Multicriteria decision making for Medical equipment maintenance ...

3 downloads 39616 Views 1MB Size Report
Three service/support options are possible for maintaining medical equipment: using in-house biomedical engineering service; negotiating OEM contracts; ...
Multicriteria decision making for Medical equipment maintenance: Insourcing, outsourcing and service contract Zeineb Ben Houria1,2, Faouzi Masmoudi2

Malek Masmoudi1

2

1

Ecole Nationale d’Ingénieurs de Sfax Unité de Mécanique, Modélisation et Production Route de Sokra km 3.5, B.P w 3038, Sfax – Tunisia

Université de Lyon, F-42023, Saint Etienne, France; Université de Saint Etienne, Jean Monnet, F-42000, SaintEtienne, France; LASPI, F-42334, IUT de Roanne,

Abstract— Hospitals outsource several activities of support in order to focus on healthcare production. Maintenance is one of these support activities. Recently, faced with rising healthcare costs, governments have implemented new reforms to control costs and improve efficiency and quality. Hospitals became interested in minimizing the total cost of the activity, by minimizing both healthcare production activities and support activities. In developing countries, medical equipment maintenance is costly and partially mastered most of the time because it is usually managed by external service contracts [1]. Reorganizing medical equipment maintenance service became a priority for hospital managers to reduce the cost and dependency while raising quality and reliability. In this paper, we propose an efficient procedure to take the appropriate decisions for medical equipment maintenance such as the strategy, to insource or outsource and the type of contract in case of outsourcing and its content. Keywords—medical equipments; insourcing/outsourcing; multicritiria; workload/capacity; maintenance strategies, contract types;

I.

Medical Equipment Maintenance

According to the Centre for Biomedical engineering and hospital maintenance [9], the main purpose of a biomedical maintenance service is to ensure patient and user safety by maintaining an optimal performance for all biomedical devices. The Biomedical maintenance activity is complex and includes several tasks:  Corrective maintenance: performed after detecting a failure and intended to return the medical device to an operational state [11].  Preventive maintenance (time-based and/or conditionbased): performed at predetermined intervals or according to prescribed criteria and intended to reduce

  

the probability of failure or degradation of the medical device [7]. Quality control: assessment of equipment performance, called inspection and is planned precisely [7]. Selection and monitoring different contracts with suppliers, subcontractors, service companies... Making recommendation for buying devices and training cycles.

Maintenance is characterized by the plurality of tasks that are different in nature and durations. These tasks are grouped into five levels [7] depending on where they can be carried out (inhouse or outside the hospital), by internal or external resources, their complexities and natures and tools necessary for their achievements. Levels 1 and 2 are carried out inhouse; level 1 by internal resources and level 2 by internal and/or external resources. Level 3 and 4 are carried out inside or outside by internal or external resources. Level 5 is rare and carried out in Original Equipment Manufacturers (OEM). Resources (Operators and engineers in biomedical maintenance) are considered competent per equipment and per maintenance level. For many health-care institutions in developing countries, contracting maintenance services is inevitable because they often neither have properly trained staff nor the material resources available to handle these functions on their own [2]. In fact, in-house maintenance needs special tools and test equipment that may be not available or needs additional costs with a staff that is typically generalist rather than specialist [4]. Three service/support options are possible for maintaining medical equipment: using in-house biomedical engineering service; negotiating OEM contracts; outsourcing to third party service provider (with or without contracts). Each contract contains clauses that formalize the relationship between the in-

978-1-4799-6773-5/14/$31.00 ©2014 IEEE

269

house biomedical service and the Service Contract Provider (third party service or OEM). According to [3], the most desirable clauses featured in any contract between a hospital and a Service Contract Provider (SCP) are: Heading, term, repairs, engineering improvements, parts and tools, response time, uptime, maintenance and repair log, adding or removing equipment and so on, price and terms of payment, responsibilities of the hospital, service limitation, termination, indemnification, limitation of liability, insurance, entire agreement, applicable law, assignment and waiver. The possible types of contracts differ from one country to another [9, 6]. In [9], the possible contracts in the Tunisian context are described:  Contract Type A: Time-based maintenance with parts included in the package.  Contract Type B: Parts included in the package (corresponding to time-based and condition-based maintenance).  Contract type C: by intervention, without package. In practice, a fourth type of contract is often preferred by inhouse biomedical engineering service:  Contract Type A*: all risks; labor and parts, timebased and corrective maintenance included in the package.

incorporates risk and other criteria namely the importance of the missions to which the equipment is assigned, the maintenance request and the utilization of equipment. The formulation is a weighted sum of these criteria: NGM = (Level of importance of the mission + 2*maintenance)*utilization +2 * Risk In [12], the authors proposed a sequence of weighted criteria to define the criticality of the equipment and assign a priority degree compared to other equipment in the hospital. Based on this priority degree, a maintenance strategy is associated to the equipment. In [6], the authors provide a procedure to select a type of contract per equipment in order to optimize the maintenance by reorganization. The considered criteria are mainly the availability of resources, the possibility of training, the availability of tools, the cost of parts and the Mean Time Between Failures. A new type of contract called "partnership contract" is proposed in the procedure. This type of contract is the subject of several studies in the literature and already applied in several hospitals in developed countries [4, 6]. This type of contract is not currently available in the Tunisian context, thus it is out of our study. II.

Decision Support Procedure

Some clauses in these contracts are the same as for example the intervention duration, the response time and the equipment down time. The monitoring is done with a dashboard that contains all of these criteria.

To our knowledge, no decision support procedure is available in literature to define the maintenance strategy, to choose to insource/outsource and to select the appropriate contract. In Figure1 a hierarchical decision support procedure is provided to take these decisions.

Insourcing or outsourcing maintenance has advantages and disadvantages that can be identified according to human resources, material resources and the overall cost of the activity [6]. The decision to insource or outsource depends on the availability of appropriate skills and tools in-house. Other criteria are considered and related to equipment, hospital and subcontractor. A contract is usually signed for more than one year and managed by the in-house service in coordination with the subcontractor. Contract monitoring (assessment of the subcontractor) is crucial to master the maintenance cost (price and penalties).

The provided decision support procedure is based on technical, financial, human, and organizational criteria:  Availability of maintenance tools  Availability of competent staff  Equipment criticality defining the maintenance strategy to apply  Maintenance load time and cost  Complexity and frequency of failures  Costs of spare parts

In the literature, we identify several articles that discuss the criteria for insourcing/outsourcing and the choice of contract [6]. The majority of researchers are interested in the reliability [8] and criticality [5, 12, 13] of medical equipment. In [5], Fennigkoh and Smith identify three main issues to calculate the criticality index that are: the function performed by the equipment, the physical risks associated with the clinical application and the degree of need for maintenance. The proposed formula is a summation of these criteria: CI = function + risk + required maintenance. Levels are associated to each criterion according to its importance.

The procedure is composed of three steps:  Step 1: Defining the maintenance strategy per equipment by calculating its criticality.  Step 2: Insourcing by applying a Heuristic to set up the maintenance service workload with the most benefic maintenance tasks.  Step 3: Outsourcing the rest with or without a contract and choose the convenient type of contract. These three steps are detailed below.

In [13], Wang and Levenson offer a formulation that

270

important weight is in the direction of the subsequent classification "time-based preventive, condition-based preventive and corrective".

Equipment

No

Skills and tools are available inhouse?

Yes H=1

Purchase of tools and training are planned?

According to the experts, the classification "time-based preventive, condition-based preventive and corrective" is more appropriate to a descending order of equipment criticality. Thus we consider this classification and do not use the cost criteria (labor and spare parts) for the calculation of criticality. We keep the cost criteria for next steps in the decision procedure.

No H=0

Yes

No Outsourcing

In-house resources are available?

Yes Insourcing

Criticality of the equipment? High G=3

Low G=1 Average G=2

Is the labor cost important?

No L =1

Yes L =2

I the spare parts cost important?

Are complex failures frequent ?

No F =1

Are complex failures frequent ?

Yes F =2

No O =1 No O =1

Yes O =2

Yes O =2

Analytical Hierarchy Process (AHP) has been widely applied to many applications for prioritizing alternatives when multiple criteria are considered. Taghipour et al [12] employed AHP to determine criteria and sub-criteria weighting values. In our sense, the weighting can be removed by adjusting the criterion levels ie for maintenance which has 5 levels and a weighting of 2 in [13], we can consider 10 levels instead of 5 and eliminate weight. This way is easier and more practical especially in case where thousands of devices are considered. Thus, we adopted this idea and requested experts’ point of view to associate levels to criteria and sub-criteria (see table1). TABLE1 : CRITERIA AND SUBCRITERIA TO CALCULATE THE CRITICALITY Criteria

Sub-criteria

Degree of complexity of the maintenance (A)

-

Function (B)

-

Risk (C) Insourcing

No contract

Contract type C

Contract type B

Contract type A

Contract type A*

FIGURE1. DIAGRAM OF DECISION SUPPORT OF MAINTENANCE CONTRACT TYPE

Level of importance of the mission (D) Age (E)

First Step : Defining the maintenance strategy per equipment The objective of this section is to determine the maintenance strategy (systematic preventive, conditional preventive or corrective) to be considered for each of the medical equipment based on the calculation of its criticality. Several methods are developed in the literature for determining equipment’s criticality. In our model we calculate the criticality based on 5 criteria ( degree of maintenance complexity, function, risk, level of importance of the mission and age ) and 6 sub-criteria (rate of use, availability of alternative devices, frequency of failures occurrences, detectability, impact on the production of care and impact on safety ). Taghipour et al [12] have used these criteria for determining the criticality and have added in particular the cost of maintenance. According to a descending order of criticality, the authors consider the following order of maintenance policies: condition-based preventive, time-based preventive and corrective". We have some critics regarding the applicability of this work in our procedure: the cost criterion is perfectly in the direction of the considered classification “condition-based preventive, time-based preventive and corrective”, but the function criterion which has the most

detectability frequency security downtime utilization availability of alternative devices -

levels

3 9 3

3 2

Below we explain the different criteria and sub-criteria and associated levels. Degree of complexity of maintenance (A): Fennigkoh and Smith [5] considered the degree of complexity of required maintenance as a criterion to calculate the criticality of medical device. Five levels are associated to this criterion according to its importance. In our model we propose three levels with a score from 1 to 3:  High maintenance required (note=3): basic mechanical equipment, pneumatic or hydraulic  Average Maintenance required (note=2): equipment that only requires verification of performance and safety tests.  Low maintenance required (note=1): equipment that only receives visual inspections. Function (B): We define the function of a medical device as the primary purpose for which it is used. Fennigkoh and Smith [5] associated 9 levels to the criterion function. In our model we use quite the same definition (see Table2).

271

TABLE2 : EQUIPMENT FONCTION [7] Classes

Therapeutic

diagnostic analytical Miscellaneous

note

Life support Surgical and intensive care Physical therapy and treatment Surgical and intensive care monitoring Additional physiological monitoring and diagnostic Analytical laboratory Laboratory accessories Computers and related Patient related and other

The criticality value ranges from 5 to 20. In our model, we proposed three levels (see Table3).

9 8 7

TABLE3. DIFFERENT LEVELS OF CRITICALITY AND STRATEGIES RELEVANT

6

Strategies

Criticality

Classes

G

Time-based maintenance (G =3)

Criticality≥15

High

3

Condition-based (G=2)

10≤Criticality