For any organization to run efficiently, it takes planning, a set of internal policies, a roadmap for the future and an effort to make employees the best at what they do. Finding a way to achieve these goals will help ensure that the organization realizes success while meeting any metrics it has challenged itself with achieving. Making a plan, and following it, also provides direction for employees. It provides an environment where costs are contained, employees obtain proper training and customers are served.
Achieving all of these goals can sometimes be a challenge in CE/biomed departments where budget and resources must coexist with needs, compliance and existing inventory. Cost savings have become an expectation while there is no room for compromise. An evolving health care model, with inherent disruptions, further requires that a solid plan be in place.
At the AAMI 2017 conference, Mike Busdicker, MBA, CHTM, system director of clinical engineering at Intermountain Healthcare and Aaron Goryl, general manager, in-house and on-demand services with GE Healthcare, brought this topic into focus in a panel discussion presentation titled “Balancing Cost and Quality: Managing Risk in Your Service Program.” Other panelists were Steve Vanderzee, AA/BAS, CBET, Advocate Health Care and Erin Schipper, BSBME, Thedacare Regional Medical Center.
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The presentation touched on six primary areas: 1) Human Capital Optimization, 2) Asset Availability, 3) Flexibility for Evolving Needs, 4) Hidden Administrative Costs, 5) Program Compliance and 6) Sustainable Verses Short-Term Savings.
Busdicker says that the human capitalization element requires an organization to get its ducks in a row. He says that considerations should include technical training, specialization, geographic coverage, and enabling service tools and technology factors when evaluating financial impact.
“With this category, it becomes very important to build an implementation and business plan around the equipment a department is looking to service, or equipment they might currently be servicing,” he says. “This includes measuring staff competency and skill knowledge sets, requirements for the servicing of the equipment, availability of all service tools (manuals, test equipment and keys), parts availability and resources outside of the organization.”
“The organization really needs to look at the geographic area being serviced and what it is going to take to provide the coverage level expected by stakeholders,” he adds. “Other things to consider in this area include the availability of backup equipment, history of the equipment, costs (vehicles, on-call, specialized test equipment, call dispatching and communication devices) to support the identified equipment.”
Busdicker says that these internal variables need to be evaluated for cost effectiveness and efficiency when compared to “service partnerships with authorized service providers.”
“The end result should be the development of a program that optimizes internal and external staff to support equipment in an efficient manner,” he says.
GE Healthcare’s Todd Hall stresses the importance of “optimizing your human capital” in the white paper “Balancing Cost and Quality: Managing Risk in Your Service Program.”
“Considering the cost of imaging assets, the mission critical importance to care delivery, and publicized concerns about the potential effects of over utilization, technical service labor may be the most important issue you need to get right in your new model,” Hall says. “Starting with how many resources are needed to support your organization. What is the optimal mix of in-house versus outsourced resources? How will you scale and optimally deploy these resources to meet the needs of your organization as it grows and changes?”
“For example, advanced service diagnostics and tools from OEMs are important to support the engineers. Will your team have access to these items? Usage of diagnostic tools can help support productivity. To provide an estimate of the value of an OEM diagnostic tool, an engineer could multiply the number of hours saved when using each diagnostic tool by the hourly cost of downtime, and then replicate that analysis for each modality,” Hall adds.
Blueprint for Success
To continue to hone that roadmap, Busdicker suggests that certain levels of expectation should be well defined and that communications with customers, providing clear instructions, is part of constructing an efficient level of understanding with all stakeholders.
Regarding asset availability, Busdicker says that biomed departments should “identify specific commitments on response time and equipment uptime, as well as remedies for noncompliance.”
“Here at Intermountain Healthcare, we have developed and distributed an equipment brochure to departments throughout the organization,” he says. “This brochure includes: key definitions – ‘urgent and routine service request;’ this explains how we define a request for service from the stakeholder.”
“For example, the urgent request would be for equipment that goes down and creates a loss of the facility’s primary function, safety hazard or interruption of immediate patient care,” Busdicker says.
“The routine request includes service that might not be needed right away, can be performed at the first opportunity, or does not significantly impact the primary function of the department/facility.”
He says another element is service level agreements; both in-house and ASP.
“Here we identify the service level agreements established with our service providers during contract negotiations and the service level agreements of our in-house staff established with internal stakeholders,” Busdicker says.
The brochure distributed to customers also outlines how to obtain service referencing stickers, call number and tag number.
“The brochure identifies the process for requesting service through our service coordination center. It includes the call in number, how to locate the equipment asset tag, information required for the request, hours of operation and the afterhours call process,” Busdicker adds.
Another step Busdicker’s team took was to establish a service coordination center at Intermountain Healthcare and all calls for on-site service are generated through this function. He says that it doesn’t make a difference if the equipment is under contract, first look or full in-house service.
“Once a call is dispatched, all service technicians are required to acknowledge and respond to the call through the coordination center,” he says. “This provides quality documentation for both the outside and internal service providers.”
The metrics of the response time are tracked; call time, acknowledged, customer contact, on-site.
“The identified response times are tracked by the service coordination center and documented in a report shared with department and organizational leadership. It provides data and information around the quality of the internal and external service providers with potential identified opportunities for improvement,” Busdicker says.
There should also be an effort to track all work performed by providers outside the in-house team.
“The service coordination center tracks all authorized service provider events to include scheduled PM work orders. The department receives and uploads all field service reports into the asset history record and tracks PM completion percentage. They work directly with the service providers on outstanding items,” Busdicker explains.
Hall suggests that remote diagnostics and support can be a valuable tool.
“The key to achieving a guaranteed performance metric is the response process. How will you be confident that guarantee will be realized? One important variable is access to remote diagnostics and support, especially if you have facilities in remote geographic locations and/or without equipment redundancies,” Hall says. “The value can grow if any of those facilities are mission-critical based on patient volumes and/or clinical capabilities. When effectively designed, remote diagnostic services can dramatically help reduce the time needed to identify and fix an issue, and may enable the proactive repair of issues prior to a decline in system performance.”
In addition to tracking PMs by providers, Busdicker says that equipment downtime should be tracked.
“The service coordination center gathers information utilized to support the Intermountain goal of zero harm to our patients,” he says. “Therefore, they capture data around patient care like if the equipment is hard down or soft down, if there was a patient on the table when the equipment went down, or if patients are having to be rescheduled. This information is used for trending analysis, patient incidents and impact on revenue.”
Another component of the approach that Busdicker advocates is to utilize an automated on-call process. He suggests the establishment of an automated after-hours process that will put stakeholders in direct contact with the on-call service technician. This eliminates the need for multiple calls and allows stakeholders to place one call and focus on patient care and treatment.
He also suggests an executive level escalation process – each with an RCA for continuous improvement.
“The department has established a continuous improvement process that includes the performance of a root-cause analysis be performed on equipment with extended downtimes as determined by department and organizational leadership,” Busdicker says.
“This process includes the potential involvement of our authorized service providers, stakeholders and service technicians. The department has developed an approved form for documentation that includes cause, resolution, suggested changes and lessons learned,” he adds.
Another component is “Flexibility for Evolving Needs.” On this topic, Busdicker says to look for usage-based coverage, pooling options, conversion flexibility during agreement term and tighter performance commitment.
“Here we were looking at the need for organizations to be flexible as needs, technology, staffing and volumes shift,” he explains. “This includes flexibility from the health care facility/system standpoint and from the authorized service provider’s position. Everyone needs to work together in order to maintain a fiscally responsible operation without negatively impacting the quality of the program.” “If the facility strictly focuses on the cost aspect it could impact cost for other organizations. If the authorized service provider focuses only on costs and increasing revenue the potential exists that this cost will be passed on to the patient,” Busdicker says. “In the end it does not benefit health care as a whole, so everyone involved in the process needs to see the bigger picture.”
Addressing the Cost Side
One of the cornerstone elements of the successful service program blueprint is controlling costs. Busdicker breaks this element into nine areas of focus.
Hidden Administrative Costs – Understand sources of hidden cost and know which expenses are simply transferred from contract to process cost.
Contract Verses In-house Cost Comparison – Organizations need to continually monitor, track and trend their equipment service. Each year we perform an assessment of our equipment costs and contract costs comparisons. Some of this review is performed in conjunction with our service providers and they provide input on suggested equipment transitions to reduce costs or improve quality.
Damaged/Abused Items – This is an item we keep track of for all equipment whether it is on contract or supported in-house. This information is used in trending reports and annual reports to organizational and department leaders. We work with individual departments to provide training and processes to reduce this hidden cost of equipment service.
Central Parts Stocking Program – We have done a lot of work with our departments, service technicians, and service providers to evaluate the inventory of on-hand parts. We stock high usage critical parts in a central location and reduced the parts with a minimal turnover rate. This has really reduced our on-hand inventory dollar amounts and positively impacted the repair process. We have implemented a complete process that includes parts replenishment, parts tracking, W/O uploading, overall downtime tracking of equipment, and savings around parts ordering and shipping.
Invoice Review Process – The HTM department here at Intermountain has implemented a comprehensive invoice review process for service contracts, parts purchasing and service events. This includes all of the following areas:
FSR/Invoice Matching – All field service reports are matched with the invoice for the particular service event. This is done to ensure we are not being charged for repeat events, labor hours match, parts usage is correct, travel time is accurate and whether overtime has been charged correctly.
Parts and Labor Discounts – Invoices are matched with any service agreements that might be in place to ensure all discounts for labor, parts and all other negotiated items are included on the invoice.
Contract Reviews – Adds and Deletes – Our contract invoice process includes no more than quarterly billing with a preference on monthly for higher level agreements. This allows our department to review each contract invoice for correct billing, matching of equipment adds and deletes with amendments and potential incorrect invoice amounts.
Warranty Expirations and Budget Building – Organizations need to ensure they are capturing all warranty information for new equipment and repaired equipment. We have implemented a comprehensive process to record the warranty information for equipment and parts. This process has prevented expense on items that were still under warranty from suppliers or from the manufacturer.
Achieving and Surpassing Targets
Part of assuring a quality program is the compliance component. Busdicker says that this means it is a program that monitors changing environment, implements adequate policies and measures results.
The tracking of regulatory service includes in-house and ASP compliance (RepTrax, competency, downtime and documentation). This topic covers numerous areas that include adherence to organizational requirements for entrance into the facility, compliance to state and federal regulatory requirements and observance of organizational standards related to the installation and ongoing maintenance of medical equipment in the facility.
Busdicker says that another element of quality and compliance is to sit down with stakeholders and discuss it regularly.
“We schedule quarterly business reviews with all major service providers and our in-house teams to provide data and information around program performance. These reviews include information around regulatory compliance, performance against service level agreements, special interest items, equipment downtimes, and targets for the next quarter. Most of these reviews are done in conjunction with the in-house and authorized service providers,” he says.
Besides bringing in service providers, a HTM department should look internally.
“The HTM department here at Intermountain has developed and implemented an internal audit process for our program. This audit evaluates regulatory compliance, policies/procedures, implementation of organizational requirements and overall HTM program implementation,” Busdicker explains.
“We complete a final audit report for each facility within the system and develop an action plan to be implemented and completed the following year. This includes a formal report to executive leadership.”
Finally, keeping the lines of communication open within the department through daily and weekly huddles can achieve several goals.
“These huddles are not problem-solving forums, but provide an opportunity for staff and leaders to share important information centered on patient care and treatment. The huddles ae limited in time and provide an opportunity for a safety minute, recognition of caregivers, performance in relation to metrics, any compliance concerns, and any other organizational issues that might need to be shared with leadership,” Busdicker says.
To make cost savings more sustainable instead of just temporary, Busdicker suggests using an analytics-driven approach to control service spend, increase utilization and reduce expenditures.
“It is very important to use analytics and reports to ensure the program is driving sustainable savings over the long term instead of just focusing on the short term,” he says.
“If short-term savings are the only goal, the long-term result will be an increased cost for the organization and for health care as a whole. Therefore, it is very important for the organization to develop analytics and reports to demonstrate consistent results that can be benchmarked and used as performance metrics. These analytics, benchmarks and metrics need to be monitored on a routine basis in order to continue controlling cost and maintaining or improving quality,” Busdicker adds.
With this roadmap in mind, the HTM department can be a model for all departments in achieving levels of efficiency, self-monitoring and cost savings to benefit the whole organization.
Hall points out that every health care facility has unique needs.
“There are many different approaches to medical maintenance, and there is no single solution that works for all health care providers. And the advantages and trade-offs of each must be considered across a variety of factors. Some models may achieve a reduction in operating expenses through brute force limitations that pare equipment service back to a near break-fix mentality and leave large gaps that can increase costs, potentially imperiling patient care delivery and staff productivity,” Hall says. “Some may have hidden costs resulting from administrative paperwork or a lack of access to training and advanced tools. Others may inherently have more risk and can have downstream operational impact that can offset cost savings.”
“There are many approaches to cutting costs, but the approach you choose should not come at the expense of equipment performance, continuity and timeliness of patient care, staff satisfaction and productivity, or the ability to capture and utilize data to improve and guide decision making,” he adds.
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