1. Lúcio Flávio de Magalhães Brito, CCE Engineering Director
Return on Investment
Introducing Clinical Engineering
Ladies and Gentlemen Good Afternoon.
My name is Lúcio Flávio and I would like to thank you all for being here today.
I am very delighted to be here to talk to you about clinical engineering and I hope that this presentation can provide you with the tools to improve your hospital organization and its investment capacity.
I’d like to express my personal acknowledgments and, the first one is:
To you, again, mainly because of your efforts to continue working in the healthcare field, in a market that needs us to be fully prepared in order to improve it in the right direction.
To the AHMC and MEDICORP PANAMÁ Teams for their hard work and initiative to start up clinical engineering in the Caribbean Countries and Northern Region of South America. For its understanding that healthcare technology must be managed in order to achieve necessary business performance.
Over the past 20 years, I have the impression that my presentations are always changing since Administrative Techniques and Client Satisfaction Standards are also changing. Today, I will make a presentation in 3 parts.
The first part that I will present to you is about concepts, definitions and other words that are used in modern clinical engineering. They will allow us to create a base upon which we will develop the second and third parts of the presentation.
The second part I will talk about is PRACTICE, the way to get results in the clinical engineering field through continuous hard work.
In the final part I will present 4 cases where practicing HEALTHCARE TECHNOLOGY ADMINISTRATION leads hospitals to better results.
But, first of all, let me tell you a little about myself.....
Lúcio Flávio de Magalhães Brito, CCE
Engineering Director

2. About the speaker Mechanical Engineer Occupational Safety Engineer
Federal Engineering School of Itajubá
Occupational Safety Engineer
Industry Engineering School
Hospital Administration Specialist
Getúlio Vargas Foundation
Certified Clinical Engineer
International Certification Commission
Healthcare Technology Foundation
Biomedical Engineering Specialist
Campinas State University
Engineering Director of Medicorp
São Paulo - Brazil
I have been working in the hospital field for the last 20 years.
During these years, I have learned a lot of things about technology, its principles, its advantages and disadvantages, prices, costs, etc. but the most important things I learned about are those management techniques that are required in modern hospitals.
Since the beginning of my career to this day, I have learned many things about hospitals and professionals, but I confess that the most important lesson was to better understand what is missing in today’s healthcare technology management and in clinical engineering profession.
Hospitals cannot be managed by traditional entrepreneur techniques. They must be managed as a system where executives, managers and employees are responsible for their results; in such a way that the entire organization can always provide satisfaction to its clients.
At MEDICORP my job is focused on implementing tools that permit hospitals to change their relationship with healthcare technology, from traditional maintenance to a modern, engineering point of view.
My work, during all these years, has helped Top Management to better understand that their tasks as professionals do not become less important or less demanding because of technology advancements.
I try to show them healthcare technologies are forcing hospitals to take new approaches to management. They must lead the way administratively and motivate their employees or as Peter Drucker calls them their “knowledge workers” in order to improve their hospitals. These knowledge workers must take on new professional challenges and commit themselves to the results of the contemporary hospital organization.

3. Our Agenda Concepts and definitions Tips Case Studies Engineering
Healthcare Technology
Financial
Tips
During presentation
Case Studies
Clinical Engineering
Hospital Engineering
Maintenance
Technology Administration
Our agenda for today, in other words, is:
- To define work concepts, to think differently about engineering.
- To know and learn how to practice modern, clinical engineering techniques.
- To be able to measure our results, both big and small, and observe how they affect hospital performance.
- And finally, I hope to be able to answer all of your questions and to be able to help you take the right direction.

4. Return on Investment
The greater the risk, the greater the expected return on investment, because the risk must be rewarded
Minimize operational expenses
Increase sales volume
Reduce equipment down-time
Avoid exaggerated installations
Increase both “Current Ratio” and “Quick Ratio”
To begin with, I would say that there is nothing new in terms of Return on Investment but just remember one important principle that we cannot forget:
“No one with money in their pockets will use it if there is no compensation or satisfaction. The possibility of having no satisfaction is a “risk” and therefore, these risks must be rewarded”.
But what can clinical engineering do in order to minimize these risks? To improve ROI?
Many things can be done in technology planning and management, but some deserve special attention, such as
- to understand and minimize operational expenses with electricity, water, and waste treatment – common, important areas where money is lost.
- to increase sales volume by reducing the down time of important revenue-producing equipment and hospital facilities
- to avoid exaggerated hospital installations that are completely beyond existing healthcare technology and hospital budgets, as well. Remember that many actions can be taken and improvements made, that do not need money to be implemented.
The fact is that, clinical engineering should start to understand how many dollars the hospital has in its pockets for each dollar it must return to the investors and should learn to view the entire business, the entire management picture, rather than see a piece of equipment as an isolated resource within the hospital operation.
But engineering itself cannot change the whole system, it needs to have its efforts aligned with the efforts of the larger organization, expressed in its mission, vision and mainly its objectives and goals. By doing this, the engineers and their assistants will be working as knowledge professionals who can make a difference in the hospital’s performance.

5. Engineering Concepts Clinical Engineering
“A Clinical Engineer is a professional who supports and advances patient care by applying engineering and managerial skills to healthcare technology." - ACCE Definition, 1992
Other terms used to specify this professional are:
Healthcare engineer, hospital engineer, biomedical equipment technician, equipment managers, technology manager, biomedical engineer, maintenance engineer, healthcare technologist.
There are many different definitions of clinical engineering and how a clinical engineer should best apply his knowledge, effort and time.
Clinical Engineers are known by many different names, but really, a clinical engineer means all of them. It is important to note that although there are clear definitions, both Hospital Administrators and Directors of Nursing are creating new expectations and clinical engineers must to be able to respond to these new expectations.
For example, today’s Clinical Engineers must be able to help hospitals make decisions based on measurable values, by demonstrating the impact of a new technology on the hospital’s healthcare costs.
In the past, nurses always asks engineers for an equipment repair of if the equipment is read work, but today, they ask if the surgery will canceled or not.

6. Clinical & Hospital Engineering
Clinical Engineering equipment responsibilities
Infusion pumps, defibrillators, monitors, x-ray machines, cath scan, MRI, ultrasound, ventilators, surgical table and lights, electrosurgical units, pulse oxymeters, CT scan, etc.
Hospital Engineering equipment responsibilities
HVAC, medical gases, electrical systems, medical compressed air, vacuum systems, elevators, construction support, communication systems, vehicles, steam, hot water, etc.
Healthcare technology is a vast subject and its management can be improved if we divide and share responsibilities between Clinical Engineering and Hospital Engineering.
Knowledge, costs, time, quality, benefits, etc. can all be used to decide which technology is better for a hospital’s planning and needs.
Hospitals should discuss and decide how to start their own clinical Engineering Departments and which strategy to use in choosing healthcare technology activities which add true value to the healthcare services and increase Customer Satisfaction.

7. Typical Engineering Responsibilities
Supervision, coordination and technical orientation
Studies, planning, projects and specifications
Technical and economic feasibility studies
Counseling and advisory services
Manpower and resource management
Inspections, audits, evaluation, survey, technical reports
Technical functions
Teaching, research, analysis, experimentation, tests
Budget preparation
As well as these typical responsibilities, an Engineering Department should help the Hospital Administrator answer questions about Customer Satisfaction and be able to both attract and maintain the hospital’s clients.
Patients, partners, suppliers and employees, all, have specific and different needs which need to be understood and met.
Some of these needs are simply related to equipment and installation maintenance, but is important to expand the Engineering Department’s responsibilities and contribute new types of information upon which strong and educated decisions can be made.

8. Typical Engineering Responsibilities
Standardization, measurements, quality control
Constructions
Fiscalization of service execution
Specialized technical production
Technical evaluation of work conductions
Management of installation, mounting, operation, repair or maintenance team
Execution of installation, mounting, repair and remodeling
Installations and equipment operations and maintenance
Technical drawing
In addition to traditional maintenance activities, Hospital Administrators must also consider
- Inventory and Asset Management
- Technology Strategic Planning
- Quality and Safety
- Compliance
- Vendor Management
- Education
Help Desk
Installation and Integration
Testing and Inspection, but not only in maintenance and repair
Of the 18 Typical Engineering Responsibilities, which are presented on these two slide, only 2 of them involve traditional maintenance activities.
These activities are very important to the Hospitals, but do not encompass all of the responsibilities associated to modern technology management.

9. Engineering or Maintenance ?
When Hospital Administrators think only in terms of maintenance activities, they can only achieve preventive and corrective maintenance objectives, but when they think differently, they can add new values to their traditional departments and set new goals which involve healthcare technology management and the life cycle of technologies.

10. Engineering !!!
What are the positive aspects of implementing an organizational structure which includes a Clinical Engineering Area and a Hospital Engineering Area?
What are the specific objectives, goals and results that these two new Areas need to contribute to the Hospital’s larger challenges?
How much money does a Hospital need to save?
What are the costs which a Hospital Administrator cannot control, by himself?
Which healthcare technology should the Engineering Department have complete control over?
What can be done in order to increase the traditional maintenance responsibilities?
What are the steps that should be taken, for the Engineering Department to start focusing on business, epidemiology, technology and regulatory issues which will help the Hospital Administrator in his decision-making?

11. Healthcare Technology Definitions
Healthcare Technology. What is it?
Healthcare technology includes the devices, equipment, systems, software, supplies, pharmaceuticals, biotechnologies, medical and surgical procedures, organizational structures used in the prevention, diagnosis, and treatment of disease in humans; for rehabilitation; and for assistive purposes.
Here we will focus on medical equipment and hospital installations and facilities.
In order to make the correct decisions, it is important for us to greatly increase how we perceive healthcare technology. It is much more than equipment, much more than hardware, computers, tools cell phones,
Healthcare technology includes highly sophisticated equipment such as anesthetics, breathing circuits, transducers, thermometers and others which when poorly managed, contribute decisively to hospital losses. Probably, the best example of poorly managed technology resources, which can sink a hospital, are the medical gases.
Healthcare technology has been accused of being the villain of ever increasing healthcare costs, but it is so important to know that “there are hospitals that know how to use technology to make money and there are hospitals that simply do no know!”
Top hospitals usually keep expenses with medical gases at 1% of total expenses, while maintaining medical gases revenues at 4% of total revenues. On the other hand, the majority of hospitals spend 4% to 5 % of their expenses on medical gases and have no idea how much money they make from these same gases.
But how and why does this happen? Why should we get more benefits from technology? How and when can we transform the old structure into a modern organization? What should be done first? Who can help us with this challenge?

12. Healthcare Technology Concepts
Technology Efficacy
A benefit from a given medical technology under ideal conditions of use.
Technology Effectiveness
A benefit from a given medical technology under average (real) conditions of use.
Technology Efficiency
Lowest price when different technologies have same efficacy and effectiveness.
Hospitals need to develop their own expertise or contract outside services which are able to quantify the value of each type of technology.
We need to understand the concepts - efficacy, effectiveness and efficiency – as they are applied to healthcare technology.
We need to understand how to use these concepts practically and choose the best way to measure results. Sometimes it is possible that technology management is doing very well, but the measurement techniques which we use show exactly the opposite.

13. Technology Life-Cycle
We should use the technology life cycle in understanding and analyzing healthcare technology.
We need to know how and why some technologies die and when a certain technology will begin to give a return on investment.
Hospitals must be able to answer if technologies are adequate for their present situation, as well as in the future.
In addition, one has to know the risks that are involved in deciding to adopt a new technology.
By using the technology life cycle analysis, decision-makers will be able to make rational decisions and measure the real added values before committing themselves to the new technology.
A process by witch technology is created, tested, applied, and replaced or abandoned.
Know the maturity of a technology
Support systematic and rational decisions

14. Cost-Effectiveness
A process that combines qualitative and quantitative considerations in order to know the costs of a project compared to the resultant benefits.
Costs are normally expressed in dollars
Benefits in terms of:
Lives saved
Disabilities avoided
Quality-adjusted life years saved
Other relevant objectives
On the other hand, it is difficult to find an adequate base to compare costs and benefits because Costs are normally expressed in dollars and Benefits in terms of:
Lives saved
Disabilities avoided
Quality-adjusted life years saved
Other relevant objectives as client satisfaction or marketing strategies

15. Life Cycle Cost analysis (LCC)
Initial purchase price
Shipping
Renovations
Installation
Supplies
Associated disposables
Cost per use
And OTHER costs as: staff training, ease of use, servicing, spare parts, upgrades, networking …
By knowing the life cycle and details of each operational, technology principle, it is possible to estimate operational expenses for the entire life cycle of the technology.
For example, some x ray machines can use x ray tubes from various suppliers which normally cost much less than the tubes provided by the machines’ manufacturer.
Clinical laboratory equipment can use reagents supplied by other companies, different than the original manufacturer.
These supply possibilities are not normally calculated and such errors can spread to other issues, which collectively can lead to bad decisions.
The life cycle cost analysis (LCC) can measure the cost of technology more precisely and correctly reflect the total costs – and, therefore, can mean a much better decision.

16. Ease of Use Clinical Evaluation Prior to Purchase Decision
Prepare the user for proper operation
Inservice Training
Documentation
Equipment design
User’s ability
Human factors
Patient and user discomfort
Keyboard
Device controls
Alarms
Other questions must be answered by hospitals before deciding to incorporate a new technology. User-friendly aspects need to be considered.
Training, operational documentation, quality, equipment design, human factors, keyboard language, display colors, etc. are factors that must be seen from the users’ point of view. The users’ opinions are not normally considered in choosing new technologies.
There are so many stories of technologies which were never fully adopted, simply because the users did not like what they were asked to do and the hospital ended up losing money.

17. LCC & NPV Analysis $ 398,359 Items Initial Capital Year 1 Year 2
Hardware Costs
$ 225,000 $ $
Software license
$ 17,500
$ 18,200
$ 18,928
$ 19,685
$ 20,473
Facilities costs
$ 25,000
Disposable costs $
$ 4,500
$ 4,680
$ 4,867
$ 5,062
$ 5,264
Support costs
$ 3,375
$ 3,510
$ 3,650
$ 3,796
$ 3,948
Service costs
$ 11,250
$ 11,700
$ 12,168
$ 12,654
Training costs
$ 1,125
$ 1,170
$ 1,217
$ 1,265
Misc. costs
$ 1,125
$ 1,316
Cash out flow
$ 267,500
$ 9,000
$ 39,935
$ 41,532
$ 43,193
$ 44,920
Present value of $1 discount rate at 10% (NPV = 1/(1+I)n) -
0.9091
0.8284
0.7513
0.6830
0.6209
Net present values
$ 8,182
$ 33,082
$ 32,203
$ 29,501
$ 27,891
Total present value
$ 398,359
This table shows us an example of a life cycle cost analysis.
This Hospital evaluated direct and indirect costs associated with a new technology over a six-year operational period.
There is a direct relationship between how much the hospital knows of possible costs related to a new technology and how accurate the results of the analysis can be.
In acquiring a new technology, it is more important for the hospital to ask the right questions to the vendor, than know how to answer the vendor’s questions. The right questions will enable the hospital to complete the LCC analysis correctly.
In this example, you will see that the final price of the equipment is, at least, 77% more expensive than the initial price presented by the vendor.
The initial price is normally the tip of the iceberg.
To correctly use the LCC analysis, you must calculate future operational expenses at the present value, in order to reach the final price. This analysis should always be done for more than one possible equipment vendor.

18. Modules for practicing?
Full Clinical Engineering Implementation
Partial Clinical Engineering Implementation
Technology Advisory Counseling
Accreditation Preparation
Technology Audit & Action Plans
Technology Inventory
Economic Rescue Plans
Technology Incorporation Planning
Case Studies
Now, I will present some activities which you should be able to practice normally at your Hospital.
I have chosen 8 activities, each of which represents part of the role played by a Clinical Engineer in the Hospital.
Full Clinical Engineering Implementation
Partial Clinical Engineering Implementation
Technology Advisory Counseling
Accreditation Preparation
Technology Audit & Action Plans
Technology Inventory and Asset Management
Economic Rescue Plans and
Technology Incorporation Planning

19. Full Clinical Engineering Implementation
16 Complementary areas
Diagnostic Studies
Inventory
Market Procurement
Law Standards and Regulations
Equipment Control
Costs & Expenses Control
Process Management
Risk Management
Contract Management
Personal Management
Technology Incorporation
Maintenance
Patient Safety
Technology Planning
Training
Quality
During the last 15 years we have tried different techniques to solve technology-related problems. From a maintenance point of view to an engineering point of view, we have learned that engineering itself can’t solve all of these problems.
Today, we advise hospitals to start practicing, at least, these 16 programs:
Diagnostic Studies
Inventory
Market Procurement
Law Standards and Regulations
Equipment Control
Costs & Expenses Control
Process, Risk, Contract and Personal Management
Technology Incorporation
Maintenance
Patient Safety
Technology Planning
Training
Quality
These programs are not presented in order of importance or priority, although usually, the Diagnostic Studies and Inventory are the first activities we advise you to start with.
Back

20. Diagnostic Evaluation Criteria Continuing Education Risk management
Technology Incorporation & Acquisition
Equipment Control
Legal Standards & Regulations
Maintenance
Preventive
Corrective
Documentation
Administrative
Technical
Safety
Different techniques can be used to do a diagnostic analysis of the situation in a specific hospital. However, we do advise that you, at least, use these evaluation criteria
The main idea is to check out or verify what actions “the maintenance team” or the Engineering Department is taking in regards to these criteria.
A full study of these criteria should give us enough technical information to evaluate technology management, as presently being used in the Hospital.

21. Diagnostic Excellence & Quality Leadership: participation
Planning: actions
Social Concerns: attended
Clients: necessities
Information: use
Personal: capacitating
Processes: practice
Results: defined
Besides the technical aspects, administrative aptitudes also need to be evaluated to get a complete idea of technology management in the Hospital:
Leadership participation and its commitment to engineering development in the Hospital
Actions to align strategic planning to existing technology and to improve the entire Engineering Department
Social Concerns considered by the Engineering Department, such as “radiation control” and waste management
Efforts to anticipate client needs as related to technologies
Use of information to change the perception of engineering within the hospital organization (change paradigm)
Actions taken in order to keep engineering personnel up-to-date on technology and business issues
Management use of Processes (Policies and Procedures)
Defined Results versus obtained results

22. Diagnostic National Accreditation Organization SWOT
Physical Projects Management
Physical Infra-Structure
Facilities Management
Waste Management
Medical Equipment Management
Safety Management
SWOT
Strengthens - I
Weakness - I
Opportunities - O
Threats - O
Other techniques may be used, such as the famous SWOT analysis and the Joint Commission International Standards of quality or other existing National Standards for Hospital Quality.
Back

23. Inventory Applied to medical equipment and facilities and accessories
State of Conservation
Age of Technological
Registers in organizations as FDA
Recall Evaluations
Value – US$
New
Substitution
Energy consumption
Technical & Administrative Data
Serial number
Model
Manufacturers
Owner
Contracts
Warranty
Technical Responsible
In addition to the Diagnostic Studies, the analysis of existing inventory is an important tool to understand the present situation of the Hospital.
Normally hospital inventories are conducted for accounting purposes, rather than technology management.
A complete inventory is a strong tool for developing engineering within the hospital. Among other actions, a complete inventory is used for action plans related to process management, accident investigations and external recall research concerning the hospital’s assets.
The above information can be considered to be the minimum data that we recommend for inventory purposes.
Back

24. Market Procurement Improve the knowledge of medical equipment market
Improve the knowledge about the market of healthcare facilities
Medical Equipment Fairs
Mechanical Fairs
Electrical & Electronic Fairs
Specialized Magazines
Technical Papers and Newspaper
Internet groups
Engineering and Maintenance Associations
Benchmarking
Normally Hospitals reach technical solutions, using the manufacturer of a specific equipment’s point of view. This is the normal way to solve problems. They really believe that the manufacturer and his equipment will solve their problems.
Hospitals don’t realize that in most cases, manufacturers are not especially interested in the problems of one specific hospital. Sometimes, to them, one more hospital is simply, one more client.
Hospitals do not consider that manufacturers normally do not produce all the parts for their equipment. Many times, the principal manufacturer uses parts from other manufacturers to construct the equipment they are trying to sell to a hospital, such as in the case of x-ray tubes, image intensifiers, etc…
We must learn and know that manufacturers’ prices are normally quite high.
In order to find lower prices, hospitals must know more about the market. But not only medical equipment market. Not only the hospital facilities market. Hospital should be able to think along the same lines as the manufacturers’ engineers, trying to sell their products. These engineers think differently and look for solutions in diverse markets. Hospitals should do the same.
A rubber o’ring on the conventional industrial market costs much, much less than an o’ring on the hospital market. Why does this happen? Why should hospitals pay higher prices? There are a lot of explanations, but normally prices are based upon how much money Hospitals can make by using specific equipment on their patients.
For these and other reasons, Hospitals should motivate their Engineering Department to search for solutions outside its conventional market.
Back

25. Law, Standards and Regulations
Municipal, State and Federal Laws
Water Quality
Electricity Supply
HVAC
Sterilization
Standards
NFPA, ANSI, ASHRAE, ISO, AAMI, JCAHO
FDA
Registers, Recalls
ECRI – 1991
13,000 standards and guidelines
800 organizations and agencies (North America)
In the USA, in1991, there were 13,000 different standards and legal guidelines, while in some other countries, there are no laws at all.
The fact is that the number of standards, resolutions, recommendations and allied documents is increasing and, a lot of them really do help to improve hospital technology and to increase the satisfaction of many patients and healthcare professionals.
These regulations can help Hospitals to become active participants in healthcare technology improvements by correctly applying legal and technical standards and, in addition, make more money.
Back

26. Equipment Control Equipment history Maintenance procedures
What are the expenses and costs related to maintenance? Are they high?
How many hours of work?
Who is the Responsible for the equipment?
What are the maintenance indicators?
MTBF
MTTR
Availability
Up Time
Down Time
If a Hospital clearly shows that it takes good care of its medical equipment and facilities, the patients will be able to perceive that they are receiving true value for their money spent.
Nice hospital facilities are easy for patients to notice, while medical equipment and water quality, for example, are not easily seen.
This program helps Hospitals to control and maintain their equipment and installations, not only working properly, but within accepted operational costs.
Hospitals are able to fully take control of their own situation.
Back

27. Costs & Expenses Control
Actions may be applied to the two principal types of costs and expenses, i.e.:
Medical equipments
Facilities
In addition, actions may also be taken to recuperate money as related to:
Review contracts
How to obtain more from the same contracts?
Contractual compliance
New contracts
New technologies
What kind of knowledge can be used to change the operational costs?
Some actions depend on money. Other actions depend upon a lot of money. But there are many things that can be done without spending any more money that you are spending right now. This concept should be the real focus when you talk about the impact of costs on healthcare.
What actions can Hospital take right now without spending money and guaranteeing a return on their investments?
By implementing a program like this you will be able to introduce more sophisticated processes which will create precise indicators to help you manage technology from an economic point of view.
Back

28. Process Management
How to manage a clinical engineering department using processes?
Define how workers and patient can have benefits from processes
Create internal administrative procedures
To open work orders
To prepare requisition of spare parts and consumables
Register engineering activities to monitor performance to achieve defined goals
Issue management reports
Evaluate medical equipment
Register activities of maintenance
Corrective & Preventive and others
Decision-makers in Hospitals need to factor into their present decisions, the future which has already happened.
Presently, process management is a quality indicator which is required for many quality standards.
Processes, policies and procedures are used in many hospital areas, so why aren’t they applied to engineering activities, as well?
We must consider what new processes should be applied to engineering, in order to create new concepts in the technology management program.
As Drucker said, the most effective way to manage change successfully is to create it.
Back

29. Risk Management Helps hospital by to: JCAHO – PSTM
Avoiding exposure risks
Minimizing liability exposure
Staying compliant with regulatory reporting requirements
JCAHO – PSTM
Require minimum technology-based risks management activities
Recognition, evaluation and risks control
Determination of technology-related incidents with followed-up steps to prevent recurrences
Evaluation and documentation of the effectiveness of these steps
“One has to start out with what is right rather than what is acceptable precisely because one always has to compromise in the end. But if one does not know what is right, one cannot distinguish between the right compromise and the wrong compromise – and will end up by making the wrong compromise”.
Risk management helps the Hospital Administrator distinguish between right and wrong in healthcare technology management.
Back

30. Contract Management Helps hospital fully explore its contracts on:
Service and Maintenance
Electricity
Medical gases
Combustibles
Warranties
Acceptance tests
Price of spare parts
Timeframes
Performance indicators evaluations
Hospitals have many different types of contracts which they should carefully manage and many of them are related to the Engineering Department.
There are some Hospitals that have so many contracts that they need to negotiate one contract per day, every day of the year, in order to stay ahead of the game.
Contracts are resources and not just costs, so they must be managed systematically in order to take full advantage of these resources.
The clinical engineering area should be given clear responsibilities, objectives and goals related to each contract within its area and should be able to create specific indicators to measure how each contract adds true value to the overall hospital organization.
Back

31. Personal Management
Helps the hospital’s maintenance and engineering staff be:
Involved
Prepared to execute its functions
Properly assigned to specific technical tasks
Creative and solution-oriented
Capacitated
Focused on objectives and goals
Clinical engineering is a relatively new profession and it is growing each year around the world.
One problem related to this growth is that there are not enough engineers to meet the demand created by the market.
The number of Technologists and Biomedical Equipment Technicians is also insufficient to meet the market demands.
In addition to this problem, the hospital market is not an attractive market for these professionals. Industries pay better salaries than Hospitals, as do hospital equipment manufacturers, as well.
Therefore, we advise Hospitals to create and maintain recruitment and hiring programs which will retain professionals on their engineering teams. It is imperative that Hospitals begin to consolidate the necessary knowledge in this field and as soon you can begin, the sooner you will reap the benefits.
Back

32. Technology Incorporation
Helps hospitals organize and take full advantage of technologies by:
Analyzing needs and developing specifications
Developing a vendor list
Analyzing proposals and site planning
Evaluating samples
Selecting finalists
Choosing the best proposal
Controlling deliveries and installations
Performing acceptance testing
Final acceptance
The normal and “wrong” way to incorporate healthcare technology is to consider isolated points of view such as those of the user, the owner of the business, the administration, engineering, etc.
At the same time, it is very rare to see a team or commission working on technology incorporation and technology assessments.
What we have to understand is that the incorporation of new healthcare technology can be the beginning of a problem or the beginning of a solution. It all depends on how we do it, from planning to practice.
Back

33. Technology Incorporation
Healthcare is increasingly using TCO
Initial price
Equipment, installation, initial training costs an support over the long-term
Long term costs
On-going training, equipment service, supplies, connectivity, up grades
TCO
Acquisition costs
Operation and maintenance costs
Installation and Supplies
Down time and Spare parts
Test equipment tools
Depreciation
New techniques are beginning to be used by Hospitals in order to take advantage of technology incorporation.
For example: Total Cost of Ownership allied with Net Present Value is a tool that allows the Administrator to have a full picture of the investment before spending any money.
Although this tool seem to be a natural, logical and obvious way of thinking through the process, it is rarely used by the majority of Hospitals.
Why not?
Back

34. Technology Incorporation
Clinical Team Requirements
Ability of staff to assimilate the technology
Medical staff satisfaction (short and long term)
Impact on staffing (numbers, functions)
Projected utilization
On-going related supplies required
Effect on healthcare delivery and results (convenience, safety, or standard of care)
Written, clinical practice guidelines
Credentialed staff
Clinical staff initial and ongoing training
Effect on existing technology in the department or other services/departments
First of all, it is a problem of culture. People are not trained to think of clinical engineering as an integral part of the daily operations.
Secondly, there is no formal training in clinical engineering for most of the decision-makers.
Lastly, there is nobody really pushing to implement these changes and find new solutions.
Once again, you can see that lots of these activities demand skilled management, but who will do it?
Back

35. Maintenance Preventive Corrective Management of these processes
Documentation
Operational manual
Operational maintenance
Registers
Tools
Adequate tools required
Simulators and performance equipment tests
Calibration certification of these equipments
Corrective
Service manual
Training
Functional principles
Management of these processes
For example, everybody in Hospitals think about maintenance, both preventive and corrective, but very few think about what equipment should be included in the preventive maintenance plan and how frequently should the equipment be maintained.
A sophisticated preventive maintenance plan can cost a lot. But, on the other hand, a poorly designed plan can cost lives.
The clinical Engineering Department should create specific criteria that reflect the Hospital’s needs. It should design a plan which aligns Hospital needs with low costs and safe conditions.
Back

36. Patient Safety Safety is a condition of being safe from:
Danger
Injury
Damage
Regulations and Standards
Air conditioning (tuberculosis)
X-Ray dose
Medical air quality
Electrical current leakage
Burns associated to electrosurgical units
Alarms management
Healthcare technology has its own dark side and this side must be known before incorporating new equipment or installations.
The Clinical Engineering Department, in this case, must act as a partner with the Hospital Administration and healthcare professionals in recognizing, evaluating and proposing actions in order to eliminate, minimize or control a specific hazardous condition.
Back

37. Strategic Technology Planning
Is an accountable, systematic approach to ensuring that cost-effective, efficacious, appropriate, and safe equipment is available to meet the demands of quality patient care, and allows an institution to remain competitive.
In house service management
Management and analysis of external service providers
Involvement in the equipment acquisition process
Involvement in facility planning and design
Reducing technology related incidents
Training equipment users
Reviewing equipment replacement needs
On-going assessment of emerging technologies
Today, many Hospitals have their own strategic administrative plan. They have a mission, vision, objectives and goals. On the other hand, they don’t normally have a technology plan that supports the strategic administrative plan.
In terms of healthcare technology issues, it can be said that there are no “underdeveloped hospitals”. There are only hospital whose technologies are “under-managed”.
Based on this premise, we often advise hospital leaders to adopt a strategic technology planning process that helps them address the general issues they face on the larger scale.
Back

38. Training Helps hospital to:
Disseminate user’s manual an other information
Process and track hazard, recall, and regulatory data
Provide initial and on-going personnel training
Investigate equipment-related incidents, hazards, and problems
Include discovered error in staff training programs
Engineering and maintenance personal
Corrective: X-Ray machines and autoclaves
Preventive: Almost all
Certainly, Hospital employees should be doing things that lead to positive results.
If training is about human beings, we can say that healthcare technology management is, as well.
The task of healthcare technology management is to make people capable of making their strengths effective and their weakness irrelevant. Training is one more management tool to be used in preparing people to meet the new challenges brought on by new technologies.
Therefore, training must enable the Hospital and each of its staff members to grow and to develop, as needs and opportunities change.
Back

39. Quality Quality of Care Measuring quality of care
It means providing healthcare with the most efficient use of resources
Measuring quality of care
Quality Assurance (QA) & Quality Improvement (QI) are formal sets of activities to measure the quality of care
Selecting, monitoring, and applying corrective measures
Indicators
Benchmarking
Every organization in the world wants to be recognized for its quality standards and so does the Clinical Engineering Department. The following steps can be used to introduce quality in this department:
Assign responsibilities
Define the scope of services
Identify important aspects of these services
Identify indicators
Back

40. Quality of Medical Technology
Inventory
Institution’s experience with that and similar devices
Equipment functions
Industry standards (state of art)
Age
Current device condition
Select a valid indicator to measure equipment’s clinical performance
Availability
Functionality
Financial performance
Safety
Establish thresholds for evaluation
Collect data and organize it
Evaluate services
Take actions to solve problems
Evaluate actions and document improvements
Communicate relevant information
Back

41. Quality of Medical Technology
Types of indicators
Type and # of devices scheduled for service
Total # and type of devices inspected
Type and # of devices that failed an inspection
Type and # of devices for which on-demand service was requested
Type and # of devices found with physical damage
Type and # of devices for which user’s complaint was registered, but no problem found
Type and # of devices involved in accidents or incident
Type and # of devices that were serviced more than one time in any 7-day period
Type and # of devices for which abnormal labor or replacement parts were required
These 10 steps allow clinical engineering managers to be pro-active, to understand the Hospital operation and develop the ability to determine opportunities for healthcare technology improvement in the Hospital or organization where he works.
This is a continuous, structured approach that improves the quality of the technology planning and management programs by setting minimum acceptable performance goals, by increasing equipment availability for intended clinical use, by assuring optimal device functions, and by eliminating device-related incidents.
Back

42. Partial Clinical Engineering Management
Refers to the partial application of the 16 programs previously mentioned
Medical Equipments
Hospital Installations - Facilities
Using one program or a combination of specific programs to achieve an objective
Inventory & Maintenance
Market Procurement
Patient Safety
Accident & Incident Investigation
Sometimes, a Hospital will decide to start innovations in only one area, either clinical or hospital engineering. In this case we say that it is implementing partial clinical engineering management.
The programs are the same as those for general management, but are applied to a specific area.
In the hospital engineering area, a hospital can chose to start on medical gases, electricity, water quality, steam generation, air conditioning applications, telecommunication, etc and in the clinical engineering area, a hospital can chose issues such as diagnostics, therapeutics or healthcare equipment.
The Hospital can also chose to mix specific programs in preventive maintenance, when conducting an inventory and apply specific criteria in order to obtain a well-balanced program.
Back

43. Technology Advisory Counseling
Administrators
Hospital that don’t have enough demand for an engineering department but have important costs or needs to be supported
Legal standards and regulations, specific information on medical equipment and installations
Engineers
Lack of time
Lack of knowledge or information
Other Professionals
Nurses, Infection control programs, occupational safety professionals
Another possibility is for the Hospital to start getting control over its medical equipment and facilities, by applying clinical engineering programs led by a specialized professional or a company to give them technological support.
This is what we call technology advisory counseling,
In this case, the Hospital starts with independent counseling to complete its task force.
Hospitals that already have Engineering Departments may also need this type of counseling. While its Engineering Department is involved in the daily operations, a number of actions may be taken outside the Hospital, for example in the case of equipment specifications.
Outside technology advisory counseling can also be important when there are time constraints. The cost to develop in-house knowledge may be higher than to buy it on the market and the internal Engineering Department may have more time to spend on its strategic and face-to-face activities.
Back

44. Accreditation Preparations
Safety
Inventory & documentation
Equipment and installation performance
Processes
Maintenance processes management
Technical
Administrative
Results – Indicators
Quality assurance and improvement indicators
Administrative indicators
Financial indicators
In order to have its standards of quality recognized by the professional community and for other purposes, Hospitals are increasingly moving towards Accreditation.
When these Hospitals start organizing themselves to be evaluated, it is very common that the maintenance areas get very low scores.
Using specific programs, as those we have already shown, in a short time, Hospitals can align their engineering efforts to Accreditation demands.
The main actions we recommend are related to safety, processes and results.
Back

45. Technology Audit & Action Plans
Needs
Including utilization rate of current equipment and of new equipment
Value of technology
Technical validity an maturity
Ability to assimilate and maintain technology
Medical and other staff satisfaction
Impact on staffing and healthcare delivery
Impact on facilities and code compliance
Impact on healthcare standards and quality
Economic considerations (e.g., reimbursement, life-cycle cost)
The technology audit is a tool that allows us to evaluate how healthcare technology is being used.
All hospital operations have to be analyzed, focusing on technology issues.
At the end of the audit, it is possible to develop action plans to improve the use of technology in the hospital.
It is very common to find real opportunities to improve the Hospital’s situation and reduce economic losses after the audit.
Back

46. Technology Inventory Quantify and qualify equipments and installations
Manufacturer
Regulatory aspects related
Ionizing radiation
Quality of water
Financial information
Price
Installation
Conservation conditions
Reports
Help hospitals to create performance indicators
Usually necessary to use accounting approach
Help hospitals to plan new investments
This is my favorite area and I always pay special attention to it.
It’s normal that Hospitals conduct inventories for accounting purposes. But these inventories do not represent technology management needs.
An accounting inventory shows investors where their money goes, while a technology inventory measures the capacity of an organization to make money from the technology it has.
If an ultrasound equipment, with 4 years of use, receives a software up-grade, its value changes, which satisfies the engineering personnel and the users, but these value increases are not normally given to the accounting department.
Therefore, a technology inventory, adequately conducted, will enable Hospitals to structure strong asset management of the technologies it has incorporated.
Back

47. Economic Rescue Plans Minimize costs, maximize short-run
Immediate actions that are possible because:
Easy to do but nobody has done it yet
Have no additional costs to implement the proposed solutions
Logic and reason are the only resources that need to be applied
Simple knowledge is enough to resolve the situation
Economic resources are always scarce and have to be used correctly
“Opportunity is where you find it, not where it finds you. Luck, chance and catastrophe affect business as they do all human endeavors. But luck never built a business. Prosperity and growth come only to the business that systematically finds and exploits its potential. No matter how successfully a business organizes itself for the for the challenges and opportunities of the present, it will be far below its optimum performance.”
Based on this, we can say that “Economic Rescue Plans” are structured to analyze:
- The limitations and restraints of actual technology management that make businesses vulnerable.
- The imbalances within the business that are created by poor technology management.
- What in the present technology management models scares the Hospital Administration.
These three action points can be the beginning of a rescue plan that will lead your Hospital to a new and successful model of healthcare technology management.
Back

48. Technology Incorporation Planning
Prepurchase evaluations
The level of information needed for each phase depends on the acquisition
Acquisition process strategies
Cost of ownership
Utilization information
LCC Analysis
Equipment evaluation
The conditions of sale document
Final choice
Installations
Acceptance testing
As the quality of healthcare depends to some extent on the safety and effectiveness of medical devices, it is necessary to establish “Good Purchasing Practices” that include the engineering point of view. This will allow Hospitals to:
- Prepare guidelines for preventive maintenance
- Establish user training programs
- Establish an information center on medical equipment performance which will increase value for the Hospital, as a whole.
Back

49. Study of Case Medical de Limeira Clínica Ana Rosa
Medical gases pipelines
Clínica Ana Rosa
Air conditioning system
Santa Casa de Limeira
Oxygen generation
In house maintenance
Less difficult to more difficult activities
Medical is a medical cooperative which has its own healthcare insurance plan. They decided to open their own hospital. The planned, medical pipeline gas system was composed of oxygen, nitrous oxide, vacuum and medical air. The initial price, only for oxygen to be installed was US$ 75,000. The price was given by the construction company. We presented the owners of the hospital with five different options from specialized companies. The results were tremendous. All the planned installations including medical air compressors, vacuum equipment and all delivery systems were bought for only US$ 45,000. The reason? Specialized market procurement allied to the knowledge of market peculiarities. It is rare for a negotiation like this to occur every day, but the important point is that a Hospital should always be thorough and prepared when they are acquiring equipment and installations.
Clínica Ana Rosa is a recent case we got involved in and is related to medical air conditioning used in a surgical day hospital. We were contracted as consultants in order to evaluate the financial and technical proposals made by different companies for installations and medical equipment. The proposal that was to be contracted, was evaluated at US$ 175,000 for the entire system, but did not include compliance clauses and did not comply with established standards for humidity controls, air exchanges, air renovation and air purity. In fact, the proposed system was a risk for hospital operations, mainly in the OR (operating room).
Back

50. Goals of Clinical Engineering
Medical Equipments (time or costs reduction)
Maintenance - $
20-30 %
Reduce investment levels by using correct planning techniques - $
10-20 %
Reducing the time for specifications
2-4 weeks
Adequate introduction of technology by using engineering techniques - $
10-90%
Reduce maintenance needs by training the users - $
10%
When hospital owners understood the situation and the risks, they forced the company to implement full standards for the same price and the company agreed. So can you imagine how much money the hospital saved. And, beyond the money, the benefits I mean, Lives saved, Disabilities avoided, Quality-adjusted life years saved, etc.
Santa Casa de Limeira is a non-profit hospital with 450 beds. Its oxygen consumption was about 20,000 m3/month. When we began our clinical engineering services, they were buying a oxygen generation plant for US$ 250,000. Our strategy was that the Hospital should only buy technology which it cannot really control, which meant that it should only buy the oxygen generation system and not the entire oxygen generation plant. The final price was US$ 125,000.
This hospital also used synthetic medical air that is a mixture of pure nitrogen with pure oxygen. A year before we started our job at this hospital they bought an air compressor system and never used it. We could not understand why they weren’t using the system and the answer was simple – they did not know how to use it! The next day, we started installing the system and in one week they stopped consuming nitrogen and the oxygen as synthetic medical air. What did we do in this case? We simply knew what to do.

51. Goals of Hospital Engineering
Facilities (time or costs reduction)
Reduce investment levels by using correct planning techniques - $
10-20%
Reduce the time needed for planning
30%
Use of Facilities
Out-Patient Services
20%
In-Patient Service
Diagnostic and Treatment Service
50%
The final case is about maintenance services and we strongly recommend you to think about it. In all of our consulting work, we start looking at the strategic equipment which will impact the business. And when we find it, we start training maintenance personal to repair it, to dominate the technology involved. It saves money, time, increases the confidence of healthcare professionals in engineering and in the end, the total value of the hospital will increase.
To finish my presentation I would like to repeat a text of Peter Drucker that is strongly related to this presentation, but before I do, I would like you to know that I will be at the Medicorp International Panama Booth during the entire Conference and would be glad to answer any of your specific concerns. It will be a pleasure to know more about your hospital, your problems and your ideas and start up a very good relationship.
Peter Drucker Text:

52. Bibliography
Clinical Engineering Handbook – Dyro, J. F. – Elsevier – 2004
Principles of Applied Biomedical Instrumentation – Geddes, L. A.;Baker, L.E. – Wiley Interscience
Seguranca no Ambiente Hospitalar - Brito, L. F. M. – Senac – 2003
Meditation on Ethics in Clinical Engineering Practice – Dyro, J. F., IEEE Engineering in Medicine and Biology – 1988
Planning Hospital Medical Technology – David, Y.; Jahnke, E. G. – IEEE Engineering in Medicine and Biology – 2004
Healthcare Technology Management – David, Y.; Judd, T. M. – Spacelabs Medical – Medical Biophysical Measurement Book Series, 1993
S.Woolhandler and D.U. Himmelstein, “The deteriorating administrative efficiency of the U.S. health care system,” New Eng. J. Med., vol. 324, pp , 1991.
J. Hay, S. Forrest, M. Goetghebeur, “Executive summary: Hospital costs in the US,” Blue Cross Blue Shield Association, October 15, 2001.
Banta HD. Institute of Medicine, Assessing Medical Technology. Washington DC: National Academy Press; 1985.

53. Thanks Very Much !!!! Muchas Gracias !!!! Obrigado !!!!
Lúcio Flávio de Magalhães Brito, CCE