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Planned

Preventive

Maintenance

Bringing change to the West Bengal Health Care System

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Project Summary

What does Planned Preventive Maintenance (PPM) mean?

PPM is a pilot project introducing a new concept for the improvement of health services in selected rural health facilities of West Bengal. PPM means regular preventive maintenance (namely routine checks and servicing every few weeks), instead of corrective maintenance (namely rectification and repairs whenever called for).

Who started this project and how is it being carried out?

This pilot project is part of the Basic Health Project funded by the German Government through the German Development Bank, KfW, together with the Department of Health and Family Welfare, Government of West Bengal. GOPA-EPOS is a German Consultant Group, which is implementing the project since 2001. The Basic Health Project was mainly concerned with the rehabilitation as well as new construction of health care facilities in 8 districts of West Bengal. But then the German Government took the view that it is not enough to just provide the buildings and equipment, it was felt equally important to ensure that it is all maintained and kept in good functioning condition. That is why this PPM Project was started in 2007. It is not limited to the health facilities funded by the Basic Health Project.

What preparatory work was necessary?

There were many things to do before actually starting PPM work.

GOPA-EPOS visited the districts to inform the stake-holders about the project;

in consultation with the Health Department, three districts (Jalpaiguri, Bankura and Purba Midnapur) were selected;

a PPM Supervisor was appointed in each of the three districts;

the PPM Supervisors were briefed and trained in the GOPA-EPOS Kolkata office;

a lot of paperwork was necessary before starting work;

appropriate tools had to be selected and purchased;

approvals had to be obtained from the CMOHs in each district, etc., etc......

Finally fully fledged PPM work was started in January 2008, covering more than 100 health facilities in all 3 districts.

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Project Description

What is the idea behind PPM?

Every building and every piece of equipment deteriorates gradually, whether it is in use or not. This happens by wear and tear, by sun, wind and rain, by accumulation of dirt and moisture (which cause rust and decay), by nesting creatures (which can destroy parts of building and equipment) and by misuse (generally due to lack of knowledge) and negligence. Therefore, to prolong the useful life of equipments, buildings and their surroundings, it is necessary to inspect, clean and repair them, or replace damaged or used up parts. If this is done in a planned way at regular intervals, major deterio-ration and damage, requiring “corrective maintenance” (which means expensive repairs and replacements), can be prevented.

In other words, PPM saves considerable costs in the long run, but also ensures the proper functioning of a health facility, in which the staff is happy and motivated and the patients can recover quickly.

More than 50 % of PPM is cleaning

Dirt accumulates within and outside buildings very fast. This can be due to

dirt and garbage being carried by wind, rain and animals;

fungal growth caused by water leakage and lack of ventilation inside buildings;

the bad habits of people throwing garbage and spitting wherever they please, causing indiscriminate littering, blockage of drains, attraction of disease carrying insects and rodents, and producing very unhygienic conditions;

the lack of garbage bins placed inside and outside buildings;

damaged or missing covers of water tanks, which gather dirt and birds’ droppings, attract small creatures, and develop algae by exposure to sunlight;

the general opinion that toilets and bathrooms are dirty places and users are not responsible for cleaning them after use;

the lack of cleaning staff, lack of training of such staff and lack of appropriate tools available to them.

All this can be avoided by regular cleaning, which is the largest single PPM activity. The other activities are removal of unwanted plant growth and gardening, masonry and painting works, carpentry and metal works, plumbing and electrical works, repairing of bio-medical equipment, and a few other works.

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Project Implementation

How must PPM be organised?

Every health facility has different maintenance requirements, therefore the PPM activities will differ from place to place. It is necessary to make lists of the maintenance work to be done, as well as a time schedule. Some works must be done every day, some once a month or every 2-3 months, and some every 2-3 years. The important thing is to appoint at least one person in each health facility, who is in charge of making these lists, who organises the work, and who checks that it has been done correctly. Since a number of skills are required to carry out the various maintenance jobs, they can only be done by a team of 5-7 specially trained multi-skilled technicians and cleaners. As no single health facility is able to employ such teams on a full-time basis, the best solution is to create teams for clusters of 6-10 facilities each, which are not more than an hour’s drive away from one another. A PPM team would then visit a health facility of one cluster for a specified number of days to carry out the PPM work and then move on to the next facility. When the PPM work is completed in all the facilities of that cluster, the cycle is repeated. By this way, each facility can be visited at intervals of 2-3 months. The daily maintenance work must be done by in-house staff. In the same way as bio-medical waste disposal is being outsourced to private contractors, outsourcing PPM to private companies may be a suitable option. The maintenance funds allocated to each health facility can be utilised for this purpose.

What are the most common PPM activities?

The following is a list of standard PPM activities that need to be carried out in most health facilities:

1. Garbage removal and cleaning of gutters 2. Removal of undesirable plant growth 3. Cleaning building interiors 4. Cleaning toilets and bathrooms 5. Cleaning and repairing water tanks 6. Plumbing works 7. Electrical works 8. Carpentry and metal works 9. Masonry and painting works 10. Repairing simple bio-medical equipment 11. Removing condemned items 12. Gardening and landscaping Examples of these activities are shown on the next pages.

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What tools are needed for maintenance?

The main tools and equipment (minimum requirements) are illustrated below.

General Tools

Safety Gear

Electrician’s Tools

Mason’s and Painter’s Tools

Carpenter’s Tools

Mechanic’s, Fitter’s and Plumber’s Tools

Wheel barrow

Wooden or bamboo ladder

Buckets and mugs

Waste bin Hose pipe

Jute rope

Garden spade

Shovel

Finger spade

Broom Rake

Brush and dustpan

Cobweb brush

Scrubber

Toilet brush

Plunger

Long handled brush

Plastic sheets

Sharp knife

Scissors

Axe

Katari

Face mask

Helmet

Gloves

Gum boots

Combination pliers Long nose

pliers

Circuit indicator Insulation tape

Power tester

Screwdriver set

Set of paint brushes

Float

Trowels

Spirit level

Spatula

Plumb line

Mason’s hammer

Metal pan Measuring

tape Mallet Hammer

Handsaw Try square

Bradawl Nipper

Plane

Set of screw

drivers

Hand drill Chisels

Set of files

Soldering iron

Hacksaw Adjustable spanner

Oil can

Pipe wrench

Set of spanners

Wire brush

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Examples of PPM activities

Garbage removal and cleaning of gutters

• removal of garbage from all parts of the compound; • cleaning of drainage gutters (around buildings and on

roofs); • removing garbage from open wells; • digging holes in appropriate places on the site to bury

the garbage (by filling the holes up to 18-20 inches below ground level, adding lime for disinfection, and filling up with earth).

Removal of garbage dumped in the compound.

Cleaning drainage gutters for unrestricted rainwater disposal.

Cleaning of drainage outlets on a roof top.

An open well that has been misused for garbage disposal.

Digging a pit for garbage disposal.

After filling the pit with garbage, lime is added for disinfection.

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Removal of undesirable plant growth

• which includes ripping out small plants with two fingers, as well as chopping trees growing out of walls or roofs;

• also cutting away plants growing close to buildings and chopping overhanging branches.

Ripping out a small plant is done in a matter of seconds and costs nothing.

Cutting a tree growing out of a building can take hours and the building repairs can cost thousands of Rupees.

Plants generally grow in moist places, especially around water tanks.

Also drainage gutters are usually blocked by plants, which is the cause of flooding or stagnant water.

Cleaning building interiors

• removal of cobwebs and dust in building interiors; • cleaning fans, lights, furniture, etc.; • identifying termite tunnels and appointing a pest control

agency to destroy the termites effectively.

Removal of cobwebs.

Sweeping with traditional broom distributes much dust; sweeping with a short bristled broom avoids this problem.

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Cleaning toilets and bathrooms

• thorough cleaning of toilets, washbasins, floors, walls, etc;

• disinfecting all taps, handles and surfaces that are frequently touched by patients, visitors and staff.

Cleaning a toilet pan.

Scrubbing a bathroom floor

Cleaning and repairing water tanks

• thorough cleaning of tanks inside and outside; • repairing damaged pipes; • replacing broken or missing lids.

Many water tanks can look like this if not cleaned regularly.

Cleaning the tank inside.

Cleaning the tank outside.

The cleaned water tank.

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Plumbing works • repairing damaged or leaking sanitary installations (water taps and drainpipes, WC cisterns, etc.);

• making unusable toilets function again.

Repairing a water tap.

Repairing a blocked pipeline.

Electrical works • repairing damaged or malfunctioning electrical wiring, switchboards, fuse boxes, fans, lights (inside and outside buildings), etc.;

• replacing tube lights, starters, bulbs, etc.; • test-running power generators to ensure that they work

when required.

Repairing an electrical switchboard.

Repairing an illuminated signboard.

Carpentry and metal works • repairing damaged doors and windows, entrance gates, etc., replacing missing or broken parts;

• welding and repainting metal parts; • repairing and repainting wooden and metal furniture.

Repairing a window.

Welding a metal grill.

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Masonry and painting works

• repairing damaged walls, ceilings, floors, and roof surfaces with plaster and/or tiles;

• sandpapering and painting walls and ceilings; • repainting old signboards.

Repairing external plaster.

Making a new toilet platform.

Painting an external wall.

Repainting the name of the health facility.

Repairing simple bio-medical equipment

• repairing and servicing electrical items (refrigerators, suction apparatus, operation theatre lamps, etc.);

• repairing and servicing mechanical items (microscope, BP apparatus, autoclave, weighing machine, wheelchair, needle cutter, etc.).

Repairing an autoclave.

Servicing a dental lamp.

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Removing condemned items

• preparing lists of damaged and condemned equipment and furniture, in order to remove them and thus regain useful space.

Removing old water tanks.

Removing old furniture.

Gardening and landscaping • filling up holes or repairing paving in pathways and cutting away plants growing on or close to them;

• planting flowery plants and trees to make the site attractive;

• painting masonry or wooden enclosures of gardens and borders along paths, etc.

Preparing the ground for planting.

Planting bushes and flowery plants.

A BPHC garden before PPM.

The same garden after PPM.

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What is the difference between the existing maintenance practice in the health care system and the new concept of Planned Preventive Maintenance?

Existing maintenance system Planned Preventive Maintenance developed by GOPA-EPOS

An overall maintenance concept does not exist.

PPM has a standard list of activities (see page 4), which is followed during each PPM visit.

Maintenance is not carried out on a regular basis, but as and when decided by the hospital management authorities or medical officer in charge.

PPM is conducted on a regular basis, that is, each health facility is visited in 2-3 month intervals (about 4-5 times a year). Each health facility belongs to a cluster of 3-6 facilities (located within one hour’s drive from each other), which are visited within a period of 10-14 days.

The maintenance and repairing work to be carried out is usually specified by the Sub Assistant Engineer (SAE), who is entrusted with all kinds of government infrastructure – not only health facilities.

PPM is carried out by specialists in the maintenance of health care facilities. In the gaps between clusters, the PPM Supervisors visit each facility of the next cluster to identify the necessary work at each site.

Very few health facilities have ladders to inspect the roofs, which – if damaged – are the main cause of deterioration of buildings.

Inspecting the condition of roofs and water tanks belong to the priority checks at any PPM site. If no ladder is available, the PPM Team will organise or make one.

The duration of official procedures, from preparing the specifications, tendering, evaluating tenders, awarding contracts, and then finally implementing the work, can take several weeks, sometimes months.

In PPM there are no time consuming procedures. Even in the case of emergency repairs, the PPM Teams can act quickly during the gaps between clusters.

Sweepers and Group D staff, who are in charge of cleanliness and maintenance in health facilities have no training, guidance or the appropriate equipment. Generally, there are not sufficient sweepers and Group D staff to do the work in a health facility.

The PPM workers are multi-skilled and specially trained to do all kinds of cleaning and maintenance jobs (electrical and mechanical works, plumbing, carpentry, masonry, painting), for which they have a full set of good quality tools. In order to complete a job, the PPM workers frequently work overtime and help each other, showing real team spirit. This way, a great deal of work is done in a very short time.

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Existing maintenance system Planned Preventive Maintenance developed by GOPA-EPOS

Safety measures are not common amongst workers doing cleaning and maintenance work.

In order to ensure that nobody is injured or gets ill, the PPM workers are equipped with gloves, gum boots, face masks, and helmets, depending on the kind of work they do. After all, working in health facilities is not without health risks.

As the health facilities do not have trained maintenance specialists, cleaning or maintenance works are not supervised. Therefore, many maintenance jobs are not done satisfactorily and corrective measures are rarely carried out.

All PPM work is monitored by the PPM Supervisors, and unsatisfactory work is rectified on the spot. A report on the work done is prepared after each PPM visit, and the person in charge of the health facility is given a short feedback form, in which comments, criticisms, proposals can be noted. This will help the PPM Team to improve the work during the next visit.

Most maintenance works are carried out when buildings or equipment are visibly damaged, requiring major repairs, which may cost thousands or even lakhs of Rupees.

Regular PPM work ensures that buildings and equipment are always kept in good working condition. Regular cleaning, tightening of screws, lubrication, replacing defective parts, etc. cost relatively little and save the cost of major repairs in the long run.

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What are the costs of PPM? PPM can only work effectively with well-trained, multi-skilled teams of 4 to 8 workers (depending on the size of the health facility), working 8 to 10 hours per day. They have to be equipped with high quality tools and safety gear. The teams and tools have to be transported safely from site to site, and their work is closely monitored by specially trained PPM Supervisors. The whole operation has to be carefully investigated beforehand, then planned, approved by the authorities and properly organised, in order to achieve the desired results. The overall coordination of the scheme from the head office in Kolkata, the administrative support, the audio-visual material and training workshops, all add to the costs of PPM. In order to achieve the high PPM standards, all the above factors have to be taken into account in determining the actual costs of PPM. On average, the costs of carrying out PPM work in a Rural Hospital (with 8 PPM workers and a PPM Supervisor, including tools, transportation, administrative support, etc.) can amount to Rs. 6,000 per day, while PPM work in a BPHC (with 7 PPM workers and a PPM Supervisor, including tools, transportation, administrative support, etc.) can cost about Rs. 5,600 per day, and PPM work in a PHC (with 6 PPM workers and a PPM Supervisor, including tools, transportation, administrative support, etc.) can cost around Rs. 5,000 per day. Therefore, if a PPM team works in a Rural Hospital for 4 days, the average cost can be around Rs. 24,000, while 4 days in a BPHC can cost around Rs. 22,400. With four visits per year, the costs would be approximately Rs. 96,000 and Rs. 90,000 respectively, which lies within the annual maintenance budget of Rs. 100,000. In the case of a PHC, the duration of visits varies from 2 to 3 days per visit, depending on the size and condition of the facility. Hence the average costs vary between Rs. 10,000 and Rs. 15,000 per visit. Assuming that the first 2 visits take 3 days each and the next 2 visits take 2 days each, the total annual costs for 4 visits would amount to Rs. 50,000, corresponding to the annual maintenance budget of Rs. 50,000. Prior to commencing PPM work, cost estimates are to be worked out. Should the costs exceed the available funds, then the least urgent works must be postponed to one of the next visits, unless additional funds can be made available.

Future Outlook Until December 2009, the PPM Pilot Project conducted by GOPA-EPOS is being funded by the Basic Health Project West Bengal. If the PPM Scheme is to continue beyond December 2009, a new concept for the organisational setup, responsibilities and funding will have to be developed. It is highly unlikely that any single rural health facility can maintain a PPM Team of its own, as the costs would not be manageable and the PPM Team would not have enough work to do. The only feasible solution is to maintain each PPM Team for a cluster of up to 10 health facilities, which can share the services and the costs. If this can be institutionalised within the government health system, it would be a great advantage. However, this may be difficult to achieve within a short period. Another possible solution is to outsource the PPM work to private undertakings, as in the case of ambulances and bio-medical waste disposal. In all considerations, the main aim should be to find a sustainable solution, which will serve to maintain a high standard of health care and provide a healthy and pleasant environment for the patients and staff of the health facilities.

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What health facilities can and should do even without PPM Irrespective of regular maintenance through PPM, every health facility should be concerned about regular cleaning procedures. The following cleaning routine will help to ensure a high degree of cleanliness and hygiene, which is absolutely essential for providing effective health care:

What and where When and how often

Sweep the entrance area, patients' waiting space and corridors, and disinfect the same area with a mop and disinfectant solution (1% bleach solution, or diluted phenyl, Dettol, etc.).

At least twice a day (in the morning, before the outpatients queue up in the entrance area, and after the outpatients have gone).

Repeat the same procedure in all the other rooms, including the wards (inpatient department).

At least twice a day.

All bathrooms and toilets must be cleaned and disinfected.

At least twice daily, or whenever there is a need.

The outside area should be swept, and water should be sprayed, if the space is very dry and dusty. All waste bins should be emptied and the waste disposed of in special pits, which are excavated as far away from the buildings as possible.

In the later part of the morning.

Inside the buildings, all waste bins must be replaced by a fresh set of bins, while the full bins have to be taken away for appropriate disposal of the contents, after which the bins must be cleaned with bleach solution.

At least once a day, or when-ever the bins are full.

All furniture, doors and windows must be wiped to remove dust.

Every alternate day.

Cobwebs must be removed from ceilings and walls, lights and fans must be wiped with a moist cloth, and dust removed from high level furniture, such as cupboards, shelves, etc., also behind and under furniture.

Once a week.

Rooftops must be swept clean and drainage gutters and outlets must be cleared of any debris.

Once a month.

Water tanks on roofs must be emptied completely and thoroughly cleaned inside and outside. It must also be ensured that the lids are not damaged and that they close the tank opening very firmly.

Every 6 months, or more often, if necessary.

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PPM Checklist The following checklist is a summary of the information given in this booklet, as a quick reference. The checklist gives the standard PPM activities, which need to be carried out during each visit to a health facility, but not all of these are required at each site, as each health facility differs in size, design and condition. Garbage removal and cleaning of gutters

• removal of garbage from all parts of the compound; • cleaning of drainage gutters (around buildings and on roofs); • removing garbage from open wells; • digging holes in appropriate places on the site to bury the

garbage (by filling the holes up to 18-20 inches below ground level, adding lime for disinfection, and filling up with earth).

Removal of undesirable plant growth

• which includes ripping out small plants with two fingers, as well as chopping trees growing out of walls or roofs;

• also cutting away plants growing close to buildings and chopping overhanging branches.

Cleaning building interiors

• removal of cobwebs and dust in building interiors; • cleaning fans, lights, furniture, etc.; • identifying termite tunnels and appointing a pest control agency

to destroy the termites effectively.

Cleaning toilets and bathrooms

• thorough cleaning of toilets, washbasins, floors, walls, etc; • disinfecting all taps, handles and surfaces that are frequently

touched by patients, visitors and staff.

Cleaning and repairing water tanks

• thorough cleaning of tanks inside and outside; • repairing damaged pipes; • replacing broken or missing lids.

Plumbing works • repairing damaged or leaking sanitary installations (water taps and drainpipes, WC cisterns, etc.);

• making unusable toilets function again.

Electrical works • repairing damaged or malfunctioning electrical wiring, switchboards, fuse boxes, fans, lights (inside and outside buildings), etc.;

• replacing tube lights, starters, bulbs, etc.; • test-running power generators to ensure that they work when

required.

Carpentry and metal works • repairing damaged doors and windows, entrance gates, etc., replacing missing or broken parts;

• welding and repainting metal parts; • repairing and repainting wooden and metal furniture.

Masonry and painting works • repairing damaged walls, ceilings, floors, and roof surfaces with plaster and/or tiles;

• sandpapering and painting walls and ceilings; • repainting old signboards.

Repairing simple bio-medical equipment

• repairing and servicing electrical items (refrigerators, suction apparatus, operation theatre lamps, etc.);

• repairing and servicing mechanical items (microscope, BP apparatus, autoclave, weighing machine, wheelchair, needle cutter, etc.).

Removing condemned items • preparing lists of damaged and condemned equipment and furniture, in order to remove them and thus regain useful space.

Gardening and landscaping • filling up holes or repairing paving in pathways and cutting away plants growing on or close to them;

• planting flowery plants and trees to make the site attractive; • painting masonry or wooden enclosures of gardens and borders

along paths, etc. Designed and prepared by GOPA-EPOS Consultants, CA-87, Salt Lake, Kolkata 700 064 - (2009) Printed by Monaj Haque, E-mail: monajhaq@gmail.com