LAV Process Explained: Equipment Maintenance Medical Equipment and Logistics Solutions Directorate Naval Medical Logistics Command

Context Commands can benefit from applying LAV methodology in support of Audit Readiness Purpose Describe the LAV Process for Equipment Maintenance Objectives Learn key methods and metrics to review during a self- assessment FOR OFFICIAL USE ONLY 2

What is LAV?  Assist Logisticians to achieve Total Asset Management (TAM) and improve internal management control of accountable equipment.  Evaluate the effectiveness of the Equipment, Technology Material Management (ETM) processes from materiel procurement planning to eventual property disposal  Evaluate the effectiveness of the Purchasing Management, Acquisition Planning and Requirements Development, and Contracting Officer’s Representative (COR) Programs  The Logistics Assist Visit is NOT an inspection, this is strictly an assist visit to help your staff identify strengths and weaknesses and to provide them with the tools that they need to successfully carry out their mission. FOR OFFICIAL USE ONLY 3

Tracer Methodology– Providers vs. System Do Patient Care Providers: Know if their medical equipment's preventive maintenance is current? How? Know who to contact in case of medical equipment failure? Who? Know who to contact in case they need user training on a piece of brand new medical equipment Know that they need to submit Test and Evaluation (T&E) approval request via BIOMED for new equipment user test? Have input on what equipment to buy? How are providers trained on how to use demo medical equipment? How does the command document requisition input received from providers? FOR OFFICIAL USE ONLY 4

Medical Devices: Does all maintenance significant medical equipment have PM stickers/labels IAW NAVMED P-5132? If NO, what system does the command have to let users devices are safe for use? Does equipment appear to be well maintained (i.e. is it clean, is the power cord and plug intact)? FOR OFFICIAL USE ONLY 5 Tracer Methodology– Providers vs. System

BIOMED: Are maintenance plans developed for each equipment type or make and model? Validation: Print the maintenance plan and procedure of a defibrillator. Is it current? Is preventive maintenance being performed in accordance with the established maintenance plan and interval Validation: Print the maintenance plan and procedure of a defibrillator. Has maintenance been performed IAW the maintenance plan/procedure? Are the audible alarms being tested? FOR OFFICIAL USE ONLY 6 Tracer Methodology– Providers vs. System

BIOMED: Are maintenance histories properly recorded? Are outputs properly recorded? Does the BMET who worked on the equipment have the proper training or use a PM checklist to perform the maintenance? Are the clinical staff educated on the use of new medical equipment being introduced at the site for the first time? Is this being documented? If YES, how? Is patient health information (e.g. name, SSN, medical/treatment information) removed from medical equipment memory prior to disposal, or being sent out for repair? FOR OFFICIAL USE ONLY 7 Tracer Methodology– Providers vs. System

FOR OFFICIAL USE ONLY 8 Scheduled Maintenance Work Load SWO Workload/Metrics June 2010 (Before LAV) July 2010 August 2010 As of April 2012 Beginning Work Order Balance Qty New Work Order Qty Reopened WO Qty Completed Work Order Qty Cancelled Work Order Qty Ending Work Order Balance Qty Carryover Completion Rate79.96%93.72% 95.6% 99.75% Relative Inventory Accuracy9.43%18.82% 30% 0.00%

FOR OFFICIAL USE ONLY 9 LAV Maintenance Metrics Criteria Number of Maintenance Significant (MRI) Equipment in DMLSS4,326 Number of Equipment under Full Service Contract438 Number of Equipment under In-house Service3,888 Percentage of MRI Equipment under Full Service Contract10% Est. Total Acquisition Cost of MRI Equipment35,031,186 Est. Total Acquisition Cost of MRI Equipment under Contract 14,782,700 Est. Total Cost of Service Contracts1,476,214 % of Contract Costs vs. Acquisition Costs10% Number of Equip under Prime Maintainer (PM)154 Est. Tot. Acquisition Cost of Equipment Under PM9,759,575 Est. Total Cost of PM Contract999,745 Ave % of Contract Costs vs. Acq. Costs (PM)10%

FOR OFFICIAL USE ONLY 10 Workload Analysis Criteria TOTAL MAINTENANCE SIGNIFICANT EQUIPMENT (Equipment with Maintenance Requirement Indicator (MRI)) 4,326 UNDER PRIME MAINTAINER438 ADJUSTED TOTAL MRI EQUIPMENT COUNT3,888 BMET to EQUIPMENT RATIO (MRI equip/# of BMET: 3,888/8)1:486 AVERAGE COMPLETED WORK ORDER PER MONTH (Jul09-Jun09)655 BMET TO COMPLETED WO RATIO PER MONTH82 AVERAGE COMPLETED WO PER DAY PER BMET4

Medical Equipment Management Plan (MEMP) Does the site have a Command Environment of Care Plan? Does BIOMED know where the plan is physically located? Does BIOMED have a MEMP? Is the MEMP physically located in BIOMED? Is the objective, scope, performance and effectiveness of the MEMP reviewed annually? FOR OFFICIAL USE ONLY 11

Medical Equipment Management Plan (MEMP) Does the MEMP cover the following How to manage medical equipment risk? Emergency maintenance response? Corrective and preventive maintenance? Testing? Inspection? Emergency management plan for resource sharing? Inclusion of contractors and vendors in the plan? Guidelines for using patient-owned medical equipment inside the facility? Has the MTF designated roles and responsibilities for maintaining, inspecting and testing for all medical equipment on the inventory? Is BIOMED using the Maintenance Plan and Procedures provided in DMLSS? FOR OFFICIAL USE ONLY 12

Does BIOMED have the following references: NAVMED P-5132? Comprehensive Accreditation Manual for Hospitals (or know where to find it)? College of American Pathologist manual (or know where to find it)? NFPA-99 Healthcare Facilities manual (or know where to find it)? American Association of Blood Banks Accreditation Requirements Manual (or know where to find it)? FOR OFFICIAL USE ONLY 13 Medical Equipment Management Plan (MEMP)

Document Control and Reporting: Is the failure reason "User Error" being documented? Is the command conducting trend analysis and implementing appropriate follow-up action (e.g. staff re-training)? Are medical device hazards reported to the Risk Manager? Based on a review of the QA log or DMLSS-QA, is the site tracking and documenting responses to medical device alert and recall reports? Based on review of history for selected equipment, is there documentation of acceptance testing? FOR OFFICIAL USE ONLY 14 Medical Equipment Management Plan (MEMP)

Document Control and Reporting: Is the X-ray acceptance package documentation maintained throughout the life of the system? Can the site provide documentation of completed staff training on new medical devices? Are the test equipment calibration certificates on file? Are any of the certificates more than one year old? Are the BMETs Training Certificates on file and recorded in DMLSS? Does the site maintain hardcopy of all Service Contracts? Has service contract data been properly input into DMLSS? FOR OFFICIAL USE ONLY 15 Medical Equipment Management Plan (MEMP)

Management Control Reports Has the hospital identified in writing frequencies for inspecting, testing, and maintaining medical equipment on the inventory based on criteria such as manufacturers’ recommendations, risk levels, or current hospital experience? Run the Unable to Locate (UTL) Notification Report? Are UTL reports sent to the responsible departments for action? Are copies sent to EM and Safety Committee? Is the UTL report submission mentioned in the Safety Committee meeting minutes? FOR OFFICIAL USE ONLY 16

Management Control Reports Run the Equipment Without Maintenance Activity Report. Any equipment retrieved? Run the Equipment Without Maintenance Plan Report. Any equipment retrieved? Run the Maintenance Interval Without Date Due Report. Any equipment retrieved? Run the Suspended Scheduled Work Order Report. Any equipment retrieved? Run the Maintenance Management Report. What is the overall PM completion rate? What is the completion rate for Risk Level 1 equipment? FOR OFFICIAL USE ONLY 17

Management Reviews Are User Errors documented and reported to the Safety Committee? Does BIOMED monitor trends on user errors vs. staff training work orders? Are all unable to locate (UTL) equipment reported to the Safety Committee and included in the meeting minutes? Are EM and responsible department's documenting actions taken to locate UTL equipment? Validation: Run a report showing all UTL items greater than 30 days old. Has a DD 200 been initiated for all items on the report? Is there BIOMED representation in the Equipment Program Review Committee? Is there BIOMED representation in the Environment of Care committee? FOR OFFICIAL USE ONLY 18

Management Reviews Is there BIOMED representation in the Equipment Program Review Committee? Is there BIOMED representation in the Environment of Care committee? Are equipment requisitions routed through BIOMED for technical review? Are all maintenance significant medical equipment assigned to a maintenance activity? Does all maintenance significant medical equipment have a maintenance plan and procedures? FOR OFFICIAL USE ONLY 19

Management Reviews Are all BMETs properly trained to perform maintenance on equipment assigned to them? Are their training certificates on file? Has their training been recorded in DMLSS? Are the alerts and recalls QA actions documented? Are there carry-over work orders from previous month? Does the command conduct trend analysis to identify corrective actions, improve the process or acquire additional BMET support? Is the command in a Prime Maintainer Program (PMP)? Was the PMP contract competed? If NO, why not? FOR OFFICIAL USE ONLY 20

Questions 21

Related Sessions FOR OFFICIAL USE ONLY 22