by K. Richard Douglas
Your department is responsible for a boatload of medical equipment and managing it doesn’t always allow for learning by mistakes. In some cases, that boatload could be the Queen Mary. In other cases, it’s just a matter of working through the best workflows, procedures, protocols or practices to make managing all those devices an exercise in efficiency.
The successful approach of others can often provide a blueprint for handling that equipment throughout its life span; from cradle to grave. From evaluation to procurement, and all the way to disposition, having the right framework in place can make the task that much easier.
One such model comes from the Bon Secours Health System, a model for large system equipment management programs, with lessons for smaller systems as well. Hospital systems are beginning to operate more collaboratively to drive efficiency through standardization and that approach is working for the ARAMARK-managed program.
“By having a centralized model, efficiencies and economies of scale were realized which resulted in tremendous savings,” says Ayman Assanassios, Vice President of Operations at ARAMARK Healthcare Technologies.
“Our equipment distribution program’s ability to track equipment utilization was instrumental in not only rightsizing the inventory, saving capital dollars, but in also reducing the equipment rental spend across the system.”
The program is used throughout the equipment life cycle to find savings or efficiencies.
“The areas where we saw the most savings were related to the elimination of service contracts and controlling the equipment rental spend,” Assanassios says. “Our ability to service the equipment using our trained technicians and engineers and leveraging our national parts and support center were key to the savings realized.”
The health system had a goal of eliminating $41 million annually.
“ARAMARK provided a ‘THINK FORWARD’ model which consists of a comprehensive Clinical Asset Management (CAM) program that resulted in over $10 million of savings in the first two years alone with incremental savings year over year,” Assanassios says.
The Bon Secours Capital Asset Management Program is a centralized program that includes managing all aspects of equipment from acquisition to disposition. The program includes managing capital planning, technology assessment, procurement, standardization, project management, deployment, service, distribution of mobile equipment, utilization and disposition.
Through the elimination of service contracts, and controlling funds spent on equipment rentals, the initiative saw some of its greatest savings. The centralized model was also a fundamental component of the approach.
“Our equipment distribution program’s ability to track equipment utilization was instrumental in not only rightsizing the inventory, saving capital dollars, but in also reducing the equipment rental spend across the system.”
– Ayman Assanassios
PREPLANNING BASED ON FACTS
“Most large health systems have the desire to have a centralized model and to operate more as a system,” Assanassios says. “It requires a great deal of change management which is discouraging hospitals from pursuing. With the challenges the healthcare industry is facing now, and the savings a centralized model can bring, more systems will be taking that approach.”
The CAM model does a technology assessment and looks at capital planning five years out. This provides a snapshot of what needs to be replaced every year and what dollar amount needs to be budgeted for that.
“We start with that and it helps finance and it helps the hospital to plan accordingly,” Assanassios says.
Assanassios says that the clinicians and users know when their equipment will be replaced. They use many factors to make the decisions, not only age. A newer piece of equipment could be replaced before an older unit based on utilization, reliability and support. The advance budgeting also allows them to go to market with more buying power.
“If we are replacing 38 CT scanners and 22 MRIs in the next four years, give us a price and we will sign with you for that,” he says. “Instead of negotiating on a one-on-one basis for each location with vendors each year, we are negotiating now for the next four or five years. Having your dollar go farther, you can get more bang for your buck.
“The engineers at the site also help assess the reliability of the equipment since they are the primary folks who service the equipment, they tell us what’s the best equipment and we use the TVI (technology value indicator) score to assess those types of devices,” he adds.
Assanassios points out that the approach aids in achieving standardization. They also use the centralized approach for redeployment.
“Sometimes we have locations that, due to the high utilization of this equipment, sometimes the equipment needs to be replaced sooner. But, that equipment is still supported and it’s still working properly. So, what we do, is we use it or we redeploy it to another market or to another facility where they are not using it as frequently as the first place,” he says.
“We use our proprietary asset management system called iDesk to manage all of this,” Assanassios explains. “At any given time, you can go in the system and track any clinical asset at any of the Bon Secours locations.
This allows those at any facility to know what assets are available system-wide. The database allows for factbased decisions on capital investments.
“By standardizing the types of equipment across the system, it gives our engineers and technicians the ability to work together. We share resources and we take advantage of efficiencies due to proximity of some of the locations to each other,” Assanassios continues.
“Our engineers get trained on modalities before the warranty is up on those devices,” he says. “We have engineers and technicians that are based at each location and we have engineers who are floaters based on their specialty. If we have equipment, where we have only one of that type at each location, we might use a floating engineer to service them. If we have enough equipment at the facility that would justify having a specialized engineer there, we have that as well, specifically for high-end diagnostic and imaging equipment.”
The program also addresses the distribution of mobile equipment.
“One of the challenges that clinicians face is that when they need a piece of mobile equipment, it’s finding it. Sometimes when they find it, it’s not ready to use,” Assanassios says. “They are challenged with that. Many times, to plan for the next event, they start hoarding some of the equipment because they know that next time, if they need that, if it calls for a suction machine or hypothermia machine, will they find it or not.”
“ By standardizing the types of equipment across the system, it gives our engineers and technicians the ability to work together. we share resources and we take advantage of efficiencies due to proximity of some of the locations to each other.” – Ayman Assanassios
“We have established, across the entire Bon Secours system, an equipment distribution program,” he says. “We have dedicated equipment technicians at each location. Their job is to manage the mobile equipment aspect. From infusion pumps to incubators, ventilators, any equipment that is mobile and that is shared between the various departments and the hospital.
“From the cleaning aspect of the equipment, and to have infection controls in place, and minimize hospital acquired infections to making sure that the clinicians find the right equipment at the right time,” he adds. “When a piece of equipment is needed, it is available to them and they can easily identify if it is ready to be used.”
According to Assanassios, this is all accomplished through the use of software that tracks utilization. The software indicates when a piece of equipment is used, the software can tell when the equipment left and how long it has been used for each location or on different floors. This establishes the amount of equipment that is kept on-hand. Since it is cleaned while it is down, it also minimizes infections. The use of handheld wireless scanners keep track of equipment.
Most medical devices will be assigned a unique device identifier (UDI) by Sept. 24, 2014. High-risk medical device man-ufacturers will be required to include the UDI on their label and packaging. Those manufacturers will also be required to submit data to a Global Unique Device Identification Database (GUDID). Some low-risk devices will be exempt from the rule.
How would the Capital Asset Management Program incorporate the new requirement into their workflows?
“Our database has the ability to track that. Currently, we assign an asset tag to each piece of equipment, so internally; this is the unique identifier for that asset,” Assanassios says. “Once the FDA releases UDIs for the equipment, our database allows us to cross-reference. We will be able to capture that in our database in case of recalls.”
DISPOSITION
Assanassios says the process monitors devices throughout their useful lives.
“It’s part of the global ministry for Bon Secours. Once equipment is identified to be removed or disposed of at a certain facility, we explore the various options for what can be done with that specific device,” he says. “What we do, is first we look at the entire health system, not just this one facility. That device may not have any use at that specific location. It might be useful at an outpatient facility or a low-end users facility, so we will redeploy it to that location.”
“If it’s found not to be needed elsewhere, or it’s past its useful life or there’s no need for it at any location, we have two other options,” Assanassios adds. “We can take it to the outside market and sell it, which helps with the purchase of newer equipment if it has no use here, we can donate this equipment and it will be redeployed to a third-world country or somewhere overseas as part of the Bon Secours ministry.”
The framework has garnered attention within the industry and was recently included as a session at the American College of Healthcare Executives annual congress.
GOOD THINGS COME IN SMALL PACKAGES
“One best practice around PM completion, which we have consistently (had) high rates, consists of monthly monitoring of status. However, each month, each technician sends an email to the department leadership that has PMs due and explains the importance from a safety perspective of PM completion. The department also helps locate missing items.”
– Jeffrey Hooper
When problems crop up with certain equipment, it can benefit a department to flag that equipment.
“I think one of my team’s most important activities around equipment management is in analyzing repairs,” says Jim Fedele, director of biomedical engineering at Susquehanna Health. “We group work orders on a rolling quarter and sort by asset ID number, then look for equipment that has had three or more work requests.”
“For devices that meet the criteria, we pull the work request to see what is going on,” Fedele says. “We look for issues with technician training, poor replacement parts and if the equipment is old and worn out. This helps us keep problematic equipment out of the hands of our customers and allows us to make factual recommendations on equipment replacement.”
Sometimes, equipment management best practices can come out of a simple idea, motivated by a well-defined goal. Start out with your customers’ expectations and work backwards to understand a way to meet those expectations.
“When I joined the team, I interviewed all the various departmental clinical leaders to understand how biomedical engineering could better meet the needs of their department,” recalls Jeffrey Hooper, director of the biomedical engineering department at Children’s National Medical Center in Washington, D.C.
“They were regularly commenting that they did not feel the equipment was being repaired in a timely manner,” he says. “However, the biomedical engineering team did not receive this feedback and the technical team was under the impression that the equipment was repaired timely.”
The biomed team at Children’s National Medical Center then took a hard look at expectations and how to track the process so that expectations could be met. They reasoned that like other service industries, certain objectives should be addressed and met. Hooper says, these included:• Knowledge that the device has been received by biomed and is being assessed for repair.• There should be a general measure that all items are repaired in X amount of time. Further discussion led to the reality that ideally, most customers expect the item to be repaired within 24 hours.• If the item is not repaired in 24 hours, the user should know the status including diagnosis, prognosis, time frame and cost.• When the item is repaired, what was done and whom it was returned to.
“This led to the need to track this information in a much more aggressive manner for all devices receiving work,” Hooper says. So, the team began managing workflows closely to meet expectations.
“We are utilizing a maintenance management software package that is robust and has a high utilization,” Hooper explains. “However, the team agreed that if each technician had a to-do list of items that they were currently working on, with key information that tracked the above items, then they would be able to independently manage and communicate the repair status better.”
“Since we agreed for everyone to use a standard format – we also agreed that the admin for the team would roll it up into one document and post it on the intranet every day – so that if anyone has any questions – they can easily look at the status,” he says.
“It has become more of a competition among the technicians as to who has a long list and who has nothing on their list. At the end of each day, each technician updates the work orders in our maintenance management system and places any items that did not get fixed 100 percent during the day on the spreadsheet for themselves and sends the owner an email (copying the department leaders) of the status of the device. Therefore, every day that a piece of equipment is not repaired the users get an email with the status.” – Jeffrey Hooper
Meeting customer expectations meant hitting certain benchmarks, which they did.
“Our goal is 100 percent, but that is unrealistic,” Hooper says. “It has become more of a competition among the technicians as to who has a long list and who has nothing on their list.”
“At the end of each day, each technician updates the work orders in our maintenance management system and places any items that did not get fixed 100 percent during the day on the spreadsheet for themselves and sends the owner an email (copying the department leaders) of the status of the device,” he explains. “Therefore, every day that a piece of equipment is not repaired the users get an email with the status.”
The end result worked out so well that the team was the winner of AAMI’s Best Practices Award for 2012. Hooper believes that the department has established several other best practices along with meeting customer expectations with repair times.
Bruce Baum sets up a test configuration for an ECMO device test
Steve Jindra performs a preventative maintenance inspection on a syringe pump
Marc Wareing repairs a MEDRAD Veris MRI monitor. He is simulating a patient load to validate the repair
Innovative thinking does not end there.
“One best practice around PM completion, which we have consistently (had) high rates, consists of monthly monitoring of status,” Hooper says. “However, each month, each technician sends an email to the department leadership that has PMs due and explains the importance from a safety perspective of PM completion.”
The department also helps locate missing items.
“During the month, the technicians engage the users within the clinical department to help locate items, then one week prior to the end of the month, the technician schedules a walking meeting in which they look for items that could not be located.”
If PM goals are met, the department sponsors a monthly luncheon with the team’s choice of restaurants catering the eats.
“Our administrative assistant keeps a separate computer LCD large screen at the front of the shop updated with a status log that displays many items, including PM completion rate, any system outages, staff shortages, critical equipment issues, and the number of repairs pending for each technician,” Hooper says.
The biomed team also makes collecting and analyzing data a priority.
“Our department is very engaged in pulling, analyzing and sharing data from medical devices. We have a dedicated clinical engineer who prepares reports on a regular basis providing information to clinicians on how many alarms occurred from our physiologic monitors in each unit; how many soft and hard alerts were generated from our smart infusion pumps; how many refrigerators are out of temp range in our refrigeration management system; and reviews the amount of code blues that occur by unit on a daily basis comparing against census and acuity,” Hooper says.
“These reports are fed to various committees. Our vision is that data exists within the medical devices and should be used proactively to improve the care provided.”
Hooper’s department also has tackled the system management component of current-day equipment management. The days of the sin-gle-function, stand-alone device are waning. The recognition that so many devices belong to a system or network and share information drives the team’s approach, along with the management of hardware and software components.
“As a result, we have created clinical engineering positions (such) as system managers — separate from our technical BMET — that manage the systems (physiologic monitoring network, nurse call, OR video integration, video surveillance, temperature monitoring, and infusion management network),” Hooper says.