Controlling costs of medical equipment in Hospitals of IUMSHS

Noori Tajer, Maryam (PhD in health management, Associate Professor of Islamic Azad University, Branch Islamshahr Islamic Azad University, Islamshahr, Iran

ABSTRACT Much medical equipment in hospitals has become technically defect and therefore runs out of order every year, and as a result, a large proportion of hospital expenditure isallocated to supplying and repairing this equipment, and as such, great scientific damage and economic losses are imposed on the health care system of Iran. The purpose of the present cross sectional study was to evaluate the maintenance status and the controlling costs of medical equipment in the hospitals of IUMSHS. In this regard, 284 items of medical equipment and devices being used for at least 5 years in the hospitals of IUMSHS were selected, (using the stratified sampling method) and evaluated. The data collection tool was a questionnaire completed by the enquirer; descriptive and deductive statistics, biased variance analysis, and Spearman's correlation coefficient were used for data analysis. The research findings revealed that about 60% of the medical equipment in the hospitals of IUMSHS is controlled by the related employees, and that a medical engineering and maintenance department was absent in the investigated hospitals. In addition, variance analysis revealed that the mean score of controlling costs of the medical equipment did not show a statistically significant difference as compared to various international standards. Overall, the controlling costs of medical equipment in the investigated hospitals was unacceptable in 74.6% of the cases. In addition, there was a statistically significant correlation between supplying status and the costs (p<0.005; r = 0.35), between repairing status and the costs (p<0.001; r = 0.15), and between the training status and the costs (p<0.000; r = 0.35) of medical equipment. The results of the present research indicated the absence of appropriate planning for the costs of medical equipment in the hospitals of IUMSHS. Key Words: Controlling, costs of medical equipment.

INTRODUCTION

Taking advantage of a sufficient number of items of medical equipment and trained employees for operating this equipment, guarantees the position of managers in providing the best possible, accurate, and prompt health care services and diagnostic systems in their hospitals.
According to studies performed in Iran, one third of the total costs of establishing and equipping new hospitals is allocated to purchasing medical equipment; on the other hand, during budgeting, 10 - 20 % of the total price of this equipment should be allocated to their maintenance and repair.
According to Kendal's study in 1998, more than 60% of medical equipment lack facilities for their maintenance and repairing is useless in some countries, and this problem should be solved using the following plans:
1. Concurrent maintenance of medical equipment;
2. Controlling medical equipment;
3. Selecting appropriate medical equipment when purchasing it; and
4. Providing basic training programs for technicians of medical equipment.

Current evidence shows that ignoring maintenance, results in malfunction of medical equipment, and ineffective maintenance reduces hospital income and also confuses the patients and wastes their time and money. On the other hand, replacing and repairing the equipment imposes great costs on hospitals.
In this regard, Walsh suggests that implementing appropriate maintenance systems may result in strategies that not only increase the productivity of medical equipment, but also reduces the mean duration of hospital admissions.
The aim of our study was the controlling costs of medical equipment in the hospitals of IUMSHS, and noting this status may be a necessity and a useful platform for future research being performed in the hospitals of IUMSHS in Tehran, Iran.

METHODOLOGY

The present cross sectional study was performed regarding the controlling costs of medical equipment in the hospitals of IUMSHS.
The study population consisted of all medical equipment in the hospitals of IUMSHS, and regarding a 95% confidence interval for estimating qualitative and quantitative variables of research and also regarding acceptable accuracy levels for each of the variables, the sample size was estimated to consist of at least 10% of the population meeting the inclusion criteria (n = 284).
In this research, the maintenance status of medical equipment consists of actions performed for the status of controlling costs of medical equipment, and includes the costs incurred for the controlling, repairing, and providing training for employees working with this equipment (being classified into 2 groups, namely: acceptable and unacceptable). Sampling was performed by the stratified sampling method with appropriate allocation, and the hospitals of IUMSHS in Tehran constituting the strata.
Then, 10-15 % of the equipment of each hospital meeting the inclusion criteria was selected by the simple random sampling method, and was evaluated as the research sample.
The data collection tool was a questionnaire consisting of 2 sections: the first section pertaining to demographic characteristics of the research subjects; and the second section was of the 4-choice Likert type, the choices being: always (3 points), sometimes (2 points), rarely (1 point), and never (no points).
The mean and standard deviation were calculated after scoring, the criteria for controlling costs of medical equipment being defined as follows: acceptable (score of 1.5 - 3) and unacceptable (score of 0 - 1.49).
The research method was as follows: the hospital managers and related authorities were consulted for collecting background data such as the number of wards equipped with medical equipment, the type of medical equipment, and the financial authorities and related experts in the hospitals who were consulted for collecting data regarding the controlling costs of medical equipment.
At the next stage, the clinical and pre-clinical departments of the investigated hospitals (including the laboratory, operating room, ICU, CCU, physical therapy, pathology, radiology, emergency room, cardiology clinic, sterilization, internal medicine, pediatrics and neonatology, burn care unit, orthopedics, neurology, CT scan, ENT, ophthalmology, isolation unit, laser therapy, nuclear medicine, plastic surgery, infectious diseases, renal transplantation, hematology, and health care) were visited, and according to the questionnaire (data recording sheet), the operators were questioned regarding the controlling status and the training provided for each item of medical equipment. It should be noted that a separate questionnaire was completed by the researcher for each item of equipment.
In addition, descriptive statistics were used for achieving the objectives of the research, for answering the research questions, and for analyzing the data; Spearman's correlation coefficient and biased variance analysis were used for evaluating the relationship between maintenance status and controlling costs of medical equipment.
In the entire research, the criteria for calculating the means were the scores obtained (with 0 being the minimum and 3 being the maximum score).

RESULTS

The results of the present research revealed that regarding functional status, 45.7%, 64.5%, and 12.4% of the medical equipment in the hospitals of IUMSHS were diagnostic, therapeutic, and educational/investigational devices, respectively; the mean life expectancy of the equipment was over 20 years.
The highest definite frequency of purchasing and installing the medical equipment was observed from 1996 to 2000 (23.24%) and from 1991 to 1995 (21.8%).
Diagram 1 reveals that most medical equipment in the investigated hospitals met international standards and were manufactured in Germany.
Cleaning of the devices was performed by technicians, the medical equipment maintenance department, the experts, the attendants, and the professionals in 44.8% (most frequent), 3.2% (least frequent), 7.8%, 39.9%, and 3.2% of the cases, respectively.
30.4% of the investigated equipment lacked the required technical documents, and 46.47% of the medical equipment in the investigated hospitals had naming labels and the servicer's address attached to the devices.
Regarding the operators' experience in operating the devices, 32.4%, 18.3%, 14.1% 13.4%, and 9.9% of the operators had < 5 years, 5-9 years, 11-14 years, 15-19 years, and over 20 years of experience in operating the devices, respectively.
In addition, catalogues were the most frequent technical document present pertaining to the equipment in the investigated hospitals.
Most (30%) of the medical equipment in the investigated hospitals were devices used in the laboratory and the operating room.
The results obtained after surveying operators regarding their opinion about the purchasing conditions, revealed that most of them (35.2%) considered all conditions (e.g. written certificate, availability, cost-effectiveness, and possessing international standards), and 24.6% of them said that purchasing the medical equipment was cost effective.
Moreover, biased variance analysis showed that the mean scores of supply status (F = 0.91), repair status (F = 0.08), training status (F = 0.51), and cost status (F = 0.15) of medical equipment did not have a statistically significant difference compared to international standards.
Table 1 shows the mean and standard deviations of medical equipment maintenance status in the investigated hospitals and according to international standards.

Variance analysis revealed that in various standards, the mean score of medical equipment supply status did not have a statistically significant difference (F = 0.91)

In addition, the correlation coefficient matrices in Table 2 shows that statistically significant relations are seen between maintenance status and cost status of medical equipment, between supply status and cost status (p = 0.005, r = 0.35), between repair status and cost status
(p = 0.016, r = 0.15), and also between the training status and cost status of medical equipment.

* The medical equipment cost status was unacceptable in 77.4% and acceptable in 22.6% of the cases, respectively.

DISCUSSION

According to the facts presented in the "Results" section, neither of the investigated hospitals had a medical engineering and maintenance department.
After performing research on the hospitals of England for 7 years, Hosper (1991) suggested that the presence of a medical engineering department reduces the hospital costs by 30% on average. In this regard, the results performed by Jadidi showed that neither of the hospitals in Arak, Iran have a medical engineering department. Most (28.9%) medical equipment present in the hospitals of IUMSHS was manufactured in Germany. In Jadidi's research performed in Arak, 27.93% of the medical equipment present in the hospitals of Arak University of Medical Sciences was manufactured in Germany. This fact reveals that Germany has more commercial relationships with Iran and therefore, provides better facilities for exporters, manufacturing companies, and customers.
Evaluation of the technical documents pertaining to the medical equipment in the hospitals of IUMSHS revealed that a user manual for medical equipment was present in 37.2% of the cases in the investigated hospitals.
Due to the great importance of the user manual for training the operators, such a manual should be procured and translated (if needed).
A service manual was present in 15.6 % of the investigated medical equipment. In this manual, the servicing process and the effective inspection timetable for medical equipment is presented; thus, it should be carefully studied and carefully respected by the medical engineering and maintenance department or by the companies offering after sales service.
In this regard, Kumar (1998) performed research on describing anesthesia machines and concluded that a well-designed checklist for anesthesia machines was present in only 8.8% of the investigated hospitals.
A catalogue was present in 64.8% of the investigated medical equipment. This figure was reported to be 42% in a study performed by Mohammadi-Nejad in 1993 on the hospitals of IUMSHS.
Generally speaking, it seems that the operators and the various hospital authorities pay no attention to recording and maintaining the technical documents of medical equipment and don't consider a well-defined place for filing these important documents. In addition, during his research, Mohammadi-Nejad suggested that in neither of the investigated hospitals was a "Maintenance and Educating Committee" present for keeping the compiled guidelines.
Due to the critical role of international standards in effective maintenance of medical equipment, it is claimed that most medical equipment is under the supervision of a well known standard (such as TUV of Germany, FDA of USA, BSI of England, CSA of Canada, etc.), partly as a result of the export regulations of these countries which don't permit exportation of medical equipment lacking the required standards. Overall, 53% of the investigated medical equipment had an international standard, 28.88% of which had TUV of Germany, 5.6 % having BSI of England, 19.1% having FDA of USA, and the remaining 12.3% having IRN of Iran, and 10.56 % having JS of Japan (being present only for medical equipment manufactured in Japan).
If this equipment was manufactured in East Asian countries under the license of Japan, they usually lacked a confirmed international standard.
In this regard, biased variance analysis regarding the mean scores of the investigated medical equipment maintenance status (according to the international standards of Germany, USA, and England) did not show a statistically significant difference, i.e. neither of the TUV, FDA, or BSI standards provided services (for improving training, supplying, and repairing status) to the hospitals of IUMSHS; this could be due to a lack of appropriate planning before purchasing the equipment.
According to the research findings, in most cases (40%), cleaning the medical equipment in the investigated hospitals was performed by the attendants, and in Jadidi's research, this figure was reported to be 54%. Regarding the regulations of maintenance accompanied with prevention, in which cleaning has been entrusted to the operators or the medical engineering and maintenance department personnel, entrusting this task to the attendants isn't justifiable and may cause irreversible damage to the equipment.
Regarding the medical equipment's standards, the results of our study indicate that 46.1% of the medical equipment did not have any of the required standards (e.g. FDA, TUV, BSI, CSA, JS), probably due to inappropriate purchasing strategies and also due to ignoring the need to acquire the technical expert's opinion regarding the quality of the equipment. Usually, the lower price of the equipment is considered the most important factor at the time of purchasing.
The results of research performed by Sunseri (1999) in this regard indicated that in two thirds of the investigated hospitals, the medical equipment's status regarding international standards were such that a number of items of medical equipment (especially in departments such as pharmacies, laundries, etc.) were out of order each year and should be discarded.
Regarding the training of medical equipment operators, the results obtained show that 74.8% of the operators need training, which in turn indicates that some hospital authorities disregard the importance of training, which causes the sub-optimal utilization of medical equipment.
On the other hand, 46.1% of the operators noted they had never received any training courses related to the medical equipment; in Jadidi's research, 76% of the operators needed training.
Due to job transfer common among the operators, their incomplete understanding of the materials being instructed, or the defective training provided by the supplying companies, it is suggested that hospital authorities pay more attention to periodic and frequent training.
In this regard, training was often (in 44.9% of the cases) rendered by supervisors of the pertinent wards; however, this training should be provided by the medical engineering and maintenance department of the hospitals or the engineers of the companies providing after sales service, which results in appropriate utilization of medical equipment.
56.7% of the equipment was useless due to the lack of spare parts and overdue repairing. In 1991, Wong performed research on medical equipment in Brazil and indicated this figure to be 20 - 40%, and suggested the spare parts to be supplied beforehand, in order to reduce the time required for repairing and servicing, and to prevent losses in hospital income or in services provided for patients.
According to the research findings, the mean time interval between the announcement of defects and the completion of repairs was at least 1 month. This could be due to a lack of coordination and also due to inappropriate relationships between hospitals, the company's monopoly, or overdue payment of repairing and servicing fees by the financial departments of the hospitals.
Regarding the importance of the mean repair time of the medical equipment, Dikerson suggested that since the mean repair time indicates promptness of after sales services provided by the companies and the attention they pay to their customers, this time interval should be reduced to the least possible interval, i.e. a few days.
In 2000, Augusta performed research on preventive maintenance of medical equipment, and suggested that decision-making regarding preventive maintenance is accomplished using two managerial tools:
1. Management plan of medical equipment, and
2. The valuation system of medical equipment maintenance.

The results of his research revealed that 49% of the defects could be prevented by preventive maintenance.

The authorities of the maintenance department and the procurement department in the hospitals should emphasize and pay attention to other commitments. In the present study, the least frequent (2.9%) commitment acquired was related to consumed accessories, because most of these accessories are produced in Iran, and also because hospitals store them in their warehouses.
The controlling costs of medical equipment indicated that the costs of medical equipment was unacceptable in 77.4% of the cases, and 9.6% of the yearly budget was allocated to repairing and servicing medical equipment. In research performed in 1993, Mohammadi-Nejad reported that documents indicating purchasing costs, maintenance and repair costs and the yearly total budget were available in neither of the hospitals of IUMSHS.
In research conducted in relation to the yearly budget of hospitals, Kendal suggested that the hospital authorities should allocate one fourth of their total yearly budget to the controlling costs of medical equipment.
In the present research, a special budget (expressed as a certain fraction of the hospital total budget) was allocated to the controlling costs in only 24% of the investigated hospitals, and regarding the mean and standard deviations (being 1.08 and 0.66, respectively), the medical equipment cost status in the investigated hospitals was defined as low to intermediate.
In his article titled "The structure of service centers for economical efficiency", Irnichw (1999) stated that for beds 100 need 1 person and that there are differences between the
medical equipment in the investigated hospitals.
Therefore, statistically significant relations are seen between maintenance status and cost status of medical equipment, but the correlation coefficient matrices have no correlation coefficient between two variables showed that the perhaps reasons are that there was no correct planning system of Repair and Supply status of medical equipment.

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