The phrase “capital equipment” can be found in most biomed job descriptions—and for good reason. Whether it is acquiring a new CT scanner or hundreds of new infusion pumps, clinical/biomedical engineering plays an important role in ensuring that patients get the best possible care from new capital equipment. And some veteran biomeds see that role expanding in the future.
“We’re getting more and more involved in capital purchases,” says Dan Dudley, CBET, director, medical engineering department, at Wishard Hospital in Indianapolis. His team focuses on building strong relationships with other hospital staff. “We’ve been seeing an increasing confidence level with the staff—we’ve worked at that a long, long time. Clinicians will seek us out to ask, ‘What would you recommend?’ ”
Although Dudley’s team does not play much of a role in analyzing clinical needs for new capital purchases, there is plenty of other data that they provide to help make the best decisions. “The questions are: What does nursing want? How well can we support it? and How much does it cost to maintain?” Dudley says. “Have we worked with the vendor before? Do we need special training? Can we get parts? What does a service contract cost? There are other considerations too. We provide data on equipment history and reliability.” After Dudley’s team gathers the data, they make a recommendation from a clinical engineering perspective.
Dudley again emphasizes the importance of collaboration. “Nursing needs to decide what’s best from a clinical and end user perspective. If nursing likes it, they’ll try harder to make it work once it’s installed. So harmony between biomed and nursing during the acquisition phase is important.”
Alan Gresch, director of corporate clinical engineering for Aurora Health Care in Milwaukee, also says that interaction with other hospital staff is critical to successful capital equipment acquisition.
“The newest and sexiest thing isn’t always something that you’re going to get a reasonable ROI for,” Gresch says. “You need to partner with the clinical departments, and they’re going to need to look at it and ask whether or not the technology advancements will justify replacing the current devices.” He added that this principle is particularly important for replacement purchases versus new. “We have to look to see if this is really something that will bring value to our patients.” He adds that important biomed contributions also include information on maintenance costs, end-of-life planning, and safety data.
Technology On the Move
When it comes to capital equipment purchases, changing technology represents an important trend that biomeds need to be aware of, according to Gresch. He says that maintaining equipment to manufacturers’ specifications for as long as possible is feasible for clinical applications that are not as technologically driven. But for some areas, keeping up with technology has to be an additional consideration for clinical engineering.
“For example, you cannot get the diagnostic image quality on a 10-year-old ultrasound that you can on a new ultrasound,” Gresch says. “Subsequently, if that limits what can be done clinically as far as getting diagnostic information, it’s important to partner with the clinical folks to help them out with that. That’s one of the reasons why the clinical engineering department needs to be more than just fix-it guys. We need to learn about new technology and what it can bring that the old cannot. So guys that service imaging equipment ought to be participants at things like RSNA [Radiological Society of North America] to see what’s out there, to be able to understand the differences in technology.”
Of course, some clinical/biomedical engineering departments are more involved than others in capital equipment purchases due to the organizational structure or managerial emphasis of each hospital organization. For example, at the Minneapolis VA Medical Center, clinical engineering plays an integral role both before a specific capital equipment purchase has been approved, as well as after.
It’s a Process
Michael Phelps, MS, director of biomedical instrumentation service at the Minneapolis VA, explains the process. “As director, I’m an active member of the hospital’s equipment committee—a multidisciplinary team comprised of the chief of staff, nurse exec, associate director of operations, and other administrative and technical stakeholders. Logistics, facility engineering, finance, IT, and biomed work together to review all capital equipment wish lists and actively discuss them with the requesting clinical service line.”
Phelps explains that there are some purchases that are nonnegotiable, such as technology needed to bring the hospital into compliance with regulatory agencies or VA guidelines. Equipment for new construction that is part of a larger strategic plan for the hospital is also in that category.
“Those equipment needs come off the top,” Phelps says. “Then we start looking down the list and going back to confirm other equipment priorities. The reality is that our annual equipment budget is finite. We consistently have more requests than funds available each fiscal year. For example, the surgery service line has 80 different equipment items requested on their wish list, and they’ve prioritized what’s number one and what’s number 80. Since we may only be able to fund the top 10 or 20 items, we have very robust discussions with each clinical area to make sure that each and every item is really a priority for them.”
At the Minneapolis VA, biomedical staff become even more involved after a capital equipment purchase request has been approved. “Biomed is tasked with developing specs, performing technology assessments and other market research, and communicating directly with clinical end users in order to configure the quotes for purchase through our process,” Phelps says. “Something distinctive to the Minnesota VA is that biomed is often leading discussions with vendors, facility engineering, IT, and our clinical stakeholders to ensure that everyone who needs to can participate in overall procurement.”
One of the most valuable prepurchase activities for some clinical engineering professionals is a site visit to a facility that is currently using the capital equipment under consideration. One of those professionals is David Barbrow, assistant director of clinical engineering at UCLA Healthcare System in Los Angeles, who was part of a multidisciplinary team that conducted a site visit before the purchase of more than 2,400 infusion pumps.
“I highly recommend site visits,” Barbrow says. “You often get a different and more unbiased perspective from the staff on-site about where difficulties were and any kind of struggle that they might have had getting the device online.”
He also says that visiting sites with staff from other functional areas can also be very productive. “When we were deciding on a new monitoring system, we did site visits with nursing, transport, anesthesia, IT, and materials management—a fairly large and broad group. And we always requested to have our counterparts available for consultation.”
Dudley agrees that site visits can be helpful, but says that networking can be problematic if the vendor is not very cooperative. “Sometimes, a vendor will know of a hospital that’s using their equipment, but they can’t tell me who to contact—I can’t relate to a nursing supervisor; I need biomed. If a physical site visit isn’t possible, it’s a good idea to at least arrange a phone call to discuss their experiences.”
Because it’s such an important part of vetting new capital equipment purchases, Dudley proposed an independently maintained database of hospitals that would allow hospital staff to cross-reference different types and brands of equipment by facility—perhaps administered by an organization like AAMI. “It may not be simple to do, but I think it would be very helpful,” he says.
The Importance of Training
Another important consideration for biomedical engineering when purchasing new capital equipment is maintenance and training, but negotiating can be tricky because of the way that some institutions treat certain expenses.
“Finance doesn’t like to capitalize any training, so I add training as a line item,” Dudley says. “Also, any kind of extended warranty is not included in the capital cost. We try to make sure that we’re looking at training as a locked-in price. It might be cut out of a different pile of money, but we try to get a commitment from the vendor up front. If I’m involved in the quote process, I want to make sure training is a part of it.”
Barbrow considers it unfortunate when accounting policies get in the way of negotiating training or service costs for new equipment. At UCLA, he says that training can be included with the initial purchase. “More so with certain product lines—like respiratory therapy equipment and anesthesia machines,” he says. “We always tie in multiple class schedules with those. For large RFPs we try to tie in training to include on-site training, if at all possible.” He explains that for large institutions, it can be difficult to send a large biomedical staff across the country for classes.
In addition to training for new devices, Phelps considers other things as well. “Test equipment, laptops with software service keys, specialty tools—whatever is needed to service and repair the equipment,” Phelps says. “Even things as simple as service manuals can be built into the equipment purchase.”
He adds that strong relationships with purchasing personnel are essential to success. “The process can definitely be bureaucratic at times, so biomed works closely with purchasing to translate clinical and technical requirements into their lingo,” he says. “This relationship can be effective for getting what biomed needs if the work is done right on the front end.”
Effective training for new equipment is especially important for clinical engineering departments that emphasize an internal service philosophy.
Says Phelps, “I have 24 people in my department responsible for approximately 5,000 medical devices worth $80 million, and we have less than 10 full service contracts. We’re able to procure the equipment, tools, and training for biomed up front so that we’re able to maintain it without depending a lot on vendors for service contracts.”
Gresch’s department has a similar approach. “We provide over 98% of our repair support internally,” he says. “We do all the MR and CT, nuclear med, and radiation oncology support in-house.” But he also admits that vendor service support is sometimes the best option for highly specialized equipment, such as a gamma knife. “We may only have one of them in the system, so even if we could train somebody on that, are we going to maintain a high enough level of expertise where we could repair it very quickly and efficiently?”
Gresch sees other bright spots for vendor service support. “Because we have response time and turnaround time constraints, if we have people tied up, out with an illness, or on vacation, we’ll use a vendor in order to get the job done,” he says. “You always need the vendor—sometimes there are no second source parts. We’ll at least try to negotiate parts discounts with the vendor so that it’s as equivalent as possible to a third party.”
Overall, though, Gresch views training as ‘negotiable’ when looking at new capital equipment purchases. “Training isn’t automatically added,” he says. “But if it’s a new device and I did not have the opportunity to budget for it, what other choice do I have other than to include it?”
Fortunately for Gresch, as an Integrated Delivery Network (IDN) with 14 hospitals and more than 100 clinics, Aurora Health Care has many resources to help the biomed department get what it needs. “We will add in the training, then the capital equipment specialists negotiate everything,” he explains. “If they can incorporate training costs in the purchase, they’ll do that. If not, they’ll try to minimize the cost as much as possible. Sometimes we might have a master agreement, where training and parts are already prenegotiated.”
Standardize to Economize
While an IDN can leverage its centralized management and purchasing power, stand-alone, public hospitals like Wishard can use other strategies to help clinical engineering get the most out of their resources. One of those is equipment standardization, which can help minimize maintenance costs.
“We’ve been pretty successful with this strategy,” Dudley says. “Certain devices just don’t have the longevity that others have. There’s a vital sign monitor that we’ve pushed hard because it’s just bulletproof, and the nurses like it.”
He says that buying nonstandard equipment “off the grid” is not worth it in the long run. “Standardization has helped us reduce training time and be more efficient with the training we’ve had. We do a lot of cross-training in the department here, so the more consistency you can have, the more experts you have.”
It’s All About the Data
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For Gresch, biomedical engineering’s involvement in capital equipment purchases starts long before the purchasing process for a specific piece of equipment begins. For him, the most important factor comes down to two words: “data integrity.” “I’m on a workgroup that is trying to do a better job at long-range capital planning, and trying to make it as objective as possible,” Gresch says. “The way you do that is with data. Data is the foundation for any capital planning process. If you don’t have the data to bring to bear, you’re dead in the water.”
According to Gresch, from a biomedical engineering perspective, good data starts with intelligent reports. “Are you documenting everything that you’re doing?” he asks. “Are you capturing all of your labor and parts expenses on your work orders? If those things are collected haphazardly, without an emphasis on completeness and accuracy, you’ll be in trouble down the road when that data is needed to support a new equipment purchase.”
Participating on a planning committee for capital equipment purchases also represents a good way to raise department visibility. “Clinical engineering departments are always looking for ways to raise their value to their organizations,” Gresch says. “The best way I know to do that is by providing reliable information. Purchasing equipment will always involve a team of people, but if you want to promote your value, the clinical engineering department has to be able to provide a good foundation. Without good data, you won’t be able to do it. No data is better than bad data.”
Kent Lupino is a contributing writer for 24×7. For more information, contact .