Quality Evaluation of Inpatient Services Audit Through Death In RSD Col. Bangko Abundjani Jambi Province in 2005

EVALUATION OF QUALITY OF SERVICE THROUGH AUDIT Inpatient DEATH
IN RSD cabbage. BANGKO ABUNDJANI JAMBI PROVINCE OF 2005

THE EVALUATION Inpatient CARE QUALITY
Mortality BY AUDIT IN cabbage. ABUNDJANI DISTRICT HOSPITAL
JAMBI PROVINCE IN 2005.

Joni Rasmanto1, Tjahjono Koentjoro2, Hanevi Djasri3

INTISARI


Background: Increasing number of deaths occurred in Col Regional Hospital.
Bangko Abundjani (RSKA), Kab. Merangin Prov. Jambi from year 2002-2005
requires a critical evaluation of the action, because of the increased mortality may be wrong
one reason or need for medical audit can be a topic in medical audit in
hospital. Audits of death as a critical evaluation of improvements made
quality of health services.

Research Objectives: This study aims to determine the reasons for death
unwarranted abuses in the areas of health service management.
Research Methods: The type of research is restrospective review, meriview death
is not reasonable to use the checklist in the death deviation
RSKA.

Results: Of 413 sets of RM patients audited deaths amounted to 102 sets, death
The highest of the total deaths occurred in 2005, the number of patients occurred in 2004,
Most think the code 002. 60% of deaths cost occurred in intensive care class. Death occurs diusia> 45 years amounted to 49%
with the largest gender is female, the time of death increased in the month
September and December and nurses most often to witness the death of the patient.
The family is the greatest guarantor of maintenance costs.

Of the 21 deaths is not unreasonable distributed: 8 deaths occurred because the incident
the cause is not known; 7 deaths due to incorrect diagnosis; 5 deaths occurred
because prevention is not adequate, and 1 death due to diagnosis
major late enforced. The most important causes occurred in the area:
administration / management, Members of SMF / individual, service unit, and clinic services
special. RM patients incomplete. Theoretically the quality of administration and RM RSKA
is not good. Death is not reasonable to give an idea of how
diagnosis enforcement, anamnesa, physical examination and inspection
supporting prevention and treatment.

Conclusion: The causes of death of the most important deviations as a result of
of the audit and Riview occur in areas: administration / management, Members of SMF /
individual, inpatient care units, and specialized clinical services.

Keywords: audit of death, death is not reasonable, the quality of inpatient services.
1) RSD Col. ABUNDJANI BANGKO, KAB. MERANGIN. JAMBI PROVINCE
2) BAPELKES GOMBONG
3) Public Health Graduate Programs FK UGM

EVALUATION OF QUALITY OF SERVICE THROUGH AUDIT Inpatient DEATH
IN RSD cabbage. BANGKO ABUNDJANI JAMBI PROVINCE OF 2005

Introduction

Increased mortality occurred in Col Regional Hospital.
Bangko Abundjani (RSKA), Jambi Province Merangin District from 2002 --
2005 requires a critical evaluation of the action, because death can be wrong
one cause may be needed or audit the implementation of medical topics
for the home sakit.1 mortality rate is one indicator that
relating / referring to the aspect of medical service. Total mortality of patients>
48 hours can describe how the quality of service in hospitals and
how to implement professional standards and procedures
service, both clinically and administratively to pasien.2
Various activities to support quality management has been done
RSKA but not affect the improvement when seen from the increase
mortality> 48 hours and still the patient's hospitalization installation of
referred to another hospital between the years 2002-2005. If connected with
quality of service, it can give the picture is still high
mortality rates, high mortality rates can be assumed
low quality of service sakit.3 home
Patients in clinical death can be caused by the failure of the stages
disease diagnosis, incomplete anamnesa, physical examination
and investigation and also as a result of the information
required doctors can not be given by the patient and or family
so that efforts can be of service is not the right target and is not adequate.
Medical records at a critical phase of patients dying from medical record
an information and important component of quality management at home
ill.
The American College of Surgeons (ACS) to formulate a standard
for professional work in hospitals, among others, there are 5 (five) items
significant associated with death, and there are threshold limits and
not too difficult to collect data, including: number of deaths
rough; post-surgical mortality; anesthesia mortality; mortality
birth and death rates bayi.4 Medical Care Quality Standard can
seen from the high and low mortality rate in hospitals and as
The following numbers are the indicator is a general reference: crude death rate
3-4%; post-surgical mortality 1-2%; anesthesia mortality rate <1%;
childbirth mortality rate 1-2 ‰ and 15-20 ‰ infant mortality .2
Department of Health requires hospitals to audit
medical, hospitals are expected to be responsible for improving the quality of
service with high standards in accordance with the conditions of the hospital
so that the realization of prime medical service in hospital. Aspects of quality
medical service at the hospital strongly associated with medikolegal 5.
The main issues to note in this study are:
cause of death in the installation of hospitalization RSKA from 2002-2005;
the percentage of deaths that are not justified and was justified on the
expectations of research results used as input in the planning
improvement of service quality.

Materials and How to Research.

Audit includes qualitative type of research, with a retrospective method
Riview. Researchers use the "List Tilik Diversion Analysis Mortality"
to determine why the death of> 48 hours RSKA years in 2002-2005.
Research Results
Audit found distribution in the event of death by death,
SMF code number according to the care, according to treatment costs, according to the
treatment classes, according to age groups, by gender, according to the moon
events, according to testimony, according to insurer costs. While for
unwarranted death is described as follows:
a. Diagnosis of late.
One case of death with the diagnosis of malaria Decompensatio Cordis +
Falciparum is happening because of late diagnosis with enforcement
RM code 002-12. Audit results showed that the diagnosis of malaria and
action to address the new Malaria issued after laboratory results
note on the third day of treatment. Actually, there was suspicion
Malaria on the first day because at that time there have been results
Malaria blood tests, but still in doubt. General physician
consultation with the doctor treating the room on the second day but not
can be reached because of out of town.
b. Incorrect diagnosis
There are 7 (seven) of death due to lack precision
in enforcement diagnosis. Examples of cases with the code RM 002-1, where
diagnosis on the first day of malaria without complications were not
accordance with the evidence. Evidence indicates that should the day
The first is the diagnosis can be established Ilius malaria with complications
Cc Paraltik obstruction.
Audit results provide evidence for the answers that obstruction at Ilius
The first day is still considered weak, specialized medical consul answered the following
day because the nurse did not find a doctor and also because konsulen
results of laboratory and radiological examinations did not support the establishment of
diagnosis consistent with patient's illness. Suggestions for
fasting before the examination is not radiological follow the patient, the patient ate
porridge in the morning. The main causes of laboratory and radiology are not
support the establishment of an appropriate diagnosis with the illness
patients.
c. Inadequate prevention
There are 5 (five) cases of death due to causes of death not
prevented by good. An example of this is the case of RM death 004-5
due to the central nervous system depression due to recurrent febrile seizures. Tindakantindakan
to prevent recurrent seizures were considered to be taken by way of
adequate and not also just in time, ie: not done
cold compresses, there is no re-provision of anti therapy suppository seizures
perrectal, installation not in veins IVFD Sectio that intervention
IVFD re-installation will stimulate an outbreak of seizures. Discussion
concluded that these precautions are not taken with
adequate way and on time because there is no doctor's instructions, physicians
not renew the instructions in the days following treatment.
d. The cause is unknown
There are 8 (eight) mortality due to causes of death is unknown,
not known to be caused by limited communications, no
examination progress notes, do not do checks
vital sign, laboratory tests and radiology doctors doubted
main, this is the case for the RM 002-1 deaths because it is still
suspected patients short of breath as a result of pulmonary TB disease who suffered
patients. Recording of the symptoms of sepsis is, treatment directed
the primary diagnosis. The results of the discussion found that the lack of results
recording of patient progress is communicated and the
doubts about the results of malaria and the number of leukocytes and
culture culture, whereas the primary physician can not be contacted.
From the above description there are several causes of death
not unreasonable and cause them grouped in the area
health services management irregularities as shown in table
following.

Table Area deaths unjustified cause

NO causes of Audit Results Area Main Cause Number
1 1. Equipment pack is not available
2. No rectal suppository
3. Policies for the existence of the duty physician-patient rooms there is no
4. SMF policy set when a specialist left the task no
5. Oxygen hose often loose
6. Nurses trained in the morning service only
7. Equipment not yet ready for use when needed
8. Many family members waiting
9. The availability of fresh blood
10. Doctor-patient care there is no space
11. Internal training for clinic staff is not maximized
12. Advocacy PMI RSKA no results
Administration / management
RS: related to facilities, equipment, incentives, policies, leadership,
12
2 1. The first day of general practitioners treated patients
2. Specialist medical consultation was answered by a general practitioner after doctors briefed the main
Staff / Section / Medical Services;
2
3 1. The doctor did not write instructions
2. The doctor did not write the instructions clearly and properly
3. Installation of NGT on the third day after a complaint bloating
4. Doctors just write idem, continue therapy
5. Large off exercising their rights
6. Specialist medical consultation to answer the next day
7. The nurse did not find a doctor konsulen
8. General practitioners treated patients in the first day of treatment
9. Results malaria doubt SMF Member / Individual:
9
4 1. The absence of standard Protap and laboratory services
2. The results of laboratory and radiology tests do not support the establishment of diagnosis
3. Inspection is not maximized culture results
4. Results malaria dubious Special Clinic Services: laboratory, radiology, elektromedik, anesthesia, surgery, and other
4
5 1. Equipment not yet ready for use when needed
2. Internal training for clinical staff with experience which is still not functioning lower maximal
3. Oxygen hose often loose
4. Rehydration did not use Venasectio
5. Many family members who waited in the room
6. Using cardboard spalk
7. Bowl of water is available only to sink doctors and nurses wash their hands
8. Preparation catater as consumables exhausted
Units of service: inpatient, outpatient, ER, etc. 8
6 1. Trained nurses sexy veins are not easily contacted
2. Lack of knowledge about anatomy and nurse physiological respiratory system
3. Oxygen hose often loose
4. The nurse did not keep records of checks of vital signs
Nurse / Individual 4
7 1. Doctor's instructions 1 liter / minute, the nurse put 3 liters / min
2. There is no doctor's instructions Therapy Services Not By Doctor 2
8 1. Refused intensive care
2. Cateter catheter is not just after the doctor's instructions made
3. Suggestions for fast ahead of radiological examinations of patients not followed
Conditions and / or disobedience of patients 3
9 1. Many family members who waited in the room
2. Family still searching for blood donors
3. The patient had not bought the equipment and materials needed community Factor 3
10 1. Doubts about the results of blood tests for malaria
2. The nurse did not keep records of checks of vital signs
Something you need further research. 2

There are several important areas that need intervention to
improve service expected hospitalized later can
reduce the number of deaths is not unreasonable. Twelve causes
deaths are in areas of administration / policy-related RSKA
service facilities, equipment availability, policy incentives, policy
services, human resources policy, advocacy and leadership.
HR policies for example, are not supporting the process structure
including advanced nurse training is a new kid started in
2004 and the diberangkatkanpun new 2 (two) people, when research
last one of them has graduated and placed on civil servants
Muara district health centers in Madras and there is no similar program in
Work Unit Budget documents RSKA year in 2005 but there are plans
Budget Work Unit RSKA year 2006. The other is the head
the patient himself.
If RSKA HR policies to support quality of service process structure,
the entrance exams for civil servants before they were given recommendations and
Submitting a letter of application of their placement if return to RSKA
they graduated. Placement back those who passed will still provide
contributions for the availability of trained personnel is expected to be more
competent again with a change in their employment status
in providing health services in inpatient care. Leadership efforts
with communication between the leadership of local agencies which, if carried out will
contribute to human resource management in order to increase capacity
providers. 6
Nine causes of death are in the area of SMF / Individual
related to individual factors. The cause of deviation is a good example
The main doctor did not write the instructions, or even if write instruction is not a
clearly and correctly and that the implementation of actions to be taken by
need to consult another nurse who takes time and
exclude the opportunity to give relief to the patient's right
in time. Riview of RM 003 SMF code and development notes
therapy patients had bore SOAPIE visit at any time. Why 3
(three) other primary physicians do not practice such a popular model is still
requires further research.
No written instructions resulted in the absence of certain information
how treatment today against the disease condition of patients
changed from the first day of treatment. According to Kathie in writing to ensure
that the documentation of the various information about the patient's slightest
benefits will be able to reduce patient data errors, reducing the incidence
medical error and increasing documentation keperawatan.7
Cast doubt on the results of laboratory tests and physical examination
what happened could happen to doctors who are in the relation
with limited access to the latest information.
It is estimated that a general practitioner who wants to update his knowledge must
read the article in the journal 19 per day for 365 days a year, the fact
The average doctor is only bothered reading the journal is less than 1 hour
a week later argued that the bulk of practice
implemented medical menafikkan development of science, research
which has absorbed a lot of human resources, time, cost, and even
sacrifice patients, the results left some redundant. 8
Atul, conveying the story of medical decisions and actions
taken from the uncertainty of the patients with the end sellulitis
certainly suffer from necrotizing fasciitis. Performed with initial therapy
giving antibiotics, anti-tetanus, analgesics; red rash spreads after
a few days later when there is suspicion of necrotizing fasciitis day
after the patient entered hospital. The decision was taken after treatment
consider the response of 2 (two) senior resident doctors, the patient still
The young and the patient relationship with her parents so that intimate things
is very rare in Amerika.9
Eight causes of death are in areas such as service units
installation of hospitalization, emergency room, operating rooms and intensive care. Causes
deviation is used as an example the discussion of education and
training (training) who becomes the responsibility of internal Quality Control Task
RSKA not running optimally. Further discussion concluded that if the program
Training once a week for nurses is going well and
sustaining the nurse will have knowledge of the expected
able to improve themselves in service delivery.
Equipment as an element in the management of health services with
criteria is available and ready to use with a different meaning that can be
not ready for use. Availability is adequate if its use
accordance with the number of patients in need, do not have to stop
the use of ventilators to someone who began to abate noise
respiration if needed by others who had experienced problems
breathing. Budget needed for maintenance, 10 people who did
and schedule maintenance and other procedures so that such equipment
always in a state ready for use. Conditions like this can help service
and can reduce the occurrence of medication errors that can result in
pasien.11 death

Conclusion

Death in patients> 48 hours were recorded and 413 people are audited RM
RM 102 numbered sets. The highest percentage of death events to the total
deaths occurred in the year 2005 while the number of patients going
in the year 2004. Most deaths by physician code of good 002
of total mortality and the number of patients. Sixty percent
cost of death under Rp. 3.000.000, oo while according to the class
Most treatment occurs in the intensive care class. Deaths
diusia> 45 years amounted to 49% with the largest gender is
women, whereas incidence increased in the month of death
September and December and nurses most often as a witness in
this patient's death. The patient's family becomes the guarantor of patient care costs
during treatment until death.

Audit of death from death encountered unreasonable consisting of:
1. 8 deaths occurred due to unknown causes of the incident;
2. 7 deaths due to incorrect diagnosis;
3. 5 deaths occurred because prevention does not adequate; and
4. 1 death due to late primary diagnosis is established

The causes of death> 48 hours is not unreasonable to be
in all areas with the details of deviations areas: administration / management
Hospital with 12 causes, Members SMF / 9 causes of individual, service unit
with 8 cause, 4 special clinics pelayanann causes, and nurse /
4 individual causes, while the condition or lack obedience and patient
with 3 causes, with 3 factors cause people, something that
require further research with the causes and 2. 2 causes
including in the areas of staff / medical service section.

B. Advice

Providing health services to patients consist of a series of
the processes of some systems, this system associated with unsurunsur
such as equipment management, people, policies, and budgets.
Deviations in the critical areas of health service management
cause death, the act requires structured
risk management and quality management.

Menginvetarisir the root cause of internal factors
affect the quality of health services and administration, especially in the RM
areas: human resource education factors, factors additional training and knowledge,
factors and long term of office, workload factors, facility factors and
equipment, Standard Operating Procedure factors and / or work instructions, factors
administrative and service flow, control and evaluation factors, factor
inpatient management and medical staff functional factors.

Also recommended that the general steps for solving the following
quality problems and the effectiveness and efficiency of hospital services:
1) Solving the structure of the problems already identified into
components, analyzing the components that
found the root problem. The root of the problem is the most basic cause of
ethical issues that occur. He can be a weakness in humans,
leadership, management, organizational culture, facilities, equipment, systems,
procedures, or other factors; 12
2) Conducting further analysis of the root problems that have been found
(root cause analysis), to determine the direction of the solution;
3) Establish and choose alternatives to solving the root problem;
4) Monitor and evaluate the implementation of resolution efforts that have been
implemented;
5) Conducting corrective action if unresolved ethical issues or
happen again occur. Corrective actions that can cause problems
new ethic is that if humans as the root cause of the problem
repeatedly removed from the hospital.