Al Gresch: Good morning everyone and welcome to this edition of our podcast. We are here at CMIA in sunny San Diego, California. Last day of the conference, both Nader and I have done presentations yesterday. Mine was on data integrity and the impact of machine learning. And Nader did one on AEM (Alternative Equipment Maintenance), a practical guide to how to set up an AEM program and best practices around that. And we talked about it. They're really tied together, right?
Nader Hammoud: Yeah.
Al Gresch: I talked to many of our customers who aren't using an AEM program and sort of curious why and the answer I get back is pretty consistent. We don't have the data that we can rely on to support our decisions and so we just kind of throw up our hands and go with manufacturer's recommendations.
Nader Hammoud: Well the AEM, the first challenge, because I do remember, I was one of those people. I don't want to do AEM, it's scary. Because, practically you're putting yourself out vulnerable that anything that happens to the device now, you're 100% liable and accountable because you're changing whatever the manufacturer is asking you to do. And we're not used to that. So you don't like to be vulnerable. When you say we don't have data, it's easy to get the data, but it's not easy to take that first step because what's next? How are we going to measure that? How are we going to keep track of that? What you should do? What other people have done it? Have they succeeded or is it still vague?
Nader Hammoud: So, this is why I did my presentation to tell people that it's not that scary. The first step is the scariest step and this is the information we have. This is what we've been doing for the last three years. And to invite them that, ask don't be scared to ask. Once they start asking, once they start seeing that we did it and we did it for a bunch of equipment, we did 15 AEMs, that covers more than two or 3,000 devices. So it's very useful. It saves us lots of money and resources and it's working.
Al Gresch: Yeah. I want to back up a little bit because I neglected to do a proper introduction, Nader. So, we've known each other for a long time. We go back to a point, we worked together at TriMedx and you've been around a couple of different places since then and currently, you're with John Muir in here in California. So tell me a little bit about what your role is there.
Nader Hammoud: I'm the manager of Biomedical Engineering for John Muir Health, for the whole health system. We have three hospitals and more than 80 outpatient clinics and centers. My role is practically to make sure that everything is working as it should be, as any Biomed. And I'm expanding into the role of taking over and making sure that our equipment is managed and maintained as efficiently as possible without having to be reliant and dependent on OEM or anyone else. So it's a huge task. And one of the best ways I was able to achieve this is AEM. Because I know we're not the only organization that's running their Biomed shop at the threshold. That if you throw a new project to the team, they're overwhelmed and they need to do overtime or they have to hire more people. So AEM did really help us to get that bandwidth to take more stuff on.
Al Gresch: When I first implemented ... this goes back to the days before anybody coined the phrase alternative equipment maintenance, right? But it followed the same premise, right? Let's look at what we're doing and whether or not what we're doing is bringing value, right? The things that we're doing on planned maintenance, is it really making a difference in keeping the equipment safer. And I'll tell you our first iteration of implementing that program, using a formulary to determine what would be safe to set up on a different schedule, gained us over 3000 hours annually. And that's two, three guys. Right?
So, tell me what steps you started with. I mean it's been great. There's been a lot of good information from folks who had been doing this roadshow around the country talking about AEM, why it's important. But your session yesterday was much more on the practical side. So share with us what steps you took to start that process.
Nader Hammoud: So, as I said, the first thing is the scariest thing is the first step. It's not easy to take that decision to get yourself into that no-confidence zone as you did a few years ago before the panic of, you have to follow manufacturer recommendations and then we had to push it back to the point that we can do AEM. People were able to do whatever they want. Now we're at this stage, we need to do this. So, my presentation yesterday was kind of similar to help others exactly as I found Matt Baretich and Frank Painter helped me. Because when I attended their session, they presented AEM, they made it ... it's not a taboo anymore. It's something that can be done. They have done it in some organizations, they gave examples. They went through it and I felt that you know what? This can be done if other people have done it. It means I can do it. It just needs some more study.
So, I went back to my organization, start looking at the equipment that I can do, the low-end, no risk that even if I don't do anything to them and it fails, it's not going to hurt anyone. And I find myself doing the Risk Assessment indirectly, because what is a Risk Assessment? It is to identify the risk of the device if it fails or if you don't do proper maintenance. So what's the missing link? So if I'm doing this, but I'm not calling it AEM, so why don't I call it AEM and follow the process? So then I identify that I need to have a process. To have a process, you have to have a policy, you have to develop something and write it out. Okay, where do I start? I don't even know where to start with the policy.
Nader Hammoud: So, I reach out to different resources that I got introduced through Matt and Frank. They have some sample policies. So I took that and start building on it. Start analyzing, get to the point, okay, I'm ready to start the first step, but I'm not the paper person. If I put things on paper, I'm never going to do it. Never. I need to see the numbers calculated and formulas and give me the bottom line at the end of the day. So I had to create my own spreadsheet and then I was creating this spreadsheet. I thought you know what? I need to create a program to automate everything. I just need to plug in the numbers that I pulled from my work orders and I need everything to be automated and give me the final result. So I started doing the database. While I'm building the database, I start understanding AEM even more because I was referring to the materials and what should I do, what foremost do I need to do.
Nader Hammoud: At the end of the day, I found myself, I have a very robust database program. I have the system, let's test it out. Ask my guys what would you like to put on AEM. Definitely, the first answer is no, no, no, no, no. We don't want to do this. It's scary. We don't want to go there. Okay, then I'll do it. The first thing, I took the vital sign monitors, did the analysis review, the history by myself, all on my own, to test the system. Put in the numbers and it came out to be low-risk. So it is low risk. And while doing the database, since I have all the numbers in there, why don't I throw in also the number of hours savings, if I change this from OEM to AEM. I did this and it was significant. It was like close to 150 hours. Okay, that's interesting. I did it. Sent it to my team, tell them going forward, these equipment are in AEM, it means the next PM you don't have to do it. Just remove the OPM sticker and put it in the AEM sticker.
Nader Hammoud: And we give it a number so we can keep track of it. Once the team did it, even though they were hesitant to do it, they found out, oh, we have plenty of time this month on our hands. We like it. Instead of being overwhelmed and looking for resources to do the job, now we have plenty of time. So they start being creative. They start liking it. They start coming to me with everything you can think of. They want to put in an AEM. Some things that do make sense, we start putting it on AEM, some things that I told them, you know what? No, we're not ready yet. We don't want to step more than what we can do. So it was just, as I said, the first step was the hardest step. Once you taste the advantage of it, you will see that this is what I need to do. I need to move forward from here.
Al Gresch: It's really not that hard, is it?
Nader Hammoud: No, it's not.
Al Gresch: I mean you think about what the requirements are, right? Regulatory agencies like DNV and the Joint Commission are looking for some pretty simple things. The first is they want to know what criteria you use to determine whether or not ... or how to determine whether or not a piece of equipment should be on an AEM program, right? And so, you built out that formulary using the information you got from Frank and Matt, right? So that's step number one. And step number two is identifying your database, what items you have on an AEM program, right? And I'm presuming that you've got that laid out in your CMMS. And then the third thing is to do follow up, right?
Nader Hammoud: Annually.
Al Gresch: Some people forget that piece of it, that you have to make sure that the decisions that you made were good decisions, right? And that you didn't decrease the safety, that you didn't experience an increase in failure rates. Right? So, what are some of the things that you look at in that follow-up assessment, Nader?
Nader Hammoud: So that was the question that I was asked yesterday in the presentation as well, what is the data you look at and what are you looking for? So, we set the AEM at a specific date, based on specific history and a specific set of equipment, list of equipment. At the end of the year or whenever you want to do the annual assessment, that list, that history is no more the same history. So you have to review whatever has been added. Whether it's new equipment to that same list or new history. And as you said, we need to identify has there been any failure that could have been prevented by doing the PM? Not necessarily any failure just in general because the equipment will still fail, but that failure could you have prevented that failure if you would have done what we have eliminated by the AEM? If yes, then you need to review your AEM because it means you missed something. You need to redo that task.
Nader Hammoud: If no, it means then you're fine. Because of some failures, as I said, even if you do the PM today, some failures will happen just after you deliver the device back to the department. It's just the nature of those devices. Those are not preventable failures. You don't count those as something that will affect your AEM, you need to look at the failures that actually could have been prevented. Good examples are battery leaks, broken cases because those are something that the end-users, the nurses will not call you for it. They will just sit there and if there is a crack in the case, fluid gets in, then you damage the whole system, the whole equipment.
Al Gresch: So, did you find a need to adjust any of your CMMS codes to actually identify whether or not failure was preventable and then capture it in that manner?
Nader Hammoud: Yes. So, after we started doing AEM, thinking that how we want to track that, we created a new code called it PM preventable failure.
Al Gresch: Okay.
Nader Hammoud: So, when my team receives a repair work order, they look at it. If it was something that we could have prevented during the PM, they will code it as such. So at the end of the year, when I'm doing my annual assessment, I can pull those and see, do we have any PM preventable failures?
Nader Hammoud: Now we have to be a bit careful. My team, they do the best that they can, but could it be that they have dealt with a PM preventable failure, but they didn't code it appropriately? Definitely, yes. So for now, until we get ourselves very well comfortable with the process and everyone is aware, I'm still reviewing all the history. I use the PM preventable failure code as guidance if you want to, but I still review all the remaining history that I haven't touched before to make sure that we didn't miss anything.
Al Gresch: Okay. Yeah. So, one of the things that people lose sight of when they implement an AEM program as well, it's a two-way street, right? So you identify the devices that ... there's low risk. If that thing were to fail your failure rates are such that, you've determined it's safe to extend out the PM frequency and you've garnered some significant time gains from that. On the flip side of that, have you gotten to the point yet where you've identified devices that are at a failure rate that's higher than would be desired and perhaps look at adding steps to your PM procedure or actually increasing your PM frequency to try and reduce those failure rates?
Nader Hammoud: We did actually.
Al Gresch: Okay.
Nader Hammoud: We did. And that was one of the first things we have identified even before we implement an AEM program. And we said you know what? We cannot keep doing this at this rate. We have to change it. So, before the AEM program, we have identified something and then we added it later on. The example was the vacuum suction unit on the crash cart. It's battery-operated and the manufacturer recommends that you have to replace the battery once every three years. So when we're replacing those once every three years, we found that most of them are actually, the batteries are leaking. And it's starting to cause damage, corrosion inside. So, we realized that… you know what? We need to change that frequency from two years to a year and a half, and then we need to monitor that after a year and a half. Is it still leaking? Then we need to change it back to a year.
Nader Hammoud: So, the AEM, to your point, that's a very good point, very good question. AEM doesn't always necessarily mean you need to reduce the frequency or reduce the tasks you need to do. Because as I said in my presentation and as Matt and Frank had been always promoting, when you do an AEM program, you don't want the goal and the target of your AEM program cost savings or reducing resources. Your goal should be equipment safety.
Al Gresch: Right.
Nader Hammoud: And I promise you, you can come back to me, the cost savings and resources savings, it's going to be something automatic. It will come automatically with it. You don't even have to put any effort on that side. It's something that will come with it, but don't make this your goal.
Al Gresch: Yeah, I've heard that and actually, Matt talks about that and if a surveyor comes and asks you about your AEM program, that better not be the answer that we were short on hours, short on techs, and so we implemented the program for that reason. It is about safety and you know what? There are some additional gains that you get from that. I know from my own personal experience having done that, identified those ... not just those items that didn't require as much service but those that required more. We actually ... and I cite this the number often, that by adding 350 hours of additional PM time to try and reduce the failure rates, we were able to garner over 1500 hours in less corrective maintenance time. That's a pretty good investment. Right?
Al Gresch: So, I want to talk a little bit about the time savings that you did garner. Obviously, there are a lot of things that your team should have been doing, right? To further increase safety in other areas, cybersecurity, right? All these bricks on the load. So tell me how you were able to reapply those hours to do more with your team.
Nader Hammoud: So, as I was saying, my team was running at the threshold, and none of us like that. And I always communicate with my team, I want you to work 80% of your productive time. I want you to spend 20% of your time doing nothing. I don't care what you do. Even if you want to play on your phone, check Facebook, I don't care. I don't want you to work 20% of your time. And that was a surprise to them. Why are you saying this? That's crazy coming from a manager. The only way you can be creative and help the department is to have that gap of time that you can sit and think. When you're so much focused and doing the work that you do, you become like a machine. You're not useful to me. We need to go to the next step. We were not stuck in this phase now at this time. We need to take the next step. We need to be more productive, more efficient, and help the whole society, the whole profession.
Nader Hammoud: So, once we get those times back, those hours back, that gave us maybe more than 20% that we're looking for. So the first thing we did is we start bringing in house, equipment that we were outsourcing. One of the first ones we did was ultrasound equipment. So we have more than a hundred devices across the health system. And just a quick number, the immediate savings that we were able to achieve was half million a year. And that we didn't take over 100% in house. We brought it to a third party so we can manage it because now we have the time.
Nader Hammoud: Another thing is now at least once a week, my teams on both campuses, you see them doing cross-training. So instead of the knowledge being with one person who is overwhelmed with everything that he's doing, now he's sharing that knowledge so they can go and do the work. Even we changed our workflow in a way that everyone will get a chance to work on all the departments, in a way or another. So they can get exposed to everything and get all the knowledge. So we are expanding. We're looking at how we're going to get there.
Nader Hammoud: To your point, cybersecurity is a new challenge. One of the bugs that I know most, probably all organizations like ourselves, are challenged with. We have a very robust and reliable inventory, but we don't have all the IT information that's needed. We don't have [inaudible 00:20:25] addresses, we don't have IP addresses. Capture that, that's a whole desk. Do you want to hire a contractor to come and do it? If you have the resources, go ahead and do it. We don't. So, we were able to actually get a time that when we go out and find the equipment, we have time to capture all this information. Versus my Biomed being concerned, he has a hundred PM this month. I even have time to get into the system and capture this information to put it back in the system. Now they have the time. So it gave us that [inaudible 00:20:57] that we lacked.
Nader Hammoud: To answer your question, we didn't assign those saving hours and two specific things, but giving us that… we were able to be creative and to free our minds instead of our brains all being hot and sparkling all the time, we cooled down and we start being more efficient by doing that.
Al Gresch: No, that's great to hear. So it's interesting you talked early on about the fear, right? Of taking that first step into it. And yet from what you've shared, you've gained back hours, made your techs happier, garnered additional time to take on higher-end technology that I'm guessing your staff is excited about doing, and you've increased your staff engagement in the process. So what advice would you have for somebody that hasn't started down this path yet? Because it just seems from what you've shared with me that you'd almost be foolish not to. Right?
Nader Hammoud: I agree. And actually, that's funny you said that because the last joint commission survey we had before we implement the AEM program, the surveyor, the engineering surveyor asked me, do you have an AEM program? And I said no, and his answer was, "Why not?" So I was shocked that you're asking me why not? I thought I'm doing good that I'm doing OEM and I should be fine. Now you’re asking me why not? I said, "Because we don't have data and we haven't done this program yet." And he said, "Well, you have to take advantage of it because it's out there for you so you better take advantage of it."
Nader Hammoud: So exactly to your point, you would be crazy if you don't do it. And again, the first step was the scariest step. I hope that this podcast and this is why we're doing this. This is why I did my presentation. This is why Matt and Frank have been doing this. Reach out. There are lots of people that have done it. We have history, we have the knowledge, we have tools that we can help you out with. I know you will never do it on your own. It's so scary. You will never do it on your own. We are here to help you. So if you need help, reach out. It's free of charge.
Al Gresch: Awesome. Well listen, Nader, I really appreciate your talking with us this morning. Great words of encouragement for those that haven't taken that step yet. And hopefully, after hearing this, people will be inspired to take that first step and to help really make a difference in their organization.
Nader Hammoud: I hope so.
Al Gresch: All right. Thanks, my friend.
Nader Hammoud: Thank you. Thank you, sir.
Al Gresch: That's a wrap.
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