Deepak Venkatesh Agarkhed, General Manager-Engineering Services, Quality & Facility, Sakra World Hospital, Bangalore
The first patient billing for new equipment for Endoscopic retrograde cholangiopancreatoscopy (ERCP) had increased by 15 percent than estimate since Laser probe cost was not built in patient costing while planning procurement of new cholangiopancreatoscopy tower. The cost of damaged probe of new ultrasonic unit is not covered in warrantee of equipment by service provider. Only 6 percent utilization was achieved for CT scan in spite of one year of installation and huge maintenance cost needs to be given for coming year.
These are few examples hospital administrative team bump into after procurement of new medical equipment. The root cause for these kinds of issues lies in ignoring basics during medical equipment procurement. We do lot of study and comparison while buying home appliances like TV, refrigerators. But sadly most of the purchase decisions on medical equipment in hospital are done based on clinician’s recommendation and referring service provider’s estimate/quotations.
The procurement of medical technology is fine art of wovening of interlacing all techno-commercial parameters to achieve objective of enhanced clinical capability on long term basis with assured utilization of asset. The proficient stage by stage approach of procurement adopted by Japanese hospital includes:
• Hourensou: The management team keeps in touch with what is going on in current market including understand current technology.
• Hoshin kanri: Policy deployment: Mostly all capital equipment including medical equipment are planned based on targeted clinical goal for coming financial year .This participative goal setting process with all stakeholder including relevant clinicians ,medical administrative team, purchase and clinical Engineering .The capital equipment budget will be prepared by clinical engineering team along with user and purchase team.
• Kouteihyou: Establish Process map for procurement and follow: Defining the major activities of procurement will help each team to align their activity. The efficient and effective adherence process map for procurement will define success of procurement of medical equipment. The following points are recommondated to be incorporated by hospital as part of procurement process.
o Ensuring that clinical requirements in terms of application are clearly defined so that it gets built in scope of supply and cost per application as worked out by finance team.
o The formation of capital equipment selection committee will ensure participation of all relevant stake holders.
o The creation and monitoring of activity time line chart with stakeholder responsibility will help in tracking the progress.
o Clinical Engineering and facility team will assess the feasibility like equipment load, entry point and environmental requirement so that equipment can be installed with no delay.
o Visit website of service providers/their principal companies to know the range of products offered by each service provider. The meeting potential service providers to understand the technology will help to build technical specifications for equipment.
o Market survey of prominent service providers and site visit to see demo by Clinician and Clinical engineer will clear most of the doubts.
o The technical specification including scope of hardware, software, accessories and consumable should be comprehensive and must be generic in nature. All the service providers should provide their estimate based on hospital defined scope only including upgrade.
o The general terms and conditions like warrantee period, performance bank guarantee, application training to user, delivery period, payment terms, commissioning checklist, uptime guarantee should be at par with current practice in industry .
o The commercial quotation /estimation should be clearly based on hospital scope of supply only .The joint assessment of purchase &clinical engineering will set path for start of commercial negotiations. The common mistake hospital do is to ignore the life cycle cost of equipment and only consider capital cost.
o There is no need of initially sharing which model offered by one service provider to other as each one claims their model is always superior to competitor and when it comes to giving estimate, service providers tend quote not the top of line to make themselves comfortable on commercial ground.
o The evaluation of outright purchase, lease, rental or reagent rental for equipment, financial evaluation like Break-even, payback, NPV analysis and non-financial evaluation like opportunity cost, overall hospital strategy will looked closely for high end capital equipment.
o The commercial negotiation may have many strategies but involving Clinical engineering and user team in certain stage will help to tackle service provider and get best price in comparison with approved budget.
o Proper service provider selection methodology using tools like prioritization matrix based on Clinical, technical and commercial aspects is vital stage.
o Inclusion & exclusion criteria for maintenance, switching over from labor to comprehensive and vice versa, establishing maintenance contract payment linked to preventive maintenance and certain consumables like Helium Gas for MRI as part of maintenance should to be included as part of deal.
o Purchase order should be comprehensive in nature and must bind both sales & service team of service provider besides principal company to honor terms as agreed during negotiation.
o The site preparation for equipment installation should be triggered by purchase order release to service provider. The input of Clinical engineer and service provider need to be incorporated.
o Equipment custom clearance, delivery status, insurance aspects are to be closely reviewed by hospital stores for timely arrival at hospital site.
o Commissioning is ignored part of most of the hospital as it is left to technician at user and engineering team. The proper checklist for acceptance of equipment including safety checks, scope of supply matching purchase order and successful application training of user and engineer etc. The joint sign off by user team and Clinical engineer should be last stage of medical technology adoption in any hospital.
The outcome of above recommended good practices will eliminate most of following issues in new technology adoption.
• Muda i.e. waste like delay in vendor short listing
• Muri i.e. non value addition like downsizing the technical specification at the time of commercial negotiation
• Mura i.e. unevenness like ensuring proper time gap between each procurement spread equally.