Transforming Organization:

The Next agenda

Andreasta Meliala
andremeliala@ugm.ac.id
CRITICS…
• The Business Model of Hospitals

Why are hospitals so costly? The answer

lies in an examination of their business
model.
Background…
KMKB: Apakah masih ada paradigm ini?
Number of Patient
Low

Highly
Hi- Non BPJS Specialized
margin

Low- Emergency
margin Case BPJS
Contoh Sukses Kendali Mutu & Biaya dengan
Profit Luar Biasa…..
•Facebook •Kuncinya:
•Whatsapp • Volume/crowd
•Gmail & Google • Add on
content/multi-
•GoJek function
•Grab & Uber • Partnership
• Parameter klasik
Law of Large lainnya
Number
Terjemahannya di Rumah Sakit
• Paradigma: zero marginal revenue
• Price is given
• Creating crowd:
• Make it “free”
• Multi-function:
• Hospital & hospitality
• Partnership:
• Referral system
Hospital Survival and HC Management

Hospital
Survival
&
Development
Hospital Survival and HC Management

Hospital
Survival
&
Development

Result
Development
Network
Hospital Survival and HC Management

Financial
Performance

Hospital
Survival
&
Development

Result
Development
Network
Hospital Survival and HC Management
Financial
Ratio Social
Responsibility
Profit

Financial
Performance

Hospital
Survival
&
Development

Result
Development
Network
Hospital Survival and HC Management
Financial
Ratio Social
Responsibility
Profit

Financial
Performance

Customer Hospital
Satisfaction Survival
&
Development

Result
Development
Network
Hospital Survival and HC Management
Financial
Ratio Social
Responsibility
Profit

Financial
Performance

Internal
Customer Customer Hospital
External Satisfaction Survival
Customer &
Development

Result
Development
Network
Hospital Survival and HC Management
Financial
Ratio Social
Responsibility
Profit

Financial
Performance

Internal
Customer Customer Hospital
External Satisfaction Survival
Customer &
Development
Business
Process
Result
Development
Network
Hospital Survival and HC Management
Financial
Ratio Social
Responsibility
Profit

Financial
Performance

Internal
Customer Customer Hospital
External Satisfaction Survival
Customer &
Development
Performance Business
indicators Process
Result
Development
Network
Hospital Survival and HC Management
Financial
Ratio Social
Responsibility
Profit

Financial
Performance

Internal
Customer Customer Hospital
External Satisfaction Survival
Customer &
Development
Performance Business
indicators Process
Result
Development
Network
Learning &
Growth (HC)
Hospital Survival and HC Management
Financial
Ratio Social
Responsibility
Profit

Financial
Performance

Internal
Customer Customer Hospital
External Satisfaction Survival
Customer &
Development
Performance Business
indicators Process
Result
Development
Engagement Network
Learning &
Innovation Growth (HC)
Hospital Survival and HC Management
Financial
Ratio Social
Responsibility
Profit

Financial
Performance

Internal
Recruitment Customer Customer Hospital
External Satisfaction Survival
Customer &
Development
Performance Business
indicators Process
Result
Release Retention Development
Engagement Network
Learning &
Innovation Growth (HC)
Hospital Survival and HC Management
Financial
Ratio Social
Responsibility
Profit

Financial
Performance

Internal
Recruitment Customer Customer Hospital
External Satisfaction Survival
Strategic Customer &
Planning Development
Performance Business
indicators Process
Result
Release Retention Development
Engagement Network
Learning &
Innovation Growth (HC)
Hospital Survival and HC Management
Health Financial
System Stakeholder’s Ratio Social

Context value National Profit

Responsibility

Strategic HR Policy
Financial
Operation Leadership
Performance

Internal
Recruitment Customer Customer Hospital
External Satisfaction Survival
Strategic Customer &
Planning Development
Performance Business
indicators Process
Result
Release Retention Development
Engagement Network
Learning &
Innovation Growth (HC)
Hospital Survival and HC Management
Health Financial
System Stakeholder’s Ratio Social

Context value National Profit

Responsibility

Strategic HR Policy
Financial
Operation Leadership
Performance

Internal
Recruitment Customer Customer Hospital
External Satisfaction Survival
Strategic Customer &
Planning Development
Performance Business
indicators Process
Result
Release Retention Development
Engagement Network
Learning &
Innovation Growth (HC)
Transformation….
Human Resource
Cost Management
Waste Management
Human Resource Management
 Aligning Human
Capital to
Evolution of HRM in Hospital stakeholders value
Human
Creating HC value cloud
Talent Management
Linking organization HR
strategy to HR From outside-in
strategy
Staffing
Training
Compensation HR Strategy HR Strategy
Job design
Level Regulation
Terms of contract HR practice HR practice
HR practice
Punishment
Managing process

HR HR HR HR
Administration Administration Administration Administration

1930 1970 1990-2000 2010

Types of Waste
• Overproduction
• Waiting
• Transportation
• Inventory
• Motion
• Overprocessing
• Defects

9-25
Sign of Unsynchronized Behavior
Siapa SDM Kita:
SDM Medis SDM Non-Medis
Dokter, Perawat, RM
Teknis Bidan, dll
Medis

Direktur, Ka Keuangan, SIM,

Administrasi Instalasi, SPI, dll SDM, dll
-
Framework Manajemen
Rumus kinerja
Interactional
Agenda

Kinerja = Motivation x kompetensi x kesempatan

Management
Individual agenda Agenda
 Kinerja manajer

Motivation x Ability
Performance =

Barrier

Insentif
Matrix of HR vs Productivity
Teamwork, Policy and Politics
To full fill the need as a basis of
of HR in casual way Job completion
RELAX MANAGEMENT. TEAM MANAGEMENT
QWL
Balance among
Production,
H Motivation,
R Satisfaction
M Minimum effort Compliance and Command
to facilitate employees To push
the process of production
BANKRUPT MANAGEMENT. YIELDING MANAGEMENT

productivity
Cost Management
Cost & Revenue
Opportunity
Invest-
ment

1.Revenue > Cost

Reinvest- Opera-
ment tion 2.Revenue = Cost
3.Revenue < Cost
Mainte
nance
Darwis
Gaps: Cost Structure & Pricing

Practical Normative
Fraud
? Investment Gaps ?
Investment Gaps

BPJS Operation Gaps OperationGaps

?

? Maintenance Gaps Maintenance Gaps

? Reinvestment
Gaps Reinvestment Gaps
Product & Income

Product A Price A

Product B Price B Income

Product C Price C
Tarif & Biaya
MEKANISME PENYUSUNAN POLA TARIF DI RS
Layanan Umum (Sebelum JKN)

UC Jasa Sarana
• Persetujuan Pemilik /Akomodasi
• Usulan Tarif B MHP
• Biaya
• Kemampuan masyarakat
• Tarif RS lain UC Jasa Usulan
Pelayanan Pemilik
Tarif

Aspek Pasar; Ability to pay,

PAD dan kemampuan Subsidi
Pemda, aspek Sosial Ekonomi,
Mutu layanan,

Shadow Pricing /
karakter pesaing dll
Tarif & Biaya
Pola Pikir Biaya, Tarif, dan Revenue
Layanan BPJS
UC Jasa Sarana
Tarif : Ina CBG /Akomodasi
Unit Cost 1: prosedur *) BMHP
Unit cost 2: inefisiensi K
UC
• Jasa Pelayanan M Penetapan
NCC &
• Cost for Quality Tarif
K BPJS
Waste:
Transport
Inventory (work in
B
progress)
Motion Kebijakan
Waiting Time
Over-processing dan Politik
Over-production
Defects
Perhitungan Cost dan Tarif untuk Pasien BPJS
• Tarif telah ditetapkan (INA CBG)
• Rumah Sakit wajib membalik cara berhitung:
• Fixed Tariff
• Variabel Cost Pemilihan Kasus
(selecting best
• 4M benefit)
• Clinical activities
• Waste (efficiency)
• Margin diperoleh dari pengelolaan cost & manajemen
inefisiensi:
• Keuntungan= ((Tarif INA-CBG)-(Waste))
Perbedaan Prinsip
• Pelayanan Pasien BPJS:
• Aktifitas adalah sumber biaya.
Semakin banyak aktifitas, maka
semakin banyak biaya yang
diperlukan
• Obat adalah sumber biaya. Jika
banyak pemakaian obat di luar
Fornas, maka semakin besar biaya
yang dikeluarkan pasien
• Pelayanan “over-service” akan
diaudit untuk menentukan “up
coding”, “abuse”, atau “fraud”.
• Pelayanan Pasien Non BPJS
• Aktifitas adalah sumber
pendapatan. Semakin banyak
aktifitas, semakin besar
kesemoatan memperoleh revenue
• Obat adalah sumber pendapatan
terbesar. Semakin banyak obat
dipergunakan, maka semakin
besar pendapatan
• Tidak ada audit untuk tindakan
“over-service”
Gaps: Cost Structure & Pricing

Practical Normative
Fraud
? Investment Gaps ?
Investment Gaps

BPJS Operation Gaps OperationGaps

?

? Maintenance Gaps Maintenance Gaps

? Reinvestment
Gaps Reinvestment Gaps
Cost Containment Strategy

Practical Normative

? Investment Gaps Investment Gaps

BPJS Operation Gaps OperationGaps

?

? Maintenance Gaps Maintenance Gaps

? Reinvestment
Gaps Reinvestment Gaps
What to do….?
Translating Volume into “Margin”

Cost
• Value-added containment • Result
• Non value • 4 Cost • Revenue
added cost • Removing
non 4Cost
Calculating
Output
cost recovery
ACTIVITY-BASED COSTING
ACTIVITY-BASED COSTING
PENENTUAN BIAYA DENGAN METODE ABC
IDENTIFIKASI AKTIVITAS DAN SUMBER DAYA : (MATRIKS Expense Activity Dependence)
Aktivitas pendaftaran pemeriksaan fisik radiologi tes lab1 tes lab 2 operasi persalinan pemulihan vaksinasi fisioterapi
sumber daya
obat-obatan x x x x x
reagen dan bahan lab x x x
tenaga dokter spesialis x x x x x x x x x
tenaga perawat x x x x x x x x x
listrik x x x x x x x x x x
telpon x x x x x x x x x x
air x x x x x x x x x x
keamanan x x x x x x x x x x
kebersihan x x x x x x x x x x
promosi x x x x x x x x x x
biaya bank x x x x x x x x x x
 PENENTUAN BIAYA DENGAN METODE ABC
ESTIMASI PEMAKAIAN SUMBER DAYA:
Aktivitas pendaftaran pemeriksaan fisik radiologi tes lab1 tes lab 2 operasi persalinan pemulihan vaksinasi fisioterapi Total cost driver
Sumber Daya
obat-obatan
reagen dan bahan lab
tenaga dokter spesialis
tenaga perawat
listrik 5% 5% 10% 5% 15% 25% 15% 10% 5% 5% 100% pemakaian listrik
telpon 25% 5% 10% 5% 10% 10% 10% 10% 5% 10% 100% pemakaian telpon
air 5% 5% 10% 5% 15% 25% 15% 10% 5% 5% 100% pemakian air
keamanan 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% 100% rata-rata
kebersihan 5% 10% 15% 10% 10% 20% 10% 5% 5% 10% 100% aktivitas kebersihan
promosi 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% 100% rata-rata
biaya bank 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% 100% rata-rata
DIMENSI PROSES DALAM ABM (Activity-Based Management)

TUJUAN: Meningkatkan customer value melalui

pengurangan biaya yang tidak bernilai tambah bagi
customer
Source of Inefficiency:
Inappropriate cost driver
Translating Volume into “Profit”

Cost
• Value-added containment • Result
• Non value • 4 Cost • Revenue
added cost • Removing
non 4Cost
Calculating
Output
cost recovery
Types of Waste
• Overproduction
• Waiting
• Transportation
• Inventory
• Motion
• Overprocessing
• Defects

9-51
Translating Volume into “Profit”

Cost
• Value-added containment • Result
• Non value • 4 Cost • Revenue
added cost • Removing
non 4Cost
Calculating
Output
cost recovery
Cost Containment Strategy

Practical Normative

? Investment Gaps Investment Gaps

BPJS Operation Gaps OperationGaps

?

? Maintenance Gaps Maintenance Gaps

? Reinvestment
Gaps Reinvestment Gaps
Translating Volume into “Profit”

Cost
• Value-added containment • Result
• Non value • 4 Cost • Revenue
added cost • Removing
non 4Cost
Calculating
Output
cost recovery
Perhitungan Cost dan Tarif untuk Pasien BPJS
• Tarif telah ditetapkan (INA CBG)
• Rumah Sakit wajib membalik cara berhitung:
• Fixed Tariff
• Variabel Cost Pemilihan Kasus
(selecting best
• 4M benefit)
• Clinical activities
• Waste (efficiency)
• Margin diperoleh dari pengelolaan cost & manajemen
inefisiensi:
• Keuntungan= ((Tarif INA-CBG)-(Waste))
Result of Calculation
Margin-based
Low-cost Hi-cost

Hi-price

Low-price
Revenue-based
Low- Hi-
volume Volume

Hi-
margin

Low-
margin
Driver Utama Pengembangan Rumah Sakit

Burden of
Investasi
Disease

Health
Misi Sosial Financing
Pengembangan & UHC
Rumah Sakit
Waste Management/
Lean Management
Persediaan terlambat/kurang/habis
Pengembalian barang oleh unit lain
Mis komunikasi, SOP Tidak diikuti

Obat Non Fornas, Persediaan campur aduk

Keterbatasan tempat, Lay out tdk tepat

Regulasi massif, Tarif INACBG kurang?

• Persaingan antar RS, penggunaan teknologi meningkat

• Kurang : SDM, mutu pelyanan, kepuasan staf/SDM
• Akses meningkat, Antrian panjang
• Biaya meningkat, Byk proses dilakukan dgn boros,
berulang
• Kurang kepuasan pasien/staf
• Masih ada (bahkan banyak) defect/KTD
 Profitability

£ 3,1 jt/thn (56M)

Royal Bolton Hospital

Menghemat

$ 426.244 /thn
£ 0,5 jt/thn
(5,6 M)
(9M)
RS Anak
Biaya ICU RS Pittsburgh
Hasil Implementasi Lean di LN
Direct Labor/productivity 45-75% 20-80%
improved
Cost /Overhead Reduced 25-55% 10-30%
Throughput/Flow Increased 60-90%
Quality (Defects/Scrap) Reduced 50-90%
Inventory Reduced 60-90% 50-90%
Space Reduced 35-50% 30-50
Lead Time Reduced 50-90% 50-99%
Virginia (Kerpchar
Mason et al., 2015)
 Menurunkan
76,9%
Waktu tunggu keluar RS
32,4%
Waktu pendaftaran

67,7%
Waktu transit keluar RS 54,5%
Waktu antrian

(Ker, et al., 2014)

Firman, SE, MPH> Lean Management
Hasil Implementasi Lean di RS (1)
• Menurunkan rata2 waktu tunggu utk semua kunjungan dari 119 menit
ke 82 menit (Duska, et al., 2015)

• Menurunkan 54,5% waktu antrian, 32,4% waktu pendaftaran,

76,9% waktu tunggu keluar, dan 67,7% pada waktu transit
keluar(Ker, et al., 2014)
• Menurunkan 13% total biaya diagnostik (Vegting et al., 2012)

• Meningkatkan efisiensi aliran proses Lab.

Menurunkan waktu perputaran pd byk pemeriksaan . Sprti
TAT troponin T brkurang 33 mnit, sedimentasi urin 88 mnit. Troponin I turun mjd 12 mnit, urine 9 mnit, urine HCG 10 mnit (White, et al., 2015)
Hasil Implementasi Lean di RS (3)
• Meningkatkan efisiensi ruang operasi & mmberikan keuntungan
finansial yg besar ketika diimplementasikan pd seluruh paket operasi (Collar et al., 2012)

• Meningkatkan jumlah total pasien tanpa i.v. dari 8054 ke

9907. Dgn proses baru, RS Anak diproyeksikan dapat mewujudkan
penghematan mingguan $ 8,197 ($ 426.244 /thn) (L’Hommedieu & Kappeler, 2010)

• Menurunkan rata-rata waktu tunggu pasien infus

kemoterapi menurun dari 88 mnt mjd 68 mnt (Belter et al., 2012)
1 Defect Transportation 5
Keliru/salah Transportasi Alat

2 Over Production Inventory 6

Lebih dari kebutuhan Persediaan

3 Waiting Motion 7
Pergerakan orang
Menunggu

4 Non Uti Talent Extra Processing 8

Tidak bernilai bagi pasien
Tidak memanfaatkan orang
 Wastes Healthcare Examples
Defects 1. Hospital-acquired illness
2. Wrong-site surgeries
3. Medication errors
4. Dealing with service complaints
5. Illegible, handwritten information
6. Collection of incorrect patient information

Over- 1. Multiple signature requirements

2. Extra copies of forms
Production 3. Multiple information systems entries
4. Printing hard copy of report when digital is sufficient

Waiting 1. Idle equipment/people (Nganggur)

2. Early admissions for procedures later in the day
3. Waiting for internal transport between departments
Non Utilized 1. Not using people’s mental, creative, and physical abilities
2. Staff not involved in redesigning processes in their workplace
Skills 3. Nurses and Doctors spending time locating equipment and
supplies
4. Staff rework due to system failures
 Wastes Healthcare Examples
Non Utilized 1. Not using people’s mental, creative, and physical abilities
2. Staff not involved in redesigning processes in their workplace
Skills 3. Nurses and Doctors spending time locating equipment and
supplies
4. Staff rework due to system failures

Transport 1. Moving patients from room to room

2. Poor workplace layouts, for patient services
3. Moving equipment in and out of procedure room or
operating room
Inventory 1. Overstocked medications on units/floors or in pharmacy
2. Physician orders building up to be entered
3. Unnecessary instruments contained in operating kits
 Wastes Healthcare Examples
Motion 1. Leaving patient rooms to:
• Get supplies or record
• Documents care provided
2. Large reach/walk distance to complete a process step
Extra 1. Asking the patient the same questions multiple times
2. Unnecessary carbon copying
Processing 3. Batch printing patient labels
Lean and Customer Orientation

Supply side Demand side

Lean
Patient Safety
Integration

Lean Financial
Orientation Performance
 Lean Building Block

Contextual
Creativity Socio-technical
Values Stream Mapping system
Takt Time Guiding
Ishikawa
Load Balancing Principle
Mistake Proofing

Way of
Thinking
5S: Sort, Set in order, Shine, Standardize, and Sustain
• Metode utk mengatur pengurangan waste waktu dan pergerakan staf, serta membuat masalah di
tempat kerja mjd lebih mudah terlihat

Visual Management, Kanban

• Metode utk membuat masalah bisa dilihat, memudahkan respon (cepat) dan pemecahan
masalah
• Istilah jepang yang berarti sinyal, penanda. Utk mengelola inventory

Value Stream Mapping

• Gambaran/peta aliran dari penyedia (RS) kpd pelanggan (pasien)

Error proofing, Heijunka

• Metode untuk merencanakan dan memperbaiki proses sehingga mencegah terjadinya kesalahan
• Metode untuk meratakan beban produksi/pelayanan
Kaizen
• Istilah Jepang utk “continuous improvement,” berfokus pd improvement oleh staf di area kerja
masing2
Firman, SE, MPH> Lean Management
 4 cara membuat Future state
mapping

01 Menghilangkan 03 Menyederhanakan

02 Mengurutkan 04 Mengkombinasikan
Visual Management Membuat proses
kerja menjadi terlihat
Kanban
• =Kartu, Tiket, penanda
atau Sinyal.
• Sistem yang memberi
tanda kapan suatu
barang/alat/kompone
n harus diganti/harus
ditambah = sistem
Kanban.
Kanban (2)

• Kanban  sbg
papan
petunjuk suatu
rangkaian
aktifitas.
Error Proofing/Mistakes Proofing/Poka Yoke
• Alat anti salah. Tools utk
Jidoka (otomasi mesin)
• Dpt mencegah kesalhan yg
dpt mengancam jiwa
• Setiap kegagalan perangkat
ini dpt mnyebabkan
misdiagnosis, cedera serius
atau bahkan kematian px.
• “good change” atau
“improvement".
• Dasar penggunaan kaizen adlh
analisis & solusi cepat dlm skala
kecil suatu masalah yg mudah
ditangani & dpt diukur
secepatnya.

Kaizen Event
Kaizen (2)
Jarang menyebutnya sbg Kaizen
 Unit Product Aktivitas Value Aktifitas Waste
Diperiksa oleh dokter
Menunggu diperiksa
Ruang IGD Pasien Dilakukan tindakan
Menunggu tindakan medis
medis oleh perawat
Spesimen
Spesimen Spesimen dikumpulkan dulu untuk
Laboratorium disentrifugasi
pasien diproses sekaligus
Spesimen diuji
Melakukan pengecekan obat berulang
Farmasi Resep Obat disiapkan
kali
 Unit Product Aktivitas Value Aktifitas Waste
Melakukan pengecekan obat berulang
Farmasi Resep Obat disiapkan
kali
Instrumen disterilkan brsama dgn
Waktu utk
Instrumen instrumen lainnya dlm instrumen kit,
Pelayanan perioperatif sterilisasi
Steril tetapi sbenarnya instrumen itu tdk
instrumen
pernah digunakan.
Waktu utk
Nampan
memasak makanan Menata ulang karena nampan tidak
Pelayanan Gizi makanan
atau menata disusun dengan benar
pasien
nampan
Takt Time
Takt Time
• Takt Time = waktu yg tersedia utk memberikan
suatu pelayanan kpd pelanggan (pasien).

• Dlm pelayanan kesehatan, Takt Time berarti waktu

yg hrs dipenuhi untuk melayani satu orang pasien
dalam satu tahap proses.
• Dengan patuh pada takt time, dapat mengurangi
sumbatan aliran pasien (antrean)
Cerita sukses
Implementasi Lean
Tips Sukses Implementasi Lean (1)
1. Langsung action; ikuti cepat dgn perubahan budaya
2. Pastikan semua anggota staf dilatih yg benar
3. Mulailah dengan pilot project value stream
4. Lakukan workshop improvement
5. Kembangkan komunikasi & saluran umpan balik utk
semua orang
Tips Sukses Implementasi Lean (2)
6. Oportunistik mengidentifikasi peluang utk dampak
keuangan besar
7. Bangun fondasi organisasi "cara“ sendiri.
8. Kembangkan Lean Leadership & sistem suksesi nya
9. Leader hrs benar2 memahami, percaya, & punya “cara”
spy RS hidup
10.Manfaatkan tenaga ahli, manfaatkan data
11.Evaluasi kinerja & buat hasilnya terlihat
12.Jangan cepat puas diri / menyerah terlalu cepat
Tantangan
• “No Time” • Berikan waktu bagi sumber daya and
frontline staff

• “Not Japanese” • Temukan “Lean” special untuk konteks

RS dan budaya kita.

• “Not relevant” • Hubungkan lean dgn prioritas dan

masalah besar khususnya dlm safety
and quality

• Not our job” • Buat itu sbg tanggung jawab dasar

bagi manajer frontline

• “Flavour of the • Siapkan diri krn hasilnya jk panjang–

month” tetap fokus, ulet dan optimis
Detect and Change
Can You Do It?
Mistake Proofing
• Fail safe • Risk management
• Redundant system • Single system
Lean Principle: Manufacture vs Hospital

Time
The Ladder
Behavioral Analysis

Lean Management

Quality Management System

Donabedian Approach
Terima Kasih…