An institution must manage its medical equipment well in order to provide high-quality medical care at competitive prices. For this reason, the clinical engineering department should avail itself of the many methods of providing service to its institution. A clinical engineering director must be flex­ible and fully aware of the skills of the clinical engineering staff and the budgetary constraints of the department in or­der to select the proper cost-effective mix of services. The in­tent is always to provide quality service while striving to re­duce overall costs. When outside services are selected to supplement in-house capabilities, they must be monitored to ensure quality, correctness of charges, and receipt of appro­priate documentation for entry into the equipment history files and computerized system (30). Several service options are discussed below.

In-House Service

Advantages. In-house service is cost-effective, provides very short response times (measured in minutes rather than in hours (20), and allows for single-point (one phone call) ser­vice. Informal (not always chargeable) service requests can sometimes be accommodated. Specialized service such as sup­port for a cardiothoracic surgery program is also feasible (Fig. 9). Providing in-house service for complex state-of-the-art equipment requires an adequate number of well-trained staff. If staffing levels permit, in-house service should be substi­tuted for service contracts whenever possible.

Considerations. Maintaining equipment in-house requires consideration of the critical importance and downtime that can be tolerated for each device. Consideration must also be given to the availability of backup equipment, tools, spare parts, test equipment, diagnostic software, and manuals, as well as how the equipment will be repaired should it fail off- hours (30). Some equipment such as ECG machines lend themselves to in-house repair as they are not one of a kind, parts are easily obtained, and backup units are readily available.

Original Equipment Manufacturer (OEM) Service

Advantages. Manufacturer’s service has the advantage of parts availability, servicer familiarity with the equipment, possibility of equipment upgrade as part of the service, and possibly remote diagnostic capability (37).

Figure 9. Cardiothoracic support, bedside monitor setup. Clinical engineering support for cardiothoracic surgery assures a specially trained engineer is available in the operating room throughout the surgical procedure to check the physiological monitoring equipment prior to patient connection as well as to troubleshoot equipment prob­lems should they develop. The engineer is shown checking the patient bedside monitoring setup in the Cardiothoracic Surgical Intensive Care Unit (CTICU) to assure its functionality. He also verifies that all patient cables are available for quick connection upon patient ar­rival to the CTICU following surgery.

Service Contracts and Clinical Engineering Screening. Service contracts are available that include parts, materials, and la­bor. Yearly cost can be roughly estimated by taking 10% of the equipment acquisition cost (the closer to 5% the better the deal). Original equipment manufacturers often bundle PM and upgrades with repair service as an enticement to select them as a service provider. Decisions must be made as to whether these items should be unbundled, and their value and need for determined separately (17). Clinical engineering screening lowers service contract cost. Screening requires that the clinical engineering department verifies that the equipment malfunctioned and the problem was not due to user error, prior to a service call being requested. For easily rectified problems the service provider may opt to supply the parts for clinical engineering to install. Screening keeps the clinical engineering staff familiar with a wider variety of in­strumentation, allowing them to better assist during emer­gency situations. Screening may not be feasible for equipment that must be up continuously and requires the service con­tractor to be called in immediately to reduce downtime and minimize revenue lost to the institution. Equipment lends it­self to a service contract if it is relied on heavily, only limited downtime is acceptable, and backup equipment is not readily available. Intra-aortic balloon pumps could fall into this cat­egory.

Fee-for-Service. OEM service is also available on an as — needed basis (fee-for-service). Fees include travel time (to or from the institution), labor, parts and materials, or, using printers as an example, a flat fee may be specified. Repair and/or PM service can be provided. Service may be provided either on-site (infusion pump) or at a remote depot or facility (glucometer). A vendor-supplied repair estimate assists in de­termining if the repair is cost-effective. Fee-for-service may be chosen for sophisticated repairs of equipment or when clinical engineering staff cannot find the cause of a problem after a reasonable troubleshooting time period has elapsed.

Third-Party Service Providers

Independent service organizations (ISO) tend to be less ex­pensive than OEM. Service vendors should be selected based on the quality and timeliness of past service. Service con­tracts and fee-for-service are available. Repair and/or PM ser­vice can be provided. It should be determined if parts other than OEM will be used and whether the manufacturer might void the warranty or negate product liability if a nonfactory authorized service provider is used. The equipment has less chance of getting factory upgrades and product recall ret­rofits.

Shared-Service Providers

Services can also be obtained from shared-service providers, which can be for-profit or nonprofit. These organizations are formed by health-care institutions usually located close to­gether that do not have the resources necessary to maintain an equipment management program on their own. Instead they pool their resources and have a common entity provide service to all of them. They share in the capital cost of setting up such an entity and then pay for services in proportion to their use (20). The logistical problems of providing such ser­vices must be overcome.

Some clinical engineering programs after becoming suc­cessful within their own institution expand and provide shared services to neighboring institutions as well. As an ex­ample, Thomas Jefferson University Hospital in Philadelphia, Pennsylvania, has a full-service in-house program as well as a shared-service component.

Maintenance Insurance

This insurance protects against catastrophic failures by smoothing out service cost. Service is done on an as-needed, fee-for-service basis. The insurance company either pays the vendor directly or reimburses the institution for the service. Some programs pay clinical engineering personnel to handle those repairs it wishes to in-house. Proper clinical engi­neering screening of service calls and good equipment man­agement decisions can result in year-end rebates. However, the paperwork in managing an insurance program often re­quires dedicating at least one full-time employee (FTE) to this task. Maintenance insurance backup provides a reasonable way for clinical engineering to start assuming equipment maintenance duties in areas in which they may not as yet be involved, such as radiology and clinical laboratories.

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