As part of a decentralisation reform in the Albanian public healthcare service, local hospitals are provided with a maintenance budget and asked to prepare service contracts for the maintenance CT, MRI, ultrasound and radiography devices. The technical departments are facing many problems like; low competence, lack of manuals, no records of interventions in the equipment etc. Instead of experimenting with completly new contracts we are advicing them to study comprehensive and other service contracts used by professionals in other countries. So we'd appreciate very much if you could share with us any service contract templates or at least details of important requirements used in a maintenance contract like; calculation of annual cost (as % of purchase cost) , number of visits etc
Any suggestion would be very appreciated

Aldo Ndoca
Project Coordinator
Albanian Biomedical Engineering Association

What do you think these contracts should cover, Aldo?

One tip though:- forget all about linking contract fees to equipment capital value. Unless, that is, your hospitals are loaded (with money). Another tip is to forget "number of visits" ... what you want is "resident engineers" (or at least engineers shared between sites).

Sounds to me like you have serious problems (with technical support) in your hospitals. Is the new plan to use local companies? Are they any better than what you already have?

Or is the intention to bring in tenders from outside the country? Expect to pay "big bucks", if that is the case.

Frankly, without a greater understanding of the conditions prevailing, it is difficult to advise. A contract that may have seemed ideal for, say, Athens, London or Milano may (or may not) be entirely suitable for Tirana. In my experience, to be truly successful, technical support operations need to be geared to local conditions. That might sound obvious, but how often is it put into practice?

Are accurate inventories of equipment to hand? Is the condition of equipment known? How old is the equipment (would parts still be available)? Would an incoming contractor need to spend the first n months establishing such information? Would he then have to embark on a repair programme to bring equipment up to scratch? Where would the manuals come from? Do you hold spare parts? What facilities - workshop space etc. - would be available (to the contractor)? How have you been managing until now? ... such is the list of questions needing to be answered. It is most likely that a survey would need to be carried out before you think about going out to tender, I should imagine.

Meanwhile, what are Mr G.E., Mr Philips and Herr Siemens saying, I wonder?

Have you seen this article, by the way?

Hi Geoff
thank you for replying
The hospital managers know very little about maintenance. Because of the lack of qualified engineers at local hospitals (the best engineers are working at the only university hospital and at the private companies like GE, siemens, philips etc) they believe the only solution is contracting local private companies. This "saudi arabia" short term solution could work if Albania would be a rich oil producing country but the fact is Albania is just one of the poorest countries in europe.
Anyway we believe that if we could provide the regional hospitals with contract templates it would at least have an education benefit towards biomedical engineering and also orientate them in using their meager budget the best they can by covering just a few equipment

Yes, I can see that example contracts would help. But I rather sense that there is an "elephant in the room" scenario here. That is, all medical equipment needs to be covered by some sort of maintenance scheme, not just the imaging equipment.

Am I right in assuming that healthcare is provided in Albania through a "free" service provided at government hospitals? Do the hospitals have biomeds on the staff? Wouldn't the meagre budgets you mention be better applied there? That is, recruiting in-house biomeds, and getting them properly trained, etc.

Do the local companies you mention offer a good service, at a reasonable price?

Can I ask what your own involvement is here, Aldo? Ministry of Health, or similar? I'm asking because (if the managers at the regional hospitals lack expertise) I'm wondering if it wouldn't be better to administer maintenance contracts from there. That is, centrally (even though your first post mentions decentralisation).

Sorry for posing so many questions.

yes there is a very unpleasant situation with the maintenance
PPM doesn't exist, there are only some attempts here and there mainly with not sophisticated devices.
All the maintenance budget goes for the expensive devices. The service contracts covering these equipment are very simple, favouring the suppliers that provide this service (the annual fee is 8-12% of equipment capital value, there is no proper monitoring of the service delivered, no records of the interventions). So these contracts are real black holes for the taxpayers money.
So our intention is to help hospitals to develop new service contracts and without previous records we find it a very difficult challenge. That's why we'd like to consult service contract samples that you could help us with and maybe next year after monitoring the service delivered, develope contracts that would fit to the local requirements. I know the example service contract is not the long term solution, but this is an emergency change that could save lots of money on inefficient existing service contracts.
Answering your questions: yes there is a free service provided for everyone financed by state budget (ninistry). a decentralization is going on. The health insurance institute (again government) will buy the health service from the hospitals. that means who is paying insurance contributions will get the service for free the others not. It sounds fairer but at the moment it is not managable because hospitals don't know the cost of their service. so back to our concern. Ministry will support hospitals this year with procurement of new devices, but the hospitals will take care of the mainetnance. A BIG MESS, isn't it.
The service offered by private companies is very questionable, mainly because there are no good monitoring routines from the hospital management
We are just an association of engineers/technicians mainly of public sector trying to help each other through educational materials by collecting information about management and maintenance of med dev, translating them, trying to pilot them whenever we find a chance and lobbing to Ministry and high healthcare managers for changing the system. We believe that by carrying out successful simple interventions in local hospitals we can create good examples and force policy makers to listen and make changes.
this message is getting too long for the forum

thanks again for your interest and any professional advice you are offering is very appreciated
Aldo
Albanian Biomedical
Our engagement is on voluntary basis

An interesting scenario, Aldo!

The nub of the problem is, of course ... funding. That is, lack of (as usual, or always). And one that is not unique to your country, believe me.

In days gone by people from the "West" used to enjoy visiting such situations, travelling around, taking a look, fixing equipment (sometimes), drawing up lists of equipment, and lists of deficiencies, advising local managers and techs, perhaps writing a report ... and then never returning.

It was probably a great adventure for them, but the long term benefits to the country concerned may only be guessed at. It was like putting your hands into a bucket of water, splashing about a bit, then pulling them out again. See how still the water becomes!

(actually, it may have been the lists that were the most useful ... if only they had been acted upon)!

These days, with the introduction and near global uptake of the internet, I believe we have a new paradigm for tackling issues such as those you describe. A new approach, which is, I feel, far more likely to reap long term rewards. As long as there is access to the web, the tech, however remote, is empowered by the same information sources as any other tech, anywhere else in the world.

You have your Albanian Biomedical Engineering Association. A great step forward! This is the ebme forum. Another great resource! We had nothing like this in "my day" ... we had to struggle on alone, often in circumstances not dissimilar to the ones you describe.

By now, I'm hoping that various example service contracts will have found their way to you. Other than that, this forum remains at your service.

"Helping techs to help themselves". "Spreading the Word", "Sharing the Wealth (of Knowledge)". "Learning by doing" ... and stuff like that.

Like you, my engagement is on voluntary basis.

If the system there favoured direct vendors' service contracts, there will be many contracts to be signed. Set up a system that there is a single department, e.g., the biomed, to oversee the management of the contracts. All service requests will likewise be directed to the department so that there is a trail to all the reported corrective or preventive maintenance. You probably need a maintenance database to track each periodic maintenance and also to log in those under corrective maintenance.

You will also need a contract document specifying your terms and conditions detailing the frequency of maintenance, the response time, the turnaround time, a loaner unit (if necessary), whether it is labour-only cost alone or comprehensive, etc.

Workflow for the contract document will need to be initiated by the requestor (the department user), flowing to the procurement office, biomed, etc. At each phase there will be an authorizating officer providing approval and feedback before the contract document is signed between the vendors and the hospital.

Your probably need to lock in the price for at least the next 3 years in the contract and also have an annual appraisal of the vendors for its service, etc. I would like to say an experienced biomed is suggested here.

Of course, you could consider simply establishing a guaranteed hourly rate from each service provider and just call them in as and when required. That is, no contract(s) at all. If the companies know that a long-term arrangement is in the offing (and if they've got any sense at all), they will seek to impress, rather than simply gouge ... especially if it can be shown that they are in competition with each other. This may well end up being the cheapest option.

If you must use service companies (whether under contract, or on a call-out basis), then that's the key:- never put all your eggs in one basket, and strive to maintain an atmosphere of competition between them.

Another point when awarding service contracts is that you should always include penalty clauses to guard against poor (or non) performance. By this I mean a financial penalty to be be applied, typically on an upwards sliding scale (to a maximum) that kicks in once the agreed response time (or any other criteria agreed upon) has passed. It's a great way of ensuring that contractors actually meet their obligations and keep their promises. And I write here from experience of O&M contracts myself (on the contractors' side). Many a long night was spent beating those penalty deadlines, let me tell you.

Honestly direct vendors' (authorized dealers) charges are sometimes extremely high. Why pay such high prices when you can settle for less. I agree that some of the kits only need on "call-out" basis and the contract must include a penalty clause for downtime recovery if they cannot deliver for the time they promised.

Cheers!

The "answer" is to have your own people available "in-house"! But you need to find them in the first place, then train them, keep them, motivate them ... and all the rest. It's really more about leadership than any other single factor (with funding being prominent)!

Despite what politicians would like us to believe, quick fixes never provide the long term solution!