Equipment Service KPIs

Purpose  

• To establish guideline for all Healthcare Technology Management (HTM) leaders and their roles and responsibilities with tracking equipment service key performance indicators for regulatory and essential functions.  HTM leadership is responsible for the implementation and management of this procedure.   

Outcomes 

• All HTM leaders understand their roles and responsibilities with tracking equipment service key performance indicators for regulatory and essential functions. 
• By standardizing equipment service KPIs, HTM can accurately benchmark, create action plans for improvement, and improve service for our customers. 

Definitions

• CMMS: computerized maintenance management system 
• EH&S: Environmental Health & Safety 
• EOC:  Environment of Care
• KPI: Key Performance Indicator 
• MEMP: Medical Equipment Management Plan is designed to establish organizational protocol for administering clinical technologies that ensure continual availability of safe, effective equipment via a capital management assessment and procurement program, life-cycle support program which includes scheduled maintenance, timely repair, and evaluation of events that could have an adverse impact on the safety of patients or staff. 
• HTM EH&S/EOC Annual Report:  Annual report generated and presented to EH&S/EOC encompassing HTM’s compliance and performance at an individual facility 
• HTM EH&S/EOC Quarterly Report:  Quarterly report generated and presented to EH&S/EOC encompassing HTM’s compliance and performance at an individual facility 

Procedure 

Equipment Service KPIs - Regulatory: 

A. Each site leader has the responsibility to track equipment service KPIs to meet regulatory compliance. 

B. Scheduled Maintenance:

i. High Risk equipment have a target of 100% completion. 

ii. Completion is the sum of SM performed plus SM addressed (tracked by response codes listed below) 

• Could Not Locate 
• Attempted to Locate/Perform 
• SM Parts Available Past EOM 
• Equip at Vendor for Service Past EOM 
• Equip in Use 
• Equip no Longer at Facility 
• SM Failed 
• Retired 

iii. Non-High Risk equipment has a target of 100% completion. 

iv. Completion is the sum of SM performed plus SM addressed (tracked by response codes listed below) 

• Could Not Locate 
• Attempted to Locate/Perform 
• SM Parts Available Past EOM 
• Equip at Vendor for Service Past EOM 
• Equip in Use 
• Equip no Longer at Facility 
• SM Failed 
• Retired 

v. Could Not Locate and In-Use 

• Could Not Locate and In-Use number 
• Could Not Locate and In-Use % as related to total Scheduled Maintenance Work orders requested 
• Target is less than 5% of total site Schedule Maintenance work orders 

C. Corrective Maintenance 

i. Metrics outlined in Medical Equipment Management

• Number of repairs work orders opened 
• Number of repair work orders resolved 
• The target is 90% resolved within 30 days 

D. Excessive Equipment Failures – Operator Error 

i. Metrics outlined in Medical Equipment Management Plan

• All Items addressed and documented with operator training 

E. Excessive Equipment Failures – Unable to duplicate 

i. Metrics outlined in Medical Equipment Management Plan

• All Items addressed and documented with unable to duplicate response code. 
• Target is 1% of entity inventory for a calendar year 

F. Incident work orders 

i. Metrics outlined in Medical Equipment Management Plan

• All Items addressed and documented with Incident work order and Incident related response codes (sequestered or incident) 
• Number of Incident work orders opened 
• Number of Incident work orders resolved 
• Percent of incident work orders in relation to Corrective Maintenance work orders created 

G. Recall work orders 

i. Metrics outlined Medical Equipment Management Plan

• All Items addressed and documented with Hazard/Recall work order and appropriate response code 
• Number of Hazard/Recall work orders opened 
• Number of Hazard/Recall work orders resolved 
• Number of equipment involved in Hazard/Recalls 
• Number of equipment involved in Hazard/Recall work orders yet to be resolved 

H. Could Not Locate/In Use 

i. Metrics outlined in Medical Equipment Management Plan

• All Items addressed and documented with Hazard/Recall work order and appropriate response code 
• Number of Hazard/Recall work orders opened 
• Number of Hazard/Recall work orders resolved 
• Number of equipment involved in Hazard/Recalls 
• Number of equipment involved in Hazard/Recall work orders yet to be resolved 

2. Equipment KPIs – Essential Functions: 

A. Each Service Department should be compiled independently 

B. Corrective Maintenance 

i. Response Time 

ii. Average Closure Times 

iii. Measured by AIMS CMMS report Service Performance Analysis 

iv. Work orders older than 30 days 

v. Metrics should take into considerations resources and geographic restrictions 

• Reference SOP Name for best practice 

C. Scheduled Maintenance 

i. Percent performed after 15^th, 20^th, and 25^th day of the month 

• Between 60% and 70% by the 15^th  
• Between 75% and 85% by the 20^th  
• Between 90% and 95% by the 25^th  

ii. Metrics should take into considerations resources, schedule maintenance load, and geographic restrictions 

References: 

• Centers for Medicare & Medicaid Services.  State Operations Manual.  Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. Rev. 176, 12-29-17.  Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf.  Accessed November 30, 2018. 
• The Joint Commission.  Environment of Care Essentials for Health Care. 2020 ed. Chicago: Joint Commission Resources, 2020.