Slide Standarmedpractice

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Faculty of Medicine

Gadjah Mada University

Standards for Medical

Professional

Tjahjono Kuntjoro


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Faculty of Medicine


OBJECTIVES

1. Understand and explain the definition ofstandard for medical professional

2. Explain the importance of standards in

providing medical services 3. Explain types of standards being used in

medical professions

4. Understand the steps of developingstandards

5. Understand how to monitor and evaluate

the implementation of standards


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Subtopics

1. Definition of standards in medical practice 2. The benefits of standards in medical

practice

3. Types of standards in medical practice

4. The steps of developing standards

5. Monitoring and evaluating theimplementation of standards


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Definition of standards

Oxford dictionary: standards are degrees of excellence,

standards serve as a basis of comparison

standards are a minimum with which a

community may be reasonably content,

a standard is recognized as a model forimitation.


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Donabedian: professionally developed expressions ofthe range of acceptable variations from a

norm or criterioncriteria are defined as predetermined

elements against which aspects of the

quality of medical services may becompared, and norms as measures ofusual observed performance.


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Katz & Green: Standard is defined as a written statement

that specifies expectations

Standards in health care practices are

divided into three domains: standards of

governance, standards of practice, and

standard of service.


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Meissenheimer: Any established measure of extent, quantity,

quality, or value; an agreed-upon or expectedlevel of performance;

The expression of the range of acceptablevariations from a norm or criterion.

WHO:

A benchmark of achievement which is basedon a desired level of excellence.

Standards become models to be imitated and may

serve as the basis for comparison.


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Benefit ofstandards

in medical

practice

Needs

Expectation

Customer

Focus

Requirement

Process Variation

Process Improvement

S D

A C

P D

A C Re-engineering

Q S

P AEvidence Based

8 dimensions:

access effectiveness

efficiency

safety

continuity of care

technical competence

amenities

human relationship

Principles:

Customer focus

Process focus

CommitmentEmpowerment

Vision, Mission, Values, Management System, Leadership

Chan e of Behavior


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Why standard/practice guidelines

may be needed ?

Problem in clinical decision makingrelated to:

Size of health burden Cost

Variations in practice

Existence of available evidence


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Benefits of standards in medical

practice

Reducing process variations (Schroeder, 1994) Safety of the patients and the health workers: (Moss &

Barrach, 2002; Reason, 2002) Care can not be considered to be high quality unless it is safe

Standards should be established in order to reduce patient harmas well as workers harm

Professional requirements:

As a profession we have a duty to maintain good standards ofpractice and care, and to show respect human life (Swage,2000)

Articulate what the professions do (Schroeder, 1994)

A framework for measuring quality (Schroeder, 1994).


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Use of guidelines by clinicians

(Feder et al, 1999)

Guideline for practice

Information source for continuing professionaleducation: overview of the management of a

condition or the use of an intervention Instrument for self assessmeent

Answer specific clinical questions arising out

of day to day practice Allows the clinicians to identify what sort of

evidence to search for


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Potential benefits for patients

Improve health outcomes Reduce mortality and morbidity

Improve quality of life Improve consistency of care

Make more informed health carechoices, preferences in selecting the

best options


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Potential limitations

Scientific evidence about what to recommendis often lacking, misleading, or misinterpreted

Recommendations are influenced by the

opinions and clinical experience andcomposition of the standard developmentgroup

Patient needs may not be the only priority inmaking recommendations, otherconsiderations maybe: managerial, political,economic, etc)


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Potential harms to patients

Recommendation that do not take dueaccount of evidence can result in suboptimal,

ineffective or harmful practices

More consistent practice patterns andreduced variation may come at the expense

of reducing individualized care for patients

with special needs

Adversely may affect public policy (example:

displace limited resources)


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Potential harm for

professionals

Conflicting guidelines/standardsfrom different professional bodies

Unfairly judgment the quality of care

based on invalid

standards/guidelines

Ignoring complexity of medical care


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Types of standards

Donabedian:

Structure standards: the things we use( human, financial, physical resources)

Process standards: what we do (activities

that constitute care, service, ormanagement)

Outcome standards: address the results


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Standard

External Standards

Internal Standards

Developed by people/organization outside the health care

facility

Developed by the health care facility itself based on evidence,

References, and the conditions of the organization

(Burrill & Ledolter, Achieving Quality through Continual Improvement)


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Standard

Minimal

Optimal

Achievable

No service should fall bellow

this standard

A must, bellow which lies the

unacceptable

The best level of service that

can be achieve

Represent a degree of excellence

The level of performance achieveby the top quartile of service

(MuirGray, J.A., Evidence Based Health Care, 2001; WHO, 1993)


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Focus of standards

Organization and management of health

care: Standard Operating Procedures Clinical Practices: Clinical Practice

Guidelines/Standards or Clinical

Protocols, and Care Pathways


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Standard developed

by

external organization:MOH

Standard for Evaluating

The Quality system or

Assuring the service

quality

(optimal)

Developed by

Accreditation body

Accreditation

Licensing

Professional

Organizations

Clinical standards

Professional guideline

Clinical Procedures

Standard of care

Standard of practice

Standard of

governance

Standards for public

service

Standards forclinical practices

Standards for

Administration &

management

Internal Standards

(achievable)

Health

Professions


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Read this statement:

The development of practice standards is notwithout controversy: many physicians argue

that such standards are too restrictive and

impede exercise of their best judgementwhen treating individual patients (WHO,

1993).

So instead of using the term of standard, theprofessional organizations tend to use the

term of guideline as a softer standard.


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Organization and management

standards are easier todevelop, monitor and evaluate

but.

Clinical practice standards require

a great deal of consensusbuilding to achieve and to

interpret appropriately


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How standards are set

Collectiveprofessional

judgment

Evidence basedValue based


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Steps in developing standards Basic principles:(NHMRC,1998).

should focus on outcomes,

should be based on the best available evidence and shouldinclude a statement about the strength of theirrecommendations,

the method used to synthesize the available evidence should bethe strongest applicable,

the process of guideline development should be multi-disciplinary and should include consumers,

should be flexible and adaptable to varying local conditionsincluding the technology development and resources available,

should be developed with resource constraints in mind,

guidelines are developed to be disseminated and implementedtaking into account their target audiences,

the implementation and impact of guidelines should beevaluated,

should be revised regularly


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Steps in developing standards

determining the need for and scope of the

guidelines, convene a multi-disciplinary panel tooversee the development of the guidelines,

define the purpose of and target audience for the

guidelines, identify health outcomes,

review the scientific evidence,

formulate the guidelines,

formulate a dissemination and implementation

strategy,


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Steps in developing standards

formulate an evaluation and revision strategy,

proceed to produce the guidelines,

reporting on the guidelines development

process,

assessing the guidelines document whether it

conforms to the principles of guideline

development, and

consultation to wider group of interested parties

that may not have already been involved.


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Should all activities orprocesses be standardized ?


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Criteria for prioritizing the need

for developing standards

High risk High cost

High volume Problem prone


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Monitoring and evaluating the

implementation of standards

Clinical micro-system: small organizedgroups of providers and staff caring for

defined populations of patients,assessing and monitoring theperformance.

Self assessment: using a check list

Peer-review: using a check-list.


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Conclusions

Standards for medical professional as written

statements that specifies expectations, degreesof excellence, expressions of the range ofacceptable variations from criterion, are needed

for assuring quality, safety, and professionalmedical care services.

The standards can be divided into structure,

process, and outcome, as well as practice,service, and governance. Concerning the levelsof standards, there are minimum and optimum

standards.


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Conclusions

The implementation of appropriate standardwill improve quality of care, assure patient

and provider safety by reducing patient andworker harms.

The development of standards or practice

guidelines should involve professionals aswell as customers, and should be based onthe best available evidence.

Standards should be tested, implemented,monitored, and continually revised basedon the best evidence, knowledge,

evaluation results, and medical technologydevelopment.


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References

Bapelkes Gombong (2000), Laporan Evaluasi Pasca Pelatihan Jaminan Mutu, Gombong.

Katz, J.M., Green, E.,(1997) Managing Quality: A Guide to System-Wide Performance

Management in Health Care, 2nd ed, Mosby, St Louis: 24-32

Meisenheimer, C.G., (1997) Improving Quality: A guide to Effective Programs, 2nd ed, Aspen,

Maryland:33-44. Mohr, J.J., Batalden, P.B., (2002), Improving Safety on the front lines: the role of clinical

microsystems, Qual Saf Health Care: 11:45-50.

Morris, A.H., Decision support and safety of clinical environment, Qual Saf Health Care. 11:69-

75.

Moss, F., Barach, P., (2002), Quality and Safety in Health Care: a time of transition,

Qual Saf Health Care, 11:1. NHMRC (National Health and Medical Research Council), 1998,A guide to development,

implementation, and evaluation of clinical practice guidelines, Canberra.

Pusdiklat DepKes RI, (1996) Modul Pelatihan Jaminan Mutu Pelayanan Kesehatan Dasar di

Puskesmas, Jakarta

Reason, J., Combating omission errors through task analysis and good reminders,

Qual Saf Health Care, 11:40-44. Schroeder, P., (1994), Improving Quality and Performance: Concepts, Programs, and

Technioques, Mosby, St Louis: 9-11

Swage, T., (2000), Clinical Governance in Health Care Practice, Butterworth Heinemann,

Oxford: 197.

WHO, Division of Strengthening of Health Services District Health System, The Contemporary

use of Standards in Health Care, 1993.

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