Dr SAIFUL ANWAR GENERAL HOSPITAL MALANG Referral Regional

Dr. SAIFUL ANWAR GENERAL HOSPITAL MALANG

Referral Regional Map of Dr. Saiful Anwar General Hospital Malang Annotation : 1. Kota Malang 2. Kab. Malang 3. Kab. Pasuruan 4. Kota Pasuruan 5. Kab. Probolinggo 6. Kota Probolinggo 7. Kab. Lumajang 8. Kota Blitar 9. Kab. Blitar 10. Kota Batu

MAIN SERVICES of Dr. Saiful Anwar General Hospital INTEGRATED AND INTENSIVE EMERGENCY INTEGRATED KIDNEY CARE (KIDNEY CENTER) MATERNAL PERINATAL CARE (MOTHER & CHILD CARE) STROKE CARE (STROKE CENTER) INTEGRATED ONCOLOGY CARE INTEGRATED LABORATORY CENTRE

THEME DECREASING PATIENTS’ COMPLAINT OF DISCOMFORT IN LABOR PROCESS BY PERFORMING NIPPLE STIMULATION IN DELIVERY ROOM TITLE RELIEVING PATIENTS’ NIPPLES PAIN IN LABOR PROCESS BY PERFORMING NIPPLE STIMULATION IN DELIVERY ROOM OF OBGYN DEPARTMENT AS MUCH AS 100% NO LATER THAN ON MAY 2013

ORGANIZATIONAL STRUCTURE OF QCC BERLIAN Director dr. BUDI RAHAJU, M. PH Head of Quality Control Vice Director of Medical Service and Nursing drg. Robinson Pasaribu , Sp. BM dr. Hanief Noersjahdu, Sp. S Head of IRNA III dr. Nugrahanti P. , Sp. OG. K. Facilitator Chief dr. Bambang , Sp. OG Ani , Amd. Keb. Secretary Dian , Amd. Keb. Member Odilia , Amd. Keb.

PROBLEM FLOW PATIENTS COMING TO DELIVERY ROOM WILL GIVE BIRTH PATIENT EXAMINATION BY DOCTORS DIAGNOSE: PATIENTS IN LABOR PROCESS INADEQUATE CONTRACTION PERFORMING NIPPLE STIMULATION

Schedule of Plan and Activity Realization in 2012 - 2013 STEP 1 2 3 De January February c 4 PLA NNI 1 2 3 4 1 2 3 4 NG March April May June July X X X O OO O O X X O O OO X X O O REA LIZ ATI ON 5 x 5 x 4 x 6 x 4 x 4 x X X 4 5 6 7 O O O O X X X X 4 x O O X X O O 4 x 4 x 4 x 2 x 29 x

STEP I Determining Theme and Title

THEME DETERMINATION Patients’ Complain about nipple stimulation process in delivery process C A Inaccurate patient administration record B incomplete delivery assistance equipment outside delivery room Problem inventory

Theme Determination Based on six quality dimensions as follows: Bar Chart of Occurence Frequency Bar Chart of Hospital Loss Potential

Theme Determination Bar Chart of Waste Cost of Patients Bar Chart of Patient Safety Level

Theme Determination Bar Chart of Waste Time of Officers Bar Chart of Asphyxia Occurence Percentage

Conclusion Complain of discomfort of patients who have nipple stimulation in labour process DECREASING PATIENTS’ COMPLAINT OF DISCOMFORT IN LABOR PROCESS BY PERFORMING NIPPLE STIMULATION IN DELIVERY ROOM

REASON OF THEME DETERMINATION If these problems had been solved, complain of discomfort in nipple stimulation and prolonged labour process would never happen, and then infant mortality rate caused by asphyxia would decrease

1. 3 Title Determination Title stratification: tingling shame fatigue disturbed mobilization nipple pain

Table of Title Stratification No 1 2 3 4 5 Sub Problem (patients’ complaint) Nipple pain Shame Disturbed mobilization Fatigue Tingling Total Frequency Cummulative Frequency Percentation Present cumulative frequency in cummulative percentation 39 25 39 64 34, 2 21, 9 34, 2 56, 1 22 86 19, 3 75, 4 18 10 114 104 114 15, 8 8, 8 100 91, 2 100

PARETO DIAGRAM OF OCCURENCE FREQUENCY

Conclusion TITLE RELIEVING PATIENTS’ NIPPLES PAIN IN LABOR PROCESS BY PERFORMING NIPPLE STIMULATION IN DELIVERY ROOM OBGYN DEPARTMENT AS MUCH AS 100% NO LATER THAN ON MAY 2013

REASONS OF TITLE DETERMINATION TANGIBLE INTANGIBLE • Patients spent money • Patients did not feel for cost as much as IDR satisfied 1, 248, 000. • Officers had moraly • Officers wasted time for burden thought if they 570 hour per month did incorrect nursing care to post partum • There were potential patients infants having asphyxia for about 684% per month

STEP II Analizing Causes

ISHIKAWA DIAGRAM MATERIAL HUMAN Patient feels ashamed Patient is referred because of prolonged labor There are more than 1 patient in labor process Cortisol hormone increases Patient’s pain threshold decreases Officers are still not able to perform nipple stimulation Officers perform nipple stimulation based on their own perception Patients need nipple stimulation treatment simultaneously Pain sensory is more sensitive Nipple stimulation treatment is performed to patients in a hurry The nipple stimulation tool used now makes patients feel uncomfortable The tool for nipple stimulation is the officers’ fingers There is no particular tool for performing nipple stimulation ENVIRONMENT Officers have not been educated yet about nipple stimulation Patient is not cooperative while having nipple stimulation treatment Patient comes in fatigue condition Patient is in open environment New officers MACHINE The nipple stimulation performance is not sufficient There is no particular methodl for performing nipple stimulation There is no guide for nipple stimulation performance METHOD Nipple stimulation takes a long time There is patients’ complaint of discomfort in labor process by performing nipple stimulation in delivery room of IRNA III

TABLE OF RANKING RECAPITULATION (GROUP) OF NOMINAL GROUP TECHNIQUE (NGT) NO CAUSAL FACTOR MEMBER VALUE TOTAL ANI WINA DIAN ODILIA VALUE Ranking 1 New officers exist 7 5 5 5 22 IV 2 Patients feel ashamed 4 2 3 3 12 VI 3 More than 1 patient who is in labour process Patient is referred because of prolonged labor 1 3 1 1 6 VIII 3 1 2 2 8 VII 2 4 4 4 14 V 8 8 8 6 30 I 6 7 7 8 28 II 5 6 6 7 24 III 4 5 Nipple stimulation needs a longer time 6 There is no guide in nipple stimulation yet There is no particular tool for nipple stimulation Patient environment is opened 7 8 Sign

Factors supposed as dominant causes formula ½ n + 1 No. Causal factor grade 1. There is no guide for nipple stimulation I 2. There is no particular tool for nipple stimulation II 3. Patient environment is opened III 4. New officers exist IV 5. Nipple stimulation needs a longer time V

STEP III Testing and deciding the dominant causal factors

Dominant causal factors having been had trial for corelation X 1 : There is no guide for nipple stimulation Y 1 : The Nipple stimulation is not sufficient in the practice X 2 : There is no specific tool used for nipple stimulation Y 2 : The nipple stimulation tool used make patients feel uncomfortable and need a longer time X 3 : Patients’ environment is opened Y 3 : Patients are not cooperative when we performed nipple stimulation X 4 : There are new officers Y 4 : The new officers perform nipple stimulation based on their own perception X 5 : Nipple stimulation needs a long time Y 5 : There are complains about nipple pain of patient who have nipple stimulation in labour process

TRIAL RESULTS Number of officers performing insufficient nipple stimulation Not available guide of nipple stimuation performance Not available partcular tool for performing nipple stimuation Significant correlation Number of patients performed nipple stimulation Open environment of patient New officers Long time nipple stimulation performance

PIE DIAGRAM Not available guide of nipple stimuation performance Not available partcular tool for performing nipple stimuation Long time nipple stimulation performance New officers

STEP IV Making plans & Doing improvements

Improving plans Main Causal. Why factor N Penyebab o dominan What Where When How W h o Kamar Minggu A 1. bersali III - IV ni n April 2013 - How 1. There was no guide in 1. Made a guide plan 1 Belum ada Agar Membuat Make a guide plan in nipple stimulation yet panduan pelaksanaan SPO stimulation based on Asuhan 2. Consulted to fetomaternal pelaksanaan RPS bisa Rangsanga Persalinan Normal book: Why consultants RPS dilakukan n Puting Prosedur pemakaian alat dengan Susu memenuhi standart nyaman 3. Proposed a guide plan to In order to have nipple stimulation tepat dan aman buat pasien Mudah dalam pemakaiannya which could be done corretly Head of IRNA, Quality dan tidak menimbulkan Control, and Director beban kerja tambahan buat What 4. Socialized 1. petugas Konsultasi kepada dokter Made a guide in nipple 5. Evaluated Konsultan Feto maternal 2. Ajukan usulan SPO ke stimulation Ka. IRNA III , Instalasi 3. 4. Pengendali Mutu dan kemudian diajukan ke Direktur untuk mendapatkan persetujuan Sosialisasi SPO kepada petugas kamar bersalin Evaluasi setiap bulan How muc 100 %

Why When W How What 2. There was no What Where 3. nipple ho Tidak ada alat a. tool Agar for Membuat alat 1. Rancang alat berupa bra stimulation needs a 2 specific khusus untuk perangsang puting susu ( Bra PPS melakukan RPS melakuka puting susu ( longer time ) nipple stimulation n RPS Bra N Penyebab o dominan tidak menggun a kan jari tangan Agar pelaksan aan RPS tidak memerlu kan waktu lama Perangsang Puting Susu ) yang tidak menimbulkan nyeri Konsep : How much WHY : Bra dibuat dari cup melamin WHY : Made a nipple Dilengkapi perangsang puting a. In order to do nipple In order to relieve stimulation tool susu menggunakan kuas halus b. yang digerakkan secara simultan complains of nipple stimulation without effectively dan periodik dengan dinamo Bagian yang menyentuh puting pain using our finger How susu secara langsung dibuat dari bahan yang lembut namun cukup b. In order to do nipple Minggu O untuk memberi efek kontraksi III - IV Kamar dil 100 % stimulation without Bersalin April 1. Ajukan rancangan alat ke ia 1. 2013 Planned a tool in a form of Supervisor Kamar Bersalin taking a longer time 2. Buat Bra PPS yang telah disetujui nipple stimulation bra Agar tidak Membuat alat oleh Supervisor Kamar Bersalin 3 Pelaksanaan RPS ada lagi perangsang 3. Soaialisasi cara pemakaian 2. Proposed a tool plan to the membutuhkan keluhan nyeri puting susu kepada petugas kamar bersalin waktu lama puting susu yang bisa Supervisor in delivery room pada pasien menghemat 4. Evaluasi pemakaian setiap bulan dalam proses waktu persalinan 3. Socialized how to use the yang dilakukan rangsangan tool puting susu 4. Evaluated

Improving plans N Penyebab o dominan Main causal. Why factor What Where When Wh How o 4. There were new Agar petugas Membuat Kamar Minggu III Di 1. Susun konsep edukasi tentang RPS 4 Petugas baru 1. Made an educational concept baru bisa program Bersalin - IV April an Sasaran : setiap petugas di kamar melakukan RPS edukasi tentang 2013 officers bersalin about nipple stimulation tidak berdasarkan persepsi sendiri RPS Why In order to have new officers who could do nipple stimulation which was not based on their own perception What Made an educational program about nipple stimulation Waktu : terbagi dalam beberapa gelombang agar efektif dan mencakup semua petugas kamar bersalin How much 100 % 2. Proposed an educational plan to Supervisor in delivery room Narasumber ; QCC BERLIAN 2013 3. Educated all officer in delivery Tempat : kamar bersalin room Materi : a. Pengertian RPS b. Tujuan RPS c. 4. Evaluated in every month Cara pelaksanaan RPS d. Metode baru RPS dengan menggunakan bra PPS e. Mitos mitos seputar RPS f. Tanya jawab 1. Ajukan usulan edukasi ke Supervisor Kamar Bersalin 2. Lakukan edukasi pada semua petugas yang ada di Kamar Bersalin. 3. Evalusi setiap bulan

Do Improvements i Made a guide of nipple stimulation QCC result: The test was sucessful

2. Made a nipple stimulation tool (nipple stimulation bra) 3. Made a nipple stimulation tool which could not make complain of discomfort i Do correction QCC Result: THE TEST WAS SUCCESSFUL

Do Improvements Made an educational program about nipple stimulation QCC result: THE TEST WAS SUCCESSFUL

STEP V Examining the correction result Period of May 16 th – June 14 th, 2013

Evaluation to the main causal factors Bar Diagram of Dominat Causal Factors before improvement t a No No rs ce . . . Ne w O ffi ot n ve h a rs ce ffi O t a va ila va bl ila e bl pa e rtc gu ul id ar e fo to r. . . ol . . . after improvement

Comparison of the title target before and after correction before improvement after improvement

Evaluation to theme improvement result EVALUATION OF THEME IMPROVEMENT RESULT before improvement after improvement

positive reasons TANGIBLE • Patients did not spend money for insufficient nipple stimulation (Rp 0, -) • Officers did not waste time (0 menit) • Asphyxia did not occur to infants (0%)

INTANGIBLE REASONS 1. Patients felt satisfy and had safe privacy 2. There was no morraly burden of officers 3. There were supports for RSSIB program, joined nursing, and lactation management 4. There were decrease of prolonged labour and hemorrhagic post partum 5. Cooperation among QCC members was more closely and solid

STEP VI MAKING NEW STANDARD Period of June 15 th – July 14 th, 2013

2. Making of PPS BRA 3. Education about nipple stimulation bra

STANDARD RESULTS 1. The occurence of patients’ nipple pain in labour process by performing nipple stimulation in delivery room of IRNA III was 0 2. The nipple stimulation performance to the patients in labour process used PPS bra 3. The Standard Result Evaluation was done once a month

THE ADVANTAGES OF STANDARD GUIDE 1. For patients • Patients did not feel nipple pain • Patients’ privacy was safer • Labour process was quickly • Patients became more cooperative

2. For officers • Officers were more satisfy in taking care • Officers were easier to observe patients 3. For hospital • The quality care of mother and baby increased • There were supports for realization of RSSIB , lactation management, and joint nursing

IMPLEMENTATION SRATEGY 1. The guide of nipple stimulation had been sosialized once a week 2. Every new officer must have sosialization of short training about nipple stimulation 3. The guidance book must be prepared in the delivery room to make sure that nipple stimulation peformed was done in accordance with the nipple stimulation guide

STEP VII Collect new data & purpose correction plan Period of July 15 th – July 31 st, 2013

RESULTS OF EVALUATION REACHED MONITORING OF PATIENTS COMPLAINTS OF DISCOMFORT PERFORMED NIPPLE STIMULATION 350 300 319 285 250 200 FREQUENCY USE OF STIPUT BRA 142 150 120 118 COSTUMER COMPLAIN 107 100 81 50 0 0 0 0 TM III 2013 TM IV 2013 TM I 2014 TM III 2014 TM IV 2014 TM I 2015 TIME OF OBSERVATION

THEME DETERMINATION inappropriate data about post placenta of IUD insertion C A Problems B Complain of disomfort while breast feeding infants of post partum patients Family disobedience about the regulation of family attendant

theme DETERMINATION based on quali. Ty dimension. S : BAR DIAGRAM OF OCCURENCE FREQUENCY BAR DIAGRAM OF HOSPITAL LOSS BAR DIAGRAM OF PATIENT SAFETY LEVEL BAR DIAGRAM OF PATIENTS LOSS

Conclusion Theme “Reducing complain of discomfort while breast-feeding infants of post partum patients in joint nursing in IRNA III“

• REASON OF THEME DETERMINATION If these problems can be solved, breast-feeding-milk can be produced maximally so that the infants’ nutrition is fulfilled and infant mortality rate reduces

SCEDULE OF ACTIVITY PLANNED BY QCC IN 2013 - 2014 STEP July August Sept Nov Des Jan Feb plan 1 2 3 4 1 2 3 4 1 2 X X X X 4 x X X 3 4 x X X 4 5 6 4 x X X X X 4 x X X 7 4 x 28 x RE AL