By Michael Bassett

About 35 years ago, Kaiser Permanente Northern California decided to take over its x-ray recycling program—the process of reclaiming silver from used x-ray negatives—from an outside provider. That process was so successful, says Andy Ulvenes, clinical director of clinical technology for Kaiser Permanente Northern California, that the hospital system chose to bring the servicing and maintenance of its x-ray equipment in-house as well.

Today, according to Andy Ulvenes, Kaiser Permanente Northern California staff service and maintain not only the system’s x-ray equipment, but other modalities like CT and MRI, and many other types of medical equipment as well. All told, Kaiser’s in-house program has a staff of about 250 people to support a footprint of about 169,000 pieces of equipment.

The Advantages

What lies behind the decision to bring such services in-house? Ulvenes says his department goes through a process to determine whether from a service, staff, and financial perspective, it all makes sense.

Will the in-house staff be able to deliver what clinical operations needs in the way of equipment uptime, service responsiveness, and 24×7 on-call support? Can the staff handle the technical challenges of maintaining and servicing the equipment? How much more staff will be needed to maintain and operate the assets, and is that at least as cost-effective as a full-service contract with an OEM? If the answer is yes to all three questions, Ulvenes says, then Kaiser will move forward to bring the services in-house.

Ulvenes splits the benefits of taking over x-ray servicing into two buckets—direct and indirect. The first direct benefit, he says, is that it can be more cost-effective than relying on an original equipment manufacturer (OEM). “We’ve seen that we’ve been 15% to 30% cheaper than an OEM’s ability to deliver the same kind of service program,” Ulvenes says.

Todd Boyland, CPSM, vice president and director of training for RSTI, a diagnostic imaging training center in Solon, Ohio, agrees that a major reason for bringing services in-house is to reduce costs. It can be more cost-efficient, he points out, for a hospital to have one or two engineers capable of servicing multiple imaging modalities, rather than carrying service contracts to cover all of those units.

Ulvenes says that Kaiser’s in-house program also provides a direct benefit by providing a higher level of service responsiveness. “We have 24×7, 365-day coverage, and there are several OEMs that aren’t able to provide either weekend or after-hours support. And we have a 2½-hour on-site response, and I know a lot of manufacturers can’t offer that kind of guarantee,” he says.

As far as indirect benefits, Ulvenes points out that his clinical technology staff plays a consultative role in a number of ways. “If a hospital wants to renovate a wing or move equipment around, we can be the subject matter expert on the implications of moving the technology and we can be part of the project plan,” he says.

Boyland says that some hospitals “just want to have that internal control”—of not having to rely on outside sources to keep equipment up and running, and ensuring that preventive maintenance is done.
Art Larson, general manager, US services operations at GE Healthcare in Waukesha, Wis, says that hospitals “want control, the lowest costs, and the highest-quality services when it comes to looking at capital expenditures. So they are looking at different options.”


The major challenge, Larson says, has to do with the quality and competency of the hospital’s in-house group. Depending on the type of equipment a facility has, the in-house group becomes the hospital’s “multi-vendor supplier of service.” Consequently, the staff could be dealing with several different types of OEM equipment, Larson points out, so the level of the team’s competency will be critical.
So, hospitals need to identify whether staff are capable or willing to take on the challenge of taking these services in-house. Furthermore, Larson says, facilities should analyze the equipment they currently have since some vendors “are more service friendly than others.”

Larson says that GE believes it’s important that providers who decide to bring their services in-house have access to support from OEMs. “Even though they are the feet on the street, a facility should have the ability to reach out to an OEM for remote support so that they can partner with the in-house team to provide them with solutions,” he says.

But, Boyland points out, some OEMs are a little more difficult to deal with. For example, some vendors have software keys that prevent in-house service providers from accessing a system to do even simple things like change IP addresses and network configurations, never mind the more sophisticated adjustments like system calibrations. “So a question to ask is whether the equipment you are trying to service in-house limits you from doing anything as far as normal service and normal maintenance is concerned,” Boyland says. “Because if you can’t get into the system and you’re locked out, you are really limited.”

Boyland adds that some vendors require a software key and password to get into a system simply because they want to be able to track things on their database. “So a lot really depends on the manufacturer,” he says. “And since most facilities have a mix and match of vendors, they’ll have to pick and choose in order to see what is serviceable and what isn’t.”
Hospitals don’t necessarily have to commit to a full in-house service model. It’s really a sliding scale, Larson says, with the full in-house model on one side of the spectrum, and on the other side a model in which the OEM provides full service.

“So the scale can slide either way,” he says. “An OEM should be able to come in and offer to help a hospital meet its needs. If a hospital has what it considers to be a great in-house team, the OEM can offer to train it and provide access to parts and the diagnostics that it provides to its own in-house team. That is what we do at GE. We want to provide our customers with options.”

Vendor support has to come in other forms as well. Part availability is a question that “needs to be addressed up front,” Boyland says. Will a hospital have to go through a third-party parts company to find a part, and if so, will it have the right parts for the right piece of equipment?

“If it’s a popular machine, the parts can be a dime a dozen,” Boyland says. “But if it’s something like a Shimadzu [imaging system] that doesn’t have [a large] market share in the United States, then it can be a little more difficult to get parts, which also means the pricing will be higher as well.”

The vendor-hospital relationship has become “extremely important” for in-house models to be successful, says Ulvenes, who adds that Kaiser is looking to partner with vendors who are willing to be flexible with service and maintenance offerings.

“GE is a good example of a vendor that has come to the table to help us be more successful with our in-house program, providing parts support and high-level troubleshooting technical support,” he says. “But not all vendors want to play in that space. Some are reluctant and hesitant to be flexible. So we are going through some vendor analysis to see whether we should be moving away from some partners who aren’t that flexible when it comes to working with us, and staying with—and even getting in deeper—with those who are willing to come to the table.”

A final challenge, Ulvenes says, is just keeping up with the evolution of technology. The technology is moving at such a fast pace that part of the financial analysis in determining whether to bring services in-house is determining whether staff is capable of handling the evolving technology, Ulvenes says. “We used to be able to train someone on a piece of technology every couple of years, but now it might take an annual investment just to keep up competency on a piece of equipment.”


As Larson points out, the competency and quality of the in-house staff has much to do with successfully bringing x-ray services in-house, and training is critical to ensuring staff competence.
The resources necessary to bring technologists and engineers up to speed will vary according to the experience of the in-house staff. For example, Boyland says, if a hospital has an in-house engineer who has been working on CT scanners for 20 years and wants to make a switch from one CT vendor to another, “it won’t involve much of a transition.”

However, if a hospital has had its CT scanner under contract for 20 years and has now decided to bring that service in-house, the chances are the hospital won’t have anyone trained in CT. “So they’ll have to answer some questions about how long it will take to get someone up to speed,” Boyland points out.

And if a hospital wants to get someone trained on CT, that person will have to take basic x-ray services courses first, which, according to Boyland, will take between 4 and 8 weeks, followed by several CT courses. In all, it will take 2 or 3 months to get a tech ready to take over service.

“Now, he won’t be able to do the same thing as the guy with 20 years of experience, because you can’t get that in 2 or 3 months,” Boyland says. “But our objective in training is to shorten that learning curve.”
Most training, whether performed by a company like RSTI or vendors like GE, is done at an off-site facility. RSTI, for example, has a 30,000-square-foot facility with its own equipment, which “is a big advantage,” Boyland says, “because it allows students to come in here and really get their hands dirty. They’re not limited in any way.”

Some hospitals request on-site training, but that can be problematic because of the question of equipment availability. “If we’re going to be working on something in their cath lab, the chances are it has to be working at six in the morning the next day, so we’re really limited as far as what we can do with the equipment,” Boyland says.

A Continuing Process

Even after a decision has been made to move things in-house, Ulvenes says, there’s always a need to continue to evaluate the process.

“While we have some robust processes and great vendor relationships in place, it’s always an ongoing effort to examine what is in our portfolio of what’s in-house, and what is not,” Ulvenes says. He adds that getting the balance right between the two depends on shifting technologies and the willingness of vendors to partner with Kaiser. “So we go through a monthly process to see where we’re at, where things are moving, and to make sure that we are always on point.” 24×7

Michael Bassett is a contributing writer for 24×7. For more information, contact [email protected].