Failure Mode and Effect Analysis

Herkutanto

Herkutanto
KETUA KOMITE KESELAMATAN PASIEN
KETUA KONSIL KEDOKTERAN, KKI

Guru Besar Fakultas Kedokteran Universitas Indonesia

HERKUTANTO

ALASAN UTAMA MELAKUKAN REGULASI

(Schellekens, W : Patient Safety Conference,

European Union Presidency Luxembourg, 4 5 April 2005)

TUJUAN PAPARAN
Strategi
Pengendalian Risiko
melalui FMEA
Mengenal langkah2
Failure Mode and
Effect Analysis
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KUALITAS PELAYANAN
(Donabedian)

OUTCOME

PROCESS
PRO
CESS
STRUCTURE

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HERKUTANTO

SUMBER

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SISTIMATIKA PAPARAN

INTRODUKSI FMEA

DELAPAN LANGKAH FMEA

KESIMPULAN
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INTRODUKSI FMEA & HFMEA

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What is FMEA ?

Adalah metode perbaikan kinerja dgn

mengidentifikasi dan mencegah potensi
kegagalan sebelum terjadi. Hal tersebut
didesain untuk meningkatkan keselamatan
pasien.

Adalah proses proaktif, dimana kesalahan

dpt dicegah & diprediksi. Mengantisipasi
kesalahan akan meminimalkan dampak buruk

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What is HFMEA ?
Modified by VA NCPS

Focus on preventing defects, enhancing safety, increase

positive outcome and increase patient satisfaction

The objective is to look for all ways for process can fail

The famous question : What is could happen?

Not What does happen ?

Hybrid prospective analysis model combines concepts :

FMEA (Failure Mode and Effects Analysis)
HACCP (Hazard Analysis Critical Control Points)
RCA
(Root Cause Analysis)

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FMEA Terminology

Process FMEA - Conduct an FMEA on a

process that is already in place

Design FMEA Conduct an FMEA before

a process is put into place
Implementing an electronic medical records or
other automated systems
Purchasing new equipment
Redesigning Emergency Room, Operating
Room, Floor, etc.

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FAILURE MODE AND EFFECTS ANALYSIS

FAILURE (F) : When a system or part of a system
performs in a way that is not
intended or desirable
MODE (M) :
The way or manner in which
something such as a failure can
happen.. Failure mode is the
happen
manner in which something can
fail.
EFFECTS (E) : The results or consequences of a
failure mode
Analysis (A) : The detailed examination of the
elements or structure of a process
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Why should my organization

conduct an FMEA ?

Can prevent errors & nearmisses protecting

patients from harm.
Can increase the effectiveness & efficiency of
process
Taking a proactive approach to patient safety
also makes good business sense in a health
care environment that is increasingly facing
demands from consumers, regulators & payers
to create culture focused on reducing risk &
increasing accountability
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Where did FMEA come from ?

FMEA has been around for over 30 years
Recently gained widespread appeal
outside of safety area
New to healthcare

Frequently used reliability & system safety

analysis techniques

Long industry track record

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DELAPAN LANGKAH FMEA

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LANGKAH-LANGKAH
LANGKAHANALISIS MODUS KEGAGALAN & DAMPAKNYA
DAMPAKNYA
(JCI )

1.

Tetapkan Topik FMEA dan Bentuk Tim

2.

Gambarkan Alur Proses

3.

Identifikas Modus Kegagalan & Dampak

Dampaknya
nya (Hazard Analysis)

4.

Identifikas Prioritas Modus Kegagalan

Kegagalan

5.

Identifikasi Akar Penyebab Modus Kegagalan

Kegagalan

6.

Disain ulang Proses

7.

Analisis dan Test Proses Baru

8.

Implementasi dan Monitor Proses Baru

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Output setiap langkah

LANGKAH

OUTPUT

1 Tetapkan Topik FMEA dan Bentuk Tim

Topik dan Tim

2 Gambarkan Alur Proses

Alur Proses tergambar

3 Identifikasi Modus Kegagalan &

Dampaknya

Modus Kegagalan &

Dampaknya

4 Tetapkan Prioritas Modus Kegagalan

Daftar Prioritas Modus

Kegagalan

5 Identifikasi Akar Penyebab Modus

Kegagalan

Akar Penyebab
Modus Kegagalan

6 Disain ulang Proses

Proses Baru

7 Analisis dan Uji Coba Proses Baru

Hasil Uji COba

8 Implementasi dan Monitor Proses Baru

Penerapan Proses Baru

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LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus
Kegagalan &
Dampaknya

4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan

TETAPKAN TOPIK & TIM

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6 Disain ulang
Proses
7 Analisis dan Uji
Coba Proses
Baru
8 Implementasi dan
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Monitor Proses
Baru

TUJUAN & HASIL

Terpilihnya Topik FMEA

Terpilihnya TIM Pelaksana untuk topik

tersebut

Daftar Tim

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PEMILIHAN TOPIK FMEA

Proses spesifik di rumah sakit:

Highrisk
Highvolume
highcost

Didasarkan pada data incident report

keselamatan pasien

Data rutin keselamatan pasien

Sentinel

event
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TUJUAN PEMILIHAN TOPIK

Fokus pada proses spesifik yang dianggap
prioritas (hospital
(hospital specific)
specific)
Melakukan tindakan korektif pada proses
melalui redesign proses
Contoh:

Proses pelayanan Transfusi darah

Proses pemberian obat kepada pasien

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Characteristic of a high risk process

Variable team

Complex

Non standardized

Tightly coupled

Heavily dependent on human intervention

Hierarchical vs team

Tight time constraints

Loose time constraints

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LANGKAH 1 : PILIH PROSES YANG BERISIKO TINGGI

Pilih Proses berisiko tinggi yang akan dianalisa.
Judul Proses :
__________________________________________________________________________

_________________________________________________________
_________________________________________________________
LANGKAH 2 : BENTUK TIM
Ketua
:
____________________________________________________________
Anggota
1. _______________
4.
________________________________________
2. _______________
5.
________________________________________
3. _______________
6.
________________________________________
Notulen? _________________________________________
Apakah semua Unit yang terkait dalam Proses sudah terwakili ?
YA / TIDAK
Tanggal dimulai ____________________ Tanggal selesai ___________________

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TIME LINE AND TEAM ACTIVITIES

Premeeting

Identify Topic and notivy the team (Step 1 & 2)

1st team meeting

Diagram the process, identify subprocess, verify the scope

2rd team meeting

Visit the worksite to observe the process, verify that all process &
subprocess steps are correct (Step 3)

3 rd team meeting

Brainstorming failure modes, assign individual team members to

consult with process users (Step 3)

4rd team meeting

Identify failure modes causes, assign individual team members to

consult with process users for additional input (Step 3)

5th team meeting

Transfer FM & Causes to the HFMEA Worksheet (Step3). Begin the

hazard analysis (Step 4)
Identify corrective actios and assign follow up responsibilities (Step 5)

6th,7th , 8th. team

meeting plus 1

Assign team members to follow up individual charged with taking

corrective action

team meeting plus 2

Refine corrective actions based on feedback

team meeting plus 3

Test the proposed changes

team meeting plus 4

Meet with Top Management to obtain approval for all actions

Postteam meeting

The advisor or his/ her designee follow up until all actions are
completed
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LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus
Kegagalan &
Dampaknya

4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan

Gambarkan Alur Proses

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6 Disain ulang
Proses
7 Analisis dan Uji
Coba Proses
Baru
8 Implementasi dan
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Monitor Proses
Baru

TUJUAN & HASIL

Tergambarnya alur / langkah2 PROSES

dan SUBPROSES pelayanan yang dipilih
dalam suatu bagan yang jelas

LEMBAR ALUR
PROSES dan SUBPROSES PELAYANAN
ELAYANAN

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LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim

2 Gambarkan Alur
Proses

3 Identifikasi Modus
Kegagalan &
Dampaknya

4 Tetapkan Prioritas
Modus Kegagalan

5 Identifikasi Akar
Penyebab Modus
Kegagalan

Identifikasi
Modus Kegagalan &
Dampaknya
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6 Disain ulang Proses

7 Analisis dan Uji Coba
Proses Baru

8 Implementasi dan
Monitor Proses30Baru

TUJUAN & HASIL

1.

Teridentifikasinya MODUS KEGAGALAN

pada setiap langkah proses pelayanan

2.

Teridentifikasinya DAMPAK KEGAGALAN

pada setiap langkah proses pelayanan

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HAZARD vs RISK vs.

COMPLICATIONS
1. A hazard is something that can cause harm, e.g. electricity, chemicals,
working up a ladder, noise, a keyboard, a bully at work, stress, etc. [...
tindakan medik ...??]
...??]
2. Complication
Complicationss are things that happen as a result of a disease or a
treatment that you prefer didn't happen [stroke from hypertension,
hypertension, or
bleeding following surgery]
surgery]
A complication may be described as an adverse event caused by prepreexisting factors that were outside the doctors control.
control. Patients are not the
same in health, habits, immunity or healing power, and have varying susceptibility
to complications

3. A risk is the chance, high or low, that any hazard will actually cause
somebody harm.
harm.
Risk factors are things that make it more likely that you will develop a
disease or condition. They may be things you can't do anything about,
about,
like gender, family history, or race, or things you can control,
control, like smoking
and diet.
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DIFFERENCES BETWEEN RISKS vs COMPLICATIONS

RISKS

COMPLICATIONS

Allergy

Anaphylactic Rx

Leucocytosis

Sepsis

Bleeding

Hypovolemic shock

Fragile tissues

Tissue damage

Naucea / vomit

Hyponatraemia

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Hazard analysis: What is it?

Hazard: Potentially dangerous condition,

which is triggered by an event,
event,
called the cause of the hazard.
hazard.
Risk: hazard that is associated with a
severity and a probability of
occurrence..
occurrence
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Hazard, Barrier, Target Analysis

Hazard

Barrier

Target

Dog

High
Fence

Child

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Hazard, Barrier, Target Analysis

Hazard

Medical
Mishaps

Barrier

Policies
Procedures

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Target

Patient

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PENERAPAN HBA PADA FMEA

Prinsip:: the DEVILS are in the DETAILS

Prinsip

Cari modus / cara suatu langkah dalam

suatu subproses dapat gagal

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DIAGRAM THE PROCESS

PROCESS STEPS :
Describe the process graphically, according to your policy & procedure for the activity and number each one
If the process is complex you may want to select one process step or sub process to work on
1

Selection &
Procurement

Storage

Failure Mode

Failure Mode

Pemesanan obat
Berlebihan (tdk
Sesuai kebthn
kebthn))

Penyimpanan
vaksin tdk
sesuai suhunya

Prescribing,
Ordering,
Trancribing

Failure Mode
Penulisan obat
dlm R/ tdk jls

Preparing
&
Dispensin
g

Administration

Failure Mode

Failure Mode

Peracikan obat
tdk sesuai dosis

Wrong drug

Wrong dosage
Penulisan Obat R/
tdk R/
Dlm formularium

Wrong frequence
Wrong route
administration

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Hazard analysis: What is it?

Hazard analysis
analysis:: Identify all possible
hazards potentially created by a
product, process or application
application..
Risk assessment
assessment:: It is the next step
after the collection of potential
hazards.. Risk in this context is the
hazards
probability and severity of the hazard
becoming reality
reality..
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Hazard analysis: What is it?

General risk assessment
Establish Analysis Parameters
protocol :
Identify Hazards

Assess Risks

Derive Risk Rating

Reduce Risks

Verify Effectiveness
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Document Results

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Hazard analysis: What is it?

Establish Analysis Parameters

Identify Hazards

Assess Risks

Derive Risk Rating

Reduce Risks

Verify Effectiveness

Document Results

These parameters can

be
limits
of
the
machine or design,
limits on uses, limits
on the scope of the
analysis,
or
other
limits.
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Hazard analysis: What is it?

Establish Analysis Parameters

Identify Hazards

Assess Risks

Derive Risk Rating

The nature of this

step lends itself to a
team approach such
as brainstorming.

Reduce Risks

Verify Effectiveness

Document Results

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Hazard analysis: What is it?

Establish Analysis Parameters

Identify Hazards

Assess Risks

Derive Risk Rating

Two risk factors are used:

severity of injury
probability of occurrence

Reduce Risks

Verify Effectiveness

Document Results

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Hazard analysis: What is it?

Establish Analysis Parameters

Risk matrix:
Severity Category

Identify Hazards

Assess Risks

Derive Risk Rating

Reduce Risks

Verify Effectiveness

Document Results

Probability Level Catastrophic Critical

Marginal

Negligible

Frequent

High

High

Serious

Serious

Probable

High

High

Serious

Low

Occasional

High

Serious

Low

Low

Remote

Serious

Low

Low

Low

Improbable

Serious

Low

Low

Low

If the risk is determined to not be acceptable, it

is necessary to reduce that risk by
implementing protective measures.
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Hazard analysis: What is it?

Establish Analysis Parameters

Identify Hazards

Remedy actions are taken to

reduce risks following the
hazard hierarchy:

Assess Risks

Eliminate hazards through the design

Derive Risk Rating

Protect
Warn the user

Reduce Risks

Train the user(s)

Personal protective equipment

Verify Effectiveness

Document Results

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Hazard analysis: What is it?

Establish Analysis Parameters

Identify Hazards

Assess Risks

Derive Risk Rating

Reduce Risks

This
assessment
verifies
that
the
remedy actions have
reduced the risks to an
acceptable level.

Verify Effectiveness

Document Results

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Hazard analysis: What is it?

Establish Analysis Parameters

Identify Hazards

Assess Risks

Derive Risk Rating

Reduce Risks

The documentation can be added to a

technical file for future use.

Verify Effectiveness

Document Results

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Full Hazard Analysis

Proactive Controls

Threat

Hazard

Threat

Threat

Reactive Controls

Barrier Barrier

Recovery
Measures

People

Barrier Barrier

Recovery
Measures

Asset
Damage

Top Event
(Incident)

Barrier Barrier

Recovery
Measures

Environment

Recovery
Measures

Reputation

Escalation
controls

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Completed Hazards & Effects Register

HAZARDS & EFFECTS REGISTER

Risk
Initial Final Remedial
Hazard ThreatsBarriers Top Recovery Consequences Rating
Event Measures
Risk Risk Action
Required
P A E R
X

C5
X X X X D4,5
E3,4,5

X X X X

C5
X X X X D4,5
E3,4,5

X
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X X X X

X
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HERKUTANTO

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LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim

2 Gambarkan Alur
Proses

3 Identifikasi Modus

Kegagalan &
Dampaknya

4 Tetapkan Prioritas
Modus Kegagalan

5 Identifikasi Akar
Penyebab Modus
Kegagalan

6 Disain ulang Proses

Tetapkan Prioritas
Modus Kegagalan

7 Analisis dan Uji Coba

Proses Baru

8 Implementasi dan
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Monitor Proses Baru

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TUJUAN & HASIL

Tersedianya urutan prioritas

DAFTAR PRIORITAS MODUS

KEGAGALAN

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ANALISIS
DAMPA
K

MINOR
1

HAZARD LEVEL DAMPAK

MODERAT
2

MAYOR
3

KATASTROPIK
4

Kegagalan yang tidak

mengganggu Proses
pelayanan kepada
Pasien

Kegagalan dapat
mempengaruhi
proses dan
menimbulkan
kerugian ringan

Kegagalan
menyebabkan kerugian
berat

Kegagalan menyebabkan
kerugian besar

Pasien

Tidak

ada cedera,
Tidak ada
perpanjangan
hari rawat

Cedera

ringan
Ada Perpanjangan
hari rawat

Cedera

luas / berat
Perpanjangan hari
rawat
lebih lama (+> 1 bln)
Berkurangnya fungsi
permanen organ tubuh
(sensorik / motorik /
psikcologik /
intelektual)

Pengunj
ung

Tidak

ada cedera
Tidak ada
penanganan
Terjadi pada 11-2 org
pengunjung

Cedera ringan
Ada Penanganan
ringan
Terjadi pada 2 -4
pengunjung

Cedera luas / berat

Perlu dirawat
Terjadi pada 4 -6
orang
pengunjung

Kematian

Tidak

Cedera

Staf:

ada cedera
Tidak ada
penanganan
Terjadi pada 11-2 staf
Tidak ada kerugian
waktu / keckerja

ringan
Cedera luas / berat
Ada Penanganan /
Perlu dirawat
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Tindakan
Kehilangan waktu /
Kehilangan waktu
kecelakaan kerja pada
/ kec kerja : 22 -4
4-6 staf
staf

Kematian
Kehilangan fungsi tubuh
secara permanent (sensorik,
motorik, psikologik atau
intelektual) mis :
Operasi pada bagian atau
pada pasien yang salah,
Tertukarnya bayi

Terjadi

pada > 6 orang

pengunjung

Kematian
Perawatan

> 6 staf
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ANALISIS HAZARD LEVEL PROBABILITAS

LEVEL

DESKRIPSI

CONTOH

Sering (Frequent)

Hampir sering muncul dalam waktu yang

relative singkat (mungkin terjadi
beberapa kali dalam 1 tahun)

Kadang-kadang
Kadang(Occasional)

Kemungkinan akan muncul

(dapat terjadi bebearapa kali dalam 1
sampai 2 tahun)

Jarang (Uncommon)

Kemungkinan akan muncul

(dapat terjadi dalam >2 sampai 5 tahun)

Hampir Tidak Pernah Jarang sekali terjadi (dapat terjadi dalam

(Remote)
> 5 sampai 30 tahun)
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HAZARD SCORE
TINGKAT BAHAYA
KATASTROPIK
4

MAYOR
3

MODERAT
2

MINOR
1

SERING
4

16

12

KADANG
3

12

JARANG
2

HAMPIR TIDAK
PERNAH
1

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Laboratory Test Ordering Process

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LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus
Kegagalan &
Dampaknya

4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan

Identifikasi Akar Penyebab

Modus Kegagalan
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6 Disain ulang
Proses
7 Analisis dan Uji
Coba Proses
Baru
8 Implementasi dan
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Monitor Proses
Baru

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Teridentifikasinya AKAR PENYEBAB

modus kegagalan yang telah teridentifikasi

Lembar AKAR PENYEBAB

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Possible Characteristics of Root

Causes

Root causes are systemic

systemic..

Root causes appear far from the origin of

the failure.
failure.

The origins of root causes lie in common

common-cause variation of organization systems
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many of the failure modes

had the same root causes

Omission errors secondary to automatic stop order

Suboptimal patient involvement in medication histories

Suboptimal medication reconciliation by clinicians

Confusing epidural and patientpatient-controlled analgesia

order sets

Lack of electronic medication administration record

Lack of computerized order entry

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PROBING
to uncover root causes and their relationships

What could happen? (the failure mode)

mode)

Why could this happen?

That is, what are the most proximate causes?

causes? These
typically involve specialspecial-cause variations.

Why could these proximate causes happen?

That is, what systems and processes underlie those

proximate causes?
causes?
Common--cause variation here may lead to special
Common
special-cause variation in dependent processes.
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What could happen? - FACTORS

Human factors

Assessment process factors

failure to follow policieson precaution orders or failure

to conduct appropriate staff education/training

faulty initial assessment process

Equipment factors

nonfunctional paging system that delays

communication with the individuals physician
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Questions to Uncover Causes

What safeguards are missing in the process?

If the process already contains safeguards (for

example,, double checks), why might they not work to
example
prevent the failure every time?
time?

What would have to go wrong for a failure like

this to happen
happen?
?

If this failure occurred, why would the problem

not be identified before it affected an individual?

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What could happen?

What could happen?

Contributory Factors to Suicide

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What could happen?

DIABETES SCREENING

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Laboratory Test
Ordering Process

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LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus
Kegagalan &
Dampaknya

4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan

Disain Ulang Proses

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6 Disain ulang
Proses
7 Analisis dan Uji
Coba Proses
Baru
8 Implementasi dan
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Monitor Proses
Baru

TUJUAN & HASIL

Teridentifikasinya PROSES BARU yang

bebas dari modus kegagalan

Lembar langkah2 PROSES BARU

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Decision Tree
Gunakan Decision Tree utk menentukan apakah modus perlu tindakan lanjut diProceed..
Does this hazard involve a
sufficient likelihood of
occurrence and severity to
warrant that it be controlled?
(Hazard score of 8 or
higher)
YES

NO

Is this a single point weakness in

the process? (Criticality failure
results in a system failure?)
CRITICALITY

NO

YES
Does an effective control measure already exist
for the identified hazard?
CONTROL THE HAZARD (=BARRIER)
NO
Is this hazard so obvious and readily
apparent that a control measure is not
warranted?
DETECTABILITY
(FORESEEABILITY)
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YES

STOP
Do not proceed
to find potential
causes for this
failure mode

YES
NO

Proceed to Potential
Causes for this
failure mode

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PREPARING TO REDESIGN

Conduct a literature search to gather

relevant information from the professional
literature. Do not reinvent the wheel

Network with colleagues

Recommit to out of the box thinking

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REDESIGN STRATEGIES
Prevent the failure from happening
(decrease likelihood of occurrence)
occurrence)
Prevent the failure from reaching the
individual (increase
(increase detectability)
detectability)
Protect individuals if a failure occurs
(decrease the severty of the efects)

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PROSES
RISIKO TINGGI

METODE
REDESIGN

Variable input
Complex
Nonstandarized
Tightly Coupled
Dependent on human
intervention
Time constraints
Hierarchical culture

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Decreasing variability
Simplify
Standardizing
Loosen coupling of process
Use technology
Optimise Redundancy
Built in fail safe mechanism
Documentation
Establishing a culture of
teamwork

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REDESIGN PROCESS
Process

Failure
Mode

Potential
Effect

Potential
Causes

Redesign
Recommend
ations

PIC

Target
Completi
on
date
for test

New
Process
Implementat
ion
date &
Actions

Outcome
Measure /
Monitoring
mechanism

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Proses
Redesign

Bandingkan :

Analisis & Ranking

Analisis & Ranking

Failure
Mode

Effect

Causes

Failure
Mode

Effect

Causes

Proses Baru

Proses Lama
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LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus
Kegagalan &
Dampaknya

4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan

Analisis dan Uji Coba

Proses Baru
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6 Disain ulang
Proses
7 Analisis dan Uji
Coba Proses
Baru
8 Implementasi dan
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Monitor Proses
Baru

TUJUAN & HASIL

Terujinya PROSES BARU dilapangan

Le

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SIKLUS PDSA

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SIKLUS PDSA

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HERKUTANTO
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LEMBAR KERJA
UJI COBA

HERKUTANTO
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LEMBAR KERJA
UJI COBA

LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
3 Identifikasi Modus
Kegagalan &
Dampaknya

4 Tetapkan Prioritas
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan

Implementasi & Monitor

Proses Baru
HERKUTANTO

6 Disain ulang
Proses
7 Analisis dan Uji
Coba Proses
Baru
8 Implementasi
dan Monitor 90
Proses Baru

TUJUAN & HASIL

PENERAPAN PROSES BARU

Manajemen Perubahan

Lembar MONITORING PROSES BARU

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Strategies for Creating and Managing

the Change Process

Establish a sense of urgency

Create a guiding coalition

Develop a vision and strategy

Communicate the changed vision

Empower broad
broad--based action

Generate short
short--term wins

Consolidate gains and produce more change

Anchor new approaches HERKUTANTO

in the culture

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LEMBAR MONITOR PROSES BARU

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LEMBAR MONITOR PROSES BARU

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KESIMPULAN
PROSES

BARU YANG LEBIH AMAN

KEBIJAKAN
RUMAH

& SOP LEBIH BAIK

SAKIT YANG AMAN

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HERKUTANTO

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