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IMPROVING THE EFFICIENCY OF A CLINICAL ENGINEERING

MAINTENANCE SERVICE BY AN OUTSOURCING SOLUTION OR AN

INTERNAL ONE? THE THIRD WAY

I. Castenetto*, A. Fundone*, A. Giannoni*, A. Donatelli**, C. Lamberti***

* S.Orsola-Malpighi University Hospital, Biomedical Technology Unit, Bologna, Italy

** Elettronica Bio Medicale srl, Clinical Engineering Division, Foligno (PG), Italy

*** Bologna University Dep. of Electronics, Computer Sciences and Systems, Bologna, Italy

mailto: [email protected] ; [email protected]

AbstractThe Biomedical Technology Unit of Bolognas

Hospital manages about 6.000 biomedicalequipment, with an increasing trend of maintenance

cost in recent years. How to stop this trend? Thesolution adopted is the outsourcing of maintenance

of a group of biomedical equipment, selected by their

maintenance costs. A consortium of companies -

awarded an European open procedure - workstogether with the previous in-house service, and

manages the maintenance of this group of devices,

allowing to the hospital useful resources.

The number of technical staff increased from 4 to

8, so that the hospital got a considerable benefits: a)

a reduction of time to recovery, due to a largernumber of first level maintenance executed in the

early days after the failure (the number is increased

42% within the first day from request), b) asubstantial unvarying costs c) especially an

augmented productive capability of biomedical

equipment (more than 10.000 days in 2007 vs 2006),

which economic quantification is a challenge for the

future.

Introduction

The Biomedical Technology Unit (BTU) of

BOLOGNA University Hospital has been operating

since 1974 and it is one of the first Italian Clinical

Engineering service.

The Support Area is high on the BTU management,

indeed it employs relevant human and economical

resources. Support Area performs first-level

maintenance on all medical equipment groups and more

performs second-level maintenance on the strategical

biomedical equipment; these are the cases for which the

Biomedical Equipment Technicians (BMETs) education

is part of buying contract.

The approval of Council Directive 93/42/EEC on

medical devices leads the BTU to improve a quality

system that meets ISO 9000 requirements (ISO

certification, got in 1997). Moreover, the designed

procedures allow BMETs to work in safety1.

Because of high managing cost and the difficulties

to respond to biomedical equipment needs, BTU

decided to strength resources and let out on contract

some activities (outsourcing). In this article is described

the development of AS IS model, the start of

partnership and first year results.

The situation until 2006

In the 2006 the staff was composed by: 1 engineer, 7

BTEMs and 2 administrative personnel; BTU got 3.722

work requests on its own biomedical equipment: 47%

done by BMETs and 53% put out on external company;

and the total maintenance cost was 2,6 M.

BTU only put on service contract a limited group of

biomedical equipment; it can be said that less than 500

on 6.000 managed items were on contract.

The comprehensiveness of contracts was different

and depended on technology level (preventive

maintenance, limited calls, full-risk partner with internal

first response, full-risk): the cost per year was 837.000, that is a little more than 30% of the entire cost. The

cost maintenance was proportionate to the purchase cost

of managed goods, even though it had slowly been

increasing (see tab 1).

Table 1 Maintenance and Purchase Costs years 2003-

2006 (the maintenance cost includes personnel cost).

The key performance indicator on the corrective

maintenance is Mean Time To Restoration (MTTR)2,

that is the mean time lapsed between a work request and

the restoration of the item. This does not consider the

derived uphold level. In 2006, total MTTR was 17 days:

it is important to notice that for internal maintenance

MTTR was 10 days, while for external maintenance

MTTR was 25 days (see fig 1).

Year 2003 2004 2005 2006

Maintenance Cost(MC)

2,0M 2,3M 2,6M 2,6M

Purchase Cost(PC)

34,0M 36,9M 40,4M 40,2M

MC/ PC 5,9% 6,2% 6,4% 6,5%


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Figure 1 Internal vs external completed task in 2006

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

DAYS

REPAIRED

ITEMS

INTERNAL

EXTERNAL

In external maintenance the start-up task time is

delayed because of administrative and logistical

reasons. These problems are removable by putting on

service contract more items, but the cost management

results increased. The solution to get better themaintenance performance was to reduce external tasks

vs a complete internal management. To determinate the

margin of improvement, BTU analysed 1880 work

documents about external tasks in 2006: 19% of them

were first-level maintenance and might be operated byjunior BMETs, using simple tools and basic knowledge3

(low difficult tasks, works similar to preventive

maintenance, false failure); 37% were second-level

maintenance senior skilled BMETs might operate on

some of them; 44% always needs manufacturer work

e.g. embedded technology and endoscopy.Next, it is reported the task classification (see fig 2):

False failure: operator mistake or wrong setting Works similar to preventive maintenance:

lubrification, battery change, transducer replace

First-level maintenance: filter, pipe, gasket, button,

false contact, wire, cleaning, check

Second-level maintenance: software, hardware,

pump, engine, optical fibre, calibration and gauge

Endoscopy: internal failure finding and analysis

Breakdown on embedded device

Fig 2 Classification of 1880 works in 2006

SECOND-LEVEL

37%

FALSE FAILURE

0.4%

FIRST-LEVEL

13.8%

EMBEDDED DEVICES7.4%

PREVENTIVEMAINTENANCE

4.3%ENDOSCOPY

37%

Designing the service

In spite of all difficulties of financial andadministrative nature to integrate internal technical

staff, the BTU examined the possibility to get resources

by joining external services4,5.

So it has been found very interesting and convenient

to agree to the Framework Agreement named SIGAE

(Servizi Integrati per la Gestione delle Apparecchiature

Elettromedicali: Integrated Services to Manage

Biomedical Devices), drawn up by CONSIP spa (acompany that is entirely and directly property of the

Italian Ministry of the Economy and Finance that

operates exclusively on behalf of the State, with the aim

of engaging in information technology, consultancy and

support of public administration activities) and awarded

to companys association named SIGE (consisting of

Elettronica Bio Medicale Srl a company on the

Clinical Engineer market since 1978 - Esaote SpA eDrger Medical Italia S.p.A international leaders in

medical equipment manufacturing). To this Framework

Agreement, made for the needs of public administration,

28 Italian Health Centres agreed, in 2006-2007 period,

with a fee amount of more than 72 M.Although not planned, but neither prohibited, the

decision to entrust to an external companies group, the

management of equipment subsets maintenance was

certainly a special case. That is why several operative

aspects were agreed among the parts, as allowed by

SIGAE (supplying loaner equipment, management of

systems etc.)Understandable operative reasons led BTU to divide

items into groups related to the same type of device

except few singular cases. What it is done was to

simulate several scenarios in order to get the greatest

attainable savings; all these scenarios was built on a

robust amount of data about the costs in severalactivities (corrective maintenance, scheduled

maintenance, compliance check and operating check)

from BTUs database. Some kind of items were

excluded because too complex to be managed by an

external company (e.g. rigid endoscopy, particular

embedded technology). Moreover, BTU considered

further factors, as BMETs knowledge and relationship

with authorized maintenance company. All the

conditions above mentioned have been validated by a

multidisciplinary team.

In the case of items on full-coverage contract it is

been noticed that SIGAE resulted to be cheaper:

averaged cost decrease was 56% (in a range of40%70%); lesser savings was foreseen for

maintenance tasks operated by external company ondemand. Considering the low number of items on full-

coverage contract (only 148) the savings expected was

about 4,5% on total maintenance cost. Because of the

equipment increasing value and the evolved technology

maintenance cost, the real savings should have been less

than the expected one.BTU decided to put out on SIGAE a little more than

3.000 items (50% of total equipment), the contract price

is 920.000 per year.

The classification of items, in accordance with

SIGAE Framework Agreement, is related to


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maintenance cost and divided into four groups (from the

highest -A- down to the lowest -D-).

Table 2 Total equipment and SIGAE items

distribution

TOTALEQUIPMENT

SIGAEFRAMEWORK

AGREEMENTGROUP

number value number value

A 2% 3% 4% 8%

B 8% 31% 10% 27%

C 16% 29% 16% 27%

D 74% 38% 70% 38%

The human resources offered by Elettronica Bio

Medicale Srl (EBM), in partnership with Esaote Spa and

Drger Medical Italia Spa, are composed of 1 junior

BMETs, 3 senior BMETs, 1 administrative unit, and

EBM engineer for assistance on demand.

The chosen integration strategy between BTUSupport Area and SIGAE organization consisted of

sharing the logistics (call-centre, disposable warehouse,

tools), while the procedures have been updated in

accordance to the related needs. Instead BTU decided to

go on keeping the relation with medical staff. The final

resource staff is composed: 1 engineer, 11 BMETs, 3

administrative unit.

Results

In this chapter are showed the first year results

related to the incoming SIGEA activities. The BTU and

SIGAE integrated staff is understood as internal staff.

From analysis of the internal and external completed

tasks distribution it can be noticed that it got a better

performance although the growth of activity volume

(April 2006 March 2007 period: 3.407 tasks

previous -; April 2007 March 2008: 3.686 tasks

current): the percentage of internal completed tasks has

grown from 48% up to 63%. During this period the

internal completed tasks was 712 more than before,

conforming with the expected improvement (minimum

357 first-level tasks up to 1.053 first and second level

tasks).

Figure 3 Internal tasks vs external tasks distribution

63% IN48% IN

37% OUT52% OUT

0%

20%

40%

60%

80%

100%

PREVIOUS CURRENT

MTTR fell down from 19 days to 15 days, this

improvement is described by the chart in figure 4: it can

be noticed that the resolution of first-level tasks

operated by internal BMETs gave positive effects

during the early days after the failure. The tasks

completed within the same day of request was 32% vs

23 % of the previous period.

Figure 4 2006 completed tasks vs 2007s ones

0%

20%

40%

60%

80%

100%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

DAYS

REPAIRED

ITEMS

CURRENT

PREVIUS

MTTR about the items, put on full-coverage contract

in the previous period, resulted 13 days against 14 daysperformed by SIGAE, yet the performance related to the

tasks operated on demand is better than in the previous

period.

The entire maintenance cost was steady, meanwhile

the equipment increased its value: the ratio between

maintenance cost and equipment value resulted 6,1%;this data is like the performance obtained in 2003 and

2004 BTUs management (see tab 1) and the other localHealth Centres management6.

Effectiveness of internal maintenanceAn analysis about task operated by internal BMETs

deserves a particular attention: thanks to the integration

of human resources granted a very good increasing of

the first-level tasks up to 22%, while a discrete

increasing of the task closed internally up to 15% (see

fig 3).

The effectiveness of the first-level task, expressed as

to be the ratio between the number of first-level tasks

completed internally and the number of attempts, stood

on high level (80% vs 82%); this proves that throughthe failure diagnosis activity the tasks are allocated to

the internal BMETs only when the restoration

probability is high.

Over increasing the BMETs number produces

positive effects on MTTR, whilst the savings tends to be

reduced down to a bottom limit. This limit is

determined by the failure able to be repaired only by

authorized maintenance company. This level is

estimated to be 2025% on total failures.

Conclusion

The analysis showed that the increasing of BMETs

number produces important improvement of MTTR,

thanks to the decreasing of tasks completed by external


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company. Technical staffs expansion can be obtained

by putting out, totally or partially (as at the present

situation), the maintenance of biomedical equipment. It

is fundamental that rules and management are

exclusively led by internal managing staff.

Most important are education and training of

internal BMETs, because of, for strategical biomedicalequipment groups, after first-level task, it is often

necessary for internal BMETs to operate a second-level

task .

Costs management control can be considered a

positive result in view of the fact that the service quality

has largely been improved. The decreasing of MTTR

(from 19 days down to 15 days) represents a positive

factor for patient hospitalizing reduction time (withcosts decrease DRG - note that pre-surgery and

surgery are based on intensive equipment usage) and for

providing outpatient services. The increment of

providing number (diagnosis with usage of biomedical

equipment, laboratory examinations) has positive effectson patient satisfaction: waiting time decreasing, minordeleted appointments number and hospitalizing time

reduction.

References

1 A. Giannoni, G. Plicchi, L. Manganelli, A. Conti, F.

Falcone,La Certificazione Di Qualit Nelle Strutture

Sanitarie, Tecnica Ospedaliera N. 2 Febbraio 1995

2 UNI 9910 CQA, Terminology on Reliability,

Maintainability and Quality of Service, 1991

3 C.Lamberti, W. Rainer,Le Apparecchiature

Biomediche e la Loro Gestione, Patron Editore, 1998

4 Jill Schlabig Williams, The Pros and Cons of

Outsourcing: Which Way Should You Go?, Biomedical

Instrumentation & Technology, Volume 38, Issue 4,

July-August 2004

5 Walter Iannaccone,Ingegneria di Manutenzione,

FrancoAngeli, 1998

6 Gruppo Regionale Tecnologie Sanitarie Emilia

Romagna, Progetto Q-MIC, Aprile 2008

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