|L-R, Jerry Krueger, regional clinical engineering manager; Alan Gresch, corporate manager, clinical engineering; and Tom Horner, imaging technician.|
If there is one lesson that has been learned in this Information Age, it is that the proper management of data can bring significant benefits. Even within a small hospital, clinical/biomedical engineering departments can find it difficult to manage a piece of equipment from the moment its purchase is concepted, through its acquisition and delivery, to its maintenance and care, to its removal, replacement, and possible reuse. Sometimes, this is due to politics; other times, it is a lack of resources; and still other times, it is simply a matter of physics. Members of a clinical/biomedical engineering department cannot be everywhere at once—but a system that captures data throughout a life cycle or workflow can be.
Integrating data and workflows can result in improved patient safety, increased productivity, enhanced service, raised satisfaction, greater access, and potential cost savings. Capital equipment services of Aurora Health Care, Milwaukee, has seen all of these benefits since undertaking a centralization effort in 1999.
“What we’ve got today is a capital integration strategy that allows clinical engineering to touch every piece of that process, pretty much from cradle to grave, starting with technology assessment,” says Alan Gresch, corporate manager of clinical engineering for the group.
The program encompasses nearly every aspect of clinical engineering’s workflow, plus a few others. Those not yet covered are in development. The vision was that of capital equipment services’ director Patrick Trim, CPM, who started the process to integrate clinical engineering into the capital supply chain. He then hired Gresch to centralize clinical engineering across the entire Aurora Health Care system.
Aurora offers integrated health care services in more than 90 eastern Wisconsin communities, including 13 hospitals, more than 100 clinics, and 130-plus community pharmacies. “We were a bunch of separate, distinct clinical engineering departments, all of which did a great job supporting their respective facilities,” Gresch says. Unfortunately, acting alone, the departments lost opportunities that could have been realized through centralization—opportunities that have added up to more than $2 million in savings already.
Before Trim’s vision of centralization could be realized, he needed a plan and the buy-in of all involved, including the clinical engineering staff. “Unfortunately, when people think of a reorganization, the first thing they think of is contraction, but in this process, we hired 19 additional staff,” says Jerry Krueger, regional clinical engineering manager for Aurora’s capital equipment service. “We reinvested in our employees and their development, and that process engaged our staff in growing with us and getting the program off the ground.”
At the time, employee morale in the clinical engineering department had been low; the department had some of the lowest scores in a hospitalwide survey of employee satisfaction. But the reorganization held the promise of an improved work environment, with more staff and more efficient processes to ease workloads and permit specialization in core competencies. And it delivered.
“We are probably close to the top quartile in employee engagement right now,” Trim says, crediting the staff’s enthusiasm with the program’s success and the department’s turnaround.
“If you had to compare the importance of engaging the finance department and our staff, it was more important to get our staff on board,” Trim says. “If they don’t see the vision, you’ll never meet finance’s goals.”
However, finance and customers also had to climb on board. Trim and Gresch traveled to the various hospitals in the system to present the opportunities and advantages that a centralized clinical engineering department would bring. “We put together some very detailed presentations outlining those savings and benefits,” Gresch says. “When we talked about cost reductions, we actually went so far as to say we would reduce our budget by this exact amount.”
Advantages mentioned included the ability to bundle contracts and to provide higher levels of service to all facilities than were previously available to an individual site. “We went from a single stand-alone hospital model to more of a modality-zone service model,” Gresch says. Biomeds now specialize in core competencies rather than focus on particular facilities, increasing their expertise and improving subsequent service.
The motivation was based on replacing expensive equipment contracts with in-house services. “We had to make sure we did this at an extremely high level of quality—or at least as good as the OEM—because if we saved $100,000 on a contract but our equipment downtime increased, what we lost in revenue far offset whatever dollars we saved,” Gresch says.
Such promises, however, demanded a significant commitment. “If you make the type of promises we were making, there has to be a strong level of commitment to do whatever it takes to meet those goals,” Gresch says, warning that the process required significant work.
The first step was to combine all of the separate databases. “It would be pure luck for everything to be set up and have all the definitions applied in the same way [across the facilities in the system],” Gresch says. More commonly, everyone makes the rules as they go along. Aurora was no exception. So rules and nomenclature needed to be standardized first. “We had to pull our staff together and educate them on the sets of rules and the new definitions, which really set the foundation to do a lot of things we’ve done subsequent to that,” he continues.
The integrated database is invaluable and used to support many of the programs put in place. “It’s key to being able to maintain all information for us to make our business decisions more effectively and efficiently,” Krueger says.
Data captured throughout the life of equipment provides useful information for every stage, beginning with capital acquisitions. Procurement teams can discern if existing equipment needs to be replaced and, if so, with what. Clinical engineering data can answer questions such as, “What is the cost of servicing a device compared to its acquisition costs?” Users even can select a replacement threshold for the ratio of service costs to acquisition costs at anywhere from 10% to 100%.
|Aurora Health Care’s dedicated clinical engineering team.|
Capital equipment services also provides an electronic path for clinical personnel to request capital equipment through an authorization for expenditure, or AFE. Requests are routed through the appropriate channels for approval based on the employee’s title and department.
“What often happens is that whoever makes the best argument is the one who gets the money,” Gresch says. But now, those arguments can be supported or debunked with fact. Take, for instance, someone who claims that a device needs to be replaced because it keeps breaking down. “Everyone has access to the inventory and service information, so a finance director or administrator can go in and validate that the device really does keep breaking down,” he says. “Maybe the system shows only a couple of thousand dollars were spent throughout its life in support, and it is not actually breaking down frequently.” The information might lead to the decision to keep the equipment currently in the inventory and apply the funds elsewhere.
Once approval is granted, the request goes to clinical engineering, where the entire cost of ownership is formulated. “Say radiology is looking at acquiring a nuclear medicine camera that is not typical of the cameras we already have,” Gresch says. Potential costs might result from the need for specialized training, test equipment, and/or necessary renovations to the room in which it will be installed. “We will identify all costs so that finance has the complete picture and someone does not have to come back later and ask for additional funding.”
Aurora’s capital equipment services department also will evaluate a potential purchase for its value. An assessment checklist tailored to the category of device helps to determine whether a specific piece of equipment is a smart purchase. The department has an employee who handles capital technology reviews, including the assessment of new technologies. Criteria considered include the value the device would bring to the organization, the projected volume, and the expected return on investment.
“I can’t tell you how many organizations spend millions of dollars on the latest and greatest technology only to have it collecting dust in a corner a year later. We can’t afford to make those poor decisions,” Gresch says.
New builds, both hospitals and clinics, also fall under the purview of capital equipment services with clinical engineering involvement. The process often starts with a footprint based on the inventory of similar facilities (such as a surgicenter) and then modifications directed toward the needs of the individual site, which gives the department the ability to plan its resources accordingly.
The clinical engineering team supports most of the equipment in the hospital, including MR, CT, and nuclear medicine machines, although it does not handle unique devices, such as the CyberKnife radiosurgery system. “There are two in the entire state, and it would be extremely difficult for anyone on our team to maintain competency,” Gresch says.
The department does oversee all service contracts, which provides consolidation benefits. “Being a large system of 13 hospitals, there were a lot of opportunities to bundle contracts and get better pricing,” Gresch says. The move saved money while also providing greater in-house control. Access to contracts enables the biomed to know what the specific coverages are.
Never a group to sit still, clinical engineering at Aurora Health Care of Milwaukee is already working on the next phase of its integrated system: the equipment status board. Currently in the pilot phase with key high-volume departments, such as imaging and surgery, the tool ties into the equipment maintenance management software and displays information about the status of repairs and equipment.
“The health care providers need to know if a room or device is available and don’t want to chase people down to find the answer,” says Alan Gresch, corporate manager of clinical engineering for the group. Technicians often fix the problem and alert the person on-site that the room is ready. Unfortunately, that person may neglect to inform everyone else in the department.
The status board will list items submitted for work with color coding to identify readiness: red means waiting for service; yellow means the device repair is incomplete (such as waiting for a part); and green means ready to go. Green items eventually drop off the board.
“So, if a customer is wondering about the status of an imaging room, they can look at the board, and if it is not listed, then the room is up and working. If it is listed up there in anything but green, they know it’s not ready yet,” Gresch says.
Aurora’s in-house service starts with the actual receipt of the equipment. “When a receiving department accepts purchases, they count boxes but do not go through them to make sure every piece is there,” he says, citing a lack of knowledge and background as the reasons. With clinical engineering accepting deliveries, someone does verify that the shipment has been delivered in whole and in working condition before it is accepted. Warranties that start when a device is clinically accepted are therefore maximized; and final payments on the same terms maintain some leverage to ensure that things are 100% correct with the shipment. At reception, the equipment is added to the maintenance management database, where, as Gresch puts it, “the magic is.”
A centralized call center handles all requests for repairs. The setup is simple, according to Krueger, with customers all calling one number.
Documentation tracks response times, turnaround times, and equipment uptimes. Reports are easily generated for trending or to respond to a specific situation, such as a complaint. “One thing many clinical engineering departments struggle with is complaints from customers saying that it took too long to respond to a particular call,” Gresch says, citing surgical departments as particular offenders. Documentation can sometimes provide a reality check showing that what felt like 20 minutes to the surgical team was actually only 2 minutes.
When parts are needed, the system speeds the process and again provides documentation. Two staff members with expertise in parts acquisition and inventory management facilitate parts procurement by finding the best deals. Biomeds in the field use the maintenance management system to confirm that a needed part is in the database and to order it. Confirmation e-mails verify the order and provide shipping status.
E-mail is used throughout the workflow process to automate, speed, and document communications. One key area is the Aurora Recall Web site (ARW), an online tool that allows information about medical equipment recalls and alerts to be easily distributed throughout the health care system.
Rather than rely on the blanket yet haphazard fashion by which this information is often circulated (at Aurora, everyone received the information but few knew how to act on it), the ARW provides a centralized repository for reporting and following up on these notices. “So if I get a recall on my desk and am not sure anyone knows about it, I can check the repository to see if it has been posted,” Gresch says.
Once posted, the “critical task receiver” in each department is alerted to the necessary actions required by the notice and must then document completion in the system. The main concerns were not about equipment that needed related service or updates that would be missed—which did end up in clinical engineering and were corrected—but rather, the concern was for notices that required departmental actions, such as additional training on the correct use of equipment or supplies. Automated escalation ensures that if the first recipient does not respond or does not complete a required action, the person next up on the list is notified. If categorized at a serious enough level, a task could escalate all the way to the CEO.
Reaching Out and Getting Work Done
When Aurora Health Care of Milwaukee reorganized the disparate clinical engineering departments of its many facilities within its system into one centralized unit, the technicians’ focus also changed—from a specific facility to a core competency. With more techs more mobile, communications posed a challenge.
To overcome that challenge, the team employs Blackberries, wireless handheld devices with phone and Internet capabilities. Technicians stay in touch, receiving and closing work orders and communicating easily with one another. “Not a day goes by when I am not talking to one of my colleagues, whether they call me or I call them asking for their expertise,” says Tom Horner, imaging technician I for Aurora’s clinical engineering department. “There’s quite a bit of troubleshooting that goes on over the Blackberry.”
The immediate connection with someone to help solve a problem means that solutions are reached more quickly and equipment downtimes are shortened. Jerry Krueger, regional manager of clinical engineering with the group, believes that the communication tools put in place as part of the reorganization have increased productivity, which improved the department’s ability to handle more projects.
Alan Gresch, corporate manager of clinical engineering for Aurora’s capital equipment services, says there has been a tremendous improvement in sharing and communications. Technicians within the distinct modality groups hold regular teleconferences during which they review what is going on as well as any new ideas.
“The way we were structured before, if a tech in Green Bay servicing CTs found a better way of doing something or found a better source for a particular part, the guy doing that same service in the south region likely did not benefit from that information,” Gresch says. Now, if someone learns something new that benefits everybody, it gets shared.
The system has been successful, already meeting the goal of measurement. “An old adage goes, ‘You can’t improve what you can’t measure.’ Just being able to measure is a great improvement,” Gresch says. Since the implementation of ARW, Aurora has measured a 72% closure rate on recalls and alerts. When recalls still waiting for a manufacturer solution are eliminated, that rate climbs to 78%. “But we want to be at 100%, and this gives us the mechanism to get there,” he adds.
The final step in the cradle-to-grave management of the equipment life cycle, and the one that enables a complete turn back to cradle, is the asset investment recovery program, or AIR. It draws on the ability of an integrated system to provide visibility of a device from anywhere in the system, taking advantage of the extended asset life cycle.
In the past, when a department removed equipment, often it was thrown away or traded in for pennies on the dollar. Now, departments can alert capital equipment services through an online system that they want to get rid of a device.
Perhaps the most efficient option, and often the first considered, is reuse within the system. Departments in need of specific devices can scan the database to see if any are available. “One part of our region might need something that the other one has sitting in storage. That region can now claim this equipment off the Web site, have a new piece of equipment to service customers with, and not spend money,” Krueger says. At the same time, the old owner clears valuable square footage, and the system as a whole has saved the capital investment.
Other options for removal of equipment can include using an old device for parts for existing equipment, selling it at a fair market value, trading it in, donating it, or disposing of it in an environmentally friendly manner.
Each electronic step has helped clinical engineering deliver on its promises to staff, customers, administration, and—indirectly—to patients. Response times have decreased, productivity has increased, and equipment uptime has improved with corresponding benefits in patient care and safety. Customers like the system, claiming better service.
These benefits have translated into significant cost savings. Aurora’s capital equipment services has reduced its budget by $2 million since its integration across the system, and Gresch believes that more can be realized through further development. “We actually have a mechanism in place to make things happen,” Gresch says.
“It’s easy to get buy-in when you want to implement a program for patients that will, by the way, also save a million dollars,” Trim says. “The money saved is great, but we are here to make the patient experience more beneficial. Money sells [the process], but care matters.”
Employees matter too. Aurora’s technicians now have greater job satisfaction, reporting better utilization of high-end skills and expanded expertise.
Renee Diiulio is a contributing writer for 24×7. For more information, contact .