Working for the inventor of the world’s first blood glucose monitor was an interesting experience. I don’t think I’ve ever pricked my finger so many times in my three years that I worked for him. He was a guy who used to… He lived not far from Derby, in the Midlands, and worked out in Australia.
It was a great couple of years, working for an inventor. Everywhere you went, you would always see an opportunity to invent something and make some money out of it.
By now I’m told that, after 15 minutes, caffeine should be now seeping through your veins, reaching a maximum blood concentration of caffeine after about 45 minutes, so it should make a fun time of Dave Mulvey’s question-and-answer session in a little while (Laughs…)
Unfortunately, I’ve not got any slides to make you go, “Ah,” but I have got this one that makes you go, “Oh.” What I’m going to talk about this morning, the role of the clinical engineering department in the organisation, I’m not going to stand up here this morning and teach you to suck eggs. I’m sure you can all do that very well. There’s a lot of experience in this room, and you’ve probably been working in healthcare for many, many years.
However, what we can do is we can teach the younger folk to suck eggs and learn from our experience that we’ve amassed over the years. We must remember to pass that on in the best way possible. Educational events like this are excellent for doing that sort of thing. We are very pleased to be able to come along today and support it-
-and I hope that everybody takes away something from this day.
The Role of Clinical Engineers.
What is our role, clinical engineers? It may be that you regard us as the complex and comprehensive healthcare professional in the top left-hand corner there, diligently using his oscilloscope and repairing what looks like it might be some sort of diathermy.
People might look at us in the bottom left-hand corner as a bank of managers who are managing our medical engineering department and all their equipment in the hospitals. Some people, looking at the nuts and bolts, might get the name ‘medical’ mixed up with ‘mechanical’ and think of us as mechanical engineers.
Perhaps in the bottom right-hand corner we are what we perhaps think of ourselves to be: the competent, professionals who work in and around healthcare on a daily basis, giving advice and helping our colleagues, our clinicians, and our patients.
Perhaps we would really secretly, though, like to be part of the ‘Top Gear’ team, designing the Reliant Robin space shuttle, as, being engineers at heart, we’re all very, very practical people and we do really enjoy getting our hands on practical things.
I have news for everybody: if you haven’t already known already that, in the words of Bob Dylan, “The times they are a-changing.” Back in 1964 when Bob Dylan penned those lyrics, around about the same time cardiac recorders were developing the CR180 defibrillator.
I won’t embarrass anybody by asking you to put your hand up if you recognise it, or maybe if you acceptance tested the very first one, but let’s just fast forward all those years now to where we are today, where we’ve got automatic external defibrillation in railway stations and, heaven forbid, on coffee shops’ walls, where members of the public go. We’re expecting people who’ve got 15 minutes’ worth of training to rip off the defibrillation pads, slap them to a customer’s chest, and discharge high voltage.
Who would have thought it back in the days, in the 1970s, that we’d be putting high voltage in the hands of – let’s face it – amateurs? But times have changed. We’ve changed, if we look back over all the equipment that we’ve dealt with over the years, but we’ve still got to develop and change further.
A quick whistle-stop tour through some ideas this morning in the next 20 minutes on some new thinking, new ideas that we can think about; some thoughts on a new toolbox – the things that might be available to help us do our job better – a little look at our new workshop and how that might change, and then what’s our role and vision going to be?
Firstly: new thinking. The first term I want to – sorry, I just swallowed an ice cube (Laughter) – the first term I want to suggest to you, you might have come across the term and the phrase ‘value’ before. It has been mentioned in one or two seminars over the last few years, but there’s a definition: it’s the importance or worth of something that’s not necessarily financial.
These days in the NHS, you’d be chucked out the back door if you didn’t mention the word ‘financial’, because everything is so important about the money in the budget, but value is more than just the money. We’ve defined value as the ratio of benefits to cost.
We’re engineers, we’re technical people; we just love numbers in our job. If you can’t measure it, we don’t really give much credence to it, but with value it’s a more qualitative sort of thing, it’s subjective. It’s hard to put into a number what value you can ascribe to something. However, by inventing a few graphics, these value diagrams that you might come across, we’ve helped to put it into sort of an engineering way of thinking about it.
We can show how value increases or decreases, and how cost can increase and decrease, and the benefits – sorry, [I got that the wrong way 0:06:20] – benefits and cost increase and decrease, giving you the value at the end. It’s a good way of being able to almost quantify what you can’t.
An example, an example of how you might use this value ratio, is that you’re in charge of a clinical engineering department. You’ve been told that you want to throw a lot of money at your endoscopy department. There’s a lot of equipment that needs replacing, it’s going to cost an awful lot of money. You sit there, you scratch your head, and you realise that actually there’s no way anybody is going to give you the money to replace all that equipment and put it on service contract. So, what you do is you think about different ways of how we can afford that.
One of the options that you might go to is you might take on a clinical engineer specifically to do endoscopy equipment and embed them in that department. What you’ve done then is you have increased the benefits, increased the value of that person to the department. You’ve got somebody in there who is actually doing the work, who’s replacing equipment, they’re checking equipment; they’re fault-finding and fixing things right on time, right when it needs to be done. You’ve increased the value because you’ve increased the benefits and you’ve lowered the costs if you’ve done your sums right.
One quick way of doing that, then, thinking about value. There are lots we can talk about value, but I’ll leave that thought with you as one thought and move on to the next one, which is the ‘Twin Pillars’ approach to healthcare technology management. You might have come across this before, courtesy of John Amoore.
The ‘Twin Pillars’ approach is based on the keystone model, where the idea is that patient care is only really effective when it’s supported by two pillars. One is supporting and advancing care, which are the things that we probably don’t do so much of these days that we have to think about in the future – I’ll come onto them in a bit more in a second – and, of course, our traditional pillar of equipment management where we’re doing the day-to-day maintenance, repair, and acceptance testing and so on of equipment.
Only when those two pillars are present and equally emphasised can you actually then support equally the patient care of the organisation and it becomes patient focused. That’s a dual remit that clinical engineering have. That dual remit breaks down into many, many areas. I’m not going to go through all of these, but on the right-hand side are the traditional medical equipment management sorts of things that we do on a day-to-day basis, and we’re very familiar with them.
On the left-hand side, there are things that we might do one or two of but perhaps we don’t do a lot of, that we haven’t really got the time to get into, that we’d like to do but we haven’t got the resources. I haven’t got a magic bullet here, there are resource problems in our healthcare system, but, if we know what we want to do and we can work slowly towards it, then perhaps we can achieve more of the supporting and advancing care. My colleague this afternoon, Richard, is going to be speaking more about the advancing care role, so I’ll leave that to him to expand on.
Moving on to a new toolbox and three things which I just want to briefly mention this morning: ISO 55000 – Justin’s just touched on that a little bit this morning – an introduction to equipment support plans, and then some skills that we need to get to grips with.
Our new toolbox: ISO 55000.
ISO 55000 was published just a couple of years ago or so, after a very long period in development, and there’s [the PAS 0:10:23] before that. It’s a standard optimised for equipment management. It’s not specifically for the NHS. It’s used in many, many organisations already. Any industry can use it. Certainly I know local to where I am in Liverpool there are organisations. I think it’s Peel Holdings. They have 55000 for all of their container management at the ports, so it’s not just a medical standard.
What it does is it aims to realise asset value. We come back again to this word ‘value’ here that value is becoming an important buzzword for us to learn more about. It is a key standard. I’m sure you’ll be getting a little bit fed up, not because of what Justin said this morning but a little bit fed up about standards, because, I don’t know about you, but I know about 55000, there’s 9001 and the revision for 2015. We’ve got ICEPSS, we’ve got British Standard 70000, and then somebody comes along and says, “50000,” and they go, “What on earth?” – Too many standards to manage.
But pick up a copy, have a read of it, because what we actually have found, looking at ISO 55000, is we actually do an awful lot of it now in our day-to-day jobs. It talks about asset management policy and objectives. I’m betting that in all our organisations now we already have some sort of medical device policy, an overarching policy for the organisation.
It talks about strategic asset management plans. It’s a grand word, but that’s really what our medical device committee does: it looks at that medical equipment management on an organisation wide and plans the strategy for that.
Then it talks about asset management plans. It leaves them quite vague as to how you want to implement them, but in our own organisations we have asset management plans that are implemented by clinical engineering, by rehabilitation engineering, point-of-care testing teams, pathology, radiotherapy. All those are different asset management plans which all, in turn, break down into their own equipment support plans. We’ll talk about equipment support plans next, but all this is done within that good old favourite loop of ours: the ‘Plan-Do-Check-Act’ cycle.
Equipment support plans.
What on earth are equipment support plans? I’m betting that what we do already is a long way to achieving the equipment support plan. The equipment support plan is bringing together not just clinical engineering expertise but also supplier expertise and user input, and maybe even the patient as well if that’s appropriate in this, to bring them all together to decide what you want to do to support a piece of equipment or a group of equipment – you get a fleet of infusion pumps or defibrillators – in order to achieve best value.
We’ve broken down there there’s the user support training, performance verification; there’s your scheduled actions and your unscheduled actions. All of those can be done in different combinations by the user, by the clinical engineer, or by the engineer from the contractor, the supplier engineer.
But the key to all this, is it’s holistic. It’s not something that just the clinical engineering management in an office is planning to do, sign the order, raise it, job done, check the services are carried out. It’s a holistic approach involving lots and lots of different stakeholders. Then, of course, in line with ‘Plan-Do-Check-Act’, you need to review it; you need to act on any changes that are suggested that come out of that.
When thinking about an equipment support plan, there are different actions that people can do and different people who are involved, as I’ve said. This is an example, but it also shows you where that information can be kept. The user will be involved, and they will keep all their records of what their actions are to do, in a ward system, in a documented ward system, whereas the clinical engineer and the support engineers’ information would be kept locally on the medical equipment database.
I like to think, looking at that - in an ideal world, that the users would perform daily checks and look after equipment that did automatic self-checks. I think we’ve got a little way to go before we can achieve that, because I think everybody is under so much pressure to be able to achieve it, but by getting people together to agree it, to sign up to it, at least then it takes the weight of responsibility with them. They know what their responsibilities are, rather than just passing them the instruction book and saying, “What you have to do is on page five.”
Another way of looking at is to give your equipment support plans, levels. I think a lot of us probably do this to some extent already where there may be some assets in your organisation that you actually say, “You know what? We’re not going to do any planned maintenance on that. It’s a battery-operated ophthalmoscope. If it goes wrong, the light doesn’t come on and they’ll tell us about it.”
Here, we’re looking at that as sort of a Level I, only reactive sort of suggestion here. As we go up, we might start implementing proactive technical support, which would take it into a Level II, or developing it further and involving the end users in that equipment to a Level III, which becomes a holistic approach to equipment management.
Then, of course, for some equipment you might actually want to get some great assurance and governance on that equipment and take it to an audit level, where you’re doing all this holistic approach and then you’re actually getting somebody else or you’re doing it internally, some sort of audit to make sure that you’re doing what you say you’re doing.
So, you’ve put your equipment support plan in place and off you go. You’re going to have to review it – ‘Plan-Do-Check-Act’ – so we’re going to review it now and you say, “Actually, is it cost-effective what we’re doing?” As a rule of thumb, the cost-effective index is what is defined as the annual cost of your plan, divided by the list price of the equipment, expressed as a percentage.
We’re back now in familiar territory as engineers. We do like our numbers and our formulas. We’re looking here that perhaps manufacturers would typically charge between 8% and 10%. A bit of partnership working might bring that down to, maybe, 6% to 8%, and, if you do it in-house, maybe you’re looking at 3% to 6% as a cost-effective index.
The other way, the other good idea for using cost-effective indexes is that it can actually help you indicate when equipment is becoming ready for replacement. Rather than just looking at how old it is or what its end of life is, you can actually start thinking about how much it’s costing you to maintain. If it’s looking at, say, 20%, really you need to start thinking about replacing it. Reviewing it is a cost-effective basis.
You can also dream up some key performance indicators, as well. There are lots of ways and lots of information available on key performance indicators. The Audit Commission did a really good booklet a few years ago called ‘On Target: the Performance Indicators’. It’s not available anymore, but I do have a copy, so, if anybody wants a copy, then just email me and I’ll send you a PDF copy of it.
They broke down what they thought good key performance indicators would be like. They were relevant, they were balanced; it was action focused and so on. That was a good way of looking at it, but a lot of people are reticent about KPIs because they think that “You’re going to benchmark me against the hospital down the road,” but here we’re looking at your own internal KPIs for, “Is your equipment management plan doing what you want it to do?” You don’t need to tell anybody else about it; you’re keeping these internal.
Another way of reviewing the performance of your equipment support plan is going back to our value ratio again, of the benefits-to-cost ratio. You might decide that you want to set up an equipment support plan at a Level III, but later on, when you’re reviewing it, you might find that actually it’s not achieving what you wanted to achieve and actually, sadly, it’s not achieving. Looking at the ratio of benefits to cost is a way of being able to show whether it’s achieving what you wanted to achieve or not.
It also has another benefit: that you can compare them alongside each other. If you’ve got a fleet of or, which you will have, a hospital full of equipment, you might want to compare your equipment support plan value of defibrillators to that of infusion pumps. If you find that one is under-resourced and the other one is over-resourced, then it’s a method of being able to reallocate those resources. Of course, on a sort of graph you can also plot your cost-effective index, as well.
That’s ESPs – nothing to do with extrasensory perception. I knew you were going to say that. Overall, the ESP is looked at as a ‘Plan-Do-Check-Act’ cycle. You define your support plan, you think, you involve other people, you define what it is you’re going to do. You set that in motion and you record it, locally in your database or elsewhere on the ward; you check to make sure that it’s working properly, and then you act on the results.
Another iron in our new toolbox, as I mentioned before, was skills. I’m not going to say too much about skills, because I think we all know what’s expected of us and that we can see how things are developing, certainly with IT and communication technology. I think we’re all going to be working in the cloud soon, so we won’t even need to come to work.
The diagram shows how clinical engineers are centrally positioned in healthcare. We have a unique point of view: we see things technically, we see things clinically. At some point in our lives, we’ve been a patient. We can see things from a human, from a patient point of view. Being centrally positioned allows us to offer a unique insight, and that unique insight we need to be disseminating as best as possible throughout the organisation. We need to get involved in departments, in finance, in human resources, because people need to know what it is that we do.
We need to embed our engineers in departments. We’ve mentioned before about perhaps embedding an engineer in the endoscopy department. Engineers have traditionally been embedded in neonatal units. I think theatres are also another place where engineers can be embedded. It gets us alongside the clinical staff so that we are better placed to advise and to react when things go wrong or they need help. That helps us to develop, in turn, specialist application knowledge.
We need to be an advocate. We need to be an advocate for clinical engineering, we have to be agile and flexible in our work, and we have to be holistic in our outlook. That’s going to need some culture change, and you need to be a champion to take that forward.
Our new workshop, things are changing. Perhaps we’re not going to be leaving our traditional workshops in our large acute hospitals, but community work is expanding, and I’m sure that you’ve come across this in your own departments. We’re doing more work outside of the normal acute teaching hospitals. Patients are being treated more in the community, and what we need to do is we need to start getting involved holistically with other departments and other teams, to work as part of a multidisciplinary team.
A classic example of this is ventilation services in the community. A few years ago they didn’t exist. Now we’ve got patients on CPAPs and ventilators, with a spare ventilator, and they’re scattered all over the region. Who’s looking after those patients? Have we got engineers to do that?
Here, by a strange quirk of fate, we actually can learn from our colleagues in rehab engineering, who have been doing that sort of thing for years. When you go back, find out who your local rehab engineers are and develop some contacts there, as well.
In finishing, really: developing our new role and vision. We’re engineers, as I’ve said. We don’t believe in crystal balls, we don’t believe in looking mystically into the future. I think we’d rather design our own crystal ball and look at that ourselves, as engineers, but what we have to do to conclude, then, is we have to think holistically and include other people in our working. Let’s not sit behind closed clinical engineering doors; let’s get out there, be part of multidisciplinary teams. Let’s develop our skills. Let’s look to where the skills are needed in IT and comms, and get some skill build-up on that.
We need to become indispensable. Like it or not, the pressure is on the NHS. If we’re not careful, we might be relegated to some other avenue that we didn’t really want to go down to. We need to remain at the centre of that patient, clinical, and technical triangle. We need to be developing presence. We need to be located with the users. Then always remember and keep your mind on value and the ratio of benefits to cost.
Lastly: a plea to get involved. Get involved with training of your new staff. Get them involved in quality management standards. Get them involved professionally. Pick an institute – any institute – but get involved in it. You only get out what you put in. We hear so many times about “What’s such-and-such an institute done for me?” but you really do only get out what you put in.
Lastly, think on governance, because that’s a real hot topic, and think again on advancing patient care, the left-hand side of those twin pillars, that twin remit, and how we can get involved in developing our role with the patients.
Thank you very much.
Paul Blackett's presentation from the 2017 EBME Seminar may be downloaded here: