Dr. dr.

Agus Susanto Kosasih, SpPK, MARS

Birth Place and Date
Current Position

: Jakarta, Feb 1st 1961

: Head Of Clinical Pathology Department
Dharmais National Cancer Hospital, Jakarta, Indonesia

Education
2015 Graduated as Doctoral in Medicine, Medical Faculty University of Indonesia,
Jakarta
2001 Graduated as MARS (Magister of Hospital Administration), University of
Indonesia, Jakarta
1991 Graduated as Clinical Pathologist, Medical Faculty University of Indonesia,
Jakarta
1987 Crash Program doctor type C hospital laboratory, Medical Faculty University of
Indonesia, Jakarta
1985 Graduated as Medical Doctor, Medical Faculty University of Indonesia, Jakarta
Professional Experience
1992 - present Consultant of Clinical Pathology Laboratory in Metropolitan Medical
Centre Hospital, Jakarta, Indonesia
2002 present Responsible for Clinical Pathology Laboratory of Hermina Women
and Children Hospital, Jatinegara, Jakarta, Indonesia

Efficiency in Medical Laboratory:

Lean Management

Agus S. Kosasih
Instalasi Patologi Klinik
RS. Kanker Dharmais

Efficiency in Laboratory
Goal of the organization is improving efficiency
defined as the effective operation as measured by a
comparison of production with cost; the ratio of the
useful energy delivered by a dynamic system to the
energy supplied to it
Efficiency reduce product and service quality, BUT
simply effective time & resource management
High-quality of laboratory testing improve patient care
and employee safety
One of the ways to accomplish is with implementation of
Lean Management Principles

Lean Management?
Lean is a systematic approach to process
improvement that focuses on the reduction
and elimination of waste, variations, and
imbalance in the process.
Lean principles can be applied to any
organization that has a defined set of process
steps.

History of Lean

Lean Thinking
Lean thinking is the identification and elimination of
waste which allows managers to pursue perfection
through continuous improvement.
Developing a change in the management of the process
and looking at process reorganization

This is done while intently concentrating on

eliminating redundant motion, recognizing waste,
and identifying what creates value from the clients
perspective
Lean is a continuous process improvement initiative and
not an end destination.

Objective of Lean in Lab

The main objective of Lean, when applied in
the laboratory, is to deliver quality patient
laboratory results, at the lowest cost, within
the shortest time frame while maintaining
client satisfaction.

Patients value: quality,

speed, personal
attention

Specify Value

Eliminate all of the

waste

Map the value Stream

Value added steps

Work to Perfection

Establish Flow

Implement Pull

Lean-Getting Started
FIRST:
Emphasis directed on the waste elimination
Waste walk direct observation of the
process while in the laboratory see and
identfy
Challenge: courage to identify and call it waste
and to instill the desire to eliminate

Example of Waste

Lean Tools
Tools to Identify Waste:
Process Mapping
Time Observations
Takt Time
Spaghetti Diagram
Communication Circle
Waste Walk
Voice of the Customer
Root Cause Analysis

Tools to Eliminate Waste:

5S
Standard Work
Poke Yoke
Heijunka
A3 Thinking
Visual Management
Quick Change
Kanban

Lean-Getting Started
SECOND:
Examine and document the current system
from start to finish mapping the value
stream
Identifying, documenting, and reviewing the
entire system for each testing process

Lean-Getting Started
THIRD
To envision the future state for the process
with the waste eliminated
Optimizes the whole value stream, from the
time it receives an order until the test result is
deployed and the request is adressed

A Typical Lean Project

Establish a laboratory team:
A supervisor
A lead tech
2-3 people front lines
A non-laboratory person
An experienced lean leader

Initiate Team
Training:
Read required literature
Attend team and leadership training, lean overview

Tools:
Standardized analysis and simulation tools
Video cameras, TVs, and VCRs
Computers, Printer, and Projector

Facilities:
Lean War Room located in the operational area
Office area appropriately furnished and supplied

Lean Six Sigma

Lean waste and cycle time reduction
Six Sigma focus on reducing errors and
customer acceptance
A methodology that integrates concepts and tools
from both Lean operations and Six Sigma
methodologies

Introduction to 5S
Purpose of 5S arrange work areas in the
best manner to optimize:
Performance
Comfort
Safety
cleanliness

Sort
The S where items are
distinguished between
needed or unneeded
Items can include supplies,
tools, materials, equipment,
etc.
Four steps:
Determine frequency of use
for each item
Mark the items not used
Dispose of the nonessential
items
Eliminate sources of clutter
or unwanted items

Set-In-Order
This step involves simplifying access by
arranging items in the work area in a way that
make sense
Set-in-Order places items in order of
frequency of usage

Shine
The step where the work area is cleaned and
straightened regularly
This step helps you know instantly if
something is missing or misplaced or if there
is a problem

Standardize
With standardization, it is easier for people to maintain
the previous 3 Ss
Its a way to keep items and procedures uniform to
ensure maintenance

Standarized phlebotomy
trays

Sustain
This is the toughest S to maintain
Self discipline is necessary and depends on all
individuals to maintain the component agreed
upon

Contoh Lean Management:

Upaya menurunkan TAT
pemeriksaan Kritis Analisa Gas Darah

Instalasi Patologi Klinik

RS Kanker Dharmais

Identitas Proyek
Nama : Upaya menurunkan turn around time
(TAT) Pemeriksaan Kritis Analisa Gas Darah
Deskripsi:
Pemeriksaan analisa gas darah merupakan salah
satu pemeriksaan kritis yang memerlukan hasil
yang cepat dan akurat untuk penanganan pasien
tepat waktu. Untuk itu ditetapkan bahwa TAT
analisa gas darah adalah 30 menit, dengan target
pencapaian >90%.

Latar Belakang
Data laporan indikator mutu menunjukkan bahwa
target ini belum tercapai selama periode
pemantauan Januari-April 2015, dengan pencapaian
tertinggi 79,35%.
Konsep Lean: Menggabungkan perubahan mindset
SDM dan perubahan proses yang meliputi perubahan
cara bekerja dengan benar dan efisien serta
menghilangkan aktivitas yang tidak memberikan nilai
tambah (Non value Added/ NVA)

Latar Belakang
Analisis Fakta/ Kondisi saat ini: Alur ideal
Permintaan
pemeriksaan

Pengambil
an bahan
di ruangan

Bahan
diantar ke
lab oleh
pramu

Bahan
didistribusikan ke ruang
kimia

Registrasi
HIS
Tarik data
registrasi
ke LIS

Bahan
diterima
petugas Lab

Cetak
Barcode

Authorisasi
hasil

Proses di
alat

Verifikasi
hasil
Lingkup laboratorium

Latar Belakang
Analisis Fakta/ Kondisi saat ini: Alur tidak ideal
Permintaan
pemeriksaan

Bahan
didistribusikan ke ruang
kimia

Registrasi
HIS

Pengambil
an bahan
di ruangan

Bahan
diantar ke
lab oleh
pramu

Tarik data
registrasi
ke LIS

Bahan
diterima
petugas
Lab

Cetak
Barcode

Authorisasi
hasil

Proses di
alat

Verifikasi
hasil

Lingkup laboratorium

Latar Belakang
Tidak dapat dilakukan penghitungan waktu
TAT sejak registrasi karena perbedaan alur
bias penghitungan TAT dihitung sejak
spesimen diterima

Latar Belakang
Analisis Fakta/ Kondisi saat ini: Penilaian TAT
(rata-rata berdasarkan data LIS April 2015)
Bahan
diterima
petugas
Lab
CT: 1
VA: 1
NVA: 0

WT: 2
WT: 1
Bahan
WT: 7 didistribusiVerifikasi
Proses di
hasil
kan ke ruang
alat
kimia
CT: 1
VA: 0
NVA: 1

CT: 1330
VA: 1
NVA: 1130

CT: 3 55
VA: 2
NVA: 155

WT: 1
Authorisasi
hasil
CT: 1611
VA: 2
NVA: 1411

Tujuan
Menurunkan TAT Analisa Gas Darah

Manfaat
Penatalaksanaan pasien lebih tepat waktu
Efisiensi SDM laboratorium
Kontrol lebih baik dengan adanya supervisi
oleh PJ Pelayanan
Mengurangi konflik antara petugas
laboratorium dengan ruang rawat

Ruang Lingkup

Bahan
diterima
petugas
Lab
CT: 1
VA: 1
NVA: 0

WT: 2
WT: 1
Bahan
WT: 7 didistribusiVerifikasi
Proses di
hasil
kan ke ruang
alat
kimia
CT: 1
VA: 0
NVA: 1

Memindahkan alat AGD ke ruang

putar serum dan menjadikan 1
station dengan sistem HIS dan LIS

CT: 1330
VA: 1
NVA: 1130

CT: 3 55
VA: 2
NVA: 155

WT: 1
Authorisasi
hasil
CT: 1611
VA: 2
NVA: 1411

-Merubah sistem pemeriksaan menjadi

non-batch
- Supervisi langsung oleh PJ pelayanan
atau PJ shift

Output Kunci
Output antara:
Kontrol terhadap penerimaan bahan AGD lebih
baik

Output akhir:
TAT AGD lebih singkat, terbukti pada pencapaian
indikator mutu

Pentahapan (Milestone)
1. Melaksanakan pemindahan alat AGD ke ruang putar
serum sekaligus interfacing alat dengan LIS, Mei 2015
2. Mengajukan permohonan untuk set up station HIS di
ruang putar serum Mei 2015 (belum terealisasi)
3. Sosialisasi kepada semua petugas mengenai
perubahan alur dan sistem non-batching Mei 2015
4. Implementasi sistem baru Mei 2015
5. Evaluasi hasil implementasi sistem baru Juni 2015

Tata Kelola Proyek

Struktur Tim efektif:
Sponsor: Direktur Medik dan Keperawatan RSKD
Project Leader/ PIC: Ka Instalasi Patologi Klinik
Sumber daya tim efektif:
Penanggung Jawab Pelayanan Rawat Inap Instalasi
Patologi Klinik
Kepala Ruangan ICU-HCU-IGD
Bagian Program dan SIM-RS
Provider LIS (Wynacom) sebagai pihak eksternal

Anggaran
Set up station HIS :
1 unit komputer + monitor
Pemasangan jaringan (koordinasi dengan SIMRS)
1 unit printer untuk cetak Billing

Identifikasi Stakeholder
Internal Instalasi Patologi Klinik
Dokter Spesialis Patologi Klinik
Analis dan petugas administrasi

Eksternal Instalasi Patologi Klinik

Ruang Rawat Inap, ICU, HCU dan IGD
Keperawatan
DPJP

THANK YOU / TERIMA KASIH