Three federal organizations—the Veterans Health Administration (VHA), the Department of Defense (DoD), and the Indian Health Service (IHS)—are all funded by billions of dollars from congressional appropriation, they oversee hundreds of health care facilities spread over an entire continent, and they strive to provide the highest-quality medical care possible to their constituents. Effectively managing existing and new medical technologies represents challenge enough for smaller, more nimble private service providers, but how do biomedical engineers at such behemoth organizations do it? Quite well, it turns out.
Veterans Health Administration
The Veterans Health Administration—the health care branch (and also the initials for VHA Inc, the hospital system based in Texas)—is actually one of three subadministrations that make up the US Department of Veterans Affairs, and is home to the nation’s largest integrated health care system. While commonly referred to within health care circles (and in this article) as “the VA,” VA officially refers to the whole department, including benefits and the cemetery. With a medical care appropriation of more than $48 billion in 2010, the VA employs more than 300,000 staff at more than 1,400 sites—including 153 medical centers, 773 community-based outpatient clinics, and numerous other facilities. The VA calculates that more than 5.7 million unique patients were treated at those facilities in 2009.
It goes without saying that managing technology at that scale requires some unique systems and tools—but it also takes a fair amount of local vigilance.
Paul Sherman, CCE, is a senior biomedical engineer at the VA Center for Engineering & Occupational Safety and Health (CEOSH) in St Louis. He’s worked at the VA since 1988 and has been a biomedical engineer since 1990. After working at the VA hospitals in Portland, Ore, and St Louis for about 10 years, he arrived at CEOSH 12 years ago.
Sherman serves as a resource for the 153 medical centers and hundreds of outpatient clinics, and acts as a sounding board for the staff at each facility. The hierarchy is not as set in stone as some might think. Although the VA divides the United States into 21 veterans integrated service networks, or VISNs, some hospital managers act locally, while others prefer a regional approach.
“CEOSH is an in-house field support office, which includes biomedical engineering, safety engineering, and facilities engineering,” Sherman says. “I’m the only biomed in the office and function as a consultant for the medical centers. I’m responsible for hazard alerts and recalls for medical equipment, and I also manage our benchmarking program.”
Hazard alerts and recalls require a multitier process. “I review notices from manufacturers, FDA enforcement reports, and issues brought up by medical centers,” he says. “I help determine the risk in order to decide how to proceed with any notifications or actions required. I provide input to the people that manage the internal VA database for equipment issues, and am in fairly constant communication with National Center for Patient Safety (NCPS). They manage pretty much everything else, except for maintaining and servicing the equipment itself.”
Even though Sherman’s efforts and those of the NCPS help local facilities grapple with potential issues before they become larger problems, local biomed staff is expected to contribute too. “We also rely on the medical centers to do their part—to keep their eyes open for what affects them,” he says.
According to Sherman, the combination of centralized data analysis and local vigilance helps the VA stay ahead of the curve when it comes to managing equipment and patient safety issues. “If there is a major issue that needs to be addressed, we create our own equipment safety alert with guidance on how best to proceed. Unfortunately, manufacturers can sometimes create confusion when communicating about safety issues, so it helps to have a resource like CEOSH that can sort through all that.”
Another important aspect of managing technology—life cycle management—happens at the local level at VA. “As technology changes faster than the equipment itself, it’s more a matter of keeping up with clinical needs than equipment that’s just beyond repair,” Sherman says. “Many of our biomed departments are directly involved in the acquisition and selection of equipment for their own facilities.”
And when it comes to single-source provider solutions, the VA has found that consolidating or standardizing at the national level really does not work. “While we might save money on the initial purchase, it can cost a lot more over the entire useful life of a device,” Sherman says. “For example, a particular vendor may not offer the same level of support in Walla Walla, Washington, that it does in Boston. So what may work at one site may absolutely not work at another.”
But make no mistake—an organization the size of the VA can flex some pretty impressive muscle when it comes to certain aspects of technology management.
“We are starting up a national, real-time location system and RFID office, which will be under the national biomedical engineering office,” Sherman says, noting that biomed involvement in such broad-reaching technology applications reflects the changing role within the biomedical field.
Department of Defense
The DoD operation responsible for providing health care services to all US military personnel worldwide is the Military Health System (MHS), which combines resources from all military branches and oversees 59 hospitals and 364 health clinics around the globe. Chances are, the first military health care experience that all enlisted personnel have occurs when they sign up.
The United States Military Entrance Processing Command (USMEPCOM) is a joint service command staffed by representatives of all branches of the US armed forces. The command determines whether applicants are qualified for enlistment through various tests and exams conducted at 65 Military Entrance Processing Stations (MEPS) nationwide.
A big part of that process is the medical exam. In 2008, more than 450 MEPS physicians administered 386,000 medical examinations. The exam consists of height and weight measurements, hearing and vision examinations, urine and blood tests, drug and alcohol tests, muscle group and joint maneuvers, a complete physical, and other specialized tests if required.
Robert Dondelinger is a senior logistics management specialist at USMEPCOM’s headquarters in Chicago. He manages a small but essential fleet of medical equipment at the MEPS used to evaluate potential enlistees. There are room-sized audio booths, 500 audiometers, multiple centrifuges, 65 EKG machines, specialized equipment for color vision testing and other vision screenings, eye refractors, noncontact tonometers for checking glaucoma, automated blood pressure machines, electronic scales, and urinalysis equipment.
A civilian now, Dondelinger is a 30-year Army veteran who served as a warrant officer and was trained as a biomed while in the service.
While he is responsible for managing equipment life cycles and monitoring regular preventive maintenance, much of the actual hands-on work is handled by the the medical maintenance operations division of the US Army Medical Materiel Agency’s (USAMMA) service depot in Tobyhanna, Pa—one of three such depots in the country. In addition to regular maintenance, each one is an established center of excellence for specific equipment functionalities and can also refurbish older devices.
“They operate an exchange program for shippable items,” Dondelinger says. “Things that can’t be shipped, like exam tables or audio booths, can be serviced by the supporting Army hospital or medical center maintenance shop for that particular MEPS.” He explains that every Army installation has a certain geographical area that it is responsible for and that biomedical staff make regularly scheduled rounds twice per year, bringing a list of work orders with them from the centers.
“The MEPS are generally located in larger population centers, but not necessarily near military installations,” Dondelinger says. As a result, most maintenance and repair is handled remotely. “A replacement item is sent out to the field right off the shelf, then the unit needing maintenance or repair is sent back to the depot,” he says. “The MEPS can’t stop processing due to equipment failure.”
Centralized and Tracked
Like the VA, the DoD likes to keep close track of equipment, and there are sophisticated, centralized tools to do it. “Anyone who’s ever lost their cap during basic training will remember having to pay for it,” Dondelinger says. “For medical equipment, there’s a single property book and software management tool, which ties accountability and maintenance together in a single database. In DoD, everything’s centralized and tracked, which makes everything much easier for me.”
Similarities with the VA do not end there. “Military medical facilities have their own dedicated maintenance managers,” Dondelinger says. “It’s not up to lab or ICU to handle their own stuff. We do a lot more in-house in the military than the private sector, and contract out very little. For example, most imaging PMs and calibrations are done in-house in DoD. If something is desperately wrong or stumps the resident experts, we can pay the vendor for a single-service visit.”
Such high levels of technical proficiency demand a different approach when it comes to managing training for high-tech devices, so the DoD runs its own biomed school. “It lets us train on the equipment you’ll find in standard brick-and mortar facilities as well as very specialized field equipment that tends to only be found in the military—like folding OR tables,” Dondelinger says, adding that the training is full time, 6 hours per day, 5 days a week, for a full year. Students in the program can also get other classes paid for toward a degree.
Then there is also manufacturer’s school. “Lots of our guys sit shoulder to shoulder with a manufacturer’s in-house repair guys in classes run by the manufacturer itself,” Dondelinger says. “They don’t see us as competition until we get out of the military. Besides, it just makes sense. We’d much rather send a soldier to their [OEM] school than for them to send their techs out to a war zone—unless they’re willing to wear flak jackets and Kevlar helmets.”
What about new technology adoption at the DoD? Overall, Dondelinger says, the DoD tends to be pretty conservative when it comes to new kinds of devices. Tried and tested is generally preferred over the new and fancy. But there are always exceptions to the rule.
“If you’re Walter Reed, Bethesda, Wilford Hall—a flagship military medical center used for teaching and research—you’re going to have more need for cutting-edge technology than you would in a community DoD hospital supporting a small base,” Dondelinger says. He adds that organizationally, a distinction is made between a teaching hospital and a medical center, and that can affect the kind of technologies adopted at a facility.
The DoD has rolled out a tool for assessing clinical needs and new technologies called the technology assessment and requirements analysis, or TARA. It is a program overseen by the USAMMA that provides an unbiased review of specific needs at a given facility. A group of clinical consultants will look at existing and proposed equipment, and current clinical trends, and will make recommendations on the best kinds of equipment for that specific need.
Indian Health Service
The Indian Health Service might be the largest federal government health services provider that you have never heard of. It provides health care services to members of the 564 federally recognized American Indian and Alaska Native tribes and their descendants. As an agency within the Department of Health and Human Services, the IHS serves approximately 1.9 million of the nation’s estimated 3.3 million American Indians and Alaska Natives. Its fiscal year 2010 appropriated budget is approximately $4.05 billion. Health services are provided directly by the IHS, through health programs operated by the tribes themselves, and through services purchased from private providers. The federal IHS system consists of 29 hospitals, 63 health centers, and 28 health stations located on or near reservations or villages—all accredited by The Joint Commission or certified by the Centers for Medicare and Medicaid Services.
Federal provision of health services to Native Americans is the result of the unique relationship between the US federal government and Indian tribes, a relationship dating back to the 18th century and based on Article I, Section 8 of the US Constitution. Since then, it has been given form and substance by numerous treaties, laws, Supreme Court decisions, and Executive Orders. The IHS views itself not only as the principal federal health care provider, but also as an important health advocate for Native American people.
Jonathan Flannery, CHFM, SASHE, currently the executive director of engineering & operations at the University of Arkansas for Medical Sciences (UAMS) in Little Rock, Ark, started his career at the VA, where he worked for 10 years, before moving to the IHS where he served for another decade. He has been at UAMS for about 6 months.
“The IHS divides the country into 12 areas,” Flannery says, “which together contain about 60 smaller service units. Some areas have just two or three service units, some have a dozen. Then there are facilities within each service unit.” He adds that since most reservations are very spread out, so are the various facilities. “We took health care out to the people instead of making them come to a few larger facilities.”
Flannery started out at IHS as facilities manager for Gallup Indian Medical center in Gallup, NM, and eventually left there as acting administrative officer where he had direct oversight of the clinical engineering program for that service area.
Based on his own experience, Flannery believes that the IHS’ structure and relationship with local tribes has created a very unique culture of autonomy. “It is not a top-down organization, like the VA or the military,” he says. “Nobody at HQ tells you what to do because each service area is autonomous. That kind of independence is very powerful, but can also be challenging because you’re on your own sometimes.”
When it came to managing the service area’s equipment, Flannery says that success came from the dedication of the clinical engineering staff. “We had a great staff that did whatever they needed to do to keep stuff running. We were very aware of which equipment needed maintenance and which ones didn’t—there were very few surprises.” He added that most employees were also either existing or potential patients, since there were no other health care providers for miles. “They knew that they or their family might need that equipment at some point, so they were very invested in what they were doing and did the best that they could as a result.”
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In spite of an independent organizational culture, Flannery found himself involved in an effort to implement a centralized equipment tracking system for all of IHS. Without centralized asset tracking, it was difficult to know the location of equipment with any accuracy. It also made asset reporting somewhat of a nightmare. “I served as one of about a dozen members of a multi-disciplinary task force to evaluate and select a single CMMS system to be implemented throughout all of IHS,” he says.
The task force evaluated multiple programs and eventually selected a single system for both facilities management and biomedical engineering that worked well in both worlds. “The fact that we could put together that task force and adopt a tool that everybody could use and benefit from was very unusual,” Flannery says. “It was groundbreaking, really, for IHS. And being able to see where equipment was almost in real time made life easier for everyone.”
Kent Lupino is a contributing writer for 24×7. For more information, contact .