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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