As part of this year's Health Technology Excellence Award competition, we received noteworthy submissions from member organizations across the globe, describing efforts for improving processes and systems in a variety of settings and circumstances. We highlight a few of these projects below. Though not selected for the award, the projects described may prove instructional for facilities around the world facing similar challenges.
The Health Technology Excellence Award recognizes outstanding initiatives undertaken by member healthcare institutions to improve patient safety, reduce costs, or otherwise facilitate better strategic management of health technology. ECRI announced McLaren Northern Michigan as the winner of the 16th award in May 2022. For details about the winning submission, see Integrating Patient-Centric Technologies to Improve Care and Enhance the Patient Experience—McLaren Northern Michigan's Award-Winning Initiative.
Clínica Imbanaco Grupo QuirónSalud (Cali, Valle del Cauca, Colombia)
Implementation of an Intelligent Infusion System in a High-Complexity Hospital
To improve medication safety at a high-complexity hospital in Colombia by implementing smart infusion pumps with dose error reduction system (DERS) technology.
While the use of smart infusion pumps with DERS is common in the United States, the adoption of this safety technology has been slow in many parts of the world. Barriers to implementation can include differences in clinical practice, infrastructure challenges, limited access to technologies, and other factors.
In Colombia, the path to a robust smart pump installation has not been well traveled. Clínica Imbanaco Grupo QuirónSalud (Cali, Valle del Cauca, Colombia), like so many other facilities in the country, had not implemented a drug library, let alone the additional components that are part of a comprehensive smart infusion technology installation—namely, remote drug library management, real-time infusion status monitoring, and other features.
Such shortcomings expose a facility to large safety gaps. Clínica Imbanaco believed that this situation required an immediate intervention.
As a critical component of its effort to decrease the risk of medication errors, and in alignment with the World Health Organization's (WHO) 2017 campaign to reduce severe, avoidable medication-associated harm in all countries, Clínica Imbanaco decided to make the investment in a smart infusion technology solution.
Rolling out the system was a collaborative effort between the DERS solution vendor and the facility's biomedical engineering staff, IT department, and other personnel. Strategies to approach the platform implementation were established according to guidelines published by the Institute for Safe Medication Practices (ISMP). Project tasks included establishing the necessary network infrastructure; developing a drug library, including defining administration protocols and limits for hundreds of medications; and implementing system tools to facilitate interoperability, global viewing of patients' infusion status, and collection of data for continuous quality improvement.
The organization reports that with the completion of the project in 2019, Clínica Imbanaco became the first medical institution in Colombia to complete a comprehensive implementation of the DERS vendor's online suite, achieving an ideal configuration of both the drug library and online management portal.
Following system implementation, adherence to drug management protocols in ICUs was good, with clinicians using the drug library in 317,422 of 381,964 reported infusions (83%) in the two-year period from 2020 to 2021. Over this period, the organization estimates that use of the system for high-complexity services prevented 1,825 drug administration errors.
These improvements, along with the other benefits of implementing smart infusion pumps with DERS technology, such as enabling drug administration traceability, facilitating inventory and software management, and promoting quality improvement, have helped the organization to be an infusion safety leader among its peers. As part of its patient safety program, the organization was able to track compliance with drug library use, identify dosing errors, and make improvements to the libraries themselves based on usage data.
KIMSHealth (Thiruvananthapuram, Kerala, India)
Implementation of an In-House Medical Device Testing and Calibration Lab
To develop an in-house medical device testing and calibration lab that, in the absence of reliable third-party options, could ensure the accuracy and readiness of medical equipment.
Ensuring the ongoing accuracy, reliability, and safety of medical equipment requires regular maintenance, service, performance verification, and safety testing. In India, healthcare facility guidelines aim to assure device safety and reliability through mandated annual or biannual device performance testing/calibration. Like other Indian healthcare organizations, KIMSHealth Trivandrum (Thiruvananthapuram, Kerala, India) depended on third-party calibration labs to help meet this requirement. However, the organization found these services to be insufficiently reliable, having repeatedly experienced significant turnaround delays, lack of prompt availability during emergencies, and equipment test results of uncertain validity.
Recognizing the impact on the facility in terms of equipment unavailability, uncertain accuracy of devices, and, ultimately, the potential threat to patient safety, the organization made the decision to expand its in-house capabilities.
The facility started by forming a small team within its clinical engineering department. This group set up a lab with test equipment and began testing equipment in-house. However, despite adherence to best practices in the setup and operation of the lab, the effort didn't reach the expected level of acceptance among clinicians, due to a lack of external validation of the whole process.
Seeing that improvement was needed, the organization set out to achieve an ambitious goal: to get the lab accredited to the same medical device testing and calibration standards as government organizations and large private laboratories (specifically, International Electrotechnical Commission/International Organization for Standardization IEC/ISO 17025:2017, General Requirements for the Competence of Testing and Calibration Laboratories).
According to the facility, securing this accreditation is not something many healthcare organizations pursue, and it proved to be difficult and labor-intensive. All staff received training, and the quality system, processes, procedures, guidelines, and documentation system were all extensively revamped and restructured. And, as the hospital states, "continuous quality improvement became a habit."
The team's extensive efforts paid off. The organization reports that it is the first hospital in India to be granted the accreditation it sought for over 50 parameters, including electrical safety. This authorized the organization to test and calibrate and certify medical equipment.
The equipment at KIMSHealth hospitals now gets certified through the lab. This program has helped the hospital stay on yearly schedules and more quickly address time-sensitive needs. In addition, any equipment requiring major part replacement goes through the calibration and safety testing procedures before it is placed back into clinical use. A key reason for this success is that the program, backed by careful documentation and evidence, has gained the confidence of the clinical device users.
With the lab services up and running, the facility plans to offer its services to other healthcare organizations looking for equipment testing and calibration.
Medical Equipment Life-Cycle Management in a Public Health System
To establish a well-coordinated approach for medical equipment life-cycle management across the public healthcare institutions in the province of Québec, Canada, providing services to 8.5 million people. Goals included making the best use of limited capital resources, improving the ability to identify medical strategic assets and equipment within the healthcare system (which is a key capability for addressing a health crisis like the COVID-19 pandemic), and promoting the clinical engineering position within healthcare institutions.
The Ministère de la Santé et des Services Sociaux (MSSS) clinical engineering team is responsible for overseeing the management of medical equipment within all public healthcare institutions in Québec, representing assets valued at more than Can$4 billion. The team's responsibilities cover the entire equipment life cycle, from planning the budget requirements for the equipment to issuing guidance for its proper disposal. The large scale and scope of the team's duties presented the opportunity for significant efficiencies, safety improvements, and cost savings, but achieving these benefits would require improved coordination across the province.
The team developed an approach to central equipment management that, after refinements over the years, currently incorporates the following components:
- The use of central medical equipment management software. The software provides visibility into the healthcare institution's equipment inventories, includes information about life-cycle durations and replacement costs, and allows institutions to submit three-year replacement plans.
- The dissemination of guidance documents—for example, to help local clinical engineering teams develop equipment replacement plans for their facilities.
- The development of a clinical engineering "community of practice" to facilitate information sharing across the province. For instance, the local teams can provide input about processes or about the central software.
MSSS's approach to medical equipment life-cycle management has yielded several benefits, one of which has been particularly important in recent years: The improved ability to identify and locate strategic assets, such as ventilators and physiologic monitors, has been critical during the pandemic. Other benefits include smarter use of capital equipment budgets, improved coordination and cooperation among clinical engineering teams within the province, and better-coordinated decisions when introducing new technologies within the healthcare institutions. The "community of practice" approach to asset management, with clinical engineering involvement, can help public health systems make the most effective use of scarce resources.
Stanford Health Care (Palo Alto, California, United States)
Ensuring the Availability and Readiness of Hypo/Hyperthermia Equipment
To improve the readiness of Arctic Sun hypo/hyperthermia equipment at Stanford Health Care (Palo Alto, California) by instituting an equipment control process to make the equipment easier to locate when needed and ensure the functionality of the equipment before clinical use.
At Stanford Health Care, clinicians often had difficulty locating the facility's Arctic Sun hypo/hyperthermia systems when the devices were needed for patient therapy. Furthermore, once located, the equipment often wasn't ready for use, either exhibiting functional problems or missing cables and accessories. The resulting delays negatively impacted patient outcomes and were the subject of numerous complaints to the biomedical engineering department from physicians and clinical staff.
An investigation identified several issues related to how the Arctic Sun equipment was being managed:
- Devices were not stored or controlled in any centralized manner. Rather, the devices would be moved to one location for use and sometimes left there, making them hard to locate when needed.
- The devices were not routinely assessed for readiness, except during scheduled semiannual preventive maintenance inspections. The result was that devices located in patient care settings could be in a state of disrepair.
A multidisciplinary team was assembled to address this operational issue. Members included nursing leadership, patient equipment management solutions (PEMS), biomedical engineering, and an Arctic Sun vendor representative.
The team recommended—and the organization implemented—the following measures to ensure that Arctic Sun equipment is available and working properly every time it is needed for patient care:
- When therapy ends, transporting the device to the biomedical engineering department, where a short, simple evaluation and functional test of the system is performed. This inspection includes checking fluid levels, checking for leaks, testing the temperature probe system, and configuring the machine to make it immediately evident that the unit is ready to treat patients.
- Coiling the temperature probe and "sealing" it with a tie wrap, to signify device readiness for use. To access the contents, this visible seal would need to be opened. A missing tie wrap indicates that the machine is not ready for patient care use.
- Transferring the machine to a central location for storage (instead of having the equipment scattered throughout the hospital).
This project demonstrates that solutions don't have be complicated to be effective. After this system was implemented, the complaints related to Arctic Sun equipment reliability dropped significantly.
This program also served as a springboard for similar quality assurance/quality control (QA/QC) processes for other types of equipment. For example, a QA/QC inspection process has been developed to conduct a final check of infusion pumps once preventive maintenance activities have been completed; pumps must pass that inspection before they can reenter the patient care workflow.
Tabba Heart Institute (Karachi, Sindh, Pakistan)
Enhancement of Medication Safety Features of a Computerized Provider Order-Entry System
To enhance the medication safety features in a computerized provider order-entry (CPOE) system.
For healthcare organizations in Pakistan, implementation of large-scale, high-cost health IT technologies such as CPOE systems is very rare. Although CPOE offers proven benefits, including the potential to reduce medication errors and preventable adverse drug events (ADEs), a number of factors at play in Pakistan prevent adoption. For example:
- Hospitals have limited budgets and must prioritize purchases carefully.
- Most staff in public and private hospitals have little or no experience with CPOE and electronic health record (EHR) technologies; and little direction is available from other healthcare organizations in the country, since only a very small number of Pakistani organizations have implemented these technologies. Healthcare across the country is still heavily dependent on manual processes.
- External forces that would push a facility toward using such technology are largely nonexistent. Such forces might include availability of funding or pressure from the government to use the technologies, a trend of adoption by other organizations, or health IT conferences that would build interest in and sell the concept of the technology.
Despite these challenges, the leaders at Tabba Heart Institute (Karachi, Sindh, Pakistan), driven by a firm commitment to patient safety, made a strategic decision to invest in a CPOE system.
Tabba Heart Institute purchased, implemented, and began using a CPOE system. However, after the system went live, facility medication error reporting showed that the safety benefit wasn't materializing as expected. The implementation had two problems, both related to a lack of compliance with the "5R" rule (sometimes referred to as the "Five Rights" rule) of safe medication administration (right drug, right route, right dose, right patient, and right time):
- Patient labels did not include the medication dose. This made it difficult for nurses to verify the correct dose in the event that, for example, a pharmacy dispensing error was suspected.
- For all formulary medications, the default route was designated peroral (PO), even for drugs intended only for other routes. This error could result in wrong-route administration if not detected.
Medication error reports showed that among all error types, errors involving the above problems had the highest rates. To address these issues, the organization initiated a quality project to be conducted by a multidisciplinary team consisting of physician, pharmacy, IT, quality department, and nursing staff, as well as the CPOE system vendor. The team reviewed medication error trending data, discussing every error in detail, and performed an extensive literature search.
The quality team recommended measures that eliminate the need to rely on human intervention to avoid medication errors. First, the system was modified so that the dose appears on the label. Second, the vendor provided a list of all the formulary medications and asked the pharmacists to specify the preferred route for each one. This task was completed in three months' time, then this information was updated in the CPOE system.
CPOE has been shown to decrease ADEs up to 80%. This reduction translates into shorter hospital stays and lower average cost of a hospital admission. However, as the pharmacy team at Tabba Heart Institute experienced, fully realizing these benefits requires properly addressing safety issues encountered in the deployment of the system.
The pharmacy team identified the shortcomings in the implementation of the CPOE system's pharmacy module and successfully instituted improvements. In the first quarter of 2020, before the changes, 146 medication errors were reported. In the first quarter of 2021, after the improvements were implemented, reported errors dropped to 53—a 64% reduction.
 Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999 Jul-Aug;6(4):313-21.