuel. Telaah 30 rekam medik serta FGD dengan 32 responden. Tahap planning action terutama digunakan untuk memfinalkan instrumen, merekrut manajer kasus maupun ICP dan memantapkan jejaring. Setelah itu dilakukan tahap taking action dan evaluating action secara bersamaan. Log book dan ICP distandarkan kepada ICP dari model manajamen kasus diterapkan kepada 153 pasien TBC yang dirawat inap. Analisis data pada tahap diagnosing hingga taking action menggunakan thematic analysis, sedangkan pada tahap evaluating action digunakan uji statistik beda dua mean independen untuk membandingkan sebelum dan sesudah intervensi dengan manajer kasus. Hasil penelitian: Pasca pelaksanaan ICP kepuasan meningkat dari 20% menjadi 88 %. Kelengkapan resume medik dan keperawatan meningkat dari 30 % menjadi 83%. Kepatuhan terhadap standar meningkat dari 20% menjadi 33,3%, ketepatan order ke farmasi dari 0% meningkat menjadi 54,9%, kejadian dekubitus menurun dari 6,7% menjadi 0,7%, kejadian infeksi dari 6,7% menjadi 0,7%, serta kesesuaian melaksanakan DOTS dari 13,7% menjadi 50%. Pada thematic analysis ditemukan tema proses, dimensi, strategis, interaktif, identitas, kultur, konsensus, program, indikator yang mempengaruhi kualitas MK dan pelaksanaan ICP. Uji hipotesis bermakna secara statistik dengan uji beda mean dua sampel dengan alpha 0,05 pada variabel kepatuhan terhadap standar penatalaksanaan TBC, lama hari rawat, biaya perawatan total murah, angka kejadian infeksi dan dekubitus serta kelengkapan catatan medis. Kesimpulan: Penelitian ini menerapkan model disease case management melalui peran manajer kasus menggunakan ICP meskipun model ini belum dapat meningkatkan kepuasan pasien, mengurangi cost dan LOS.Model manajemen kasus dapat meningkatkan kolaborasi dan informasi pemberi pelayanan kesehatan, kualitas pelayanan dan harapan pasien. Manajer kasus dapat mengembangkan model ini untuk penyakit-penyakit lain di RS.

Background: Cost effectiveness, patient safety and quality assurance stimulates comprehensive changes from service excellence paradigm to clinical excellence. Therefore, efforts to improve clinical quality is an important endeavour. Objective: This study was aimed to measure of disease case management model for TB implemented by case manager using ICP at Immanuel private hospital Bandung West Java. Method: Action Research was applied in this two year study. In diagnosing action phase, activities were carried out to improve understanding on case manager and ICP, to assess current nursing services and to describe TBC case manager in inpatient department. Indepth interview with 24 keys informats and 12 additional informants, participant observation in inpatient department, analysis of 30 TB medical record as well as FGD with 32 respondent were carried out. Planning action phase aimed to finalize the instrument, recruit case managers, develope ICP and establish external network for TB. This phase was followed by taking and evaluating action, implemented con currently. The log book and ICP were distributed to case manager and the disease case management was implemented to 153 TB cases. Thematic analysis was used for qualitative data during diagnosis, planning and taking action phase. While statstical test was applied in the evaluating action phase to compare before and after intervention. Result: The use of case manager and ICP increased patient satisfaction from 20% to 88%. Medical record completeness increased from 30% to 83%. Compliance to standard increased from 20% to 33.3%, the order accuracy to pharmacy increased from 0% to 54.9%, decubitus decreased from 6.7% to 0.7%, infection decreased from 6.7% to 0.7% and compliance to DOTS strategy from 13.7% to 50%. Thematic analysis identified process, dimension strategic, interactive, identity, culture, consensus, programs, and indicator influencing case manager quality and implementation of ICP. Significant differences were found in TB case management standard, LOS, total, the proportion of infection and decubitus and medical record completeness. Conclusion: In conclusion, this study applied disease case management model for TBC inpatient case management, through the role of case manager and use of ICP. Although this model has not been able to reduce cost and LOS, however, case manager has improved collaboration of service providers information, service quality and patient expectation. The model can be further developed for other preventing diseases in the hospital.

Kata Kunci : Manajemen Keperawatan,Mutu Layanan Klinik Rumah Sakit,Model Manajer Kasus,case manager, integrated clinical pathway, TB case management, nursing management