Managed Equipment Services a Case Study

Case Study 1

Managed Equipment Services: Equipment Review

Organisation An English NHS Acute Trust.

Purpose Determine the actual scope and feasibility of a perceived opportunity to improve the quality and efficiency of acute hospital services through improved equipment management.

Objectives 1. Identify, and assess the scale and impact of, equipment related service quality issues. 2. Determine the extent of surplus medical equipment capacity – if any. 3. Measure the potential value to the Trust of redesigning equipment management structures and systems.

Method The current situation was assessed by means of: 1. Primary research by personal observation 2. Interviews with key staff 3. Analysis of existing Trust data

Summary Findings 1. Ineffective equipment management processes exposed patients to increased risk through sub-optimal equipment decontamination and staff training. 2. The Trust owned and operated previously unrecognised substantial surplus equipment capacity. 3. This surplus capacity incurred significant procurement and maintenance cost for no added value. 4. The existence of spare capacity was attributable to ineffective equipment management processes. 5. Service quality was adversely affected by the procurement and maintenance of surplus equipment capacity since it prevented sufficient investment in leading edge technology. 6. The Trust’s equipment base was relatively old and the average age of equipment was increasing.

Case Study 1 Page 1 of 5 © Pentagon Healthcare 2008 Key Learning Points 1. Operation of an Equipment Library does not, of itself, deliver optimal equipment management. 2. Separation of control of equipment management services from equipment users resulted in users failing to comply with equipment management systems. 3. Fragmentation of responsibility and accountability for equipment management prevented the development of effective and efficient business processes. 4. Inability of staff to locate a required item of equipment is every bit as likely, if not more so, to be attributable to the absence of effective equipment access arrangements than insufficient equipment capacity. 5. When front line staff are subjected to intense time pressure they tend to bypass decontamination (and other) policies and procedures which are intended to reduce risk to patients and increase service efficiency – especially if compliance is not adequately monitored. 6. Absence of the application of objective, evidence-based purchasing criteria can lead to surplus equipment capacity and poor returns upon investment.

Detailed Findings 1. Patients received inappropriate treatments because the correct equipment was not immediately available. In many instances the required item was standing idle in large numbers elsewhere on the hospital site. However, front line staff had no means of locating the required item. 2. During 2007 approximately 90 patient related incidents were reported involving equipment failure in use of some kind. 3. Annual equipment purchases over recent years averaged £600,000 on an equipment base of £15 million (4%) – meaning that it would take 25 years to renew every item. Average age of equipment was 9.5 years and surgeons reported frequent failures of equipment in use. 4. There was no formal system by which staff training in the use of equipment was recorded and monitored. Most training was cascaded from one staff member to another with no formal accreditation. Some reported patient related incidents were attributable to poor staff training in the use of specific equipment. 5. Staff training issues were aggravated by a failure to achieve standardisation of equipment types. The wide variety of makes and models made it even more difficult to ensure that every member of staff was competent to use every different type of equipment. 6. The Trust had attempted to address some of the equipment related issues by operating an equipment library. However, most staff saw this as a ‘failed experiment’ since the system adopted did not meet user requirements. 7. There was no single person or department responsible for equipment management. Maintenance, decontamination, procurement, storage and distribution were handled by different departments with little effort being made to achieve effective integration. 8. There was no objective means by which equipment purchase requests could be prioritised. This resulted in scarce resources being expended upon items demanded by individuals with the greatest power and influence. 9. Some front line staff circumvented formal procurement rules to obtain new equipment by approaching charities with specific requests.

Case Study 1 Page 2 of 5 © Pentagon Healthcare 2008 10. There was no single source of information containing essential equipment data. Three separate databases were in use concurrently and equipment information was spread across all three. In all three instances data integrity had been multiply breached making it difficult to arrive at a clear picture of what equipment the Trust owned and operated. 11. Some front line staff were so confused by contradictory equipment decontamination policies that they decided to ‘do their own thing’. There were numerous instances where the decontamination procedure recommended by the equipment manufacturer were not followed (indeed staff were not aware of their existence). 12. Analysis of the validated Trust equipment database indicated that it owned and operated around 800 items surplus to requirement with a value in the order of £2.5 million. 13. Highly qualified healthcare staff complained that a significant proportion of their time was consumed by equipment ownership issues. They believed that they should be equipment users not equipment owners. 14. In spite of the oversupply of routine items of equipment in wards and departments the Trust continued to approve requests for additional items in these categories without any serious attempt to establish genuine need. Such expenditure reduced the Trust’s ability to invest in advanced technology to support their position within the healthcare marketplace.

Consequences for the Trust 1. The Trust had received a reduced rating by the Healthcare Commission because of its equipment training issues. 2. Patients were exposed to avoidable risks because of staff training issues, equipment non-availability and sub-optimal equipment decontamination processes. 3. Competitive strength had been diminished by the Trust’s inability to keep pace with technological advancements exploited by neighbouring Trusts. 4. Cost per case was inflated for no added value by the requirement to maintain and finance approximately 800 items of surplus equipment. 5. Cost per case was also inflated by the requirement to consume front line staff time compensating for poor equipment management processes. 6. The aging equipment base has led to equipment failing in use, higher risks to patients and less efficient use of staff time.

Options Considered The following seven options were considered: 1. Do nothing – hope that identified problems would eventually right themselves. 2. Allocate responsibility for Trust-wide equipment management to an existing Trust manager alongside his/her existing responsibilities. 3. Recruit a new Trust-wide equipment manager to take full responsibility for equipment management systems. 4. As option 2 but retain the services of a small team of external experts to advise and guide Trust managers. 5. Obtain external consultancy advice only 6. Appoint an external specialist company to manage equipment across the Trust according to the terms of a legally binding contract. 7. Transfer the ownership of assets to an external company and negotiate a service level agreement guaranteeing a defined level of service in return for a unitary payment.

Case Study 1 Page 3 of 5 © Pentagon Healthcare 2008 Option Evaluation The following table contains the results of an option appraisal:

Option: 1: Do 2: 3: 4: 5: 6: 7: Nothing Reallocati Recruitme External Consultan Managem Outsourc on nt Support cy ent e Contract Avoid controversy √ √ √ √ √ x x Cultural fit with Trust x √ √ √ √ x x Best use of Trust resources x x x √ x √ √ Transfer of skills to Trust x x x √ x x x Trust control of pace x x √ √ √ x x Trust control over outcomes x √ √ √ x √ √ Low cost x √ √ √ √ x x Value for money x x x √ x √ √ Low risk x x √ √ x √ √ Likelihood of successful x x x √ x √ √ outcome 1

Although Trust managers recognised that Options 5 and 6 may possibly deliver superior outcomes in some respects, the Trust selected Option 4 on the grounds that it was the only option which met all of its evaluation criteria – especially those relating to organisational culture and political sensitivity to outsourcing. Whilst the use of internal staff resources may not maximise equipment productivity in the short to medium run, it would enable the Trust to deliver immediate improvements in its equipment management capability and lay the foundations for longer term progression to an even more effective solution.

Staff Response Predictably, front line staff were initially intrigued by the extent of data collection and suspicious of any possible change to their established routine. However, as they were exposed to the underlying ethos of intelligent equipment management they quickly recognised the potential benefits to them and their patients. Anxiety surrounding the possible relocation of ward and department based equipment was gradually replaced by enthusiasm for a system which would place control of equipment management systems where it belonged – with the users – and which would reduce the workload of frontline staff.

By the time the final report was produced every member of the management team was committed to implementing intelligent equipment management.

Case Study 1 Page 4 of 5 © Pentagon Healthcare 2008 Benefits to the Trust By adopting intelligent equipment management the Trust has identified opportunities to:  Reduce the risk of hospital acquired infection by improving the effectiveness of equipment decontamination;  Reduce the risk of harm to patients by improving the competence of equipment users;  Reduce the procurement and maintenance cost of medical equipment;  Release frontline staff time for improved patient care; and  Make better informed medical equipment procurement decisions