By Dallas Sutton
Regardless of which regulatory body you subscribe to, the requirement for PM completion rate is 100% for high and non-high-risk equipment. While one could argue the application of the word “rate,” we will presume the intention is to close an open PM during the month due.
PMs have been the bane of healthcare technology management (HTM) programs for decades and we have always struggled with the same issues. Equipment unable to be located, in use, awaiting parts, awaiting vendor service or any number of subcategories have always contributed to a failure to achieve the infamous 100% (even back when it was 90%). Because of this, arguments have arisen as to when to actually close a PM work order that was not actually completed, when to surplus equipment that has not been found or maybe to leave work orders open. Ideally, it would be agreeable to have them all, or as many as possible, completed.
To get there, we need to understand more about the distribution and monitoring of the PM workload.
The total volume of PMs is a function of your equipment inventory and how you have chosen to utilize allowable PM modifiers such as an alternative equipment maintenance (AEM) program. Not everything in your inventory requires a PM and certainly not everything requires the level of maintenance specified by the equipment manufacturer. There are volumes written on the subject elsewhere, but I highly recommend the use of an AEM to safely reduce your PM burden. That being said, at the end of the day, your PM workload will equal 100% of the PMs generated in any given month, but not neglecting those lingering from past months, but how do you distribute them?
Traditionally, in my experience, PMs have been distributed based primarily on technical aptitude and/or some geographical assignment. This is a logical approach when considering the fact that some PMs do require specific technical insight or validated technical training in order to complete, but geography generally has little impact (when considering equipment located on the same campus). Some will argue that a dedicated OR technician makes for more efficient work in that space and all PMs will be assigned to those typically working in that space, but a counter argument would say that limiting other technicians’ exposure to that area can be counterproductive during absences and to the development of depth in that space.
So, in order to make distribution easier and “fair” our approach is that everyone should work everywhere and on everything (within reason). Yes, this is a huge lift, but as leaders we have the responsibility to incorporate some form of succession planning that not only provides agility when filling vacancies internally, but also to see the strengths and weaknesses of our staff. Yes, this will require increasing the depth of training of your staff and will burden your training budget, but the benefits outweigh the costs. The rub to the traditional methodology of PM distribution is that you end up with a highly unbalanced PM workload among your technicians. It would not be uncommon to have one technician with 60 hours of PMs for any given month and another with 100 hours for the same month. I don’t know about you, but I have rarely heard a technician rave about their desire to do PMs. So, what’s the fix?
There is obviously work involved in everything being discussed here and any changes to how you should be distributing PMs is no different. As opposed to skill/geography-based distribution, we have found success in distributing based on anticipated work hours can not only produce the same or better completion rates, but more importantly, increase technician satisfaction. This means that you would need to review the historical work effort required to complete a PM on a given modality or specific model, in addition to considering any hard technical requirements for safely completing the PM. The hard technical requirements will serve as a guide in development of a training plan that will reduce risks to your organization should you incur a vacancy and help to spread the workload among other trained staff.
When considering dividing by PM time, it is important to consider two factors in addition to the total PM work effort required. The first is knowledge that 100% a month is roughly 25% a week and 5% a day. This is helpful when assigning work to individual technicians. The second is technician absence. If you have a tech on vacation for two days, it is admirable to reduce their PM burden by 10% (5% x 2 days) or if you have a tech in school for a week, reduce theirs by 25% – there is no benefit in penalizing a tech for taking vacation or going to school. So, once you have a calendar that reflects your teams total available time for the month and a total PM workload for the month, with a little math you can divide them fairly. As stated earlier, technician satisfaction is important and is becoming more important as the available workforce dwindles, but there is another, not so obvious benefit. When you have the ability to balance scheduled and unscheduled work (approximately and relatively), you gain the ability to objectively analyze productivity of individual technicians against their immediate peers which can assist in identifying training, aptitude, attitude and general performance related issues. This data can also be helpful in performing evaluations and promotion recommendations.
The presumption is that you are distributing your PMs at least 2 weeks before the month to give time for your technicians to procure required PM parts and schedule either access or vendor service. If this is the case, theoretically, the closed PMs should start rolling in, right? Unfortunately, this is rarely the case. Human nature seems to dictate that PMs take a back seat to any other possible form of work and therefore tend to be left to the end of the month, the longest, most difficult PMs performed last and high-risk PMs sometime after that. So, how do we monitor for success?
We have found that monitoring a few different metrics will keep the various categories of work in the forefront of a technician’s mind and break the work into smaller more manageable pieces in order to spread the work evenly throughout the month. Most of the communication will take place during a short, daily, 15-minute huddle that the technician is only required to provide a simple red or green status. Green is good, red means they have a barrier and are given the opportunity to discuss. Leadership on the other hand should already know each technician’s status prior to the huddle based on the following metrics:
Individual PM Completion Rate:
This is as simple as it sounds. As stated earlier, you should have a goal of 5% PM progression per day. This should be posted and updated daily so everyone knows the current goal. The shop will have a conglomerate PM completion rate, but each technician should know their own as well. You will probably find that meeting a daily goal can sometimes be unattainable based on other taskings, so we tend to allow for a 10% variation from the daily goal, but this should keep them within 3 days of being up to speed. The hard and fast rule is 25% PM completion per week. By monitoring this metric daily, it serves to keep everyone moving in the right direction and no one individual can slip beneath the waves and end up in trouble at the end of the month. The huddle serves as a means to ask for help (or be appointed help by leadership) if someone is behind (red).
High-Risk Completion Frequency
This one may seem a bit odd, but technicians sometime grab low hanging fruit when trying to maintain a complimentary completion rate, but in doing so may neglect some more critical PMs. Our practice is to require that each technician complete at least one high-risk PM every three days. There is no real science here other than forcing visibility of the importance of this work. Combined with overall PM completion, we tend to keep them moving more so than without some methodology of monitoring.
Actionable vs. Non-Actionable PMs
Not all open PMs are PMs that are actionable by your technicians. These PMs do however require some level of monitoring lest they fall off your radar and turn into perpetually open PMs. When you consider a documented PM status like “Hold for Information,” “Awaiting Parts,” “Awaiting Vendor Service” or “Pending Equipment Availability,” they all essentially stop forward progression of the work order. They also account for a fairly significant percentage of your open work orders at any given time during the month. You may be at 25% complete (closed) at the end of the first week of the month, but 47% when you consider non-actionable PMs. PM volume and completion are real numbers but can be demoralizing when not taken in context. By including non-actionable PM completion rates when communicating with staff allows them to see the fruits of the work that they have acted on, even if the work order is not closed – scheduling a vendor or ordering a part are real work and should be recognized as such. A non-actionable status also means that the work order is still open, still on someone’s radar, and that someone can routinely check on the status of a work order that seems to have gone a little long waiting on a vendor or a part.
Unable to Locate PMs
This is probably the most troublesome category that a PM work order can fall into. When a device, due for maintenance, is unable to be located, it immediately turns into a liability for the organization. Should that device, whether a contributing factor or not, be in the room during an adverse patient event, it could open the facility up to litigation simply because the maintenance records are not current. Unfortunately, when you consider a 1,000-bed hospital can have 40,000 devices in its inventory, being able to avoid missed PMs due to equipment that is unable to be located is practically unavoidable. That being said, what’s the best move – do you close the work order to get the numbers up, or do you leave the work order open to maintain visibility to the problem devices? How do you document your efforts in searching for the device? Who is ultimately responsible for the missing device?
To answer these in reverse order, in general, HTM departments do not “own” clinical equipment. We may be responsible for the maintenance, but the owner is responsible for producing it (regardless of what they might believe to be true). The use of RTLS may complicate this position as we can be responsible for maintaining tag batteries and if that’s not happening, it makes it harder for the owner to locate their equipment, but regardless, we still don’t own it. We do however put stickers on the devices to aid the user in identifying a compliance status. We have gone as far as to color code the stickers by month to aid in identification of expired PMs and send out weekly reports to department leadership specific to their missing devices. Engaging the environment of care committee, patient safety and creating language in your medical equipment management plan regarding those responsible for looks at stickers prior to use can also aid in reducing these numbers.
As far as documenting efforts to locate equipment, it is easy to dispute the fact that a technician actually made an effort to locate equipment, but it is much harder to dispute if they document the date and to whom they spoke during that effort. We required three attempts during the month before a device can be moved to a “cannot locate” status, which is a non-actionable status and is calculated in the overall non-actionable PM completion rate. Work orders in this state enter into another process that I will not address here, but the work orders will remain open until the device is either found or surplused.
Aged PMs
Aged PMs are those that have broken the plane between the month they were due and the new month. The key to these is to ensure that they all have a non-actionable state and that the reason for the status is apparent in the work order notes. Any work orders that are considered aged can be considered to be in direct violation of your governing regulatory requirement of 100% completion. In the days leading up to the end of a month, I remind technicians to ensure their PM statuses are valid and documentation is complete for any work order that will not be closed.
Aged PM status is something else that needs periodic review and should remain in the technician’s work order queue. The status of these work orders should be discussed in your morning huddle, once again, to maintain visibility. It is valid to ask a technician why a particular device is listed as pending equipment availability for two months and to suggest a schedule change in order to work around department hours in order to access it. You may also need to get involved in dealing with unresponsive vendors regarding delays in receiving parts, service or paperwork.
In general, while critical, preventive maintenance is burdensome to perform and to manage effectively, but with fair and equitable distribution and consistent and appropriate monitoring, we can positively impact the safety of the environment of care. I understand that everything written here, should you choose to implement, will take a significant amount of work, but the alternative is a patch work of decades old processes that leave technicians frustrated and work orders overdue. I assure you it can and is being done elsewhere and therefore is not impossible. Best of luck to you in your PM adventures.
