Risk-Based Maintenance Carries Its Weight: Smarter Equipment Strategies Mean Safer Patient Care
Two decades ago, hospital preventive maintenance (PM) strategies focused on upholding the electrical integrity of medical devices. In the years since, manufacturers have improved designs and materials to where clinical engineering departments can turn their attention to tailoring more advanced risk-based strategies. In the most forward-looking hospitals and healthcare systems, these strategies include careful evaluation of equipment inventories to decide if, when and how often to intervene throughout the lifecycle of many thousands of devices.
"Equipment has gone through an evolution. It's 100 times different than it was 20 years ago," says Raymond Ongirski, director of clinical engineering at Alexian Brothers Health System in Arlington Heights, Ill. "The challenges have less to do with electrical safety than with making sure the equipment is doing what it's designed to do."
Common motivations for improving PM include increasing patient safety, meeting regulatory compliance, saving resources in the preparation for healthcare reform and minimizing operational expenses. Clinical engineering (CE) departments typically use risk-based preventive maintenance strategies to schedule routine checkups on clinical equipment throughout their hospital systems. Based on the type of device, equipment can fall into one of hundreds of risk categories for PM strategies, and equipment checks can include varying tasks. Preventive maintenance strategies include fixed schedules, run-to-fail (as needed) and random sampling where the extent of PM vary as well. Sometimes all that's required is operation verification, while other instances prompt further probing of equipment to verify its safety and effectiveness.
While the traditional approach to preventive maintenance involves monitoring equipment on fixed timeframes, many CE departments are evaluating the effectiveness of PMs to understand whether clinical engineering interaction with equipment prevents downtime and produces value. Oftentimes engineers find they can eliminate PMs without negatively impacting the equipment. Meanwhile, some evaluations point to the need for more frequent PMs.
Trinity Health in Novi, Mich., has a total of 47 owned and managed hospitals. Of those, 33 hospitals and more than 150,000 pieces of equipment are managed through a centralized CE program. Recently, an evaluation of the organization's PM strategies determined after 18 months of research that 12,000 hours of labor could be saved by eliminating PMs that don't add to equipment uptime or improve safety and quality.
The data in Trinity's computer maintenance management system (CMMS) date to 2003, accumulating a vast amount of service information. In 2008, John-Paul Guimond, Trinity's director of clinical engineering operations, asked his senior management team to look at PMs that add no value.
"Because of the large number of hospitals and medical equipment within Trinity, there was a good probability that a significant amount of labor hours were wasted on ineffective PMs. Thus, I suggested we increase efficiency by eliminating waste," says Guimond.
IV pumps, he notes, were a surprising example of devices that did not benefit from PM, and Trinity has a lot of them.
"A 250-bed hospital has approximately 200 to 300 IV pumps, so a significant amount of time was wasted doing PMs on IV pumps at 33 hospitals," says Guimond. "The majority of the problems we were having with IV pumps were not related to equipment breakdown, but, rather to equipment breakage caused by users. A PM could not impact that."
So they changed that process. Importantly, PMs for equipment designated as life-support equipment went unchanged.
Aurora Health Care, a nonprofit network of 15 hospitals in Wisconsin and northern Illinois, also recently evaluated its PMs to assess whether all of them were necessary. In reviewing the data, they determined where they could redeploy clinical engineering labor for maximum impact. The department ultimately eliminated 1.13 percent of PMs—minor lab equipment, patient visual monitoring equipment—and reduced 18.8 percent of PMs—patient monitoring equipment, aspirators and electrosurgical units. PMs remained unchanged for 78.9 percent of equipment and 2.3 percent of PMs were increased—on devices such as radiology equipment, instrument washers and sterilizers.
"There is always an emphasis on reducing cost and doing more by utilizing current staffing levels more effectively. We looked at what we were doing that really served a purpose and what didn't serve a purpose," says Ongirski. "That was the germination of this idea: Take a look at the failure risk assessment of all the equipment across the board and actually have a measurable outcome by which we can make educated decisions based upon data."
Aurora now uses a formula to assess failure risk—comparing the number of pieces of equipment with corrective maintenance work orders over a predetermined period. This establishes a baseline by which to measure failure frequency. If a piece of equipment fails more often than the established baseline, an evaluation of the device is prompted, notes Ongirski, who was an architect of Aurora's PM system before leaving for Alexian Brothers.
For example, if a clinical engineering department has recently introduced new infusion pumps into its inventory, and repair rates increase, an evaluation may indicate a large number of user errors. This would indicate a need for additional user training. "We have designed our database to reflect those codes to delineate and report on that," he says.
The formula was a product of six months of work between Ongirski and Jerry Krueger, Aurora's manager of corporate clinical engineering, to establish a method to measure PM effectiveness. Additionally, Ongirski says, it can be an indicator of PM depth and a metric for determining capital equipment replacement.
"We were trying to come up with a quantifiable method to adjust our PM frequencies based on how often the device fails," says Krueger. "We took that information to come up with a number based on a period of years and see what the impact was."
It's an evolution of the risk-based system, notes Ongirski, adding that, by evaluating these types of data, Aurora was able to identify where to shift resources in PM strategies.
Managing an inventory of more than 72,000 pieces of equipment, Aurora was able to save 3,000 hours of PM work. The time saved meant refocusing the efforts of clinical engineering so their energies are directed toward activities that add more value, says Krueger. "We're shifting those resources to be of more value to the organizations we serve," he adds. "We're more involved in project management, technology management and capital planning."
In total, Advocate's CE group manages more than 60,000 assets. Of those, approximately 55 percent are included in some form of PM program. "Exactly what we do varies, depending on what we've determined is the most prudent strategy. We do everything from fixed-based schedules to predictive maintenance," says Vanderzee.
Advocate's clinical engineering department monitors repairs that have been classified as preventable, and they adjust strategies based on feedback.
Like many organizations of similar size and means, Advocate has been taking a closer look at their PM strategies. "In the last couple of years we've really focused on a number of high-volume movable medical devices and looked at our strategies. Based on their risk levels of the equipment, we indicated that they should be included in a regular scheduled maintenance program," says Vanderzee. "But the data—repair history, failure trends—were showing that, really, there wasn't anything failing that could be prevented, or benefit from a PM. Thus, we moved some equipment to a less aggressive program, removed some from PM altogether or extended the frequency of inspections on others."
By evaluating trends in this way from 2009 to 2010, Advocate's CE team was able to save the cost of approximately one full-time position.
"The discussion we're having internally and within the profession is: If we've reduced time and requirements, where do we redirect those time savings?" says Vanderzee. "Within Advocate, it's spending more time with clinicians as we perform PMs. Do they need training? Have they had issues that may drive future procurement decisions? Our goal is to get more information and interact with clinicians to support existing technology to make better decisions for the future."
Like Advocate and Aurora, Trinity reallocated the clinical engineering labor hours that were saved in the reduction of preventive maintenance, according to Guimond, who was asked by his team if layoffs were to follow a reduction in PM hours. His response: "Absolutely not."
The affected CE departments instead evaluated opportunities to apply the newly available labor and improve efficiency.
"You need to look at your operations and be ready to justify sending your technicians to service school and use the added labor hours to service equipment once relegated to outside vendor labor," he says. "Our drive has been to take more [service] in-house and limit our reliance on vendor labor to reduce costs."
Clinical engineering departments have varying responses to the elimination or reduction of PMs. Within Aurora, technicians are able to spend more time with clinicians, shifting resources to where they bring about a greater return. "It allows the CE department to drive all of our resources to what's needed for the patient and assisting caregivers to provide better care," Krueger says.
For engineers on the ground, this means spending less time on repetitive tasks that don't bring value to the organization and spending more time with clinicians. "It's a win for techs," says Ed Staroselec, clinical engineering supervisor at Aurora.
At Trinity, some technicians opposed the idea of eliminating PMs for IV pumps, says Guimond. Essentially, the issue was resistance to change.
In a culture in which many technicians have decades of experience, transitioning from a "traditional" preventive maintenance approach can be a tough sell. However, within Trinity, hospitals vary in size and equipment utilization and, if a technician can provide a compelling argument to continue with PMs that had otherwise been eliminated system-wide, exceptions may be granted after review by a senior management team, notes Guimond.
"The technicians were uncomfortable with some of the changes, but the service data supported the need to change past practices and eliminate waste," he says. "If they make an argument for an exception, we may grant one. If we don't, we tell them why."
Trinity didn't mandate the changes, but instead included technicians in the conversation, according to Guimond. "The majority of technicians understand that we must be more efficient if we are to contribute to controlling the rising costs of healthcare."
At Aurora, for example, the next evolutionary step is to include in corrective maintenance work orders information that can help predict whether or not a PM will prevent a given unit from breaking. If a nurse drops an infusion pump, a PM would not have made a difference, Krueger points out. But if an engineer finds a battery issue while doing preventive maintenance, an adverse event may be headed off.
Closely monitoring data and re-evaluating preventive maintenance strategies can save healthcare systems money while improving the safety and effectiveness of their equipment. And don't those goals add up to the very reason for the existence of hospital-based clinical engineering?
"Equipment has gone through an evolution. It's 100 times different than it was 20 years ago," says Raymond Ongirski, director of clinical engineering at Alexian Brothers Health System in Arlington Heights, Ill. "The challenges have less to do with electrical safety than with making sure the equipment is doing what it's designed to do."
Common motivations for improving PM include increasing patient safety, meeting regulatory compliance, saving resources in the preparation for healthcare reform and minimizing operational expenses. Clinical engineering (CE) departments typically use risk-based preventive maintenance strategies to schedule routine checkups on clinical equipment throughout their hospital systems. Based on the type of device, equipment can fall into one of hundreds of risk categories for PM strategies, and equipment checks can include varying tasks. Preventive maintenance strategies include fixed schedules, run-to-fail (as needed) and random sampling where the extent of PM vary as well. Sometimes all that's required is operation verification, while other instances prompt further probing of equipment to verify its safety and effectiveness.
Cutting back, yet doing more
 | |
| Chuck Cardenas, a biomedical equipment technician at St. Joseph Mercy Oakland Hospital in Michigan, checks for dust accumulation inside a Philips IU-22 ultrasound machine. The IU-22 is part of the hospital’s preventive maintenance program. Source: St. Joseph Mercy Oakland Hospital. |
Trinity Health in Novi, Mich., has a total of 47 owned and managed hospitals. Of those, 33 hospitals and more than 150,000 pieces of equipment are managed through a centralized CE program. Recently, an evaluation of the organization's PM strategies determined after 18 months of research that 12,000 hours of labor could be saved by eliminating PMs that don't add to equipment uptime or improve safety and quality.
The data in Trinity's computer maintenance management system (CMMS) date to 2003, accumulating a vast amount of service information. In 2008, John-Paul Guimond, Trinity's director of clinical engineering operations, asked his senior management team to look at PMs that add no value.
"Because of the large number of hospitals and medical equipment within Trinity, there was a good probability that a significant amount of labor hours were wasted on ineffective PMs. Thus, I suggested we increase efficiency by eliminating waste," says Guimond.
IV pumps, he notes, were a surprising example of devices that did not benefit from PM, and Trinity has a lot of them.
"A 250-bed hospital has approximately 200 to 300 IV pumps, so a significant amount of time was wasted doing PMs on IV pumps at 33 hospitals," says Guimond. "The majority of the problems we were having with IV pumps were not related to equipment breakdown, but, rather to equipment breakage caused by users. A PM could not impact that."
So they changed that process. Importantly, PMs for equipment designated as life-support equipment went unchanged.
The numbers speak
 | |
| Mike Billings of Saint Mary Mercy Hospital in Livonia, Mich., completes installation of a repaired pump mechanism in an infusion device. Billings also will perform delivery verification and functional inspection. Source: Saint Mary Mercy Hospital. |
"There is always an emphasis on reducing cost and doing more by utilizing current staffing levels more effectively. We looked at what we were doing that really served a purpose and what didn't serve a purpose," says Ongirski. "That was the germination of this idea: Take a look at the failure risk assessment of all the equipment across the board and actually have a measurable outcome by which we can make educated decisions based upon data."
Aurora now uses a formula to assess failure risk—comparing the number of pieces of equipment with corrective maintenance work orders over a predetermined period. This establishes a baseline by which to measure failure frequency. If a piece of equipment fails more often than the established baseline, an evaluation of the device is prompted, notes Ongirski, who was an architect of Aurora's PM system before leaving for Alexian Brothers.
For example, if a clinical engineering department has recently introduced new infusion pumps into its inventory, and repair rates increase, an evaluation may indicate a large number of user errors. This would indicate a need for additional user training. "We have designed our database to reflect those codes to delineate and report on that," he says.
The formula was a product of six months of work between Ongirski and Jerry Krueger, Aurora's manager of corporate clinical engineering, to establish a method to measure PM effectiveness. Additionally, Ongirski says, it can be an indicator of PM depth and a metric for determining capital equipment replacement.
"We were trying to come up with a quantifiable method to adjust our PM frequencies based on how often the device fails," says Krueger. "We took that information to come up with a number based on a period of years and see what the impact was."
It's an evolution of the risk-based system, notes Ongirski, adding that, by evaluating these types of data, Aurora was able to identify where to shift resources in PM strategies.
Managing an inventory of more than 72,000 pieces of equipment, Aurora was able to save 3,000 hours of PM work. The time saved meant refocusing the efforts of clinical engineering so their energies are directed toward activities that add more value, says Krueger. "We're shifting those resources to be of more value to the organizations we serve," he adds. "We're more involved in project management, technology management and capital planning."
Safety first
At Advocate Health Care in Oak Brook, Ill., a dedicated PM strategy has been in place for more than 10 years, according to Steve Vanderzee, manager of clinical engineering technology. "The goals of that program have always been to maintain patient and user safety, extend the life of our assets and maintain a high level of reliability," he says. "That is the main focus."In total, Advocate's CE group manages more than 60,000 assets. Of those, approximately 55 percent are included in some form of PM program. "Exactly what we do varies, depending on what we've determined is the most prudent strategy. We do everything from fixed-based schedules to predictive maintenance," says Vanderzee.
Advocate's clinical engineering department monitors repairs that have been classified as preventable, and they adjust strategies based on feedback.
Like many organizations of similar size and means, Advocate has been taking a closer look at their PM strategies. "In the last couple of years we've really focused on a number of high-volume movable medical devices and looked at our strategies. Based on their risk levels of the equipment, we indicated that they should be included in a regular scheduled maintenance program," says Vanderzee. "But the data—repair history, failure trends—were showing that, really, there wasn't anything failing that could be prevented, or benefit from a PM. Thus, we moved some equipment to a less aggressive program, removed some from PM altogether or extended the frequency of inspections on others."
By evaluating trends in this way from 2009 to 2010, Advocate's CE team was able to save the cost of approximately one full-time position.
"The discussion we're having internally and within the profession is: If we've reduced time and requirements, where do we redirect those time savings?" says Vanderzee. "Within Advocate, it's spending more time with clinicians as we perform PMs. Do they need training? Have they had issues that may drive future procurement decisions? Our goal is to get more information and interact with clinicians to support existing technology to make better decisions for the future."
Like Advocate and Aurora, Trinity reallocated the clinical engineering labor hours that were saved in the reduction of preventive maintenance, according to Guimond, who was asked by his team if layoffs were to follow a reduction in PM hours. His response: "Absolutely not."
The affected CE departments instead evaluated opportunities to apply the newly available labor and improve efficiency.
"You need to look at your operations and be ready to justify sending your technicians to service school and use the added labor hours to service equipment once relegated to outside vendor labor," he says. "Our drive has been to take more [service] in-house and limit our reliance on vendor labor to reduce costs."
Cultural shift
 | |
| Kachi Enyia, imaging equipment technician at St. Joseph Mercy Oakland Hospital, checks test point voltages. Source: St. Joseph Mercy Oakland Hospital. |
For engineers on the ground, this means spending less time on repetitive tasks that don't bring value to the organization and spending more time with clinicians. "It's a win for techs," says Ed Staroselec, clinical engineering supervisor at Aurora.
At Trinity, some technicians opposed the idea of eliminating PMs for IV pumps, says Guimond. Essentially, the issue was resistance to change.
In a culture in which many technicians have decades of experience, transitioning from a "traditional" preventive maintenance approach can be a tough sell. However, within Trinity, hospitals vary in size and equipment utilization and, if a technician can provide a compelling argument to continue with PMs that had otherwise been eliminated system-wide, exceptions may be granted after review by a senior management team, notes Guimond.
"The technicians were uncomfortable with some of the changes, but the service data supported the need to change past practices and eliminate waste," he says. "If they make an argument for an exception, we may grant one. If we don't, we tell them why."
Trinity didn't mandate the changes, but instead included technicians in the conversation, according to Guimond. "The majority of technicians understand that we must be more efficient if we are to contribute to controlling the rising costs of healthcare."
Taking charge of change
Preventive maintenance has been evolving since it started—and will no doubt continue to morph alongside the new equipment constantly entering the U.S. healthcare system.At Aurora, for example, the next evolutionary step is to include in corrective maintenance work orders information that can help predict whether or not a PM will prevent a given unit from breaking. If a nurse drops an infusion pump, a PM would not have made a difference, Krueger points out. But if an engineer finds a battery issue while doing preventive maintenance, an adverse event may be headed off.
Closely monitoring data and re-evaluating preventive maintenance strategies can save healthcare systems money while improving the safety and effectiveness of their equipment. And don't those goals add up to the very reason for the existence of hospital-based clinical engineering?
| Formula for Less Risky Business | |
| Raymond Ongirski and Jerry Krueger devised this risk-based formula for Aurora Health Care in Wisconsin to establish a baseline by which to measure frequency of failure in medical equipment. When a device’s failure rate exceeds the baseline, clinical engineering deals with its particular problem. Managing an inventory of approximately 72,000 devices, Aurora used this approach to save more than 3,000 hours of preventive maintenance and redeploy staff to more productive pursuits. Krueger is Aurora’s manager of corporate clinical engineering. Ongirski, former clinical engineering supervisor with Aurora, is now director of systems clinical engineering with Alexian Brothers Health System in Illinois. | Baseline Equation: FR=(CM/(INV*TFY))/12
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