best practices presentation: implementing an alternative equipment management program

COMPANY CONFIDENTIALISS Company Confidential

COMPLYING WITH CMS GUIDELINESJULY 2015

Barbara Maguire, CCE, MS, MBA

VP, Quality & Geisinger Clinical Engineering

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COMPANY CONFIDENTIAL

Background, Qualifications, and Capabilities Geisinger Health System

$4 billion, non-profit Healthcare Organization

Approximately 23,500 employees Headquarters in Danville, PA

ISS Solutions Geisinger Health System business Approximately 351 employees Headquarters in Langhorne, PA Clinical Technology Management

• Asset Lifecycle Management• Diagnostic Imaging• Specialty Medical Equipment• Biomedical Equipment

Information Tech Management• Contact Center Solutions• Integration and Support Services• Network Security Solutions• Managed Print Solutions

Clinical Engineering

Information Technology


ISS Solutions’ – Metrics

WHO WE ARE… 41 States throughout the United States

5 Operating Regions

386 Healthcare Clients

1333 Healthcare Clinics

Active Inventory Medical Devices

Geisinger Health System: 64,582

Non-Geisinger clients: 96,415

34 Clinical Engineers and Site Managers

138 Biomedical Techs and Imaging FSEs


ISS Solutions Corporate Parent – Geisinger Health SystemParent Corporate Entity: Geisinger Health System

Main Campus: Danville, Pennsylvania

Founded: 1915 by Abigail Geisinger

President and CEO: David T. Feinberg, M.D., M.B.A.

Revenue: $4 billion

Employees: Over 23,500

Market Served: Central and Northeastern Pennsylvania 3 Million Population 48 of Pennsylvania’s 67 Counties

Scope: Physician-led system 1,200-member multi-specialty group practice 9 hospital campuses 2 research centers +481,000-member health plan Estimated $7.7 billion positive impact on the

Pennsylvania economy

Patient Care Profile: Over 1.9 million Outpatient Visits per

Year Over 62,800 Admissions Over 49,900 Surgery Cases Over 1,700 Licensed Inpatient Beds 72% Average Occupancy Rate Over 185,700 Emergency Visits 2,195 Patient Air Transports


Independent and Objective Service Organization with Comprehensive Capabilities

40+ Years Delivering CE Services

64,500 Clinical Devices

1,740 Licensed Inpatient Beds

14 Clinical Engineers and Supervisors

59 Biomedical Technicians – AAMI Certifications, Military, and OEM Training

28 Imaging FSEs

State-of-the-Art Test Equipment

24 x 7 Coverage Capability

Robust On-line Maintenance and Program Management Documentation

Geisinger Clinical Engineering


Background• CMS Memo December 2013, Survey &

Certification Group :14-07, Hospital Maintenance Requirements

• Appendix A-Survey Protocol, Regs & Interpretive Guidelines

• TJC Revised Equipment Maintenance Standards EC.02.04.01 and EC.02.04.03, effective July 2014

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ISS Solutions PM Program-three tiers

• Equipment which must follow manufacturer guidelines.

• Identify high risk/critical equipment. May be on AEM, but surveyors will focus on this equipment.

• Chose to place all other equipment on an AEM (defined by existing Risk Assessment Policy)

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Must follow manufacturer’s recommendations for

Lasers Imaging/radiologic, including therapeutic

ultrasound Equipment types that are new to the

marketplace Must be able to identify this equipment in

your inventory-Risk Group

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ISS Response• Service contracts include language

requiring vendors to follow manufacturer guidelines

• You still must ask for documentation Contract/warranty T&M Third party or OEM

• Document in ISS AssetManager

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Maintenance Requirements

• All other equipment may be part of an AEM

• Hospitals must identify high/risk critical equipment

• Surveyors must focus their review on high risk/critical equipment

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ISS Response

• We have identified high risk(TJC)/critical(CMS) equipment

• We have chosen not to put this equipment on an AEM, but to follow the manufacturer guidelines.

• Implemented means to document this

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High Risk/Critical• Anesthesia units• Blood Pump/Perfusion Systems• Chest Compression system• Defibrillators (including AEDs)• Heart Lung by-pass (including Heater/cooler systems, blood

pumps, tubing clamps)• Ventilators• Ventricular Support Device• Robotic surgery device (new)• IABP (new)

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Identified High Risk Critical

• Identified using Risk Group• Create new reports to easily produce

inventory if requested

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Inventory-Maintenance Strategies

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Control Device Category Manuf Model : Model Desc Risk Group Serial # In Date Dept NameMaintenance Strategy

050075133 Anesthesia Unit Datex Ohmeda Aestiva 3000 High Risk/Critical AMRD00543 04/07/00 Anesthesia Units High Risk/Critical

050075563 Anesthesia Unit Datex Ohmeda Aestiva / 5 High Risk/Critical AMRL00108 02/21/07 Anesthesia Units High Risk/Critical






050168549 Anesthesia Unit Datex Ohmeda Aespire High Risk/Critical APHS00265 04/01/13 Anesthesia Units High Risk/Critical

050168557 Anesthesia Unit Datex Ohmeda Aespire High Risk/Critical APH800266 04/01/13 Anesthesia Units High Risk/Critical

050204988 Anesthesia Unit Datex Ohmeda Aespire S/5 High Risk/Critical AMXJ00519 04/20/05 Anesthesia Units High Risk/Critical





050051462 Blood Pump Stockert/Cobe 10-65-00 : SIII High Risk/Critical 10S8313 08/01/12 Perfusion High Risk/Critical

050051463 Blood Pump Cobe 10-60-00 : SIII High Risk/Critical 10S5653 08/01/12 Perfusion High Risk/Critical




050051479 Blood Pump Cobe 10-60-00 : SIII High Risk/Critical 10S5082 08/01/12 Perfusion High Risk/Critical

GCMC GCMC


Documenting PMs follow Mfr Guidelines• To standardize documentation, PM Procedures for all

Life Support/Critical Equipment, lasers and imaging will include a PM Checklist.

• There is a required Pass/Fail question “PM was performed per manufacturers specifications”.

• The technician must follow the manufacturer recommended procedure for maintenance and document it in the work order by attaching the completed checklist or pasting the steps into the work order notes.

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Access to Manufacturer Procedures

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• Manufacturers service manuals should be available at the facility which owns the device.

• Manufacturers service documentation will also be attached to the model record by ISS AssetManager Team.

• This can be viewed/printed/downloaded from ISS AssetManager.


Mfr Documentation attached

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High risk/critical PMs

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PM Checklist completion required

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Manufacturer Procedures in ISS AssetManager

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• Manufacturers PM Procedures attached to the Model record.


Manufacturer Procedures in ISS AssetManager

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• Manufacturers PM Procedures can be viewed/printed/saved.


Justification for Defibs• Reviewed extensive steps required by Defib

manufacturers.• Analyzed 479 repairs over three year period. Used

ISS AssetManager to export data on all repairs, had to review Notes.

• None of the repairs could have been prevented by manufacturer PM

• Concluded ISS PM Procedure in place was effective

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Scoring with Repair Data

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Global Data Facility Interval Data Risk Assessment Data

Device CategoryTotal

Device

Global Dev

Inventory Total

Global Work Order

Total over 3 year period

Global Repair

Rate Per Year

Average Global Repair

Rate

Total Devices

with Repair Component

Work Order Total

Repair Rate FCT USE EXP

Total Score

Recommended Interval

Defibrillator/Monitor 55 883 1678 0.6334 0.2655 129 46 0.3566 5 5 1 11 SemiannualCapnograph 3 93 32 0.1147 0.2655 3 1 0.1147 3 3 1 7 AnnualPatient Warmer 73 869 383 0.1469 0.2655 206 42 0.2039 2 2 5 9 AnnualPulse Oximeter 38 1774 931 0.1749 0.2655 157 43 0.2739 2 2 5 9 AnnualScale, Patient 6 385 132 0.1143 0.2655 35 5 0.1429 3 3 5 11 SemiannualScalpel, Harmonic 2 61 51 0.2787 0.2655 8 0 0.0000 4 4 1 9 AnnualSpirometer 1 62 15 0.0806 0.2655 2 3 0.0806 3 3 1 7 Annual

Equipment Data


Annual Review of MEMP

• Include review of effectiveness of PM Program

• Added Repair Fault Code ‘P-PM Preventable’

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Annual Review of MEMP

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Review of Work Orders by Fault Code

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Next Steps• Verify you have access to manufacturer guidelines for

all devices, especially high risk/critical• Confirming Techs are folllowing mfr guidelines for all

imaging, lasers and high risk/critical devices• Conduct self-audits• Follow-up with all vendors (OEM and third party) that

they are performing PMs according to mfr guidelines and get documentation from them.

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best practices presentation: implementing an alternative equipment management program

Healthcare

tiers equipment

clinical devices

clinical engineers

nongeisinger clients

abigail geisinger president

high riskcritical equipment

member health plan

healthcare clients