EBME Forums Forums Management Medical Equipment Management The Zero-Budget Department

I am interested in the idea of the “zero-budget department”, whereby the in-house hospital biomed department (or whatever you want to call it) is allocated only a limited amount for basic overhead and generic parts, service consumables and the like. Such a department would be funded almost entirely (or, even entirely) by billing the user (customer) for all work carried out, just as outside commercial biomed shops do.

In this way, the tension between biomed and the hospital departments (that we all know so well) may be reduced (or eliminated altogether), as the user then has a choice about how her equipment is serviced and repaired. She can use an outside vendor if she wishes (the in-house biomed would generally be cheaper, we hope). If she wants “instant service” (hand-holding, or whatever), she can pay extra for “premium service”. Rates can be negotiated for all forms of service (night-time call-outs etc.). In this way, the user gets what she pays for (and only that – it’s tough in the real world!).

All parts and consumables allocated to each job would be charged for, of course. Again, the user would be given a choice to out-source expensive parts from elsewhere, if preferred.

Similarly, PM would be down to the user. She can arrange for it to be done when she wants it done, and by whomever she chooses. Or, not at all if she wants to take responsibility for that. Biomed would simply post reminders when PM falls due.

It’s all about getting the user to take responsibility for her equipment, and giving biomed the chance to grow, and become more efficient, by adopting business practices. And even a way of retaining bright young techs., as they each aspire to become the manager of this exciting enterprise!

I am aware that some EBME departments within the NHS already operate such a scheme. So, does it work? How do you get on?

Personally, I would have thought that this is the “way forward” for NHS biomed departments. Anybody else have any comments about this?

If you think in terms of a better way, you will always find one.

“Such a department would be funded almost entirely (or, even entirely) by billing the user (customer) for all work carried out, just as outside commercial biomed shops do.”

Surely the main advantage of an in-house department is that the user doesn’t get a bill !


"In this way, the tension between biomed and the hospital departments (that we all know so well) may be reduced (or eliminated altogether), as the user then has a choice about how her equipment is serviced and repaired."

They have that choice now ! If it’s an expensive repair the user should be asked if they want to go ahead. They can always choose to scrap it instead.


"She can use an outside vendor if she wishes (the in-house biomed would generally be cheaper, we hope). If she wants “instant service” (hand-holding, or whatever), she can pay extra for “premium service”."

An in-house department should always provide a premium service to all users.


"Rates can be negotiated for all forms of service (night-time call-outs etc.). In this way, the user gets what she pays for (and only that – it’s tough in the real world!)."

Terms and conditions should be a Trust negotiated area. How would you afford to run an on-call system if only the theatres wanted to pay for it ?


"All parts and consumables allocated to each job would be charged for, of course. Again, the user would be given a choice to out-source expensive parts from elsewhere, if preferred."

So the user is going to pop down to the RS Trade Counter, is she ?


"Similarly, PM would be down to the user. She can arrange for it to be done when she wants it done, and by whomever she chooses. Or, not at all if she wants to take responsibility for that. Biomed would simply post reminders when PM falls due."

That’s exactly how we work now. We administer all the contracts and if we have the knowledge and facilities to do the work, we offer an in-house service – which they always accept ! If they decide they don’t want to pay for a service contract and just deal with repairs as they arrise, then that’s what they do. It’s their equipment, so it’s their choice !


"It’s all about getting the user to take responsibility for her equipment, and giving biomed the chance to grow, and become more efficient, by adopting business practices. And even a way of retaining bright young techs., as they each aspire to become the manager of this exciting enterprise!"

Charging everyone for everything is more likely to encourage people to carry on using equipment which should be repaired (e.g. if it’s been dropped). If they know they can just call us and get it sorted, it makes the hospital much safer.


"Personally, I would have thought that this is the “way forward” for NHS biomed departments. Anybody else have any comments about this?"

Yes – but it would probably be edited out in case it offended someone !

Speaking from a physics (rather than EBME) point of view...

Back in '93, we expanded our range of services offered within our hospital/trust. This was setup via a capital injection (from our trust) and we cross-charged for EVERYTHING we did.

What a pain in the a** - we practically needed to employ someone just to handle the billing process, how much hassle it caused upstream (finance dept etc) I've no idea. The scheme was dropped very quickly 2 yrs later and we were "top sliced" an amount to provide a service.

This new service is much easier to administer, they have no worries about calling us in Jan/Feb/March because it is not going to impact the overspent budget. In your scenario, if a directorate/department is on a spending freeze and a piece of kit goes tits-up what happens?

BTW
Its a damned site easier to get rid of a department operating in the manner you propose than a full in-house service. I am told that many moons ago, one of our departments did >50% of it's work on contract to whoever would pay. When a review of service took place, 50% of the staff were cut (read : fired) and external work was stopped.

At Yeovil, we have run on a “Zero Budget” since 1997, after actively encouraging the Trust to move to move to a recharge system for all of our work. The funding for the department and electro-medical equipment had been historically from within an Estate Management Organisation. At that time, our organisation had gone through a period of several years where funding and resources had been cut and surprise surprise, despite all best efforts the revenue didn’t follow the equipment .In the political climate of the time, the services we provided were not considered a priority. Were we unique in this? I don’t think so. As a contract manager with, a fixed budget and a “though shall not overspend” culture (unlike today’s blameless culture!!) , I was frequently being required to make judgments and decisions that I considered to have clinical consequences i.e. with my fixed budget for the period, do I repair the ITU ventilator or the transport incubator. Our budget (overspend) was devolved to the clinical directorates on the rationale that they were best placed to prioritise their resource. They were also best placed to acquire additional funding when they needed it. We are now in our sixth year, and as a department I feel we have not looked back. We run a paperless system, which is administered on reliable and robust SEMS system (which is worth looking at). All labour and parts etc. are put on to the system at time of repair by the technicians. Work is recharged via a monthly report to finance which takes about an hour.
We have found some of the benefits to be:
The clinicians have been better placed to secure funding for THERE equipment;
We work closer with equipment managers and users;
Users take greater responsibility for their equipment, and are quick to deal with problems that cost THEM money;
It has allowed us to focus on our true costs to ensure we are as efficient as possible;
We can clearly demonstrate savings against external contracts, sharing the savings with users. This enables us to develop and improve or test equipment and IT.

Bob..

Who should actually pay for equipment repair? The user department the owning department who might have lent it out or it might have just "wandered". We cross charge major repairs and we get in to so many arguments over who actually pays. And it is amazing how much suddenly become pool equipment. Our NICU even tried to claim most wards used an enclosed specialist incubator and it was pool equipment.
This leads to a lot of time wasted in trying to get people to pay.
Surely the best policy is the exact oposite. All equipment is owned by the hospital in a pool for general use by where ever it is needed at the time and maintained by a centrally (and fully) funded department. Their only ionterest is to make sure the equipment is correctly maintained and service and to do it within budget so their is incentive for them to look for ways of saving money. If you cross charge then why make the effort to look for cheaper options? In theis way the overall hospital budget will be reduced.
Not on my budget is not a very helpful position for a Trust and us tax payers, just the manager of that section.
Robert

Which provides a safer service ? The user knowing that unless it's a major disaster and going to cost an absolute fortune (in relation to the value of the equipment) - then they just contact the in-house team, and it's sorted.

OR

The user having to look at the budget statement before picking up the phone - and hiding the broken item in a cupboard if they are overspent.

I don't think there's really any contest !

As long as people know that repeated abuse of equipment will be reported to Nurse Management, then they will be careful with it - relatively speaking !

As for department budgets - get the money committed when the equipment is purchased - and get the Director of Finance to sign up to it. If the user department tries to hold back, he (or she) can just take it off them. If you keep the equipment inventory you know exactly what equipment has been purchased every year, so you've got all the amunition you need.

You don't need a slipmat to keep in the groove.

I'm not quite sure that we have enough essential equipment for our users to "hide in cupboards", and I think on the whole they are professional and responsible enough not to cinsider that as an option.
Revenue is bid for and generally committed when equipment is purchsed. On advice from myself, the relevant clinical budgets receive this. This makes them focus on their equipment management service, and take an active role. It's not just something that happens. "Major disasters" are always dealt with in consultation with the equipment owner, finance and ourselves.
Your comment on needing "amunition" makes it sound like you are fighting a war with your users, we have made allies of ours.
Bob..

Thank you for that, Bob.

Let’s hear from a few more of you Zero-Budget Holders, then (I know there are more of you out there).

I didn’t want to respond to any of the kind remarks posted above just yet, but I can’t resist a couple of quick ones. No-one is talking about taking away the “in-house” team (D.J.), we’re just discussing how to pay for it. And “pool” equipment repairs should obviously be charged to whomever owns that equipment (the Trust, most likely – someone must own it, after all; if not, what sort of “equipment management” is that?). Personally, I believe that the fact that “the user doesn’t get a bill” is definitely part of the problem, Roy. If they did perhaps they would not be so careless with our (ie, us tax-payers’) equipment!

That’s probably enough for now.

Hi Guys, just a couple of comments from a user of ebme services rather from inside.
There might be a number of disadvantages to the transparent charging/billing for everything culture. One problem that I can forsee is a potential view that the end user may get a lower cost service from elsewhere, or worse, feel that minor "fixes" may be done by themselves! Another issue may be that although there are those of us who do actually see our statements but still substantially exceed budgets simply because we have to have equipment to provide a service, and worry about justifying it later, may be outnumbered by those who panic at the mere thought of exceeding budgets and shy away from prompting work that may be expensive. Items on "loan" may appear to replace unusable kit and incompatibility issues will arise.

My major plan when taking on my role as Theatres Equipment Co-ordinator was to forge as close a working relationship as possible with ebme services. I think I've just about managed that, we make decisions jointly and communicate freely.

Although I do try to instill a sense of fiscal responsibility with end users as this attempts to mitigate equipment damage through disregard of the costs involved this is by no means the best way to gain support from clinical staff. The mere mention of finances can generate a backlash from clinical staff and howls of "we're here to treat patients not worry about money".

Whilst I can see financial arguments for both methods the practicalities of zero-budget systems may well be harder to actually manage. Do we then employ an accountant or heaven forbid another manager to sort out the billing arguments!

As I understand things, one of the definitions of a “quality system” is one that "fully meets the customer’s requirements”. Welcome to the forum Tim. I’m heartened to hear that your hospital actually has an Equipment Co-ordinator in the Theatres (and yours certainly sounds like the correct approach). So let’s hear from more of you Equipment Co-ordinators, then. What service are you looking for from the biomeds (and what kind of a service are you getting at the moment)?

It seems like I hear the “…I’m here to treat patients” cry every day, too. Frankly I regard it as somewhat trite (see my comments elsewhere about “emotional blackmail”!). With that sort of flippant attitude, nothing is ever going to get better, is it? One quick question – when budgets are “over-spent”, where does the extra money actually come from?

And, I don’t see why there should be arguments about billing (bottom line is, if they don’t want to pay, then they don’t get the service next time – just as in the “real world” that everyone else has to function in). I stress that it’s all about getting the hospital departments to take responsibility for their equipment assets (whilst realising, of course, that some of our Brethren who sit at management level would never let that happen, as they see that as being firmly within their own “empires”).