TechNaion - February 2015 by MD Publishing

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VOL.2

EMPOWERING THE BIOMEDICAL / CE PROFESSIONAL

FEBRUARY 2015

Equipment Replacement Strategies Hunting Down Cost Saving Measures

Biomed Adventures Action and Relaxing

The Roundtable Digital Radiography

What's on Your Bench? Highlighting the workbenches of HTM professionals

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TECHNATION: EMPOWERING THE BIOMEDICAL / CE PROFESSIONAL

EQUIPMENT REPLACEMENT STRATEGIES — HUNTING DOWN COST SAVING MEASURES Tight budgets and new regulations make medical equipment management very important when it comes to cost savings and device replacement planning. Insiders discuss ways to promote quality patient care while also developing a strategy for medical device management in today’s healthcare environment.

Next month’s Feature article: 5 Things Every HTM Professional Should Know

TechNation (Vol. 6, Issue #2) February 2015 is published monthly by MD Publishing, 18 Eastbrook Bend, Peachtree City, GA 30269-1530. POSTMASTER: Send address changes to TechNation at 18 Eastbrook Bend, Peachtree City, GA 30269-1530. TechNation magazine is dedicated to providing medical equipment service professionals with comprehensive, reliable, information concerning medical equipment, parts, service and supplies. It is published monthly by MD Publishing, Inc. Subscriptions are available free of charge to qualified individuals within the United States. Publisher reserves the right to determine qualification for a free subscriptions. Every precaution is taken to ensure accuracy of content; however, the information, opinions, and statements expressed in the articles and advertisements herein are those of the writer and/or advertiser, and not necessarily those of the publisher.

INSIDE

Departments PUBLISHER

John M. Krieg

VICE PRESIDENT

Kristin Leavoy

ACCOUNT EXECUTIVES

Sharon Farley Warren Kaufman Jayme McKelvey Andrew Parker

ART DEPARTMENT

Jonathan Riley Jessica Laurain

EDITOR

John Wallace

EDITORIAL CONTRIBUTORS

Roger Bowles K. Richard Douglas Myron Hartman Patrick K. Lynch Todd Rogers Manny Roman Cindy Stephens Matt Tomory Karen Waninger

CIRCULATION

Bethany Williams

WEB DEPARTMENT

Betsy Popinga Taylor Martin

ACCOUNTING

Sue Cinq-Mars

EDITORIAL BOARD

Manny Roman: manny.roman@me.com Patrick Lynch: Biomed Support Specialist at Global Medical Imaging, patrick@plynch.us Karen Waninger: Director of Clinical Engineering at Community Health Network in Indianapolis KWaninger@ecommunity.com Eddie Acosta: A Clinical Systems Engineer at Kaiser Permanente, Northern California, Fastedy99@yahoo.com John Noblitt: Program Director at Caldwell Community College & Technical Institute in North Carolina jnoblitt@cccti.edu

P.12 SPOTLIGHT p.12 p.14

p.18

Professional of the Month: Laurent La Brie Department Profile: Methodist Hospital of Southern California Biomedical Engineering Department Biomed Adventures: Action and Relaxing

P.22 THE BENCH p.22 p.25 p.26 p.29 p.30 p.32

ECRI Institute Update Tools of the Trade AAMI Update Webinar Wednesday Biomed 101 Shop Talk

P.48 EXPERT ADVICE

p.48 Career Center p.50 Ultrasound Tech Expert Sponsored by Conquest Imaging p.52 The Future p.54 Karen Waninger p.56 Patrick Lynch p.58 Roman Review

P.62 BREAKROOM p.62 p.64 p.66 p.74

Did You Know? The Vault What’s on Your Bench? Parting Shot

p.73 Index Like us on Facebook, www.facebook.com/TechNationMag

MD Publishing / TechNation Magazine 18 Eastbrook Bend, Peachtree City, GA 30269 800.906.3373 • Fax: 770.632.9090 Email: info@mdpublishing.com www.mdpublishing.com

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Laurent La Brie, MBA, MSBME

By K. Richard Douglas

aving the opportunity to say that you work for the prestigious Johns Hopkins Hospital and Health System might seem like reward enough. But, when Pacific Medical ran a contest looking for the most interesting biomed, and after receiving hundreds of entries, they chose Laurent La Brie, MBA, MSBME, a clinical engineer with the facilities department at Johns Hopkins, La Brie had a new title to tout.

La Brie had related to Pacific Medical his experiences of setting up a health clinic in Mexico and working as the European Director in charge of medical and orphanage work in Romania, Moldova, Iraq and Uzbekistan. That kind of background certainly helped cinch the award. Besides the recognition, the award included a flight to Orange County, Calif. to attend the California Medical Instrumentation Association (CMIA) symposium and tour Pacific Medical’s facility in San Juan Capistrano. La Brie has held positions both in management and as a clinical engineer, but it all started with the U.S. Army and logistics. “The Army gave me a four-year ROTC scholarship, which allowed me to go to an expensive private university; Lehigh,” he says. “I received my commission as an officer in the Medical Service Corps. Although I tried to convince them to not send me to logistics school, because I wanted to get to my first assignment, they selected me anyway.” “After serving as medical officer of a clinic in an armor battalion in Colorado, I received orders to supervise BMETs and supply technicians in Vicenza, Italy,” he says. “I loved the job and the career it

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launched almost as much as I loved the freedom, people, art, architecture, food, wine and cappuccino of Italy.” His early training spanned military and civilian education. “The Army Medical Department’s 67K logistics course at Fort Sam Houston, Texas, in 1985, was my first training in the field,” he says. “Then, to prove I could do the job in the civilian world, I got an internship at the University of Connecticut Health Center with Nick Noyes as I did my Master’s in BME at Rensselaer Polytechnic Institute’s branch in Hartford, Conn.” Today, La Brie can be found at his job in Maryland at Howard County General Hospital (HCGH), a member of Johns Hopkins Medicine. He has worked for the prestigious institution since June of 2009. His work includes handling the investigation of incidents involving patient safety events and equipment planning for new construction. He is the primary clinical engineer for the hospital. He is also involved in helping with equipment selection, monitoring work, network configurations in the OR and alarm management. “I am responsible for projects to install the physiological monitoring and nurse call systems in construction projects at JHH,”

FEBRUARY 2015

Laurent La Brie was recently named Pacific Medical’s “most interesting biomed.”

La Brie says. He is also tasked to “provide assistance to clinical areas assuring that medical equipment meets established operation and performance standards.” An area of specialty is alarms. Alarm fatigue has become a growing concern in healthcare in recent years. La Brie and colleagues have faced down this problematic challenge for their employer with measurable results. “I co-chair the Clinical Alarms Committee. Any device with an alarm is reviewed for effectiveness and to reduce alarm fatigue. This includes physiological monitors, nurse call, ventilators, etcetera,” he says. La Brie says that the alarm problem plagued his institution just as it has others. “Clinical alarms should be accurate, intuitive and readily interpreted and acted

Johns Hopkins Hospital and Saudi Aramco representatives prepare for a joint venture in Saudi Arabia. Pictured are, from left, Barry Meyer, Yasser Badreddine, Cheryl Spencer, Laurent La Brie, and Lorrie Mills.

upon,” he points out. “We found that at the beginning of JHH patient alarms management program, a nurse heard about 350 alarms/bed/day. This was way too much, so we have taken these as a high priority here. For HCGH, I review the logs for physiological monitors and determine what the prevalent alarms are. Then, we try to reduce those. For instance, to reduce the 10 ‘replace telemetry battery’ alarms/patient/day, we have gone to replacing the batteries every shift,” La Brie explains. “Nurses were getting 12 ‘low SpO2’ and ‘desat’ alarms/patient/day, so we addressed sensor issues, intensified training and mentoring in alarm customization, programmed a 60-second delay in the paging system to allow the patient to autocorrect, and are lowering the default low SpO2 from 90 to 88” ge ads. “This should halve the number of low oxygenation alarms and improve patient safety by reducing the system ‘crying wolf.’ ” When the year over year paging data was compared from the fourth quarter of 2014 to the previous year, La Brie says that they were able to see a decrease of 20 percent in pages per patient per day. “That makes for greater patient safety, better nurse working conditions, and a quieter, more pleasant patient environment,” he adds.

Laurent La Brie enjoys spending time with his twin daughters

In addition to the Pacific Medical award, La Brie’s achievements have been recognized with other awards. “Awarded three Army commendations, an Army achievement award, the Expert Field Medical badge and 7th Medical Command Award for Excellence,” he says.

Who would expect any less wisdom from someone who has seen and done so many things.

FAVORITE BOOK:

FAMILY AND ADVICE

The Bible

La Brie is married and has twin 6— year old daughters. “The girls are what fill my time as I help with homework, cook, clean, take them to Girl Scouts, AWANA and softball. They are the love of my life,” he says. He also has a passion for cycling and dabbles in acrylic painting. It is the interpersonal part of being an HTM professional that La Brie sees as the most important. “Too often, we think of our own proficiency and neglect the interaction with customers, collaboration with and training of colleagues, and contributing to the institutional knowledge of our departments by documenting systems and procedures,” he says. “We all have parts to play to developing our departments into cohesive teams that work together to produce a quality service called health technology management. Silo thinking, self-promotion and belittling the contribution of others detract from our service to the patient, our customers and our departments,” he adds.

FAVORITE MOVIE: “Monty Python and the Holy Grail”

FAVORITE FOOD: Lasagne

HIDDEN TALENT: Haven’t found one yet. If you find one, please let me know.

FAVORITE PART OF BEING A BIOMED: Customer service.

WHAT’S ON MY BENCH? A cup of coffee. Tecnica Ospedaliera magazines to give me hospital perspectives from Europe. Pictures of my family and Italy. A USB drive of music to keep me alert despite the droning sound of computers and air conditioners. Drawings from my daughters to keep my perspective.

SPOTLIGHT

DEPARTMENT PROFILE Methodist Hospital of Southern California Biomedical Engineering Department By K. Richard Douglas

ore than 110 years ago, a hospital was born in downtown Los Angeles in a twostory house. Founded by the Women’s Home Missionary Society of the Southern California Conference of the Methodist Church, the little hospital grew. The society secured a former mayor’s residence in 1909 and equipped it with 18 patient beds. A 100-bed facility replaced this structure in 1915 at a cost of $500,000. The hospital later relocated to a campus at the Arcadia Civic Center. It has served the community in the San Gabriel Valley since 1957. Today, the Methodist Hospital of Southern California is a modern 520-bed hospital with an outpatient surgery center, neonatal intensive care unit, physical rehab facilities and is a Los Angeles Countycertified stroke center. The nine-member Methodist Hospital of Southern California Biomedical Engineering Department, managed by Renovo Solutions LLC, handles all the modalities found throughout the hospital, including network systems. Renovo has managed the department since November of 2010. The department is responsible for Methodist Hospital and two outpatient facilities, including more than 6,000 pieces of medical equipment. The department is managed by Account Manager Anthony J. Coronado, BS. Other team members include Supervisor Michael Cabrera; Radiology Specialist Debash Gupta, CBET, CRES; IT Integration Specialist Joseph Diaz, BS, CCENT; Anesthesia Specialist Blaze Molas, CBET; Biomed Tech II Gabriel Luque, BS; Biomed Tech II Daniel Ponce; Biomed Tech I Mark Guzman and Biomed Tech I Edward Lopez Jr. The team has made it their mission to solve any problems that are presented to them. “The goal of any clinical engineering department is to be the ultimate problem solvers,” Coronado says. “What our team

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has done; we have identified all the problems with our medical devices by providing a strict risk assessment. Our mitigation plans have provided the problem solving. If it’s upgrading the operating system on a PC interfaced with a medical device or disabling a USB port, we problem solve.” The Methodist Hospital of Southern California Biomedical Engineering Department has been particularly proactive in protecting their networked devices from cybersecurity threats. “With our Integrated Systems Management Program, we provide services in risk management, systems management, project management and asset management,” Coronado says. The department manages all service contracts that are proposed to their facility. When equipment comes off of warranty, it is flagged in their clinical engineering database and is added to the Clinical Engineering Service Agreement with Renovo Solutions. “Based off of the service history and trended information during the warranty period, Clinical Engineering will establish a sub-agreement with either the manufacturer, an independent service organization or service the unit with our in-house staff,” Coronado says. “All service is managed and documented by the clinical engineering staff and service events are scanned into the clinical engineering database, RenovoLive.” Service contracts are reviewed on an annual basis to determine if the service

FEBRUARY 2015

Methodist Hospital of Southern California is served by a nine-member biomedical engineering department.

organization has met their contractual obligations. The department meets with vendors and reviews the contractual relationship during the renewal period. “All equipment is trended for down time, failure rate, abuse, operator error and financial liability,” Coronado says

MANAGING INTEGRATION The Methodist Hospital of Southern California Biomedical Engineering Department instituted a Integrated Systems Management (ISM) Program, with resources from Renovo, to help mitigate risk with the integration of medical devices onto the hospital’s network. The team took extra steps to assess each device that

The Methodist Hospital of Southern California Biomedical Engineering Department has instituted an Integrated Systems Managment Program.

After completeing a PM, Michael Cabrera and Mark Guzman prepare a Medgrpahics’ PFT unit for QC.

would be integrated into their system by reviewing how it met HIPAA regulations. They also utilized NIST Special Publications 800-30 and 800-66 and developed a system assessment form. The department uses proprietary software to flag special case scenarios from data collected through service events. Monthly reports convey this information to the hospital’s safety committee. “The data also allows us to establish a Performance Improvement Program based on the trends from our data collection,” Coronado says. “Our department is always trying to improve our program and patient safety. In addition to service events, our team does something unique to the clinical engineering field in regards to privacy and cybersecurity. Any medical device that stores or transmits electronic patient information goes through a 57-question risk assessment that details any vulnerabilities to cybersecurity or HIPAA violations.” Coronado says that the answers are then uploaded into a database which generates a risk score. A mitigation plan is generated to address the vulnerabilities. “We continue to manage our equipment throughout its service life. This initiative allowed our team to be the first clinical engineering team to win the ECRI Institutes’ Health Devices

Achievement Award in 2013,” he says. “Our department has recognized that medical equipment technology has changed in the past 10 years and we developed a program to meet that change and protect our patients in all areas.” Pioneers in merging many elements of IT and biomed, the biomedical engineering department takes a forward-looking approach that reflects the realities of current day medical equipment integration. “We have brought this integration to another level; actually we changed the culture within Methodist Hospital,” Coronado explains. “Our ISM program bridged the gap between CE and IT,” he adds. “Our IT Integration Specialist works within the IT Department and also serves as a project manager for any medical device network activities. The two departments meet on a monthly basis to review any findings with our Cybersecurity Program or any new activities. Our CE database communicates with the IT network or domain on a real time basis through our client’s service module. I believe our program is the program of the future.”

EXTENDING THEIR REACH Remaining involved in the HTM community, even away from their workplace, is something team associates are engaged in also. The members participate in California Medical Instrumentation Association (CMIA) activities and Coronado is a part-time instructor for the bachelor’s program at the Southern California Institute of Technology. He teaches courses such as FDA regulations, biomedical imaging, biomechanics, medical instrumentation design and application, and anatomy. He has also been published in the AAMI Horizons magazine. Patients at Methodist should feel extra assurance that, not only is the clinical engineering staff watching out for the medical equipment, but their personal information also.

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BIOMED ADVENTURES Action and Relaxing By K. Richard Douglas

here is a HTM professional who has known even more excitement than a frantic call from the OR. Albert Hardy, CBET, a biomedical technician with McLaren Regional Medical Center in Flint, Mich., knows a thing or two about adrenalin rushes on and off the job. Hardy is a paid on-call firefighter with the City of Burton Michigan Fire Department. It was actually his mechanical skills that landed him in the firehouse. “I have always lived in the area that I am in now and have driven by the fire station almost every time I leave my house. At the time that I joined the department, I was interning for my biomed degree, but in the past, I have been a mechanic for many types of equipment including generators. Through a friend of a friend, who was a firefighter, I was asked if I could take a look at the standby generator at the fire station because it would not start,” Hardy remembers. “I jumped at the opportunity to help out those who helped others. When the job was complete — simple overhaul of the carburetor — I [heard about] how much they owed me and I responded with ‘It is the least I can do for what you guys do for us.’ The Battalion Chief stepped forward and asked if I would be interested in joining, because they needed more people that had the same goal, and I am still being woke up in the middle of the night 14 years later,” he adds.

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SUITED UP AND READY TO SHOOT It was the need to let some steam off that landed Hardy in his action-packed hobby of paintball. He suggests that anyone who needs to get some frustration out might want to give it a try. “I started 11 years ago by simply purchasing a paintball marker from a local store and found an indoor field and quickly realized that I had a lot of learning to do, and equipment to buy, because these guys take it serious,” Hardy says. “I told my best friend about it and he was intrigued and went with me and was hooked as well. But the indoor fields that we went to, known as speedball courses, just were not our forte. I wanted the military style action, the stealth, the hundreds of people battling to achieve an objective; that was what I wanted and that was what we found,” he says. What Hardy discovered is called Scenario Paintball. He found a field where he could play this brand of paintball about an hour from home. It goes by the intriguing name of Hell’s Survivors Paintball Field. “We started playing and realized that these guys are even more serious than what we had seen at the indoor fields. These guys have set ups that imitate what real life guns look like, and even wear the same gear that you would see in the military, including Ghillie suits. It was exactly what I was looking for, but again, I would need more gear,” Hardy says. After a few years of being immersed in this action-packed version of paintball, Hardy was asked by the Great Lakes Rangers to join them because of his style of aggressive play. “I now have a seven foot by fourteen foot enclosed trailer that houses all my

FEBRUARY 2015

Albert Hardy, CBET, also serves as a firefighter.

gear and carries my team’s gear when we go to travel games, and players ask me now, do you have enough stuff? My team is very proud of our reputation for playing hard on and off the field and has earned us the respect to be sponsored by many companies including Tippmann and Coca-Cola,” he says.

ON THE JOB Hardy started his biomed career at a home healthcare facility in 2000. He was hired by McLaren Health Care in 2004. “Working at McLaren, I primarily maintain our six Cath Labs, which include two EP Labs. Within our EP Labs, McLaren is proud to have our 3D mapping systems from St. Jude and Biosense Webster, combined with GE recording and multiple other systems all linked together to increase the quality of life for our patients,” he says. “I am quite proud to say that I get to keep it all working properly.”

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Albert Hardy is a proud member of the McLaren Regional Medical Center’s biomedical department.

Albert Hardy is a member of the Great Lakes Rangers Scenario Paintball Team.

Hardy also assists in maintaining his facility’s STERIS surgical tables. He says that his department has an electric winch installed to aid in complete teardowns and rebuilds; a cost saving measure. “I try to continue to learn as much as possible, and be a team player, to help the rest of the department as much as I can,” he says.

A BREAK FROM THE ACTION The excitement of fighting fires, paintball battles and HTM duties is counter-balanced by time on the water for Hardy and his family.

“My family and I love spending time out on the lake on our pontoon when I am not working, playing paintball or fighting fires,” Hardy says. He bought his pontoon boat in the fall of 2011 and found some restoration was in order. He replaced the upholstery, carpet and fabric. “I figured, why stop there, and replaced all the electrical, upgraded all the lighting to LED and upgraded the stereo — of course — and then finally added the decals labeling it as ours. We did all this through the winter to have it ready for the summer of 2012,” Hardy says. “The goal was to have it on the water for my stepdaughters 17th birthday, but due to a faulty ignition module, I missed my mark by one day,” he says. “We rent a slip on Lake Nepessing, which is 15 minutes from our house, for the season.” Hardy and his family spend a lot of time on the boat despite the short season in Michigan. “There is truly nothing better than a warm summer day winding down, watching the sunset, and being in the company of your family,” he says. After putting out fires, dodging paintballs and the challenges of being an HTM professional, what could be better?

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INTRODUCING

ECRI Institute’s Top 10 Health Technology Hazards for 2015

ealth technology hazards can be the result of IT-related problems such as improperly configured systems, incomplete data, or inappropriate malware protection. They can be caused by inappropriate human-device interactions. They can also be problems that are intrinsic to the devices themselves.

It’s vitally important to recognize such hazards and address them before they cause problems. But the big question is, where do you start? That’s where ECRI Institute’s Top 10 Health Technology Hazards list comes in. The purpose of ECRI’s list is to help prioritize technologyrelated safety efforts on issues ECRI has judged to be the most serious.

1. ALARM HAZARDS: INADEQUATE ALARM CONFIGURATION POLICIES AND PRACTICES Alarm hazards again occupy the No. 1 spot on our list of the Top 10 health technology hazards. With the Joint Commission establishing clinical alarm safety as a National Patient Safety Goal, this should come as no surprise. This year, we encourage healthcare facilities to expand their alarm safety efforts beyond alarm fatigue to include an assessment of alarm configuration practices. Such practices include determining which alarms should be enabled, selecting the alarm limits to use, and establishing the default alarm priority level. Alarm management strategies that focus too narrowly on alarm fatigue don’t address unrecognized alarm conditions. Scrutiny of alarm configuration practices can help prevent a wider range of alarmrelated adverse events. ECRI Institute has investigated several deaths and other cases of severe patient harm that could have been

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prevented with more effective alarm configuration policies and practices.

2. DATA INTEGRITY: INCORRECT OR MISSING DATA IN EHRS AND OTHER HEALTH IT SYSTEMS Many care decisions are based on data in an electronic health record (EHR) or other IT-based system. When functioning well, these systems provide the information clinicians need for making appropriate treatment decisions. When faults or errors exist, however, incomplete, inaccurate, or out-of-date information can end up in a patient’s electronic record, potentially leading to incorrect treatment decisions and patient harm. For example: Data entry delays or interface issues could prevent updated test results from being displayed. Clinicians could fail to sever the link between a medical device and a discharged patient’s record, resulting in the next patient’s data being included in the previous patient’s record. Default values could be used by mistake, or fields could be prepopulated with erroneous data. These are just a few of the ways that the integrity of patient data can be compromised.

3. MIX-UP OF IV LINES LEADING TO MISADMINISTRATION OF DRUGS AND SOLUTIONS In previous Top 10 lists, we’ve addressed the role that infusion pump

FEBRUARY 2015

programming errors play in infusionrelated adverse events. This year, we focus on the tangle of tubing that exists when multiple intravenous (IV) infusions need to be administered to a single patient. If care is not taken to clearly distinguish one infusion line from another, a fluid or medication could be delivered at the wrong rate, leading to an overdose or underdose, or via the wrong administration route, as in the case of an IV solution mistakenly being delivered into an epidural catheter.

4. INADEQUATE REPROCESSING OF ENDOSCOPES AND SURGICAL INSTRUMENTS With the Ebola virus dominating the news, the importance of the reprocessing function — that is, the cleaning and disinfecting or sterilizing of objects that may have been contaminated with body fluids — has gained increased attention. For

healthcare facilities, the reprocessing of reusable surgical instruments and devices is a matter of routine. But when the routine involves shortcuts or improper procedures, pathogens can be spread to subsequent patients, potentially leading to hospitalacquired infections or the spread of disease. Despite our inclusion of this topic on previous Top 10 lists, we continue to see media reports, receive problem reports, and investigate cases involving the use of potentially contaminated instruments on patients.

5. VENTILATOR DISCONNECTIONS NOT CAUGHT BECAUSE OF MIS-SET OR MISSED ALARMS A disconnection at any point along the ventilator breathing circuit could quickly lead to anoxic brain injury and ultimately could be fatal. To prevent such outcomes, ventilators incorporate sensors and alarms to warn caregivers when a disconnection occurs. To be effective, however, such alarms must be set to appropriate levels and must be heeded when they sound. ECRI Institute has investigated cases in which serious patient harm resulted from alarms being set to inappropriate levels, and thus not activating to warn of a disconnection, or from staff not hearing the alarms that had been activating.

6. PATIENT-HANDLING DEVICE USE ERRORS AND DEVICE FAILURES Staff injuries associated with the lifting, transfer, or movement of patients are a key factor contributing to OSHA’s conclusion that hospitals are among the most hazardous places to work in the U.S. Furthermore, patients themselves can be injured if patient-handling activities are not carried out effectively. A diverse range of patient lifts and other patient-handling technologies are available to help prevent staff and patient injuries during such activities. While use of these devices can help reduce the risk of injury compared with manual techniques, reports show that improper use, failure to maintain the devices appropriately, or failures associated with the devices themselves can likewise result in injuries.

7. “DOSE CREEP”: UNNOTICED VARIATIONS IN DIAGNOSTIC RADIATION EXPOSURES

of healthcare services, or the inappropriate access to patient data.

“Dose creep” refers to a pattern of increasing radiation exposure levels (i.e., dose) over time in an attempt to achieve better image quality in digital diagnostic radiography. The consequence is that patients may routinely be exposed to unnecessarily high levels of ionizing radiation during diagnostic imaging exams. While the effect of any increase in dose for a single exam would likely be negligible, the cumulative effect on patients subjected to multiple studies during the course of their treatment — particularly neonatal patients — can become significant. Fortunately, tools are now becoming available to help healthcare facilities identify exposure trends that might indicate variation from the optimal values.

10. OVERWHELMED RECALL AND SAFETY-ALERT MANAGEMENT PROGRAMS

8. ROBOTIC SURGERY: COMPLICATIONS DUE TO INSUFFICIENT TRAINING Robotic surgical systems are particularly complex devices that change the circumstances of surgery for all involved. Thus, adverse events can result if surgeons, the rest of the surgical team, and associated staff are not sufficiently prepared to manage these conditions. ECRI Institute has investigated several incidents in which situations unique to robot-assisted surgery likely contributed to patient harm.

9. CYBERSECURITY: INSUFFICIENT PROTECTIONS FOR MEDICAL DEVICES AND SYSTEMS The growing trend toward the networking and connectivity of medical devices is associated with a corresponding increase in the vulnerability of these devices to malware and malicious attacks. It is important to keep this issue in context: there is little evidence to date of direct harm to patients. Nevertheless, cybersecurity is a potential threat that healthcare facilities must begin addressing. The exploitation of medical device cyber vulnerabilities could lead to device malfunctions, the disruption

Despite the best intentions of manufacturers and healthcare professionals, defective medical devices sometimes make it onto the market, failures and use errors occasionally occur, and hazardous situations do develop. Given that reality, it is essential that healthcare facilities have an effective program for identifying and addressing defective devices and other sources of danger or difficulty involving medical technologies before patients are harmed. While all healthcare facilities have some form of recall and safety-alert management program, some of these programs have not kept pace with the growth over the last decade in the number of recalls and other alerts that have been issued. In addition, several challenging technology management scenarios can lead to gaps that result in missed recalls or alerts.

11. PROMOTE SAFETY Spread the word about ECRI Institute’s 2015 Top 10 Health Technology Hazards – and let it help your facility focus its patient safety efforts. A free version of the report can be downloaded at www.ecri. org/2015hazards. The free report contains detailed recommendations from ECRI Institute on how to address each of the hazards on its list. Let ECRI Institute know how your hospital is using the list to help manage health technology related safety. Feel free to contact Jim Keller, Vice President, Health Technology Evaluation & Safety, ECRI Institute, at jkeller@ecri.org if you have some best practices that you’d like to share. THIS ARTICLE is based on the report that was posted on ECRI Institute’s membership website on November 24, 2014. To learn more about the Health Devices System or any ECRI Institute services, visit www.ecri.org or call (610) 825-6000, ext. 5891.

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FEBRUARY 2015

TOOLS OF THE TRADE Fluke Biomedicalâ&#x20AC;&#x2122;s ESA609

luke Biomedicalâ&#x20AC;&#x2122;s ESA609 Electrical Safety Analyzer pairs portability and ruggedness with quality assurance. Engineered to meet the needs of on-the-go technicians, the ESA609 is built tough with a rubberized case that helps prevent damage if accidentally dropped.

Additionally, its featherweight design and functional hand strap make it one of the most portable analyzers in its class. The ESA609 tests to ANSI/AAMI ES1, NFPA-99, and parts of IEC62353 and IEC60601-1. It integrates all functions needed to test medical devices when patient lead testing is not required, including: line (mains) voltage, ground wire (protective earth) resistance, equipment current, leakage current and point-to-point tests. Requiring no training to use, the simple push-button design on the ESA609 ensures quick testing and fast transition between tests for complete basic testing in minutes. Heavy-duty switches allow users to effortlessly change polarity and configuration of the neutral connection between open and closed. FOR MORE INFORMATION ON THE ESA609 ELECTRICAL SAFETY ANALYZER, visit www.flukebiomedical.com/ESA609.

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FEBRUARY 2015

1TECHNATION.COM

AAMI UPDATE

AAMI Unveils Summit Report on Ventilator Technology

ostering an enhanced culture of safety is a necessary condition for addressing challenges with ventilator technology, according to a comprehensive new report from AAMI. The report, “Creating a Culture of Safety, Priority Issues from the 2014 AAMI/FDA Summit on Ventilator Technology,” sheds light on the complex challenges associated with the use of ventilator technology and sets forth a series of ideas for addressing them. More than 160 multidisciplinary stakeholders brought their expertise, personal experiences, and wisdom to the AAMI/ FDA Summit on Ventilator Technology, which was held Sept. 16-17, 2014, in Herndon, Va. Participants and presenters at the summit shaped a vision of a safer and more effective environment of care for patients who depend on ventilators — remarkable, life-saving equipment that could be even better. The summit report, sponsored exclusively by Philips Healthcare, describes six “clarion themes” that will be vital to achieving this vision. Patients and the entire healthcare community would benefit from: 1. Clear, standardized language for mechanical ventilation and ventilation modes, used broadly and consistently to improve patient care and enhance clinical information. 2. Shared understanding of biocompatibility expectations for ventilator technology — and a safer, clearer, faster path to market. 3. Clinicians who are consistently trained, competent, and certified to care for ventilated patients and operate the ventilators they use. 4. Integrated devices and systems,

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including alarm systems, that provide clinicians with comprehensive, actionable information about ventilated patients. 5. Intuitive and consistent user interfaces that make it easy to set up and operate ventilators in clinical and nonclinical settings. 6. A strong and transparent culture of cooperation, coordination, and collaboration in which shared information spurs improvements in the safety and outcomes of mechanical ventilation. As described in the summit report by Anya Harry, branch chief of the FDA Center for Devices and Radiological Health (CDRH) Respiratory Devices Branch, work is needed to improve patient safety and outcomes, including: • Balancing adequate gas exchange and avoiding lung injury associated with positive airway pressure and oxygen exposure • Minimizing the duration of mechanical ventilation with protocol-driven, spontaneous breathing trials and autonomous weaning functionality • Improving visual and auditory alarm signal functionality The report is available at www.aami. org/publications/summits/2014_ Ventilator_Summit_Report.pdf.

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COMMITTEE EXPLORES INTERACTION BETWEEN EAS GATES, MEDICAL DEVICES With a growing number of patients receiving implantable electronic medical devices, there is increased concern about their exposure to electronic article surveillance (EAS) gates, which are designed to deter shoplifting. AAMI’s Cardiac Rhythm Management Device Committee recently met to discuss the potential risks patients face when they are exposed to these surveillance systems. The FDA has taken notice, issuing guidance in 2000, titled “Labeling for Electronic Anti-Theft Systems” and summarily referred to as “don’t lean and don’t linger.” The guidance recommends “that all manufacturers of electronic anti-theft systems develop labeling or signage to post on or near all new and currently installed systems, indicating that an electronic anti-theft system is in use.” At the meeting, committee members discussed whether this guidance was becoming ineffective. A primary concern of the committee, which is co-chaired by Bob Stevenson, senior scientist at Greatbatch Medical in Clarence, N.Y., and Roger Carrillo, MD, thoracic and cardiac surgeon at the University of Miami Hospital, was that many retailers are obfuscating EAS gates. Examples of how EAS gates may be hidden include the following: • Advertisements and other signage, vending machines, coffee stations, and other attractive elements can cause individuals (including patients with medical devices) to potentially “linger and lean” near EAS gates. • High-end retailers placing chairs and lounge-type furniture in close proximity to the gates.

• Under-the-floor EAS systems are becoming more prevalent. Because they are not visible, patients may not be aware of their presence. • Signs alerting people of the presence of EAS gates typically are quite small — typically 3-by-5-inch — and can be easily hidden from view by advertisements or other objects. To help gain insight into the topic, the committee heard the views of physicians, representatives from pacemaker manufacturers, and scientists who have performed extensive EAS gate testing. In addition, representatives from EAS system manufacturers offered their perspectives. Hubert Patterson, Tyco vice president and chief technology advisor at Sensormatic in Boca Raton, Fla., provided an EAS manufacturer’s perspective. Patterson said Sensormatic takes the “don’t lean and don’t linger” guidance very seriously and has a policy of “zero harm.” He noted that electromagnetic field (EMF) levels for EAS gates have not changed in 20 years; that Sensormatic is not going to make larger, more powerful systems; and that it does not wish to raise EMF levels, but only maintain current ones. Furthermore, Sensormatic is revamping its guidance to retailers to mitigate the risk of patients lingering around EAS gates, Patterson said. In addition to sending letters to retailers, the company is educating its front-line sales employees about the dangers of attractive factors that can increase the probability of customers lingering near EAS gates. Mitchell Shein, branch chief for pacing and defibrillation devices at the FDA, recommended that industry conduct human factors testing to determine whether patients are able to determine

whether EAS systems are in place, given a variety of factors (e.g., presence or lack of signage on or around gates). Such research, he said, could provide better data on the likelihood of customers/patients to “lean and linger.” Shein noted that although this is a not a public health crisis, interactions do occur between EAS gates and medical devices, and more research is needed to improve the understanding of these relationships.

EXPERT WARNS HEALTHCARE FACILITIES: WATCH GUEST ACCESS Healthcare facilities need to perform a real balancing act with wireless applications. If management doesn’t constantly evaluate facility needs in terms of apps, something will break, warned Bob Zemke, healthcare solutions manager at Extreme Networks and member of AAMI’s Wireless Strategy Task Force (WSTF). Zemke made these comments during a WSTF session of the mHealth Summit 2014, just outside Washington, D.C. The meeting brought together a range of stakeholders to examine collaboration in the use of mobile health, including members of the pharmaceutical industry and telecom. During the WSTF session, titled “Everything You Wanted to Know About Wireless but Were Afraid to Ask,” Zemke reminded the audience that healthcare facilities are unique environments, quite different from the typical office. Troubleshooting the various wireless applications throughout the hospital is a huge concern. Managers have to ensure that mission-critical applications, such as HVAC and security systems, remain functional. They also have to make sure that life-critical applications, such as

telemetry and infusion pump systems, deliver safe and effective care. With the rise of online social media platforms, managers have a new concern: how patients will portray their facilities on social media. “Guest access is an increasing challenge,” he said, “it used to be a nice-to-have.” However, “what we’ve seen happen is that it’s mandatory to have this type of service.” Patients want to have access to high-speed downloads and streaming videos, putting an additional strain on the wireless network. Facilities need to think of the network holistically and evaluate the number of devices already in the building, as well as those being brought in by patients. And it’s not just the patients that management needs to account for: “We have to understand the real workflow of our clinicians,” Zemke said. “We have to understand how they’re communicating and where.” For example, doctors and nurses might do their work in stairwells; facilities need to be ready to take the mobile clinician into consideration. AAMI’s work in the wireless arena took off at the October 2012 Wireless Workshop, during which 75 attendees created a list of priority wireless issues. These priorities include clarifying roles and responsibilities in the wireless arena; managing spectrum to improve safety and security; designing wireless infrastructure for high reliability; learning from other industries; and managing risk and preventing failure. The findings from that workshop paved the way for the development of the WSTF — a group of about two dozen representatives from hospitals, companies with wireless expertise, the medical device industry, and the U.S. Food and Drug Administration.

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FEBRUARY 2015

WEBINAR WEDNESDAY MedWrench caps off successful first year of Webinar Wednesday By John Wallace, Editor

he amazing popularity of the TechNation Webinar Wednesday series was evident again in December. Kaylee McCaffrey’s informative guide to the productfocused social network MedWrench.com capped off the inaugural year of webinars.

More than 400 people registered to attend the Dec. 17 webinar with a reported attendance of 206. McCaffrey, the marketing and sales manager of MedWrench, outlined how to find answers, information and documents related to the medical equipment on the site during the webinar. Attendees were also treated to a live user demo for MedWrench.com. McCaffrey shared her expert knowledge and provided tips to new and experienced MedWrench users.

“This is the second TechNation webinar I have been a part of and each time I learn something new and share the post-webinar recording with my team.” - Jared W. Some of the highlights from the webinar included how to post questions regarding medical equipment, how to search and download available manuals and specification sheets, and how to bookmark equipment, categories, and manufacturers to remain updated on the latest news and technology.

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McCaffrey also reviewed how to utilize additional resources found on the site including an app library, the FDA alerts and notices section, continuing education information and a career board. An informative question-andanswer session followed the presentation. Webinar attendees praised the session and the Webinar Wednesday series in a post-webinar survey completed online. “Good job explaining the site. Now, I can use MedWrench to its fullest potential,” Michele H. said. “The webinar was very helpful. Before, I was not too familiar with the site. I only knew how to locate manuals,” said Matthew B. “I am very happy to have attended your webinar. It provides me with a link to new and broader scope of information, sources and contacts,” John K. said. “MedWrench is a great resource for the biomedical (HTM) community. You have more than filled the void left by a previous forum that collapsed. The information is well organized and it is difficult for someone to go on a rant or personally attack other forum members. MedWrench is well organized, professional and comprehensive,” Ron M. said. “TechNation has aired excellent webinars. I applaud your

KAYLEE MCCAFFREY Marketing & Sales Manager at MedWrench

efforts in development of the HTM and engineering communities.” “This is the second TechNation webinar I have been a part of and each time I learn something new and share the post-webinar recording with my team,” Jared W. said. For a recording of the December webinar and details about upcoming webinars, visit IAmTechNation.com/Webinars. FOR MORE INFORMATION about upcoming webinars visit IAmTechNation. com and click on the “Upcoming Webinars” tab at the top of the page. For sponsorship opportunities, email webinar@ mdpublishing.com or call 800-906-3373.

FEBRUARY 2015

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BIOMED 101

Testing 1, 2, 3: The Importance of Authenticating Refurbished Ultrasound Parts and Probes By Lawrence Nguyen

ue to its safe, non-invasive method to obtain images and expanded imaging capabilities, the reliance on ultrasound technology continues to escalate in the healthcare industry. As such, the biomedical engineers responsible for maintaining a hospital’s ultrasound equipment are constantly striving to minimize costly machine downtime — which prevents caregivers from conducting critical procedures for patients — while also controlling expensive equipment service costs. An excellent way for healthcare facilities to control costs and ensure that ultrasound equipment is functioning properly is to partner with a credible ultrasound support organization that can repair transducers and systems with high-quality refurbished and tested replacement parts. This cost-effective approach can maximize the useful life of equipment and save operators as much as 97 percent relative to OEM solutions. Ensuring the credibility of third-party support vendors and authenticating refurbished parts is vital to ensuring the reliability of the parts and the quality of ultrasound images and patient diagnosis, so if a part is not repaired correctly there may be serious consequences. Fortunately, there are steps that biomedical engineers can take to authenticate parts and catch any flaws prior to installing an inferior part. All ultrasound repair companies are required by the FDA to meet original equipment manufacturer (OEM) specifications, but every company documents these specifications differently, and every vendor interprets them differently. Therefore, some ultrasound repair companies may inadvertently make mistakes during the refurbishing process. Even more concerning, some repair companies have

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been found to intentionally distribute bootlegged parts or parts with inferior or fraudulent repairs in order to increase their profits. For example, some companies remanufacture probe cables offshore and the result is often brittle, sub-quality wires that fail prematurely. There have even been instances of metal transducer connectors being replaced with plastic connectors spray-painted to give them the appearance of metal. This is particularly concerning because it compromises the grounding of the entire system and could put patients in danger. When parts are not repaired correctly, whether inadvertently or otherwise, there can be serious repercussions. The biggest concern is the safety of the patients who are being examined with the machines. If a probe isn’t performing reliably due to poor repairs or inferior parts it will affect the monitors performing the scans, and diminish a physician’s ability to accurately identify abnormalities and provide a proper diagnosis to guide patient care and ensure the patient’s safety. In order to avoid the repercussions of an incorrectly repaired part, it is important for clinical engineers to authenticate every refurbished part so they can catch flaws prior to installation. To make this process easier, biomedical

FEBRUARY 2015

LAWRENCE NGUYEN Founder and CEO of Summit Imaging

engineers should start by identifying vendors that consistently provide high-quality parts. One good indicator of how reliable a company’s parts will be is the length of its warranty. Companies that offer longer warranties deliver higher quality parts that last longer. Another good indicator of a company’s service quality is its reputation within the clinical engineering community.

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Phillips Multi-Measurement Server M3000A, M3001A Upon receiving a refurbished part, healthcare technology managers should ask if the equipment was repaired using OEM specified parts. Although there is no guarantee that the vendor will answer honestly, it is important for clinical engineers to state that they expect OEM specified parts in order to ensure the highest level of quality. Ideally, a refurbished part will exactly match what an OEM would provide and perform to OEM specifications. If a part does not match the OEM, it could indicate a non-OEM specified part or repair. The FDA requires technicians to meet OEM specifications for parts repairs, but this can be difficult to achieve because manufacturers often do not provide a thorough description of their specifications. This is because the OEMs offer their own repair services to healthcare organizations, so it behooves them to protect this information. As a result, third-party technicians must try to emulate the specs by breaking down and analyzing the quality characteristics of a probe, which is not always an accurate process. In addition, when the FDA is testing for compliancy they do not take into account important repair objectives such as image quality, resolution and how the repair was conducted. All of these elements are incredibly important to the long-term functionality of the part. The best way for a clinical engineer to determine a refurbished partâ&#x20AC;&#x2122;s quality is to test it over and over again. When doing so, they should pay particularly close attention when testing arrays, the group of piezoelectric crystals within the transducer housing, because these are replicated with inferior pieces more frequently than other parts. If an engineer is concerned about the quality of a part they should also ask for the partâ&#x20AC;&#x2122;s repair history. Companies must keep on file the repair and testing logs for every part they refurbish for 10 years. This information provides insight into the repairs that have been performed in the past and confirms that they were completed. When reviewing the repair log clinical engineers should look for specific details about the type of repair to ensure these actions have actually been taken. For example, notations that specify at what point a chip was replaced or when a joint was soldered, can help confirm whether a repair was completed accurately. Although testing and authenticating parts can be a tedious process, it is paramount to ensuring that ultrasound equipment functions properly. Every individual component contributes to the overall performance of an ultrasound machine. If one part is sub-par the entire machine and the images it produces will be affected and the quality of patient care may be adversely impacted.

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SHOP TALK

Ventilator Air Supply Q:

What are the pros and cons of running a ventilator from the central compressed air supply versus built-in turbine/blower technology? I understand that the former helps the patient get clean air. But if you are given an option what would you choose?

I’ll start off by saying that it’s been a few years since I worked on some ventilators with turbine/blowers. At my last hospital I was the primary biomed trained by the manufacturers for all the respiratory care department ventilators there, which included more than 60 ventilators of various manufacturers. The “main” advantage, in my opinion, that a turbine/blower has over compressed wall air is that not all hospitals have compressed wall air in every patient care area. Having a ventilator that only needs an oxygen tank versus one that needs both O2 and air tanks is an advantage. Also in some medical facilities the compressed wall air may not have been adequately cared for. Water (especially condensation) in the wall air could be a contamination issue for the ventilators. Without dry and clean medical air, the patient is put at risk. The engineering/plant operations department has scheduled maintenance that needs to be rigidly adhered to in order to keep the condensation from occurring within the wall piping. The turbine/blower ventilators that I was trained on all had well-filtered “room air” and were relatively easy to maintain. If you can rely on your facilities engineering department to keep the medical air dry and clean, then either ventilator type will be a great. Be sure,

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though, to choose a reliable ventilator manufacturer as not all manufacturers are necessarily equal.

My personal preference is a self-contained ventilator, based strictly on the issue of portability. If the patient is on a self-contained ventilator (inbuilt turbine/blower/pump) with batteries and needs to be moved, the worst-case is that they are on oxygen therapy and a bottle of O2 is needed to supply the blender. If they are on a machine that is dependent on medicalgrade pressurized air, this is more difficult.

More expensive to upkeep the turbines. I know the RT techs like them here. From a biomed-cost standpoint, the compressed air types are less expensive to upkeep. From the RT tech standpoint, they will probably go with the turbines.

How do you deal with angry clinicians? Do you have any perfect responses that you use over and over to calm clinicians so that you can get the repair made? Do you have a nice way to tell them they are using the equipment wrong so you can then show them the correct way to use it?

Our philosophy on this is to always try to remain calm and focused on the actual issue at hand and to correct the problem without getting caught up in the drama and/or excitement of the moment. There’s nothing worth getting angry or loud about. When it is an equipment system issue, focus on fixing the problem and the drama will go away.

FEBRUARY 2015

I just read an article by Roger Gil Mamft who specializes in marriage therapy. He says that just because you know you’re right, doesn’t mean getting into an actual argument is worth it. Sometimes, it’s best to just let things go. At the very least, before you set out to prove that you’re right, it’s good to check your own argument. To those ends, Mamft suggests you consider a few points before you even react. • Don’t get emotionally overwhelmed: When you’re opposed by someone, you have an emotional response. That’s normal, but Mamft warns it’s best to keep yourself calm. “I like to tell people to be wary of passing a 5 on a scale of 1 to 10 for a given emotion when engaging in disagreements.” Essentially, you don’t want to get into a heated debate, and to do so you can’t react too aggressively. • It’s not always necessary to change someone’s mind: Sometimes it’s just plain not worth it to try and change someone’s mind. Unless an issue is serious, it’s occasionally best to just agree to disagree and move on. • Some issues are objective and others are subjective: With concrete issues (like the time, or the height of the tallest mountain), it’s very possible you’re right provided you have observable, objective facts. That’s not the case with subjective issues, and Mamft notes that it’s a good idea to know the real difference between the two when someone says you’re wrong. “We have to remember that opinions are usually based on a set of assumptions that are likely unique to the individual. Your ‘rightness’ (no

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matter how certain you are of it) may really be nothing more than a reflection of your values rather than a reflection of observable facts.” • Your relationship should dictate how you respond: When a friend or family member says you’re wrong about something you know how to temper your response because you’ve known them for a long time. When it’s a stranger, or worse, a boss or co-worker, it’s important to weigh the usefulness of a response. If your boss is vindictive, it’s likely best to accept their wrongness and move on if you want to keep your job (unless their wrongness is a danger to you or your company). • Make sure you’re really correct: It seems obvious to you that you’re right, but that doesn’t mean you’re not making assumptions.

You’ve just got to listen at first and agree with things that you can. Ask them to show you exactly how they use a particular unit so you can learn from them. Explain that this unit works this way as you were taught by the manufacturer (if that is the case) and it may be different than what you had before because it is newer/older. Use a monotone for no one likes to be lectured and especially in front of others.

I need to repair some nonworking OR lights. I have never actually worked on ceiling-mounted OR lights. It seems to me that they are just like the light fixture above my dining table with multiple lamps connected to a dimmer/controller on the wall. Can different controllers be used with different heads? Why or why not? Do

some manufacturers use diﬀerent voltage bulbs? Or are they all 110v? These are very basic questions, so you can see the level of education I need. Does anyone have a source I could read?

All of the older lights I have dealt with were DC voltage. The wall controller was also the transformer/ rectifier. The center mast would also have a set of brushes on a commutator to keep from twisting wires when the light heads were rotated around the mast. I agree, at first glance it wouldn’t be too bad to “jury-rig” if it were all running on AC wall voltage. Sadly, I don’t believe that I’ve seen a set of OR lights that do. Since they are likely DC voltage, you may not be able to jury-rig it. I’ve had these fail from everything from bulbs, sockets, rheostats, transformers, brushes, circuit boards, you name it, and they were all proprietary other than the bulbs.

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KNOW A NURSE? TELL THEM ABOUT

Just a word of caution: Most of the overheads are balanced in order to articulate in all three planes, but it takes two healthy people to disassemble or reassemble them because of the spring loading in the arms. I had an Amsco SQ240 almost take my arm off when trying to repair a commutator.

NURSES THESE POSTS are from TechNation’s ListServ. Go to www.1technation.com to find out how you can join and be part of the discussion.

SURGICAL TECHS NURSE MANAGERS free to subscribe at ortoday.com/subscribe

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ROUNDTADigital Radiography

TechNation keeps readers updated on the latest in technology when it comes to medical devices. We recently reached out to digital radiography experts to gather their insights on the state of this imaging technology. We also asked for their tips on finding training and the ideal device.

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NOVEMBER2015 FEBRUARY 2014

he digital radiography experts participating in the roundtable include AMX Solutions CEO Bill Bentley, Mindray’s International Marketing Director for Digital Radiography Systems Jason Li, Multi Diagnostic Imaging Solutions Chief Operating Officer Dan Moretti and Carestream’s Worldwide Marketing Director for X-ray Solutions and Ultrasound Helen Titus.

WHAT ARE THE LATEST ADVANCES OR SIGNIFICANT CHANGES IN DIGITAL RADIOGRAPHY IN THE PAST YEAR?

Bentley: AED (Automatic Exposure Detection) Technology wireless DR detectors are significantly lighter than the current tethered detectors and are much easier to use. Some AED detectors offer more features such as storing the last 100 images and indicating over/under exposure. Also, costs are reducing significantly due to the number of detector options available. Li: The conversion from conventional film radiography to the no-film digital radiography has enabled Mindray to move forward by introducing higher quality detectors that improve images, reduce operational expenses significantly and speed workflow, while reducing radiation dosages for patients.

upgrade from film to CR/DR, from CR to DR or to expand their DR systems — easily and affordably.

HOW WILL THOSE CHANGES IMPACT THE DIGITAL RADIOGRAPHY MARKET IN THE FUTURE?

Bentley: More customers can afford DR since the costs are more favorable. The same detector can be used with the portable and in the rad room. The GE AMX-4 Plus portable can now be used with the customer’s choice of detector and software giving the customer more flexibility to choose the product they like the best. Li: The advancements in digital radiography have already enabled several benefits. Digital radiography can lead to better diagnosis and more treatment options for the patient.

Moretti: In the last year, we have seen a greater presence of wireless DRs as well as improvements to DR technologies for the enhancement of image quality, reliability, decreased weight, ease of installation, use and support.

Moretti: The constant improvements will aid in providing better image analysis, improved workflow, increase patient throughput and greater customer satisfaction.

Titus: The markets for both CR and DR systems have expanded, so customers today have more choices than ever before. Affordable systems are available for providers that capture 150 images a day — or 150 images a month. Facilities can now

Titus: The market for digital radiography will expand and extend to smaller facilities/specialty offices that can now afford these systems. We will see new software features and workflow enhancements in addition to equipment advances.

THE ROUNDTABLE

comparing apples to apples. They should know if the company offers affordable training and proper support after the sale.

JASON LI

HELEN TITUS

International Marketing Director for Digital Radiography Systems, Mindray

Worldwide Marketing Director for X-ray Solutions and Ultrasound, Carestream

HOW CAN A FACILITY WITH A LIMITED BUDGET MEET ITS DIGITAL RADIOGRAPHY NEEDS? Bentley: They can purchase a DR ready GE AMX-4 Plus portable that comes with everything except the software and detector at a very affordable price and select an affordable detector/software package to fit their needs. There are a lot of options available in today’s market. Li: Much attention has been given not only to the acquisition costs, but also to the operational costs. Those operational costs are of course impacted most positively by the transition from film to digital. However, operational costs are also impacted by ease of installation (impacting start-up costs), ease of use (reducing training and expertise requirements), system reliability (long term cost-of-ownership), and overall system flexibility and expandability. Moretti: DR pricing is falling at a dramatic rate, so being able to afford a

1TECHNATION.COM

DR system these days is not entirely out of the question for facilities with a limited budget. I always calculate overall cost of ownership when I quote DR. With all things factored, DR typically costs less to own over a 3-5 year period than CR or film/chemistry systems. Titus: The market’s broad range of CR and DR systems allows film users to upgrade to digital technology and equips CR users to upgrade to DR. Facilities can retrofit existing film or CR systems with DRX detectors that enable immediate access to high-quality images without replacing existing room or portable X-ray systems.

WHAT ELSE DO YOU THINK TECHNATION READERS NEED TO KNOW ABOUT PURCHASING AND SERVICING DIGITAL RADIOGRAPHY? Bentley: OEMs aren’t always the answer. Customers should get to know the company with whom they are working, obtain references and make sure they are

NOVEMBER2015 FEBRUARY 2014

Moretti: It is very important that someone looking to purchase a DR system does his or her homework. There are different technologies, applications (radiology, chiro, vet, podiatry, etc.) and many brands to choose from. When choosing what DR to purchase, some things to consider should be image quality (the best patient care should lead the decision), reliability, support, ease of use, etc. Regarding service, DRs are typically not field serviceable. If a hardware failure transpires, a loner is generally sent out while the failed DR is repaired. What can be done in the field are calibrations of the DR panel. It is recommended to perform periodic calibrations of the DR in order to get the very best image quality from it. Titus: Healthcare providers should select systems that can evolve to meet changing needs. It’s also important to evaluate accident protection or extended maintenance agreements and choose a supplier that offers a variety of service options.

WHAT ARE THE MOST IMPORTANT THINGS TO LOOK FOR IN A DIGITAL RADIOGRAPHY SYSTEM? Bentley: Evaluate your requirements and what equipment is reliable. Purchasing new equipment isn’t always the answer. Tried and true equipment with a reputation for quality and a supplier who will stand behind the product they sell can be the answer. Li: Because almost all of the digital radiography system information is provided through DICOM-compliant images, the primary focus should be first on the ease of acquisition and the quality of the images. Beyond these most important clinical aspects, the decision process should include a review of

acquisition and implementation costs and overall longer term operational expenses. Moretti: The best answer to give is, the correct DR. As previously mentioned, there are many DR system types to choose from ranging from Cesium, Gadox, Selenium, CCD to varying sizes and connectivity (wireless vs. tethered). The facility and X-ray type will determine the appropriate type of DR system to purchase. There are application specific DRs that would work well for one type of practice, but not for another practice type. It is crucial that all the bases are covered by the sales team throughout the sales process in order to provide the most appropriate DR for the respective facility. Titus: Critical factors for selecting a digital imaging system are: image quality, flexibility (the system’s ability to meet current and future needs), and reliability. A supplier’s ability to deliver responsive service and support is also essential.

WHAT ELSE WOULD YOU LIKE TO ADD OR DO YOU THINK IS IMPORTANT FOR BIOMEDS TO KNOW ABOUT DIGITAL RADIOGRAPHY? Bentley: Get to know the company from whom you purchase. Get your IT department involved early. Establishing wireless DR can be compared to setting up one’s cellphone. You’ve got to eliminate “dead zones” where signals drop. Work with a company who understands the IT side of the product.

BILL BENTLEY

CEO, AMX Solutions

full documentation and end-user training.

HOW CAN PURCHASERS ENSURE THEY ARE MAKING A WISE INVESTMENT IN A DIGITAL RADIOGRAPHY SYSTEM? HOW CAN THEY MAKE SURE THEY WILL RECEIVE THE NECESSARY LITERATURE AND TRAINING TOOLS? Bentley: Work with a company with a proven reputation for delivering quality products and that doesn’t always mean “buy new.” There are a lot of companies in the secondary medical equipment market with proven reputations for delivering and standing behind quality products. Make sure they can get a good return on their investment from a supplier on which they can depend.

Moretti: I always recommend that customers get references from sites that are using the DRs they are interested in. It is always helpful to get feedback from the technicians using the DR as well as from the radiologists reading the images from the DR. The feedback, whether good or bad, will help make the decision process less arduous while aiding in a DR purchase that is the best fit for the facility. Most DR systems come with the appropriate literature or user manuals that the technician can use for reference. Applications training is vital when a facility purchases a DR system. Without the appropriate training, the staff will more than likely not be able to use the device as intended.

Li: A strong consideration in any decision process are the local references, not just the glossy literature. Beyond image quality and workflow support, does the system provide the flexibility needed? What has been the experience with reliability and support? No purchase is complete without

Titus: It’s always wise to look for a supplier with a strong sales, service and applications/training infrastructure, a large install base and a broad portfolio of innovative products. Users can also check with a provider’s reference sites prior to making a decision.

LI: In the future, more and more doctors will be using digital radiography to diagnose and treat, while patients will experience even more benefits. Biomedical staff can assist in the decision process with evaluation and consideration of installation, implementation, and operational expenses associated with service and maintenance. Moretti: The DRs of today really minimize the interaction of the biomed staff to the DR because of the improvements in reliability and the fact that the DR hardware (the panel itself) is not field serviceable. Another reality is that most of the support applied to these systems is performed remotely. This is a huge convenience for the facility as it does not have to burden the already over-engaged day-to-day schedules of the biomed staff. Titus: Major equipment suppliers provide specialized training for biomeds so they can evaluate and service their own equipment. Some OEMs offer management tools that equip biomeds or managers to verify the image quality and productivity of their CR and DR systems. These automated tools save time and enable a small staff to keep imaging systems running at peak performance.

THE ROUNDTABLE

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Equipment Replacement Strategies Hunting Down Cost Saving Measures BY K. RICHARD DOUGLAS

ost hospitals have to be run like businesses with a constant eye on the numbers and that has become more critical in the past few years. Budgets are impacted by new constraints and subjected to penalties that can be substantial. CMS is on the lookout for any healthcare provider that takes Medicare and misses their metrics. Those penalties, or even the threat of a potential penalty, is enough to take slim budgets and make them into tight budgets. Medicare reimbursement penalties are a game changer.

Hospitals across the country, especially in poorer areas, are facing penalties based on the readmission of Medicare patients. Medicare cuts reimbursements based on the number of patients who have to make a return visit to the hospital for everything from complications after knee replacement surgery to heart failure. In New York state alone, 80 percent of hospitals face these penalties. Medicare considers these readmissions as avoidable and the profits made by hospitals from these returning patients is something the feds want to stop. These penalties have doubled in the past year. In combating the impact of these penalties, many hospitals and health systems have instituted other services, like home care and telemedicine, to help reduce the numbers of readmissions. These

additional services also impact the bottom line. For these reasons, and because hospitals are businesses, the reality of measured patient safety, medical equipment buying strategies, maintenance considerations and budget must all coalesce. They cannot be mutually exclusive and all have to recognize the realities of a changing healthcare environment. This impacts every capital purchase decision, every equipment retirement decision and replacement assessments. Determining what to buy, when to buy it and what to remove from service is a huge issue. It is a task taken on by HTM professionals in every corner of the country alongside those tasked with scrutinizing their facilityâ&#x20AC;&#x2122;s budget. When the capital dollars arenâ&#x20AC;&#x2122;t there, or are sparse, what are the options?

EQUIPMENT REPLACEMENT STRATEGIES

WHEN TO PULL THE TRIGGER Doug Dreps, MBA, director of Eastern Regional Operations for Mercy Clinical Engineering Services in St. Louis, Mo., characterizes the environment that these decisions are made in as “difficult times.” “We concentrate on $150K and above. With limited capital these days, end of life items we still support, until we no longer can,” he says. “We have even had local machine shops build mechanical parts for imaging units to extend their life. We have a capital replacement matrix we use that scores equipment and then we make recommendations to our departments and capital review committees.” Dreps points out that hospital leadership still depends on the HTM professionals to provide accurate data to help with these decisions when funding is squeezed. “I stopped doing projection past one year several years ago as our capital dollars have shrank. Some of our end of life items, we end up maintaining until we have to replace it due to failure and the unit can no longer be repaired. Of course, we do take into effect a failed

DOUG DREPS MBA, Director of Eastern Regional Operations for Mercy Clinical Engineering Services

unit that is end of life could shut down a service line, so those instances are looked at differently. Patient safety, technology obsolesce and reliability are all very important factors.” Dreps says that it is a red flag when service costs reach 50 percent of purchase price. “With capital reduction in pricing from manufacturers, and increased costs from

“It is still more cost effective in many cases to spend $100K-$200K on a high-end imaging device that’s technology is not obsolete yet, than replacing it for $700K.” - Doug Dreps

1TECHNATION.COM

FEBRUARY 2015

manufacturers in supporting equipment, high-end capital can often equal purchase cost within seven years, a big change from the past, where it could take 15 years or more to reach this,” he says. “Doing proformas on replacement is a must for high-dollar items,” he adds. “Times continue to change and we continue to change with them. It is still more cost effective in many cases to spend $100K-$200K on a high-end imaging device that’s technology is not obsolete yet, than replacing it for $700K.” As Dreps points out, budgets dictate that decision making criteria are more important than ever today. Those criteria don’t always lead in the same direction as in the past. The biomed department must use well-defined guidelines to provide leadership in these decisions. “My belief has always been that the role of HTM is not so much to tell the hospital what to buy, but rather what not to buy,” says Pat Lynch, CCE, CBET, fACCE, CHTS-PW, CPHIMS, chief do-gooder for Global Medical Imaging (GMI). “Obviously, the final decision has to be based upon the ability to treat the patient. Financial concerns include the hospital’s ability to pay, the strategic value to the institution and reimbursement issues.” Lynch says that HTM’s concern should be the ability to address reliability issues, total cost of ownership, service options and compatibility with existing systems. “By knowing the technology, and having access to other HTM professionals who may already have the new technology, we are able to give advice about service, failure rates, company response, and overall cost to maintain and operate,” he says. As an example, Lynch points out that if

a hospital were considering five different manufacturers for medical telemetry, it would be HTM’s role to evaluate “the solidity of the technology, interfaces with existing systems, upgradeability, life cycle costs, and manufacturer support.” HTM has an important role to guide the decision makers away from any problematic brands. He adds that HTM might want to leave them with a choice of approximately three acceptable candidates. “I have performed hospital-wide technology assessment, and developed a long-term — 5-year — equipment replacement plan,” Lynch says. “It requires dusting off the old crystal ball. I solicited the input of clinical managers and physicians in an attempt to assess the healthcare delivery structure in coming years. Only then can you begin to build a technology system that will meet the needs of the future.” When the trigger is pulled on new technology, the strategy in place must be sound. “The clinical engineering replacement strategy is to focus on those technologies that helps us meet emerging standards of care, technologies that are no longer being supported by the vendor, and/or pose a HIPAA security risk for lost or stolen ePHI, and equipment with the highest recent service costs,” says Eddie Acosta, CBET, CLRT, clinical systems engineer. “In general, the equipment that the technology committee manages is being planned to be used longer than the industry average,” he adds.

PURPOSEFUL EVALUATION One large healthcare system takes a methodical approach to this process. The Technology Management Department at Banner Health has a division within that department that is tasked with optimizing technology acquisitions cost and reducing the operational expense

EDDIE ACOSTA

PAT LYNCH

CBET, CLRT, Clinical Systems Engineer

CCE, CBET, faCCE, CHTS-PW, CPHIMS, Global Medical Imaging

and total cost of ownership. The decision when to make a purchase follows very well-delineated protocols. “New book of business technologies are evaluated through the Technology Assessment Process. This process enables us to field new technology requests centrally and make judgments either to investigate them further or that they are not ready for adoption at this time,” says Perry Kirwan, MSE, CCE, senior director of Clinical Technology Assessment and Planning for Banner Health System. “The team is constructed of strategic planners, finance, physicians, care management, and operations leaders. Decisions are made through impact analyses that evaluate the clinical, market, and financial implications of the technology. Sometimes a clinical trial will be required to vet the technology as well,” he says. Kirwan says that the net result of the

“My belief has always been that the role of HTM is not so much to tell the hospital what to buy, but rather what not to buy [...] By knowing the technology, and having access to other HTM professionals who may already have the new technology, we are able to give advice about service, failure rates, company response, and overall cost to maintain and operate.” - Pat Lynch

EQUIPMENT REPLACEMENT STRATEGIES

process is to provide an up or down vote on the technology. If they decide to go with the purchase, then the determination must be made how the technology is adopted — whether for use in one facility, a regional deployment or an enterprise deployment. “Technology refresh purchases are made based on specific metrics that are scored and maintained in a master document by clinical modality. The metrics includes – regulatory status, equipment age, projected end of life, clinical utilization, clinical criticality to the facility, service costs to acquisition value ratio, and severity of service events over the last three calendar years,” he says. “Certain scores then correlate to specific capital cycles that the equipment should be replaced within. In Banner, those scoring thresholds are as follows: capital cycle within one year, 2-3 years, 3-4 years and greater than five years,” Kirwan adds. “Although the process itself is quite detailed – it functions via two core constituencies – a corporate based

oversight group and ad-hoc working committees with subject matter experts on the given technology at hand.” Kirwin explains that the oversight group is appraised of purchasing requests that come in several different forms; new book of business technologies, technology refresh, and technology standardization. “The oversight group’s main functions are to ensure requests fit with organizational strategy, prioritize the ones requiring deeper review, and hearing recommendations from the working groups relative to technology selection and adoption,” he says. “The ad-hoc working groups are chartered by the oversight group to do the detailed work around making technology recommendations. This process starts with detailed development of the clinical, technical, and business requirements that the technology has to possess. This phase of the process consumes about 60-70 percent of the overall process time, as the objective is to get a thorough

PERRY KIRWAN

MSE, CCE, Senior Director of Clinical Technology Assessment and Planning for Banner Health Systems

understanding of the needs and the problems the technology is expected to solve,” Kirwan explains. These collective requirements are then recorded on a master document and given relative weighting based on importance, so that they can ultimately be scored against any given potential supplier’s product, Kirwin adds.

“Technology refresh purchases are made based on speciﬁc metrics that are scored and maintained in a master document by clinical modality. The metrics includes – CUTTING COSTS THE regulatory status, equipment age, projected end of life, HTM WAY clinical utilization, clinical criticality to the facility, The HTM professional, through their service costs to acquisition value ratio, and severity of clinical engineering, biomedical engineering or healthcare technology service events over the last three calendar years.” management department offers special - Perry Kirwan

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FEBRUARY 2015

insights into the process.

“By knowing the technology, and having access to other HTM professionals who may already have the new technology, we are able to give advice about service, failure rates, company response, and overall cost to maintain and operate.” - Pat Lynch “HTM is concerned with, and able to address, reliability issues, total cost of ownership, service options, and compatibility with existing systems,” Lynch says. “By knowing the technology, and having access to other HTM professionals who may already have the new technology, we are able to give advice about service, failure rates, company response, and overall cost to maintain and operate.” In addition to the purchase decisionmaking process, there is the timing factor. This can be a critical element within the process. “Annual budget recommendations are based on technology assessment submissions that were presented, reviewed, and prioritized by clinical engineering, hospital input and by the technology committees,” Acosta explains. “Medical equipment with articulated operational, strategic, and/or financial priority are approved.” Dreps says that there are ways to cut costs. “Get involved with the quote process on equipment that is high end, mainly imaging equipment. Compare several vendor’s costs for capital, technical training and contract costs. Compare full

contract cost for 5-10 years versus in-house costs for training and reduced shared contract or no contract,” he says. “Having trained technicians on site will improve uptime. In most cases in-house models will save significant dollars. Depending on the facility or system size, this will transform into tens of thousands to millions (of dollars) annually. Sometimes you can negotiate technical training to be included at no charge.” As Kirwan pointed out, Banner Health is able to leverage economies of scale. Dreps says that this is an advantage some healthcare systems have to save on costs. “For larger departments, you should try and negotiate agreements between your department and the vendor for reduced pricing on parts, labor and contracts. You can do this with ISOs too,” Dreps says. “If you know that a contract will be needed for imaging, a POS (Point of Sale) contract can be signed with most manufacturers that will not take effect until the warranty expires, however by doing this there is usually an opportunity for additional savings,” he continues. Additionally, Dreps suggests having contracts under the HTM department, which will allow for the leveraging of

additional savings by bundling them together. This also assures you have control of saving money for your organization, he says. “Track these efforts and compare year by year the cost savings you have provided for your organization, so you can show leadership all the good works your team has accomplished,” Dreps adds. “Try not to look at one year at a time. By taking risks, sometimes you could spend more in one year by not having a contact on high-end equipment, but over five years the risks usually pay off with savings overall.” When the whole hospital has to be focused on the most efficient use of funds, the HTM department can step up to the plate and deliver.

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CAREER CENTER

Down the Applicant Memory Hole By Todd Rogers

he phrase “down the memory hole” comes from George Orwell’s book “Nineteen Eighty-Four.” It’s where inconvenient or unwelcomed memories go to be forgotten, and it is likely where many job-applicants feel their resumes go right after completing an online application.

TODD ROGERS Talent Acquisition specialist for TriMedx, Axess Ultrasound, eProtex and TriMedx Foundation

1TECHNATION.COM

The sequence goes like this: you receive a call about another opportunity that sounds interesting enough that you’re open to the possibility of a change. You conduct a phone interview with someone at the employer who ends the call by asking you to complete their online employment application. You log on to their career page and suddenly it occurs to you that you just committed yourself for at least the next 30 minutes answering questions about dates of employment, income and a few dozen other things that the employer deems necessary. One minute, you’re on a career exploration (burning up a precious vacation day) and then next thing you know, you’re bearing all of your professional secrets to someone you’ve never met. It’s a little off-balanced, in my opinon. There are two basic avenues by which someone can electronically apply for a job. In smaller (and younger) companies, you will likely find a career page with some jobs listed and there will be a contact email address that is designated for job applicants. You create a message to that address and you attach a resume and cover letter, hit send, and you pray (or maybe just wait). The second application avenue is an “applicant tracking system” otherwise known as an “ATS.” This will generally require you to create a user name, log on and answer a lot of questions. These are a hallmark of more established employers; an ATS cost a bunch of money and there is a lot of behind the scenes work to keep them updated and functioning. Regardless of which avenue brings you into an employer’s consideration, you will be transmitting information which will be directly involved in your job pursuits. This electronic procedure has some pitfalls and dead ends. This column will assist you with getting to the application finish line.

FEBRUARY 2015

The first point is a reminder: there is an economy of scale in job applications. With the advent of email and the Internet, where someone would mail off a resume and wait weeks to hear a response, people can now send dozens of resumes out each day. The person on the receiving end can process them no quicker than time will allow. You can send out lots, but it doesn’t mean that you’re deserving of a response from each one! The second point is that you should create and maintain an Excel spreadsheet that contains a running history of your applications. Every time you apply for a job, you add it to your spreadsheet. You include the company name, the date, the job title, the version of your resume, the cover letter that you used, your username/ password for their career site, and any other important information that you can think of that will aid you in tracking your job search. This should become a habit. The reasons are extensive. Just know that in 2-5 weeks when the employer calls you back for an interview, you would rather sound like an informed job seeker than someone who says, “Yeah … I … I … think that I applied to … ahhh … that one job on your website.” Don’t be that guy. Create a spreadsheet to track your job applications and stay on top of it. The next point I would like to address relates to the pre-screening mechanisms used by employers to reduce the candidate pool. These are most frequently found during the completion of the online application. These are questions about general things such as employment status or the willingness to relocate, and these questions are sometimes specific about a job. There is a tendency to bend the truth in answering these questions. The hope is that you won’t get caught in an outright lie and even if you do, you have plausible

deniability, stating, “Oh, I think that I may have misunderstood the question.” From the other side of the applicant tracking system, we tend to only use those questions when the hiring manager specifically indicates a very strict requirement, i.e. no substitutions allowed. If you find that you just don’t measure up to the requirement, you need to say so, but you should also give thought to maneuvering around that screening barrier. Nevertheless, the point is that those questions are usually meant to be the low bar and there isn’t really a way around them.

resume to this email. I’ve also included a cover letter that speaks to the job and my qualifications. Thank you.” The person on the receiving end of that email gets more new applications each day than time allows for them to digest them all. In order to do his or her job, that person has to screen through a lot of applicants. Your one simple email provides a shortcut that time-stretched people habitually seek out. It won’t guarantee that you get the interview. It will increase the odds and that makes all the difference. It will keep you one step away from

Just know that in 2-5 weeks when the employer calls you back for an interview, you would rather sound like an informed job seeker than someone who says, “Yeah … I … I … think that I applied to … ahhh … that one job on your website.” The last point is the follow up email. You can bet that almost every career site has an email address for general delivery purposes. This email probably goes to someone who will A) respond personally, B) forward it to another person, or C) do nothing at all and leave you out in the cold (see memory hole above). To increase the odds that your application will be viewed send an email like this: “I completed your online application for (position name). To assure that I don’t get lost in the mix of candidates, I’ve attached a

eed. N u o Y o D

tory? rate inven u c c a % 0 0 a1 stallation? a remote in lan al action p a biomedic ? TJC survey ahead of a g t in movin is s s a to ity? a team a new facil to t n e m equip taff ET while s a temp BM t? ou member is st several pa te a d p u to due PM’s?

sliding down the candidate memory hole. There you have it: a few simple steps that will keep your ones and zeros from getting too mixed up with someone else’s. The workforce mechanism is always looking for fast ways to dispose of applicants. Candidates apply at a rate equal to how easy it gets for candidates to apply. This means, even though it will get easier, there will be more applicants, thus, no net change. Keep track of your applications and stay away from the memory hole.

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sually this column deals with the technical aspects of ultrasound support, but I would be remiss if I left out an equally important component of service which is the relationship and communications you need to establish with your customers.

MATT TOMORY Vice President of Sales, Marketing, and Training

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Recently, we were interviewing candidates for a field service engineer position at Conquest and I was asked to screen several individuals. My focus was not if they could fix an ultrasound system; it was whether they could fix a customer. The majority of readers of TechNation are technical people which can be an art all on its own but when combined with the ability to communicate well and form a relationship with a customer it makes a good service engineer a great one. As a former service engineer with 25 years field experience, I became very good at my craft. Did I fail occasionally? Absolutely! We all do, but what separates a mistake or failure from a catastrophic customer loss is having a good relationship with your customer. They are much more forgiving with a friend than a stranger and they are much more likely to share with you any problems or risks in your business relationship if you have a personal relationship.

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Ongoing communication is also critical to develop a solid working relationship with a customer. How many times have you or someone you know gone to a customer site, walked past a multitude of people into a room and closed the door to get to work? When creating our preventative maintenance process many years ago, the first and last step we instituted involves a customer interface. At the beginning of every PM, the customer is interviewed to find out how the system is performing and if any issues need to be addressed. At the end of the PM, the customer is told exactly what was performed, any action items are identified and, finally, they are thanked for the opportunity to serve them. As with all relationships in life, good communication is critical to maintaining them in good and not-so-good times.

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THE FUTURE

Teaching from the hospital bed By Myron Hartman

ast year, at the end of a wonderful Valentineâ&#x20AC;&#x2122;s Day dinner in the hospital with my wife Amy, things took a turn again. A large object that looked like chicken fat was found in my ostomy bag. The nurses were very concerned and I was off for an emergency CT that evening. In the morning, I found out that several inches of my intestine wall were enlarged, but the physicians were not sure why. So, I was scheduled for a colonoscopy. But this was going to be very different, as I had no colon. An Ileostomy or a stoma is when the intestine comes out the front of the abdomen, about four inches to the right side of the belly button. In the GI lab, I chatted with the physician as he was getting the video equipment ready.

EDITORâ&#x20AC;&#x2122;S NOTE: This is the sixth installment in a series of columns. The series began with a column in the December 2013 issue of TechNation. The columns can be found online at www.1technation.com.

Myron Hartman

Biomedical Engineering Technology Program Coordinator at Penn State University

1TECHNATION.COM

FEBRUARY 2015

The flexible scope was small in diameter, much smaller than a colonscope. I requested no pain meds, as I wanted to be alert during the procedure. It was a very strange experience seeing a scope being inserted into your abdomen at the stoma (intestine). There was no pain or sensation of the scope, other than at the entrance at the skin. The images were fascinating to see and it was obvious were the problem was in the intestine. The inner walls of intestine were red and had a mucus look that was very different than the other areas. Biopsy forceps were used in one of the scope channels to take several samples of the inflamed tissue, I could not feel the forceps as they grabbed and pulled the tissue, but it did create a small amount of blood at the sample site. The physician was not completely sure what it was and would have to wait for the pathology report. Over the next several weeks, the tissue discharges in the ostomy pouch continued and my abdominal pain increased. The pathology reports came back clear for cancer and other disease, but indicated the tissue was ischemia, or dying from a lack of blood supply. This could be caused by a clot in the

blood supply to the intestine, created back when I went into septic shock several days after surgery. The plan was to monitor it and see how it progressed. At the end of February, I was finally discharged from the hospital. My two months in the hospital had come to an end. I looked forward to coming home, but it was strange to be leaving the hospital. The nurses helped me 24x7 if I needed anything. I had a routine for meals, pills, dressing changes, physical therapy and my snacks in the evening. When at home I would need to make sure the walker could navigate the rooms, have my pills, dressings and supplies in place and I would now be on my own for attending to my ostomy bag. With the support of Amy and my family, I transitioned back home and started living in my new environment. When I went into the hospital in January, I had made plans with Penn State to return to the classroom in March. I had not accounted for the complications and my extended hospital stay. I could not drive and there was no way I had the strength and endurance to be back in the classroom. I talked with my supervisors at Penn State

Biopsy forceps are used to examine Myron Hartman’s colon.

and decided that I would teach the spring medical equipment course from home through distance learning. I had been using GoToMeeting.com for other Biomed Ed courses and had a good comfort level with it. The students were informed and the IT department at Penn State New Kensington set up the PC, projector and connection. About half of the

Myron Hartman teaches one of his college classes remotely from the game room in his house before being readmitted to the hospital with leg pain.

was the next best thing to being there. I like to walk around talking with my hands and use the white board in a traditional classroom setting, so there were some changes to my teaching style. Overall, the classes went well and the feedback from the students was positive. This was somewhat of a test as well, as we have been talking about doing distance teaching at Penn State

“When class time rolled around, I connected to the hospital’s public Wi-Fi and class went on as scheduled. I sat up in my ICU bed giving the lecture as if I were at home in my recliner.” - Myron Hartman students came into the classroom for the lecturers and the other half connected at home. As time went on, more and more students did go into the classroom for the interaction with the other students. For me, I used my laptop in the game room while in my recliner with all of my supplies by my side. I taught on Tuesdays and Thursdays from 9:30 a.m. to midafternoon. At the beginning, I would be exhausted after teaching. However, I think this helped me build up my endurance and strength. I had a web camera on me and there was one in the classroom so I could see the students. What appeared on my screen was projected on the screen at the front of the classroom. This

to other campuses for the program. I continued teaching from home and then one evening in mid-April I had a cramp in my left leg. This was one of those cramps that would not stop. I tried drinking water, hot therapy, cold therapy, walking on it, pain pills, and anything else I could think of to stop the pain. This continued for over six hours and after seeking advice from my wife and doctor, I was taken to the hospital in an ambulance. After running some tests, they found I had three hematomas in my left leg. One of the arteries tore, possibly from the cramp, and bleed into the tissue in the upper leg. The leg was very swollen and sore. They did not want me moving around to prevent

more bleeding. Being on blood thinners to prevent clots made this a challenge for the physicians. I was admitted to the ICU. I had my wife bring in my laptop, headphones and the other materials I was using to teach. When class time rolled around, I connected to the hospital’s public Wi-Fi and class went on as scheduled. I sat up in my ICU bed giving the lecture as if I were at home in my recliner. One morning the physician team rounded while I was in the middle of a lecture. I told my class to take a break. The physicians asked what I was doing and I explained that I was teaching my biomedical engineering technology classes. They were amazed. One asked what the next subject was and said he may send over one of the residents to sit in on the class. After five days in the ICU, I was moved to a general med-surg unit. Due to my limited movement to prevent bleeding at the hematomas, I developed a blood clot or deep vein thrombosis (DVT) in my left leg. So, I was back in bed with restricted movement to prevent the clot from going to my lung. I continued to teach my PSU classes during the day and my certification preparation courses for Biomed Ed in the evenings. The nurses were great at giving me the time to teach, as they would make their rounds as best they could not to disturb me while I was teaching. Some individuals could not understand my drive to teach and be active, but to me it was therapy and mentally stimulating. My faith, wife, family and a personal desire to become healthy again, all pushed me to remain positive, motivated and to return back to normal.

EXPERT ADVICE

KAREN WANINGER

The Good, the Bad, and the Undefined By Karen Waninger

am a fan of Clint Eastwood movies of all types, especially the old westerns. Some pieces of some movies stick in my head more than others. The first time I heard the theme song to “The Good, the Bad, and the Ugly,” it stuck. That was many years ago. To this day, though, I think of those opening notes when I find myself in the middle of some situation that looks like it will turn out to be either really good or really bad, with little chance of it being mediocre. It’s too bad there isn’t a way to add an audio link to a magazine article. The best I can do is tell you where to find it if you aren’t hearing it in your head already. Go to your favorite search engine and look for something on YouTube about “The Good, the Bad, and the Ugly” theme song. DISCLAIMER: All comments, ideas, opinions or suggestions expressed herein are those of the author and are not in any way representative of the author’s employer or of any organization the author may be associated with.

KAREN WANINGER Director of Clinical Engineering for Community Health Network

1TECHNATION.COM

I’m not sure if “ugly” in the title of the movie was actually meant to describe the situations depicted or the physical appearance of some of the characters. I guess it could fit either way. To clarify, I often use the word “ugly” in reference to circumstances and conditions, not people. In our current situation, I am not even sure that “ugly” fits, so I will just use “undefined” for now. Following up from the last article I wrote, we have landed downriver and for the most part, the raft and the family are all still whole. Now, we are starting to see enough of the new surroundings to begin to be able to start categorizing some aspects of what we have discovered. I am typically an optimist until something or someone really makes me angry, and even then I usually get back to a positive perspective pretty quickly. In my experience, most people only stay negative when they feel there is no hope of changing the root cause of a problem. Some are willing to devote more effort to driving change than others, so there is always variation in each individual’s perceptions of hopelessness. Likewise, there may be variations in whether things are perceived as good or bad, depending

FEBRUARY 2015

on the perspective. So, from my perspective (and please don’t forget about that opening disclaimer), there are a few things that look like they are going to be really “good” in this new environment. The natives we encountered have been very friendly and helpful, showing us how to survive in some unfamiliar circumstances. The families who arrived before us had cleared rocks and trees from part of the land as they built the foundations of their own future. We are the beneficiaries of their efforts, and can start from where they left off to further remove some obvious obstructions and improve productivity for everyone. Certain relationships have already been forged, allowing us to begin trading immediately with reliable suppliers, steering us away from the trappers and miners who are potentially less trustworthy. At the same time, we have some experiences and processes to share with our new neighbors, which are helping create mutually advantageous opportunities for further expansion of the settlement. All of this is expected to work together to produce a bountiful harvest in the long run. Laying aside the analogies

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OPEN for a moment, it looks like this new service arrangement for our organization may result in cost savings for the healthcare system, additional supportive resources for our employees. We are also seeing actions being taken that provide some assurance that we are working with individuals who understand the business of Healthcare Technology Management. Things like creating new positions and hiring necessary additional employees are able to happen without getting buried under all the layers of hospital processes. As in all new situations, there are some things that were not anticipated, and a few of those fall into the “bad” category. There are definite language barriers, with significant differences in slang and dialect that require someone to provide translation at times. Unfortunately, the interpreters are not always immediately available when and where needed, so miscommunication is a common occurrence. We did lose some things of value as we made the move, many of which were previously taken for granted. In that respect, we are living the old saying of “you never know what you have until it’s gone.” Beyond the loss of some personal material benefits, the whole aspect of having complete autonomy to design and build freely within our surroundings has vanished. We are now accountable for demonstrating that any investment of time and energy will result in significant positive impact for everyone, since many more people will be affected by anything that does get built in this new environment. Since change is a continuous process and not a single event, it is impossible to classify every aspect as either good or bad, which leads to the fact that most of this adventure is still “undefined.” Once we arrived at this place, we diligently investigated the

surroundings before we committed to settling here. Even after all of that effort, a few things are not exactly what they appeared to be from the outsider’s vantage point. Like the typical Clint Eastwood character, there is no such thing as giving up and going back. We will continue to explore and map out the paths as we go deeper into the unknown areas. So perhaps you are wondering if there is any message in all of this that applies to your situation, or if it was just a story to fill a couple pages in the magazine. There are two big messages. First, as with all changes in your life, the outcome will depend on you to a great extent. It will be whatever you make it, depending on how you choose to respond to your new situation. Second, as things are going on around you, you can choose to watch and learn, or you can choose to ignore it and think it won’t happen to you. I prefer to be more in the role of watching and learning, and perhaps adjusting future responses based on what I see as success or failure from previous experiences (my own or someone else’s). For us, it remains to be seen whether the projected “Fistful of Dollars” will be saved, or whether in reality the decision will cost “A Few Dollars More”, but what fun is a movie if you know the ending before you watch it?

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EXPERT ADVICE

PATRICK LYNCH

Prepare for the Future – Its Only Going to Get Worse By Patrick K. Lynch

s your job secure? Is it as secure as it was five years ago? Healthcare is changing. We see it all around us. When driving a car, there are warning signs to tell us of upcoming things that could wreck our lives and careers. Not so in the hospital.

PATRICK K. LYNCH, CBET, CCE Biomedical Support Specialist for GMI

1TECHNATION.COM

Administration always tells us that things are wonderful, until that time that they announce that the management of the department has been turned over to ACME Biomedical. It’s nothing personal, just a business decision. Because there are no warning signs, we must be proactive and prepare for whatever might happen. When it is foggy outside, don’t we slow down and ride with our foot ready to hit the brake? We must build a similar safety system for out HTM departments. Most HTM departments and technicians do not do this. They do only what is asked of them. For example, if administration does not care about cost reports, they do not keep the records to generate them. This is a major mistake. In order to prove our worth to our employers, we need to keep meticulous records of every activity that we engage in. Every day, every week, month in and month out. Year after year. It is only through the complete records of HTM activities that future reports can be created. If the basic day-to-day documentation of time, activities, parts, and other costs are not in the system, it is impossible to create an answer to questions from administration. I am shocked by the frequency that I visit what are obviously high-performing HTM

FEBRUARY 2015

departments to find that they cannot drill down into their inventory to create reports, charts, spreadsheets, etc, related to individual equipment failures, costs and uptime. They cannot compare themselves to other HTM departments. They cannot know if they are truly better or worse than their neighbors across town or in the next county. It is really very simple. Here are the steps: Use your computer system (CMMS) to tie every cost related to an individual asset to that asset. This means all internal labor, all external labor, all purchased parts, all service contract costs, all PM labor and parts, and anything else that goes into keeping an individual asset in operation, safe and reliable. Each technician must be especially careful to record everything about every item. And they must do this every day. It takes a year of careful daily documentation to create enough information to be able to begin meaningful analysis. And every service contract must be split up and the costs entered into the system for each asset that is covered. For example, if you have a contract for six anesthesia machines for $66,000, an entry should be made once per year to log $11,000 to each of those anesthesia machines. This is the only way to allocate costs to individual assets for future analysis.

services, minor equipment purchased, tools, training and any other costs to keep the HTM department running. This cost is then divided by the total annual labor hours available for actual equipment service or PM. This is significantly less than the annual full-time hours of 2,080. After subtracting vacation, holidays, sick time, meetings, and adjusting downward by an additional 15 percent for normal unproductive time, the average for a fulltime BMET is in the range of 1,420 to 1,600 hours per year. Managers and supervisors will be even less, since their daily work is not chargeable to individual assets. Secretaries have zero chargeable time. Educate your guys (and gals) about the importance of minute-to-minute documentation. Emphasize that the goal is not to critique them, but to build an information resource that can be used in the future to protect all of their jobs. If they do not provide the initial documentation, the manager does not have the data to prove their worth to administration. Look at your CMMS. Are all the fields filled in? Why not? If you are doing only what is required today, your ability to protect your job from unforeseen threats in the future are severely limited. Get busy, or get your resume dusted off.

Fill in the acquisition cost for each and every asset in your computer system. When using Cost of Service Ratio (COSR), the acquisition cost is the only other number that you need other than a full yearâ&#x20AC;&#x2122;s maintenance costs. If you do not have all of these filled in, use my technique: Download a spreadsheet from the HTMA-SC website (www.HTMA-SC.org). It has the average price paid for many hundreds of equipment types. You can use these numbers to fill in the missing information in your database. It may take a while, but it is vital. (By the way, it will also help you clean up the non-standard names that your BMETs call things in your inventory). Determine the actual charge-back cost for an hour of labor of one of your technicians. It should be in the neighborhood of $100 per hour. Note: The chargeback cost is the hourly labor rate that you load into your CMMS to convert the hours spent by your in-house technicians into dollars. This is needed to make item-to-item comparisons of costs to maintain. The hourly cost is totally unrelated to the hourly rates your technicians are paid. The charge-back labor rate is the total cost of running your department, minus parts and service contracts. This number should include all personnel costs, calibration

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THE ROMAN REVIEW

On Leadership Courage By Manny Roman

recently read an article by Peter Bregman titled, “Why So Many Leadership Programs Ultimately Fail.” The main point of the article is that “…there is a massive difference between what we know about leadership and what we do as leaders. Most leadership programs teach knowledge.”

MANNY ROMAN CRES, Founding Member of ICE imagingigloo.com

1TECHNATION.COM

This hit home pretty hard since I have been in the training and education business for over 33 years. We have always had a quasi joke that said that we are not teachers because teaching implies that learning is taking place, thus we are instructors. Learning, by our definition, is a relatively permanent change in behavior. A behavior is observable and since we rarely had the opportunity to see new, long-term behavior from our students, we could not truly ascertain that they had learned. So the outcome of the training we provided was knowledge. Knowledge by itself is relatively useless. We all know a great deal of stuff. Even a non-swimmer knows what to do to stay afloat. Throw that person in the water and he now has to apply that knowledge. For knowledge to have value, it must be applied and then it becomes an observable behavior. Education and training are also different animals. Education is the type of general stuff we were provided in our early years. Two plus two equals four. This is knowledge. Training provides specific task-based programs where we are taught to apply knowledge to specific situations. When we provide fundamentals of servicing radiology equipment courses, we provide mostly education, even if there are laboratory exercises. When we provide a specific product course on a particular manufacturer’s machine, we are providing mostly training. In one we provide the knowledge necessary to be applied in the other. Back to Bregman’s article regarding leadership training. He is essentially saying that most leadership training is not training at all, by our above definition. We

FEBRUARY 2015

spend a lot of time and effort and money on leadership education. We generate a great body of knowledgeable, welleducated leaders. We provide that education in a safe, non-threatening environment. The evaluations are anonymous to ensure safety and preclude bruised feeling and egos. His conclusion is that no leaders fail due to lack of knowledge, they own that part. Most failed leadership is the result of a lack of what Bregman calls emotional courage. He states that what makes leadership difficult is not the theoretical, it is the practical. It’s not about knowing what to say or do. It is the willingness to place yourself in the discomfort, risk and uncertainty of saying it or doing it. It is about doing this without separating yourself from others and remaining strong in the face of uncertainty. It is speaking and doing when others are silent. In the TV show “Game of Thrones,” the son asks his father, “Can a man still be brave if he’s afraid?” The father replies, “That is the only time a man can be brave.” This means that saying or doing the easy things does not demonstrate emotional courage. Emotional courage can only be demonstrated when it needs to be said or done and you are the only one who will stand up. Doing the right thing when others may get angry, or against a politically correct situation, or a distracted situation, and not becoming defensive yourself, is emotional courage. John Maxwell makes a very clear distinction between managers and leaders: Managers do things right, leaders do the right things. Bregman states that, to be effective, training must be conducted in a real life

environment without the safety of a controlled classroom. This is where leaders can be challenged to be courageous in the face of whatever fear they are facing. This is where they can ask themselves, “What will it take for you to speak up?” I have conducted customer relations skills seminars for many years now. I speak on communications, personalities, dissatisfaction, competence and other topics. When I am given additional time, I even conduct role play exercises where we put volunteers into likely circumstances and observe and evaluate their behavior. The attendees leave energized and ready to take on those difficult customers. I do a marvelous job of providing valuable knowledge. I suspect that the knowledge disappears, or at least fades, rather quickly for most and they get squashed like a grape by their irate customers. I have often been accused of being disruptive at meetings because I am willing to say what others don’t want to hear. Sometimes they just don’t want to hear my voice. I now have Bregman’s article and permission to be my normal emotionally courageous and witty self.

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DID YOU KNOW

A high-tech look at healthcare

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CrowdOptic enables smart glass wearers to simply aim at another device to inherit its point of view. Surgeons and their trainees can wear Google Glass powered by CrowdOptic to see through the eyes of one another during surgeries.

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Caregivers can observe patients through smart glass at home and in remote locations in order to discharge patients earlier and reduce readmittance to healthcare facilities.

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THE VAULT

o you consider yourself a history buff? Are you widely regarded among coworkers as an equipment aficionado? Here is your chance to prove it! Check out “The Vault” photo. Tell us what this medical device is and earn bragging rights. Each person who submits a correct answer will receive a $5 gift card and will be entered to win a $25 gift card. To submit your answer, visit 1TechNation.com/vault-february-2015. Good luck!

LAST MONTH’S PHOTO

SUBMIT A PHOTO

An Advanced Med-Science, Model CP, Coronary Perfusion Unit from 1975.

Send us a photo of an old medical device to jwallace@mdpublishing.com and you could win lunch for your department courtesy of TechNation!

The photo was submitted by George E. Ross III, CBET, at Yale New Haven Hospital, Saint Raphael Campus. To find out who won a $25 gift card for correctly identifying the medical device visit 1TechNation.com.

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FEBRUARY 2015

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Email photos and requests to: info@eng-services.com 330.425.9279 X.11 Kenneth C. Saltrick www.eng-services.com FEBRUARY 2015

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