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LAV Process Explained: Equipment
Maintenance
Medical Equipment and Logistics Solutions DirectorateNaval Medical Logistics Command
Context• Commands can benefit from applying LAV
methodology in support of Audit Readiness
Purpose• Describe the LAV Process for Equipment
Maintenance Objectives• Learn key methods and metrics to review
during a self-assessment
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What is LAV? Assist Logisticians to achieve Total Asset
Management (TAM) and improve internal management control of accountable equipment.
Evaluate the effectiveness of the Equipment, Technology Material Management (ETM) processes from materiel procurement planning to eventual property disposal
Evaluate the effectiveness of the Purchasing Management, Acquisition Planning and Requirements Development, and Contracting Officer’s Representative (COR) Programs
The Logistics Assist Visit is NOT an inspection, this is strictly an assist visit to help your staff identify strengths and weaknesses and to provide them with the tools that they need to successfully carry out their mission.
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Tracer Methodology–Providers vs. System
Do Patient Care Providers:• Know if their medical equipment's preventive maintenance is
current? How?• Know who to contact in case of medical equipment failure?
Who?• Know who to contact in case they need user training on a piece
of brand new medical equipment• Know that they need to submit Test and Evaluation (T&E)
approval request via BIOMED for new equipment user test?• Have input on what equipment to buy? • How are providers trained on how to use demo medical
equipment?• How does the command document requisition input received
from providers? FOR OFFICIAL USE ONLY
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Medical Devices: • Does all maintenance significant medical
equipment have PM stickers/labels IAW NAVMED P-5132?
• If NO, what system does the command have to let users devices are safe for use?
• Does equipment appear to be well maintained (i.e. is it clean, is the power cord and plug intact)?
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Tracer Methodology–Providers vs. System
BIOMED: • Are maintenance plans developed for each
equipment type or make and model? • Validation: Print the maintenance plan and procedure of
a defibrillator. Is it current?
• Is preventive maintenance being performed in accordance with the established maintenance plan and interval• Validation: Print the maintenance plan and procedure of
a defibrillator. Has maintenance been performed IAW the maintenance plan/procedure?
• Are the audible alarms being tested?FOR OFFICIAL USE ONLY
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Tracer Methodology–Providers vs. System
BIOMED: • Are maintenance histories properly recorded?• Are outputs properly recorded?• Does the BMET who worked on the equipment have the
proper training or use a PM checklist to perform the maintenance?
• Are the clinical staff educated on the use of new medical equipment being introduced at the site for the first time?
• Is this being documented? If YES, how? • Is patient health information (e.g. name, SSN,
medical/treatment information) removed from medical equipment memory prior to disposal, or being sent out for repair?
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Tracer Methodology–Providers vs. System
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Scheduled Maintenance Work Load
SWO Workload/Metrics
June 2010
(Before LAV)
July 2010
August2010
As of April 2012
Beginning Work Order Balance Qty 34 90 29 1
New Work Order Qty 403 372 522 787
Reopened WO Qty 12 0 0 1
Completed Work Order Qty 321 363 405 787
Cancelled Work Order Qty 38 70 122 0
Ending Work Order Balance Qty 90 29 24 2
Carryover 56 -61 5 0
Completion Rate 79.96% 93.72% 95.6% 99.75%
Relative Inventory Accuracy 9.43% 18.82% 30% 0.00%
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LAV Maintenance Metrics
CriteriaNumber of Maintenance Significant (MRI) Equipment in DMLSS 4,326
Number of Equipment under Full Service Contract 438
Number of Equipment under In-house Service 3,888Percentage of MRI Equipment under Full Service Contract 10%
Est. Total Acquisition Cost of MRI Equipment 35,031,186
Est. Total Acquisition Cost of MRI Equipment under Contract 14,782,700
Est. Total Cost of Service Contracts 1,476,214% of Contract Costs vs. Acquisition Costs 10%Number of Equip under Prime Maintainer (PM) 154Est. Tot. Acquisition Cost of Equipment Under PM 9,759,575
Est. Total Cost of PM Contract 999,745Ave % of Contract Costs vs. Acq. Costs (PM) 10%
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Workload Analysis
Criteria
TOTAL MAINTENANCE SIGNIFICANT EQUIPMENT (Equipment with Maintenance Requirement Indicator (MRI))
4,326
UNDER PRIME MAINTAINER 438
ADJUSTED TOTAL MRI EQUIPMENT COUNT 3,888
BMET to EQUIPMENT RATIO (MRI equip/# of BMET: 3,888/8) 1:486
AVERAGE COMPLETED WORK ORDER PER MONTH (Jul09-Jun09) 655
BMET TO COMPLETED WO RATIO PER MONTH 82
AVERAGE COMPLETED WO PER DAY PER BMET 4
Medical Equipment Management Plan (MEMP)
• Does the site have a Command Environment of Care Plan?
• Does BIOMED know where the plan is physically located?
• Does BIOMED have a MEMP?• Is the MEMP physically located in
BIOMED?• Is the objective, scope, performance and
effectiveness of the MEMP reviewed annually?
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Medical Equipment Management Plan (MEMP)
• Does the MEMP cover the following• How to manage medical equipment risk?• Emergency maintenance response?• Corrective and preventive maintenance?• Testing?• Inspection?• Emergency management plan for resource sharing?• Inclusion of contractors and vendors in the plan?• Guidelines for using patient-owned medical equipment inside
the facility?• Has the MTF designated roles and responsibilities for
maintaining, inspecting and testing for all medical equipment on the inventory?
• Is BIOMED using the Maintenance Plan and Procedures provided in DMLSS?
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Does BIOMED have the following references: • NAVMED P-5132?• Comprehensive Accreditation Manual for Hospitals
(or know where to find it)?• College of American Pathologist manual (or know
where to find it)?• NFPA-99 Healthcare Facilities manual (or know
where to find it)?• American Association of Blood Banks Accreditation
Requirements Manual (or know where to find it)?
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Medical Equipment Management Plan (MEMP)
Document Control and Reporting:• Is the failure reason "User Error" being documented?• Is the command conducting trend analysis and
implementing appropriate follow-up action (e.g. staff re-training)?
• Are medical device hazards reported to the Risk Manager?
• Based on a review of the QA log or DMLSS-QA, is the site tracking and documenting responses to medical device alert and recall reports?
• Based on review of history for selected equipment, is there documentation of acceptance testing?
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Medical Equipment Management Plan (MEMP)
Document Control and Reporting:• Is the X-ray acceptance package documentation
maintained throughout the life of the system?• Can the site provide documentation of completed staff
training on new medical devices?• Are the test equipment calibration certificates on file?• Are any of the certificates more than one year old?• Are the BMETs Training Certificates on file and
recorded in DMLSS?• Does the site maintain hardcopy of all Service
Contracts?• Has service contract data been properly input into
DMLSS?
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Medical Equipment Management Plan (MEMP)
Management Control Reports
• Has the hospital identified in writing frequencies for inspecting, testing, and maintaining medical equipment on the inventory based on criteria such as manufacturers’ recommendations, risk levels, or current hospital experience?
• Run the Unable to Locate (UTL) Notification Report?
• Are UTL reports sent to the responsible departments for action?
• Are copies sent to EM and Safety Committee?• Is the UTL report submission mentioned in the
Safety Committee meeting minutes?
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Management Control Reports
• Run the Equipment Without Maintenance Activity Report. • Any equipment retrieved?
• Run the Equipment Without Maintenance Plan Report. • Any equipment retrieved?
• Run the Maintenance Interval Without Date Due Report. • Any equipment retrieved?
• Run the Suspended Scheduled Work Order Report. • Any equipment retrieved?
• Run the Maintenance Management Report.• What is the overall PM completion rate?• What is the completion rate for Risk Level 1 equipment?
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Management Reviews
• Are User Errors documented and reported to the Safety Committee?
• Does BIOMED monitor trends on user errors vs. staff training work orders?
• Are all unable to locate (UTL) equipment reported to the Safety Committee and included in the meeting minutes?
• Are EM and responsible department's documenting actions taken to locate UTL equipment?• Validation: Run a report showing all UTL items greater than 30
days old.• Has a DD 200 been initiated for all items on the report?• Is there BIOMED representation in the Equipment Program
Review Committee?• Is there BIOMED representation in the Environment of Care
committee?
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Management Reviews
• Is there BIOMED representation in the Equipment Program Review Committee?
• Is there BIOMED representation in the Environment of Care committee?
• Are equipment requisitions routed through BIOMED for technical review?
• Are all maintenance significant medical equipment assigned to a maintenance activity?
• Does all maintenance significant medical equipment have a maintenance plan and procedures?
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Management Reviews• Are all BMETs properly trained to perform
maintenance on equipment assigned to them?• Are their training certificates on file?• Has their training been recorded in DMLSS?
• Are the alerts and recalls QA actions documented?• Are there carry-over work orders from previous
month?• Does the command conduct trend analysis to identify
corrective actions, improve the process or acquire additional BMET support?
• Is the command in a Prime Maintainer Program (PMP)?• Was the PMP contract competed?• If NO, why not?
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Related Sessions
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