LAV Process Explained:
Equipment Maintenance
Medical Equipment and Logistics Solutions Directorate
Naval 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 selfassessment
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2
What is LAV?
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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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3
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?
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4
Tracer Methodology–
Providers vs. System
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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5
Tracer Methodology–
Providers vs. System
BIOMED:
• Are maintenance plans developed for each equipment
type or make and model?
•
•
Is preventive maintenance being performed in
accordance with the established maintenance plan and
interval
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Validation: Print the maintenance plan and procedure of a defibrillator. Is
it current?
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?
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6
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?
FOR OFFICIAL USE ONLY
7
Scheduled Maintenance Work Load
June
2010
(Before
LAV)
SWO Workload/Metrics
Beginning Work Order Balance Qty
34
As of
April
2012
August
2010
July
2010
90
29
1
403
372
522
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
2
Carryover
56
-61
24
5
79.96%
93.72%
95.6%
99.75%
9.43%
18.82%
30%
0.00%
New Work Order Qty
Reopened WO Qty
Completion Rate
Relative Inventory Accuracy
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787
0
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LAV Maintenance Metrics
Criteria
Number of Maintenance Significant (MRI) Equipment in DMLSS
Number of Equipment under Full Service Contract
Number of Equipment under In-house Service
Percentage of MRI Equipment under Full Service Contract
4,326
438
3,888
10%
Est. Total Acquisition Cost of MRI Equipment
35,031,186
Est. Total Acquisition Cost of MRI Equipment under
Contract
Est. Total Cost of Service Contracts
% of Contract Costs vs. Acquisition Costs
Number of Equip under Prime Maintainer (PM)
Est. Tot. Acquisition Cost of Equipment Under PM
14,782,700
Est. Total Cost of PM Contract
Ave % of Contract Costs vs. Acq. Costs (PM)
FOR OFFICIAL USE ONLY
1,476,214
10%
154
9,759,575
999,745
10%
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Workload Analysis
Criteria
TOTAL MAINTENANCE SIGNIFICANT EQUIPMENT (Equipment with
Maintenance Requirement Indicator (MRI))
UNDER PRIME MAINTAINER
4,326
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
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10
Medical Equipment Management
Plan (MEMP)
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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)
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Does the MEMP cover the following
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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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12
Medical Equipment Management
Plan (MEMP)
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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13
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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15
Management Control Reports
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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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16
Management Control Reports
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Run the Equipment Without Maintenance Activity Report.
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Run the Equipment Without Maintenance Plan Report.
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Any equipment retrieved?
Run the Suspended Scheduled Work Order Report.
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Any equipment retrieved?
Run the Maintenance Interval Without Date Due Report.
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Any equipment retrieved?
Any equipment retrieved?
Run the Maintenance Management Report.
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What is the overall PM completion rate?
What is the completion rate for Risk Level 1 equipment?
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17
Management Reviews
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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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18
Management Reviews
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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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19
Management Reviews
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Are all BMETs properly trained to perform maintenance on
equipment assigned to them?
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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)?
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Was the PMP contract competed?
If NO, why not?
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Questions
NMLC-ETM@med.navy.mil
21
Related Sessions
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