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Imaging Equipment Maintenance – Best Practices for Promoting Efficiency

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Corporations often rely on consultants to tell them how to squeeze every last drop of efficiency out of their systems, methodologies and employees. They pay these consultants large fees because an improvement of a percent or two can result in cost savings that more than make up for the expense.

Hospitals and health care systems have a similar motivation; to seek out opportunities for efficiency, save money, follow best practices and seek methods that improve the bottom line while maintaining patient safety. It’s basic economics, compounded by the demands of a changing health care environment, that takes a pay for performance approach. Efficiency isn’t an option; it’s a necessity and the metrics are everywhere to measure it.

If you are an HTM professional and find yourself shaking your head and muttering something along the lines of “no kidding dude,” as you read these words, then you have learned this reality firsthand. Health care systems have to work so efficiently that sometimes you can hear them squeak; the tolerances have been set that tight.

We take a look at how the HTM department can reduce costs while improving service in the management of imaging equipment. There are ideas and concepts that can be derived from the management of imaging equipment and employed in the management of all other equipment; we highlight each.

Technation Magazine | Cover Story | Imaging Equipment Maintenence“It can’t be over-emphasized, the importance of securing the HTM department’s seat at the table when diagnostic imaging technology is purchased,” says Perry Kirwan, MSE, CCE, senior director of Clinical Technology Assessment and Planning at Banner Health. “The ability to influence a few variables at the front end of the life cycle can pay tremendous dividends over the total life cycle.”

“Technology standardization enables an organization to leverage the full extent of its purchasing power while at the same time reducing clinical variation on the patient care delivery side. Clear purchasing requirements prevent the opportunity for under-utilized technology to be procured. Extended warranties, more favorable service terms, service training and enhanced clinical training are all things that are better negotiated before the purchase is made,” Kirwan says.

Ownership of the budget is a key area of leverage for strengthening the negotiation and leadership position of the HTM department.

“One important event that allowed for us to better manage and negotiate improved strategies for service was when we took over the organization’s maintenance and service budget,” says Steven Bowers, CET, manager of Biomedical Engineering at Rex Healthcare in Raleigh, North Carolina. “Previously, each clinical and imaging area had their own maintenance account to manage and utilize. Having the full budget line for service meant that vendors developed stronger working relationships with our team, felt that they knew what was expected from them, and were more inclined to adjust to our specific needs and requirements.”

“As we made it known that all service reports were to be scrutinized and matched specifically to invoicing, accountability improved as well as responsiveness to delivery of field reports,” Bowers says.

Using Available Resources

“Set the bar high,” suggests Steve Letourneau, senior director of diagnostic imaging services for Banner Health.

“It all comes down to changing the culture within a facility,” adds Anthony Coronado, biomedical engineering manager at Methodist Hospital of Southern California and account manager for Renovo Solutions LLC.

Each suggest that the work culture and expectations are important. Also, the expectations for bringing imaging services in-house requires a goal of service quality that aims to exceed the OEM service.

cover-2“In addition to utilizing the same industry standard service metrics, productivity and efficiency is a major factor. Many in-house organizations that have 10 or more facilities still use the same formation as their in-house BMET counterparts do where they are assigned to one facility,” Letourneau says, from the perspective of a large health care system.

“Banner uses field deployable imaging engineers who are not assigned to one facility. Our BMET department does the same thing with specialty trades within the BMET area,” he explains. “The service personnel are commonly dispatched from home and have over 10 different facility responsibilities within a given territory.”

Letourneau says that the most common issue with having engineers deployed or allocated to one facility is that they tend to only be trained on equipment at that one particular facility. He says that with imaging service, this especially becomes a problem when the goal is to provide on-call 24/7 service, where the imaging engineer can receive a call from any facility and may have to service a variety of makes and models of multiple OEM manufacturers.

F. Mike Busdicker, MBA, system director, Clinical Engineering Intermountain Support Services/Supply Chain at Intermountain Healthcare remembers that his health care system faced the issue of reducing costs and improving service in the management of imaging equipment when they started their imaging equipment service program in 2012.

“At the start, organizational leadership created an Imaging Services Guidance Council, and one of their tasks was to oversee implementation of the service program and to track program performance,” he says.

“Of course, the first thing we needed to do was understand the current state of the program in relation to things like customer service expectations, equipment uptime, service level agreements, response times, service cost, total cost of ownership, and strategic planning,” he adds. “Once we had concrete data in these areas, we could start building a business plan to focus on implementing and delivering an internal service program at levels equal to, or better, than those being delivered in the current model.”

Busdicker says that they were sure to include all areas of service and not focus strictly on reducing the cost of service.

cover-3“It is important to deliver a high-quality product to the stakeholders at a financially responsible level for the organization,” he says. “As we remained focused in these areas, it helped build trust in our service program. We gained the trust of personnel across the organization from the front-line staff to system level leadership and included most of our service providers.”

“We continuously evaluate the specific needs and requirements of each system, look at vendor options for economic, effective service plans and our own in-house team capabilities in order to make customized choices for each imaging platform,” Bowers says.

Bowers says that often, his biomeds are able to “train up” via a vendor provided or other service training option to take maintenance requirements in-house and reduce costs while still providing quality service and uptimes.

“Over time we have developed first look, shared, PM only and parts only agreements to keep costs down, yet still maintain vendor assistance and support,”

he says. “We lobby hard with our finance and executive staff during fiscal budget planning for training and technical education budget dollars as we have found and promote that investing in ourselves not only improves on-site response times but also provides cost savings year after year.”

Making the Transition

“Transitioning from full service contracts to an in-house support model involves trust at all levels. This includes open dialogue with internal customers, organizational leadership, and with current service providers. In order to build a successful in-house program it will require buy-in at all levels of the organization and a collaborative effort with service suppliers,” Busdicker says.

Busdicker points out that perspective is important in cultivating a relationship with outside service providers. Outside providers are still necessary in some cases. He says that the relationship with those providers begins with viewing them as suppliers and not vendors.

Technation Magazine | Cover Story | Imaging Equipment Maintenence

“A vendor is someone that sells hot dogs and popcorn at ball games and exists mainly on a transactional basis. In our business, a supplier is someone who works with you to deliver a product that provides a win for health care as a whole,” Busdicker says. “It is imperative everyone be involved with the process and the focus is on the end result of providing the best service possible to our patients. It is not about cutting out the supplier and strictly reducing costs, it is about providing the best possible solution that will enhance patient care without driving up the overall cost of health care. This means we must work in a collaborative relationship with our suppliers to ensure we achieve our overall goal.”

“It is all about creating internal standards and metrics that allow for successful growth and implementation of programs,” says Tim Riehm, vice president of Technology Management at Banner Health.

Riehm says that the transition to in-house service doesn’t mean completely excluding all OEM service. He says that you have to look at the value your team brings to the equation and which functions can be improved by doing them internally.

“A great example would be high-end proprietary glassware,” he says. “Chances are that your team can’t produce glassware and the current after-market costs for the proprietary glassware are far too costly,” Riehm points out.

The likelihood of a better cost model through the OEM in this area requires sharpening your pencil, according to Riehm.

“It is highly likely that you could negotiate a much better cost model working with the OEM to cover this area as opposed to being exposed to huge one-time costs,” he adds. “In order to effectively do this, you will need to understand the costs of doing this function by each option using historical data to support your decision. Utilizing this data will enable you to more effectively negotiate the glassware with the OEM or third-party based on factual data and the need to further reduce those expenses using volume.”

“Having a solution in place for glassware will also improve uptime for the systems since you won’t be searching for tubes and will likely have some on-site or close by your hospital,” Riehm points out. “We have managed to reduce costs and downtime by more than 50 percent since negotiating the glassware options of our partnership agreements.”

“It all depends on the relationship that is established with the HTM department and the radiology department,” Coronado says. “Trust is the key for transition for the change of service to in-house and with the HTM personnel you are going to train.”

When transitioning to in-house support, the oversight to measure those metrics is the key to making it work.

“Early in the process, we established a sub-committee to focus on program implementation, identifying milestones, and maintaining program oversight,” Busdicker says. “Part of their tasks included identifying key metrics used to measure the success of program implementation and ongoing management. This group developed a five-year plan outlining manpower projections, equipment transitions, and metrics to track successful service delivery. This plan has been a key to the successful implementation of the program and ongoing monitoring of performance.”

Kirwan says that an important piece of the puzzle for a contract conversion is to have a clear and defined mission in the beginning to help set tactical strategies for the HTM department. That strategy should include touchpoints in every aspect of the a given technology’s life cycle. He says there are resources that can be used during the pre-procurement phases when assessing new technology, for developing technology standards that are undefined and for standards enforcement on those that are defined.

There are also resources that work during the procurement process, he suggests, to ensure that technology is “right-sized” relative to the organization’s strategy. The goal is to “bring business intelligence skills to the table to help set thresholds” for what an organization is willing to pay for technology.

“HTM departments possess the data and experience to provide that kind of insight which is extremely valuable to the purchasing process,” he says.

“With the above processes in place, it is also important to have feedback loops from implementation and on-going support perspective back to the pre-procurement and procurement processes. This feedback has the power to influence standards, strengthen programs already in place [and] gap analysis of program elements that need to be addressed moving forward,” Kirwan adds.

Comparing Models

In dissecting the three primary service models, Letourneau says that two have some downfalls, while the third offers the right balance for his employer.

According to Letourneau, full OEM contracts provide no opportunity for cost savings, may contain additional hidden costs – OT, CT slice count overages, etcetera, and provide no control over service outcomes. Time and materials has the potential for huge variation in cost and service delivery quality, comes up short because of a lack of vendor support – diagnostics, training, and technical support. It also requires the need for high aggregate volumes to make the risk model work financially.

“This model does not work well when there are very expensive consumables such as X-ray tubes, flat panels, etcetera,” he adds.

Then, there is the hybrid-partnership model. This is the model that Banner employs.

“We have also seen where some companies will use a mix of all three leaving the high-end equipment under a full-term OEM contract. The problem with using all three is the fact that most of your higher cost contracts will come from the high-end devices and the cost reduction is not fully optimized,” Letourneau explains.

“Many of the models we see do not have solid OEM partnerships and this limits their ability to provide fully competent engineers who have all the tools necessary to perform their jobs,” he says. “Many in-house service organizations bill individual departments based on each service event and occurrence, Banner spreads this cost over all of Banner facilities and allocates a fixed cost to each facility. This cost allocation is based on each facility size. Nobody takes a hit for any one-service incident. This greatly improves the sometimes bitterness between in-house service and the end-users.”

Riehm adds that with full service agreements, there is no chance to further collaborate on options, they make it difficult to manage service escalation, difficult to manage response time, and they typically identify every system the same regardless of criticality or importance to the hospital.

Technation Magazine | Cover Story | Imaging Equipment Maintenence“Time and materials — complete lack of support by anyone. Essentially these are no more than an internal insurance model for medical equipment. Requires a significant amount of effort for very little reward,” Riehm says.

He says that first pass contracts are essentially just a larger discount on a contract that allows the local staff to take a first look at the system and then call the vendor in for service. Riehm says that this model delays service and increases downtime while having a minimal impact to the overall cost structure.

“The vendor expects very little from the local staff and prices the model accordingly,” he says.

“Partnerships allow for creative approaches to creating a new model for future service delivery. [They offer a] great ability to reduce costs far below any of the other models,” Riehm says.

Inevitable change demands that the HTM professional take a central role.

“We are going to see continuous changes in health care over the new few years and the HTM department needs to be a proactive part of the change process; not reactive. It is time for our field, in-house programs and service suppliers, to step up and be part of the solution process for health care,” Busdicker says.

“This means working together to find solutions and then implementing these solutions in our organizations and sharing the outcomes with the Healthcare Technology Management field,” he adds.

Finally, going back to our original assertion about incremental cost savings, the true impact of efficiency that can originate in the HTM department is summed up in this example by Letourneau.

“If you think about what the ratio of revenue to margin is today, in the health care business, and how much actual revenue is needed to scratch out a small margin, that ratio might be 20 to 1. So in essence, if we were able to save $20 million dollars in operational costs, this would be equivalent to not having to produce $400 million dollars in more revenue to provide the same impact,” he says. “This is especially important when health care in general is continually subject to many outside influences that negatively impact revenue across the board.”

That is how HTM gets the attention of the C-suite.

Roundtable: Nuclear Medicine

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Nuclear medicine continues to be a very important aspect of health care in the United States and throughout the world. TechNation examines the future of the market and the best approaches to maintain and upgrade these devices with a roundtable Q&A discussion.

The experts on the roundtable panel are Michael Eaton, Field Service Engineer at Southeast Nuclear Electronics; Danny Hamm, Vice President of Sales, InterMed Nuclear Medicine Services; Nik Iwaniw, MM, RT, CNMT, Vice President, Marketing and Services, Universal Medical Resources Inc.; Eric Langsfeld, owner, E.L. Parts LLC ; Will Martinez, Director of Field Service/Global Medical Imaging; Don McCormack, Chief Executive Office, Southwest Medical Resources; Josh Nunez, Molecular Imaging Product Manager, Block Imaging; and John Shaw, Service Engineer, Northeast Electronics Inc.

Q: What are the latest advances or significant changes in nuclear medicine?

Eaton: Although not a new concept, hybrid modalities such as SPECT/CT are gaining popularity in clinics and hospitals. Many of these systems are approaching the end of their OEM warranty, if they haven’t already.

Hamm: The latest advance that has the most significant impact on nuclear medicine is Wide Beam Construction software. It has the ability to acquire images in about half the time as standard software, enables the study to be performed with half the dosage of isotopes, or both at the same time (depending on the version and type of software).

Iwaniw: Not unlike other imaging modalities, technical advances in nuclear medicine continue to be introduced to improve clinical decisions for physicians and patients. Some of these are related to improved SPECT, SPECT/CT, and PET/CT systems. In addition, due to budget restraints, imaging providers are searching for less costly nuclear imaging system alternatives. However, advances in creating new disease specific radiopharmaceuticals will be a driver for nuclear medicine utilization. Also, Appropriate Use Criteria (AUC), radiation dose reduction, and maintaining a consistent supply of Mo-99 for Tc-99m will impact the future of nuclear medicine.

Langsfeld: As a parts vendor, we have noticed a rise in the demand for parts on the hybrid systems of SPECT/CT and PET/CT. As more of these systems are coming off OEM warranty, the third-party market has stepped in with service and support offerings for these systems while raising the demand for quality used or refurbished parts and technical support.

Martinez: Circuits are getting smaller, so things can be packed into smaller, thinner packages. There are digital detectors, but the usable yield of producing CZT crystals is less than 20 percent per batch. The size of the good yield is still only for small FOV (Field of View) detectors. Overall resolusion has not significantly improved for the past 10 plus years. If you check detector specs between a Siemens eCam and the newest Symbia, there is NO improvement. Only post processing has improved with half time imaging being the chief advancement.

McCormack: Nuclear medicine has changed over the years in the way it handles data. On the hardware end of things, different types of collimators, hybrid imaging, and workflow enhancements have allowed health care providers to deliver information to patients in ways never seen before. New radiopharmaceuticals are also in the pipeline that will potentially offer clinicians better ways to analyze disease both qualitatively and quantitatively.

Nunez: One of the main advances in nuclear medicine is the introduction of Cadmium Zinc Telluride (CZT) detectors by Spectrum Dynamics and later by GE. These are faster and have higher resolution than previous sodium-based detectors. They are also very expensive. Another significant advancement in nuclear cameras is the spread of hybrid imaging in the form of SPECT/CT. It broadens the ability of nuclear cameras into areas where the hybrid study can stand alone and cover more areas of diagnosis.

Shaw: Nuclear medicine has seen quite a few changes over the past few years mostly by adding another modality (hybrid) to the SPECT system such as SPECT/CT. PET imaging, also a form of nuclear medicine, has made many advances in oncology and cardiology. The basic gamma camera has not changed much in the past 10 years.

Q: How will those changes impact the nuclear medicine market in the future?

Technation Magazine | The Roundtable | Nuclear MedicineEaton: According Dr. Schwaiger of the Technical University of Munich, the border between the imaging modalities “will have disappeared” by 2020. The trend seems to be shifting away from a modality-specific focus, onto organ or disease specific groups. This will certainly impact the parameters in which imaging equipment is purchased and utilized.

Hamm: The main benefit to physicians, hospitals, and other medical providers is that it allows a facility to perform studies on more patients within the same timeframe. This enables the facility to increase the amount of revenue generated without increasing any additional costs or time needed to perform the studies.

Iwaniw: Most predictions forecast growth in the nuclear medicine market. A favorite saying of mine is “The best way to predict your future is to create it.” In order to better create our future, proactive measures such as AUC that communicates to CMS about cost-effective treatment algorithms, especially for nuclear cardiology, are intended to justify reimbursement. The aging population will also support the effective outcomes provided by nuclear medicine imaging procedures. Budget restraints support the sale of reconditioned systems that can be upgraded in the future.

Langsfeld: There will always be a market for used and refurbished parts whether it be strictly nuclear medicine or for a hybrid system. Users of the equipment are always looking for a less expensive but quality option to support their equipment. While many facilities are moving toward hybrids, there are still several facilities that do not have the budget or need for them. So, the standalone nuclear market will still exist.

Martinez: When CZT yield and size improve, detector overall size will significantly decrease. The digital nature may open more possibilities with the use of ever improving software control. The half time imaging software algorithm will likely improve in sync with the acquisition control software.

McCormack: As nuclear medicine becomes more efficient and is able to offer greater information, doctors will continue to turn to this modality for the answers they need. Nuclear medicine has been and always will be the only way to image physiology, or functional process. With the ability to quantify tumors, for example, we are able to better understand where the patient needs to be in the treatment process. No other modality can really do this like nuclear medicine.

Nunez: Widespread use of the higher-resolution detectors will bring the unit cost on these down. In addition, the higher resolution and higher sensitivity will enable nuclear cameras to expand into studies and uses that have been traditionally part of the domain of PET and PET/CT. It can’t replace these other modalities, but is becoming a viable alternative in some circumstances and markets.

Shaw: Nuclear medicine has been considered a dyeing modality since I entered the field in 1982. First the word was that CT will do the studies that nuclear formally did, then it was MRI then it was PET. Nuclear medicine departments still seem to be an important modality in spite of the death that I had always been warned about. In the future, the basic gamma camera will still be around but the hybrid systems seem to be the future at this point.

Q: How will new technology and other advances impact the maintenance of nuclear medicine devices?

Eaton: From a maintenance standpoint; hybrid systems will require a broader knowledge in theory of operation in what may have previously been foreign territory. From an end user standpoint, your cost of ownership analysis may require some revaluation.

Technation Magazine | The Roundtable | Nuclear MedicineHamm: Nuclear cameras are more software-driven than ever before. The newer cameras have fewer moving parts, are more accessible to service from an engineer’s perspective, and allow for more detailed and thorough diagnostics through the workstation/computer; minimizing some of the mechanical diagnostic aspects, which are generally more time consuming and costly.

Iwaniw: They shouldn’t drastically affect the maintenance standards that are already in place. It will be vitally important that thorough preventive maintenance is performed on a regular basis. The technology for SPECT cameras will tend to be geared toward software technology versus actual camera technology, which would require clinical engineers and field service engineers to be more computer savvy.

Langsfeld: Preventative maintenance has always been and will continue to be very important for any system. PM checks are recommended on all systems, and the OEM guidelines should be followed no matter who is servicing the machine. Some facilities try to save money by ignoring PM, but in the end, it will lead to more costly repairs.

Martinez: The smaller lighter overall size of the machine will allow for better mechanical reliability of the gantry system. The smaller electronics will be more integrated. Fewer PCBs will allow for faster troubleshooting. Software will be the chief troubleshooting aid.

McCormack: As the technology advances, the local service engineers need to be trained so that they can repair the equipment. Workflow enhancements like automatic quality control are fairly new concepts in the industry and bring with it the need to have a little more knowledge of radiation safety when handling radioactive sources. In addition, these systems are becoming more advanced mechanically which means there is more potential for things to go wrong.

Nunez: Brand new technologies may take a while for the knowledge and access to spare parts to trickle down from the OEM. CZT detectors are a case in point. We have not seen many nuclear cameras with the newer detectors on the market. We have no parts for them. This will change in a couple of years as systems are harvested for parts and the engineering expertise on them grows. On the other hand, for hybrid technologies like the SPECT/CT, we have engineers familiar with both halves of that product, so there is no delay in being able to service and maintain them.

Shaw: Gamma cameras are now driven by computers and software. Many manufactures will boast about repairs done remotely and some repairs can be done this way. Detector tuning and maintenance is all done through software programs to tune the PMTs and align the offsets in the detector. The service engineer of the future will need to be more computer savvy but the electromechanical portion of the system will never go away so the engineer needs to also be a mechanic.

Q: How can a facility with a limited budget meet its nuclear medicine needs?

Eaton: If a facility is looking to add or replace a nuclear medicine system, I suggest researching third-party refurbished systems. A reputable company can provide OEM quality systems and service at a fraction of the cost. Ask about renting/leasing as well. For a facility looking to maintain a department on a budget, a bi-annual preventative maintenance schedule is your best ally. Skipping one or two PMs may save a little in the short term, but this practice usually ends up costing more than you save.

Hamm: Initially they should buy a reconditioned camera from a reputable company. This will save significant dollars on the front end, and a properly reconditioned camera should come with the same warranty as a new camera. In addition, adding half-time imaging software will allow the facility to maximize patient throughput on the days they are scanning patients. Also minimizing the indirect costs by having a quality service provider will maximize the overall efficiency of the nuclear program. By performing thorough preventative maintenance, offering quick response times, and having competent engineers, the camera will be running and generating revenue a larger percentage of the time. This equates to scanning more patients and minimizing the need to reschedule studies.

Technation Magazine | The Roundtable | Nuclear MedicineIwaniw: Limited budgets support the purchase of refurbished/reconditioned nuclear medicine systems. It is important that the reconditioning process is comprehensive in order to provide a camera system that an imaging provider can rely on for many years. Flexible financing options are also important for the imaging provider to be able to afford updated camera systems.

Langsfeld: Making sure the facility is purchasing the correct system for their needs is important. When first purchasing a system, everyone affected by the transaction should be involved to ensure the correct system and options are included to meet the current and future demands without buying unnecessary equipment or purchasing something that won’t support the needs. Finding a reputable service and parts vendor is also very important in maintaining a budget. Based on useage and availability of parts, discussing service contract options or time and material support with your vendor will be helpful.

Martinez: Easy. Buy reputable reconditioned equipment with updated processing workstations. As mentioned earlier, there has not been any significant improvement in acquisition resolution. New systems are great if you can afford it. It does perpetuate what we are doing in the third-party arena and we need to appreciate that OEMs are continually releasing new products. If you are on a limited budget, a good reconditioned system will give you the same diagnostic quality.

McCormack: Well, that’s where we come in. We can offer these same products to health care providers at a price point that is lower than that of the OEM. These systems have previously been used by other hospitals but we remove them, replace old and damaged parts, and re-install them into other facilities. With the care that third parties provide, these devices will continue to produce the diagnostic images that physicians require for a long time.

Nunez: Consider used or refurbished equipment. Nuclear medicine is a great place to save money in your imaging facility. There are several high-quality companies in America that can provide refurbished or reconditioned nuclear cameras and SPECT/CTs that will meet or exceed OEM specifications when new.

Shaw: Many rural facilities are looking for good quality refurbished equipment to fulfill their nuclear medicine needs. This has been a great option for hospitals and clinics for over 40 years. Most manufactures have moved to hybrid systems that are very expensive and will leave the small hospitals and clinics out. You don’t need a hybrid SPECT/CT system to do general nuclear medicine procedures. There are also fusion programs that allow the user to overlay one modality over the other. Hybrid systems are not needed to do this.

Q: What do you think TechNation readers need to know about purchasing and servicing nuclear medicine equipment?

Eaton: Don’t allow yourself to be over sold. It is posable to purchase quality equipment and produce desirable results without breaking the bank. A good service/sales company should be able to provide viable solutions at a reasonable cost.

Hamm: Find a camera that fits their specific needs and a service provider they can rely on. For example, if a facility only performs cardiac studies, they would be better off going with a designated cardiac camera as opposed to a larger variable-angle system. They take up less space, use less power, cost less to service, and tend to be more reliable. Though both cameras perform the same function, one is much better suited for a specialty practice, and they want to partner with a company that has their best interest in mind. When they have a service agreement, the practice should be confident that their service provider will effectively maintain their equipment so they don’t have to worry about that aspect of their business and they can focus on patient care.

Iwaniw: They should look for a camera/service provider who is able to provide effective, timely service, has a ready inventory of parts, and can offer flexible service contract options. They should also be partnering with nuclear medicine camera providers that can offer flexible financing options in order to meet their budgetary needs. They may wish to take into consideration the provider’s ability to offer training for in-house clinical engineers.

Technation Magazine | The Roundtable | Nuclear MedicineLangsfeld: While price is important, it should not be the first deciding factor. I would recommend asking questions to ensure you are getting the best value for your equipment, service and parts. Any good vendor will take the time that is necessary to make certain you are getting exactly what you need the first time.

Martinez: When purchasing equipment, whether new or reconditioned, service options are imperative. Your unit will require repair and general maintenance no matter what. Be sure that you are not limited to a make/model that has a limited install base.

McCormack: Purchasing capital equipment is a big deal. In many cases, the room needs to meet specific requirements, and the equipment and maintenance throughout the life of the system can be quite costly. I suggest doing your research on the camera and serviceability of the system you want. The big equipment manufactures all provide ways to acquire patient data but it’s the bells and whistles that tend to set them apart. These bells and whistles can, in some cases, add challenges to the way the systems are serviced so these things need to be looked at.

Nunez: If you are not looking at an almost unlimited budget or a large grant to buy a nuclear camera or SPECT/CT, consider looking on the secondary market. We are seeing a good number of quality used systems coming out as first-tier establishments order the latest and greatest.

Shaw: TechNation readers/purchasers should start with the facility’s radiology manager and nuclear medicine technologists. These are the front line people using the equipment every day and know what is available for procedures and what their referring physicians are requesting. Service can be a tough spot for the clinical engineer. Many ISO companies will offer training and some sort of “first look” program that would allow the facility to save money. It is often stated, by the biomed engineer, that nuclear medicine is a real thorn in their side. The training is great if you work on the system regularly but is easily forgotten if you don’t get to touch the system for a year or so.

Q: What are the most important things to look for in a reputable third-party nuclear medicine provider?

Eaton: Knowledge of your specific system(s), immediate access to inventory, and enthusiasm. A dazzling website and/or expensive advertising does not necessarily translate into quality service. Take the time to have a conversation and ask questions. Personally, I love what I do, and enjoy discussing it with customers and prospects alike.

Hamm: How long they have been doing business, and how much of the camera reconditioning, relocations, installation, and service is performed with their own engineers. Whether or not they have a Radioactive Materials License; this is important when reconditioning cameras so they may be tested with sources to ensure all parts of the cameras are functioning properly. Lastly, I would say to check customer references; reach out to some facilities who have used the third-party for service and ask them about their experiences. All cameras will inevitably go down at some point, it’s how prompt, professional, competent, and thorough the service provider is when things do go down that separates the top third-party companies from the rest.

Iwaniw: Technical competency with your system, readily available parts, response time, technical phone support capability and accessibility, comprehensive refurbishment process, and customer service culture to name a few.

Langsfeld: Seeking referrals is a good start to finding out the reputation of a provider. You can also research the company online and see if there have been any issues or concerns reported on forums or with the Better Business Bureau. But most importantly, do not be afraid to ask questions; if they are unwilling to provide information or take the time to address your concerns, then they may not be the right fit for you.

Martinez: Many third-party providers do all major OEM models that are highly installed. While this is true, most providers have a bread-and-butter line that they do best. Find out what that is.

Technation Magazine | The Roundtable | Nuclear MedicineMcCormack: Knowing that your service provider has an adequate number of engineers with the knowledge needed for servicing you equipment is probably the most important. There are a lot of companies out there claiming they can service nuclear medicine, but many will only manage your asset without having direct knowledge of the equipment. Parts availability, facilities, and strategic proximity to their supply chains are also important things to think about.

Nunez: We tell our customers that the nuclear medicine world is very small. You can’t run from a bad reputation. You want to work with someone who has the resources to fix things if they go wrong. Things can happen to any system, but can your nuclear camera provider cover those if it ends up being a loss for them? You need to know that they aren’t just willing to provide your imaging needs, but that they are capable of supporting them as well.

Shaw: Third-party organizations are always required to perform better than the OEM, one slip up and you’re out. OEMs are almost never thrown out unless it is for saving money. The best reference is other facilities that have used the ISO and can give a recommendation. Nuclear medicine is a very small community, almost all technologists know each other and this would be the best way to compare notes.

Q: How can purchasers ensure they will receive the necessary literature and training tools when purchasing nuclear medicine devices?

Eaton: Don’t be afraid to ask questions and be engaged. Nobody knows your business like you do. Be sure to communicate your needs and expectations before, during, and after the buying process.

Hamm: Any reputable company should provide the purchaser with all applicable literature relating to their camera and should be able to offer detailed applications training. The better the nuclear tech knows how to operate the camera, the better it is for everyone involved, so that should be a priority of the company selling and servicing the equipment.

Iwaniw: Service manuals can be a challenge as these are generally proprietary. General system operating manuals and software operating manuals should be part of the system purchase (these can be hard copy for older systems and within the software for newer systems). I would encourage the purchaser to inquire into whether the third-party provider offers formal training classes.

Langsfeld: When purchasing a system, always make sure to request the operator’s manuals and software disks, if applicable. Ask about training and support offerings to ensure a level of comfort for use. If you do encounter a problem, you want to make certain that the seller will be available and willing to help you seek resolution.

Martinez: The literature is generally available from the original point of sale OEM. There is no lack of highly capable applications specialist in the third-party market. The selling third-party company should be able to answer this upon the initial consult.

McCormack: Service is about having proper knowledge of the equipment. Purchasers need to make sure they are buying from companies that have the resources at their disposal and not just a middleman. All the systems we sell and service come with customer manuals and if there are ever questions, we offer tech support over the phone as well as onsite training once systems are installed.

Technation Magazine | The Roundtable | Nuclear MedicineNunez: Manuals, system demonstration, and extensive applications training are all available with any system we sell. However, we find most customers don’t need a lot of training. If we schedule three days of applications training, many sites will feel comfortable in two days.

Shaw: Facility purchasers should require training and technical manuals when ordering their systems. If the OEM or ISO will not provide these items then they should look at another vendor. A large facility will have much more clout than the small facility and that can be quite a hurdle for the small group. Finding leverage in order to get the vendor to comply is always a challenge. Don’t rule out ISO companies when looking at new systems. Many ISO groups offer new cameras along with high-quality refurbished systems.

Q: What else would you like to add or do you think is important for biomeds to know about nuclear medicine devices?

Eaton: Listen to your technologists! These men and women spend more time with this equipment than anyone else. Their input is a valuable resource that all too often remains untapped.

Hamm: Nuclear cameras are a different animal than other diagnostic imaging systems, so find a company with a long-standing, positive reputation within the industry so they have confidence the camera will be maintained and function as efficiently as possible. Find a full service company that can perform all aspects of nuclear medicine services with their own engineers and also has the same goals and focus of taking care of their customer. Once they find a company they trust who is like-minded in the delivery of quality service, together they can exceed the customer’s expectations and ensure a long-term, mutually beneficial relationship.

Iwaniw: Nuclear medicine systems remain a technical service challenge for biomedical engineers/clinical engineers. With the evolution of clinical engineering departments becoming responsible for the budget to maintain their nuclear medicine systems, it is extremely important for them to develop a mutually beneficial partnership with their third-party service provider. This should be a collaborative effort to work together for cost effective and reliable system maintenance.

Langsfeld: Finding the right vendor is very important. From your first part purchase to a service repair or full system integration, seeking a partnership is critical. Every system has differences, and depending on what is needed for the repair, re-tuning and calibrations must be performed by a trained and qualified engineer to guarantee your system remains up and running.

Martinez: Nuclear medicine requires the most patience of all the imaging modalities. Sometimes the bad result doesn’t come for two or three hours. The usual remedy is to just start over. Appreciate your service engineer.

McCormack: I would say that these devices are quite different from other modalities in radiology. The physics are quite different from one device to the next. In my experience, most engineers don’t understand or even like nuclear medicine. That’s why we are here to provide our expertise.

Nunez: I think most biomeds are comfortable with nuclear camera equipment in general, but if their facility has ever purchased a nuclear camera from an unqualified vendor then they likely have some concerns about second hand equipment. It’s critical to find a reputable vendor.

Shaw: Clinical engineering departments should consider training, applications and technical phone support at the top of their list. If the clinical engineering department is big enough to take on the nuclear department it is best to train one person so he is proficient and will be able to cross train other engineers. Training is out there and many companies, especially ISOs, are very willing to work with clinical engineering departments in order to get in the door even if it is only a small piece of the pie. Once in, and the vendor can gain the confidence of the technologist and the clinical engineering department, this can make for a win-win relationship and will make the job for the technologist and biomed engineer much easier if they have a good source to contact. Applications support is always important for the nuclear medicine technologist.

Company Showcase: Perkins Healthcare Technologies

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A pioneer in its field, Perkins Healthcare Technologies provides solutions focused on improving integration, workflow efficiency and extending the useful life of existing capital equipment. True system neutrality and backward/forward compatibility are key elements of the company’s approach. As a result more and more hospitals are turning to Perkins.

Based near Dallas, Texas, Perkins has been synonymous with innovation for almost 100 years and continues to deliver unique, industry-focus concepts and solutions.

“Today, we continue to specialize exclusively in the design, development and distribution of clinical integration and workflow solutions for procedure suites and their related departments,” says Steve Plaugher, Manager/COO, Perkins Healthcare Technologies.

“We offer a diverse, innovative and exciting array of products that represent the next generation of integration, control and workflow improvement tools,” Plaugher says. “These include: OR VisionTM and IPS VisionTM that bring together control of all technology and integrate seamlessly into our Customer’s ORs and Interventional Procedure Suites; and RoomVisionTM that allows for the observation of room status for improved workflow and scheduling of multiple rooms in real time.”

These offerings illustrate Perkins’ ability to remain on the cutting edge.

“Each Perkins solution offers common advantages that make its selection clear and implementation easy for each hospital,” Plaugher says.

He points out that the many solutions offered by Perkins Healthcare Technologies provide:

• Improved Workflow – Our solutions deliver new workflow efficiencies that often reduce costs and improve safety.

• Perkins’ Systems Neutral Approach – This means our solutions work with all equipment regardless of manufacturer or age allowing hospital staff to make best-of-breed buying decisions without being locked into a single vendor.

• Forward and Backward Compatibility – This allows hospitals to more economically upgrade rooms and get an improved ROI by extending the life of existing capital equipment.

When upgrading a room, Perkins can transform the room without a fork lift upgrade – all at a fraction of the cost of a new room. When the hospital does buy new imaging or surgical equipment, Perkins integration solution can be repurposed with the modern equipment. In addition, Perkins continues to integrate older equipment such as a legacy ultrasound unit – saving the hospital the cost of buying new equipment. By reducing the overall cost of upgrading a room, this forward and backward compatibility streamlines the process and preserves capital asset budgets without sacrificing patient care.

• Seamless Integration – Perkins integration and control solutions work seamlessly with new or existing imaging, surgical, or hybrid procedure suite equipment. Their solutions complement the Customer’s existing capital equipment providing improved workflow and delivering critical patient information to the various stakeholders where and when they need it.

• Comprehensive Connectivity – Perkins’ solutions allow hospitals to connect and share real-time information improving efficiency and documentation control. That connectivity extends to the ability to observe and communicate among multiple rooms for clinical collaboration as well as improved scheduling, enterprise-wide. Collaboration can also be extended beyond the hospital to remote resources, regardless of location, providing increased communications and education.

• Customized Solutions – Perkins looks at each hospital’s integration needs and objectives as unique. The company customizes its solutions to meet those needs.

Plaugher says he is excited about the future, especially after the launch of game-changing new products like RoomVision.

“Providing automated situational awareness of each procedure suite status allows staff to adjust schedules proactively in real-time resulting in improved efficiencies” Plaugher says about RoomVision. “One example: room cleaning can be alerted as closing begins so room turnover times can be improved. This can result in an additional procedure per room, per day. The revenue potential of this is significant. Another advantage is alerting all parties to scheduling adjustments, especially delays, and allowing them to react accordingly. This is a significant advantage for staff and patients.”

Looking at both a given day and data over a wider period, department managers and senior management can also move to balance room usage. This “smoothing” of room usage and making sure certain rooms aren’t underutilized means efficiency, improved patient and staff experiences and potential increases in revenue – again by increasing the number of procedures handled facility-wide, per day.

Plaugher also said he is excited about Perkins’ 8MP collaged displays.

“These large HD displays, up to 60 inches, allow information to be organized and displayed in an efficient, user-selectable way on a single monitor,” Plaugher says about the 8MP collaged displays. “The reduced number of screens needed and the way information is shared has significant advantages in Interventional Procedure and Hybrid Suites as well as Control Rooms.”

Meeting the needs of customers, sometimes before the customers even know what their true needs are, is nothing new for Perkins. It is a part of the company’s mission to provide exceptional products and outstanding service. These traits are among the reasons Plaugher and the rest of the team at Perkins are excited about the future.

“As we work with our client-hospitals on customizing solutions that improve workflow efficiency, reduce costs and improve safety we consistently increase our knowledge and experience base. This allows us to deliver continuously evolving – continuously improving – solutions to each hospital,” Plaugher says. “If we were just providing off-the-shelf or cookie-cutter solutions this level of evolution and improvement would not be possible.”

This razor-sharp focus and company-wide dedication does not go unnoticed. Customers are quick to praise Perkins’ products and customer service.

“By partnering with Perkins, we have been able to consistently improve our workflow with the ease of use of their unique integration system and our surgeons rave about the image quality on the high-definition monitors,” says Blu Baillio, RN, Director of Perioperative Services, Memorial Hermann Southeast, in Houston, Texas. “From their state-of-the-art integration to their helpful, knowledgeable, friendly staff, our experiences with Perkins confirms that we have partnered with true leaders in the world of medical technology.”

For more information about Perkins Healthcare Technologies visit

www.perkinshealthcaretechnologies.com.

Professional of the Month: Airman 1st Class Theo Shakir

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Baghdad is the capital of the Republic of Iraq and boasts a population of 7.2 million people. The city has faced turmoil since the American withdrawal in 2011 and before.

In 1990, Iraqi dictator Saddam Hussein ordered the invasion and occupation of neighboring Kuwait. Operation Desert Storm commenced in January of 1991. Iraqi forces in Kuwait surrendered or left the country by the February 28 cease fire. The Iraqi war began in 2003.

Escaping the sectarian violence, the on-again, off-again electricity and the assassination of an uncle was reason enough for Iraqis like Theo Shakir to flee Baghdad, and that’s what he did in 2005. His grandfather urged Shakir’s family to leave, but stayed behind himself.

In the spring of 2003, Shakir could hear the gunfire from the nearby Baghdad Airport, as coalition forces took control.

“I lived my entire life in Baghdad [and] left because my uncle got assassinated and it became too dangerous,” Shakir remembers. “Only a few countries were allowing Iraqis to come; one of them was Jordan. If you bought a house in Jordan, you can get a permanent residency just like a green card.”

“That’s what my family did. Jordan, [in] 2006, is where I got into my first English school. My stepdad, at the time, was already working in Kuwait and got my mom a visa, so she left half way through the year. They worked that entire time until I finished my school year and through the summer vacation of my 7th grade. They met a person from the royal family, who heard my story, and got me a visa. (It is very hard for Iraqis to get residency in Kuwait since [the] 1990 war). I lived in Kuwait until 2008, with a couple of trips in between, for fun and vacation with family,” Shakir says.

Shakir eventually landed in Greenwood, Arkansas, for six months, getting a green card in the process. He left Arkansas and returned to Kuwait to finish school and get a GCSE diploma; the high school diploma under the British system.

“In 2009, my stepdad quit his job in Kuwait and moved to [the] states six months prior to my mother and I following him. In June 2010, I made it to Grand Rapids, Michigan, which is where I consider my home in the states,” he says.

Shakir received his high school diploma in the U.S.

“That is where I visited my first recruiter and signed up; after a few more trips, and moving around, I shipped out to basic military training in Greenville, South Carolina,” he adds.

That’s right, the young man who saw so much and experienced different education systems was now in the U.S. military; the Air Force to be exact.

An American Career

Today, his official title is Airman 1st Class Shakir, 375th Medical Support Squadron, Biomedical Equipment Technician at Scott Air Force Base in Illinois. It’s been a long road from those days nervously watching the nearby battles.

But, how did he choose to become an HTM professional?

“It caught my interest because I love cars and it was a way for me to get better at working on advanced electronics, which is where I think the automotive industry is going, without actually having to limit myself to just being a mechanic,” he says.

“I also loved hospitals, although I never knew anything about being a biomedical equipment technician. I get this feeling that I am the reason the hospital runs. I know it’s false and everyone has an equal part, but it’s nice seeing my work in the hands of doctors all around the hospital,” Shakir says.

An uncle in Iraq performed similar work and Shakir had decided the job that he wanted to do in the Air Force by his junior year in high school.

“I have taken on the project of making sure all the overnight refrigerators are properly monitored and have the proper security system. This project had a total value of around $3 million and I was grateful that my shop entrusted this responsibility to me,” he says.

Shakir says that the project isn’t particularly difficult, but if power should go out, the vaccines and medicine in the refrigerators have a high value and the task reminds him of how important his job is.

In terms of specialization, Shakir has gained some expertise in air evacuation equipment.

“I like the equipment because of the vast variety of options, but most importantly, they are absolutely crucial to saving someone’s life,” he says.

It’s Not All Work

Technation Magazine | Professional of the Month | Airman 1st Class Theo ShakirAway from work, Shakir has other family members in the U.S. and likes to kick a white and black ball between goal posts.

“I am probably the biggest soccer fan on this base, or maybe Illinois,” he says. “I am very lucky to be on the base team with a great group of friends.”

“My parents live in South Carolina and the rest of my family lives in New York. I try to see them as often as possible and they come visit every chance they get,” he adds.

Shakir became a U.S. citizen last year. Working on medical equipment in Illinois is a world removed from listening to the sounds of artillery fire in Baghdad. He has learned a very American principle during his time in the U.S. He has also learned that becoming an HTM professional was the right move.

“I would like readers to know that I didn’t know a lot about this job when I first signed up, but I quick

The Vault - July 2015

- Do you consider yourself a history buff? Are you widely regarded among coworkers as an equipment aficionado? Here is your chance to prove it!

Reserve a Booth to Exhibit at MD Expo Las Vegas

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We are now accepting booth reservation requests for MD Expo Las Vegas, October 21-23, 2015. If you would like to reserve your exhibit hall booth space, visit the MD Expo website.

Reserve a Booth

Patrick Lynch: How Do I Comply With CMS’ Preventive Maintenance Requirements?

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Not since the infamous multiple outlet strip debacle from CMS (Centers for Medicare & Medicaid Services) has the HTM community been so confused about how to do their job. Just when we thought we had it figured out, a well-meaning but ill-informed federal agency screws us up again.

For over 25 years, we have been using risk-based criteria to modify manufacturer maintenance suggestions to meet the needs of the real world. The standardized risk-based systems have been refined and accepted by the Joint Commission and every other agency (except CMS). Using these procedures, the HTM community has adjusted the procedures which the manufacturers have written BEFORE the equipment is placed into everyday use in hospitals. We either increase or decrease inspection frequencies, and either add or omit steps in the inspection process, based upon our real-world experience as medical equipment maintenance professionals.

In this process, we have saved our employers, our hospitals and our patients millions of dollars in unnecessary costs. It should also be noted that there have been no increases in costs, associated either with equipment maintenance costs or liability to patients. Because of our careful and conservative approach to modifying these procedures, we have only had positive results for all stakeholders.

But, I guess CMS, in their infinite wisdom (and close ties with the manufacturers) must know more than the collective HTM community’s 40 years of experience.

But I digress. Since it has been decreed, we must comply with their edict. But how? (I am going to address ultrasound machines here, because that is what my company has unequalled expertise in, and where my knowledge comes from). There are over 70 different makes and models of ultrasound machines in health care today. Each manufacturer has different inspection standards and inspection intervals for each model. Some state that there is NEVER a reason to inspect the unit. Some are inspected every 6 months. Some do only safety testing. Some require inspection of all internal components. Some require testing all transducers. How is the HTM manager or Imaging Engineer or Ultrasound Service Engineer supposed to compile the current service literature, extract the specifics of each model, and incorporate them into their in-house maintenance program? It would be nearly impossible.

Well, let me share a simple solution for you that gets you in instant compliance with all manufacturer and CMS requirements almost instantly.

Introducing the GMI Diagnostic Ultrasound Preventive Maintenance Guidelines.

Introduced at AAMI in Denver, this 14-page document combines the most rigorous PM procedures and intervals from every current model and manufacturer of diagnostic ultrasound. You can apply the same PM procedure and inspection interval to every ultrasound machine in your facility. And you will be in full compliance with all CMS and manufacturer PM requirements. All in one easy step.

To summarize, we have set the inspection interval at 6 months. This meets or exceeds the interval for every model or ultrasound.

We have included PM sections for Visual Inspection of the System and each transducer, Review of onboard diagnostics, System cleaning, System disassembly (and cleaning), System reassembly, Imaging testing, Leakage testing, and Completion of a certification report. Copies of the blank Certification Report are available from GMI in .pdf format.

All this research and documentation is provided for free from Global Medical Imaging (GMI) as a service to the HTM community. If you desire a copy of the guidelines and the Certification Report, please make the request at the GMI website – www.GMI3.com .

Tools of the Trade: MedWrench – My Bench

- MedWrench.com is a resource and sharing network for users of medical equipment. You can get answers, find information and read what others think about the equipment they use. It is free to join and easy to keep informed. You simply bookmark your favorite communities (equipment, categories, or manufactures) to your “My Bench” area and you are given an intelligent feed of information from other professionals as they help each other solve problems.

Imaging Equipment Maintenance – Best Practices for Promoting Efficiency

Roundtable: Nuclear Medicine

Company Showcase: Perkins Healthcare Technologies

Professional of the Month: Airman 1st Class Theo Shakir

The Vault - July 2015

Reserve a Booth to Exhibit at MD Expo Las Vegas

Patrick Lynch: How Do I Comply With CMS’ Preventive Maintenance Requirements?

Tools of the Trade: MedWrench – My Bench

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