Return on Investment

1. Return on Investment Introducing Clinical Engineering Lúcio Flávio de Magalhães Brito, CCE Engineering Director

2. About the speaker • Mechanical Engineer • Federal Engineering School of Itajubá • Occupational Safety Engineer • Industry Engineering School • Hospital Administration Specialist • Getúlio Vargas Foundation • Certified Clinical Engineer • International Certification Commission • Healthcare Technology Foundation • Biomedical Engineering Specialist • Campinas State University • Engineering Director of Medicorp • São Paulo - Brazil

3. Our Agenda • Concepts and definitions • Engineering • Healthcare Technology • Financial • Tips • During presentation • Case Studies • Clinical Engineering • Hospital Engineering • Maintenance • Technology Administration

4. Return on Investment • The greater the risk, the greater the expected return on investment, because the risk must be rewarded • Minimize operational expenses • Increase sales volume • Reduce equipment down-time • Avoid exaggerated installations • Increase both “Current Ratio” and “Quick Ratio”

5. Engineering Concepts • Clinical Engineering • “A Clinical Engineer is a professional who supports and advances patient care by applying engineering and managerial skills to healthcare technology." - ACCE Definition, 1992 • Other terms used to specify this professional are: • Healthcare engineer, hospital engineer, biomedical equipment technician, equipment managers, technology manager, biomedical engineer, maintenance engineer, healthcare technologist.

6. Clinical & Hospital Engineering • Clinical Engineering equipment responsibilities • Infusion pumps, defibrillators, monitors, x-ray machines, cath scan, MRI, ultrasound, ventilators, surgical table and lights, electrosurgical units, pulse oxymeters, CT scan, etc. • Hospital Engineering equipment responsibilities • HVAC, medical gases, electrical systems, medical compressed air, vacuum systems, elevators, construction support, communication systems, vehicles, steam, hot water, etc.

7. Typical Engineering Responsibilities • Supervision, coordination and technical orientation • Studies, planning, projects and specifications • Technical and economic feasibility studies • Counseling and advisory services • Manpower and resource management • Inspections, audits, evaluation, survey, technical reports • Technical functions • Teaching, research, analysis, experimentation, tests • Budget preparation

8. Typical Engineering Responsibilities • Standardization, measurements, quality control • Constructions • Fiscalization of service execution • Specialized technical production • Technical evaluation of work conductions • Management of installation, mounting, operation, repair or maintenanceteam • Execution of installation, mounting, repair and remodeling • Installations and equipment operations and maintenance • Technical drawing

9. Engineering or Maintenance ?

10. Engineering !!!

11. Healthcare Technology Definitions • Healthcare Technology. What is it? • Healthcare technology includes the devices, equipment, systems, software, supplies, pharmaceuticals, biotechnologies, medical and surgical procedures, organizational structures used in the prevention, diagnosis, and treatment of disease in humans; for rehabilitation; and for assistive purposes. • Here we will focus on medical equipment and hospital installations and facilities.

12. Healthcare Technology Concepts • Technology Efficacy • A benefit from a given medical technology under ideal conditions of use. • Technology Effectiveness • A benefit from a given medical technology under average (real) conditions of use. • Technology Efficiency • Lowest price when different technologies have same efficacy and effectiveness.

13. Technology Life-Cycle • A process by witch technology is created, tested, applied, and replaced or abandoned. • Know the maturity of a technology • Support systematic and rational decisions

14. Cost-Effectiveness • A process that combines qualitative and quantitative considerations in order to know the costs of a project compared to the resultant benefits. • Costs are normally expressed in dollars • Benefits in terms of: • Lives saved • Disabilities avoided • Quality-adjusted life years saved • Other relevant objectives

15. Life Cycle Cost analysis (LCC) • Initial purchase price • Shipping • Renovations • Installation • Supplies • Associated disposables • Cost per use • And OTHER costs as: staff training, ease of use, servicing, spare parts, upgrades, networking …

16. Clinical Evaluation Prior to Purchase Decision Prepare the user for proper operation Inservice Training Documentation Equipment design User’s ability Human factors Patient and user discomfort Keyboard Device controls Alarms Ease of Use

17. LCC & NPV Analysis

18. Modules for practicing? • Full Clinical Engineering Implementation • Partial Clinical Engineering Implementation • Technology Advisory Counseling • Accreditation Preparation • Technology Audit & Action Plans • Technology Inventory • Economic Rescue Plans • Technology Incorporation Planning • Case Studies

19. Full Clinical Engineering Implementation • 16 Complementary areas • Diagnostic Studies • Inventory • Market Procurement • Law Standards and Regulations • Equipment Control • Costs & Expenses Control • Process Management • Risk Management • Contract Management • Personal Management • Technology Incorporation • Maintenance • Patient Safety • Technology Planning • Training • Quality Back

20. Diagnostic • Evaluation Criteria • Continuing Education • Risk management • Technology Incorporation & Acquisition • Equipment Control • Legal Standards & Regulations • Maintenance • Preventive • Corrective • Documentation • Administrative • Technical • Safety

21. Diagnostic • Excellence & Quality • Leadership: participation • Planning: actions • Social Concerns: attended • Clients: necessities • Information: use • Personal: capacitating • Processes: practice • Results: defined

22. Diagnostic • National Accreditation Organization • Physical Projects Management • Physical Infra-Structure • Facilities Management • Waste Management • Medical Equipment Management • Safety Management • SWOT • Strengthens - I • Weakness - I • Opportunities - O • Threats - O Back

23. Inventory • Applied to medical equipment and facilities and accessories • State of Conservation • Age of Technological • Registers in organizations as FDA • Recall Evaluations • Value – US$ • New • Substitution • Energy consumption • Technical & Administrative Data • Serial number • Model • Manufacturers • Owner • Contracts • Warranty • Technical Responsible Back

24. Market Procurement • Improve the knowledge of medical equipment market • Improve the knowledge about the market of healthcare facilities • Medical Equipment Fairs • Mechanical Fairs • Electrical & Electronic Fairs • Specialized Magazines • Technical Papers and Newspaper • Internet groups • Engineering and Maintenance Associations • Benchmarking Back

25. Law, Standards and Regulations • Municipal, State and Federal Laws • Water Quality • Electricity Supply • HVAC • Sterilization • Standards • NFPA, ANSI, ASHRAE, ISO, AAMI, JCAHO • FDA • Registers, Recalls • ECRI – 1991 • 13,000 standards and guidelines • 800 organizations and agencies (North America) Back

26. Equipment Control • Equipment history • Maintenance procedures • What are the expenses and costs related to maintenance? Are they high? • How many hours of work? • Who is the Responsible for the equipment? • What are the maintenance indicators? • MTBF • MTTR • Availability • Up Time • Down Time Back

27. Costs & Expenses Control • Actions may be applied to the two principal types of costs and expenses, i.e.: • Medical equipments • Facilities • In addition, actions may also be taken to recuperate money as related to: • Review contracts • How to obtain more from the same contracts? • Contractual compliance • New contracts • New technologies • What kind of knowledge can be used to change the operational costs? Back

28. Process Management • How to manage a clinical engineering department using processes? • Define how workers and patient can have benefits from processes • Create internal administrative procedures • To open work orders • To prepare requisition of spare parts and consumables • Register engineering activities to monitor performance to achieve defined goals • Issue management reports • Evaluate medical equipment • Register activities of maintenance • Corrective & Preventive and others Back

29. Risk Management • Helps hospital by to: • Avoiding exposure risks • Minimizing liability exposure • Staying compliant with regulatory reporting requirements • JCAHO – PSTM • Require minimum technology-based risks management activities • Recognition, evaluation and risks control • Determination of technology-related incidents with followed-up steps to prevent recurrences • Evaluation and documentation of the effectiveness of these steps Back

30. Contract Management • Helps hospital fully explore its contracts on: • Service and Maintenance • Electricity • Medical gases • Combustibles • Warranties • Acceptance tests • Price of spare parts • Timeframes • Performance indicators evaluations Back

31. Personal Management • Helps the hospital’s maintenance and engineering staff be: • Involved • Prepared to execute its functions • Properly assigned to specific technical tasks • Creative and solution-oriented • Capacitated • Focused on objectives and goals Back

32. Technology Incorporation • Helps hospitals organize and take full advantage of technologies by: • Analyzing needs and developing specifications • Developing a vendor list • Analyzing proposals and site planning • Evaluating samples • Selecting finalists • Choosing the best proposal • Controlling deliveries and installations • Performing acceptance testing • Final acceptance Back

33. Technology Incorporation • Healthcare is increasingly using TCO • Initial price • Equipment, installation, initial training costs an support over the long-term • Long term costs • On-going training, equipment service, supplies, connectivity, up grades • TCO • Acquisition costs • Operation and maintenance costs • Installation and Supplies • Down time and Spare parts • Test equipment tools • Depreciation Back

34. Technology Incorporation • Clinical Team Requirements • Ability of staff to assimilate the technology • Medical staff satisfaction (short and long term) • Impact on staffing (numbers, functions) • Projected utilization • On-going related supplies required • Effect on healthcare delivery and results (convenience, safety, or standard of care) • Written, clinical practice guidelines • Credentialed staff • Clinical staff initial and ongoing training • Effect on existing technology in the department or other services/departments Back

35. Maintenance • Preventive • Documentation • Operational manual • Operational maintenance • Registers • Tools • Adequate tools required • Simulators and performance equipment tests • Calibration certification of these equipments • Corrective • Service manual • Training • Functional principles • Management of these processes Back

36. Patient Safety • Safety is a condition of being safe from: • Danger • Injury • Damage • Regulations and Standards • Air conditioning (tuberculosis) • X-Ray dose • Medical air quality • Electrical current leakage • Burns associated to electrosurgical units • Alarms management Back

37. Strategic Technology Planning • Is an accountable, systematic approach to ensuring that cost-effective, efficacious, appropriate, and safe equipment is available to meet the demands of quality patient care, and allows an institution to remain competitive. • In house service management • Management and analysis of external service providers • Involvement in the equipment acquisition process • Involvement in facility planning and design • Reducing technology related incidents • Training equipment users • Reviewing equipment replacement needs • On-going assessment of emerging technologies Back

38. Training • Helps hospital to: • Disseminate user’s manual an other information • Process and track hazard, recall, and regulatory data • Provide initial and on-going personnel training • Investigate equipment-related incidents, hazards, and problems • Include discovered error in staff training programs • Engineering and maintenance personal • Corrective: X-Ray machines and autoclaves • Preventive: Almost all Back

39. Quality • Quality of Care • It means providing healthcare with the most efficient use of resources • Measuring quality of care • Quality Assurance (QA) & Quality Improvement (QI) are formal sets of activities to measure the quality of care • Selecting, monitoring, and applying corrective measures • Indicators • Benchmarking Back

40. Quality of Medical Technology • Inventory • Institution’s experience with that and similar devices • Equipment functions • Industry standards (state of art) • Age • Current device condition • Select a valid indicator to measure equipment’s clinical performance • Availability • Functionality • Financial performance • Safety Back

41. Quality of Medical Technology • Types of indicators • Type and # of devices scheduled for service • Total # and type of devices inspected • Type and # of devices that failed an inspection • Type and # of devices for which on-demand service was requested • Type and # of devices found with physical damage • Type and # of devices for which user’s complaint was registered, but no problem found • Type and # of devices involved in accidents or incident • Type and # of devices that were serviced more than one time in any 7-day period • Type and # of devices for which abnormal labor or replacement parts were required Back

42. Partial Clinical Engineering Management • Refers to the partial application of the 16 programs previously mentioned • Medical Equipments • Hospital Installations - Facilities • Using one program or a combination of specific programs to achieve an objective • Inventory & Maintenance • Market Procurement • Patient Safety • Accident & Incident Investigation Back

43. Technology Advisory Counseling • Administrators • Hospital that don’t have enough demand for an engineering department but have important costs or needs to be supported • Legal standards and regulations, specific information on medical equipment and installations • Engineers • Lack of time • Lack of knowledge or information • Other Professionals • Nurses, Infection control programs, occupational safety professionals Back

44. Accreditation Preparations • Safety • Inventory & documentation • Equipment and installation performance • Processes • Maintenance processes management • Technical • Administrative • Results – Indicators • Quality assurance and improvement indicators • Administrative indicators • Financial indicators Back

45. Technology Audit & Action Plans • Needs • Including utilization rate of current equipment and of new equipment • Value of technology • Technical validity an maturity • Ability to assimilate and maintain technology • Medical and other staff satisfaction • Impact on staffing and healthcare delivery • Impact on facilities and code compliance • Impact on healthcare standards and quality • Economic considerations (e.g., reimbursement, life-cycle cost) Back

46. Technology Inventory • Quantify and qualify equipments and installations • Manufacturer • Regulatory aspects related • Ionizing radiation • Quality of water • Financial information • Price • Installation • Conservation conditions • Reports • Help hospitals to create performance indicators • Usually necessary to use accounting approach • Help hospitals to plan new investments Back

47. Economic Rescue Plans • Minimize costs, maximize short-run • Immediate actions that are possible because: • Easy to do but nobody has done it yet • Have no additional costs to implement the proposed solutions • Logic and reason are the only resources that need to be applied • Simple knowledge is enough to resolve the situation • Economic resources are always scarce and have to be used correctly Back

48. Technology Incorporation Planning • Prepurchase evaluations • The level of information needed for each phase depends on the acquisition • Acquisition process strategies • Cost of ownership • Utilization information • LCC Analysis • Equipment evaluation • The conditions of sale document • Final choice • Installations • Acceptance testing Back

49. Study of Case • Medical de Limeira • Medical gases pipelines • Clínica Ana Rosa • Air conditioning system • Santa Casa de Limeira • Oxygen generation • In house maintenance • Less difficult to more difficult activities Back

50. Goals of Clinical Engineering