By Renee Diiulio
Today, every health care organization faces restricted resources, a challenge that affects every department. At veterans’ care facilities, the pressure to perform efficiently, economically, and effectively is a little greater: Staff report not only to their supervisors and administrators, but they must also report to the government and the American people. Spending is subject to rules, documented thoroughly, and carefully controlled, requiring more time and thought. But money is also spent wisely, with a focus on value and outcome: How can resources be allocated so that patients receive the best care possible?
This question guides everyone, including the staff of the biomedical engineering department at the Southern Arizona VA Health Care System, Tucson. They have answered with thoughtful approaches that incorporate efficiency in every aspect of their workflow, from structure to service. The main goal is not just to save money (though, of course, that is a planned benefit), but to provide veterans with quality care in a comfortable environment.
“The culture of putting veterans first is reflected in the high patient-satisfaction scores received by the facility,” says Christopher Woo, biomedical engineering manager for the facility, adding that he often hears positive anecdotes about the hospital outside of work.
Of course, the biomedical engineering staff don’t spend a significant portion of their time directly interfacing with patients (though they do not hesitate to help direct an individual who looks lost). But they are responsible for nearly 9,500 devices (9,444 to be exact), 3,675 of which have a preventive maintenance schedule handled in-house and through contracted services.
“We all share a greater purpose for why we are here, and that is to ensure that the veterans get the best care possible. And even though our role is not as direct as some, we do have a role and we take it seriously,” says Richard (Rick) Harker, staff biomedical engineer.
Assigning by Area
To achieve its mission, the Southern Arizona VA Health Care System is organized into two lines: care and service. The care line covers the clinical departments; service includes administrative and other groups. The clinical engineering team of 19 staff falls into the service line under facilities management.
The department is then further divided into two sections: biomedical engineering and electronics. Biomedical engineering manages customer-interfacing equipment; electronics handles systems such as nurse call, fire alarm, and pneumatic tube.
The larger of the two groups, the biomedical team, includes the program manager (Woo), one biomedical engineer, eight biomedical equipment support specialists (the VA changed its terminology from technician to specialist several years ago), and a program assistant; the electronics group comprises five electronics technicians, including one lead. Both groups also have work-study students through an educational program in which the department participates regularly.
Among the biomedical engineering team, workload is organized using an area concept. Specialists are assigned specific units and are responsible for all of the equipment in those units.
“This allows the specialist to develop true competency on the equipment, making it easier to perform repairs and locate equipment more efficiently,” Woo says. Knowing the inventory and where it is likely to be found has been a boon to completing PMs, particularly on portable equipment. It has also fostered relationship building, which positively impacts both the workflow and the working environment.
There are, of course, exceptions to the rule, such as devices found in multiple units throughout the facility, which include defibrillators, EKG [electrocardiogram, ECG] machines, and temporal thermometers, but the approach and goals are the same—one specialist takes the lead to develop true competency and offer improved service as a result. Knowledge of location is an even bigger advantage when the potential “hiding spots” include multiple wards and floors, says Russell McCormick, senior biomedical equipment support specialist on the team.
The electronics group works similarly, with the technicians each assigned the lead for systems under their purview. So one individual will take the lead on the nurse call system and another on the pneumatic tube transport, but any team member can provide backup. All five electronics technicians have completed factory training on all of the systems the group manages.
In general, training is key to the entire team’s equipment management efforts, and the administration supports this approach with dollars. “Our executive management is a very strong proponent of training because they realize that if you buy a system, you really need to train technicians in-house to maintain it most cost-effectively,” Woo says.
Where possible (imaging, for instance), shared service agreements are implemented to hold costs down. VA policy permits the inclusion of tuition in negotiations and purchase agreements, where it makes sense, and supplements coursework with travel and per diem costs.
“Typically, our staff will handle the first look and, if it’s something we can fix, we’ll repair it on the spot. If not, we’ll have an idea about where to start troubleshooting,” Woo says.
Equipment for which constant uptime is a priority is often kept under vendor contract. This includes laboratory analyzers, sterilizers, and anesthesia devices. “We keep our critical systems—those that need to be operational and maintain a very high throughput—under service contract so we have that extra security from the vendor to ensure maximum uptime,” Woo says.
Whether negotiating a full-service or shared-service contract, the Southern Arizona VA Health Care System can seek further savings through cooperative agreements that consolidate contracts across VA facilities within a regional grouping. “When it’s appropriate, we reach out to other facilities in our VISN [Veterans Integrated Service Network], and if we can combine our service contracts, we can usually recognize a cost savings,” Harker says.
The facility also tries to consolidate savings through standardization. “We standardize equipment wherever we can, which reduces the space required for repair parts, makes maintaining staff competencies and training easier, and improves employee knowledge for use, repair, and support of the devices,” Harker says. Money is saved through more efficient use of staff time, maximum equipment uptime, and high quality of care.
Shortcuts to Shopping
The biomedical engineering department has been able to positively influence a standardization effort through a well-defined role in the capital acquisitions process. Like all other VA health care facilities, the Southern Arizona VA Health Care System must follow the organization’s national directive regarding procurement and assessment.
The preprocurement procedure involves a multidisciplinary team, including biomed and IT representatives, that works with the contracting department to complete the appropriate forms, obtain necessary approvals, and make purchases. Pending the type of acquisition, there are various paperwork forms and procedural steps that must be completed before a purchase is complete; with recent governmental changes, these requirements have multiplied. Requested information to approve an acquisition may include market research, vendor backgrounds, and product data.
“We’ve developed an electronic library to store this repeat type of information so that we can quickly reference the data we might need for a procurement form and cut down the lead time,” Harker says.
With the new rules, the process takes longer overall, so any smart shortcut provides value. Building good relationships with colleagues and conducting long-term planning help, too, but in general, the biomedical engineering team finds that its day-to-day workflow is not severely impeded by delays. Specialists and technicians are empowered to make purchases that fall below a certain dollar amount without significant paperwork, facilitating the acquisition of parts and kits needed for immediate service and repair.
Greater research and time is required for larger projects, of course. As part of a constantly evolving facility, the team at the Southern Arizona VA Health Care System has often served on committees focused on new construction, renovation, or modernization. Biomed contribution is highly valued, and they are frequently charged with evaluations and recommendations regarding new equipment and technology.
If possible, assessment will include hands-on demonstrations by potential users, for which the facility’s simulation lab is perfect. Clinical engineering manages the equipment and technology in this space, which includes six rooms outfitted with the existing devices in use within the organization’s clinical departments. While typically used for training, the rooms can be set up to allow simulated use of potential new systems (in conjunction with the existing setup). When a decision is made, clinical engineering then also ensures an additional device is purchased for this area.
The initiative has worked well, with simulated demonstrations helping to better identify preferred acquisitions and simulated training helping to improve safety and service. While clinicians increase their knowledge and comfort with the devices, service specialists broaden their knowledge and capabilities as well as their understanding of the potential impact from larger systems.
Integrating with IT
Biomed involvement, therefore, regularly helps to ensure a big-picture view of equipment analysis, one that incorporates foresight in purchases, negotiations, and maintenance. The department can point out how a choice reflecting standardization can conserve resources and improve safety, or it can establish that solutions will have to be created to enable network connections (and worked into negotiations and implementation).
As for many clinical engineering departments, today’s big-picture view will likely have a lot of pixels, but it will very often include some aspect of network integration and subsequent collaboration with IT. However, unlike for many health care organizations, within VA facilities, collaboration is well defined. The organization’s national Healthcare Technology Management Program Office has outlined guidelines for a medical device network architecture for IT and biomed that local health care systems can use as a building block.
“Working with those guidelines has been key to building a good relationship with IT. We understand each other’s roles, but we don’t have to stay within our own silos,” Woo says.
At the Southern Arizona VA facility, a new position was created to further foster collaboration. The biomedical equipment support specialist, network specialist position works with IT to develop the network schema for medical devices, assure network security on devices, and provide a point of contact for networking issues.
With an eye on the future, the biomedical engineering and IT teams also traded interns for 2 weeks to give newcomers to either field exposure to both. “It provides the students with an understanding of what the other department does, broadens their perspective, and helps to strengthen our relationships,” Harker says.
Sharing with Students
Both the facility as a whole and the biomedical engineering department separately regularly participate in opportunities to provide students, particularly veteran students, with practical experience. (The health care system has affiliations with more than 70 academic institutions.)
One such program is the national VHA Technical Career Field, or TCF, program. Designed to help the organization meet mission-critical needs, the opportunity provides 2 years of training to recent college graduates, who may then stay on staff within the facility or transfer to another VA location. The program covers salary, benefits, training, and travel (including relocation to a new VA position when the 2-year program is over). This is the first year the Southern Arizona team has had an intern in the program, but they already give it high marks.
Equally successful has been a work-study student program offered in conjunction with a local community college. Students in the associate’s degree program for biomedical equipment support specialists (or technicians) who meet the requirements, which includes being a veteran, are eligible to apply. Prospects are interviewed as for any other job, and good candidates are brought in. Ideally, each section (biomedical and electronics) hosts one intern, but the largest group numbered four.
Two students are, of course, easier to manage, but there has been no downside. “When you mentor people, it takes a little bit of time, but the benefits outweigh the disadvantages,” McCormick says.
The program works so well because the job experience mirrors the course curricula. “Their studies parallel our structure. The first year, students study electronics in the classroom—so, the first year of our program, they work with the electronics team. The second year of coursework covers medical equipment and maintenance, so they work with the biomedical team during that time,” Woo says.
Whether the students stay or move on, the Southern Arizona VA team takes pride in helping them to complete the program and gain useful experience. To date, every intern has gone on to work in a community hospital, according to McCormick. He adds, “Being able to help retrain veterans or allow them to practice their job skills benefits the community and benefits us.”
Once again, serving veterans brings advantages to the team and the facility as a whole, but for the staff, it is simply a way of work. The facility’s mission states this concisely: “We provide quality healthcare to veterans in an environment of compassion, education, and research.”
“Everyone understands they are here to service,” says Brian Morris, lead electronics technician. And not everyone has to share a military background to unite under the mission. McCormick estimates that employee experience is very mixed, with approximately 30% to 40% of the facility’s staff defined as veterans.
Woo believes both individuals and management have worked together to go the extra mile to enhance patient care, focusing not only on medicine but also on comfort and experience. Small, innovative touches have been found to make a big difference and to be fairly easy to implement.
For instance, background music is piped through the hallways using the overhead paging system as a method to enhance the environment. The system falls under the electronics section’s purview, and the team was able to meet management’s request to incorporate this feature with minor adjustments.
Waiting patients are treated like waiting patrons at restaurants and are given electronic pagers that allow them to visit other areas of the hospital (such as the cafeteria or gift shop) while waiting for an appointment. A buzz lets them know they are next and to return to their appointment. This system was also developed by clinical engineering.
Electronic communication boards are another atmospheric innovation created and implemented by the electronics team. Located throughout the facility, the digital signs showcase events, facility news, special occasions, and other announcements that can simultaneously communicate with and offer comfort to patients and visitors, but particularly veterans. “The technicians maintain the cabling and provide the signals to keep them operational,” Woo says.
It is, therefore, no wonder that the facility receives such high patient satisfaction scores, even as the initiatives are implemented with care and caution. Cost savings, improved efficiency, and collaborative workflows are all benefits that take a back seat to happier (and ideally, healthier) patients, but they also provide solutions to the problem of restricted resources. The focus always remains on how those resources can be allocated so that patients receive the best care possible. Other biomeds may want to ask themselves the same question: How can resources be allocated so that patients receive the best care possible? 24×7
Renee Diiulio is a contributing writer for 24×7. For more information, contact [email protected].