The first EBME workshop that I set up from scratch was at the Princess Alexandra Hospital in Harlow.  I worked closely with the head of estates to find a suitable location, which ended up being an old disused generator room.  It is not unusual for the medical equipment maintenance workshops to be in a basement, or an out of the way room, and the facility provided forces innovative working processes to be adopted.  I have subsequently been involved in setting up many more EBME facilities and reviewing existing NHS and Private hospital facilities to advise on improvements. Most EBME workshops I visit are tight on space, so it is important to consider workflow management. i.e. How can we make the best use of what we have?

Workflow management

Workflow management is the coordination of tasks or jobs that make up the work your EBME department does. By ‘workflow’ I mean the sequence of tasks that are part of some larger task such as planned maintenance or a repair and is a definable ‘work process’. The purpose of a workflow is to achieve some result, and the purpose of workflow management is to achieve improved results in accordance to your goals. Workflow management is principally focused on the structure of work within your organisation and how hospital teams collaborate to complete this work. For example, phone call comes in for a break down – what do you do? In principle, workflow management doesn’t require software, but in practice a computerised maintenance management systems (CMMS) is used to keep track of the work and to automate some processes. Workflow management is concerned with the work that people do, but repetitive tasks, such as planned maintenance, may also be scheduled through this.

Inefficient workflow: Faulty equipment is brought to the workshop

example 1

The caller reports the fault (3 minutes nursing time) and is told to notify the porters to bring the device to the EBME workshop for repair (3 minutes nursing time). There is a wait before the porters pick up the device (90 minutes wait – non-urgent) then the porters bring the device to the workshop (10 mins porter time). The device is logged on the CMMS (5 minutes admin time) and then put on the goods in shelf (2 minutes). The device stays on the shelf until a technician is assigned the job (24 hours). The technician discovers it is a simple fault (repaired in 30 minutes).

The technician puts the device on the goods out shelf and reports to the caller it is ready for collection (3 minutes technician time), the caller notifies the porters to bring the device from the EBME workshop back to the ward (3 minutes nursing time). The porters log the request (90 minutes wait – non-urgent). The porters collect the equipment and return to the caller (10 mins porter time).

In this example, the time taken from reporting the fault to the equipment being back in service is:

3 + 3 + 90 + 10 + 5 + 2 + 1440 + 30 + 3 + 90 + 10 = 1686 minutes (to return device to service)

‘Lean’ workflow: Technician goes to the faulty equipment

example 2

The caller reports the fault (3 minutes nursing time) the technician logs the call on the CMMS (5 minutes admin time)  and goes to the ward (10 mins) completes a simple repair in-situ (30 minutes time) and notifies the caller face to face that the device is ready to use, job closed on CMMS (5 mins).

3 + 5 + 10 + 30 + 5 = 53 minutes (to return device to service)

Workflow management may include IT systems integration, in order to share data between workflows and other IT systems within an organisation. The visibility of the work that comes with workflow management tends to lead to awareness of how to improve these workflows.

As illustrated, the time taken to return the device to service in ‘example 2 Lean workflow’ is 30 times faster than ‘example 1’.

Quality improvement

Quality process improvement is a natural part of workflow management. A good quality process should document what you do with regard to workflow and therefore your team should be “doing what you document that you do” as outlined in your quality management systems. This is also one reason why workflow management is a management discipline and not just a software process.

Improvement is about changing how people do their jobs, which is harder than reconfiguring software. One of the most common areas for improvement is carrying out planned maintenance on equipment where it is located.  The majority of equipment does not need to be returned to the workshop for planned maintenance, but unfortunately many departments are in the habit of bringing equipment back to their workshops for simple maintenance. 

Even if the equipment is being repaired, the majority of the repairs can also be rectified where the equipment is located. The benefits of not bringing equipment back to the workshop include faster turnaround for planned maintenance and repairs, and less requirement for storing equipment in the workshop (that is waiting for planned maintenance).  It is better that the equipment remains with the clinical user, and therefore available for use, then be out of use sitting on a shelf in the workshop.

Adopting these methods stops large quantities of equipment being brought into workshop areas that are already limited in terms of storage space.  Sometimes, managers must adapt to the situation at hand, and find solutions that suit them, and the clinical users.

It is important to understand that if medical equipment is kept and located in the clinical areas where the devices are required, the uptime (the time available for clinical use) is much improved, and therefore less equipment is required in the clinical areas resulting in higher utilisation rates and lower procurement costs.

Evidence shows that effective healthcare technology management can improve utilisation of medical equipment and reduce costs. The World Health Organization (WHO), states that poor management leads to a lack of standardisation, and the purchase of sophisticated equipment for which operating and maintenance staff have no skills.

I have always endeavoured to find ways that make it easier for me and easier for my team to be able to carry out our work.  When inside the workshop, it is important to segregate the areas so that when equipment arrives for repair or maintenance, it can move from a goods in area to a goods out area in a logical fashion. 

Workflow inside the workshop

When thinking about how to improve flow within you workshop, it is important to understand how devices flow through the facility. You want the devices to ‘flow’ through as quickly as possible. This means thinking about where equipment comes in, how it is dealt with once in the workshop, and how it goes out. This is effectively a quality management process. You will need to segregate ‘dirty’ equipment waiting for repair with ‘clean’ equipment ready to return. Setting up quality management processes is common sense. You would not put clean repaired equipment, on the same shelf as dirty equipment awaiting repair. The written processes should mirror what you actually do. If you use a modern CMMS, in conjunction with ‘Lean’ quality management processes and lay out your workshop in a logical fashion, not only will this improve the efficiency of your team, it will also result in lower ‘down time’ and keep devices in the hands of the medical staff, ultimately benefitting the patients.

example 3

This is a quality management in action, and the CMMS, with the lean processes, and good workshop layout maximise the impact on uptime. If everyone in the team understands what the processes are, and how to use the CMMS, the workshop will run much more smoothly.

Sources:
https://www.signavio.com/post/what-workflow-management-is/
https://www.ebme.co.uk/articles/management/medical-devices-getting-management-policies-right
https://apps.who.int/medicinedocs/documents/s17709en/s17709en.pdf
https://www.ebme.co.uk/articles/ebme-quality-management

Dr John Sandham