Scott Priester, SSM senior diagnostic imaging engineer, finishes up a repair on a linear accelerator.

To standardize can be defined as causing to conform to a standard or established normal. As a word, it implies assimilation, homogenization, and order. As a philosophy, it can mean consistency, quality, and efficiency. For SSM Integrated Health Technologies or SSMIHT, headquartered in St Louis, standardization has been translated into cost savings, improved customer service, and better patient outcomes.

Over the past 2 years, SSMIHT, part of SSM Health Care, St Louis, has undergone a number of transformations that have pushed the standardization of its organizational structure, database, service contracts, reports, and communications. Although not all the initiatives have been implemented long enough to provide quantitative measures, early results indicate the efforts have been successful.

Many of the best practices of the SSMIHT team are based on the requirement of the SSM organization to raise the bar every year. SSM Health Care employs 23,000 people and owns and operates 15 acute care hospitals—making it one of the largest Catholic health care systems in the United States. Honored with being the first health care recipient of the Malcolm Baldrige National Quality Award, SSM’s culture places a large emphasis on quality improvement and exceptional patient care.

The SSM clinical engineering service (CES) department manages the clinical equipment at SSM’s 15 hospitals and nearly a dozen affiliated health centers—an inventory of approximately 65,000 clinical devices throughout Missouri, Illinois, Wisconsin, and Oklahoma. The SSM CES team is comprised of more than 100 BMETs, diagnostic imaging engineers, managers, and support staff, who together provide in-house management and service on most of the equipment, including high-end diagnostic devices.

Following a merger of SSM’s CES and information services (IS) departments in 2007, SSMIHT has restructured the organization’s hierarchy and goals. To facilitate the transition and intended efficiencies, the computerized maintenance management system (CMMS), service approach, and communications have also been impacted, with greater uniformity throughout the organization and its facilities.

The efforts for standardization have been supported—as well as driven—by advances in technology and educational opportunities. The new organizational structure made enterprisewide initiatives possible, and early achievements combined with thorough analyses have encouraged administrative buy-in.

“We have had a lot of success at showing administration that by getting the training and doing the work in-house, we ultimately save a lot of money,” says Heidi E. Horn, vice president, CES for SSMIHT. “They see the value in the employee satisfaction, and they see the value in the cost going down.”

Metrics have borne this out. Horn notes the department currently boasts its lowest equipment value percentage at 4.3%. This benchmark represents the ratio of the total annual maintenance cost to the total acquisition cost for the medical devices managed by the clinical/biomedical engineering program, expressed as a percentage. Employee satisfaction, customer satisfaction, clinical outcome, and safety levels are also climbing toward the high standards that have been set as shared objectives.

Standard Structure

Goals are established on both individual and organizational levels. Shared department objectives and management hierarchies help improve collaboration, particularly among groups with different philosophies or cultures. Since SSM integrated CES and IS into one institution reporting to the same leader, collaboration between the two groups has increased.

The reorganization was driven by the implementation of a systemwide electronic health record (EHR), which Horn describes as “a monumental, multiyear project that requires IS and CES to work closely together to integrate our medical equipment with Epic [Verona, Wis].” But collaboration has extended beyond the EHR initiative.

“More and more often, we’re finding out that the equipment we use to monitor patients has to be tied into a network to perform patient tracking, and a lot of time it takes IS to help us out with that,” says SSMIHT’s Brett Armstrong, a BMET III, adding, “Now that we’re one group, there’s a lot more cooperation between us.”

Information sharing has also increased, with more cross training among and between departments. CES team members with expertise in an area train newer employees to provide greater depth throughout the team. IS has offered classes in networking to CES. “It’s a bigger pool of knowledge,” Armstrong says.

Horn has seen the merger influence the disparate cultures, with IS staff better understanding their role in patient care and CES gaining appreciation for the use of data to make decisions and guide processes. “This has helped improve our operations quite a bit,” Horn says.

Centralizing management has also provided the opportunity to implement enterprisewide initiatives that are intended to positively impact patient safety, care quality, and health care cost. For instance, systemwide incident reports not only identify equipment failure trends but have also streamlined the alert recall process, reduced service contracts, and expanded database use.

The larger organization has also created opportunities for staff—a 600-person institution offers more chances for career growth than a six-person department. Previous employee complaints about lack of room to grow have abated, according to Horn. And the mean overall satisfaction with the organization by SSM employees was found over the summer to be 74.6%, a significant increase over 2006 levels.

With 600 people on staff and a budget to match, SSMIHT has a greater voice in decision-making, and CES along with it. The group is able to influence high-level decisions and technology strategy for the enterprise’s benefit.

Michael Woulfe, CBET, CMMS product specialist, during customer rounds at an SSM facility.

Systemwide Service Contracts

One initiative that has already shown success has been the implementation of systemwide service contracts. “When I took over the leadership role of CES 3 years ago, we had dozens of contracts across the system with the same large equipment manufacturers,” Horn recalls.

Each contract was initiated and managed at the local level with its own terms and conditions, pricing, support options, and expiration dates. “We had no idea what service we were supposed to be getting, and we were paying top dollar,” Horn says.

SSMIHT approached each vendor to inquire about creating a systemwide contract. Initially, most vendors resisted, but ultimately, they were all receptive to greater flexibility in the contracts. Each negotiation required about a year to complete, during which time SSMIHT remained focused on its goals.

Each effort started with CES determining what the ideal contract would look like—no restrictions allowed—then abandoning the unreasonable requests, such as unlimited parts or free 24/7 service coverage; and identifying those items that were non-negotiable.

“There are several things that go into it,” Armstrong says. “They look at how much it costs to maintain a device versus how much it costs to have it on contract, and they compare data like projected man-hours, parts costs, and downtime.”

Ultimately, SSMIHT wanted service contracts to support the in-house organization, but that were fair to the vendor. “We understand they have to plan their staffing and budget as well,” Horn says.

If a vendor wasn’t willing to negotiate or grant those demands deemed deal breakers, SSMIHT was prepared to walk. Horn recalls one negotiation that went through 26 contract revisions. Ultimately, however, all the contracts were renegotiated, including those with third-party vendors.

“Each contract looked a little different, but we did have something from all of the vendors that we thought we could live with and were happy with,” Horn says, crediting SSMIHT’s leverage as a major contributor to success.

Contract bundling enables better economics. “Obviously, the more hospitals and the more departments you can bundle from a service contract standpoint, the better pricing you can get,” says Scott Midlikowski, senior diagnostic imaging engineer with SSMIHT in Wisconsin.

CES expects to save SSM more than $2 million annually, along with staff time and effort, with the new contract terms. Many vendors permit devices to be added and deleted at different coverage levels with predetermined discounts to avoid negotiations on every device; the contracts cover parts and labor discounts so equipment does not have to be placed under full or shared service; and one third-party diagnostic imaging supplier maintains a full-time representative on-site to provide parts nonexclusively. “If we can get the part cheaper somewhere else, we will, but it is a great service that keeps prices competitive and provides a resource for us to look for parts and get them in quickly,” Horn says.

Formalized Training

Education was also included in the vendor contract negotiations. “We operate on the premise that there is not a lot the vendors can do that we can’t do with training,” Horn says. “We in CES believe there is no point in having contracts if you have good technicians, and there is no point in having technicians if you have service contracts.”

SSM CES technicians have the expertise, capabilities, and willingness to take on new technologies. The teams manage everything from blood pressure cuffs to MR and CT devices. “Typically, we don’t directly handle the cardiac bypass systems or the lab analyzers, endoscopy scopes, or the very high-tech systems, such as the DaVinci robot. We manage them, but don’t do the actual work,” says Michael Woulfe, CBET, CMMS product specialist for SSMIHT.

Free and discounted training were included in the negotiations, and where not available, the SSM administration is willing to pay. CES budgeted more than $350,000 in service training for 2009, according to Horn.

Training programs are planned annually to meet the needs of the facilities, the regions, and the technicians. “We’ll try to match training based on the needs of the hospital and the career direction of the techs,” Horn says.

A new goal is to increase the depth of knowledge within the organization, and CES is now moving to formalize cross-training efforts. “We will look at identifying people who are ‘experts’ in their field and matching them up with people in the organization who are interested in learning those skills,” Horn says. Competency checklists help not only to identify the appropriate experts who can train others but also to determine when the trainee has achieved the learning objectives, whether it be performing a PM, troubleshooting, or taking the first look.

“Education is a huge part of what we do here because technology has changed so much, especially over the last 5 to 10 years,” Midlikowski says. “If you fall behind, it becomes very difficult to work on new equipment because things have changed so much and will continue to change.” His diagnostic training has been conducted through manufacturers, third-party providers, and on-the-job experience.

Database Code

Technician credentials can be tracked within the CMMS database along with a host of other data that includes performance measures, maintenance history, and inventory information. However, as each new facility has been brought online and integrated into the larger organization, discrepancies in data storage became more noticeable and more problematic.

Heidi E. Horn, vice president, clinical engineering service department, and Scott Priester, SSM senior diagnostic imaging engineer.

“We were an accumulation of facilities that had come under one umbrella,” Woulfe says. “Like most health care systems, SSM’s medical equipment inventory and service record are just a collection of each facility’s systems. Although many were from the same provider, the supporting data—such as the manufacturer models and equipment types—didn’t match directly. GE Healthcare might be GE, GE Medical, GE Medical Systems, or even General Electric.

Complicating matters was the fact that the systems themselves resembled a hodgepodge of generations, platform changes, cultural interpretations, and workflow customizations. Complete searches for specific equipment were difficult, as were analytical efforts.

As a result, several years ago, the organization named Woulfe as CMMS product specialist and charged him with ensuring data quality and database function. Cleanup began with a thorough analysis and the elimination of statuses, response codes, and failure codes that were redundant or unclear. Current contract and device data, such as pricing and PM schedules, were verified. The “code” was developed.

A new manual explains the database policies and procedures as well as which codes to use. “For example, if you want to create a purchase order to order a part, the process is outlined, or if you can’t find a device for a PM, it explains what to enter in the work order,” Horn says.

“Each integration has the potential to degrade data,” Woulfe says. Because all data gets entered by individual biomeds, training helps to emphasize uniformity. Regular reviews by managers are intended to improve accuracy and catch trends.

Standardized data ensures everyone is referring to the same thing and that analyses capture all the relevant data. “That’s real important when you’re trying to share capital across the entire system,” Woulfe says. In addition, by coordinating standards with those of the ECRI Institute, Plymouth Meeting, Pa, whenever possible, recalls and alerts proceed more smoothly.

Global searches can be used not only to find and correct common errors, but also to find and collect common data. The program works with report-generation software to produce unique and useful information.

Written Reports

“Right now, we’re really just beginning to use the CMMS,” Horn says. “In January, we are going to start providing to the hospital management a technology plan that identifies equipment over $100,000. We’re using that as our starting point and will eventually expand that to a lower level.”

The plan will identify equipment that has exceeded its expected service life or is becoming expensive to maintain, enabling SSM to take advantage of buy opportunities that reduce the overall per-unit cost rather than becoming an emergency capital cost. Additional reports with administrative value include those addressing the cost of maintenance per device, the comparison of contracts and time and materials costs, and tracking of equipment failure trends.

CES uses the exceptional service standards report (ESSR), developed in-house, to monitor its performance on a monthly basis. The two-page graph report shows changes in the main performance metrics: planned maintenance, completed work orders, overtime and accountability, cost avoidances, equipment value percentages, actual versus budgeted expenses, customer satisfaction, and uptime for critical systems.

Each manager is responsible for updating his/her shop’s data, which is then used by supervisors in their broader reports. “This gives them a tool to manage their departments,” Horn says. “It provides supervisors with a quick and easy reference to ensure all sites are meeting performance goals. And it is also a communication tool that can be used to show hospital administration our value to them.”

Communication Buildup

CES uses many communication tools to reach out to its various audiences. “With staff stationed at 15 different locations in four states, communicating can be a challenge,” Horn notes. “When things go wrong, it is usually because of poor communication.” So a regular series of meetings and use of communication tools has been implemented to ensure nothing falls through the cracks.

Meetings occur quarterly (face-to-face) and weekly (conference calls) among CES managers, biweekly with the CES regional directors, weekly among the SSMIHT administrative council, and quarterly for the “town hall” meetings in which all 600 staff members of SSMIHT participate in a topic-focused conference call presentation and discussion. Weekly updates, shop meetings, and written communications filter information everywhere else.

This year, CES introduced Sharepoint, an online communications center intended to centralize information and minimize e-mail. Access is provided at three levels: all CES personnel, CES managers, and the CES administrative support team (such as Horn, Woulfe, and regional directors). Available data includes the department’s calendar of due dates, customer satisfaction scores, CES newsletters, the monthly ESSRs, Joint Commission and NFPA 99 info, tech resources, and a list of high-level projects. A discussion board facilitates the sharing of technical tips, cost-saving ideas, and other information. Links to important documents can be easily created, which cuts down on e-mail attachments and storage issues.

“I try to get on there at least once or twice a week,” Armstrong says, who visits the discussion board to see if he can offer assistance, learn something new, or just check in with colleagues. The site can be particularly efficient when looking for specific information. “Before, you used to just call [until you got an answer]—that’s a lot of desk time,” Armstrong says.

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Midlikowski expects that as more data is added to the site, it will become a more useful tool. Since Sharepoint debuted over the summer, he has visited it occasionally.

Horn notes that teasers were developed to draw more attention to the site, with some information available only on the site. Over time, it may become something CES team members use daily, which will help to standardize communications even further—which for SSMIHT means to cause them to conform to an established normal, and then push it to be better.

Renee Diiulio is a contributing writer for 24×7. For more information, contact .