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Faculty of Medicine
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Standards for Medical
Professional
Tjahjono Kuntjoro
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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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Definition of standards
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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Definition of standards
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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Definition of standards
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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