Guide 4.pdf

‘HOW TO MANAGE’ SERIES
FOR HEALTHCARE TECHNOLOGY


Guide 4
How to Operate Your
Healthcare Technology
Effectively and Safely


Management Procedures for
Health Facilities and District Authorities


TALCTeaching-aids At Low Cost




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Copyright © 2005 Ziken International
Ziken International (Consultants) Ltd,
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Tel: +44 (0)1273 477474, fax: +44 (0)1273 478466, email: info@ziken.co.uk,
website: www.ziken.co.uk


‘How to Manage’ Series for Healthcare Technology
Guide 1: How to Organize a System of Healthcare Technology Management
Guide 2: How to Plan and Budget for your Healthcare Technology
Guide 3: How to Procure and Commission your Healthcare Technology
Guide 4:How to Operate your Healthcare Technology Effectively and Safely
Guide 5: How to Organize the Maintenance of your Healthcare Technology
Guide 6: How to Manage the Finances of your Healthcare Technology


Management Teams
Keywords: healthcare technology, management procedures,
health service administration, district health services, developing countries,
operation, use, cleaning, safety, equipment
Any parts of this publication, including the illustrations, may be copied, reproduced, or adapted to
meet local needs, without permission, provided that the parts reproduced are distributed free or at
cost – not for profit. For any reproduction with commercial ends, permission must first be obtained
from the publisher. The publisher would appreciate being sent a copy of materials in which text or
illustrations have been used.
This document is an output from a project funded by the UK government’s Department for
International Development (DFID) for the benefit of developing countries. The views expressed
are not necessarily those of DFID.


ISBN: 0-9549467-3-1
All rights reserved
A catalogue record is available from the British Library
Design and layout by Jules Stock (email: julesstock@macunlimited.net
Illustrations and charts by David Woodroffe (email: davedraw@dircon.co.uk)
Edited by Sarah Townsend Editorial (email: sarah@sarahtownsendeditorial.co.uk,
website: www.sarahtownsendeditorial.co.uk)




‘How to Manage’ Series for Healthcare Technology


Guide 4


How to Operate Your
Healthcare Technology
Effectively and Safely


by:
Caroline Temple-Bird


Healthcare Technology Management Consultant,
Ziken International Consultants Ltd, Lewes, UK


Manjit Kaur
Development Officer, ECHO International Health Services, Coulsdon, UK


Andreas Lenel
Health Economist Consultant, FAKT, Stuttgart, Germany


Willi Kawohl
Financial Management Consultant, FAKT, Stuttgart, Germany


Series Editor
Caroline Temple-Bird


Healthcare Technology Management Consultant,
Ziken International Consultants Ltd, Lewes, UK




CONTENTS
Section Page
Foreword i
Preface i
Acknowledgements iii
Abbreviations v
List of Boxes and Figures vii
1. Introduction 1
1.1 Introduction to the Series of Guides 1
1.2 Introduction to this Specific Guide 9
2. Framework Requirements 15
2.1 Framework Requirements for Quality Health Services 16
2.2 Background Conditions Specific to this Guide 25
3. How to Ensure Equipment is Utilized Effectively 31
3.1 Accountability 32
3.2 General Good Behaviour Towards Equipment 35
3.3 Efficient Use of Equipment 37
3.4 Access to Information and Reference Materials 39
3.5 Developing Staff Skills 41
4. How to Ensure Correct Operation 49
4.1 How to Operate Equipment 49
4.2 The Correct Application 52
4.3 Care and Cleaning 53
5. How to Ensure Safe Operation 59
5.1 General Discussion on Safety 59
5.2 Safety During Equipment Operation 60
5.3 Equipment-related Infection Control 62


5.3.1 Decontamination 62
5.3.2 Linen Handling 76
5.3.3 Ensuring the Workplace is Clean 78


5.4 Waste Management 83
5.4.1 Waste Management Philosophy 84
5.4.2 Managing Different Types of Waste 86


Contents




5.5 Control of Other Hazards 91
5.5.1 Gases 91
5.5.2 Electricity 93
5.5.3 Laboratory Hazards 103
5.5.4 Radiation Hazards 106
5.5.5 Fire 109
5.5.6 Accidents 110


6. How to Ensure the Availability of Accessories
and Consumables 113


6.1 General Discussion on Accessories and Consumables 113
6.2 Storage System and Procedures 121
6.3 Calculating Usage Rates and Reorder Levels 127
7. How to Ensure Continuous Operation 137
7.1 Security 137
7.2 User Planned Preventive Maintenance (PPM) 139
7.3 Testing for Electrical and Mechanical Trustworthiness 146
7.4 Fault Reporting 148
7.5 Decommissioning, Disposal, and Replacement of Equipment 149
8. How to Undertake Action Planning and Monitoring


of Progress 155
8.1 Setting Goals (Annually) for Equipment Operation and Safety 156
8.2 Monitoring Progress With Equipment Operation and Safety 164
Annexes: 169
1. Glossary 169
2 Reference Materials and Contacts 174
3. Example of a Process Profile Common to Many Sterilizers 202
4. Example of a Supplies Order Form 203
5. Entering Items into the Stock Control System 204
6. Safety and Calibration Testing Instruments 206
7. Maintenance ‘Work Request/Job Form’ 208
8. Typical Equipment Lifetimes 209
9. Form for Registering Written-Off Equipment 224
10. Source Material/Bibliography 225


Contents




Foreword
This Series of Guides is the output from a project funded by the UK government’s
Department for International Development (DFID) for the benefit of developing
countries. The output is the result of an international collaboration that
brought together:
◆ researchers from Ziken International and ECHO International Health Services in


the UK, and FAKT in Germany
◆ an advisory group from WHO, PAHO, GTZ, the Swiss Tropical Institute, and the


Medical Research Council of South Africa
◆ reviewers from many countries in the developing world
in order to identify best practice in the field of healthcare technology management.
The views expressed are not necessarily those of DFID or the other
organizations involved.


Garth Singleton
Manager, Ziken International Consultants Ltd, Lewes, UK


Preface
The provision of equitable, quality and efficient healthcare requires an extraordinary
array of properly balanced and managed resource inputs. Physical resources such as
fixed assets and consumables, often described as healthcare technology, are among
the principal types of those inputs. Technology is the platform on which the delivery
of healthcare rests, and the basis for provision of all health interventions. Technology
generation, acquisition and utilization require massive investment, and related
decisions must be made carefully to ensure the best match between the supply of
technology and health system needs, the appropriate balance between capital and
recurrent costs, and the capacity to manage technology throughout its life.
Healthcare technology has become an increasingly visible policy issue, and healthcare
technology management (HTM) strategies have repeatedly come under the spotlight
in recent years. While the need for improved HTM practice has long been recognized
and addressed at numerous international forums, health facilities in many countries
are still burdened with many problems, including non-functioning medical equipment
as a result of factors such as inadequate planning, inappropriate procurement, poorly
organized and managed healthcare technical services, and a shortage of skilled
personnel. The situation is similar for other health system physical assets such as
buildings, plant and machinery, furniture and fixtures, communication and information
systems, catering and laundry equipment, waste disposal, and vehicles.


Foreword


i




Preface (continued)
The (mis-)management of physical assets impacts on the quality, efficiency and
sustainability of health services at all levels, be it in a tertiary hospital setting with
sophisticated life-support equipment, or at the primary healthcare level where simple
equipment is needed for effective diagnosis and safe treatment of patients. What is
vital – at all levels and at all times – is a critical mass of affordable, appropriate, and
properly functioning equipment used and applied correctly by competent personnel,
with minimal risk to their patients and to themselves. Clear policy, technical
guidance, and practical tools are needed for effective and efficient management of
healthcare technology for it to impact on priority health problems and the health
system's capacity to adequately respond to health needs and expectations.
This Series of Guides aims to promote better management of healthcare technology
and to provide practical advice on all aspects of its acquisition and utilization, as well
as on the organization and financing of healthcare technical services that can deliver
effective HTM.
The Guides – individually and collectively – have been written in a way that makes
them generally applicable, at all levels of health service delivery, for all types of
healthcare provider organizations and encompassing the roles of health workers and
all relevant support personnel.
It is hoped that these Guides will be widely used in collaboration with all appropriate
stakeholders and as part of broader HTM capacity-building initiatives being
developed, promoted and implemented by WHO and its partners, and will therefore
contribute to the growing body of evidence-based HTM best practice.
The sponsors, authors and reviewers of this Series of Guides are to be congratulated
for what is a comprehensive and timely addition to the global HTM toolkit.


Andrei Issakov, Coordinator, Health Technology and Facilities Planning and
Management, World Health Organization, Geneva, Switzerland


Mladen Poluta, Director, UCT/WHO HTM Programme, University of Cape
Town, South Africa


Preface


i i




Acknowledgements
This Guide was written:


◆ with specialist support from:
Juliette Cook, Biomedical Engineer, Advisor to Ministries of Health of Mozambique,
and Vanuatu


◆ with assistance from an Advisory Group of:
Hans Halbwachs, Healthcare Technology Management, Deutsche Gesellschaft für
Technische Zusammenarbeit (GTZ-GmbH), Eschborn, Germany
Peter Heimann, Director, WHO Collaborating Centre for Essential Health
Technologies, Medical Research Council of South Africa, Tygerberg, South Africa
Antonio Hernandez, Regional Advisor, Health Services Engineering and Maintenance,
PAHO/WHO, Washington DC, USA
Andrei Issakov, Coordinator, Health Technology and Facilities Planning and
Management, Department of Health System Policies and Operations, WHO,
Geneva, Switzerland
Yunkap Kwankam, Scientist, Department of Health Service Provision, WHO,
Geneva, Switzerland
Martin Raab, Biomedical Engineer, Swiss Centre for International Health of the
Swiss Tropical Institute, Basle, Switzerland
Gerald Verollet, Technical Officer, Medical Devices, Blood Safety and Clinical
Technology (BCT) Department, WHO, Geneva, Switzerland
Reinhold Werlein, Biomedical Engineer, Swiss Centre for International Health of the
Swiss Tropical Institute, Basle, Switzerland


◆ reviewed by:
Dr E Aniteye, Consultant/Lecturer in Anaesthesia/ICU, Korle-Bu Central Hospital,
Kumasi, Ghana
Dr P Asman, Head of the Bio-engineering Unit, Ministry of Health, Accra, Ghana
Tsibu J. Bbuku, Medical Equipment Specialist, Central Board of Health, Lusaka, Zambia
Peter Cook, Biomedical Engineer, ECHO International Health Services, Coulsdon, UK
Freedom Dellosa, Chief of Hospital Equipment Maintenance Service Division,
Region 9 – Mindanao Peninsula, Department of Health, Zambonga City, Philippines
Pieter de Ruijter, HTM Consultant, HEART Consultancy, Renkum,
The Netherlands


Acknowledgements


i i i




Roland Fritz, HCTS Coordinator, Christian Social Services Commission, Dar es
Salaam, Tanzania
Andrew Gammie, Project Director, International Nepal Fellowship, Pokhara, Nepal
Jan Huys, HTM Consultant, HEART Consultancy, Renkum, The Netherlands
Pramod Joshi, Medical Equipment Engineer, Technical Assistance Programme,
International Nepal Fellowship, Nepalgunj, Nepal
Godfrey Katabaro, Biomedical Engineering Technologist, Kagera Medical Technical
Services, church health sector, Kagera, Tanzania
Derrick Mayungo, Deputy Head of Biomedical Engineering, University Teaching
Hospital, Lusaka, Zambia
Jenny Poulter, Nursing Consultant, Green Pastures Hospital, International Nepal
Fellowship, Pokhara, Nepal
Dr. S. Samnakey, Clinical Director of Surgery, Aga Khan Foundation Private Hospital,
Nairobi, Kenya
Sulaiman Shahabuddin, Director, Patient Services, Aga Khan Foundation Private
Hospital, Nairobi, Kenya
Dr Sok Srun, Hospital Services Bureau Chief, Ministry of Health,
Phnom Penh, Cambodia
Birgit Thiede, Physical Assets Management (PAM) Advisor, Ministry of Health,
Phnom Penh, Cambodia


◆ using source material:
described in Annex 10: Source Material/Bibliography


◆ with financial assistance from:
the Knowledge and Research Programme on Disability and Healthcare Technology,
DFID, government of the United Kingdom


◆ with administrative support from:
all the staff at Ziken International Consultants Ltd, UK, especially Garth Singleton,
Rob Parsons, and Lou Korda, as well as Thomas Rebohle from FAKT, Germany


Acknowledgements


iv




Abbreviations
AAP annual action plan
AHA American Hospital Association
AMC average monthly consumption
Amps Amperes
BP blood pressure
CD–Rom compact disc – read only memory
CSSD central sterile supplies department (central sterile services


department, in the USA)
DB distribution board
DVD digital versatile disc
ECG electrocardiograph
EDP equipment development plan
ELCB earth-leakage circuit-breaker
FIFO first in, first out
g grams
GTZ Deutsche Gesellschaft für Technische Zusammenarbeit


(German government technical aid agency)
HIV human immuno-deficiency virus
HTM healthcare technology management
HTMS healthcare technology management service
HTMWG healthcare technology management working group
Hz Hertz
ICU intensive care unit
IEC International Electrotechnical Commission
IEE Institution of Electrical Engineers
ISO International Organization for Standardization
kPa kilo-Pascals
LPG liquefied petroleum gas
LT lead time
Max. maximum level
MES medical electrical safety (tester)
Min. minimum level
MOH Ministry of Health
NGO non-governmental organization
OPD out-patients department


Abbreviations


v




OQ order quantity
PAT portable appliance tester
PME protective multiple earthing
PPM planned preventive maintenance
PVC polyvinyl chloride
RCD residual current device
RFI radio frequency interference
RS reserve stock
SMART specific, measurable, achievable, relevant, time-bound (targets)
SLFO shortest life, first out
TB tuberculosis
TBO time between orders
TST time, steam-under-pressure, and temperature
UPS uninterruptible power supply
V Volts
VDU visual display unit
WHO World Health Organization


Abbreviations


vi




List of Boxes and Figures
Page


Box 1 Categories of items described as ‘healthcare technology’ 2
Box 2 Benefits of healthcare technology management (HTM) 4
Box 3 The collective responsibility for operation and safety 13
Box 4 Summary of issues in Section 2 on framework requirements 29
Box 5 Strategies for making staff more accountable 33
Box 6 General good behaviour strategies when dealing


with equipment 36
Box 7 Examples of dos and don’ts for an hydraulic


operating table 37
Box 8 Strategies for expanding your library 40
Box 9 Strategies for developing equipment skills 43
Box 10 Resources required when running training courses yourself 44
Box 11 Summary of procedures in Section 3 on utilizing


equipment effectively 47
Box 12 General strategies when operating equipment 50
Box 13 Example of operating instructions for an electrical


single-jar suction pump 51
Box 14 Common examples of application training requirements 53
Box 15 Common care and cleaning strategies 55
Box 16 Example of care and cleaning instructions for a microscope 56
Box 17 Summary of procedures in Section 4 on correct operation 57
Box 18 Some examples of common safety hazards during


equipment operation 61
Box 19 Use of different decontamination procedures 64
Box 20 Decontamination strategies 65
Box 21 Safety issues when using instrument boilers 67
Box 22 Some common chemical disinfectants and their


potential applications 68
Box 23 Strategies for ensuring sterility 69
Box 24 Different Bowie & Dick tests available 72
Box 25 Strategies for monitoring sterility 74
Box 26 Strategies for linen handling 77
Box 27 Strategies for general cleaning of health facilities 80
Box 28 Strategies for controlling vermin 81
Box 29 Strategies for waste management 84


List of boxes and figures


vii




Box 30 Strategies for handling waste 86
Box 31 Strategies for disposing of ‘sharps’ 88
Box 32 Safety issues relating to incinerators 90
Box 33 Strategies for the safety of gas cylinders 92
Box 34 Common problems with electrical installations 96
Box 35 Strategies for providing good quality electrical


installations and a decent earth 97
Box 36 Power conditioning strategies 102
Box 37 Laboratory infection risks and strategies to avoid them 103
Box 38 Safety strategies when using X-ray machines 107
Box 39 Strategies for dealing with the hazard of radioactive sources 108
Box 40 Reported radiation risks from other emission sources 108
Box 41 Issues to address when managing fire risks 109
Box 42 The most common causes of fires 110
Box 43 Typical causes of accidents 111
Box 44 Summary of procedures in Section 5 on ensuring


safe operation 111
Box 45 Advantages and disadvantages of disposables and reusables 115
Box 46 How a revolving fund works 116
Box 47 Responsibilities for recurrent materials 120
Box 48 Strategies for storing equipment-related items 123
Box 49 Strategies for creating suitable store rooms 124
Box 50 Steps for calculating annual requirements of accessories


and consumables 129
Box 51 How to calculate reordering times and quantities 133
Box 52 Summary of procedures in Section 6 on accessories


and consumables 136
Box 53 Possible security strategies to consider 138
Box 54 Typical examples of the user’s role in the PPM


of equipment 141
Box 55 Examples of user PPM instructions for


(any types of) refrigerators 142
Box 56 Strategies for developing PPM schedules 145
Box 57 Example of a replacement policy 150
Box 58 Summary of procedures in Section 7 on ensuring


continuous operation 153
Box 59 Example of how to measure a goal 160
Box 60 Strategies for running an annual action planning seminar


in the health service 163


List of boxes and figures


viii




Box 61 Examples of statistics which can be gathered regularly 166
Box 62 Summary of procedures in Section 8 on action planning


and reviewing progress 168
Box 63 WHO’s definition of technology management hierarchy


(Annex 1) 173
Box 64 Example of safety and calibration testing instruments by


type of work and skill level (Annex 6) 206


Figure 1 The place of healthcare technology management in
the health system 2


Figure 2 The relationship between the Guides in this Series 6
Figure 3 The structure of Guide 4 11
Figure 4 The healthcare technology management cycle 18
Figure 5 Sample organizational chart for the HTM service 23
Figure 6 Examples of prompts showing that training is required 42
Figure 7 Strategies for developing training materials 46
Figure 8 How to make up your own Bowie & Dick test pack 73
Figure 9 Ways of improving the quality of water 82
Figure 10 Routes for electricity to flow through the heart to earth 94
Figure 11 IEC symbols on equipment labels showing the level of


safety protection 100
Figure 12 Basic microbiological safety strategies 105
Figure 13 Sample stock card (bin card) 126
Figure 14 Sample layouts for the stock control ledger 135
Figure 15 Strategies for making user staff undertake maintenance


and repair 143
Figure 16 Strategies for expanding user PPM 144
Figure 17 Example timetable of PPM for users in wall calendar format 146
Figure 18 Strategies for safety testing 148
Figure 19 Steps in a typical decommissioning process 152
Figure 20 The planning and review cycle 155
Figure 21 Example of a process profile common to many sterilizers


(Annex 3) 202
Figure 22 Sample store requisition and issue voucher (Annex 4) 203
Figure 23 Example of a register of new stocks form (Annex 5) 205
Figure 24 Maintenance work request/job form (Annex 7) 208
Figure 25 Example ‘list of expendables to be written off ’


form (Annex 9) 224


List of boxes and figures


ix




1. INTRODUCTION
Why is This Important?
This introduction explains the importance of healthcare technology
management (HTM) and its place in the health system.
It also describes:
◆ the purpose of the Series of Guides and this Guide in particular
◆ the people the Guides are aimed at
◆ the names and labels commonly used in HTM, in this Series.


The Series of Guides is introduced in Section 1.1, and this particular Guide on
effective operation and safety is introduced in Section 1.2.


1.1 INTRODUCTION TO THE SERIES OF GUIDES
Healthcare Technology Management’s Place in the Health System


All health service providers want to get the most out of their investments. To enable
them to do so, they need to actively manage health service assets, ensuring that they
are used efficiently and optimally. All management takes place in the context of your
health system’s policies and finances. If these are favourable, the management of
health service assets can be effective and efficient, and this will lead to improvements
in the quality and quantity of healthcare delivered, without an increase in costs.
The health service’s most valuable assets which must be managed are its human
resources, physical assets, and other resources such as supplies. Physical assets such
as facilities and healthcare technology are the greatest capital expenditure in any
health sector. Thus it makes financial sense to manage these valuable resources, and
to ensure that healthcare technology:
◆ is selected appropriately
◆ is used correctly and to maximum capacity
◆ lasts as long as possible.
Such effective and appropriate management of healthcare technology will contribute
to improved efficiency within the health sector. This will result in improved and
increased health outcomes, and a more sustainable health service. This is the goal of
healthcare technology management – the subject of this Series of Guides.


1 Introduction


1




What Do we Mean by Healthcare Technology?
The World Health Organization (WHO) uses the broader term ‘health technology’,
which it defines as including:
‘devices, drugs, medical and surgical procedures – and the knowledge associated
with these – used in the prevention, diagnosis and treatment of disease as well as
in rehabilitation, and the organizational and supportive systems within which care
is provided’


(Source: Kwankam, Y, et al, 2001, ‘Health care technology policy framework’, WHO Regional Publications,
Eastern Mediterranean Series 24: Health care technology management, No. 1)


However, the phrase ‘healthcare technology’ used in this Series of Guides only refers
to the physical pieces of hardware in the WHO definition, that need to be
maintained. Drugs and pharmaceuticals are usually covered by separate policy
initiatives, frameworks, and colleagues in another department.
Therefore, we use the term healthcare technology to refer to the various equipment
and technologies found within health facilities, as shown in Box 1.


BOX 1: Categories of Equipment and Technologies Described as ‘Healthcare Technology’


medical equipment walking aids health facility furniture
communications equipment training equipment office equipment
office furniture fixtures built into the building plant for cooling, heating, etc
service supply installations equipment-specific supplies fire-fighting equipment
workshop equipment fabric of the building vehicles
laundry and kitchen equipment waste treatment plant energy sources


For examples of these different categories, see the Glossary in Annex 1.


Figure 1: The Place of Healthcare Technology Management in the Health System


1.1 Introduction to this series of guides


2


Funds
Human Resources


Facilities
Healthcare Technology
Consumable Supplies


Health Sector Organization
and Management


Health
Service


Provision


Healthy
Population


Health
System


Policies




Often, different types of equipment and technologies are the responsibility of
different organizations. For example, in the government sector, different ministries
may be involved, such as Health, Works, and Supplies; and in the non-government
sector, different agencies may be involved, such as Health, and Logistics.
The range of healthcare technology which falls under the responsibility of the health
service provider varies from country to country and organization to organization.
Therefore each country’s definition of healthcare technology will vary depending on
the range of equipment and technology types that they actually manage.
For simplicity, we often use the term ‘equipment’ in place of the longer
phrase ‘healthcare technology’ throughout this Series of Guides.


What is Healthcare Technology Management?
First of all, healthcare technology management (HTM) involves the organization and
coordination of all of the following activities, which ensure the successful
management of physical pieces of hardware:
◆ Gathering reliable information about your equipment.
◆ Planning your technology needs and allocating sufficient funds for them.
◆ Purchasing suitable models and installing them effectively.
◆ Providing sufficient resources for their use.
◆ Operating them effectively and safely.
◆ Maintaining and repairing the equipment.
◆ Decommissioning, disposing, and replacing unsafe and obsolete items.
◆ Ensuring staff have the right skills to get the best use out of your equipment.
This will require you to have broad skills in the management of a number of
areas, including:
◆ technical problems
◆ finances
◆ purchasing procedures
◆ stores supply and control
◆ workshops
◆ staff development.


1.1 Introduction to this series of guides


3




However, you also need skills to manage the place of healthcare technology in the
health system. Therefore, HTM means managing how healthcare technology should
interact and balance with your:
◆ medical and surgical procedures
◆ support services
◆ consumable supplies, and
◆ facilities
so that the complex whole enables you to provide the health services required.
Thus HTM is a field that requires the involvement of staff from many disciplines
– technical, clinical, financial, administrative, etc. It is not just the job of managers, it
is the responsibility of all members of staff who deal with healthcare technology.
This Series of Guides provides advice on a wide range of management procedures,
which you can use as tools to help you in your daily work. For further clarification of
the range of activities involved in HTM and common terms used, refer to the
WHO’s definition of the technology management hierarchy in Annex 1.
Box 2 highlights some of the benefits of HTM.


BOX 2: Benefits of Healthcare Technology Management (HTM)
◆ Health facilities can deliver a full service, unimpeded by non-functioning healthcare technology.
◆ Equipment is properly utilized, maintained, and safeguarded.
◆ Staff make maximum use of equipment, by following written procedures and good practice.
◆ Health service providers are given comprehensive, timely, and reliable information on:


- the functional status of the equipment
- the performance of the maintenance services
- the operational skills and practice of equipment-user departments
- the skills and practice of staff responsible for various equipment-related activities in a range of


departments including finance, purchasing, stores, and human resources.
◆ Staff control the huge financial investment in equipment, and this can lead to a more effective and


efficient healthcare service.


1.1 Introduction to this series of guides


4




Purpose of the Series of Guides
The titles in this Series are designed to contribute to improved healthcare
technology management in the health sectors of developing countries, although they
may also be relevant to emerging economies, and other types of country. The Series
is designed for any health sector, whether it is run by:
◆ government (such as the Ministry of Health or Defence)
◆ a non-governmental organization (NGO) (such as a charitable or


not-for-profit agency)
◆ a faith organization (such as a mission)
◆ a corporation (for example, an employer such as a mine, who may subsidize


the healthcare)
◆ a private company (such as a health insurance company or for-profit agency).
This Series aims to improve healthcare technology at a daily operational level, as well
as to provide practical resource materials for equipment users, maintainers, health
service managers, and external support agencies.
To manage your technology effectively, you will need suitable and effective procedures
in place for all activities which impact on the technology. Your health service provider
organization should already have developed a Policy Document setting out the
principles for managing your stock of healthcare technology (Annex 2 provides a
number of resources available to help with this). The next step is to develop written
organizational procedures, in line with the strategies laid out in the policy, which staff
will follow on a daily basis.
The titles in this Series provide a straightforward and practical approach to healthcare
technology management procedures:
Guide 1 covers the framework in which Healthcare Technology Management
(HTM) can take place. It also provides information on how to organize a network of
HTM Teams throughout your health service provider organization.
Guides 2 to 5 are resource materials which will help health staff with the daily
management of healthcare technology. They cover the chain of activities involved in
managing healthcare technology – from planning and budgeting to procurement,
daily operation and safety, and maintenance management.
Guide 6 looks at how to ensure your HTM Teams carry out their work in an
economical way, by giving advice on financial management.
How the Guides are coordinated is set out in Figure 2.


1.1 Introduction to this series of guides


5




Figure 2: The Relationship Between the Guides in This Series


Who are These Guides Aimed at?
These Guides are aimed at people who work for, or assist, health service provider
organizations in developing countries. Though targeted primarily at those working in
health facilities or within the decentralized health authorities, many of the principles
will also apply to staff in other organizations (for example, those managing health
equipment in the Ministry of Works, private maintenance workshops, and head offices).
Depending on the country and organization, some daily tasks will be undertaken by
end users while others may be carried out by higher level personnel, such as central
level managers. For this reason, the Guides cover a range of tasks for different types of
staff, including:
◆ equipment users (all types)
◆ maintenance staff
◆ managers
◆ administrative and support staff
◆ policy-makers
◆ external support agency personnel.


1.1 Introduction to this series of guides


6


Chain of activities
in the equipment


life cycle


Plann
ing a


nd


budg
eting


(Guid
e 2)


Procurement and
commissioning


(Guide 3)


Daily
oper


ation


and s
afety




(Guid
e 4)


Maintenance
management
(Guide 5)


Framework/structure
Organizing a network of
HTM Teams (Guide 1)


Ensuring efficiency
Financial management of HTM Teams (Guide 6)




They also describe activities at different operational levels, including:
◆ the health facility level
◆ the zonal administration level (such as district, regional, diocesan)
◆ the central/national level
◆ by external support agencies.
Many activities require a multi-disciplinary approach, therefore it is important to form
mixed teams which include representatives from the planning, financial, clinical,
technical, and logistical areas. Allocation of responsibilities will depend upon a
number of factors, including:
◆ your health service provider
◆ the size of the organization
◆ the number of decentralized levels of authority
◆ the size of your health facility
◆ your level of autonomy.
The names and titles given to the people and teams involved will vary depending on
the type of health service provider you work with.
For the sake of simplicity, we have used a variety of labels to describe
different types of staff and teams involved in HTM.
This Series describes how to introduce healthcare technology management into your
organization. The term Healthcare Technology Management Service (HTMS) is
used to describe the delivery structure required to manage equipment within the
health system. This encompasses all levels of the health service, from the central
level, through the regions/districts, to facility level.
There should be a referral network of workshops where maintenance staff with
technical skills are based. However, equipment management should also take place
where there are no workshops, by involving general health facility staff. We call these
groups of people the HTM Team, and we suggest that you have a team at every level
whether a workshop exists or not. Throughout this Series, we have called the person
who leads that team the HTM Manager.
At every level, there should also be a committee which regularly considers all
equipment-related matters, and ensures decisions are made that are appropriate to
the health system as a whole. We have used the term HTM Working Group
(HTMWG) for this committee, which will advise the Health Management Teams on
all equipment issues.


1.1 Introduction to this series of guides


7




Due to its role, the HTMWG must be multi-disciplinary. Depending on the
operational level of the HTMWG, its members could include the following:
◆ Head of medical/clinical services.
◆ Head of support services.
◆ Purchasing and supplies officer.
◆ Finance officer.
◆ Representatives from both medical equipment and plant maintenance.
◆ Representatives of equipment users from a variety of areas (medical/clinical,


nursing, paramedical, support services, etc).
◆ Co-opted members (if specific equipment areas are discussed or specific interest


or need is shown).
The HTM Working Group prepares the annual plans for equipment purchases,
rehabilitation, and funding, and prioritizes expenditure across the facility/district as a
whole (see Guide 2 on planning and budgeting). It may have various sub-groups to
help consider specific aspects of equipment management, such as pricing,
commissioning, safety, etc.


How to Use These Guides
Each Guide has been designed to stand alone, and has been aimed at different types
of readers depending on its content (Section 1.2). However, since some elements
are shared between them, you may need to refer to the other Guides from time to
time. Also, if you own the full Series (a set of six Guides) you will find that some
sections of the text are repeated.
We appreciate that different countries use different terms. For example, a purchasing
officer in one country may be a supplies manager in another; some countries use
working groups, while others call them standing committees; and essential service
packages may be called basic healthcare packages elsewhere. For the purpose of
these Guides it has been necessary to pick one set of terms and define them. You can
then modify them for your own situation.
The terms used throughout the text are outlined, with examples, in the
Glossary in Annex 1.
We appreciate that you may find it hard to pursue the ideas introduced in these
Guides. Depending on your socio-economic circumstances, you may face many
frustrations on the road to achieving effective healthcare technology management.
We recognize that not all of the suggested procedures can be undertaken in all
environments. Therefore we recommend that you take a step-by-step approach,
rather than trying to achieve everything at once (Section 2).


1.1 Introduction to this series of guides


8




These Guides have been developed to offer advice and recommendations only,
therefore you may wish to adapt them to meet the needs of your particular situation.
For example, you can choose to focus on those management procedures which best
suit your position, the size of your organization, and your level of autonomy.
For more information about reference materials and contacts for healthcare
technology management, see Annex 2.


1.2 INTRODUCTION TO THIS SPECIFIC GUIDE
The Importance of Operating Equipment Safely


Healthcare technology is such an important part of healthcare today that it cannot
easily be ignored. It has a very wide application; for example equipment is used to:
◆ help diagnose whether a patient has malaria
◆ treat a patient by removing their gall stones
◆ monitor the condition of a patient’s heart
◆ provide therapy in order to get a patient moving about again
◆ control the environment by supplying heat and light
◆ provide necessities such as running water
◆ transport patients and staff
◆ feed patients and staff
◆ provide clean surroundings.
Every different type of equipment has its own way of functioning, and its own safety
requirements. Thus it is very important to know how to make the best use of all
types of equipment, so that they can last as long as possible, provide you with
maximum benefits, and not become hazardous to you or your patients.


Did you know?
A number of investigations have shown that, of the equipment problems reported, approximately:
one-third arise from operator problems
one-third arise from minor easy-to-solve technical problems (such as a blown bulb or fuse,


or a loose power cord)
only one-third require more serious fault-finding procedures and special knowledge of


the equipment.
So at least two-thirds (and maybe as much as 80%) of the problems could be corrected by
properly trained equipment users. Leaving, at most, one-third of the problems which require
specially trained maintenance personnel.


1.2 Introduction to this specific guide


9




Staff may feel that the use of equipment is something they already know about
intuitively. But as the statistics above show, it is vital to address how operators use
their equipment, in order to ensure the correct care and handling of equipment.
Thus, it is necessary to:
◆ formalize and write down procedures
◆ ensure staff are properly trained about the procedures
◆ monitor the implementation of the procedures.
Equipment operation and safety is based on a series of commonly accepted ideas and
standards, which should be used to develop guidelines for staff.


Who is this Guide Aimed at?
This Guide is particularly suitable for the following:
◆ Equipment operators, and their department and facility managers within


your organization.
◆ Technical (maintenance) staff in their capacity both as operators and as


equipment maintainers.
◆ Equipment managers in your Healthcare Technology Management Service (HTMS).
◆ Other types of staff who have various responsibilities relating to operation and


safety work, such as administrators, safety inspectors, infection control staff,
trainers, and finance, purchasing, human resource, supplies and stores personnel.


All of these staff should have a good understanding of equipment operation and
safety, in their common effort to provide an effective and safe health service.
The recommendations and procedures outlined are primarily aimed at facility and
district level personnel. However, the Guide also explains what the responsibilities
are at all levels of the system, to help you to see the bigger picture.


What Topics are Covered?
The Guide outlines a number of practical steps for:
◆ equipment operation
◆ safety
◆ care of equipment
◆ disposal of equipment
◆ supplies management.
These will help you to use and look after your equipment without coming to harm,
and to continue to deliver health services to patients.


1.2 Introduction to this specific guide


10




The system introduced in this Guide provides a solid approach to managing
equipment operation and safety. However, we recognize that there are other ways of
organizing these issues which may be more appropriate for your administrative
system. The important thing is to implement a well-functioning system.
As you read through the recommendations in this Guide, you may find it useful to
refer to advice in other Guides in the Series, as indicated in the text. Additional
useful reference materials and contacts are given in Annex 2.


How is This Guide Structured?
The structure of Guide 4 highlights the different activities which you must manage
in order to achieve safe and correct use of equipment, as shown in Figure 3.


Figure 3: The Structure of Guide 4


1.2 Introduction to this specific guide


11


Introducing the Series, and this particular GuideSection 1


Understanding the central framework for HTM, and
background conditions specific to this GuideSection 2


Managing effective utilization of equipmentSection 3


Managing correct operationSection 4


Managing safe operationSection 5


Managing the materials used during your workSection 6


Managing continuous operationSection 7


Monitoring the progress made on all these fronts Section 8




Who Does What in Operation and Safety?
We suggest that the HTM Working Group has a large role to play in advising the
Health Management Team on all equipment matters. Depending on the size of your
facility or what level of the health service you are operating at, your HTM Working
Group may like to set up a number of smaller sub-groups.
In this Guide, we suggest various safety sub-groups which should have appropriate
members that can develop policies and practices for various safety issues, such as
radiation, fire and accidents. Infection Control Committees are also required at
district level and at facility level (depending on its size). Ideally these comprise:
◆ a micro-biologist or a medical doctor, as chair
◆ an Infection Control Officer
◆ members from all relevant departments such as laundry, kitchen, pharmacy,


cleaning services, equipment maintenance, central sterile supply department
(CSSD), theatre, wards, and teaching departments.


A stock sub-group which evaluates the recurrent stock requirements for
equipment accessories and consumables could have the following types of members:
◆ Purchasing and Supplies Officer.
◆ HTM Manager.
◆ Stores Controller.
◆ Representatives from equipment user departments (appropriate to the


equipment being considered).
A training sub-group which considers equipment-related training issues could
include the following types of staff:
◆ Human Resource Manager.
◆ Head of Medical Services.
◆ Head of Support Services.
◆ HTM Manager.
◆ In-Service Training Coordinator.
◆ Infection Control Officer, senior users, and technicians (as appropriate to the


equipment being considered).
Most organizations have a body which is authorized to oversee the process of
condemning old and unsafe equipment. In this Guide, such a body is referred to as a
Board of Survey. This body has the authority to officially condemn the property
and assets of your organization, take it out of service, and dispose of it. It has the
authority to auction-off condemned equipment and sell materials for scrap. The
monies generated must usually, but not always, be returned to the central financial
body of your organization (such as the treasury). These responsibilities are very
important: if your Board of Survey does not function promptly and effectively your
health facility will contain a large graveyard of old equipment.


1.2 Introduction to this specific guide


12




13


1.2 Introduction to this specific guide


Depending on the size of your organization and how many levels of decentralized
authority exist, you may have just one Central Board of Survey, or you may have
Regional/District Boards of Survey – you may even have Boards of Survey at facility-
level. Facility-level Boards of Survey could be comprised of the following types
of staff:
◆ Purchasing and Supplies Officer.
◆ HTM Manager.
◆ Maintenance staff.
◆ Head of Support Services.
◆ Other relevant co-opted members.


Tip • There may seem to be a large number of sub-groups but the aim is to spread the work
around different members of staff so that the HTM Working Group (Section 1.1)
doesn’t have to do everything.


• If you have a small health facility with few staff, the groups that form to oversee
operation and safety can be much smaller. Try to use relevant staff with experience
and those who show an interest in the task.


Since equipment that is well looked after lasts a long time, it is important for
operation and safety to be seen as a collective responsibility in the health service.
Thus many people have a role to play, as shown in Box 3.


BOX 3: The Collective Responsibility for Operation and Safety


Equipment Users


Section Heads


◆ are key to successful operation and safety
◆ are accountable for the equipment they use (Section 3.1)
◆ follow good practice and behaviour around equipment (Section 3.2)
◆ ensure they have the necessary skills to apply the equipment correctly (Section 3.5)
◆ ensure they are familiar with equipment operation (Section 4.1)
◆ provide adequate care and cleaning of equipment (Section 4.3)
◆ follow correct safety procedures for themselves and patients (Section 5)
◆ keep equipment secure (Section 7.1)
◆ provide regular checks on the performance of equipment in use and carry out the


planned preventive maintenance (PPM) tasks designated for users (Section 7.2)
◆ ensure equipment is in a functional state (Section 7.3)
◆ carry out basic repairs, when suitably trained


◆ are responsible and accountable for the equipment in their section
◆ ensure that equipment is used well – in other words the equipment is cleaned,


cared for, checked, calibrated, used correctly and safely, and is kept securely
◆ report faults to the HTM Team promptly (Section 7.4)


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Continued overleaf




Section 1 summary


14


HTM Managers


HTM Teams


Health
Management Teams
(at facility, district,
regional and
central level) and
their HTMWG


Finance Officers


Purchasing and
Supplies Officers


Stores Controllers


Human Resource
Departments


In-Service Training
Coordinators


Infection and Hazard
Control Officers and
Safety Sub-groups
Boards of Survey


◆ ensure technical staff carry out planned preventive maintenance and periodic user
training (see Guide 5 on maintenance management)


◆ ensure that senior technical staff correctly write-off and dispose of equipment at
the end of its life (Section 7.5)


◆ test equipment to ensure that it is in an acceptable and trustworthy condition
(Section 7.3)


◆ know the correct maintenance and repair routines, follow good maintenance
practice, and have the necessary skills (see Guide 5 on maintenance management)


◆ address the practical issues involved with implementing all the equipment usage
and safety policies


◆ ensure sufficient financial and human resources are available to guarantee the
continuous effective operation and safety of equipment (see Guide 2 on planning
and budgeting)


◆ train staff to understand their responsibilities towards equipment (Section 3.5)
◆ ensure equipment is replaced when it reaches the end of its life (see Guide 2 on


planning and budgeting)
◆ ensure annual goals and plans are set and monitored to improve the operation and


safety of equipment (Section 8)
◆ take into account the calculations of accessory, consumable, and spare part usage


rates, when calculating recurrent budgets (see Section 6.3, Guide 2 on planning
and budgeting, and Guide 5 on maintenance management)


◆ allocate sufficient funds for all operational and safety costs (see Guide 2 on
planning and budgeting)


◆ promptly procure the required accessories, consumables, and spare parts, so that
equipment remains functioning (see Section 6.1, and Guide 3 on procurement
and commissioning)


◆ make equipment accessories and consumables stockable items in the stores
system (Section 6.2)


◆ use a stock control system to reorder goods before stocks run out (Section 6.3)
◆ hire suitably skilled operators and maintenance staff and offer attractive packages


in order to retain them in post (Section 2.2)
◆ facilitate in-service training to improve the skills required for equipment (Section 3.5)
◆ ensure that staff performance, with regards to good and bad practice when using


equipment, is reflected in appraisals (Section 8.2)
◆ enable staff to express needs for equipment-related skills development
◆ arrange the necessary relevant training in equipment-related subjects for all staff
◆ develop training resources, and train staff according to timetables (Section 3.5)
◆ monitor levels and incidence of infection, hazards, and accidents (Section 8.2)
◆ develop policies and practices to control infection, hazards, and accidents (Section 5)
◆ train staff and assist them to comply with safety procedures
◆ are authorized to condemn and board equipment at the end of its life (Section 7.5)
◆ are authorized to officially dispose of the property and assets of your organization
◆ are authorized to officially auction-off condemned equipment and provide the


monies to the central financial body (such as the treasury).


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BOX 3: The Collective Responsibility for Operation and Safety (continued)




2. FRAMEWORK REQUIREMENTS
Why is This Important?
In order to deliver quality health services, it is essential to undertake effective
healthcare technology management.
There are various framework requirements to help you do this. These include
legislation, regulations, standards, and policies.
These framework requirements create the boundary conditions within which
you undertake healthcare technology management. They include central or
national guiding principles, policy issues, and high-level assumptions that can
impede or assist you in your work.
It is very difficult to function effectively if these framework requirements do not
exist, and you should lobby your organization to develop them.
Depending on how autonomous your health facilities are, you may be able to
develop these framework requirements at facility, region/district, or central level.


In most industrialized countries, laws, regulations, policies and guidelines form an
indispensable part of health service management. For many developing countries,
however, these regulatory procedures have yet to be developed.
Guide 1 provides a fuller analysis of how to develop these instruments, and shows that
effective healthcare technology management (HTM) is essential in order to deliver
quality health services. Section 2.1 summarizes these points and offers advice on:
◆ the regulatory role of government
◆ establishing standards for your health system
◆ policy issues for HTM
◆ the importance of introducing an HTM Service
◆ managing change.
Section 2.2 goes on to discuss the background conditions specific to this Guide, and
provides advice on:
◆ authorities responsible for guidance on equipment operation and safety
◆ the aims, staffing requirements, and funding issues for operation and safety.


2 Framework requirements


15




2.1 FRAMEWORK REQUIREMENTS FOR QUALITY
HEALTH SERVICES


Regulatory Role of Government
The World Health Organization (WHO) identifies four distinct functions for
health systems:
◆ The provision of health services.
◆ The financing of health services.
◆ The creation of health resources (investment in facilities, equipment, and training).
◆ The stewardship of health services (regulation and enforcement).
Health service provision and financing, as well as resource creation may be taken on by
both the government and the private sector. Thus, there are various options for
organizing health systems:
◆ Mainly public.
◆ Mainly private for-profit (for example, run by a commercial organization), and


private not-for-profit (for example, run by faith organizations, NGOs).
◆ A mixture of government and private organizations.
However in all these systems, the government is solely responsible for the regulation
of health services. The reason for this is that the government has a duty to ensure
the quality of healthcare delivered in order to protect the safety of the population.
These regulations may then be enforced directly by government bodies or they may
be enforced by publicly funded bodies, such as professional associations, which apply
government sanctioned regulations.
Most governments would agree that the protection of health and the guarantee of
safety of health services is vital. However, in many countries this regulatory function is
underdeveloped, with weak legal and regulatory frameworks.
To regulate health services, the government should:
◆ adopt suitable quality standards for all aspects of health services, including


acceptable international or national standards for healthcare technology, drugs,
and supplies in order to ensure their efficacy, quality and safety


◆ establish systems to ensure standards are met, so that the bodies enforcing
regulations have legal sanctions they can use if standards are infringed


◆ establish wide-ranging policies covering all aspects of the utilization,
effectiveness, and safety of healthcare technology, drugs, and supplies


◆ establish systems to ensure these policies can be implemented.


2.1 Framework requirements for quality health services


16




For health services, the Ministry of Health is the body most likely to develop these
government regulations. Other health service providers need to be guided by
government laws, and should look to the Ministry of Health for guidance or follow
their direction if required to do so by law or regulation.


Establishing Standards for your Health System
The government should agree on which quality standards have to be met by the
health services in general. These will cover areas such as:


◆ procedures and training
◆ construction of facilities
◆ healthcare technology, drugs, and supplies
◆ safety
◆ the environment
◆ quality management.


Since drawing up these standards can be both time consuming and expensive,
governments may often choose to adopt acceptable international standards (such as
ISO), rather than develop their own. However, they must be suitable and applicable
to your country situation and fit in with your country’s vision for health services.
The adoption of suitable international or national standards for healthcare technology
is of particular relevance to this Guide. Such standards would cover areas such as:
◆ manufacturing practices
◆ performance and safety
◆ operation and maintenance procedures
◆ environmental issues (such as disposal).
These are important since countries can suffer if they acquire sub-standard and
unsafe equipment. Again, in the majority of cases ministries of health would save
money and time by adopting internationally recognized standards. For more
information on introducing internationally recognized standards into your
procurement procedures, refer to Guide 3 on procurement and commissioning.
It is not enough simply to establish these standards; they also need to be adhered to. For
this reason, you should establish a national supervisory body that has the power to ensure
that health service providers comply with the standards in force. To be effective, such
an enforcement agency must be allocated sufficient financial and personnel resources.
It should also be linked or networked with corresponding international bodies.
Much healthcare technology in developing countries is received through foreign
aid and donations, but such products don’t always meet international standards.
Therefore, your country will need to negotiate with external support agencies.
The best way to do this is to develop regulations for donors that supply equipment
(see Annex 2, and Guide 3 on procurement and commissioning).


2.1 Framework requirements for quality health services


17


Standard
a required or agreed level


of quality or attainment
set by a recognized authority,


used as a measure,
norm, or model




The legal system plays an important role in enforcing such standards, by ensuring
that any infringements can be effectively prosecuted. It is therefore essential that
the legal system is allocated sufficient financial and human resources to enforce
claims against any institution operating equipment that does not meet the
prescribed standards.


Developing Policies for Health Services
Every country needs to establish wide-ranging policies covering all aspects of health
services. National health policies are usually developed by the Ministry of Health. If
these policies are linked to regulations, then other health service providers must also
follow them. Each health service provider can expand them internally, and must
establish systems to ensure they are implemented.
One key framework requirement for this Series of Guides is that your health service
provider should have started work on a Healthcare Technology Policy (for guidance
on this process, see Annex 2). Such a policy usually addresses all the healthcare
technology management (HTM) activities involved in the life-cycle of equipment,
as shown in Figure 4.


Figure 4: The Healthcare Technology Management Cycle


2.1 Framework requirements for quality health services


18


• Create
awareness
• Monitor
and
evaluate


Technology Assessment
and Selection


Budgeting and
Financing


Planning and
Assessment


Training and Skill
Development


Installation and
Commissioning


Procurement
and Logistics


Decommissioning
and Disposal


Maintenance
and Repair


Operation
and Safety




Here we will consider just four issues that provide key background conditions:
◆ A vision for health services.
◆ Standardization.
◆ The provision of maintenance.
◆ Finances.


A Vision for Health Services
Every health service provider needs a realistic vision of the service it can offer. This
should include a clear understanding of its role in relation to other health service
providers in the national health service. Only when this vision is known can the
health service provider decide what healthcare technology is needed, and prioritize
the actions required to develop its stock of equipment.
It is unhelpful if lots of individual health facilities pull in different directions, with
no coordinated plan for the health service as a whole. The central authority of each
health service provider should be responsible for considering what sort of healthcare
should be offered at each level of their health service. Preferably they will collaborate
with the Ministry of Health, or follow their guidance if regulated to do so.
If there is no health service plan, there is no framework on which to base decisions.
Guide 2 provides further information on developing a vision and planning your
healthcare technology stock.


Standardization of Healthcare Technology
Introducing an element of standardization for healthcare
technology will help you to limit the wide variety of makes and
models of equipment found in your stock. By concentrating on a
smaller range for each equipment type, your technical,
procedural, and training skills will increase and your costs and
logistical requirements will decrease (see Guide 1).
It is easier to achieve standardization if equipment is planned and
ordered on a country-wide, district-wide or health service
provider basis. It is therefore important to combine forces with


other facilities or health service providers, and it may be wise to follow standardization
strategies of the Ministry of Health. It is important that these standardization efforts
do not just apply to products purchased by health facilities, but also to donations.
Standardizing your healthcare technology may be difficult for a number of reasons.
Your country and local businesses may have their own trade practices and interests.
National donors may have tied-aid practices, while the procurement procedures of
international funding agencies, health service institutions, and individuals may act
against your standardization strategies (see Guide 3).


2.1 Framework requirements for quality health services


19


Standardization
(also known as rationalization,


normalization and harmonization)
– the process of reducing the


range of makes and models of
equipment available in your stock,


by purchasing particular named
makes and models.




You may need to hold discussions with organizations such as the Ministry of Industry
and/or Trade, the chambers of commerce or specific business associations, as well as
external support agencies. However, it is well worth persevering, as standardization
offers many benefits, both in terms of cost and efficiency.


Provision of Maintenance
Proper maintenance is essential to ensure that the equipment you have purchased
continues to meet the standards required throughout its entire working life.
Undertaking maintenance belongs to the service provision function of health
systems, and could therefore, in principle, be carried out by the government, the
private sector, or by a mixture of the two.
It is useful to organize the maintenance system along similar lines to the health
service provision already existing in your country. For instance, if the health sector is
predominantly run by the government, it is probably simplest to let the government
run the maintenance organization as well. In contrast, if private organizations run the
health services, it makes little sense for the maintenance activities to be carried out
by a government body. In the majority of cases, a mixed system is most likely.
However, the government may wish to take a regulatory role and establish
regulations that guarantee that healthcare technology performs effectively,
accurately, and safely. The rules established are valid for all health service providers,
irrespective of their type of organization.
Specific maintenance requirements would not need to be prescribed by the regulatory
body. Instead, it is up to individual health service providers to decide how these will
be provided. However, the nature and the complexity of some maintenance services
often call for partnerships between the public and private health service providers.
Partnerships may also exist between health service providers and private sector
sources of maintenance support. For more details, refer to Guide 1.
To provide maintenance services, you will normally need to establish good links
between maintenance workshops. This will create a network that supports the needs
of all your health facilities. Maintenance is, of course, only one of many HTM
activities that need to be carried out. However, the fact that maintenance workshops
usually already exist in most countries serves as a useful starting point for establishing
a physical HTM Service across your health service provider organization and across
your country. For more details on how to organize an HTMS, refer to Guide 1.


2.1 Framework requirements for quality health services


20




Finances
To ensure that healthcare technology is utilized effectively and safely throughout its
life, your health service provider will need to plan and allocate adequate capital and
recurrent budgets. See Guide 2 for more advice on this.
In a government-organized system these funds have to be provided by government
budgets, while private systems or mixed systems must generate the required funds
from their customers, or from benefactors and donors.
Depending on your health service provider and country, your HTM Service may be
able to generate income by charging for services provided. Whether this income can be
used to further improve the HTM Service depends on the policies of the responsible
financing authority (such as the treasury or central finance office). Guide 6 provides
advice on this.


The Importance of Introducing a Healthcare Technology
Management Service


We have established the importance of:
◆ adopting standards for healthcare technology
◆ developing healthcare technology policies
◆ establishing systems to ensure the policy is implemented.
All these aims could be achieved if each health service provider practised healthcare
technology management (HTM) as part of the everyday life of their health service.
The best way to do this is to have an HTM Service incorporated into each health service
provider organization.
Box 2 (Section 1.1) shows that HTM provides a wide range of benefits. Guide 1
attempts to express this in terms of the sorts of savings that can be made if HTM is
effectively carried out. Taking maintenance as an example, we can see that it has not
only a positive impact on the safety and effectiveness of healthcare technology, but
that it also has two important economic benefits:
◆ it increases the life-span of the equipment
◆ it enhances the demand for health services, since demand for services is crucially


dependent upon the availability of functioning healthcare technology.
Healthcare technology that is out of order quickly leads to a decline in demand, which
will in turn reduce the income and quality of services of the health facilities. You will
lose clients if, for example, it becomes known that malfunctioning of sterilization
equipment may endanger the health of the patients. Similarly, patients will avoid
visiting health facilities that do not possess functioning diagnostic equipment.


2.1 Framework requirements for quality health services


21




Thus the justification for introducing an HTM Service is that it will benefit you
economically and clinically, by ensuring that healthcare technology continues to
meet the standards required throughout its working lifetime.
The activities of an HTM Service belong to the service provision function of health
systems. However, the government may wish to take a regulatory role and establish
regulations that guarantee that HTM occurs. To achieve this, it will be necessary
to have:
◆ a government body to provide regulations that will ensure the continued


performance and safety of healthcare technology throughout its life
◆ a control mechanism to check that all health service providers pursue these


healthcare technology management activities effectively
◆ legal or other sanctions that are enforceable if the rules are infringed.
The government body responsible for providing regulations could be the central
level of the national HTM Service. Each health service provider could then develop
its own HTM Service. It should involve a network of teams and committees that
enable HTM to be practised in all facilities. In order to establish an effective HTM
Service, you will need to provide sufficient inputs, such as finance, staff, workshops,
equipment, and materials. Only in this way will you get the outputs and benefits that
you require. For details of how to develop such an HTM Service, see Guide 1.
The organizational chart for the HTM Service will vary depending on the size of your
country and your health service provider organization, and whether you are just
starting out. However, Figure 5 provides an example of the relationship between
HTM Teams and HTM Working Groups (Section 1.1) that we envisage.


How to Manage Change
The regulatory requirements presented in this Section may appear somewhat
idealistic, compared to the reality in many health systems. However, the aim is not to
highlight the deficiencies of existing systems, but to provide a blueprint for a
functioning healthcare technology management system. Hopefully, this will enable
you to get the right framework conditions in place, and thus improve the effectiveness
and the safety of your health services.
We are not recommending that your health service provider:
◆ throws out all its current HTM strategies and starts again
◆ makes sudden and sweeping changes that are likely to fail if they are over ambitious.
Rather it is better to take a step-by-step approach, introducing changes gradually, with
a careful review process. To implement an HTM system with all the complexities
described in this Series of Guides will take several years, and to try to achieve
everything at once could be disastrous. However, for healthcare technology
management to improve, it is important to act.


2.1 Framework requirements for quality health services


22




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hn


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l


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ista


nce


HT
M


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m


HT
M


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rki


ng
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rks


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p


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-


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m


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HT
M


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M


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p


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-


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nt


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m


2.1 Framework requirements for quality health services


Figure 5: Sample Organizational Chart for the HTM Service




It is possible to write down all the correct procedures and yet still fail to improve the
performance of staff. To ensure that your HTM procedures are effective, it is important
for there to be good managers who can find ways to motivate staff (Sections 2.2 and 8).
Simply ordering staff to implement new procedures doesn’t usually work. It is much
better to discuss and develop the procedures with the staff who will implement them.
This could take the form of discussion, working groups or training workshops. People
who are involved in developing ideas about their own work methods are more likely to:
◆ understand the objectives
◆ understand the reasons why processes are necessary
◆ be encouraged to change their way of working
◆ be more interested in making changes which result in improvement
◆ see that the aim of the HTM procedures is to improve their delivery of healthcare.
We recognize that many readers will face difficulties such as staff shortages, poor
finances, lack of materials, a lack of influence and time, and possibly even corruption.
Introducing new rules and procedures into a system or institution that has no real
work ethic, or which possibly employs dishonest workers, will not have any
significant effect.
Therefore, strategies may be required to bring about cultural and behavioural change.
For example:
◆ When materials are short, instead of focussing upon breakages and loss, place more


emphasis upon the importance of staff working hard and putting in the hours.
◆ Favour good managers who are seen to be present and doing what they preach.
◆ Encourage an atmosphere where staff are praised for good work, rather than a


culture of judgement and criticism.
Introducing rules and administrative procedures alone will not be sufficient to bring
about cultural change. You will also need to find ways of increasing performance and
productivity, and acknowledging/rewarding good behaviour is essential. For example:
◆ it is better to break a tool while actively undertaking maintenance, rather than


breaking nothing but never doing any work
◆ it is better to break a rule in an emergency (such as withdrawing stocks from


stores), rather than stick to the rules and risk the possible death of a patient.
Annex 2 has some examples of useful reference materials. To bring about such
changes, you will require skills in:
◆ managing change
◆ staff motivation
◆ effective communication
◆ encouragement
◆ supportive training with demonstrations.


2.2 Background conditions specific to this guide


24




All parties involved in the network of HTM Teams and HTM Working Groups need
to participate in developing the HTM Service. This will encourage a sense of
ownership of the Service and its responsibilities, and will lead to greater acceptance
and motivation among staff. If you are short of skilled staff (such as technicians,
managers, planners or policy-makers), you may need to obtain specialist support to
assist with some of these tasks.


2.2 BACKGROUND CONDITIONS SPECIFIC TO
THIS GUIDE
Your country and health service provider may have existing regulating principles
and conditions which will affect, or can inform, aspects of your operation and safe use
of equipment.
You will need to see if the regulations and policies discussed in this Section exist in
your country/organization. If they do, then follow them. If not, you will need to flag
these issues at the central level of your organization, and continue to follow the
advice provided in this Guide at your level.


Responsible Management Authorities
If you work for a health service provider organization, you will need to conform to:
◆ any regulations and guidelines concerning equipment operation and safety


produced by the central management body.
In addition, there may be professional bodies which provide guidance for their area of
expertise (Section 4). For example:
◆ Bodies such as the Medical Council and General Nursing Council which have


guidelines on clinical practices.
◆ The National Laboratory which provides guidance on laboratory practices.
◆ The National Board of Survey which has regulations and procedures on the


condemning, boarding, and auctioning of equipment at the end of its life.


2.2 Background conditions specific to this guide


25


Country Experience
Many developing countries are short of staff who can monitor and regulate safety issues,
and suffer because of this. For example:
◆ Some have few safety inspectors nationally who can monitor the performance


of boilers, lifts, electricity installations, etc.
◆ Some may only have one infection control officer for the whole country.




Authorities Responsible for Safety
A great many bodies may exist in your country which produce guidance on the wide
range of safety issues covered in Section 5. For example, you will need to conform to:
◆ national ‘Health and Safety at Work’ legislation
◆ the national body responsible for the regulations on radiation control, and


guidelines regarding dosimeters
◆ the National Laboratory which sets quality standards for laboratory tests
◆ bodies such as the Medical Council and General Nursing Council which have


guidelines on infection control
◆ the national body, such as the Ministry of Labour, which sends out inspectors who


issue certificates of safety and workmanship on pressure vessels (such as boilers
and autoclaves), and inspect lifts


◆ local government bodies or council authorities which produce building safety
regulations and waste disposal systems


◆ any environmental and/or public health authority which produces environmental
policies and procedures and waste disposal regulations


◆ local fire service authorities which develop fire regulations and guidelines
◆ the national body responsible for the regulations and standards for electricity


supply and electrical installations.
Infection and hazard control committees are required in the health service at district
level and at facility level (depending on the size of the facility). They need access to
international data on hazards. Feedback is available on hazards from international
sources, in the form of international ‘Alert’ reports (see Annex 2). The central level of
your health service provider organization will need to subscribe to the sources of this
literature, and make it accessible to health facilities.
With guidance from government, your health service provider needs to take overall
responsibility for safety issues within its facilities, from a management and legal
viewpoint (Section 2.1), since the health service provider is the body that people
will make claims against if there are any adverse incidents.


Effectiveness of Equipment
This Guide defines ‘effectiveness’ as the appropriate use of equipment and its
availability for use (Section 3.3). It does not attempt to cover cost-effective delivery of
healthcare. Measuring the cost-benefits of effective healthcare delivery requires special
monitoring techniques. It is an enormous subject, and is not the main scope or aim of
this Guide. Guide 2, however, covers how to effectively plan and budget for healthcare
technology, and will help you to deliver the healthcare that you wish to provide.


2.2 Background conditions specific to this guide


26




Healthcare technology represents a substantial asset for your health service provider
that needs to be managed efficiently. Health facilities need sufficient functioning
items of equipment which support the efficient and effective delivery of patient
care. Under-provision threatens the effective treatment of patients. Equipment can
involve risks to patients and staff, particularly if it is not used properly. Thus, the
quality of care delivered to patients is dependent upon how effectively you purchase,
manage, and use your equipment.


Staffing and Skills Levels
If your health service provider is to guarantee the correct and safe use of its
equipment, it needs to recruit enough staff with the necessary skills (Section 3.5).
Adequate training for equipment operators and managers is necessary if you are to fill
the wide variety of health service posts, and ensure specialists for many disciplines
are available. It will be very difficult to ensure effective and safe equipment
operation without sufficiently skilled staff. Thus your organization will need to offer
adequate recruitment packages so that staff can be retained in employment.
Ideally your health service provider will be able to pursue strategies (Section 8.2) to:
◆ motivate staff
◆ evaluate staff performance
◆ use staff appraisal as a positive tool to develop staff skills and enable career


progression
◆ discipline staff when necessary.
However, their ability to achieve these goals will depend on the type of human
resource policies and procedures they have in place.
In addition, the central level of your organization usually plays a significant role in,
among other things:
◆ developing training plans
◆ organizing and providing training scholarships
◆ approaching external support agencies to finance training programmes.
Staff training needs should be addressed at every level by an overall Equipment
Training Plan. This is an ongoing programme of in-service training. The development
of such a plan is described in Guide 2 on planning and budgeting , and should be
financed by your health service provider. It will also need to develop a clear policy on
what form of ‘bonding’ you will use to ensure that a member of staff sent for training
remains within the health service on their return.


2.2 Background conditions specific to this guide


27




2.2 Background conditions specific to this guide


28


To be able to hire staff, your health service provider needs an adequate structure of
suitable posts. Job descriptions are valuable tools for managers as they enable you to:
◆ identify suitable candidates for each post
◆ make the best use of the staff available
◆ plan for further training
◆ recruit suitable people.
Job descriptions are equally important for each worker: they are a guideline for the
work expected of them, the skills required, and possible ways to achieve promotion.
However, it is important not to limit any individual to working at a specific level as
this could seriously hamper the service. A doctor must sometimes be prepared to
help out with tasks such as nursing and cleaning activities.
To be able to recruit clinical and support staff with these skills, there need to be
sources of basic training in your country or geographical region. Section 3.5 discusses
the sorts of basic training required: its availability and your ability to access such
courses will depend on the country you live in. It is important for there to be modules
on the basic training courses which teach equipment-specific skills; however this will
depend on the strategies that have been adopted by your training authorities.


Recurrent Funding
Equipment only remains operational and safe if adequate recurrent budgets are
planned and allocated by your health service provider. These budgets need to cover
all equipment-related expenditure requirements, including the supply of:
◆ accessories
◆ consumables
◆ spare parts
◆ protective clothing
◆ test equipment
◆ reference materials.
Guide 2 of this Series provides advice on how your health service provider can plan
and budget for recurrent costs. You will need to work within the financial resources
allocated to you. In addition, you will have to follow the financial policies and
procedures of your organization, in order to ensure that stock management and
expenditure accounting are carried out according to the regulations.
Box 4 contains a summary of the issues covered in this Section.




Section 2 summary


29


BOX 4: Summary of Issues in Section 2 on Framework Requirements
Government


Ministry of Health


All Health
Service Providers
in general


◆ actively regulates health services whether they are delivered by public providers,
private providers, or a mixture of the two


◆ develops checking systems and legal sanctions for infringement of
health regulations


◆ adopts suitable standards for quality health services, in general
◆ specifically for healthcare technology, adopts standards for:


- design, development and manufacturing
- performance and safety
- use and training
- waste disposal


◆ develops donor regulations to ensure all equipment received through foreign aid
and donations also complies with the standards


◆ establishes public or quasi-public supervisory bodies to enforce regulations
and standards.


◆ develops national policies for health services
◆ specifically develops a Healthcare Technology Policy to cover all healthcare


technology management activities including:
- a vision
- an element of standardization
- the provision of maintenance
- provision of finances for all HTM activities
- the organizational structure for an HTM Service


◆ regulates on these issues (if required)
◆ develops an HTM Service made up of a network of teams and working groups
◆ uses the central level of the HTMS as the national regulatory body, if necessary,


and to ensure that HTM policies are implemented
◆ provides sufficient inputs to ensure the HTMS is effective
◆ uses strategies to manage the changes involved carefully, so that they can


be successful.
◆ conform to regulations and guidelines provided by government
◆ conform to the standards set by government
◆ follow the policies of the Ministry of Health (MOH) if regulated to do so
◆ develop their own internal Healthcare Technology Policy and expand strategies
◆ develop their own HTM Service made up of a network of teams and working


groups, with sufficient inputs to ensure it is effective, in order to ensure that
HTM policies are implemented


◆ follow MOH regulations on the HTMS if regulated to do so
◆ implement strategies to develop skills in managing change, staff motivation,


effective communication, encouragement, and supportive training
with demonstrations


◆ introduce rules and procedures using discussion, working groups, training
workshops, etc with the staff that will implement them


◆ include all parties involved in the network of HTM teams and working groups in
the development of the HTMS


◆ introduce changes to HTM step-by-step, with a careful review process.


Qu
al


ity
H


ea
lth


S
er


vic
es


Continued overleaf




Section 2 summary


30


BOX 4: Summary of Issues in Section 2 on Framework Requirements (continued)


All Health Staff
and Managers


Health Service
Providers


◆ conform to regulations and guidelines provided by relevant bodies on:
- equipment operation and safety
- clinical practice
- laboratory practice
- condemning, boarding, and auctioning of equipment at the end of its life
- health and safety at work
- radiation control and dosimeters
- quality standards for laboratory tests
- infection control
- safety inspections
- building safety
- waste disposal
- the environment
- fire
- electricity supply and electrical installations.


◆ set up infection and hazard control committees and a variety of safety groups to
cover all safety areas


◆ subscribe to relevant sources of operation and safety literature, such as
international data on hazards


◆ develop human resource policies and procedures to ensure staff career
development and help to motivate staff


◆ establish an Equipment Training Plan (see Guide 2) and job descriptions
◆ liaise with training authorities to provide suitable equipment-specific modules on


basic training courses
◆ develop financial policies and procedures which will ensure adequate funds for


equipment operation and safety, and effective stock management.


Op
er


at
io


n
an


d
Sa


fe
ty




3. HOW TO ENSURE EQUIPMENT IS
UTILIZED EFFECTIVELY


Why is This Important?
Equipment plays an essential role in the provision of healthcare services. Staff
must therefore be responsible for the equipment they use, be accountable for
their actions, and practise good behaviour when handling equipment.
To obtain maximum benefit from the equipment you own, it must be
used efficiently.
In order to respond to the rapid changes in equipment design and utilize
equipment effectively, you need to introduce an ongoing skill-development
programme for equipment operators.


It is necessary to monitor how effectively equipment is utilized. Proper equipment
usage leads to the following advantages:
◆ Equipment is operated safely both for patients and users.
◆ Equipment lasts longer.
◆ You will achieve maximum benefit for any financial investments.
◆ Equipment which is kept in good working order helps health staff to do their work


and deliver better services to patients.
In this Section the effective utilization of equipment is discussed through the
following issues:
◆ Making staff accountable for their actions with equipment (Section 3.1).
◆ Encouraging staff to practise good behaviour when handling equipment (Section 3.2).
◆ Using equipment efficiently (Section 3.3).
◆ Providing access to information and reference materials (Section 3.4).
◆ Developing staff skills (Section 3.5).
It is useful for your health service provider to develop an Equipment Usage Policy.
This could be based on the procedures and good practice provided in Sections 3 to 8
of this Guide. Once a policy has been developed, staff should be trained to
understand the issues involved.


3 How to ensure equipment is utilized effectively


31




3.1 ACCOUNTABILITY
Users are the custodians of the equipment they operate. It is their responsibility to
ensure that equipment is in a good functional state at all times. In other words, that it is:
◆ working
◆ giving reliable results
◆ being operated correctly and safely.
It is common for health service staff to feel that they do not own the equipment,
therefore it is not their responsibility, and it must be somebody else’s problem. It
will be necessary to introduce the following new ideas to all staff, and incorporate
such responsibilities into their job descriptions:
◆ Collective responsibility for health service property.
◆ Their new role of being accountable for equipment.
◆ Their performance with regard to equipment being registered as part of their


appraisals (Section 8.2).
Not only must users be responsible for the equipment in their care, they must also
be responsible for using consumables correctly. For example, placing the wrong type
of overhead transparencies into photocopiers or printers will result in the plastic
melting and the equipment being damaged.
It is inevitable that equipment will be lost or damaged from time to time.
Equipment security should be addressed seriously (see Section 7.1 for guidelines).
Damaged equipment that has not been subjected to abuse should not be charged to
the operator. But your organization has to consider what action will be taken if
equipment is missing or abused, and if particular individuals are the persistent cause
of problems. Good or bad performance when using equipment can then be used in
the staff appraisal process (Section 8.2).
Your response to good and bad performance will depend on local human resource
policies and procedures, your strategies for motivating staff (Section 2.1), and whether
you take a positive approach, a disciplinary approach, or a combination of the two.
One option is to take a positive approach which encourages good behaviour. Staff
who consistently treat their equipment well and take care of it are given a reward as
an incentive. This could be the chance to attend a skills-development course, or
perhaps nomination as a trainer of others: the strategies chosen would depend on the
type of equipment involved. For example, individual staff members may be issued
with diagnostic sets which are checked once a week (or once a month). Anyone who
has a complete set every three (or six) months is given a bonus: some batteries, for
example. After five years, the diagnostic set could perhaps become the property of
the staff member.


3.1 Accountability


32




33


3.1 Accountability


BOX 5: Strategies for Making Staff More Accountable


Type of Staff Strategies
◆ given overall responsibility for the equipment in their section, according to


their inventory (see Guide 2 on planning and budgeting for a description of
the inventory), and undertake regular inventory checks to look for missing
equipment and accessories


◆ made responsible for conforming to the local security regulations for the
facility and its site (Section 7.1)


◆ ensure their staff have sufficient skills to operate and care for equipment
correctly and safely, and help them to access appropriate training or
reference materials (Sections 3.4 and 3.5).


◆ during every shift, made responsible for undertaking functional checks on
the equipment as part of user Planned Preventive Maintenance (PPM)
schedules (Section 7.2).


◆ made responsible for the state of the equipment, accessories and
consumables they handle and use


◆ take personal responsibility for ensuring they operate equipment correctly,
and that they know the correct operating techniques and applications
(Sections 4.1 and 4.2)


◆ take personal responsibility for using the correct consumables in a non-
wasteful way (Section 6)


◆ take personal responsibility for ensuring they operate equipment safely, and
knowing the proper safety procedures (Section 5)


◆ made responsible for the daily care and cleaning of the equipment they use
with the correct cleaning chemicals (Section 4.3)


◆ made responsible for monitoring that equipment is functioning properly
and is providing the type of results expected, and reporting any faults
immediately to the HTM Team through their Head of Section
(Section 7.4)


◆ ensure they have been specifically trained to undertake these tasks, and if
they require further skill-development put in a request to their Head of
Section (Section 3.5)


◆ take responsibility for conforming to the local security regulations for the
facility and its site (Section 7.1).


◆ made responsible for purchasing the correct consumables and
cleaning chemicals.


◆ made responsible for keeping track of stocks of consumables and materials
in the various stores (Section 6).


Heads of Section


Operators-in-Charge


Equipment Users


Purchasing and
Supplies Officers
Stores Controllers


Continued overleaf




BOX 5: Strategies for Making Staff More Accountable (continued)


Type of Staff Strategies
◆ try to develop a suitable working environment where managers are seen to


be present, and performing well themselves
◆ consider positive strategies with bonuses and rewards for good behaviour with


equipment, as incentives for making staff more responsible and accountable.
◆ consider disciplinary mechanisms so that staff are charged for intentional


loss of, or damage to equipment and accessories, to make them more
accountable for their actions. Typical issues to consider to make the system
fair are:
- Should someone who breaks equipment while working correctly be charged?
- How do you ensure that charging doesn’t result in people breaking nothing


by doing nothing?
- Should missing or wilfully damaged equipment be charged to the operator


or the Section Head, in order to deter theft and abuse?
- Should fines be deducted from the salary of staff by instalments?
- In the case of more expensive items, should penalties be incurred in the


individual’s terminal benefits?
- Should persistent loss or abuse result in suspension or termination


of employment?
- Should equipment and accessory damage caused by the incorrect use of


chemicals for disinfection be chargeable to the individuals responsible?
- Should chemical damage caused by the purchase of incorrect products be


charged to the Purchasing and Supplies Officer responsible?


3.1 Accountability


34


Health Management
Teams


Another option is to take a disciplinary approach, and establish mechanisms so that
damage and breakages can be charged to staff. This method aims to make staff more
accountable for their actions, in the same way that maintainers are often charged for
damage to tools (see Guide 5 on maintenance management). Serious negligence
may lead to suspension – for example, for crashing an ambulance due to reckless
driving – and persistent offending may result in termination of employment. If you
choose to take such a route the system should be fair, and only target those who
abuse equipment intentionally (Section 2.1). Each case should be assessed
individually, using formal disciplinary hearing procedures. Finance and salary
departments should base fines on realistic quotes for replacing equipment.
However, any approach taken to enforce rules for general staff is only workable if it takes
place in the right working environment, otherwise petty tyranny may prevail. The most
important thing is for staff to be in an environment where their managers are present,
involved, expect the correct results, and are seen to perform well themselves.




3.2 General good behaviour towards equipment


35


DIRECT SUNLIGHT
NO


SPILLAGE
NO


RAIN
NO


HEAT
NO


MAGNETS
NO


AEROSOL
SPRAY
NO


DUST
NO


SMOKE
NO


STEAM
NO


Source: Lee, P, 1995, ‘Get it Right!: A Guide to Maintenance, Safety Precautions & Hygiene
of Medical Equipment’, ECHO International Health Services Ltd, UK, unpublished


Box 5 provides some strategies for making staff more accountable, by clearly setting
out their responsibilities towards equipment.


3.2 GENERAL GOOD BEHAVIOUR TOWARDS
EQUIPMENT
It is very important to instil in health staff good practice concerning their interaction
with equipment. Some staff will intuitively know how to treat equipment, others
will need to be guided and taught. Some staff may not have regularly come into
contact with equipment before starting their job in the health service. This Section
looks at the general behaviour of staff in relation to any type of equipment. The
approach should be to teach staff, using demonstrations, to remember the basic
motto and strategy of ‘Safety – Care – Maintenance’: they need to understand the
basic dos and don’ts when dealing with equipment.
A list of dos and don’ts is often given in the equipment manufacturer’s literature.
Staff should also have written resources from their training sessions and, in some
cases, posters which display the guidance and experience of their colleagues on good
behaviour towards equipment (Section 3.5). Copies of this advice should be made
available in the library for reference (Section 3.4).




36


3.2 General good behaviour towards equipment


Box 6 provides some examples of dos and don’ts that apply to equipment in general.


BOX 6: General Good Behaviour Strategies When Dealing With Equipment
DO
◆ only use equipment for the purpose it was designed for
◆ only use portable equipment while it is safely positioned on a suitable flat surface, such as a worktop,


trolley, or the floor
◆ ensure moveable parts such as lids, wheels, and extensions are securely locked in place before the


equipment is used
◆ only use equipment if you know the correct operating technique and are competent and trained to use it


(Section 4.1)
◆ keep loose clothes away from moving parts (Section 5.5)
◆ only use equipment when you have the proper safety gear, for example, lead aprons, gloves, goggles


(Section 5.1)
◆ only use equipment with patients when you are sure it is functioning correctly and safely (Section 5)
◆ always make sure the correct service supplies are available (such as electricity, water, gas) before switching


the machine on
◆ only use the correct accessories specific to a particular machine (Section 6)
◆ only use the correct consumables specific to a particular machine (Section 6)
◆ place and store accessories carefully in the appropriate holder, pouch, or drawer to prevent them dropping


on the floor or getting lost
◆ only use the correct chemicals and cleaning methods specific to a particular machine (Section 4.3).


DON’T
◆ pull equipment around by its lead
◆ use equipment to prop open doors
◆ balance equipment on the edge of beds
◆ drop equipment
◆ tangle and create knots in the leads
◆ spill liquids over equipment
◆ use equipment surfaces as tables
◆ scratch equipment
◆ use equipment for private purposes without permission
◆ use hot equipment surfaces for heating food (other than legitimate kitchen appliances)
◆ store food in refrigerators designed for other purposes, such as for storing vaccines, or a blood bank
◆ leave cables or equipment in positions where people may trip or injure themselves
◆ leave windows open but unlatched, as a strong wind could swing them against the wall and shatter the glass
◆ put rubbish down toilets – this will block the drains.




3.2 General good behaviour towards equipment


37


There are also specific dos and don’ts for each type of equipment. Box 7 provides an
example of the type of instructions for an hydraulic operating table.


BOX 7: Examples of Dos and Don’ts for an Hydraulic Operating Table
(these may vary or require additions depending on the make and model)


DO
◆ check leg section is secure and apply brake on table base before using
◆ only use correct mattress and accessories for table
◆ avoid placing sharp objects against mattresses/pads or radiographic table top
◆ always lower table top completely before cleaning
◆ always leave head and leg sections fully lowered when table is not in use
DON’T
◆ pull a table – always push it
◆ lift a table by its top
◆ push a table over rough surfaces – use a trolley or lift
◆ drop a table (or individual sections) when transporting it
◆ drop heavy objects onto the table (especially the radiographic top)
◆ spill oil, ether, or other chemical fluids on mattresses/pads.


Any member of staff who sees a problem arising with the treatment of equipment,
should fill in an Incident Report Form for the HTM Working Group, so that the
problem can be addressed (Section 8.2).


3.3 EFFICIENT USE OF EQUIPMENT
To obtain the maximum benefit from your equipment, it is best to use it efficiently.
There are a number of issues to address if you want to be efficient:


How Much is Your Equipment Utilized?
Some ways of utilizing equipment are more economical than others. Your main aim is
to make the most of your investment in the equipment.
For example, it is more efficient use of an X-ray machine to do at least 50 exposures a
week than to do just two. Thus, how much use you will make of a machine may
determine whether you want to purchase one in the first place. It may be better to
share an X-ray machine with several neighbouring facilities. These are issues which
should normally be discussed before you buy the equipment, in the planning phase
(see Guide 2 on planning and budgeting).




However, if you already have a machine that is not used a great deal you can either:
◆ choose to operate the machine on just one day a week, and call patients in on that


day. This way, the machine has a chance to warm up and can be used effectively
for the day, rather than being switched on and off throughout the week.


◆ or plan when the equipment will be used during the day. For example, arrange for
the majority of blood tests to be sent to the laboratory immediately after doctors’
rounds in the morning. This would give you a large number of samples available
before using your centrifuge and batch chemistry analyzer.


Do You Use Your Equipment and Materials Effectively?
How often you plan to use your equipment will have an impact on how effectively
you utilize the consumables and materials required.
For example, if you are running an antenatal clinic, it is a good idea to ensure that the
laboratory technician is available at the same time. Then he or she can do the
haemoglobin screening test while the clinical appointment takes place, and it will
not be necessary to ask the patient to return to the clinic another day for the
laboratory test. By concentrating equipment use to specific times, you can open a
multi-pack of consumables (such as stick-on electrodes or reagent strips) without
fearing that the items you do not use will go off. Thus, with better coordination you
can make more efficient use of your consumables.
Another strategy for ensuring the most effective use of equipment and materials is to
train special equipment operators, who will be responsible for running particular
equipment during clinics or work sessions (Section 3.5).
The layout of buildings and departments can also contribute significantly to the
effective use of equipment and staff. Architects can advise on placing furniture and
equipment in the available space in an orderly and effective way, which ensures
appropriate flow patterns suited to the function of the room (see Guide 2).


Is Your Equipment Economical to Run?
It is best to choose makes and models of equipment which are input-efficient. Just
as some vehicles are more fuel efficient than others, some makes of equipment are
more economic in their use of consumables. This should be considered during
equipment planning and procurement (see Guide 2 on planning and budgeting and
Guide 3 on procurement and commissioning).


3.3 Efficient use of equipment


38




39


All equipment has a life-cycle cost – the recurrent cost required to keep it going
throughout its life, such as fuel, consumables, maintenance, and training. The cost of
these factors can vary considerably between different manufacturers, especially
consumables. For example, the initial purchase price of infusion pump type A may be
cheaper than type B. However, the annual running costs for infusion sets for type A
may be much more expensive than those for type B. Thus, it would be worth the
higher initial cost to purchase pump B, so that you can benefit from the lower
running costs.
When choosing equipment which uses consumables, you should try to use ‘open’
rather than ‘closed’ procurement systems. Open systems mean that anyone can
supply the consumables for your equipment, and different manufacturers’
consumables can fit your machine; this competition leads to lower-cost consumables.
Closed systems mean that the equipment and its consumables are only made by one
manufacturer, and you are limited to one supplier only; this monopoly leads to more
expensive consumables (see Guide 3 on procurement and commissioning).
Other issues which will affect the functioning and cost of running your equipment are:
◆ the availability of spare parts
◆ a functioning in-house maintenance service (see Guide 5 on


maintenance management)
◆ the presence of a local representative of the manufacturer who can offer


you support.
If there is no local support or source of supplies, it will be much more expensive to
continually get help and materials from abroad. These issues should be considered
when products are compared during the procurement process (see Guide 3 on
procurement and commissioning).


3.4 ACCESS TO INFORMATION AND REFERENCE
MATERIALS
It is important for staff to have access to written references to help them with their
work. It is common for such data to be missing from health facilities, and for manuals
arriving with new equipment to go missing. We suggest you develop a library of
professional literature, reference materials, and equipment manuals. Box 8 provides
some strategies for developing such a library; although we recognize that following
these recommendations will require time, staff input, and money.


3.3 Efficient use of equipment




40


3.4 Access to information and reference materials


Obtain literature
which is usually
available free of charge.


Obtain literature
from neighbours
which, with negotiation,
may be available for the
cost of photocopying
and postage.
Obtain information
available internationally
which can be paid for as
one-off items, or by
annual subscription
(depending on the
material type and
source). This material
may come as a hard
copy or as part of a
software package.
Make sure you order
relevant literature
when purchasing all
your new equipment
(see Guide 3 on
procurement and
commissioning).


◆ manufacturers’ care and cleaning guidelines
(from manufacturers and their representatives)


◆ safety guidance for specific machines (from
manufacturers and their representatives)


◆ operation and safety guidance from national
bodies (Medical/Nursing Council, National
Laboratory, Fire Service, etc – see Section 2.2).


◆ operation and safety guidelines
◆ copies of manufacturers’ operator and service


manuals for older machines.


◆ text books relevant to different professional
disciplines (laboratories, theatres, laundries,
physiotherapy, child health, etc)


◆ manufacturers’ operator and service manuals
◆ equipment hazard reports and safety literature
◆ journals, data, reference books, and


reference materials
◆ internationally available advice on operation


and safety of equipment, etc.


◆ operator manual
◆ service manual which should include care and


cleaning instructions and safety guidance.


For existing equipment, find
as many of these as possible.


Contact as many other health
facilities and health service
provider organizations in your
country and neighbouring
countries as possible, to obtain
existing resources.
Try to get hold of these
resources – consider
subscribing to them – and look
for help to pay for them.


◆ when the manuals arrive,
store the original copies
in a safe place (such as
the HTMS library, the
facility library, or the
workshop library)


◆ make photocopies of the
operator manuals, and give
one copy to the relevant
user department, and one
copy to the HTM Team or
relevant workshop


◆ make photocopies of the
service manuals, and give
one copy to the HTM
Team or relevant workshop.


BOX 8: Strategies for Expanding Your Library (see Annex 2)
Strategy Type of Material/Information Action


Continued opposite




41


3.5 Developing staff skills


Investigate other
sources for getting
literature and
information which you
do not have.
If material is no
longer available on
paper, find a more
accessible format.


Scan single copies of
printed documents
into a computer and
keep them as
electronic copies.


◆ suppliers
◆ manufacturers’ local representatives
◆ international agencies
◆ links with health facilities abroad.


◆ CD-Rom
◆ video
◆ DVD.


◆ user manuals
◆ service manuals.


Make use of internet (world
wide web) contacts where
possible, as this method will
become more and more
important in future.
Investigate these alternative
sources of information. Make
copies and print-outs of the
material and make it available
to other facilities.
Scan these documents into
your computer system and
make them more easily
available to maintenance
technicians at many locations.


BOX 8: Strategies for Expanding Your Library (see Annex 2) (continued)
Strategy Type of Material/Information Action


3.5 DEVELOPING STAFF SKILLS
Since so many new makes and models of equipment are coming out almost every
year, staff (both users and maintainers) need to continually update their skills.
Training for equipment operators will need to cover:
◆ good practice when handling equipment – basic dos and don’ts (Section 3.2)
◆ how to operate equipment (Section 4.1)
◆ the correct application of equipment (Section 4.2)
◆ care and cleaning (Section 4.3)
◆ safety procedures (Section 5)
◆ management of stocks and stores (Section 6)
◆ planned preventive maintenance (PPM) for users (Section 7.2).
Maintenance staff will also need to obtain many of these skills. In addition, there will
need to be training for maintainers in PPM and repair; these requirements are
discussed in Guide 5 on maintenance management.
Remember that training should not be an activity that only happens once. Training is
required at various times throughout a member of staff ’s career:
◆ Induction training – when staff are new in post, move to a new department or


facility, or to a new location with different responsibilities.
◆ Training at the commissioning of equipment – when new equipment first arrives.
◆ Refresher training – to update and renew skills throughout the working life of staff.




42


3.5 Developing staff skills


The provision of such training must be addressed seriously by the health service
provider. There are a number of options available for developing skills in-service, and
each health service provider has to pursue a combination of strategies for sourcing
the training required. Whatever options prove to be the most feasible, a skills
development programme is vital. As explained in Section 2.2, the training needs of
staff at every level should be addressed by the overall Equipment Training Plan,
which is an ongoing rolling programme of in-service training.
We suggest that the HTM Working Group, or possibly a smaller training sub-group
(Section 1.2), is responsible for establishing all training requirements. This Section
looks at some strategies which can be taken at the facility or district level to implement
the Equipment Training Plan (developed in Guide 2 on planning and budgeting).
You will need to consider the sources of training and professional support available,
and Box 9 provides a variety of strategies to help you with this.
When you begin to monitor how equipment is used, you will notice a number of
prompts that training is required. These training requirements should be passed on
to your Health Management Team (Section 8.2). Figure 6 shows the likely prompts.


Figure 6: Example of Prompts Showing That Training is Required


Prompt Response


Staff newly arrived at a facility, or
transferred between departments


Staff admit that they need any type of
equipment-related training


Heads of Section see that staff are short
of particular equipment-related skills


Maintenance staff identify user-related
problems with equipment


New equipment arrives at the health
facility (according to the Equipment
Development Plan – Guide 2)


An incident report is submitted
(Section 8.2)


Skill shortages are discovered during the
staff appraisal process (Section 8.2)


In-Service Training Co-ordinator organizes induction
training on equipment-related skills


They request it from their Head of Section


They request the necessary training from the
HTM Working Group (or its training sub-group)


They report this to the HTM Manager


The training sub-group/Commissioning Team
organizes this


The HTM Working Group, or its safety sub-groups,
decides if extra training is the appropriate solution


Managers agree with the individual which training
would be the best development strategy,
and request it from the Human Resource
Department/training sub-group




3.5 Developing staff skills


43


BOX 9: Strategies for Developing Equipment Skills
Strategy Advantage/Disadvantage


This can be good training but may be expensive as it often entails going
abroad and paying in foreign currency. However, the equipment
manufacturer may have a local representative that has the skills to
provide the necessary training. Although this is a more affordable option,
the danger is that the company will offer a course which is either too
simple (not much more than a factory tour), or alternatively is very
theoretical. Good communication is required to ensure that this
equipment-specific training is effective and appropriate.


This option may not be the most affordable, and therefore may not be
ideal if you are facing financial constraints. If the company’s local
representative has sufficient skills to undertake the training, this may be
more affordable.


Other facilities, workshops, or teams may already have developed skills
that you need. Here your staff can either attend specific training
courses, or have a period of secondment in order to obtain skills through
on-the-job training, work experience, or work exchange visits.


When equipment is purchased from a company, you can ask them to
provide training at the time of commissioning (see Guide 3 on
procurement and commissioning). Who covers the cost of the training and
where it will take place are negotiated as part of the procurement contract,
and may be dependent on the type and total cost of the equipment.


You can make use of local, national, or regional experts who are
maintenance and/or clinical staff. It may be necessary to send some staff
for training abroad so that they can become the local trainers/experts.


These can be used as a forum to introduce staff to particular
equipment concerns. They can be run at facility, district, central, or
international levels.


These are useful for gaining additional specialist skills. They will be
available nationally, regionally, and overseas.


Health colleges (who provide basic training for nurses, doctors,
physiotherapists, etc) can introduce new modules aimed at developing
equipment-related skills for equipment users.


Practical experience, with or without supervision, provides excellent
training as long as it is targeted at the right skill level. When a piece of
equipment is not in use, staff should be encouraged to familiarize
themselves with the equipment, and learn its principles and its
different applications.


Send staff to factories that
manufacture equipment


Invite engineers from
manufacturers to visit your
facility to conduct training on
their equipment


Send staff to other locations
which have already developed
the skills required


Link the provision of training to
the procurement process


Run in-house (on-the-job)
training sessions


Make use of regular
clinical/professional meetings


Make use of academic courses
at various levels


Approach local colleges to
develop, run, and accredit new
modules


Provide opportunities for
practical on-the-job experience


Continued overleaf




A variety of resources can help you when you decide to undertake training yourself.
These will vary depending on the training source, and on which of the available skill-
development options (described in Box 9) you use. Box 10 details some of the
resources you may require.


BOX 10: Resources Required When Running Training Courses Yourselves
Information about the training required (background and needs assessment) and the


training sources available.
Training materials appropriate to the piece of equipment to be studied.
Space suitable for carrying out the training in.
Equipment to be practised on during the training courses.
Test and calibration instruments in order to verify technical conditions and safety during training.
Spare parts appropriate for user PPM training.
Supplies for user training, such as consumables, medical supplies, and cleaning


materials.
Manuals to refer to, such as the manufacturer’s operator and service manuals.
Test method and certificate a formal way of testing trainees and issuing them with a certificate at the


end of the training course, as a quality control and motivating factor
(depending on the extent of the training).


Recognition a formal way of ensuring that the additional skills attained by staff are
reflected in their promotion chances and job grades by the Human
Resource Department.


Additional expenses possible room hire, overnight accommodation, travel and subsistence,
trainers’ fees, visual aids, teaching equipment, etc.


Records a system for keeping a record of the specific training that a staff member
has received.


44


3.5 Developing staff skills


BOX 9: Strategies for Developing Equipment Skills (continued)
Strategy Advantage/Disadvantage


Books, manuals, and articles from journals will answer many questions
on principles of operation and care for different types of equipment (see
Annex 2). If staff are given opportunities to study, with a little pressure
and an expectation that they will lecture to colleagues afterwards, the
benefits for individuals can be great.
This allows staff to share experiences regarding equipment, to learn
from their colleagues, and to develop a professional approach to work.
The meetings will be available nationally and internationally.


The materials, together with demonstrations, help staff to learn as well
as providing them with something that they can regularly refer to when
they are unsure.


Provide opportunities for
studying and teaching


Let different types of staff
(nurse, radiographer, laboratory
technician, etc) attend their peer
group meetings
Provide various training materials
for staff to refer to (see Box 8
and Figure 7).




45


3.5 Developing staff skills


Developing Training Materials
We suggest you develop simple guidelines for each type of training required for every
type of equipment, based on good principles and procedures. This Series includes
the following examples:
◆ Guide 2 covers equipment planning and budgeting.
◆ Guide 3 covers procurement, adjudication of tenders and quotes, installation


and commissioning.
◆ Guide 5 covers PPM and repair for maintainers, and spare parts’ management.
◆ Guide 6 covers financial management for HTM Teams.
◆ Finally, this Guide, Guide 4, covers good practice when handling equipment (basic


dos and don’ts), how to operate equipment, the correct application of equipment,
care and cleaning, safety procedures, planned preventive maintenance for users, and
stores management.


The specific guidelines for different equipment types should be modelled on the
advice in:
◆ the equipment manufacturers’ operator and service manuals
◆ the manufacturers’ PPM schedules
◆ written resources produced by other organizations (see Annex 2).
Training can also incorporate the experience of existing staff. Figure 7 (overleaf)
shows a number of strategies to follow when developing training materials.


Training Trainers
The trainers who run the equipment training sessions are usually one or more of
the following:
◆ Staff from the equipment manufacturer.
◆ Staff from the manufacturer’s representative.
◆ Clinical or maintenance staff from other teams, workshops, health facilities, and


health service providers who are knowledgeable about the equipment.
◆ Senior clinical or maintenance staff within your team, workshop, or health facility


who were previously trained on the equipment or who have the necessary skills.
◆ Partners in technical cooperation projects, or staff from non-governmental


organizations and charities.
If you don’t currently have enough trainers, you can nominate staff who can be
trained to become trainers. When users and maintainers are being trained at the time
of commissioning new equipment, it may be useful to select staff from among the
trainees who you would like to become trainers. These individuals can then go on to
train staff who could not attend the initial training sessions: for example, a matron
could be trained to teach other nurses.




The trainers will need to be taught sufficient skills to train their colleagues. They
should be capable of running both formal and informal training sessions in order to
pass on their skills in the operation, care, and maintenance of equipment. They will
require training on the specific equipment concerned and can receive this either
from the manufacturer, from other facilities where the equipment is in use, or from
colleagues with the necessary experience.


Figure 7: Strategies for Developing Training Materials


46


3.5 Developing staff skills


Process Activity


Meet regularly


Hold special meetings when
new equipment arrives


Notify manufacturers or their
representatives of your
training needs


Observe staff training carried
out by equipment manufacturers
or their representatives


Convert the written guidelines
into a range of
resources/visual aids


Video the training activities


Buy ready-made training videos


To develop training resources for existing equipment as an
ongoing exercise to develop a library of written resources.


Study the operator and service manuals and develop suitable
training resources from them.


If manufacturers are going to carry out training on equipment,
notify them in advance of the range of training and resources
you require from them.


Attend the training sessions, record the training given, obtain
copies of any handouts or overheads used, and compile
written resources in the usual format to add to the stock of
training guidelines.


• Handouts for the trainees.
• Posters which can be placed on the wall beside the equipment.
• Laminated cards or paper in plastic pockets attached to/hung
from the equipment itself.
• Laminated cards showing User PPM schedules for the staff to
carry around and refer to when carrying out User PPM
(Section 7.2).
• Acetates (for use with overhead projectors – OHP) so that the
training courses can be run and rerun for refresher training
purposes.
• PowerPoint presentations (a developing computer tool) and
video/computer projectors for larger institutions who often
make presentations (the modern OHP).


Videos can form a useful resource for re-training, as back-up,
and for reference, etc. If the video is to be of use, it is important
that suitably experienced professionals undertake the filming.
Investigate the possibility of hiring a video camera and
cameraman from persons who currently undertake the videoing
of such technical activities.


Obtain these from manufacturers and other sources,
for example, electrical safety (RS Components), safe handling
of medical gases (BOC), care and use of the microscope
(Olympus) – refer to Annex 2.


Keep copies of the training
resources produced together
in one place


Choose a suitable location for storing the various resources
(handouts, posters, laminated cards, overhead acetates,
videos, computer files). Possibilities are: the office of the
In-Service Training Coordinator, HTM Manager, or Human
Resource Manager, or in your library if you have one
(Section 3.4).


The HTM Working Group or its training sub-group:




3.5 Developing staff skills


47


Experience in Africa
In a number of government central referral hospitals in Zambia, senior doctors nominate
members of staff to be special equipment operatives. For example, ECG recorder
attendants are given responsibility for always setting up and running ECG recording
sessions. In addition, the Biomedical Engineering Unit of the Central University Teaching
Hospital has a training centre where senior maintainers teach medical staff how to use
specialized equipment, such as those from intensive care units, operating theatres and
special care baby units.
The MOH in Ghana trains equipment users as application specialists for various service
areas, such as clinical laboratory, life support systems, and imaging devices. These
people are selected from their specific clinical area, seconded to the HTM Service part-
time, given formal technical training, and sent on training-of-trainers programmes.
Whenever new technologies are introduced by the MOH into these clinical areas, the
specialists are always available to give application training to new users.
Another strategy pursued by the Ghanaian MOH, is to set up a skills laboratory where
examples of new devices are installed and linked to simulators, for the purpose of
training new users and technical personnel. These laboratories are manned by the
application specialists.


Training Special Equipment Operatives
Another strategy is to nominate and train certain members of staff to be some form of
special equipment operative. These individuals can be trained to set up, operate,
apply, and take care of specific items of equipment in order to ensure that it is used
consistently and that it provides a reliable service. Examples are given in the country
experience box above. Such a strategy has additional benefits. For example,
nomination as a special equipment operative can be an incentive to motivate staff,
and lead on to them becoming trainers.
Box 11 contains a summary of the issues covered in this Section.


BOX 11: Summary of Procedures in Section 3 on Utilizing Equipment Effectively


Equipment Users


HTM Teams


Section Heads


Go
od


B
eh


av
io


ur


◆ follow good practice when handling equipment and make themselves aware of
general dos and don’ts (see Box 6)


◆ report any poor behaviour by equipment users that they observe, through the
HTM Manager to the Health Management Team


◆ ensure their staff follow good practice with equipment, and report any problems
to the Health Management Team so that any training needs can be addressed


Continued overleaf




48


Section 3 summary


BOX 11: Summary of Procedures in Section 3 on Utilizing Equipment Effectively (continued)


Health Service
Provider


Equipment Users
and Section Heads


Health Service
Providers and
Health Management
Teams


Equipment Users
and Section Heads


Health Management
Teams


Health Service
Provider


HTM Working
Groups (or Training
Sub-Groups)


Sk
ill


s D
ev


el
op


m
en


t
R


es
ou


rc
es





E
ffi


ci
en


t U
se








Ac
co


un
ta


bi
lit


y





◆ ensures that sufficient numbers of suitably skilled staff are recruited to operate
its equipment, and implements strategies to encourage retention of staff
in service


◆ develops the mechanisms for making staff accountable for the equipment they
work with (see Box 5)


◆ agrees the action to be taken by the Human Resource Department if persistent
loss or abuse of equipment is discovered


◆ agrees incentives for good performance with the Human Resource Department
◆ ensure they understand their responsibility for equipment and act in such a way


as to protect it
◆ ensure they understand how accountability for equipment will affect them
◆ plan the location of equipment so that it can be used efficiently
◆ consider sharing resources between facilities (see Guide 2 on planning


and budgeting)
◆ plan when to use equipment, and how to link appointments and services for


patients in order to use equipment efficiently
◆ when purchasing equipment, choose products which make efficient use of resources


such as consumables, fuel, finances and maintenance support (see Guide 2 on
planning and budgeting and Guide 3 on procurement and commissioning)


◆ use consumables efficiently without wastage
◆ plan when to use consumables, so that once a pack is opened its contents do not


go off
◆ develop a reference library (see Box 8) to contain all resource materials that staff


may need


◆ develops and funds an Equipment Training Plan (see Section 2.2 and Guide 2)
◆ provides inputs for the in-service training programme
◆ coordinates training scholarships
◆ considers ‘bonding’ issues for staff sent for training


◆ investigate and use the broad range of training sources available (see Box 9)
◆ develop training materials (see Figure 7)
◆ identify and train suitable staff to be trainers
◆ identify and train suitable staff to be special equipment operatives
◆ receive and act on any prompts which indicate that staff need training (see Figure 6)
◆ provide the necessary resources when running training courses themselves (see


Box 10)




49


4 How to ensure correct operation


4. HOW TO ENSURE CORRECT OPERATION
Why is This Important?
If staff operate equipment correctly, the equipment is less likely to become
damaged, and staff will therefore get the best performance out of it.
Staff can gain maximum benefit from equipment by knowing how to:
◆ use it
◆ apply it in different situations
◆ take care of it.


This Section covers how to ensure correct operation by discussing:
◆ how to operate equipment (Section 4.1)
◆ the correct application (Section 4.2)
◆ care and cleaning (Section 4.3).
For all these issues there are likely to be national and international bodies which can
offer guidance and regulations (see Section 2.2 and Annex 2).


4.1 HOW TO OPERATE EQUIPMENT
‘Operation’ of equipment means using the correct physical methods to get the
equipment to work. In order to do this successfully, the user needs to know:
◆ the specific operating characteristics of a machine
◆ the operational procedures that make the machine work
◆ how to use its various functions
◆ how to make it perform its customary cycles and routines
◆ how to change the bulb, paper roll, batteries, etc.
The equipment manufacturer’s user manual is often the best source of this
information. Other sources include:
◆ a wide range of reference material (see Annex 2)
◆ written resources from staff training sessions
◆ experienced colleagues.
Guidance from colleagues can be summarized as a one-page poster, laminated card,
or sheet of paper in a plastic pocket (Section 3.5) which can then be mounted near –
or on – the equipment itself. Copies of reference materials should be kept in the
library (Section 3.4).




4.1 How to operate equipment


50


Box 12 provides some examples of general strategies when operating equipment.


BOX 12: General Strategies When Operating Equipment
◆ make sure you have the authority and knowledge to operate equipment before you start
◆ refer to the manufacturer’s operating manual for correct advice
◆ always follow the safety procedures specific to the machine (Section 5)
◆ only connect a machine to an electrical socket outlet which has been checked by the electrician for


proper grounding, and only use the correct plug for the socket (for example, never put a two-pin plug
into a three-pin socket – Section 5.5.2)


◆ do not start equipment that requires water for its operation without checking that the water supply
is available


◆ use the machine only with the correct type and quantities of water, oil, fuel, etc
◆ always handle accessories carefully as these are the most easily damaged component of equipment
◆ always use the correct consumables without wasting them
◆ always respond to alarms, and check what is causing them
◆ ensure that the relevant waste pipeline is not blocked, before allowing equipment to discharge its


contents into the waste water/sewage system or special container for hazardous material (Section 5.4)
◆ if the electricity power supply is cut off, switch off all electrical equipment to protect it from electrical


surges which may occur when the power is restored. Once power is returned, ensure that vital equipment
(such as refrigerators) is switched back on


◆ ensure that any mains-powered equipment which will be required to work off batteries during a power
failure (defibrillator, vital signs monitor, ICU ventilator, etc) is always plugged into a live socket and left
switched on so that its batteries are continuously charged


◆ when oxygen and other gases are no longer required, turn off the supply so that gas is not discharged into
the atmosphere and wasted.


Each type of equipment has specific operating instructions. Box 13 provides an
example of the type of instructions required when using an electrical suction pump.
When operating equipment, it is also essential to follow good strategies for using
consumable materials (Section 6).




51


4.1 How to operate equipment


BOX 13: Example of Operating Instructions for an Electrical Single-Jar Suction Pump
(these may vary and require additions depending on the make and model)


How the equipment works:
◆ The suction pump is used to remove a body fluid such as blood, mucus or vomit from a


body cavity, wound, or respiratory tract. There are several types of suction machine.
According to the design, different flow rates and different pressures – high, low, or dual –
can be attained. Some machines can only be used intermittently and should not be used
for several hours at a time.


◆ The pump draws fluid from the patient through a flexible tube into a reservoir jar (bottle).
◆ When the jar has filled to a certain level, the float valve prevents fluid entering the pump, by cutting off


the suction. The machine must then be switched off and the jar emptied.
◆ A bacterial filter between the jar and the pump reduces the risk of cross infection and potential damage


to the pump.
To prepare for use, check the following: Think about:
◆ You have the correct machine for the task Is the pressure [kPa] sufficient?


Is the pressure and flow rate too high
for infants?


◆ The state of the machine Is it clean and in good condition?
◆ The machine is in the correct position Is it upright on a level surface?


Are the ventilation grills free of obstructions?
◆ The jar has been sterilized and is undamaged If it is dirty, cracked, or chipped, change it.
◆ The float valve can move freely If it can’t, try cleaning it, or get technical


help from the HTM Team.
◆ The filter is not wet or discoloured If so, change the filter.
◆ The patient’s (anti-static) suction tube has been sterilized If not, get a new sterile one.
◆ The jar lid, or its rubber gasket, is not broken or perished If it is, change it.
◆ The patient’s suction tube is connected Attach it to the inlet nozzle on the jar lid.
◆ The tubing is straight Ensure there are no kinks or knots in it.
◆ There is no visible damage to the electrical lead and plug If there is, call the HTM Team.
◆ Connect the machine correctly to the electrical supply Plug it into the socket and switch on.
◆ All connections are tight Ensure there are no obvious leakage points.
◆ An appropriate vacuum suction rate is selected Turn the vacuum control knob and check the


pressure gauge.
◆ The vacuum gauge reading is not permanently low Discontinue use and obtain a


replacement machine.
To use the suction pump, do the following:
1. Take the sterilized part which will enter the patient (metal hand-piece or suction catheter) and attach it


onto the free end of the patient’s tube.
2. Remove excess fluids from the patient as required.
3. Stop sucking when the level of fluid in the jar reaches the 3/4 full mark (if you let the jar overfill, the float


valve will close and the vacuum will stop).
4. When your first jar is 3/4 full, switch the machine off and:


either empty the jar, reconnect the lid firmly and continue sucking.
or reposition both the ‘patient’ and ‘inlet’ tubing from your first jar lid to the lid of a replacement


empty jar, so that sucking can continue. Then empty the full jar.
5. If the jar overfills and the filter gets wet the machine will be damaged (fluid in the pump, and risk of


cross-infection) and a replacement machine must be used. Disinfect the full machine and send it to the
HTM Team to be repaired.


6. When finished with the machine, unplug it from the electrical socket.




52


4.2 The correct application


4.2 THE CORRECT APPLICATION
Staff may feel confident about how to operate equipment, but it is imperative that
they also know the correct ‘application’ for the equipment. Staff need to be able to
apply their taught (clinical) procedures correctly, and to employ the correct methods
of application so that equipment is used to its fullest capacity.
Staff will need to be trained in order to fully appreciate when and how to use
equipment. They will need to know:
◆ when different features will be employed for different patients or uses
◆ the range of assistance a machine can offer them
◆ how to alter the relationship between the machine and the patient, or sample,


for different purposes
◆ the different procedures to pursue for different disorders or treatments.
They will also need to understand the safety precautions they must take (Section 5).
Traditionally, colleges offering basic training for health are responsible for teaching
clinical procedures. Thus, they must have access to the necessary equipment for this
purpose, both in their teaching rooms and at suitable clinical locations such as hospitals.
There will be many areas where staff need to brush up their application skills, and
it will be an ongoing requirement to identify these training needs. Box 14 provides
some common examples.
Equipment users will need to admit their need for application training and ask for
help. The HTM Working Group must consider application training when purchasing
new equipment, and the possibility of incorporating such information and training
into the ‘package of inputs’ purchased with the equipment (see Guide 3 on
procurement and commissioning).
Equipment users should only operate equipment for which they are suitably
qualified. Clinical meetings, committee meetings, departmental meetings, or
specifically organized training sessions can all be used to provide application training
(as appropriate).


Country Experience
Often in developing countries, clinical procedures are taught in health training schools
using obsolete equipment, or with insufficient units to give students adequate exposure.
When the staff graduate they then find that they lack the necessary knowledge or
techniques for the clinical procedures required. They are therefore incapable of applying
particular machines and cannot deliver the necessary healthcare.




53


4.2 The correct application


BOX 14: Common Examples of Application Training Requirements
Ophthalmoscopes in
diagnostic sets
Electrosurgical /
diathermy units


Defibrillators


Resuscitators/
ambu bags


Doppler foetal
heart-rate detectors
Infant warmers


Radiographic
equipment


Ultrasound machines


4.3 CARE AND CLEANING
To maximize the life of equipment, it is necessary that equipment users and
maintainers know how to look after the equipment and clean it. Users must care for
and clean equipment regularly, to a given timetable. It is beneficial to do this because:
◆ it is easier to see faults (such as damaged suction pump tubing) when the equipment


is clean
◆ it prolongs the life of equipment (for example, protecting electronic parts from


damage by dust, protecting metal from corrosion by liquids or chemicals,
protecting rubber seals from degradation by greases)


◆ it protects the operator and patient from infections (from microscope eyepieces,
for example)


◆ it improves the performance of equipment (clean probes for ultrasound, clean
seals on fridge doors, etc).


Eye doctors can train operators on the correct clinical application, diagnosis, and
use of the different features offered.
Surgeons need to practise with the many different features offered by newer
models (making use of pieces of meat from the kitchen, or bars of soap, and
definitely not patients!)
Management committees and surgeons need to clarify when these can be used;
users need to refresh their memories on the correct application for different sizes
of patient, as well as familiarizing themselves with the defibrillator’s controls and
how to operate it.
Operators need training from doctors concerning the correct clinical application
and use of the different features offered, as well as a policy on who is authorized
to use the oxygen facility.
Users need to familiarize themselves with these units, and get some practice in
their use with assistance from an ultrasound radiographer.
Paediatricians need to control the programming of the settings on these units,
and must closely monitor their appropriate use to ensure that no harm comes to
any infants.
Radiographers need to know the settings for various diagnostic examinations by
X-ray and fluoroscopy, of the: skeleton (fractures), head (trauma, infection), chest
(TB, infections, tumours, trauma), abdomen (trauma, intestinal obstructions),
soft tissue (foreign bodies, calcification).
Users should not perform pathological diagnosis of liver, kidney and other internal
organs unless they have received the required specialist training.




54


4.3 Care and cleaning


The best information regarding the care and cleaning of equipment is usually
contained in the manufacturer’s user manual and/or service manual. A wide range of
reference material is also available (see Annex 2). In addition, staff should have
written resources from their training sessions and, in some cases, posters which
provide the guidance and experience of their colleagues (Section 3.5). If staff do not
have personal copies of these resources, they should be available in the library for
reference (Section 3.4).
Box 15 provides some examples of general strategies when caring for and cleaning
equipment. In addition, Section 5.3 discusses the safety implications of the various
cleaning methods and materials available.


Experience in Vanuatu
When a maintainer was visiting a remote health facility, the nurse practitioner said that
she had a small gas stove in the maternity ward that had not worked for 12 months and
that she needed a new one. The stove was filthy, so the maintainer dismantled the
burners and started to clean it. The burners were full of debris, including gecko eggs.
When she removed the eggs and finished cleaning the stove, it looked new and worked
perfectly. If the nurses at the health centre had kept their stove clean, they could easily
have prevented the problem and would have been able to prepare hot food for the
mothers and staff.


NOYES


Source: Lee, P, 1995, 'Get it Right!: A Guide to Maintenance, Safety Precautions & Hygiene of Medical Equipment',
ECHO International Health Services Ltd, UK, unpublished




55


4.3 Care and cleaning


BOX 15: Common Care and Cleaning Strategies
◆ Keep all items clean and dry.
◆ Dust equipment (such as large free-standing items) regularly.
◆ Where applicable, replace the dust cover at the end of the shift; if there is no dust cover, make one.
◆ Keep equipment, such as laundry and kitchen equipment, clear of debris such as fluff, food, threads,


grease, paper waste, etc.
◆ Switch-off and unplug items when they are not in use, except for items which have a battery back-up that


must keep charging (such as defibrillators), or items which need a continuous supply (refrigerators, etc).
◆ When cleaning, never flood the machine with fluid or a dripping wet cloth, use a damp cloth instead.
◆ Clean with the appropriate chemicals, solutions and materials at the end of the shift (equipment which


comes into contact with patients, uses gels, etc). The operator manual will contain guidance on the
correct chemicals to use (Section 5.3).


◆ Disinfect equipment such as theatre equipment after each patient. Check the operator manual for
guidance on the correct disinfection method (Section 5.3).


◆ Unknot tangled leads on ECG recorders, interferential units and the like.
◆ When moving equipment, unplug the power cord and wind it up starting from the machine end and


working to the plug, in order to avoid twists.
◆ Wipe accessories such as ultrasound probes and reusable electrodes clean of lubricants and fluids.
◆ Store accessories carefully in appropriate places (pouches, holders, etc).
◆ Store small items properly when they are not in use (keep diagnostic sets in their cases, for example).
◆ Remove batteries when battery-operated items are not in use in order to avoid corrosion (for example,


ophthalmoscopes, doppler heart rate detectors).
◆ Take apart items that disassemble easily and clean internal parts (for example, unscrew stethoscope


earpieces and remove aural wax, detach and clean the valves on ambu bag resuscitators).
◆ Store lenses, such as microscope objectives and eye pieces, with a desiccator such as silica gel sachets to


prevent fungal growths.
◆ In the case of items that need water to operate, such as water stills and autoclaves, always check that


water is present before switching the item on.
◆ Check that oxygen bottles are free from oil and grease (which can cause explosions).


Each type of equipment will have specific care and cleaning instructions. Box 16
provides an example of the type of instructions required when cleaning and caring for
a microscope.




56


4.3 Care and cleaning


BOX 16: Example of Care and Cleaning Instructions for a Microscope
(these may vary and require additions depending on the make and model)


Daily
DO
◆ Dust optical surfaces (condenser, objectives,


eyepieces) using a blower or soft camel hair brush.
◆ Remove immersion oil from the objective at the


end of each day using a small amount of mild
soap solution.


◆ Clean grease from lenses only using lens paper or
medical cotton wool. For stubborn dirt, absolute
alcohol (ethyl alcohol or methyl alcohol) can be
used – but handle carefully as it is flammable.


◆ Dust the body of the microscope and then clean
with a small amount of mild soapy water and
dry thoroughly.


◆ Store the microscope under a dust cover at night
and when not in use. In humid environments,
store the microscope in an air-tight plastic cover
with blue silica to absorb moisture. This
prevents the growth of fungus. If the silica turns
pink, the item is moist and should be dried out
in a hot air oven.


General care
◆ Never remove the eyepieces from the microscope and leave the openings unplugged.
◆ Never dismantle the optical components as they can become misaligned.
◆ Never clean with a dripping wet cloth, always use a damp cloth instead.
◆ Always switch off the light and unplug the microscope when not in use.
Monthly
◆ The microscope’s mechanical parts (mechanical stage, coarse and fine adjustments, and the condenser


focusing) will need to be cleaned and lubricated with a drop of oil. This can be done as part of user PPM
(Section 7.2) when other parts and alignments will be checked.


Staff will need to ensure they know the correct care and cleaning techniques for all the
equipment they use or maintain, and that they ask for help and training when
necessary. The HTM Working Group must consider care and cleaning training when
purchasing new equipment, and the possibility of incorporating such information and
training into the package of inputs purchased with the equipment (see Guide 3 on
procurement and commissioning).
Box 17 contains a summary of the issues covered in this Section.


DON’T
◆ Use your fingers


(as they are greasy).
◆ Use other materials (tissue paper, rags, etc) on


lenses as they may scratch the surface.


◆ Use ethanol, acetone, or xylene to clean lenses as
they can dissolve the cement holding the lenses
in place.


◆ Use alcohol as it will damage painted or
plastic surfaces.


◆ Store the microscope in a wooden box in humid
environments, unless the box is heated by a
15W bulb.




57


Section 4 summary


BOX 17: Summary of Procedures in Section 4 on Correct Operation


Health Service
Provider


HTM Service


Equipment Users,
Section Heads,
and HTM Teams


Health Service
Provider


Equipment Users,
Section Heads,
and HTM Teams


Health Management
Teams


HTM Service and
HTMWGs


Equipment Users,
Section Heads,
and HTM Teams


Ca
re


a
nd


C
le


an
in


g
Co


rre
ct


A
pp


lic
at


io
n






Ho


w
to


O
pe


ra
te


◆ allocates the user departments with sufficient consumable resources for the
operation of equipment (Section 6)


◆ ensures that all necessary service supplies (electricity, gas, water, etc) are
available, are appropriate, and are in a good condition, before equipment is used


◆ ensure they know the correct operating techniques for the equipment they use,
and ask for help and training if unsure


◆ refer to operator manuals for guidance, as well as any training materials
(Sections 3.4 and 3.5)


◆ follow good strategies when operating equipment, as detailed in Box 12
◆ report any problems to the Health Management Team in order to trigger


training interventions


◆ ensures application training is planned for and given


◆ ensure they know how the equipment they use should be applied, and ask for
help and training if unsure


◆ refer to operator manuals and reference books for guidance, as well as any
training materials (Sections 3.4 and 3.5)


◆ report any problems to the Health Management Team so that any training needs
can be addressed


◆ allocate the user departments with sufficient appropriate cleaning materials and
resources for the care and cleaning of equipment (Section 5.3)


◆ prepare care and cleaning instructions and timetables


◆ ensure they know the care and cleaning techniques for the equipment they use,
and ask for help and training if unsure


◆ ensure care and cleaning of equipment takes place according to the given
timetable, and following good strategies as described in Box 15


◆ for guidance on the correct method for care and cleaning, refer to the
manufacturer’s manual as well as training resources and posters (Section 3.5)


◆ report any problems to the Health Management Team so that any training needs
can be addressed




58




59


5. HOW TO ENSURE SAFE OPERATION
Why is This Important?
Every different type of equipment has its own safety requirements, and it is
necessary to make sure equipment does not become hazardous to you or
your patients. Equipment also has a role to play in various safety strategies
around the health facility.
Thus Health Management Teams need to guarantee the safety of patients,
staff, and visitors by introducing safety procedures for equipment relating to:
◆ the use of equipment
◆ how to behave around equipment
◆ national health and safety at work legislation.


5.1 GENERAL DISCUSSION ON SAFETY
There are many different types of equipment safety issues that need to be addressed
by your health service provider. Although many of these safety areas are inter-related,
for the purpose of this Section we have grouped them under the following headings:
◆ Specific hazards when operating different equipment (Section 5.2).
◆ Infection control issues which relate to equipment, such as decontamination,


linen handling, and ensuring the workplace is clean (Section 5.3).
◆ Waste management issues relating to equipment, such as separation of general and


hazardous waste, and the handling, treatment, and disposal of waste (Section 5.4).
◆ Other equipment-related hazards, such as gases, electricity, radiation,


laboratories, fire, and accidents (Section 5.5).
The security of equipment, and testing for its electrical and mechanical
trustworthiness is discussed in Section 7.
This Section describes some commonly accepted ideas and standards for the safety
issues listed above, and the procedures staff should follow. Your health service provider
needs to develop policies for these areas of safety. Once that has been done, they will
need to expand this field further to cover any other hazards and safety issues
discovered. National and international bodies can offer guidance and regulations on
these safety issues (see Section 2.2 and Annex 2).


5 How to ensure safe operation




60


We suggest that the central HTM Working Group, or its smaller safety sub-groups
(Section 1.2), should be responsible for considering the issues, policies, and procedures
required for the different safety areas. The district and facility HTM Working Groups (or
safety sub-groups) must follow this guidance in order to implement good safety practices.
Staff will need written guidelines and training to assist them in the safe use and
maintenance of equipment. The development of such guidelines and their use for
staff training is described in Section 3.5 of this Guide.


Tip • We suggest that each health facility has some formal method of reporting problems,
accidents, and adverse incidents in all these safety areas. Some type of Accident
Record Book or Incident Report Form can be used so that staff can report whenever
any type of incident occurs. All adverse incidents should be submitted to the HTM
Working Group (or its safety sub-groups), who can monitor and act on the incidents
(Section 8.2), and report to the Health Management Team.


• It will be necessary for Health Management Teams to ensure that their staff have the
necessary safety gear required to do their jobs, such as gloves, goggles, masks, overalls
and boots.


5.2 SAFETY DURING EQUIPMENT OPERATION
Staff need to understand the hazards that equipment can pose to the patient,
operator, maintainer and visitor while it is in use. Box 18 contains some examples of
common safety issues that arise when operating healthcare technology.
Therefore, safety procedures for each type of equipment should be included in
equipment operation training. It should be requested as part of the ‘package of inputs’
purchased with the equipment (see Guide 3 on procurement and commissioning).
The best information regarding equipment safety during operation is usually
contained in the manufacturer’s user manual and/or service manual. A wide range of
reference material is also available (see Annex 2). The HTM Working Group should
provide written guidance, and, in some cases, posters can be displayed for staff which
summarize the guidance and experience of their colleagues (Section 3.5). If staff do
not have personal copies of these resources, they should be available in the library for
reference (Section 3.4).


5.1 General discussion on safety




61


5.2 Safety during equipment operation


BOX 18: Some Examples of Common Safety Hazards During Equipment Operation


Air-conditioning /
ventilation systems


Autoclaves


Centrifuges


Electrosurgical/
diathermy units


Engines


Infant incubators


Phototherapy units
Pressure-cooker type
sterilizers


Stoves
Suction pumps


Water pumps


Welding equipment


◆ not cleaning and drying the filters, and checking the air-flow regularly, can lead to
the growth of bacteria and the spread of airborne infections


◆ inadequate venting of the chamber (so that air pockets remain inside) leads to a
failure to sterilize, the infected material will not have been made safe, and staff
handling it are at risk


◆ lack of care when opening the door before the contents have cooled down leads
to steam scalds, and when sterilizing fluids can cause the bottles to explode


◆ absence of gloves or unloading tongs for hot contents can lead to burns
◆ use with water with a high mineral or salt content that has not been treated


(softened) leads to a build up of scale which blocks the safety valves


◆ use of unstoppered tubes (instead of screwcapped ones) means infectious fluids
can fly out when the machine is started or stopped


◆ use of unsealed buckets (instead of sealed ones) means that when tubes break
infectious aerosols and slivers of broken glass are released over a large area


◆ failure to balance the load or locate the trunnions and buckets properly means
these heavy objects can be ‘spun-off ’ and ejected


◆ poor positioning of electrodes, or the patient, against metal parts of the operating
table, can cause burns to the patient


◆ not replacing the safety guards after maintenance leaves the operators at risk
from fast moving parts


◆ poor cleaning of the cabinet promotes the growth of bacteria in the humid
atmosphere, which the infant will breathe in


◆ not using blindfolds on babies can lead to retinal damage


◆ allowing them to boil dry so that there is dry heating without water will damage
the contents and the sterilizer, and the operator can be burnt


◆ operating them when the steam-release valve or safety valve is faulty means that
the pressure vessel cannot release trapped steam and will explode


◆ insufficient care of the hot surfaces or naked flames will cause burns


◆ not sterilizing the machine before maintenance work is started, means
maintainers can possibly be infected by the body fluids


◆ not covering cuts or abrasions, not wearing gloves, and sucking or blowing into
any part of the machine can lead to maintenance staff being infected


◆ allowing mineral lubricant to come into contact with the water being pumped
will contaminate the water


◆ not wearing proper welder’s goggles/mask will cause retinal damage




62


5.3 EQUIPMENT-RELATED INFECTION CONTROL
Internationally, the term ‘infection control’ has come to mean control of a wide range of
practices, processes and procedures in the clinical work of the health facility as a whole.
In this Guide, we only cover the equipment issues that contribute to infection control.
Proper infection control (relating to equipment) can be achieved by making
decisions about a number of different issues:
◆ Decontamination, through appropriate use of cleaning, disinfection, and


sterilization methods, as well as monitoring sterility (Section 5.3.1).
◆ Linen handling (Section 5.3.2).
◆ Ensuring the workplace is clean (Section 5.3.3).
Many strategies in these topic areas are covered in this Section, but additional ones
may need to be developed. Associated infection control issues relating to waste
management are discussed in Section 5.4. Information and advice must be sought
from the relevant national body that is responsible for infection control (Section 2.2),
since national policies should have been established to ensure that risks are reduced.
We suggest that the central HTM Working Group, or its smaller sub-group, the
infection control committee (Section 1.2), should be responsible for establishing
policies and guidelines to prevent contamination through exposure to blood, body
fluids, body parts, and infectious agents.


5.3.1 Decontamination
It is important to correctly treat equipment that is contaminated with body fluids
and toxic substances, so that infectious diseases are not transmitted to users,
maintainers, and patients who come into contact with equipment. In order to
decontaminate equipment effectively, it will be necessary to make decisions about
and address the following issues:


◆ The appropriate decontamination methods to follow.
◆ Who will be responsible for decontamination of which


type of item.
◆ Daily procedures.
Decontamination processes are used to prevent contamination
and the spread of infection by medical instruments and
equipment. The three decontamination processes commonly
used are: cleaning, disinfection, and sterilization.
It is important to understand how successful these processes are,


and to understand what the commonly used terms actually mean. Brief definitions
are provided here to show the difference between terms, and help to show the least
successful method (cleaning) through to the most successful (sterilization):


5.3 Equipment-related infection control


Decontamination
is a broad term covering


processes which remove,
inactivate, or destroy


contaminating infectious agents
from items or surfaces, and


make items safe for handling,
disposal, or reuse (if this is


possible and advisable, see
Sections 5.4 and 6.1).




63


Cleaning removes visible material (dirt, grease, blood, body fluids, etc) and
reduces the number of some infectious micro-organisms.


Disinfection reduces the population of harmful micro-organisms on any surface,
but does not eliminate all viruses and bacterial spores. Therefore, it
is important to realize that boiling and using chemical disinfectants
do not produce sterility.


Sterilization removes or destroys all living organisms making any surface free of
micro-organisms, viruses, and bacterial spores. Sterilization is
absolute, therefore an item cannot be ‘nearly’ sterile.


In addition, you should be aware that there are two other terms you may hear which
are used in particular fields:
Sanitize a term used in connection with catering and food equipment that


means to reduce the number of micro-organisms to an acceptable level
on these items.


Antisepsis a term used in connection with living tissues and wounds that
means the destruction of micro-organisms on these areas in order to
prevent sepsis (rot) or decay.


We are going to concentrate on cleaning, disinfection and sterilization in this
Section. Three different processes, or a combination of them, are required because
equipment is made up of a variety of components (plastics, rubber, metal,
electronics, etc) which react differently to each procedure. The procedures available
have different drawbacks, for example:
◆ Some cleaning chemicals leave a sticky residue or are corrosive (ruining valves,


for example).
◆ High temperatures can distort the shape of some items (ruining face masks,


for example).
◆ Some chemicals give off fumes that must be ventilated (and therefore must not


be used for breathing circuits).
◆ Exposure to liquids over a long time can cause rusting (of surgical instruments and


the like).
◆ Chemicals require the right concentration to be effective.
◆ Most methods are dependent on a certain exposure time to be effective.
◆ Bad practice will make the methods ineffective, such as adding an additional


contaminated object to a solution that is already treating items.
◆ Use of chemicals can pose a significant danger to operators and the environment.


5.3.1 Decontamination




Thus, it is advisable to make use of expert advice to discover the best methods that
you can afford to implement for different purposes (see Annex 2). The common use
of various decontamination methods for different purposes and for different types of
equipment, are shown in Box 19.


64


BOX 19: Use of Different Decontamination Procedures
Recommended process Suitable for supplies and items Examples
Cleaning
Using water, soap
or detergent


Disinfection
By boiling or chemical
disinfection
Note: there are a wide variety
of chemical disinfection
methods (see Box 22)


Sterilization
Using autoclaves to provide
steam under pressure
– this is the preferred and
most common method


Note:
◆ Hot air sterilizers can be used but are only effective if the instructions are followed exactly, and they


reach the sterilizing temperature (160oC) and remain there for a minimum of one hour. Their
disadvantages are: long cycle time (up to two hours), high running costs, high operating temperatures can
damage sensitive items, possibility of low temperature pockets which affect sterilization, operator
interference may interrupt the cycle meaning sterilization is not guaranteed.


◆ For materials that cannot bear the high temperature of steam, there are other methods using ethylene
oxide, gas plasma, low temperature steam, formaldehyde, or radiation. These require specialized
equipment, and many of them are very expensive and require daily microbiological checks.


To prevent contamination through exposure to blood, body fluids, and other
infectious agents, the HTM Working Groups (or infection control committees) need
to develop and implement good infection control practices. Box 20 provides some
important strategies.


5.3.1 Decontamination


◆ in contact with intact skin
◆ not in contact with the patient
◆ of low infection risk
◆ to be disinfected or sterilized


◆ in contact with intact skin or
intact mucous membrane


◆ contaminated with readily
transmittable organisms


◆ of medium infection risk


◆ in contact with broken skin or
broken mucous membrane


◆ that penetrate the skin or enter
sterile body areas


◆ contaminated with readily
transmittable organisms


◆ of medium to high infection risk


Bed frames, mattresses with
impermeable covers, trolley tops
before use, work surfaces


Metal tongue depressors, work
surfaces, washing bowls, soiled
items, contaminated items,
thermometers, infectious spills
such as blood or urine on mattresses


Surgical instruments, dressings,
reusable items such as sterilizable
syringes and needles, reusable
patient hoses, bellows and other
plastic, metal, and rubber
components which do not distort at
high temperatures




65


BOX 20: Decontamination Strategies
◆ Establish a definite policy for hand disinfection, covering:


- all staff being made aware of the method of washing hands between attending to patients using soap,
alcohol impregnated tissues, or 70% alcohol spray;


- all staff (including maintenance staff) being made aware of when and how to use surgical gloves and/or
rubber household gloves.


◆ Equipment must be decontaminated by an appropriate method both after use and between uses (for
example between one patient and the next), and before maintainers are expected to handle or repair it.


◆ Decontamination of medical equipment, such as suction pumps, must be addressed by the user
department (as equipment operators know what the equipment has been used for), in order to prevent
cross-contamination due to improper cleaning and improper disinfection.


◆ General handling of infectious agents (blood, body fluids, infectious organisms, etc) to be addressed by a
Waste Management and Hygiene Plan (Section 5.4).


◆ Decontamination of equipment should be controlled by a central department or group of people in the
health facility to ensure that correct methods are followed, and that sterility is achieved when required.
Such a department should be the Central Sterile Supplies Department (CSSD), with advice from the
infection control committee.


◆ All staff involved in decontamination should be provided with appropriate safety clothing, especially
for the cleaning of equipment before sterilization. The risk of infection is high at this stage when dirt,
blood, and tissue are being removed prior to sterilization. Aprons, strong rubber gloves, facemasks, etc
are recommended.


◆ Develop preventive medicine policies to provide staff with post-exposure prophylaxis when
contaminated with infectious agents.


◆ Contaminated equipment and instruments must be transported in labelled, sealed plastic bags or boxes
to the point where they will be decontaminated.


◆ Develop staff training and a refresher training plan on infection control strategies.


Decontamination Methods
You should always use the appropriate method of decontamination according to the
guidance provided in the equipment manufacturers’ manuals, the national policies,
and the resources available to you.
As explained, the most common methods available to you are cleaning, disinfection
and sterilization. But it is important to realize when combating infection, that only
proper sterilizing equipment (the most common being steam-pressure autoclaves)
can sterilize products. Thus, each health facility needs to implement appropriate
decontamination methods, suited to its size and needs. The CSSD (or relevant
group of staff) must ensure that the correct equipment is used and the correct
method for each job is implemented, as follows:


5.3.1 Decontamination




66


Method 1: Cleaning
It is essential to clean all contaminated items since the cleaning process makes the
subsequent disinfection and sterilization more effective. Cleaning:
◆ gets rid of all visible dust and dirt
◆ removes organic matter which can reduce the action of disinfectants or


sterilizing agents
◆ removes the breeding ground for surviving micro-organisms
◆ protects against corrosion and rusting (if the item is dried adequately)
◆ ensures free movement of equipment parts.
Therefore, it is important to observe the following strategies:
◆ after use and before cleaning, all items which can be immersed in water should be


soaked to prevent deposits drying up and becoming more difficult to remove
◆ as different materials should be cleaned with either water only, water and soap, or


water and detergent, refer to the manufacturer’s manual, national guidelines, and
expert advice (see Annex 2)


◆ after cleaning and before sterilizing or disinfection, all items should be rinsed
thoroughly with clean water and dried.


Method 2: Disinfection
The two main disinfection methods are boiling and chemical disinfection. The
boiling method is chosen for items which:
◆ can be immersed in water
◆ can withstand high temperatures
◆ can fit into a container (for boiling).
If your items cannot meet these criteria the chemical method is used.


a. Boiling: This usually takes place in a special boiling pan (boiler) or a saucepan
with a close-fitting lid. Box 21 describes the safety issues that must be addressed
when using boilers, if disinfection is to be successful.


5.3.1 Decontamination




67


BOX 21: Safety Issues When Using Instrument Boilers
DO
◆ fill the boiler with clean water
◆ separate the items so that they are not


touching each other or the sides of the boiler,
and open hinged instruments


◆ cover the items completely with sufficient
water that cannot boil dry


◆ boil the items for the required time (which will
vary from 10–60 minutes depending on your
height above sea level)


◆ time the boiling period from when the water boils
◆ if boiling stops for any reason (such as a


power cut), you must restart the process again
from the beginning


◆ allow the boiler to cool down before draining
the hot water, to avoid scalds


◆ clean the boiler after each day’s use


b. Chemical disinfection: This can be achieved by making use of the wide range of
chemical disinfectants that are available. Each is best suited for a specific purpose
and must be used in a particular way to be effective. Because not all disinfectants
will kill all organisms, a single disinfectant will not fulfil all your requirements:
stocking two different disinfectants may be sufficient. Choose disinfectants which:
◆ offer a wide range of activity
◆ are not readily inactivated
◆ are non-corrosive when diluted
◆ are non-irritant to skin
◆ are low cost.
Proper chemical disinfection depends on using the appropriate disinfectant at the
right concentration and for adequate contact time. It is important to follow the
manufacturer’s instructions for disinfectant handling, preparation, use and storage.
Incorrect dilution, poor storage, and repeated use of the same working solution
reduce the effectiveness of chemical disinfection.
Box 22 summarizes some common chemical disinfectants and their potential
applications; the columns show the various benefits and hazards of using each type.
The Health Management Team should refer to the manufacturer’s manual, national
guidelines, and expert advice in order to ensure that they purchase sufficient stocks
of the correct chemicals (see Annex 2).


DON’T
◆ load the boiler with many


items touching each other
as disinfection will not
be guaranteed


◆ boil without enough water to
cover the items as this will
damage the boiler and the items


◆ add any items during the boiling cycle as this will
contaminate the existing items, and you will
need to start timing from the beginning again


◆ time the boiling period from the time the water
starts to be heated, otherwise the items will not
be disinfected


◆ leave disinfected items in the water because it
can easily become re-contaminated


◆ disinfect by boiling more than 24 hours before
you use the items, as the items may become
contaminated even if stored in a closed container


5.3.1 Decontamination




68


Box 22: Some Common Chemical Disinfectants and Their Potential Applications


Source: WHO, 1994, ‘Maintenance and Repair of Laboratory, Diagnostic Imaging, and Hospital Equipment’, WHO, Geneva


Method 3: Sterilization
To ensure that sterilization is achieved, each health facility should consider which
strategies are appropriate for its size and needs. The CSSD (or relevant group) needs
to ensure that:
◆ the correct equipment is used (there are three main types of sterilizers: those for


naked instruments and utensils, those for wrapped or porous/fabric loads, and those
for fluids)


◆ the correct method for each job is followed
◆ the ‘sterile chain’ is maintained. There must be quality control at each stage of the


process: cleaning, set-assembly, wrapping, loading, sterilizing and sterile storage
◆ a system of monitoring for sterility is implemented. It is advisable to have a


centralized sterilizing system: this ensures that sterile supplies are available for all
sections in the health facility, that bad practices are eliminated, and that the most
effective use is made of available and appropriate equipment.


Box 23 provides some strategies that may require you to make changes to your
existing system in order to achieve these ends. The main advantage of these
proposals is to ensure the sterility of items. It is also likely that these proposals will
save money. Some additional linen, bowls, trays and instruments may need to be
purchased to help the introduction of this alternative system, but the theatre and
CSSD functions will improve, resulting in a quicker, more efficient service for the
theatre and wards. If necessary, a specialist could be contracted to set up the new
system, to ensure it is functioning correctly, and to train staff.


5.3.1 Decontamination


Chemical
disinfectant


Dilution–
(g/litre)a


Contact
time (min)


Inactivates Important characteristics Potential application


Lip
id


vir
us


es
Bro


ad
sp


ec
tru


m
Ve


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tat


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sp
ore


s


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rro


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sid


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Ina
cti


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by


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ma


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Sk
in


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irri


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sp


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ry


irri
tan


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Tox
ic


Wo
rk


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rfa


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Sh
elf


life
a


>=
1


we
ek


Dir
ty


gla
ss


wa
re


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& s
urf


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Liq


uid
s t


o
be


di
sc


ard
ed




0.075 – 16


1 – 20


10 – 50


5 – 10


700 – 850
700 – 850


20


2 – 80
(of gas)


Quaternary
ammonium
compounds
Phenolic
compounds
Hypochloritesb
Iodoformb
Ethanol
Isopropanol
Formaldehyde
solution
Glutaral


10 NE


10 NE


10 NE
10 NE


10 30


10 30


10 30


10 30


+ + +


+ +


+
+


+
+


+


+


+
+


+
+


+
+


+


+


+


+
+


+
+
+


+


+


+


+
+


+
+
+


+


+


+


+
+


+
+
+


+


+


+


+
+ +


+
+
+


+


+


+


+
+


+


+
+


+


+


+


+


+
+


+


+


+


+


+


+ +


+ + + +


+ + + +


+ + + +


+ + + +


#


+ + #
+ + #


Of the pure disinfectant, stored under appropriate conditions
Available halogen
Variable results with different viruses
Not effective


a
b
#
NE


=
=
=
=




69


BOX 23: Strategies for Ensuring Sterility
◆ End the use of instrument boilers (disinfectors) as they do


not sterilize.
◆ Do not try leaving instruments in the sun, as this practice


does not work.
◆ End the practice of soaking dropped instruments for a period


of time in chemical disinfectants (liquids or creams). This
does not sterilize the instruments: in fact, if the chemicals
are not renewed regularly, they have proven to be a good
culture medium.


In small health facilities (such as clinics):
◆ Use the simple pressure-cooker type autoclave


or bench-top autoclave for small volume and
low quantity of unwrapped, non-porous,
non-fabric items.


◆ For porous or fabric items use the hot-air
sterilizer, larger autoclave, supply of sealed sterile products
from a district source, or learn a steam-pulsing method for the
pressure-cooker type autoclave (see Annex 2).


In larger health facilities:
◆ Only use bench-top autoclaves where specialist, small volume


and low quantity unwrapped, non-porous, non-fabric items
are involved, such as in the dentist clinic or eye theatre.


◆ Ensure all the remaining instruments and supplies are
sterilized centrally in the large autoclaves in the Central
Sterile Supplies Department (CSSD), to cover normal
working needs and dropped items.


◆ Ensure the CSSD supplies sterile packs to all relevant
sections in the health facility as a whole – the sooner this can
be introduced, the easier it will be to stop the ineffectual
practice of soaking and boiling at other locations around the
health facility.


◆ Reorganize the packing system (see below) in order to
facilitate the ‘sterile-pack’ service and to be more effective in
achieving sterility.


◆ Prepare smaller, individual packets of each item (cotton
dressings, mayo cloths, etc), and only sterilize them on
demand based on order lists from the user departments. This
will eliminate the practice of sterilizing large drums containing
a volume of items which will not be used in one day, which, in
turn, leads to the drum standing around for a day or two and
becoming contaminated as the lid is continually opened for
items to be removed. This will also eliminate the need for
continual resterilization of the items, which is more costly and
leads to the contents deteriorating.


5.3.1 Decontamination


Choose methods that
ensure sterility


Choose the right equipment in
the right place, in order to establish
a ‘sterile-pack’ supply service


Reorganize the packing system to
provide smaller sets and packets
of items


Continued overleaf




70


BOX 23: Strategies for Ensuring Sterility (continued)
◆ Reorganize instrument sets into ‘basic’ sets, and ‘specialized


additional instruments’ sets for specific types of operation
(for example, caesarian extras, laparotomy extras, orthopaedic
extras). Then pack these sets separately. This avoids the
practice of packing all instruments, bowls and towels for a
certain type of operation on one tray, creating a set that is
cumbersome, heavy, and difficult to sterilize.


◆ Make up bowl packs into major and minor categories, and
linen packs into major and minor categories.


◆ Secure and seal the drum closure flaps with heat-sensitive
tape after packing, so that:
- the lids do not fly open upon removal from the autoclave


thereby risking the loss of sterility
- the tape can be checked for the correct colour-change to


show sterilization was achieved (see Box 24).
◆ Label the packs with details of the owner, content,


sterilization date, and person responsible.


◆ Set up a quality control system for each of the following steps:
cleaning, set-assembly, wrapping, loading, sterilizing, and
sterile storage (correct conditions and duration).


◆ Organize the routing of goods through the department
to ensure:
- separate areas for cleaning, wrapping, and sterile storage
- there is no crossing of flows of the sterile and non-sterile goods.


It is necessary to ensure that autoclaves are working properly, otherwise sterilization
will not have occurred. Monitoring for sterility is therefore essential.


Monitoring Sterility
In order to obtain sterility, autoclave cycles need to incorporate three factors – time,
steam under pressure, and temperature (known as TST). For steam to penetrate into
large or porous loads and achieve sterility throughout the load, the autoclave must be
designed to provide pulses of steam. In addition, it is important to allow the load to
dry after sterilization before it is stored, otherwise the moisture will provide a
breeding ground for micro-organisms.
You must regularly monitor the performance of autoclaves in order to ensure that the
items are sterile by the end of the autoclave’s cycle (in other words to ensure that
sufficient time, steam under pressure, and temperature were received). The
common cycles (depending on the material to be sterilized) are steam at 134oC for
three minutes or 121oC for 15 minutes, and 115oC for 30 minutes (for fluids).


5.3.1 Decontamination


Reorganize the packing system to
provide smaller sets and packets
of items (continued)


Ensure there is a ‘sterile chain’




71


Sterilization performance can only be guaranteed if you:
◆ register the physical conditions (pressure, temperature, time,


and steam penetration) during each sterilization cycle
◆ validate (verify) these results against a known similar correct test


process profile, and
◆ ensure such results are consistent and reproducible.


The process parameters fall into two categories. The first – pressure, temperature
and time – can be easily recorded, but the second – steam penetration – is more
difficult to monitor.
For the first category, advanced automatic sterilizers usually have a recorder that
prints the basic parameters (pressure, temperature, time) on special sheets of paper
and/or stores them in a computer database. For manually operated sterilizers, the
operator needs to read and write down the pressure and temperature at specified
intervals (for example, every minute).
To monitor steam penetration in autoclaves you will also need some form of ‘passage
indicator’ – a consumable that changes colour to indicate that steam penetrated your
load/pack and that it successfully passed a sterilization process. The method to use is
the ‘Bowie & Dick test’ – the internationally accepted standard. Box 24 shows
different ways of carrying out the test depending on the resources you have available
for buying the consumables required (see Annex 2).


5.3.1 Decontamination


Registration
means that the process


parameters are recorded during
each sterilization process.


Experience in Nigeria
A mission hospital in Nigeria uses a small, vertical, electric autoclave run by two nurse aides
under the supervision of a nursing sister. With this arrangement they cover all the sterilizing
needs of the theatre, maternity department, and wards. Sterile instrument packs are prepared
for all major operations and stored on shelves in a room adjacent to the operating theatre.




72


There are a number of ways of obtaining the correct process profile:
◆ In the case of new automatic machines, the process profile


should be provided by the manufacturer.
◆ You can find and download common process profiles from the


internet (world wide web). However as the profile needs to be
specific to your machine the maintenance staff may need to
check and alter it for your autoclave. Annex 3 shows a process
profile that is suitable for many types of common autoclave.


5.3.1 Decontamination


Validation
means that the users compare


their recorded results with a
‘correct process profile’


– the results for a similar test
load made in the same


autoclave where sterilization
was successfully achieved.


BOX 24: Different Types of Bowie & Dick Tests Available
◆ Ready-made Bowie & Dick test packs:


These are square blocks that are placed inside the autoclave for a cycle. Inside the block is a sheet
containing lines of special chemical finish that change during the autoclave’s cycle, and display different
colours to illustrate if there are any TST problems. They are sensitive and diagnostic, since the different
colour changes can indicate seven different types of problem.


◆ Ready-made Bowie & Dick test sheets (arrow-check indicators):
These are individual A4-size sheets of special paper that you place inside your own Bowie & Dick test
pack made of cloths (see Figure 8) instead of strips of autoclave tape. They contain lines of chemical
finish that change from light to dark evenly across the whole sheet if the autoclave cycle has been
successful. Although they are sensitive, they only tell you that the cycle failed, they don’t tell you what
type of problem you may have.


◆ Ready-made small Bowie & Dick test TST strip/indicators:
These are individual strips of special paper with a large circle/dot of chemical finish which changes colour
if the autoclave cycle has been successful. They should be placed in the most difficult location in the load
(such as inside packs or drums). Although they are sensitive, they only tell you that the cycle failed, they
don’t tell you what type of problem you may have.


◆ Using standard heat-sensitive autoclave tape in order to make up your own Bowie & Dick test
pack (see Figure 8 and Annex 2):
This requires knowledge of the correct method of making a pack. The tape will change from light to dark
during the autoclave cycle and will show if there are parts of the tape which did not change colour and
therefore did not receive sufficient TST. Although cheaper, it is a more complicated method and does not
give you diagnostic information about the type of problem within the autoclave.


◆ An alternative method when sterilizing fluids, instruments, or glassware is to use sterilizer
control tubes containing fluid:
The fluid in the tube changes colour depending on whether the correct temperature was obtained for the
correct time. However, these tubes cannot verify that steam was present. Another drawback is that the
sterilizer control tubes must be kept in a cool place, preferably a refrigerator.




73


5.3.1 Decontamination


◆ Maintenance staff can create the process profile for each machine. They must:
- make up a typical, most difficult test load for use in your autoclave
- have thermocouples, an electronic thermometer, and a pressure gauge
- place the thermocouples at various points in the sterilizer and the load, and
connect them to the thermometer – these will show that correct temperatures
were reached at correct points in the cycle


- use the pressure gauge to verify that correct readings were obtained on the
pressure gauges of your autoclave


- put your autoclave through its various different cycles
- record all the parameters during each cycle to create a process profile – as long as
the readings are what they would expect, sterilization will have been achieved
and the profile will be a correct one.


Figure 8: How to Make Up Your Own Bowie & Dick Test Pack


Steps Issues


Obtain 36 freshly laundered
cotton cloths (for example,
theatre or Mayo cloths).
Fold them to A4 size.


Stack 18 of the folded cloths one
on top of the other.
On the top of the 18th cloth place
autoclave tape in a special cross
pattern (see diagram).
Place the remaining 18 folded
cloths on top.
Compress, and wrap all 36 cloths
into a pack and seal it with tape.
The pack should be about 25 cm
high and weigh about 7 kg.


Autoclave the pack in the centre
of an empty autoclave.


Allow the pack to cool on an
acceptable surface.


Open the cooled pack and
assess the findings on the
criss-cross tape.


Do not use cloths that have been autoclaved and not laundered
once again, as they will lack natural moisture.
The cloths must be freshly laundered, but without the use of
fabric conditioner.
The cloths must be dried and aired for at least one hour.


Criss-cross four pieces of autoclave tape (standard heat sensitive
autoclave tape) from corner to corner and from side to side,
as shown:


Always use the required temperature for the required length of
time (as per the instructions for the autoclave’s normal cycle).


Do not place it on stainless steel as this will cause condensation
to gather at the base of the pack, unless the stainless steel
surface is covered first.


If the autoclave tape has evenly changed there is no problem
with the autoclave.
However if there are differences in intensity in the tape changes,
this indicates that there are air pockets in the autoclave
preventing total steam penetration. This means that there is a
problem and the vacuum is defective and not removing the air
from the chamber. Therefore, the autoclave requires adjustment.




74


5.3.1 Decontamination


Use of registration, and
Bowie & Dick tests


Frequency for large
autoclaves


BOX 25: Strategies for Monitoring Sterility
◆ Ideally your health facility will use:


- a recorder to register pressure, temperature and time on a special
recording pad


- ready-made Bowie & Dick test packs for large autoclaves
- small TST strips for bench-top autoclaves
- heat sensitive tape for sealing drums.


◆ If the recorder and ready-made tests are not available, CSSD staff will:
- manually record pressure, temperature and time
- make up home-made Bowie & Dick tests.


◆ The Health Management Team must ensure adequate supplies of the
necessary materials are available, and that staff are trained to understand
their roles.


◆ Ideally, CSSD staff will:
- register pressure, temperature and time for every cycle of each autoclave,


and validate it against the correct process profile
- undertake a Bowie & Dick test (with a readymade test pack) on each


large autoclave once a day
- use heat sensitive tape to seal the drums for every load during the day
- keep a record of the results for referral at any time if a query is made about


the sterility of a particular load.
◆ If the tests cannot be performed this often, start with once a week and


increase the frequency when a more regular supply of ready-made Bowie &
Dick tests can be guaranteed, and staff are familiar with the regular
recording process.


The official standard validation test uses eight thermocouples to measure
temperatures, but a basic validation kit is available which uses just two: one in the
chamber, the other in the load (see Annex 2).
The idea is that CSSD staff only release the load from the sterilizer to the users if all
the process parameters were met. For every cycle, ideally, registration would take
place and a Bowie & Dick test would be performed, then only if the results are
validated is the sterility of the load or pack confirmed. However, this method
requires CSSD staff to have time and a continuous supply of these consumables.
The alternative is to undertake registration and Bowie & Dick tests as frequently as
possible over specified periods of time (daily, weekly or monthly), on the
understanding that if the machine fails to pass the tests it means that you could not
be satisfied with the sterility of any loads since the last test (in other words, for the
last day, week or month). Therefore, the longer the gap between tests, the greater
your uncertainty about sterility will be. Box 25 provides some strategies for
monitoring sterility.


Continued opposite




75


5.3.1 Decontamination


BOX 25: Strategies for Monitoring Sterility (continued)
◆ Ideally, users of small autoclaves (such as dental clinics, eye clinics, and small


health facilities) will:
- register pressure, temperature and time for every cycle of each autoclave, and


validate it against the correct process profile
- put a TST strip in every load placed into each bench-top autoclave.


◆ If tests cannot be performed this often, start with once a day (on those days
when you use the autoclave) and increase the frequency when a more regular
supply of TST strips can be guaranteed, and staff are familiar with the regular
recording process.


◆ Maintenance staff will:
- be responsible for obtaining correct process profiles, either from the
manufacturer, or by checking and modifying downloaded ones, or by creating
their own using a kit containing thermocouples, etc


- validate each autoclave using the kit: when a machine first arrives, after each
maintenance/repair job, during the annual service (or a more regular service),
and if a new type of load or pack is to be used


- undertake a Bowie & Dick test every time PPM or repairs are carried out on
any autoclave, before the autoclave is handed back to the users.


◆ If any registration fails to match the correct process profile, or any Bowie &
Dick test produces a non-uniform colour change, the autoclave requires
adjustment and the users will:
- know that the load or pack is not sterile
- know the sterility of all loads or packs since the last test cannot be guaranteed
and warn the relevant users


- contact the HTM Team for assistance.
◆ If a ready-made Bowie & Dick test pack was used, the maintenance staff (or


supplier’s technical representative) will be able to use it to diagnose the
problem (in other words, to establish whether the problem was with steam
penetration, steam temperature, time of steam penetration, air leaks, air
evacuation, non-condensible gases, superheat, or over-saturation of steam).


◆ Once the autoclave has been repaired by the technical staff, the validation
process and the Bowie & Dick test will be repeated.


Frequency for small
autoclaves


Validation and
frequency by
maintainers


Bad results




76


5.3.2 Linen handling


5.3.2 Linen Handling
All washable fabrics can easily be disinfected:
◆ either by hot water, if the correct temperature is used for the correct time
◆ or by cold water, if the correct disinfectant is used at the correct concentration, for


the correct time.
The word ‘linen’ is used to cover all items to be laundered. It is recommended that,
in health facilities, linen is divided into two categories:
◆ Soiled linen which has been used and is no longer fresh, but is uncontaminated


by infectious agents.
◆ Fouled and infected linen which is obviously fouled (with urine, faeces, blood,


vomit, pus, etc) or is known to have been in contact with an infection: this is
contaminated linen.


It is necessary to have appropriate linen handling procedures in place in order to
avoid cross-contamination, and to avoid the transmission of infectious diseases to the
linen handlers. Many linen handling strategies are dependent on the use of the
correct equipment.
To prevent contamination through exposure to contaminated linen, HTM Working
Groups (or infection control committees) need to develop and implement good
infection control practices. Box 26 provides some important strategies.
Other equipment-related safety issues in the laundry are as follows:
◆ Do not overload the washing, spinning, or drying machines as this strains


the bearings.
◆ Do not under-load washing machines as this wastes cleaning chemicals, and


increases the friction in the linen, making it wear out more quickly.
◆ Avoid accidents (Section 5.5) – laundry floors must be well drained to avoid


slippage, and pipes must be lagged to prevent burns.
◆ Do not spread linen on the ground or over bushes to dry but hang it from washing


lines if spin- and tumble-driers are not available.
◆ Always iron items that have hung in the open air if your country has insects (such


as the mango fly) that lay eggs on linen drying outdoors. The ironing process,
whether by hand or by machine, kills the eggs and prevents the larvae from
hatching and burrowing into skin.




BOX 26: Strategies for Linen Handling
All staff involved in handling contaminated linen should be provided with
appropriate safety clothing. The risk of infection is high when dirt, blood, and
infectious agents are present. Aprons, strong rubber gloves, facemasks, working
boots, etc are recommended.


Sections using linen (such as wards, OPD clinics, treatment rooms and theatres)
must use two separate types of receptacle (soiled linen containers) of different
colours with labels; one for contaminated linen and the other for uncontaminated
linen. Uncontaminated linen may be collected in some form of cotton bag:
contaminated linen should always be placed in strong waterproof plastic bags.
Used linen should be handled as little as possible to avoid cross-infection. Nursing
staff should place used linen into the correct collection bag (either for
contaminated or uncontaminated items) at the bedside to avoid carrying dirty
linen through the department. Staff should avoid sorting contaminated linen
before washing as much as possible.
No sluicing (rinsing under a stream of water) of contaminated linen should take
place within the section (for example, at ward level). Instead, this will be done in
the laundry with cold water.
Depending on the frequency of collection by laundry staff, and the availability of
pre-wash facilities in the laundry, it may be necessary to soak contaminated linen in
the sections using linen. Soaking is required to prevent stains from becoming
engrained and spoiling the linen, as follows:
◆ Sections which use linen should be provided with rubber garbage bins, in which


staff can soak contaminated linen in a freshly-prepared sodium hypochlorite
solution (such as a 0.5% concentration of bleach in water) for at least one hour


◆ Section staff send the soaked material to the laundry on a regular basis, to be
processed quickly so that the damp linen does not go mouldy.


Refer to the manufacturer’s manual, national guidelines, and expert advice in order to
ensure that sufficient stocks of the correct industrial cleaning agents and chemicals
are purchased for the laundry (see Annex 2). Laundry staff must understand the
proper use of appropriate chemicals to kill bacteria, and the correct amount of cleaning
agent which is effective, not wasteful, and does not cause foaming.
Refer to the manufacturer’s manual, national guidelines, and expert advice to ensure
that the correct temperatures for washing are used (see Annex 2). To save energy,
some hospitals wash different types of linen at different temperatures, but if you
cannot be certain of the type of contamination involved it is safer just to use the
higher temperature level, as follows:
◆ 65oC for 10 minutes for soiled linen.
◆ 93oC for 10 minutes for fouled and infected linen.
These figures only work if detergent is used, and additional time is allowed for the
warming up and mixing of contents by the washing machine. If you have no
detergent, you will have to boil the linen (at 100oC) for five minutes.
If you have no hot water, use proper laundry detergents and chemicals suitable for
cold washing, as well as chlorine bleach.


5.3.2 Linen handling


77


Staff protection


In each section


In the laundry


Continued overleaf




78


5.3.2 Linen handling


BOX 26: Strategies for Linen Handling (continued)
If you do not have washing machines, wash linen by hand, and hang it on lines to
dry in fresh air and sunlight to assist with disinfection.
To save resources, water from the laundry may be recycled, for example, for
watering garden crops. However, water from the washing machines used for
‘infected’ linen (in other words blood-stained, or containing solids) is unhygienic
and should not be recycled.


Staff should ensure hygienic storage and rotation of linen, always keeping dirty and
clean linen apart. Ideally laundries should be designed and built in such a way that
there is a physical barrier between the dirty and clean linen areas. If not, there
must be sufficient physical separation between:
◆ the routes used by dirty laundry and clean linen trolleys
◆ the trolleys designated and labelled for use with dirty or clean linen
◆ the storage locations for clean linen and piles of dirty or condemned linen.
If your linen is transported for many miles to reach the nearest laundry, or it is
laundered by a private contractor, great care must be taken to address all hygiene
and infection control risks so that you protect members of the public from your
infectious agents.


In the laundry
(continued)


Transporting linen


5.3.3 Ensuring the Workplace is Clean
It is necessary to have procedures that ensure you keep the workplace clean, in order
to maintain general levels of hygiene. Many of the issues involved are dependent on
the correct use and care of equipment, such as:
◆ cleaning the health facility in general
◆ hygiene practices in the kitchen
◆ controlling infestations by vermin
◆ guaranteeing a safe water supply
◆ general waste and sewage management (this will be discussed in Section 5.4).
To guarantee the general cleanliness of the health facility, the HTM Working Groups
(or infection control committees) need to develop and implement good infection
control practices for these areas.


Cleaning the Health Facility in General
The regular cleaning of rooms, service installations, fixed equipment, furniture, etc is
necessary to create an hygienic workplace. Most of this work can be done with readily
available cleaning agents (see Box 27 for examples). Fresh water must be used for
cleaning – no surface can be cleaned with dirty water.




It is a waste of money to use chemical disinfectants for all cleaning. Disinfectants are
not cleaning agents: they do not remove dirt, nor do they increase the cleaning power of
cleaning agents. Where a chemical disinfectant is to be used, it is more effective applied
to a clean surface. Some ‘germicidal’ or ‘bactericidal’ cleaning agents have a disinfectant
already added to them. Box 27 shows examples where disinfectants are recommended.
The importance of simply using water must not be underestimated. For example,
flushing lavatories with water is more effective for decreasing microbes and reducing
smells than the use of chemical disinfectants. This is true for facilities with piped
water (such as water closets) and also for facilities attached to pits or septic tanks
(such as pit latrines and aqua privies) where you can usefully dispose of waste water
to flush the toilet pan/squat hole. The greatest infection hazard in lavatories is
transmission by hand. Thus, the most important strategy is to provide some form of
toilet paper as well as hand-washing facilities with clean water and soap.
In order to clean the health facility effectively, it will be necessary to address, and
make decisions about, the following issues (see Box 27 overleaf for examples):
◆ Which method to use.
◆ What cleaning equipment to use.
◆ The correct daily maintenance and sterilization of the cleaning equipment.
◆ The frequency that different areas must be cleaned.
◆ The appropriate cleaning agents and disinfectants to use, and the


correct concentrations.
◆ The protective clothing required.
◆ Possible rationalization and standardization of cleaning materials in order to


enable groups of health facilities to have common purchasing power.


Hygiene Practices in the Kitchen
The regular cleaning of all the equipment in the kitchen has been discussed in other
parts of this Guide. Other equipment-related issues to address, and staff practices to
introduce, are:
◆ Separate equipment (such as knives, chopping boards and slicing machines) that


are used for handling raw food from those used for cooked food so that microbes
are not transferred to the cooked food, causing food poisoning.


◆ Hand-washing facilities with soap for kitchen staff so that they can wash their
hands between handling different types of food, between different activities, and
after going to the toilet.


◆ Adequate refrigeration through properly working refrigerators and cold
store rooms.


◆ Extraction hoods over cookers which are clean and working effectively.


5.3.3 Ensuring the workplace is clean


79




80


Controlling Infestations by Vermin
There are a number of pests that are commonly found in health facilities. All of them
carry microbes on their bodies, and their droppings are microbe-laden. In addition,
many of them get into and damage equipment. Box 28 provides some examples, and
strategies for controlling them.
Cleaners must report signs of pests immediately. If steps are not taken to remove the
pests, efforts to clean areas frequented by them are a waste of time. The regular
removal of litter is essential for reducing vermin (Section 5.4).


5.3.3 Ensuring the workplace is clean


BOX 27: Strategies for General Cleaning of Health Facilities
◆ always use clean, freshly drawn water
◆ damp dust in any area
◆ clean walls, floors, ceilings, or furniture in most areas with a general-purpose


detergent (an anionic liquid)
◆ use scouring powders (that are not so abrasive that they scratch the surface) on


sinks, wash-basins, sluices, slop-hoppers, baths, showers, and lavatories
◆ use washing soda for cleaning waste-pipes and overflows in sinks, baths,


showers, wash-basins, drain grids, and drain pipes
◆ use a grease-solvent paste for cleaning cookers
◆ use a non-foaming detergent in dishwashers.
Disinfect:
◆ baths during or after cleaning
◆ kitchen work surfaces after cleaning
◆ floors and work surfaces in operating theatres, renal dialysis units, special care


units, and other high-risk areas, during or after cleaning on some occasions
(when areas are known to have been soiled with infected organic material)


◆ patches of floor soiled by incontinence or bedpan spillings during or after cleaning.
The frequency of cleaning varies for different areas of the health facility. For example:
◆ operating theatre floors: several times a day
◆ baths, showers, basins, and lavatories: at least once a day
◆ walls: once a month, but immediately after being splashed with organic material.
◆ All cleaning should be done using one of the following, which must be wet,


but not dripping wet: cloths, sponges, scrubbing brushes, buckets and mops,
wet-vacuum pick-ups, scrubbing machines, polishers, etc.


◆ Do not use brooms, dusters, dry mops, etc as these dry cleaning methods whisk
dust and microbes into the air and increase the risk of infection.


All cleaning equipment must be sterilized regularly and maintained because:
◆ the equipment itself is a breeding ground for microbes
◆ the equipment can spread the microbes further around the facility
◆ the cleaning water must be regularly changed for fresh water otherwise you are


simply moving dirt from one place to another, and stagnant water breeds microbes
◆ redistribution of dirt is time-consuming but it is not cleaning, and therefore it


might as well be left undone.


Where to use
cleaning agents


Where to use
disinfectants


How frequently
to clean


What cleaning
equipment to use


Care and cleaning of
the equipment




81


5.3.3 Ensuring the workplace is clean


BOX 28: Strategies for Controlling Vermin
Vermin Habits Strategies
Rats and
mice


Ants and
cockroaches


Birds (such
as pigeons)


Flies and
mosquitoes


Bees, wasps
and hornets


Bats


◆ are attracted to the sewage pipelines and the
kitchen grease-trap/drains


◆ move from there through holes in floors and
walls which admit service pipes


◆ like to eat materials available in the kitchen
(food), mortuary (corpses), and the pharmacy
(glycerine tablets), thus are very effective at
spreading microbes from one place to another


◆ climb inside equipment and chew through
wires – rats have been found in X-ray
machines and electricity distribution boards,
mice in infant incubators and operating
theatre lights.


◆ like warmth and food so are common in
kitchens and autoclaving units


◆ have trails that run for long distances: they
visit drains and sluices for moisture, feverish
patients for sweat, open wounds for the
discharge, and commonly spread infections


◆ have even been found in ‘sterile’ packs,
resuscitation equipment, and drip tubes.


◆ bird droppings foul areas of the health facility
they have access to, such as verandas, laundry


◆ bird droppings – and occasionally dead birds
– can foul the water supply, if the roof to the
water tank is broken.


◆ flies breed in dustbins and garbage bags, and
contaminate food


◆ mosquitoes breed in any stagnant water, and
spread malaria.


◆ make their nests in partially enclosed areas
and the nest wraps around parts of equipment


◆ have made nests under the roof eaves around
telephone and electricity cables, in the
wiring of distribution boards, etc.


◆ make their nests in roofs, especially in
buildings of simple design where access is easy


◆ are carriers of disease and can foul areas of
your health facility with their droppings.


◆ block any likely entrance holes
◆ use poison or traps
◆ either purchase equipment with


vermin grills and guards, or make
your own from metal, mesh,
or plastic


◆ keep rooms in regular use
◆ consider keeping cats for vermin


control.


◆ cover served food and stored food
◆ store food in air-tight containers
◆ keep gifts of food for patients


covered inside lockers
◆ tightly close bags containing soiled


and fouled linen
◆ fill crevices in walls
◆ use poison and control chalk.
◆ use wire netting across openings to


keep birds out of the health facility
◆ regularly maintain water tank covers


and roofs.


◆ seal rubbish in plastic or paper bags
and put in bins with lids


◆ wash and dry rubbish bins
◆ do not let puddles and water that


has collected in open containers
stay standing for long.


◆ keep a watch out for insect
nest building


◆ destroy the nests when they are in
their early stages and are therefore
still small.


◆ cover openings with mosquito
netting if an uninterrupted form of
fixing can be found


◆ investigate chemical and ultrasound
deterrents


◆ in the long-term, alter building
designs to avoid admittance.




82


5.3.3 Ensuring the workplace is clean


Guaranteeing a Safe Water Supply
The main water supply for many health facilities (whether piped or from pumps) is safe
to drink, in others it must be treated first to get rid of bacteria. However this supply of
water will not be sterile. The water supply always contains some microbes and if it is
allowed to stand for several days their numbers will increase. Thus water for drinking and
cleaning should always be drawn fresh, and cleaning equipment should be stored clean
and dry. Even water that has collected in soap dishes usually holds high levels of bacteria.
Some clinical processes require ‘pure’ water in the form of distilled or de-ionized
water. As water purification is expensive, it is necessary to know the level of purity
required and to use precious pure water only for purposes that need it.
Depending on your geographical area, your main water supply may be ‘hard’ water
(water that has a high mineral or salts content). These substances build up inside
pipes and any equipment using water, causing scaling, furring, and equipment
corrosion. Such effects can be a safety hazard, (such as blocking valves) and can
damage the equipment. In order to prevent this build up, hard water may need to be
softened or a source of ‘soft’ water (such as rain) can be harvested.


Issues Responses


The incoming water supply may
not be safe to drink, and may
contain bacteria


Any microbes in water will
multiply if the water is left
standing for any length of time,
or is stagnant


Water which has collected in
soap dishes usually holds high
numbers of bacteria


‘Pure’ water may be required for
some clinical purposes
(for example, laboratory tasks),
but is expensive


‘Hard’ water supplies can
damage equipment and cause
safety hazards


• Treat it using methods such as sand-filtration, boiling, chlorine,
UV-light (although this will not sterilise it).


• Do not allow puddles of water to remain anywhere on
the health facility premises for long.
• Cleaning equipment (such as buckets) and other water
containers should always be stored dry and clean.
• Water for drinking and cleaning should always be drawn fresh.


• Soap dishes and soap bays on wash-basins should always
be dried by the cleaners.


• Water stills and de-ionizing units are available for water
purification (although this will not produce sterile water).
• Only use ‘pure’ water for purposes that need it.


• Soften it using resin and salt filters, chemicals, or small
electronic descaling units for pipes.
• The softening plant can be placed at the main water supply
point, or at the location of sensitive equipment, such as
boilers, washing machines, autoclaves, stills, etc.
• Collect rain water (which is ‘soft’) from the roof using
guttering, down-pipes, and storage tanks.
• Place hard water pads inside equipment (such as pressure-
cooker type autoclaves) to reduce the build-up of scale.


Figure 9: Ways of Improving the Quality of Water




83


5.4 Waste management


Figure 9 provides some strategies for guaranteeing a safe water supply. All these
strategies can be undertaken on a small scale for particular needs, or on a large,
facility-wide scale.


5.4 WASTE MANAGEMENT
Not only does equipment use and maintenance produce waste products (for
example, disposable electrodes, X-ray fixer, laboratory reagents, machine oil), but
also many waste management strategies involve equipment (such as incinerators,
biogas plants). Proper waste management is therefore required in order to reduce:
◆ risks to health staff who, for example, may be injured by sharps
◆ risks to support staff who, for example, handle infectious linen and materials
◆ risks to maintenance staff, for example plumbers unblocking sewers who may have


little understanding of the infectious nature of the material they are handling
◆ exposure of any staff to toxic or hazardous chemicals
◆ exposure of patients and visitors to any of these risks
◆ risks to the environment and neighbouring population, through contamination of


the soil, and pollution of groundwater or air
◆ risks for landfill workers and waste pickers.


5.4.1 Waste Management Philosophy
In order to dispose of waste effectively, you will need to address and make decisions
about issues such as:
◆ the identification and handling of different categories of waste from the


health facility
◆ the methods for treating different types of waste and the documentation required


to monitor its treatment (such as monitoring the use of the incinerator)
◆ the methods for disposing of different types of waste, and the documentation


required to monitor its regular occurrence.
To help you to achieve all of this, we suggest that the central HTM Working Group
develops the policies on waste management and a Waste Management Hygiene Plan
(see reference material in Annex 2) with advice from national and municipal
experts. The facility level HTM Working Group, or its smaller sub-group, the
infection control committee (Section 1.2) needs to develop and implement good
waste management practices.
Box 29 discusses the idea that waste management strategies should follow the waste
management hierarchy of – avoidance, utilization, and disposal.




5.4.1 Waste management philosophy


84


BOX 29: Strategies for Waste Management
Hierarchy Strategies Examples
Avoidance:
Avoidance and
reduction of waste
generation minimizes
the necessary effort for
waste treatment and
disposal at health
facilities.


Utilization:
Waste can be a source
of ‘secondary’ raw
materials, in other
words items that can
be reused or recycled.
If items are cleaned and
uniformly separated,
they are easier to use
again. Waste should be
sorted at source by
those who know the
dangers, such as
doctors and nurses.


◆ Waste reduction at source,
through product selection.
In practice, it will not always
be easy to decide what material
is environmentally friendly or
which chemical is less harmful.
The relevant expertise must be
developed or advice sought.


◆ Segregation of waste.
If waste is properly segregated
at source before it gets mixed
up, special precautions in waste
handling are only necessary for
the hazardous portion of the
waste (see Box 30)


◆ Reuse.
Some medical items can be
reused only if the necessary
precautions regarding
disinfection, cleanliness,
sterilization, and safety are
taken. If these hygiene
requirements are followed,
items such as infusion bottles
and some sharps can be reused.
Bandages can be reused only if
they have been washed at over
90oC. Infusion sets, catheters,
etc should not be reused.


◆ Recycling.
If articles are broken, dirty or
contaminated so that reuse is no
longer feasible, it is still possible
to use some waste as raw
material for processing and
manufacturing. Although
recycling is not the task of a
health facility, collecting and
selling recyclable material might
generate some additional funds.


◆ use reusable articles whenever possible
(as long as they have not been
contaminated by hazardous chemicals,
radioactive substances, or
infectious organisms)


◆ use products with minimal packaging
◆ give preference to products which are


made of environmentally-friendly
materials


◆ use less-harmful chemicals, if these
are available


Segregating waste at source offers
the opportunity:
◆ to separate hazardous waste from non-


hazardous waste
◆ to recover material for reuse or recycling
◆ to ensure the correct handling for each


type of waste (see Box 30).


Typical articles for general reuse within or
outside the health facility are:
◆ glass or plastic bottles and containers
◆ cardboard or timber boxes
◆ sheets and bags made of paper or


plastics
◆ plastic or rubber tubes
◆ lead batteries.


Typical examples of recycling that can
occur:
◆ Recovery of silver from the fixing baths


of X-ray film processing.
◆ Metals and plastics separated by type.
◆ Glass sorted according to colour.
◆ Paper.
All material leaving the facility must be
properly disinfected.


Continued opposite




85


There are four types of healthcare waste:
Type A General waste and non-infectious healthcare waste, which requires handling


similar to that of municipal solid waste. For example, newspapers,
magazines, books, packaging material, food residue.


Type B Infectious waste, which require special precautions during handling and
disposal. For example, sharps (syringes, needles, scalpels), blood-soaked
bandages, cultures, and stocks of infectious agents.


Type C Pathological waste, which requires special treatment for reasons of hygiene
and particularly for cultural and ethical reasons. For example, body tissue,
body parts, human foetuses, organs.


Type D Toxic waste, which needs individual disposal methods. For example, drugs,
chemicals (diesel, oil, formaldehyde, acids, solvents, mercury, developer,
reagents, etc), radioactive substances, batteries, X-ray film.


Most waste – about 90% – is non-hazardous general waste (type A) and doesn’t need
special treatment. However, if it is mixed with hazardous waste, then it all needs
special treatment. Thus it is very important to segregate different types of waste, in
order to reduce the cost of its treatment and disposal.


5.4.1 Waste management philosophy


BOX 29: Strategies for Waste Management (continued)
Hierarchy Strategies Examples
Disposal:
Waste is treated before
final disposal to lower
its hazardous potential.


◆ Treatment of healthcare waste.
It is important to segregate
different types of waste (see
Box 30), then the majority is
no more harmful than solid
waste and does not need to be
treated. Only the fraction
which is hazardous will need to
be treated.


◆ Final disposal of healthcare
waste.
The final disposal method
depends on the type of waste,
thus segregation is again
important.


◆ General waste and non-infectious
healthcare waste can be disposed
of untreated.


◆ For infectious and pathological waste,
incineration is the most appropriate
method (or possibly burning).


◆ Chemical waste may need chemical
treatment, such as neutralization
or denaturing.


◆ Radioactive substances have to be
packed and sealed for final disposal.


◆ General waste, non-infectious
healthcare waste, incinerator ash, and
neutralized/denatured chemical waste
can be landfilled with ordinary
municipal solid waste.


◆ Hazardous waste (radioactive,
carcinogenic, mutagenic, or infectious
waste) must be disposed of separately in
specially designed landfill sites, waste
pits, or guarded underground places.




5.4.2 Managing different types of waste


86


5.4.2 Managing Different Types of Waste
Box 30 discusses the appropriate handling technologies required for:
◆ collection and separation of waste
◆ transportation within the health facility
◆ intermediate storage
◆ on-site treatment
◆ on-site disposal
◆ transport to centralized waste handling and disposal facilities.
One particular category of infectious waste type B is ‘sharps’. These are items such as
scalpel blades, needles, syringes, razor blades, or even broken glass. Not only are
these items hazardous in themselves (they can cut the handler or be the cause of
‘stick’ injuries), but they also may be contaminated with body fluids that can be
transferred to the handler. Thus, both the safe handling and the safe disposal of
sharps is very important. Box 31 overleaf provides some strategies for their disposal,
and Annex 2 lists additional reference material.


BOX 30: Strategies for Handling Waste
Issues Strategies
Collection and
separation
Waste has to be collected
wherever it is generated.
According to the principle
of segregation at source,
different collection
vessels or bins must be
available for the various
types of waste. They
must be marked so that
they are not mixed up.


Transport
The transport of waste
inside the health facility


Various types of waste should be segregated and held in colour-coded
containers. To prevent waste being mixed up, the colour coding should be
agreed at national level:
General waste type A - use plastic bags, containers, or bins (50 to 150 litre),


which are black (for example)
Infectious waste type B - use puncture-proof containers (5 to 20 litre),


which are red (for example)
Pathological waste type C - use strong plastic bags or containers (10 to 30 litre),


which are green (for example)
Toxic waste type D - use puncture-proof containers, such as sealed drums


or lead boxes, labelled with the respective symbol
(5 to 10 litre), which are yellow (for example).


Waste type A - human handcart
Waste type A & B - transport trolley with a lid or hood, or 180 litre


‘tote’ bin with wheels
Waste type C - either of the above, as long as in sealed plastic bags


or containers
Waste type D - either of the above, as long as in its sealed container


Continued opposite




87


5.4.2 Managing different types of waste


BOX 30: Strategies for Handling Waste (continued)
Issues Strategies
Intermediate storage
General waste type A is
normally dumped
immediately, while waste
from the other categories
sometimes needs to be
stored before it is treated
on-site or transported to
centralized waste
handling sites outside
your facility. Thus you
will need a suitable
storage place for the
waste.


On-site treatment
Not necessary for waste
type A.


On-site disposal
Health facilities at remote
places out of reach of any
municipal waste
management structure
have to dispose of their
own waste.


Transport to
centralized waste
handling facilities


◆ Waste type A should be kept in its usual type of container, but protected
from weather and scavengers. The collection points should be fenced,
roofed, and protected from the wind.


◆ Waste types B, C, and D require special storage facilities:
- lockable to prevent unauthorized access
- large enough to store the volume of waste gathered between collection


dates, with enough space for movement of the carts used to move the waste
- well lit, well ventilated, and as cool as possible – protected from the sun


or even air-conditioned
- walls and floor to be waterproof, smooth, rustproof, well-drained, easy to


clean and disinfect
- located well away from fresh food stores and food preparation areas
- chemicals and radioactive agents should be kept separate from other


(infectious) waste in a separate room or locked cupboard.


◆ The main treatment methods for waste of category B, C, or D are
disinfection and incineration.


◆ Radioactive waste should never be treated on-site, but should be collected
and taken to an appropriate treatment site.


◆ Some liquid chemicals may be neutralized or diluted.
◆ Sewage and wastewater treatment systems include pit latrines, septic


tanks, aeration ponds, biogas plant, seedbed purification, etc.


◆ Normal dumps are sufficient for general waste of type A, and the ash from
incinerators. To avoid any danger of infecting the neighbouring population
these landfill sites should be fenced and locked.


◆ Organic solid waste (such as vegetable matter) can be composted on-site.
◆ Untreated infectious waste type B and pathological waste type C require


specially designed waste pits which guarantee that nobody is able to come
into contact with the waste.


◆ Toxic waste type D should never be disposed of on-site, but transported to
authorized collectors.


◆ Soakpits and drainfields are used for wastewater after treatment.


◆ Various open vehicles can be used for general waste, as long as they are
covered with a net, plastic foil, tarpaulin, etc to prevent the loss of waste
during transportation. Examples include animal carts, tractor and trailer,
conventional truck.


◆ Infectious, chemical, or radioactive waste should only be transported in
locked vans or lorries.




88


5.4.2 Managing different types of waste


BOX 31: Strategies for Disposing of ‘Sharps’
Strategy Examples
Countries should:
◆ Reduce overuse of


injections and assure
safe injection practices,
by implementing
multidisciplinary
strategies comprising
three elements.


◆ Choose between the
three different types
of injection
equipment available.


◆ Implement a system
of collecting used
sharps in a secure way.


◆ Implement an
effective and safe
system of disposing of
sharps containers.


i. Change behaviour, by encouraging patients and healthcare workers to
adopt safe practices and avoid unnecessary injections.


ii. Ensure sufficient quantities of clean injection equipment are available in
each healthcare facility.


iii. Establish procedures so that sharps are disposed of in such a way that
dirty injection equipment is not reused, and the risk of accidental
needle-stick injuries is minimized.


i. Reusable syringes and needles. These can be effectively sterilized with
steam, however evidence indicates that the result is difficult to ensure and
that breakdown in such systems leads to lack of sterilization.


ii. Disposable injection equipment. High rates of consumption mean high
costs. Potentially the safest method, but the quality of such equipment
must be regulated by national authorities, so that unsafe reuse of
disposables is actively prevented.


iii. ‘Auto-disable syringes’. These are inactivated automatically after one use
and prevent dangerous reuse of injection equipment.This product is new,
so may not be available in your country in all sizes.


Either use ‘sharps containers’ which are puncture-resistant,
leak-proof, shatter-proof containers into which sharps
and syringes are placed. In-house solutions include
using a plastic bottle with a small opening and a screw
top, or some form of rigid, closable cardboard box;
otherwise commercial products are available.


Or use an encapsulated mechanical destruction
device that destroys the needle only. This
should be designed to have a sealed collection
compartment which ensures any aerosol of
contaminated fluids created is not exposed to
the air. The syringes should be collected like
all other infectious waste.


Use incineration (or burning) for all sharps containers and for the sealed
collection compartments of the mechanical destruction devices.


Source: WHO, 2003, Safe Injection Global Network (SIGN) website




89


One method of waste treatment is burning/incineration. Open burning by adding
petrol, diesel, or oil to a heap of waste (in a pit or in the open) should be avoided. By
this method combustion is often incomplete leading to scavenging, the residue may
still be infectious, and the air pollution due to emission of particles and bad smells are
unacceptable. A better method is to use an incinerator. There are specific safety issues
relating to these pieces of equipment.
Many health facilities in developing countries cannot afford the expensive
investment and subsequent running costs of the sophisticated incinerators used in
modern hospitals in industrialized countries, which meet all hygiene and
environmental protection requirements. However, there are simpler incinerators that
are designed for smaller facilities, such as a ready-made two-chamber pyrolytic
incinerator, the more traditional brick incinerator (preferably with two chambers), or
a specially-designed drum incinerator (although this will be less efficient). These
types can be effective if certain technical principles are followed (see Annex 2).
The aim of incinerators is to provide high temperature combustion (around 800oC)
with good ventilation, over a long enough period to destroy infectious organisms.
This also reduces the volume and weight of waste down to ash, ensuring that
aesthetically offensive waste components (such as blood, materials soaked with body
fluids, or body parts) are destroyed beyond recognition. However, poorly functioning
incinerators do not achieve the desired results. Box 32 overleaf discusses some
issues to address in order to ensure ‘safe’ incineration (also see Annex 2).


5.4.2 Managing different types of waste


Country Experiences
◆ In Indonesia, implementing strategies which have changed people’s behaviour has


resulted in a substantial and sustained decrease in the overuse of injections.
◆ In Burkina Faso, increasing the availability of clean, disposable injection equipment


through community pharmacies has almost eliminated unsafe injection practices.
◆ In a pilot project in Côte d’Ivoire, the introduction of small-scale, locally-built incinerators


and, at the same time, training of healthcare workers have successfully eliminated
dangerous needles and other sharps waste from the environment.




90


5.4.2 Managing different types of waste


BOX 32: Safety Issues Relating to Incinerators
DO
Design issues
◆ Have an upper pre-heating chamber where wet


waste can dry out prior to combustion.
◆ Ensure good ventilation using enough air inlets and


a sufficiently high chimney (greater than 4m)
made of stainless steel.


◆ Generally require fuel (wood, charcoal, coal,
paraffin, oil, gas, coconut husks, etc) to be added
only during the start-up period.


◆ Include a method for cleaning flue gases, in other
words, a cross-draught combustion system that
requires all gases to pass through the hottest part
of the chamber.


Ensuring proper combustion
◆ Use fuel to preheat the waste in the start-up period.
◆ Add waste in small amounts: for example, load with


only a few plastic sacks, and wait for these to burn
away before adding more.


◆ Load with a good mix of combustible and non-
combustible material.


◆ Add additional fuel (firewood, oil, or gas) if the
waste does not burn properly – you can collect
waste motor oil for this purpose and soak cloths,
paper, sawdust, etc to place in the incinerator.


◆ Leave the cover closed until most of the waste has
burned away.


◆ Ensure regular maintenance.
Safety for the operators
◆ Use protective clothing, boots, and gloves.
◆ Avoid direct skin contact with wastes at all times.
◆ Avoid skin contact with, or inhalation of, the ash –


collect it in a covered metal container.
◆ Handle unburnt residues from the incinerator with


care as they may still be infectious.
Safeguarding the environment
◆ Consider the prevailing wind direction when siting


the incinerator.
◆ Attempt to separate PVC from waste where


possible to avoid production of toxic gases.
◆ Check whether you can meet local environmental


regulations on pollution control.
◆ Dispose of ash and unburnt residues in landfill sites.


DON’T


◆ load with too much waste at one time
◆ load with waste that is too wet
◆ burn polyvinyl chloride (PVC) as it produces


toxic gases including dioxins
◆ add liquid fuel directly to the fire when using


the incinerator
◆ add whole bottles filled with liquid fuel as they


can explode


◆ open waste bags or handle the waste, as it
is hazardous


◆ open observation or loading doors to look inside
during operation, as you can sustain eye injuries


◆ let smoke pollute the health facility or
neighbouring areas


◆ assume the emissions are not hazardous
– depending on the waste burnt they may
contain dioxins, metals, furans.




5.5 Control of other hazards


91


5.5 CONTROL OF OTHER HAZARDS
Besides each type of equipment having its own operational safety issues and
procedures (Section 5.2), equipment can present hazards in general. This Section
discusses the hazards of:
◆ gases (Section 5.5.1)
◆ electricity (Section 5.5.2)
◆ laboratories (Section 5.5.3)
◆ radiation (Section 5.5.4)
◆ fire (Section 5.5.5)
◆ accidents (Section 5.5.6).
There may well be other hazards that you will have to develop strategies for.
We suggest that the central HTM Working Group, or its smaller safety sub-groups
(Section 1.2), should be responsible for establishing policies and guidelines in all
safety areas. It will have to consult with the relevant national authorities that provide
guidance in these areas (Section 2.2). The facility level HTM Working Group, or its
smaller safety sub-groups, needs to develop and implement good safety practices.


5.5.1 Gases
Health facilities often contain a variety of cylinders which may contain various fuels
and gases under pressure (such as oxygen, medical air, carbon dioxide, propane, LPG,
acetylene). Various strategies are shown in Box 33 overleaf for the safety of gas
cylinders, because they can be hazardous for a number of reasons:
◆ They contain a flammable substance.
◆ Their contents are contained under pressure.
◆ They are heavy.
◆ Their invisible contents may leak.
Some health facilities may have oxygen concentrators and/or piped gas as well as
cylinders. They will require similar safety strategies to keep flammable sources away,
to prevent liquid getting into the equipment, and to test for wasteful leaks.
In addition, hazardous materials can give off fumes, such as chemicals and solvents.
A number of strategies should be pursued, such as:
◆ following the instructions for use carefully
◆ wearing face masks
◆ providing appropriate ventilation (open windows, switch on fans, etc)
◆ using fume cupboards in laboratories.




92


5.5.1 Gases


BOX 33: Strategies for the Safety of Gas Cylinders
DO
Personnel
◆ Take great care when handling the cylinders, making sure that


there are at least two people to lift and carry large cylinders.
◆ Wear good foot protection when moving a cylinder in case it is


inadvertently dropped.
◆ Use a wheeled cylinder trolley to move cylinders (regular dragging


of cylinders will cause severe damage to the fabric of the health
facility, such as stairs).


Storage
◆ Keep cylinders dry, clean, and in a well-ventilated area.
◆ Keep cylinders away from flames, lighted cigarettes, flammable


liquids, and combustible material.
◆ Use clear signs to warn of potential dangers.
◆ Sort and store different gases separately.
◆ Store E-sized and smaller cylinders of medical gas (only) on their


sides, and larger cylinders in an upright position.
◆ Store cylinders of liquefied petroleum gas (LPG) in an


upright position.
◆ Use chains and other methods to prevent cylinders from


falling over.
◆ Ensure that cylinders are used in strict rotation by date.
◆ Keep empty cylinders separate from full ones.
◆ Replace the protective covers or caps onto the valves of


empty cylinders.
◆ Ensure that empty cylinders are returned to the suppliers.


In the event of fire
◆ Raise the alarm and, unless life is endangered, attempt to move


the cylinders away from the area.
◆ If personnel are not trained to use fire-fighting equipment, leave


cylinders in the fire zone and carry out statutory fire drill
procedures.


◆ Only allow trained personnel to handle cylinders that have been
affected by fire or excessive heat.


DON’T


◆ carry a cylinder by its valve
◆ allow pressurized gas to come into


contact with the skin
◆ allow flames or smoking anywhere


near the cylinders as the contents
promote combustion


◆ use grease or oil anywhere on the
equipment as this can create an
explosion risk


◆ store cylinders in direct sunlight
as this can cause the gas to
expand and the cylinder pressure
to increase excessively


◆ use excessive force to shut
cylinder valves; tighten by hand
tool only


◆ let people gather near any areas
where cylinders are stored when
there is a fire.


Continued opposite




5.5.1 Gases


93


BOX 33: Strategies for the Safety of Gas Cylinders (continued)
DO
Use
◆ Ensure cylinders are not damaged


or rusted.
◆ Ensure cylinder valves have their


protective caps or seals in place and
that their threads and pin-indexes are in good order.


◆ Ensure the correct cylinder valves are fitted.
◆ Ensure the cylinders are colour-coded and stamped correctly


according to the standard laid down by the national
governing authority.


◆ Ensure the valves are free from oil, grease, moisture, and dust.
◆ Ensure the correct key, or spanner of similar length (not more


than 150mm), is available for opening valves; severe damage can
be caused if the wrong tool is used.


◆ Close the cylinder valve when the equipment is not in use,
otherwise the life of the regulator will be shortened.


◆ Check regularly for leaks – listen for a hissing noise and, with a
toothbrush, apply detergent solution (e.g. 0.5%) on the suspect
area and look for small bubbles which appear at the leakage point.


DON’T


◆ point pressurized gas
towards anyone


◆ use more than one Bodok washer
on a pin index valve connection


◆ attempt to remove the regulator
with the cylinder valve open as
the excessive pressure will
severely damage the thread


◆ dismantle a cylinder valve or re-
adjust a pre-set pressure regulator
– if either of these develop a leak,
they must be replaced


◆ check for leaks using oily soap as
this can create an explosive
mixture


◆ use jointing compounds or tape to
mend a leak.


5.5.2 Electricity
Electrical Installations and Earthing


Human and animal bodies are electrical conductors. The passage of electrical
current through the body can cause burns, or such severe muscle cramp that the
victims are unable to free themselves from the point of contact. If electricity flows
through the human heart (see Figure 10 overleaf) it causes irregular heartbeats. If
it is not possible for someone to switch off the electrical source immediately, the
individual will be unable to breathe and the heart will soon stop beating. The
seriousness of the electrical accident will depend on the intensity of the current
flowing through the body.




5.5.2 Electricity


94


Figure 10: Routes for Electricity to Flow Through the Heart to Earth


Source: Neureiter, J, & Tschank, A, 1989, ‘Technician’s Handbook for Hospital Engineering’,
Kenyan-Austrian Development Cooperation, Ministry of Foreign Affairs, Austria


Currents will always flow from a high source of volts
(the electricity supply) to earth (0 volts) through the
easiest path (the path of least resistance, known as
impedance and measured in Ohms). Thus electrical
installations and electrical equipment must be
designed to ensure that humans and animals:
◆ are protected from access to high voltages


(above 50V)
◆ cannot touch bare metal which is ‘live’ (connected


to a voltage supply)
◆ do not offer the best path (of least resistance) for


currents to earth (therefore a better earthing
route with an impedance of 0.3 Ohms or less must
be provided).


Earth leakage protection is therefore required to
minimize the risk of electric shock to humans and


livestock. Earth leakage currents exceeding 25 milliamperes can prove to be
dangerous and soon become fatal. Therefore to prevent dangerous earth leakage
currents, attention is required to ensure that:
◆ the electrical installation is carried out carefully
◆ the installation is examined and overhauled regularly
◆ one of the methods available for earth leakage protection is used.


Did you know?
◆ Currents as small as 0.5 milliamperes
(0.0005 Amps) passing through humans
can be felt as a tingling in the tongue or
fingers.
◆ If humans come into contact by hand
with a ‘live’ object, currents of 10
milliamperes (0.01 Amps) can make their
muscles contract and their hand grasp the
live object and not let go.
◆ Currents upwards of 50 milliamperes
(0.05 Amps) can be fatal if they pass
through the heart.
◆ For comparison, consider that such a
current is 100 times less than that used by a
single bar of a normal electric fire, which
takes 5 Amps.




There are three methods of protection which can be used to prevent the occurrence
of earth leakage currents:
i. Using extra low voltages as your power supply
Extra low voltage (below 50 volts) prevents the occurrence of dangerous earth
leakage currents and can be provided by using batteries, or transformers (the
secondary winding isolated from earth) as your power source.
ii. Using ‘all insulated’ or ‘double insulated’ systems
The first requires the complete insulation of all parts of an electrical installation. The
second requires the use of double insulated equipment. Such equipment (a hand-
held electric drill for example) has insulation around different internal components, as
well as an external housing which is insulated (because it is made of plastic). Such
equipment can be recognized by the ‘box within a box’ symbol on it , and no earth
connection is required.
iii. Earthing
This means that all metal parts of your electrical installation are linked within a
system that has an earth lead. This earth lead must be connected to the general mass
of earth via an earth electrode (a metal rod or mat). The system is designed to ensure
the immediate electrical discharge of stray currents to earth without danger.
Box 34 describes some common problems with the electrical installations at health
facilities, all of which can present safety hazards to any humans and animals
wandering around the site.


95


5.5.2 Electricity


Experience in West Africa
◆ At one hospital, the electrical installation for a ward block had much too small an earth


cable (similar to lamp flex). This was mounted on the external wall of the building and had
(erroneously) been intended to provide an earth by being buried in the ground. However,
goats had nibbled through this wire leaving no earth protection for the building.


◆ At another hospital, the main incoming electricity supply cable for the facility came in at
floor level into the waiting room of the out-patients department. There it had been stripped
of all insulation to connect into the main distribution board. This left bare metal at 380
Volts within easy reach of the children playing while they waited.




96


Strategies are required to obtain good quality electrical installations, which provide a
decent earth and prevent against electric shock hazards. Advice should be sought
from the electricity supply company and reputable electrical contractors who should
work according to wiring regulations (for example, for anglophone countries the
latest Institution of Electrical Engineers (IEE) Wiring Regulations – see Annex 2).
Box 35 provides examples of some of the strategies required, and who is responsible
for them.


5.5.2 Electricity


BOX 34: Common Problems With Electrical Installations
Poor or no earthing arrangement.
Earthing is by far the most important
factor determining safety of
equipment and installations.


Poor circuit design with little or no
attention paid to circuit loading and
cable sizing.


Unsatisfactory cable joints.


Poor workmanship.


◆ No earth is provided at all.
◆ Ineffectual attempts are made to provide an earth (and the


impedance is much too high, >0.3 Ohms), because:
- tiny earth wires are used
- the earth wire is broken
- the earth rod is too short
- the earth rod is only buried shallowly.


◆ Many installations are fed from already overloaded supplies,
and are subject to large voltage drops (indicated by dimming of
the lights).


◆ Undersized cables are used and, if the supply voltage is low,
equipment stops functioning.


◆ The circuit loading between the three phases is not balanced
and this causes voltage and frequency fluctuations.


◆ Proper connectors that give a mechanically and electrically
sound connection are not used.


◆ Bare metal is left exposed.
◆ People erroneously simply twist cables together to join them


(even main overhead incoming supply line conductors up to
25mm sq).


◆ Colour coding of cables for different parts of the circuit is ignored.
◆ Sharp metal edges are left on the cut-outs in distribution boards


which cables can catch on.
◆ Single insulated cables are run exposed on walls rather than


inside conduit.
◆ Connections and cable joints are left with the metal exposed


without any insulation (even those carrying a 380V
three-phase supply).




97


5.5.2 Electricity


BOX 35: Strategies for Providing Good Quality Electrical Installations and a Decent Earth
Providing the earth at the
origin of the installation


Installation protection


Reticulation of the earth
around the site


It is usually the responsibility of the electricity supply body to provide an
adequate earth at each site, by one of the following methods:
◆ Protective Multiple Earthing (PME) incorporated into the design of the


electricity distribution system around your country.
◆ The cable sheath (armouring) of the electricity supply company’s main


incoming cable to your site is connected back to the earth at the supply
company’s sub-station.


◆ A driven earth system at each site (either a metal rod or a mat buried
several metres underground) that provides an earth, the quality of which
is dependent on the local soil conditions and the depth of the water table.


If the chosen method is a driven earth system, the quality of earth is
inconsistent because it is dependent upon soil conditions. Thus the electrical
installation needs further protection from some form of residual current
device (RCD) that disconnects the supply when it detects small leakage
currents to earth (of between 10 and 300 milliamperes). The RCD can be
fitted at one of the following points:
◆ At the main electrical incoming point for the whole installation. Simple


and cost-effective protection, but in the event of a fault the entire
installation is disconnected.


◆ On each distribution board (DB). More expensive, but provides more
localized protection and makes faults easier to find.


◆ On each circuit. The most expensive option, but the most localized
protection, making faults easiest to find. Advisable for: sensitive areas
with several pieces of medical equipment, or the risk of using equipment
near water.


Note: earth-leakage circuit-breakers (ELCBs) sense current flowing from
equipment to earth, and automatically disconnect the supply when it exceeds
a pre-set value. But if the equipment’s earth connection has failed (perhaps
because it broke), the ELCB does not work. Thus RCDs are gradually
replacing ELCBs. RCDs work independently of the earth connection,
measure small imbalances in current flow to and from circuits, and disconnect
the supply when these leakage currents are too high.


It is the responsibility of the health service provider to run cables from the main
earth (at the incoming supply point) to the distribution board for each building,
and to run cables within each building to every socket outlet and light point.
The size (cross-sectional area, in mm sq) of the earth conductor in any circuit
should relate to the size of the main phase (line) conductor/s. For example:
◆ Phase conductors greater than 35mm sq require earth conductors at least


half the size (and rounded up to the next nearest size of cable), for
example, an incoming supply cable of 95mm sq requires a main earth
conductor of 50mm sq.


◆ Phase conductors of between 16 and 35mm sq require earth conductors of
16mm sq.


◆ Phase conductors of less than 16mm sq require earth conductors of the
same size, so a 2.5mm sq ring main circuit requires an earth conductor also
of 2.5mm sq.


Continued overleaf




98


5.5.2 Electricity


BOX 35: Strategies for Providing Good Quality Electrical Installations (continued)


Distribution boards


Correct socket outlets


Exposed metal


Lightning protection


Any electrician or electrical contractor that you employ or hire must connect up
the electrical installation to the distribution boards. It is essential that they:
◆ file off the sharp metal edges of the cut-outs made in the distribution board
◆ calculate the loading of the various circuits, and design the circuits, cable


sizes, and circuit-breakers correctly so as not to overload or unbalance
the system


◆ provide separate circuits for lights, normal socket outlets, and special
loads such as stoves, water heaters, air-conditioners, etc


◆ use the correct colour codes for the cables used for earth, live, and neutral
parts of the circuits, so that they can be easily identified


◆ label all the circuits in the distribution board, for easy fault-finding later on
◆ use proper cable terminations at all times for safety.
There are many different styles of electrical socket outlets and plugs in use
throughout the world. They all use different pin configurations and different
colour coding of wires and cables for the earth, the live, and the neutral
conductor. It is essential that the electrician or electrical contractor ensures that:
◆ enough socket outlets are available and located conveniently – the use of


long leads, overloaded adaptors, or makeshift extension blocks is
dangerous (the earth may become disconnected and the risk of
electrocution increases)


◆ sockets are at least 2 metres from any source of water (a basin, for example),
and sockets should never be placed in a bathroom or shower-room


◆ an earth wire is provided in the socket outlet and the plug, if you have a
three-wire and three-plug system (some equipment has only two wires in
the power cable, such as the ‘double-insulated’ items, and do not need an
earth connection)


◆ the correct plug is fitted to your equipment which matches your socket
outlets (for example, a three-pin plug for a three-pin socket) – makeshift
modifications are dangerous


◆ the correct cable colours are identified and correctly connected inside
the plug.


Metalwork, which is not part of an installation, could become ‘live’ and would
be dangerous under faulty conditions (gas and water pipes, radiators, water
taps, sinks, bathtubs, etc). The electrician/electrical contractor should either
‘bond’ all such pieces of metalwork (that is connect them to the earth), or
completely insulate them.
Overhead distribution lines can attract lightning, and therefore may provide a
natural route for earthing. Thus, the electricity supply body or an electrical
contractor should be asked to fit lightning arresters to the overhead poles at
the ends of the main distribution lines, or at a point where the distribution
lines change direction.




99


5.5.2 Electricity


Once a good electrical installation has been provided, it should be regularly
inspected and tested by reputable electricians, using the correct test instruments
(Section 7.3). To guarantee the safety of the installation, they need to:
◆ test for earth leakage
◆ test for circuit continuity
◆ test for loose connections
◆ perform insulation tests
◆ test switch leakages
◆ test for power
◆ check for the correct rating
◆ check whether wiring regulations were followed during installation.


Medical Electrical Safety
Another important area of safety is medical electrical safety. Medical electrical
equipment has stricter electrical safety requirements and considerations than non-
medical equipment, because it comes into direct contact with patients (for example,
ECG recorders, monitors, diathermy units, and physiotherapy ultrasound).
All such equipment should conform to (and be manufactured to) the international
safety standard IEC 60101 (see Guide 3 on procurement and commissioning). It
describes electro-medical equipment according to the type of protection provided
against electric shock (defined as Class I, II, or III), and the degree of protection
provided against electric shock (defined as Type B, BF, or CF). You can tell which
sort of equipment you have, by studying the symbols on the manufacturer’s label
attached to your equipment, as shown in Figure 11.
Such equipment will require dedicated safety testing procedures and test
instruments, which go further than the standard electrical safety tests described
above. All electro-medical equipment should be regularly inspected and tested by
bio-medical technicians, using the correct test instruments (Section 7.3). To
guarantee safety, they should perform a variety of tests on each piece of equipment
depending on its Class and Type, such as:
◆ self checks
◆ supply voltage check
◆ insulation resistance test
◆ earth bonding test
◆ earth leakage current test
◆ enclosure leakage current test
◆ patient leakage current test
◆ patient auxiliary current test
◆ mains voltage on the applied part test.




100


5.5.2 Electricity


Note: ◆ Class III equipment relies on protection from a supply at Medical Safety Extra-Low Voltage
(MSELV) and is rarely encountered now.


◆ Equipment that is battery powered is not described as Class I, II or III.
Source: Deller, A, 1994, ‘Notes on Electrical Safety’, Centre for Medical Electronics,


St Bartholomew’s Hospital, London, unpublished


ATTENTION! CONSULT
ACCOMPANYING DOCUMENTS


FUNCTIONAL
EARTH


PROTECTIVE
EARTH


PROTECTION CLASS I & II EQUIPMENT


NOTE THERE IS NO SYMBOL
FOR CLASS I EQUIPMENT CLASS II EQUIPMENT


ANAESTHETIC-PROOF
EQUIPMENT


ANAESTHETIC-PROOF
CATEGORY G


TYPE B EQUIPMENT TYPE B WITH DEFIBRILLATOR
PROTECTION


TYPE BF EQUIPMENT TYPE BF WITH DEFIBRILLATOR
PROTECTION


TYPE CF EQUIPMENT TYPE CF WITH DEFIBRILLATOR
PROTECTION


Figure 11: IEC Symbols on Equipment Labels Showing the Level of Safety Protection


Variations in Supply
When you have a mains electricity supply, it is preferable to have an emergency
back-up generator. When there are interruptions in the main supply (power cuts),
the generator cuts in to ensure that electricity continues to be supplied to key areas.
If you are used to having electricity 24 hours a day, it becomes crucial for the working
of some equipment and the provision of some services.




101


Thus, for safety reasons, the emergency generator should be connected to items such as:
◆ the refrigeration unit controlling the mortuary body store
◆ the blood bank fridge
◆ the water pump
◆ any sewage pump
◆ an autoclave
◆ an operating theatre
◆ any intensive care facilities.
Some health facilities will not have a main electricity supply from a supply company,
but will have to rely on an electrical generator alone, which will be used for only a few
hours a day. This will affect the type of equipment you can own. Other facilities will
use alternative sources of electricity, such as solar panels.
Whatever your power source, you need to protect against sudden changes in supply
(such as electrical surges, spikes, cut-outs, lightning strikes, etc) which can ruin your
equipment and mean you lose your data. The most sensitive equipment in health
facilities is the advanced electronic equipment, such as:
◆ telecommunications equipment (telephones, fax machines, radio transmitters


and receivers)
◆ data processing equipment (computers, printers, plotters, monitors)
◆ electronic diagnostic equipment (radiography, ECG, ultrasound,


monitoring machines)
◆ electronic laboratory equipment
◆ any other equipment with electronic control circuits.
Box 36 describes several measures you can take to adapt the power supply to the
requirements of your equipment, and protect it.


Tip • These measures assume that your generators and the mains supply grid are in a good
condition or cannot be influenced (in the case of the public mains supply).
If they can be improved, solve these problems first if possible.


5.5.2 Electricity




102


5.5.2 Electricity


Solution
An over- or under-voltage cut-out device.
This automatically switches off the power supply when it is too high or too
low, but your equipment may be cut off frequently.
A step-up or step-down transformer.
This provides a fixed increase or decrease of voltage, but it cannot cope
with voltage fluctuations.


Voltage stabilizers.
These stabilize (smooth) the variations in the voltage without cutting off the
power supply to your equipment. There are various manual and automatic
types of stabilizer.
Frequency stabilization.
If the problem lies with your own generator, you can improve the situation
through maintenance strategies (see Annex 2). If the problem lies with
the electricity authority’s supply, there is little you can do. In the case of
expensive equipment, using an electronic inverter type of voltage
stabilizer (see above) and a true online type of uninterruptible power
supply (UPS) (see below) may help.
Suppression of electro-magnetic interferences.
There are various strategies (see Annex 2), such as:
◆ ensuring all equipment is connected to a good earth (grounded)
◆ ensuring all ground connections are at the same voltage
◆ providing metallic shielding of power lines and data lines
◆ twisting of cable pairs which are connected to equipment input terminals
◆ separating power circuits for sensitive electronic equipment from those


for heavy loads
◆ using radio frequency interference (RFI) filters
◆ unplugging equipment during thunderstorms
◆ installing an effective external lightning arresting system (using


lightning conductors)
◆ installing a transient absorption system for high-energy peaks and


spikes (using various separate types of surge arresters at different
points in the electrical installation).


Power back-up systems using generators or banks of batteries, either for
the total installation, parts of it, or individual pieces of equipment.
These can involve:
◆ manual change-over, introducing a significant delay in restoring power


(from tens of minutes to several hours)
◆ automatic change-over with interruption of power, introducing a delay


of about 10 minutes
◆ automatic change-over without an interruption in power, using a UPS.


There are various types that can switch over immediately or within
fractions of a second (see Annex 2).


Box 36: Power Conditioning Strategies
Problem
Your power supply
voltage may become
too high or too low
Your supply voltage
is stable but always too
high or too low by a
constant amount
Your power supply suffers
from voltage fluctuations


Your power supply suffers from
frequency fluctuations
(measured in Hertz)


Your equipment is affected
by power surges, peaks, and
ripples caused by electro-
magnetic interference from
lightning, switching
operations of heavy
machinery, permanent
electro-magnetic fields from
transmitters, etc and
electrostatic discharges


You suffer from power failures
or power flaws, and want to
ensure that the supply of
power is transferred to a
back-up system




Many countries have a voltage supply system based on 230V at a frequency of 50Hz.
However countries in the Americas use a different standard of 110V at 60Hz. You
may live in the first type of country and buy or receive equipment designed for the
American standard. Then between the mains supply and each piece of equipment
like this:
◆ you will have to install a step-down transformer (to reduce your 230V to 110V)
◆ you may have to install an electronic inverter stabilizer or online UPS (to increase


your 50Hz to 60Hz) depending on the advice in the equipment documentation.


5.5.3 Laboratory Hazards
Safety in the laboratory is essential because staff are exposed to biological, chemical,
and physical agents with the risk of infection, poisoning, and injury. Many of these
issues relate to the equipment used, both because it is in contact with infectious
organisms and also because it can be a danger in itself.


Infection Risks
Infections can be spread more easily in laboratories because of the large amount of
organisms present, and because infectious materials are being handled. Whether or
not an infection occurs depends on a number of factors, including the means of entry
into the body, the number of organisms entering the body, and the immune status of
the worker.
Figure 12 overleaf provides some strategies for establishing barriers that will block
the routes of infection. The extent of these barriers depends on the nature, and to
some degree the amount, of the micro-organisms that are handled in the laboratory.
Those that are unlikely to cause human disease require little more than good
laboratory practice – more to protect the work than the worker. Those that cause
serious disease require very strict containment using highly effective barriers.
Infections can spread through a number of routes. Box 37 describes these routes,
and some strategies to avoid them.


BOX 37: Laboratory Infection Risks and Strategies to Avoid Them
Entry through the skin


Entry through the eye


5.5.2 Electricity


103


Do the following:
◆ Cover all obvious cuts and abrasions with waterproof dressings.
◆ Wash hands frequently but do not scrub them.
◆ Use barrier creams.
◆ Use disposable gloves.
◆ Wear overalls.
To avoid entry via the conjunctivae, do the following:
◆ Try to avoid splashes into the eye.
◆ Avoid rubbing the eyes with infected fingers.
◆ Consider wearing safety glasses.


Continued overleaf




104


5.5.3 Laboratory hazards


BOX 37: Laboratory Infection Risks and Strategies to Avoid Them (continued)
Inhalation
(breathing in)


Ingestion
(swallowing)


Injection


Avoid the following actions which create aerosols and infectious airborne particles:
◆ Using inoculating loops larger than 3mm in diameter or incompletely closed,


as they will shed their contents.
◆ Vigorous spreading of culture plates and slides with loops


– gentle movement is safer.
◆ Flaming charged loops in ordinary bunsens


– use hooded bunsens or disposable plastic loops instead.
◆ Blowing out pipettes causing bubbles to form and burst


– drain the pipettes instead.
◆ Vigorous mixing of cultures (such as sucking and blowing with pipettes)


– use vortex and other mixers instead together with culture tubes or bottles
that are stoppered.


◆ Allowing drops to fall from the tips of pipettes onto hard surfaces
– use an absorbent bench covering preferably soaked in disinfectant.


◆ Using unstoppered centrifuge tubes and misbalanced loads
– use screw-capped tubes and sealed buckets instead (see Box 18).


◆ Homogenization that creates aerosols that are released when the container
is opened – use stomachers instead.


◆ Mixing in unstoppered containers
– use bottles and tubes with stoppers instead or vortex mixers.


◆ Dropping cultures where possible
– plastic petri dishes release less aerosols than glass ones when dropped.


◆ Allowing probes of automated equipment to move too abruptly
– fit guards and slow the movement down instead.


◆ Pouring infected fluids straight into another fluid
– use a funnel with its tip beneath the surface of the fluid.


Do the following:
◆ Ban mouth pipetting – use pipetting devices instead.
◆ Provide hand basins and encourage hand-washing to break the hand-to-mouth


route of infection.
◆ Ban eating, drinking, and storing food in the laboratory, as contamination is


too easy.
◆ Ban smoking and the application of cosmetics in the laboratory, since they


provide opportunities for organisms to transfer from contaminated fingers to
the mouth.


Do not use:
◆ hypodermic needles and syringes in place of pipettes. If necessary, obtain


instruments which remove septum caps so that pipettes can be used.
◆ automated equipment which uses needle probes (to take samples from


septum-capped bottles) without fitting a shield.
◆ glass pasteur pipettes as hands are easily stabbed – use soft plastic ones instead.
◆ poor quality culture tubes which may break when stoppered and inoculate staff


– buy better quality items instead.
◆ chipped culture tubes, the rims of which may be contaminated and


inoculate the operator – have a glassware inspection routine and regularly
discard condemned glassware.




105


Figure 12: Basic Microbiological Safety Strategies


5.5.3 Laboratory hazards


Strategy Activities


Primary barriers
around organisms


Secondary barriers
around the worker


Tertiary barriers
around the laboratory


• good laboratory practice which minimises the possibility of
organisms escaping from their culture vessels (even with the
best methods, accidents and escapes do occur)
• disinfectants that deal immediately with accidents and
escapes that contaminate benches and equipment
• safety cabinets which prevent the inhalation of organisms if
they escape into the air
• autoclaves and incinerators that kill the organisms when
investigations are finished


• protective clothing including gowns, gloves, safety spectacles
and (rarely) masks
• personal hygiene such as hand-washing
• immunization and medical care


• safe disposal of infectious waste (Section 5.4)
• security and limited access of the public
• care of invited visitors.


Chemical and Physical Risks
There are other hazards in laboratories due to:
◆ faulty use of certain equipment such as centrifuges (risk of flying objects),


autoclaves (risk of bursting bottles), etc (see Box 18)
◆ explosion risks from gases, faulty use of gas burners, and sparking centrifuges


because of worn brushes (from lack of maintenance)
◆ incorrect storage and handling of flammable chemicals such as ether, nitric acid,


and hydrogen peroxide
◆ incorrect handling, storage, and spillage of chemicals and reagents (acids, alkalis,


ammonia, etc).
Advice on all these issues should be available from your country’s National
Laboratory Service, and reference materials (see Annex 2).


Quality Control
In addition, the National Laboratory should provide a system of quality control
procedures to monitor the performance of the work undertaken in all laboratories.
There are a variety of methods that they can employ for double-checking that test
results and readings are consistent and accurate.




106


5.5.4 Radiation Hazards
X-ray Equipment


X-ray machines are obvious sources of radiation, and safety policies and procedures
must be produced regarding:
◆ lead lining of rooms, leaded control booths, or screens with leaded glass
◆ the use of mobile machines outside of lead-lined rooms
◆ the direction and timing of firing/exposure
◆ the use, monitoring and follow-up of exposure badges for operators
◆ the use of lead aprons by operators
◆ the use of gonad protectors for patients.
Methods are required for monitoring and recording exposures and any adverse
incidents. Procedures are required for getting exposure badges (dosimeters)
checked, and implementing any follow-up actions needed.
Advice on all these issues should be available from the national body responsible for
radiation control (Section 2.2), and reference materials (see Annex 2). Box 38
provides some strategies for the use of X-ray machines.


Other Radioactive Sources
In addition, in larger facilities there may be radiation hazards from other radioactive
substances such as radio-opaque materials and radioisotopes used for imaging, and
radioisotopes and radionuclides used in laboratories for tagging and radio-
immunoassay. Follow these guidelines for these substances:
◆ Use them in a separate room to normal work.
◆ Store them in locked cupboards.
◆ Ensure monitoring equipment is available.
◆ Ensure emergency kits are available, containing protective clothing, equipment,


neutralizing agents, and information.
◆ Ensure that the room and staff are part of the routine radiation monitoring system


used in the X-ray department.
◆ Dispose of them according to your Waste Management and Hygiene Plan


(Section 5.4).
Such substances are not usually handled in large quantities. Good practice is
required to deal with the three main hazards, as shown in Box 39 overleaf.


5.5.4 Radiation hazards




107


5.5.4 Radiation hazards


BOX 38: Safety Strategies When Using X-Ray Machines
Installation
◆ Earthing is essential :


- connect the generator to the main earth, if agreed by the electricity authorities,
and follow the local regulations exactly


- if not specified by local regulations, connect to an independent earth electrode
close to the X-ray department


- never connect the X-ray generator to the water-piping system.
◆ All X-ray equipment must be installed by the manufacturer or their local representative for warranty and


safety reasons, and it must be checked before acceptance.
◆ When equipment is being relocated, it is essential that any workers you hire have experience of


X-ray installation.
◆ Incorrect installation may be both dangerous and expensive.


Operation
◆ Users and maintainers must be aware of the risks associated with the use of X-rays, and operate the X-ray


equipment accordingly.
◆ The operator must use the correct X-ray exposure techniques (kV and mAs).
◆ The operator must adjust the collimator to the size of the film.
◆ The operator must use protective devices for the patient when appropriate.
◆ The operator must protect him- or herself behind the protective screen.
◆ The operator must allow no one other than the patient in the X-ray room during the exposure (if the


patient must be held or supported, a lead apron and gloves must be worn by all who do this).
◆ The operator must process the film according to good practice techniques, following especially the time


and temperature guidelines.
◆ In the case of battery-powered machines, the operator must know how to regularly care for the batteries.


Maintenance
◆ Except for minor maintenance, only specially trained and experienced service technicians or engineers


should carry out maintenance and repair.
◆ Do not service the equipment unless the main electricity supply is turned off.
◆ Do not open the generator control console to attempt to make repairs.
◆ Never use a fuse of a different rating, or type, from that recommended by the manufacturer.
◆ If a fuse blows regularly, inform the HTM Team or the manufacturer’s representative.
◆ Check protective lead aprons and gloves every six months for tears and cracks; if necessary doubtful areas


can be examined by X-ray or fluoroscopy.
◆ Do not purchase a spare X-ray tube to keep in store, not only are they expensive, but they will deteriorate


if not put to use.
◆ As the battery pack for battery-powered machines may store enough power to give a life-threatening electric


shock, keep all metal tools away, and do not wear metal watches, watchstraps, bracelets, or necklaces, whilst
working around it.




108


BOX 39: Strategies for Dealing with the Hazard of Radioactive Sources
Skin contact


Ingestion


Spillage


◆ Wear overalls and gloves.
◆ If skin contact occurs, wash with soap and tepid water taking care not to spread the


contamination (to the eyes, for example) until monitoring shows that the radiation
levels are acceptable.


◆ Ban mouth pipetting.
◆ Ban eating, drinking, smoking, and applying cosmetics in the work area where these


substances are used.


◆ Put on the protective clothing from the emergency kit.
◆ Place contaminated articles and waste in plastic bags
◆ Decontaminate and dispose of this radioactive waste in the correct way (Section 5.4)
◆ Wash contaminated areas with water, taking care not to spread the agent any further,


until monitoring shows that the radiation levels are acceptable.


5.5.4 Radiation hazards


Other Radiation Risks
There could also be potential radiation risks from other emission sources, such as
microwaves, ultrasound, infrared, ultraviolet, etc. Little is known about the actual
hazards from some of these sources, and it is necessary to monitor, and keep up-to-
date with, international information and opinion on the possible hazards of these
other emission sources (see Annex 2). Some reported problems are shown in Box 40.


BOX 40: Reported Radiation Risks From Other Emission Sources
Ultra-violet
sources
Lasers


Ultrasonic cleaning
baths and
cell disruptors


Visual display units
(VDUs)


Microwave ovens


◆ ‘sand in the eyes’ symptom of conjunctivitis


◆ eye lesions


◆ threat to hearing
◆ skin lesions if hands are immersed in the bath
◆ respiratory infections from aerosols generated


◆ physical strain from poor positioning
◆ risks to pregnant women may be possible, but as yet are unconfirmed
◆ eye strain from poor lighting


◆ burns to hands if the source does not automatically switch off when the door opens.




109


5.5.5 Fire


5.5.5 Fire
Box 41 describes the various issues that have to be considered when managing fire risks.


BOX 41: Issues to Address When Managing Fire Risks
Fire hazards


Fire fighting


Procedures in
case of fire


Safe storage of
flammable materials


Electrical installation


◆ boilers
◆ incinerators
◆ cooking equipment
◆ poor electrical wiring
◆ bypassing of fuses, safety trips, or circuit-breakers
◆ overloading of equipment, systems, socket outlets, and extension blocks
◆ electrical machinery
◆ burning waste
◆ gas cylinders
◆ chemicals and flammable materials such as laboratory and cleaning agents,


X-ray films and developing chemicals, workshop lubricants and fuels.
◆ the presence of adequate fire-fighting equipment


(such as sand, blankets, water, extinguishers, hoses, sprinklers)
◆ its regular maintenance
◆ training in its use.
◆ the suitability of the buildings in terms of fire exits
◆ the use of alarms
◆ the use of fire drills
◆ training of staff in the evacuation of patients and visitors.
◆ store away from heat sources and not in direct sunlight
◆ store in well-ventilated areas
◆ ensure materials are clearly labelled
◆ display signs prohibiting smoking and the use of naked flames.
◆ regularly check the electrical installation for frayed or damaged


(rat eaten) cables, water, debris, dirt, etc
◆ prohibit the use of coiled cables, extension leads, adaptor blocks and


adaptor plugs.


NO


Experience in Southern Africa
The boiler that supplied the steam for all heating, hot water, laundry, kitchen and
autoclaving needs for a hospital broke down. The hospital accepted the cheapest quote
from a local man who said he was an electrical contractor. He got the boiler working
again, but only by bypassing all the safety features. This caused a tremendous fire, and
both the boiler and the boiler house burnt down.




5.5.5 Fire


110


Advice on all these issues should be available from experts such as building inspectors,
government occupational safety officers, municipal regulatory bodies, fire-fighting
bodies, etc (Section 2.2), and reference materials (see Annex 2). Box 42 highlights
the most common causes of fires.


BOX 42: The Most Common Causes of Fires
Common electrical faults responsible for fires
◆ Overloading of circuits – too may appliances plugged into one socket outlet.
◆ Long and badly positioned electrical cables – too near hotplates or similar equipment, or where they are in


contact with water.
◆ Equipment left switched on unnecessarily, overnight, or left unattended.
◆ Equipment that uses flammable liquids or gas placed too near to naked flames.


Common naked flame faults associated with fires
◆ Gas-heated appliances (cookers, bunsen burners etc) whose flame (full-flame or pilot) is left unattended.
◆ Containers of flammable liquids (oil, petrol, ether, etc) or flammable materials (cotton wool, paper, etc)


left too close to the flames of gas-heated appliances, or other naked flames (such as cigarettes).
◆ Gas-heated appliances (including those using propane and acetylene) connected with perished, incorrect,


or poor quality tubing.
◆ Use of matches instead of mechanical lighters – matches are not always extinguished when discarded.


5.5.6 Accidents
Equipment should be in an acceptable condition at all times, so that it cannot cause
harm to patients, staff, or visitors. To avoid accidents:
◆ buildings need to be structurally sound
◆ service supplies should be dependable and trustworthy
◆ equipment should perform competently and safely.
There are a number of issues to consider regarding the prevention of accidents
related to equipment, which can befall staff, patients, and visitors. These are shown
in Box 43.
Local ‘health and safety at work’ legislation and inspectors may cover these issues,
and provide guidance.




5.5.6 Accidents


111


BOX 43: Typical Causes of Accidents
Hazardous operation of equipment, such as:
◆ clothing caught in moving parts of machinery
◆ equipment which, by its nature, is dangerous, such as lathes, drills, circular saws, welding machines
◆ operation which requires protective clothing such as eye goggles, safety guards, etc
◆ lack of attention by operators, such as poor driving of health vehicles.
Hazardous condition of facilities and equipment, such as:
◆ brickwork falling down on someone
◆ broken windows
◆ holes in the ground which can trip people up
◆ flooding from blocked drains
◆ loose wires providing electric shocks from sockets and switches, etc.
Hazardous practices, such as:
◆ leaving equipment in corridors for people to fall over
◆ undertaking maintenance in a place where people will slip on oil spills
◆ wet or highly polished floors, etc.


BOX 44: Summary of Procedures in Section 5 on Ensuring Safe Operation
Health Service
Provider


HTM Working
Group (and its
Safety Sub-groups


◆ develops safety policies for all risk areas
◆ provides sufficient and appropriate resources (both financial and material) to


tackle all safety issues
◆ consults with appropriate national bodies for guidance on the various safety issues
◆ consults Section Heads to identify safety issues relevant to their sections
◆ develops appropriate safety procedures to address:


- hazards when operating equipment
- equipment-related infection control
- waste management
- control of all other hazards


◆ acts on incident reports


Di
sc


us
sio


n


Continued overleaf


Box 44 contains a summary of the issues covered in this Section.




112


BOX 44: Summary of Procedures in Section 5 on Ensuring Safe Operation (continued)
Section Heads,
Safety Sub-groups,
In-Service Training
Coordinator
Equipment Users
and HTM Teams


Section Heads,
Safety Sub-groups,
In-Service Training
Coordinator
Equipment Users
and HTM Teams


Section Heads,
Safety Sub-groups,
In-Service Training
Coordinator
Equipment Users
and HTM Teams


Section Heads,
Safety Sub-groups,
In-Service Training
Coordinator
Equipment Users
and HTM Teams


◆ ensure that staff are trained in the correct procedures to reduce risks when
operating equipment


◆ monitor implementation of the correct procedures


◆ carry out the correct safety procedures when operating equipment
◆ report any incidents (Section 8.2)


◆ ensure that staff are trained in the correct procedures for infection control
◆ monitor implementation of the correct procedures


◆ carry out correct methods for:
- decontamination and monitoring of sterility
- linen handling
- keeping the workplace clean


◆ report any incidents (Section 8.2)
◆ ensure that staff are trained in the correct procedures to reduce risks when


handling, treating, and disposing of waste
◆ monitor implementation of the correct procedures


◆ carry out the correct waste:
- reduction
- segregation
- storage
- transport
- treatment
- disposal


◆ report any incidents (Section 8.2)


◆ ensure that staff are trained in the correct procedures to reduce risks from
other hazards


◆ monitor implementation of the correct procedures


◆ carry out the correct procedures to reduce risks from:
- gas
- electricity
- laboratories
- radiation
- fire
- accidents


◆ report any incidents (Section 8.2)


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Section 5 summary




113


6 How to ensure the availability of accessories and consumables


6. HOW TO ENSURE THE AVAILABILITY OF
ACCESSORIES AND CONSUMABLES


Why is This Important?
Equipment accessories and consumables are essential because without them
equipment simply will not function.
Ensuring that suitable equipment accessories and consumables are always
available is a vital management issue.


This Section looks at assessing the need for equipment accessories and consumables,
through the following issues:
◆ A general discussion on accessories and consumables


(Section 6.1).
◆ The storage system and procedures (Section 6.2).
◆ Calculating usage rates and reorder levels (Section 6.3).
The procedures required for purchasing accessories and consumables are discussed in
Guide 3 on procurement and commissioning .
This Section is aimed at anyone responsible for ensuring that adequate supplies of
accessories and consumables are available. Equipment users are most commonly
responsible for this, though, in health systems where these needs have been
neglected, the HTM Service may have taken over this responsibility.


6.1 GENERAL DISCUSSION ON ACCESSORIES
AND CONSUMABLES
Besides accessories and consumables, staff will also need access to equipment spare
parts and maintenance materials. Equipment operators need to use these items
when undertaking user PPM (planned preventive maintenance), and the health
facility may be responsible for their storage. The specific discussion on equipment
spare parts and maintenance materials is provided in Guide 5 on maintenance
management. However, the discussion here on accessories and consumables covers
similar issues of availability and storage procedures.
Health service providers must also ensure they supply staff with adequate safety gear
needed to do their jobs, such as gloves, goggles, masks, overalls and boots. In some
health systems, these items are purchased as general supplies and paid for out of
administrative costs (see Guide 2 on planning and budgeting) and therefore are not
strictly considered accessories and consumables.




It doesn’t matter which way you purchase this safety gear, as long as it is not
forgotten. The advice offered in this Section is just as relevant for safety gear, and
can assist you with its purchase, storage, and replenishment.


Availability
Accessories are those items which:
◆ connect the machine to the patient (breathing circuits, ECG leads,


probes/transducers, etc)
◆ assist with the use of the machine (internal trays, foot-switches,


computer mouse, etc)
◆ adapt its performance (different sized adaptors, objectives, lenses, etc).
Thus accessories are often:
◆ the main link to the patient
◆ the part most handled by staff
◆ flexed, bent, twisted and even mis-used
◆ subject to a great deal of wear and tear
◆ the most vulnerable part of a piece of equipment.
Even if a piece of equipment lasts for years, accessories may need to be replaced
regularly, therefore accessories must be available for the lifetime of the equipment.
Consumables are those items which:
◆ are used up daily during the operation of the equipment (such as X-ray film,


disposable electrodes, laboratory reagents, ultrasound gel, washing powder, toner
and solder.


◆ will be needed throughout the lifetime of the equipment.
The availability of accessories and consumables will dictate how long staff can keep
using a piece of equipment. Once accessories and consumables are no longer available,
a piece of equipment cannot be used even if it is in perfect working condition.


Disposable or Reusable?
Some accessories and consumables (such as diathermy plates, probes, breathing
circuits, electrodes, and filters) are available as disposable and as reusable products,
and you may need to decide which type to buy.
Both types have advantages and disadvantages in terms of convenience and cost, as
shown in Box 45.


114


6.1 General discussion on accessories and consumables




6.1 General discussion on accessories and consumables


115


To help you to decide what type is most suitable for your health facility, you should
consider the following issues:
◆ The national policy.
◆ The resources available to you for sterilization.
◆ Whether a regular supply of stocks of these items is available.
It is usually easier and more practical to follow any existing national or local policy
regarding the use of disposables or reusables. The policy-makers should have taken
into account the cost implication of their recommendation, and should make
satisfactory recurrent budget provision for the regular supply of these essential inputs.
However, health facilities in remote areas are advised to have a stock of reusable supplies
that will help them when disposable supplies are received late or are not available.


Finance
Your aim is for equipment to remain operational, and to be available to support your
clinical workload. Thus, it is necessary for sufficient budgets to be calculated and
allocated for the purchase of the required accessories and consumables. This cost
will be relevant over the whole lifetime of the equipment. Thus, continually finding
the money for these items will be a challenge over the life of the equipment. Guide 2
on planning and budgeting provides guidance and procedures on budgeting for the
recurrent costs of equipment.


BOX 45: Advantages and Disadvantages of Disposables and Reusables
Disposables


Reusables


◆ are items designed for single use
◆ reduce the risk of cross-infection
◆ are more convenient to use than reusables
◆ should only be used once and should not be reused
◆ cost more than reusables since they need to be replaced more often and must be bought in


bulk regularly
◆ require you to have a regular and reliable recurrent budget
◆ require a regular and reliable supply of replacements from a reputable source
◆ are not designed to be sterilized.


◆ are designed to be used more than once
◆ should only be reused after proper cleaning and sterilization and/or disinfection
◆ are cheaper to buy, but you will have the additional cost of sterilizing them
◆ require you to have the necessary equipment required for sterilization
◆ put staff and patients at risk of diseases such as hepatitis B and HIV, if the items are not


properly sterilized between uses
◆ may be more reliable, if supply problems are likely for disposables
◆ can be kept as a reserve stock for times when disposables are not available.




116


Many accessories and consumables come from abroad, therefore you will need access
to foreign currency. Some organizations set up a ‘revolving fund’ to help with the
continual purchase of equipment-related supplies (spare parts, accessories, etc),
sometimes with assistance from external support agencies (donors) – see Box 46.


BOX 46: How a Revolving Fund Works
The aim of a revolving fund is to keep a pot of money full so that you can buy equipment-related
supplies regularly:
◆ The health service provider places initial capital in the fund so they can buy the supplies.
◆ Local health facilities buy the supplies from the health service provider as they require them.
◆ Their payments are put back into the fund in order to refill it.
◆ Thus the fund is always available for further purchases of equipment-related supplies.


A revolving fund can be set up to operate using local currency, foreign currency, or a mix of the two.
Seek assistance from external support agencies if necessary:
◆ The fund can be ‘primed’/pre-financed with foreign currency in order to purchase equipment-related


supplies from abroad.
◆ The initial ‘priming’ of the fund with foreign currency can be done by your health service provider or with


help from donors.
◆ Either the health facilities which purchase the supplies pay for them in foreign currency, if this is


possible, or the health facilities pay a local currency equivalent amount which is converted back into the
foreign currency.


◆ Sometimes donors have an ongoing relationship with the fund, and provide the equivalent in foreign
currency for the local currency paid into it.


6.1 General discussion on accessories and consumables


Country Experience
Planners often fail to realise that equipment operating costs have a much greater
financial impact than the initial procurement cost, and can account for anything from
5% to 100% of the procurement cost per year. For example, health staff in Germany
discovered that an infusion pump which cost US $24,000 to run over its 10-year lifetime,
mainly due to the cost of the continuous supply of infusion sets required. However, many
health service providers have not calculated and budgeted for the real operating
requirements of their equipment.




117


Procurement Issues
Different brands of accessories and consumables are not necessarily interchangeable
and cannot always be used with all makes and models of equipment. For example,
different makes and models of equipment will use:
◆ different X-ray film cassettes
◆ different pipe connectors
◆ different lead connectors (they can be the identical shape but have different


wiring configurations)
◆ different threads on gas connectors
◆ different widths of chart recorder paper
◆ different test strips for blood glucose monitors
◆ different printer cartridges
◆ different photocopier toner packs.
Therefore when ordering equipment (see Guide 3 on procurement and
commissioning), it is vital to specify particular and exact requirements for your
accessories and consumables. For each item, you will need to provide as much of the
following information as possible:
◆ The name of the manufacturer of the equipment.
◆ Make, model, and year of manufacture of the equipment.
◆ Serial number of the equipment.
◆ A full description of the item required (try to use the description and names used


in the manufacturer’s manual or order catalogue).
◆ Size, type (for infant, child, adult, etc), and material.
◆ Quantity and pack size required.
◆ Manufacturer’s order number for that part and quantity.
When buying new equipment, you can try to rationalize your accessory and consumable
stock. You achieve this by buying equipment which makes use of the types of
accessories and consumables which you already keep in stock. This would be the most
efficient use of your stock of supplies, and is an important reason for standardizing the
equipment you buy to a small number of makes and models (Section 2.1). Also,
consumables and accessories bought in bulk are often much cheaper.
However, for maximum safety there are situations where you actually want non-
interchangeable accessories and consumables. For example, you will want:
◆ gas connectors with different threads so that you cannot connect carbon dioxide


to the oxygen inlet
◆ transducers for measuring different parameters which are colour coded to prevent


confusion when you connect them to the equipment.


6.1 General discussion on accessories and consumables




118


For most countries, the procurement of accessories and consumables from abroad is a
lengthy and tedious process. It takes time to obtain quotations, secure foreign
currency, and ship goods. If you want to retain stock levels and receive items on time,
you must plan ahead for items procured from abroad.
Items procured locally should not pose such problems, as long as funds are available.
They can be obtained from local suppliers or from a body such as a Central Medical
Stores. The HTM Working Group may want to develop a policy to purchase
equipment, accessories, and consumables locally where possible, in preference to
overseas, to encourage the development of sustainable local markets.
The HTM Working Group, or its smaller stock sub-group (Section 1.2), should
develop procedures for comparing products, and reviewing their cost and
performance before reordering them, to avoid the purchase of items known to be
poor. Purchasing should be a process without political or social influence to avoid
possible allegations of bribery. You should also have a policy of only accepting free
gifts if they come with a stock of accessories and consumables, to ensure the
equipment can be used (see Guide 3 on procurement and commissioning).
The quality and effectiveness of a machine is often jeopardized by the use of low
quality accessories and consumables. Poor accessories and consumables may break if
they are not strong enough, they may not perform as expected, or they may rub,
corrode, or in some way damage other parts of the machine. Even if you have a first
class piece of equipment:
◆ poor paper gives you a poor recording for diagnostic purposes
◆ poor film or poor quality developer give you poor radiographs for diagnostic purposes
◆ poor breathing circuits which collapse easily compromise the functioning of a


ventilator or anaesthetic machine
◆ poor quality drill bits break quickly
◆ poor quality engine oil reduces the life of the engine
◆ poor quality batteries affect the performance of the equipment, have a short life,


and leak
◆ poor tyres compromise the safety of a vehicle.
Cost and quality often go together. Equipment manufacturers’ own brand of
accessories and consumables often produce better results than ‘lookalikes’. Many
companies are set up solely for the purpose of manufacturing lookalikes – these
products are often (but not always) cheaper, but may be of inferior quality. We
recommend that, as the items get more technically complex or critical, you should
try and buy better quality accessories and consumables. A discussion on sourcing
and obtaining good quality products can be found in Guide 3 on procurement
and commissioning.
High technology equipment may introduce hidden consumable problems, such as
special miniature internal batteries that store the set-up parameters of the equipment.


6.1 General discussion on accessories and consumables




119


In your country, there may be other supply routes which could help your health
service provider to obtain high quality supplies. For example:
◆ Your country may have a booming photographic industry which could help with


the sourcing, import, distribution, and storage of good quality X-ray film.
◆ Sometimes, church or mining health sectors can be more flexible than


government ones in their procurement practices. Thus, it will be useful for
different health service providers to collaborate and do business with each other.


Quantities to Buy
Many accessories and consumables have a shelf-life:
◆ Items with an expiry date.
◆ Items affected by heat.
◆ Items which rust or collect condensation.
◆ Items which deteriorate, such as batteries.
Shelf-lives will:
◆ affect your ability to buy in bulk
◆ affect your ability to buy well in advance
◆ require you to provide good quality storage facilities (Section 6.2)
◆ require you to have an effective stock control system, to ensure that you conform


to the rules for stocks with shelf-lives – SLFO (shortest life, first out) and FIFO
(first in, first out) principles (Section 6.2).


Thus, where possible use centralized storage and bulk purchasing arrangements as
these are more economical and ensure a good turnover of stock. The quantities that
you decide to buy (Section 6.3) also depend on the ‘lead-time’ for each item (the
time taken for goods to arrive once ordered).
When purchasing new equipment and funds are available, it is a good idea to purchase
a supply of consumables, accessories, and spare parts at the same time. Consider
purchasing enough for a set period, such as a two-year supply (see Guide 3 on
procurement and commissioning).
Manufacturers’ manuals, their local representatives, and suppliers can often provide
information and advice about the likely consumption rates of the items you require,
and this may help you decide on the quantity to order.


6.1 General discussion on accessories and consumables




120


BOX 47: Responsibilities for Recurrent Materials
Health Management
Team


Purchasing and
Supplies Officer


Stores Controller


Equipment Users


HTM Teams


Section Heads


6.1 General discussion on accessories and consumables


◆ ensures that adequate quantities of equipment consumables and accessories are
available at all times, through the work undertaken by the Purchasing Department
and the Finance Section.


◆ purchases the correct items of good quality from reliable suppliers.


◆ correctly and efficiently stores, issues, and controls equipment consumables,
accessories and spare parts, as well as cleaning materials


◆ monitors the stock levels of equipment materials in the main stores, and ensures
that they reorder the materials in time.


◆ correctly handle and store equipment accessories before, after and during use
◆ ensure that consumable items are not used in a wasteful manner.


◆ correctly handle and store equipment spare parts and tools
◆ ensure that maintenance materials are not used in a wasteful manner.


◆ monitor the use of equipment materials in their section
◆ monitor the stock levels of equipment materials in their sub-stores and sections,


and ensure that they reorder from the main stores in time.


Experience in Botswana
Health staff were having problems describing which equipment accessories and
consumables they wanted to order, and stores staff had difficulty identifying the items
requested. Thus the government’s Central Medical Stores decided to develop an order
catalogue that described each item, together with an illustration.


Responsibilities
Equipment-related supplies are often forgotten among all other general and medical
supplies (such as food, stationery, linen, bandages, syringes, and catheters). If you are
told that there is not enough money in the recurrent budget to cover equipment-
related needs, many clinical activities will stop because there are no rolls of recorder
paper, tubes of ultrasound gel, replacement bulbs, and the like. Therefore, staff need
to see the management of these materials as a collective responsibility. Box 47 shows
the many people who have a role to play.




121


6.2 STORAGE SYSTEM AND PROCEDURES
Elements of the Storage System


Your health service provider will need to decide where equipment accessories and
consumables are stored. There are a number of options depending on:
◆ the size of your organization
◆ the different levels of healthcare delivery
◆ the supply and distribution system
◆ the storage system used by the health service for other types of supplies
◆ the structure of your Healthcare Technology Management Service (HTMS)
◆ the skills and trustworthiness of your staff.
It is important that someone takes responsibility for these equipment-related items
so that they do not get forgotten. Options are:
◆ First decide whether to include them with all other general and medical supplies in


the health service storage system, or separate them out and place them in the
HTMS storage system.


◆ Then use your normal distribution system and store different quantities at:
- the central level
- the district/regional level
- the health facility store or maintenance workshop store.


◆ Finally, decide whether the people looking after the stocks are going to be either
trained stores personnel or departmental staff (equipment users or maintainers).
Whatever you decide, the individuals responsible should be given training on how
to run the stock control system.


Different countries and health service providers find different solutions to this dilemma.
The most important issue is that you choose a flexible system which ensures that:
◆ the person in charge of the stores (at every level) is trustworthy
◆ there is a proper stock control system
◆ equipment users and maintainers have easy access to the items they need


whenever they need them (without abuse of the system)
◆ the people running the stores are familiar with the items they order and issue.
Do not forget that you also have a responsibility for other equipment-related
items, such as the spare parts and maintenance materials. A similar discussion for
these items is provided in Guide 5 on maintenance management. The HTMS
storage system may end up being responsible for all equipment-related items.


6.2 Storage system and procedures




122


6.2 Storage system and procedures


Whether you decide to turn departmental staff into stores persons, or use the
professional skills of existing stores personnel depends on:
◆ the knowledge of the staff
◆ their recognition of the range of equipment-related supplies
◆ whether the stores are holding bulk quantities or only those for daily/weekly use
◆ whether you need access to the supplies for out-of-hours emergencies.
It is common for general stores staff to have a problem with recognizing the wide
range of equipment-related supplies in stores, and this can lead to a number of
problems such as non-issue, loss, and incorrect ordering.
It is vital to train stores staff and procurement officers to recognize
equipment-related items.
There needs to be some mechanism to control when accessories are replaced and
consumables used, to avoid abuse of the system. For example, this needs to avoid
batteries being replaced early and the old ones being used at home, printer ink
being ordered unnecessarily and sold off privately, and light bulbs being used in
people’s homes.
Box 48 provides some strategies for all these issues.
The storage system (at any level, such as a hospital) may have a main store which
stocks the major bulk of all items, but issues weekly/regular requirements to smaller
sub-stores in user-departments or the maintenance workshop. The items issued to
the sub-stores depend on the value and frequency of use of each item.
A user-department or workshop is allowed a sub-store when:
◆ they have a secure, lockable storage room
◆ it is agreed which are the regular items required on a daily/weekly basis for


storage in the department
◆ the Stores Controller provides the department with the necessary stores forms


to complete
◆ the Stores Controller trains a suitable staff member from the department to


correctly fill in the necessary stores forms for the stocks held in their department
◆ the department has special storage requirements (goods requiring refrigeration,


for example), so the Stores Controller allows bulk stores to be held outside the
main stores under agreed special conditions, as long as they are secure.


Box 49 overleaf provides some strategies for creating a suitable secure and clean
store which is organized in a simple and logical way.




123


6.2 Storage system and procedures


BOX 48: Strategies for Storing Equipment-Related Items
Strategy Suggestions
If you decide to use a general
health service store for the
majority of the stock, designate
a separate section where all
equipment-related items can
be stored together


Ensure that the correct
technical item is used for the
correct application


Any store should have an
identification code system
for the items in stock


Develop an illustrated catalogue


Use a proper stock
control system


Ensure work orders clearly show
the supplies required


This separate section would contain equipment, spare equipment
accessories, equipment consumables, equipment spare parts, and
maintenance materials. In this way, it is possible to ensure that the small
quantities of many varied technical items do not go missing and
unrecognized amongst the bulk of general items kept in the stores.


There are various possibilities:
◆ All equipment spare parts required for user PPM could be issued only


with the signature of an HTM Manager or his deputy.
◆ If there is any uncertainty concerning which is the correct part,


accessory or consumable to be issued/used for a certain application,
seek the advice of the HTM Manager or Head of Department or
consult the equipment manual.


◆ The old part should be returned to the HTM Manager for inspection
and disposal.


If such a system already exists for general and medical items, it can be
extended to cover equipment-related supplies. Some equipment items
will be covered by relevant codes for existing categories, and some will
require new ones to be set up. For example, there will usually be:
◆ existing codes for surgical items, etc
◆ an existing code for hardware, which could cover spare parts


and maintenance materials
◆ an existing code for fuel and lubricants, which will cover some


maintenance materials
◆ a new code required for equipment accessories
◆ a new code required for equipment consumables
◆ any new code as required.


This should show equipment-related items with descriptions and
photographs or drawings, together with their stores code.


This ensures that you use some form of Stock Card in order to keep track
of the stocks ordered and issued (see below).


In this way, you can check the amount and rate of use of supplies against
the stock left at the time of the annual audit.




124


BOX 49: Strategies for Creating Suitable Store Rooms
Space


Organization


Monitoring


6.2 Storage system and procedures


◆ Provide a space which is secure, clean, dry, free from pests, not too hot or cold,
well-ventilated, and not exposed to direct sunlight.


◆ Provide enough space to store all the equipment-related supplies and materials on
shelves, in cupboards, or in containers such as bins.


◆ If no shelving is available, make your own shelves using planks of wood supported on
bricks or crates.


◆ Make use of the space in the middle of the room for shelves – putting shelves only
around the walls takes up a lot of space and wastes the space in the middle of the room.


◆ Organize the store in a simple and logical way so that items can be found quickly and easily.
◆ Organize the stock into different sections for different categories of supplies: in other


words, cluster items by their application.
◆ Code each row, block, shelf and bin, in order to identify the location of each part.
◆ Clearly label each section of the store, allocate each item to a specific place and label


the position of the item on the shelf so that it is easy to read.
◆ Provide every bin and shelf partition with a stock card.


◆ Monitor stock movements, either through a paper record system or using a computer
program.


◆ Rotate stocks according to their expiry date:
- Use the SLFO (shortest life, first out) and FIFO (first in, first out) rules, and store


items that have the latest expiry date at the back and items with the earliest expiry
date at the front.


- Use the FIFO rules for items without an expiry date and mark these with the date
of receipt.


◆ Put a red star or a similar mark on the labels of all items that have an expiry date within
the current year.


◆ Remove expired, damaged, or obsolete items from the shelves and dispose of them
according to approved waste management procedures (Section 5.3).


Experience in El Salvador
The Maintenance Department of the Public Health Service in El Salvador established
their central store, and regional and local sub-stores, with support from German
Technical Aid. All their equipment-related supplies are given codes which are linked to
their equipment inventory coding system. Their storage space is divided according to
the inventory codes, and the shelves are divided and labelled accordingly. In this way,
supplies common to individual pieces of equipment are kept next to each other. In
addition, their inventory coding system included codes for families of equipment/areas of
use (such as radiographic equipment, suction equipment, heating and ventilation
equipment); in this way, supplies for individual machines are stored in the same area as
supplies for other machines in the same equipment family. In order to make the stock
control system faster and more efficient, they developed a computerized system (with
support from Dutch Aid).




125


6.2 Storage system and procedures


What to Keep in Stock
Most stores systems have what are known as ‘stockable’ items: these are items which
are automatically replenished when stocks run low, and are therefore always in stock.
This is a common system for medical and general items, but is rarely in place for
equipment-related supplies and this makes it very difficult to keep equipment
functioning. You should therefore aim to make equipment-related items stockable
too, including:
◆ equipment consumables
◆ commonly-used accessories
◆ the spare parts and maintenance materials required for PPM
◆ those parts and materials which experience tells you will be required for


common repairs.
Less commonly used equipment-related items may remain as non-stockable items.


How the System Works
Usually, the Stores Controller monitors the stock levels of stockable items and, when
stocks are running low, submits order forms to the Purchasing and Supplies Officer to
automatically buy in another batch.
However, if a stockable system has not yet been established for equipment-related
items (perhaps because funding for the health service is unstable), recurrent items
are considered for purchase each month or quarter, when cash is available. In this case,
the user department submits its order for further supplies to the Purchasing and
Supplies Officer (as described in Guide 2 on planning and budgeting) – see Annex 4.
In addition, user departments submit their orders for non-stockable items to the
Purchasing and Supplies Officer, as and when they are required.


Keeping Track of Stocks
Whenever new equipment-related supplies arrive, they should be entered into the
stores system. Also when new equipment arrives, the stocks of accessories and
consumables that were purchased with it should be entered by the Commissioning
Team into the Stock Control system (as described in Guide 3 on procurement and
commissioning) – see Annex 5.




126


6.2 Storage system and procedures


If user departments have sub-stores, the staff in the main store can consult with
the Head of Department, and issue the short-term requirements to the sub-stores
every week (or month). The Stores Controller then monitors the usage rate of
stocks in the sub-stores to ensure that the user department doesn’t request too
much for its regular issues, and ensures that the department is only issued with
what it really needs.
As goods are issued, and marked off on the stock card, the record system tells
the Stores Controller when the stocks are low and the reorder level has been
reached. Then:
◆ in the case of non-stockable equipment-related items, the Stores Controller


prompts the user department to complete an order form requesting further supplies
◆ in the case of stockable equipment-related items, the Stores Controller writes a


purchase order for approval by the Health Management Team and submits it to
the Finance Officer for payment.


Stores staff should:
◆ allocate code numbers to the different equipment accessories and consumables
◆ enter onto the stock cards (bin cards) the sorts of information that is shown in


Figure 13. Guidance on the stock levels required can be sought from the Head of
Department or HTM Manager, and information generated from a one-off exercise
(as described in Section 6.3)


◆ store the new supplies on labelled shelves with their stock cards (bin cards)
◆ issue a list of the codes for specific items to the user departments and HTM


Teams, so that they can easily identify and order items (for example, a spare
bottle for suction pump Type A may have code number EA 07 050).


Figure 13: Sample Stock Card (Bin Card)


Stock Card (Bin Card)


Date Received from/
issued to


No.
received


No.
issued


New
balance


Remarks Signature


Item description:
Unit/pack size:
Maximum level:
Reserve stock level:


Cost:
Minimum/Reorder level:
Order quantity:


Card no:
Item code no:
Location:
Lead time:




127


6.2 Storage system and procedures


The stores stock control system can be either a manual paper system or a
computerized system. It doesn’t matter which you use, because the sort of data
that you must record is the same whether you are designing the layout of a card or
the fields on your computer screen. Also, any computer system involves an element
of paperwork, as standard forms can be printed out for stores staff and departments
to fill in.
The rest of this Section covers paper forms, and various manual ways to summarize
the data. If your health service provider has a computerized stores stock control
system, this can automatically generate purchase orders when reorder levels are
reached. Stock management is an area in which simple computer systems have
proved to be quite valuable (see Annex 2).


6.3 CALCULATING USAGE RATES AND
REORDER LEVELS
When stocks of equipment accessories and consumables decrease, levels must be
replenished. Thus it is necessary to monitor and control the stock of accessories and
consumables, in order to ensure that you always have the required items in stock on
the shelves when they are needed. To achieve this, the Stores Controller needs to
know when to reorder goods and how many should be reordered. A number of factors
will affect these calculations for different types of items:
◆ The rate of use of each item (for example, 20 per day, six per week).This will be


affected by patient attendance figures, the frequency of particular clinics or
equipment sessions, timetabled care and cleaning schedules, and the likely
breakdown rate (life of an accessory) estimated from past experience and records.


◆ The lead-time for each item (that is the time taken for goods to arrive from the
supplier or central stores once ordered).


◆ How often you can place orders (the frequency of ordering).
◆ The cost of each item.
◆ The shelf-life of the item.
First, you will need to identify what is worth holding in stock and how much is
required, based on the type of work you perform. Secondly, it is necessary to
continually restock so that you always have sufficient items to carry out the necessary
work. This calculation is based on rates of consumption. The following sub-sections
discuss how to do this.




128


6.3 Calculating usage rates and reorder levels


Annual Requirements: What to Have in Stock
First, the user departments need to get an idea of how much of each type of
accessory/consumable they are using (a discussion on spare parts for user PPM can
be found in Guide 5 on maintenance management). If such goods have not been
stockable items up to now, there will be little information currently on stores stock
cards from which the Stores Controller can make these calculations. Thus, for
existing equipment, you may need to carry out a one-off exercise to identify the type
of accessories and consumables required, the quantities used, their sources, and
possible prices (see Guide 2 on planning and budgeting). The HTM Working Group
can nominate a stock sub-group (Section 1.2) to undertake this one-off exercise,
the findings of which will be based on the experience and identified needs of the
user departments.
Guide 2 describes how the information collected can be used to calculate more
realistic recurrent budgets. The information should also be given to the Stores
Controller for entry onto the stock cards, so that there is sufficient data on usage
rates, reorder levels, and reorder times for equipment accessories and consumables.
In the case of new equipment purchases, a well documented list of the accessories
and consumables supplied should be entered into the stores system automatically
during the equipment acceptance process (as described in Guide 3 on procurement
and commissioning) – see Annex 5.
You will need to decide:
◆ What type of supplies do you need? (What do you commonly use? What is worth


holding in stock?)
◆ What quantities of each item should you order? (How much do you need to have


available for use?).
◆ Which items are the most important to keep in stock? (Is the accessory/


consumable/cleaning material essential? Can you work with the majority of your
patients, samples, etc without this item? Is there somebody available who is
skilled enough to use the accessory/consumable/cleaning material?)


You will need to order large quantities of items that are frequently used, and fewer of
items that are only used occasionally. It is preferable not to stock items that are rarely
used, since it is not good to tie up your money in stocks that sit on shelves for years
doing nothing.
Ordering too little (understocking) results in shortages: your health facility will be
unable to provide effective treatment and care as a result, and staff and patient
confidence in the service will be undermined. Ordering too much (overstocking)
results in a build-up of stock and wastage (of items that are not used before their
expiry date, for example, or that become spoiled if left unused for too long) as well as
tying up valuable funds unnecessarily.




129


6.3 Calculating usage rates and reorder levels


The quantity of replacement accessories and consumables that you order depends on
factors that you can anticipate, such as:
◆ how much stock is normally used
◆ how much work is planned or can be expected
◆ seasonal demands
◆ how often you place an order
◆ the storage capacity of your store.
You may also need to order a limited quantity of extra stocks of some items so that
you can deal with unexpected events.
The number and type of accessories and consumables that you decide to own and
stock depends on the type of work you perform, and the way in which you work.
There are several things to consider, and Box 50 provides the basic calculations
required to work out how much you should own.
Remember, these calculations will have to be done for each type of accessory and
consumable, and for each type of equipment that you operate. You will also then need
to multiply these quantities by the unit price for each accessory or consumable, in
order to find out the overall cost of your needs and whether you can afford them in
your budget (also see Guide 5 on maintenance management for similar calculations
for PPM spare parts requirements).


BOX 50: Steps for Calculating Annual Requirements of Accessories and Consumables
Step 1. Consider the Type of Accessory
Consider Example
The different uses you will make
of the equipment, and therefore
the different types of accessories
you may need.


The different applications for
your equipment, and therefore
the different varieties of each
types of accessory you may need.


The different types of patient or
sample, and therefore the size of
accessories you may need.


If the accessory should be a
reusable or a disposable type.


The associated and connecting
parts for the accessories you need.


Do you need high speed as well as low speed dental drill handpieces?
Do you need bipolar coagulation forceps as well as monopolar hook
electrodes for your diathermy machine?
Do you need 40x microscope objectives as well as 100x oil immersion
objectives?


Do you need pulse oximeter probes for use on the ear, the finger, or
the toe?
Do you need temperature probes for use on the skin, or rectally?


Do you need BP cuffs for adults, children, infants, and neonates?
Do you need centrifuge rotors that can take 50ml test tubes or 15ml
test tubes?


Do you want reusable ECG plate electrodes and fixing straps, or
disposable stick-on ECG electrodes?


Don’t forget that the patient leg supports/poles for your operating
table will also need sleeves, straps, and clamps.


Continued overleaf




130


6.3 Calculating usage rates and reorder levels


BOX 50: Steps for Calculating Annual Requirements of Accessories and Consumables
(continued)


Step 2. Calculate the ‘Basic Set’
Calculation Examples
Once you know the type of
accessories you require, you need
to decide on the quantities of
each accessory required for the
way you work: this will make up
your ‘basic set’. Once this has
been established, you can order
multiples of the basic set
of accessories.


Step 3. Consider the Lifetime of the Accessory or Consumable
Consider Examples
The next issue to consider is how long the
accessory will last before it fails. Some
accessories have a long life, some have a short
life, and some are disposable (thrown away
after one use). Consumables are considered
in the same way as disposables, as follows:
a. Accessories with a long life.
These are not likely to wear out, therefore
you do not need any extra ones in stock.
When they break, you can buy them as
required as a spare part.
b. Accessories with a short life that


are reusable.
The manufacturer’s literature and your
experience will tell you the likely life of the
part, so you can calculate how many you will
need in a year.
c. Disposable accessories,


and consumables.
These are used up as you operate the
equipment, so you need to calculate the
consumption rate (this is dependent on how
busy you are and your rate of use). How much
you buy will also depend on the pack size for
these products.


Although you only use one monopolar diathermy electrode at a time,
you may need to own a basic set of three monopolar electrodes:
◆ one in use
◆ one being cleaned
◆ one as a spare.
Although your small bench-top autoclave may only have two shelves,
you may need to own a basic set of six trays (three for each shelf):
◆ two that have just come out of the autoclave full of newly


sterilized instruments
◆ two in use in the autoclave full of items being sterilized
◆ two being filled with dirty instruments waiting to be sterilized.


Baskets in pressure-cooker-type sterilizers


Jars of suction pumps, diathermy probes, patient lead sets


Stick-on ECG electrodes are disposable accessories;
they can be supplied in various quantities, such as bags of
50, or boxes of 1,000.
Rolls of recorder paper and tubes of ultrasound gel are
consumables. You can order various quantities, such as:
◆ boxes of 10 rolls of paper, or cartons of 100 rolls
◆ 100g tubes of ultrasound gel, 1 litre bottles,


or 50 litre containers.
Continued opposite




131


6.3 Calculating usage rates and reorder levels


BOX 50: Steps for Calculating Annual Requirements of Accessories and Consumables
(continued)


Step 4. Calculate Quantities
Consider Examples
a. Accessories with a long life.
Simply buy the ‘basic set’ required for
each machine.
b and c. Accessories with a short life,
as well as disposable accessories,
and consumables.
Buy multiples of the items in your ‘basic set’
by taking into account the life of the items or
their consumption rate.
Use the following calculations:


i) Quantities according to lifetime
Find out the life of the part (in months), or
how quickly it is used up [life of item A =
LA]. This type of information can be obtained
from the manufacturer, their literature,
or your experience.
Then calculate the quantity used as follows:
Number of accessory Z used per year,
[NumberZ]


= 12 months = 12Life of item Z (or rate of use) L Z
ii) Multiples according to the ‘basic set’
Take into account the multiples in your basic
set, if applicable, to allow for the way you work.
Then calculate the quantity required
as follows:
Quantity of accessory Z required per year,
[QuantityZ] = NumberZ x Multiple Z
iii) Totals according to the number of


machines you own
Consider the total number of similar
machines you are buying accessories and
consumables for [N].
Then calculate the quantity required
as follows:
Total quantity of accessory Z needed per year,
[Total Z] = QuantityZ x N


For example:
i) A suction pump jar (accessory A) may have a life of six


months; LA = 6 (months)
ii) A reusable pulse oximeter finger probe (accessory B)


may last four months; LB = 4 (months)
iii)A box of 50 diathermy disposable patient plates


(disposable accessory C) may last one week;
LC = 0.25 (month)


iv) A 100g tube of electrode contact gel (consumable D)
may last two weeks; LD = 0.5 (month)


In the examples above:
i) Number of jars used each year [NumberA] = 12/6 = 2
ii) Number of finger probes used each year


[NumberB] = 12/4 = 3
iii)Number of boxes of 50 patient plates used each year


[NumberC] = 12/0.25 = 48
iv) Number of 100g tubes of gel used each year


[NumberD] = 12/0.5 = 24


From example (ii) above:
If your basic set of pulse oximeter finger probes is two
(one in use, one being cleaned); MultipleB = 2.
Thus, quantity of finger probes required each year
[QuantityB] = 3 x 2 = 6


In example (ii) above:
Perhaps you have four pulse oximeters in use; N = 4.
Thus, total quantity of finger probes needed per year,
[TotalB] = 6 x 4 = 24.




132


6.3 Calculating usage rates and reorder levels


Regular Monitoring: When to Restock
Once the accessories and consumables are in store with stock cards, the stores staff
can record the weekly issue quantities, and monitor the departmental usage rate.
Other types of information need to be filled in on the stock cards (see Figure 13);
this data covers issues such as:
◆ when to reorder
◆ how much to reorder
◆ how long the delivery time is
◆ how low stocks can fall.
Box 51 shows you how to calculate the data that should be put on each stock card.
From experience over time, the Stores Controller should be able to help you to
calculate this data.
The purpose of recording this information on the stock cards, is so that the stock
control system will prompt you when it is necessary to buy more stocks. Then the
Stores Controller can automatically order the items to ensure that you don’t run out
of the materials you require for the work in your department.
Once a month the information on the stock cards is transferred to a ‘stock control
ledger’ (stores record book). It is simpler to make an order using the summary in the
stock control ledger than using all the individual stock cards. The stock control
ledger is also a useful tool for analyzing stock management and reviewing the
accuracy of stock levels.
A stock control ledger (stores record book) should be kept by every departmental
store in order to keep track of the quantities of accessories and consumables used
and kept in stock. The department’s storesperson should be responsible for keeping
these records. You can either obtain a stock control ledger from your Health
Management Team or make one yourself, using a separate page to keep records for
each type of item. Figure 14 shows two different sample layouts for the ledger.




133


6.3 Calculating usage rates and reorder levels


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nit


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Ex


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ple


s




134


6.3 Calculating usage rates and reorder levels


BO
X 5


1:
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w
to


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lcu


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es


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ly


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ua


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[O
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[M


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.]


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de


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In
exa


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:
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=


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24


=
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pap


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rol


ls
b.


Ma
x. =


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24


=
30



bo


ttl
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a. Y
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e 4


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eco


rde
r p


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r ro


lls
in


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m


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, or
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r th
em


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, an


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ake


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th


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. T


hu
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oll


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ace


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or


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r fo


r 2
4 r


oll
s. Y


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r sa


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ese
rve


st
ock


is
fou


r ro
lls,


an
d t


he
m


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mu


m
am


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ev


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hav


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n


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is 2
8 r


oll
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You


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4 s
uc


tio
n b


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a y


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, or


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r th


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, an


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ths


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riv
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n 1


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ott


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eft


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sto


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yo


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lac


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n o


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r fo


r 2
4 b


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. Yo
ur


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ety


re
ser


ve
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is s


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, an


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mu
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n s
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k
is 3


0 b
ott


les
.




135


6.3 Calculating usage rates and reorder levels


Figure 14: Sample Layouts for the Stock Control Ledger


The Head of Department and storesperson will routinely review the stock control
ledger, and will submit the information on accessory and consumable requirements
and rates of use to:
◆ the Finance Officer in order to improve budget allocations
◆ the Purchasing and Supplies Officer, Specification Writing Group, and Tender


Committee (see Guide 3 on procurement and commissioning) in order to
incorporate experience of the quality, performance, and cost of items into the next
round of purchasing


◆ the Stores Controller in order to prompt the reordering process and timing
of procurement.


Box 52 contains a summary of the issues covered in this Section.


Stock Control Ledger


Date Quantity received Quantity used Balance Quantity to order Signature


Item description:
Unit/pack size:


Item code no:
Order quantity:


Example 1:


Stock Control Ledger


Date Previous count
(physical)


Amount
received


Amount
used


Present count
(physical)


Signature


Item description:
Unit/pack size:


Item code no:
Order quantity:


Example 2:


Quantity to
order




136


Section 6 summary


BOX 52: Summary of Procedures in Section 6 on Accessories and Consumables


Health Service
Provider


Section Heads


Health Management
Teams


Health Service
Provider


Section Heads or
HTM Managers


Stores Staff


Health Management
Teams (or HTMWG)


Section Heads


Stores Staff


Us
ag


e
Ra


te
s a


nd
R


eo
rd


er
in


g
St


or
ag


e
Sy


st
em


Ne
ed


s


◆ ensures sufficient accessories and consumables are available for health facilities
◆ considers the use of a ‘revolving fund’ to help finance the needs for accessories


and consumables


◆ decide on the accessories and consumables required for different types
of equipment


◆ buy good quality accessories and consumables


◆ decides whether equipment accessories and consumables will be stored in a
separate section of the health service storage system, or a separate network of
HTMS stores


◆ provides the resources necessary for a full stock control system
◆ decides whether to employ stores personnel throughout the system, or to train


other staff to be storespersons
◆ provides training to ensure stores staff recognize equipment-related supplies
◆ develops an illustrated stores catalogue of equipment-related supplies


◆ create suitable stores and sub-stores for equipment-related items
◆ follow rules for keeping a store
◆ provide advice/authority for the issuing of stocks, to ensure the correct parts are


used for the correct application


◆ implement a stores code numbering system for equipment-related items
◆ enter new equipment-related stocks onto stock/bin cards
◆ make equipment-related items ‘stockable’ items, whenever possible
◆ issue regular requirements to smaller sub-stores


◆ undertake a one-off exercise to discover the usage rates and requirements of
equipment-related supplies for which there is no current information available
(see Guide 2 on planning and budgeting)


◆ calculate annual requirements (see Box 50)
◆ provide the stores staff with the results for the stock control system


◆ calculate the reorder levels and order quantities (see Box 51)
◆ enter the data on the stock cards
◆ keep a stock control ledger
◆ use the prompts from the stock control system to reorder more stocks when


they are required, so that stocks are always on the shelves




137


7. HOW TO ENSURE CONTINUOUS
OPERATION


Why is This Important?
You wish to get the most out of your equipment, and for it to be available for
use most of the time. Thus it is necessary to make it secure. Also, if you take
good care of your equipment, it will last longer.
To ensure the continuation of the health service that your equipment supports,
it is necessary to replace the equipment at the end of its life. (For example, if
you want to continue offering dental services to patients, you must replace
your dental drill at the end of its life).


In this Section, we offer advice on how to ensure the continuous operation of your
equipment, by covering the following issues:
◆ Security (Section 7.1).
◆ User planned preventive maintenance (PPM) (Section 7.2).
◆ Testing for electrical and mechanical trustworthiness (Section 7.3).
◆ Fault reporting (Section 7.4).
◆ Decommissioning, disposal, and replacement of equipment (Section 7.5).


7.1 SECURITY
Health Management Teams need to provide adequate security measures in order to
ensure their equipment is always available for use. A number of strategies should be
pursued in order to try and prevent the loss and theft of equipment. Box 53 lists
some possible strategies, depending on conditions in your country.


7 How to ensure continuous operation




138


7.1 Security


BOX 53: Possible Security Strategies to Consider
The compound


The buildings


Room occupancy


Monitoring


Response to
problems


Health facility compounds should have only one entrance; if this cannot be achieved,
additional security guards will be required to cover all entrances.
Health facilities should have security guard cover 24 hours a day; the Health Management
Team will need to review the availability, capacity, and coverage of these guards.
Security guards should check vehicles leaving the compound.


All windows on the ground floor should have security grills/bars fitted. Upper storey rooms
which contain expensive equipment and are vulnerable should have grill doors fitted.
As part of planned preventive maintenance (PPM), the HTM Team should ensure that
doors and locks are trustworthy and in good condition at all times.


In the case of all departments or rooms used only during the day (dental, laundry,
kitchen, main laboratory, main pharmacy, outpatient day-clinics, offices, maintenance
workshop etc):
◆ the Head of Section, or person responsible, should lock them at the end of the day
◆ the Head of Section, or person responsible, should hand the keys into the In-Charge’s


room, where they will be kept in a locked cupboard
◆ one person from the night-shift team should be allocated responsibility for accessing


keys if they are required in an emergency during the night.
In the case of all departments or rooms used 24 hours a day (dispensary, in-patients, 24-hour
OPD, casualty, maternity/labour, small laboratory, staff room, etc), night team members
should lock individual rooms when not in use.
While any department or room is in use at any time of day, equipment not in continuous
use (for example, sphygmomanometers, diagnostic sets, foetal dopplers) should be
locked in the Head of Section’s office.
All staff should be responsible for showing continued vigilance for items in continuous use.


Heads of Section should regularly check their inventory of equipment, to see if all items
are present.


In accordance with the accountability strategies (Section 3.1), the Health Management
Team should consider:
◆ how good behaviour is to be rewarded
◆ what penalties to introduce for non-compliance and negligence if theft is to be a


punishable offence.
Similar strategies should be pursued for all maintenance tools (see Guide 5 on
maintenance management).




139


7.2 USER PLANNED PREVENTIVE MAINTENANCE
(PPM)
Equipment which is well looked after will last a long time. The best way to look after
equipment is to maintain it. Maintenance is a collective responsibility with lots of
people involved, such as maintenance staff in workshops, equipment manufacturers,
and your HTM Team (see Guide 5 on maintenance management). However, general
health staff and equipment users, as part of the HTM Service (Section 1.1), have a
vital role to play (see Box 3). They should report any faults promptly to the
maintenance department, but they should also undertake some daily, basic-level
maintenance tasks themselves. These activities are mainly aimed at ensuring that
the performance and functioning of equipment is checked and corrected.
Planned preventive maintenance (PPM) is a series of activities carried out on
equipment with the aim of preventing breakdowns and ensuring that equipment is
operational and safe. By following a specified schedule of activities according to a given
timetable, user PPM should reduce the amount of time the equipment is out of service.
PPM is important because it enables your department to:
◆ catch any problems before they become crises
◆ prevent breakdowns
◆ save money, as PPM is cheaper than repairs following breakdowns
◆ make sure that equipment is fully operational
◆ guarantee accuracy and reliability (the autoclave sterilizes, the laboratory results


are correct, etc)
◆ increase the availability of equipment and reduce down-time
◆ extend the life-span of equipment
◆ reduce equipment running costs
◆ ensure equipment is safe, for patients, users, and maintenance staff.


7.2 User planned preventive maintenance (PPM)


Experience in West Africa
A doctor handed over a stethoscope to a maintainer complaining about a muffled sound.
The diaphragm was in order. What was the problem? The doctor was not aware that even
stethoscopes must be stored and taken care of properly, and after removing the nest of a
solitary bee from the flexi-tube, the device was working again.




140


PPM consists of a number of tasks of varying technical complexity. Regardless of the
complexity of the equipment, there may be three levels of tasks that can be
undertaken by different types of staff:
◆ The simpler duties – performed by the users of the equipment, if they are


adequately trained.
◆ The bulk of the work – performed by (in-house) technicians with a basic training


(see Guide 5 on maintenance management).
◆ More complex work – has to be done by specialized maintenance personnel. This


can be in-house maintainers or, for some sophisticated equipment, may involve
staff from the manufacturer or service agent. For details on managing such
maintenance contracts, see Guide 5.


Tip • Users should only undertake the sorts of PPM tasks that do not require the
intervention of technical staff from the HTM Service, and for which they have been
trained. For examples see Box 54.


The approach should be to teach staff, using demonstrations, to remember the basic
motto and strategy of ‘Check – Replace – Inform’; they need to know the correct
methods for undertaking maintenance and repair of equipment.
Information is available from a variety of sources:
◆ The best information on equipment PPM is usually contained in the


manufacturer’s user manual and/or service manual.
◆ A wide range of independent reference material is also available (see Annex 2).
◆ Managers should write PPM schedules and timetables (see below).
◆ Resources from training sessions and (in some cases) posters provide the guidance


and experience of colleagues (Section 3.5).
◆ Staff without personal copies of these resources should find them in the library


(Section 3.4).


7.2 User planned preventive maintenance (PPM)




141


BOX 54: Typical Examples of the User’s Role in the PPM of Equipment
◆ Calibrate equipment to ensure it is operating within its required parameters (scales, photometer, etc).
◆ Check and tighten loose screws (bed frames, etc).
◆ Change filters after their recommended duration of use (suction pumps, infant incubators, etc).
◆ Check for correct oil levels (air compressor engine oil, washing machine gear oil, etc), or water levels


(bench-top autoclave reservoirs, infant incubator humidifiers, etc), and refill as necessary.
◆ Oil or grease moveable parts (trolley wheels, microtome slides, etc).
◆ Replace lost, worn out, cracked, or broken parts (stethoscope earpieces and diaphragms, rubber seals in


pressure-cooker-type steam sterilizers, etc).
◆ Sharpen blades (scissors, microtome knives, etc).
◆ Check and replace chart recorder paper (blood bank refrigerators, ECG recorders, etc).
◆ Ensure that programmable or manual settings are returned to normal after the work of the previous day or


shift (diathermy machines, monitors, etc).
◆ Inspect for wear and damage, and either inform technical staff (in the case of cracks in bedframes, poor


condition of mains cable and connectors, etc) or replace the faulty article if it is a standard stock item
(chipped suction bottles, torn screen material, etc).


◆ Replace batteries and bulbs when they reach the end of their lives.
◆ Check battery charging level lights, and warning lights and respond as necessary (defibrillator, patient


monitor, etc).
◆ Check that dials, gauges, indicator lights, etc are working properly.
◆ Go through the machine’s automatic functional check programme (infant warmers etc)
◆ Descale elements (water distillers, boilers, etc).
◆ Perform Bowie & Dick tests (for autoclaves) according to the recommended scheme.


For each equipment type there will be specific user PPM instructions. Box 55
provides an example of the type of instructions required for refrigerators.


7.2 User planned preventive maintenance (PPM)




142


BOX 55: Example of User PPM Instructions for (Any Type of) Refrigerators
(these may vary or require additions depending on the make and model)


Note: the daily duties of checking the temperature, the burner flame, and the
gas/fuel level, fall under ‘care of equipment’ activities (Section 4.3).


Weekly
◆ Check the ice formation on the evaporator. If the ice on the freezing compartment walls


is more than 5mm (1/4 inch) thick, defrost the refrigerator. Otherwise your refrigerator
will not work properly.
Note:
- Some modern gas and electric refrigerators defrost themselves so you do not have to do it.
- If you are finding it necessary to defrost every week, the door is probably not sealing properly. You should
refer to your training notes and take corrective action to check the door seal and adjust the hinges.


◆ Check that the refrigerator is level, and adjust as necessary.
◆ If you have a kerosene refrigerator clean the flue, the baffle, and the burner, and trim the wick.


Also check whether the kerosene tank needs cleaning.
Note: if the tank needs cleaning every week, you are not filling it correctly.


Monthly
◆ Clean the condenser coils at the back of the refrigerator with a brush. If the coils are dirty, the refrigerator


will not work properly. Be careful as the coils are hot.
◆ Check the outside of the refrigerator for damaged paint work. If you find some, clean the damaged


surface, remove all the rust, and repaint the damaged area.
◆ When necessary:


- clean the refrigerator inside and out with a damp cloth. Use a mild detergent only
- clean the door gasket and powder it with some talcum.


◆ If you have a kerosene refrigerator, turn off the burner and allow it to cool, then clean the burner chamber
with a soft brush, and relight the burner.


◆ If you have a gas and electric-operated absorption refrigerator:
- clean the flue if the flame has been smoking
- follow the correct procedure for checking the gas line connections for leaks.


◆ If you have an electric compressor refrigerator:
- turn off and unplug it, clean the compressor with a soft brush, check the mains lead and plug for damage
and loose connections, then plug back in and switch on


- check that the warning notice saying “Do not switch off” is in place next to the socket outlet, and that
tape is placed over the plug and switch to ensure it is left permanently on.


Annually
◆ If you have a gas and electric-operated absorption refrigerator:


- clean the gas burner and gas jet
- clean the flue and baffle.


7.2 User planned preventive maintenance (PPM)




143


There may currently be very little user PPM undertaken in your health facility. Thus,
it will be necessary to find ways of encouraging staff to carry out PPM and to improve
any existing attempts. You can significantly reduce equipment-related problems by
implementing a user PPM system. Figure 15 provides some strategies for doing this.


Figure 15: Strategies for Making User Staff Undertake Maintenance and Repair


7.2 User planned preventive maintenance (PPM)


Strategies People Responsible


Promote a sense of ownership
among users


Provide resources


Plan the work


Managers, maintainers, and users meet together to agree on
responsibilities for measures and actions that are acceptable
to all (according to staff accountability strategies – see Box 5).


The Health Management Team ensures that adequate
maintenance and repair resources (personnel, materials,
money) are available for the continuous functioning of the
equipment stock during its life, through the work of the
HTM Service and external contractors.


Heads of Section should be responsible for planning user PPM
tasks and timetables as advised by the HTM Service, giving
the tasks to appropriate operators, and monitoring that the
work is done.


Implement the plans
Operators should take personal responsibility for ensuring that
they undertake the user PPM tasks that they have been
trained for, and allocated by their Head of Section.


Guarantee safety
To preserve the safety of the patient, operators should assume
that all medical equipment present in clinical areas is
operational at all times; therefore any faulty equipment will
have been removed.


Ensure continuous services
The Health Management Team ensures the continuation of
clinical services by promptly disposing of and replacing
equipment when it is condemned by the HTMS at the end of
its natural life (Section 7.5).


Provide career development


HTM Teams should ensure that the staff in their facility have
sufficient skills to enable them to maintain, repair, and operate
equipment effectively and safely, by implementing a rolling
programme of refresher training.
If operators and maintainers require further skill-development,
they should put in a request to their Head of Section.
The Human Resource Department includes the duties of
cleaning, basic care, and maintenance of equipment in the job
descriptions and contracts for health service staff.


Respond to faults


As soon as a fault appears on equipment which is used by the
patients’ bed-side, the operator should remove it from the
clinical area.
When equipment breaks down, or is not functioning correctly, the
user should report this to their Head of Section, who completes
a ‘Work Request/Job Form’ and sends it immediately
to the HTM Team (Section 7.4). Users should remove the
equipment or disable it, and clearly label it as faulty.
Maintainers should ensure that they respond as quickly as
possible to any maintenance and repair requests.




144


You will need a strategy to slowly expand how much of your equipment stock
receives user PPM. User departments should consult with the HTM Service and
follow strategies to build up PPM gradually over time, as shown in Figure 16


Figure 16: Strategies for Expanding User PPM


PPM Schedules
PPM schedules (protocols, or lists of activities) need to be developed separately for
both users and maintainers. They should provide simple guidelines for all types of
equipment, covering the tasks to be undertaken in the following areas:
◆ Care and cleaning (Section 4.3).
◆ Safety procedures (Section 5).
◆ Functional and performance checks.
◆ Maintenance tasks.
These guidelines should include timetables showing the frequency with which the
activities must take place.


7.2 User planned preventive maintenance (PPM)


Strategy Activity


Set priorities


Start gradually, using existing
resources


Allow for new arrivals


Initially concentrate on developing and implementing PPM work
for priority equipment, before expanding to cover further
equipment. Undertake a risk analysis – concentrate on
implementing PPM on essential or frequently used equipment,
rather than non-essential or rarely used equipment.


Make use of any existing written user PPM schedules which
you have, and implement them.
If necessary start with checks every three months, then, later-on,
increase the frequency by gradually introducing monthly and
then weekly checks (or the frequency recommended by the
manufacturer) for the most critical equipment.


As new equipment arrives write further user PPM schedules
and timetables, train staff in their use (Section 3.5), and
implement them in order to preserve the investment in your
new stock.


Expand slowly


Expand the amount of items covered, by extending this user
PPM work:
• either to cover more of the same type of equipment (in other
words, if you are doing PPM for newly purchased suction
pumps, then expand the PPM to cover the older existing
pumps too);
• or to cover additional different items (in other words, if you
are doing PPM for suction pumps, then expand the PPM to
also cover operating tables).


Allow for further purchases
Ensure that the Purchasing and Supplies Officer buys all new
equipment together with its maintenance schedules; they are
often contained in the operator or service manual but may need
to be requested separately from the supplier (see Guide 3 on
procurement and commissioning).




145


Box 56 provides some strategies for expanding your library of PPM schedules, and
hence your PPM work.
Another important task for Heads of Department or the training sub-group, is to
convert the user PPM schedules into some or all of the following:
◆ Posters which can be placed on the wall beside the equipment.
◆ Paper copies in plastic pockets attached to/hung from the equipment itself. This


is known as an equipment card and should be kept permanently with the
equipment. It will also show the date of the next service due from the HTM
Team (see Guide 5).


◆ Laminated cards, for the staff to carry around and refer to when carrying out PPM
(see Section 3.5 and Figure 7).


BOX 56: Strategies for Developing PPM Schedules
Type of Material/Information Action
PPM schedules and timetables are usually written by
the equipment manufacturers, and can be found in
their operator or service manuals.
Some PPM schedules and timetables have already
been developed by international agencies and other
sources (see Annex 2).
All these documents and systems can be modified by
technical and clinical staff to suit local conditions.


Expand the written resources and establish a library of
user PPM schedules.
Some organizations have developed computer software
programs which help with planning PPM. They
generate requests for PPM according to timetables,
and keep records of the work and results. Some
systems also provide generic PPM schedules for
different equipment types (see Annex 2).


PPM Timetables and Wall Calendars
PPM work must be carried out at specified intervals, as detailed in your schedules.
The HTM Managers and Heads of User Departments should liaise to draw up
timetables to ensure that the PPM work is undertaken at the required frequency.
Some tasks need to be carried out after every use, every shift, daily, or weekly, and so
on. If your Healthcare Technology Management Service has a computerized
maintenance management system (see Guide 5 on maintenance management), this
can automatically generate work orders when PPM is required.


7.2 User planned preventive maintenance (PPM)


Try to get hold of as many of these as possible
(using the strategies presented in Box 8).


Try to get hold of these resources (see Box 8
for strategies).


Meet with your colleagues and draw on your own
experiences to adapt the resources to local needs
and realities.
The HTMWG’s training sub-group (Section 1.2)
could be made responsible for this.
Investigate this software if your organization wishes
to use computerized maintenance systems (see
Guide 5 on maintenance management).




146


The simplest form of timetable is to have a monthly duty list. Alternatively, it is
useful to display the planned work on wall calendars indicating when PPM should be
carried out. The calendar should incorporate space where staff can sign off and date
when they finish the task, to show that each timetabled PPM activity has taken
place. This method provides you with a visual record for managers to monitor. An
example is shown in Figure 17.
It is also important to keep a record of any pieces of equipment that are substituted.
If your equipment has been labelled with some form of inventory code number (see
Guide 2 on planning and budgeting), it will be easier to tell which particular piece of
equipment you have been maintaining.
User PPM charts, calendars, and instructions should be displayed on the equipment,
or as near to it as possible, to remind staff of their duties, and for ease of completion.
Wall calendars can also be used to display daily care and cleaning schedules.


Figure 17: Example Timetable of PPM for Users in Wall Calendar Format


7.3 TESTING FOR ELECTRICAL AND MECHANICAL
TRUSTWORTHINESS


Equipment should be kept in an acceptable physical and working condition at all
times, so that it can perform competently and safely. Equipment should not be
allowed to deteriorate to such an extent that it becomes untrustworthy or hazardous
(Section 5). For example:
◆ frayed mains leads
◆ disconnected earth
◆ metal with stress fractures
◆ leaking gas valves
◆ cracked glass
◆ failing brakes
◆ perished rubber materials.


7.2 User planned preventive maintenance (PPM)


PPM Wall Calendar Timetable
Months Jan Feb Mar Apr


Week


Water Still


Microscope


Refrigerator


Key: q = 3 monthly (quarterly) m = monthly w = weekly


1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4


q q


m m m m


m m m mw w w w w w w w w w w w




147


One strategy is for staff to regularly check equipment visually for such disintegration.
However, to reduce the risk of such problems, regular testing for electrical and
mechanical trustworthiness, using test instruments, is required.
Such testing ensures the safety of equipment and calibrates its performance, and so
requires safety testing and calibration instruments. Safety and calibration testing
usually takes place regularly throughout the life of the equipment:
◆ During the acceptance process when equipment first arrives (see Guide 3 on


procurement and commissioning).
◆ Whenever staff suspect that there may be a problem, or the equipment may not


be performing properly.
◆ Regularly as part of the usual planned preventive maintenance tasks (Section 7.2).
◆ At the end of every repair process, whenever equipment breaks down (see Guide 5


on maintenance management).
Safety and calibration testing should be encouraged, even though some of the
instruments required are expensive. Section 5.5.2 discussed some tests required for
electrical installations and for medical equipment. Most test instruments are used
for electrical, electronic, or medical equipment purposes. Medical equipment has
stricter electrical safety requirements and considerations than non-medical
equipment, because it comes into direct contact with patients. Such equipment will
require dedicated safety test instruments which go further than simple electrical
safety testers.
Thus, the HTM Team will require adequate test instruments. Annex 6 provides a
list of the types of basic and more complex testers that an HTM Service will need.
Not all workshops/health facilities at every level will need all of the instruments
listed. The type of test instruments you own will depend on the skills of your HTM
Team; it may be more economical and effective if the complex items are placed at
regional or central levels, where specialist staff are based and provide maintenance
support by outreach.
Figure 18 offers some suggestions for increasing safety testing. We recognize that
following these suggestions will require a lot of resources (money, people, time).


7.3 Testing for electrical and mechanical trustworthiness




148


Figure 18: Strategies for Safety Testing


7.4 FAULT REPORTING
Besides PPM, there will be faults and breakdowns needing repair, and maintenance
work requiring more skills than the users have. Equipment users and their Section
Heads are responsible for reporting all equipment faults promptly to the HTM Team.
We suggest that fault reports are made by completing some style of Work
Request/Job Form. Relying solely on telephone calls or radio communication can
mean that there is no physical record of the request made. In many instances,
reporting a fault to the HTM Team by telephone or radio is justifiable and the only
quick method available; however, this process must be followed up by the prompt
submission of a Work Request/Job Form in order to provide a written record of the
reported fault.
You need a way of recording how many requests for maintenance support are made,
and how each request is progressing. You could keep some form of Maintenance
Book, but the HTM Service may be using a Work Request/Job Form system (such a
system is described in Guide 5 on maintenance management).
Annex 7 gives an example of a triplicate Work Request/Job Form which has multiple
uses in the maintenance record system. The user department fills in the top half of
the form, and keeps the top copy to create their own set of records.


7.3 Testing for electrical and mechanical trustworthiness


Process Activity


Obtain adequate safety test
instruments


Monitor the state of equipment


Train staff


Health Management Teams should buy safety testers (as and
when funds are available), so that the HTM Team can carry out
regular mechanical, electrical, and medical electrical safety
testing as part of their PPM activities.


Staff should notify the HTM Team if they notice anything wrong
with the physical condition or trustworthiness of equipment.


The HTM Manager and In-Service Training Coordinator should
ensure that all maintenance staff have been trained to use the
relevant test instruments (Section 3.5).


Undertake testing regularly


The HTM Manager should ensure that maintenance staff
undertake mechanical, electrical, and medical electrical testing
(as appropriate):
• during the acceptance procedure for newly arrived equipment
• whenever problems are suspected
• at the end of every repair and PPM task.




149


We also suggest that each user department establishes a User Department
Maintenance File to keep track of whether jobs were attended to. Such a file could
be divided in half, so that it becomes a record of all the maintenance work that the
department has asked for, as well as a record of those jobs that have been completed.
The Work Request/Job Form can be moved from the front of the file to the back
when the job has been completed, so that the two halves work as follows:
◆ The front of the file is the pending section and is a record of all the jobs reported


to the HTM Team, organized according to the date the report was made.
◆ The back of the file is the completed section and is an ongoing record of all the


jobs that have been completed, organized according to the date they were finished.
When a job is completed (and the equipment is returned), the Section Head:
◆ goes to the User Department Maintenance File
◆ retrieves the Work Request/Job Form (from the pending section) relevant to that job
◆ signs it to acknowledge completion
◆ moves it to the completed section.
To see how the overall maintenance record system works, and the responsibility of
the user department in it, refer to Guide 5 on maintenance management.
Whatever method is used, the department or facility initiating the job needs to keep
a record of the number of requests made and monitor their progress. By reviewing
the User Department Maintenance File regularly (at least once a month), the
Section Head can monitor the progress of maintenance requests (Section 8.2).


7.5 DECOMMISSIONING, DISPOSAL, AND
REPLACEMENT OF EQUIPMENT


Discussion
When a piece of equipment comes to the end of its life, a decommissioning, disposal,
and replacement process must take place. Decommissioning is the process of
condemning equipment when it is no longer safe, or of use, and taking it out of
service. This process is sometimes known as ‘boarding’ because, originally,
government bodies called ‘Boards of Survey’ were responsible for carrying out this
task for government property.


7.4 Fault reporting


Experience in Pakistan
The Director of Maintenance at the Aga Khan University Hospital in Karachi successfully
introduced a telephone-based fault reporting system, where a written record of each
telephone request was also made as a back-up. After evaluation, he found that a greater
number of faults were reported as a result of the new system, and in a shorter time.




150


All equipment has a life expectancy which will be dependent on the type of
equipment and the type of technology it contains. For example, five years might be
the typical life for an ECG monitor, 10 years for a suction pump, 15 years for an
operating table, and 20 years for an electricity generator. Reconditioned equipment
has a shorter lifetime than equipment bought from new. Once equipment reaches
the end of its life, no amount of intervention will help, it just needs to be replaced if
the service it provides is to continue. In fact, to keep on trying to maintain
equipment which has reached the end of its life will be costly.
To understand how equipment depreciates, it is necessary to know the likely ‘life’ of
your equipment. Typical lifetimes for common equipment are given in Annex 8,
though these may need to be modified depending on:
◆ the rate of use of the equipment (how many tests per day? How many patients


per month? etc)
◆ how many back-up units you have, (is the equipment used to its limit, overworked


or overloaded?)
◆ how the equipment is handled (is it abused?)
◆ how well the equipment is cared for and cleaned
◆ how well the equipment is serviced and how often
◆ the initial quality of the equipment (was it new or reconditioned?)
◆ the physical environment and climate that the equipment is used in.
Any replacement must be undertaken in accordance with the replacement policy (see
Guide 2 on planning and budgeting). Box 57 provides an example.


BOX 57: Example of a Replacement Policy
Equipment will only be replaced when one of the following valid reasons have been fulfilled:
a. It is worn out beyond repair (has reached the end of its natural life).
b. It is damaged beyond repair.
c. It is unreliable – faulty, old, or unsafe.
d. It is clinically or technically obsolete.
e. Spare parts are no longer available.
f. It is no longer economical to repair.
And one of the following valid reasons have also been fulfilled:
g. Utilization statistics are available to show that it is still required.
h. A demonstrated clinical or operational need still exists.
Equipment will not be replaced simply because:
◆ it is old
◆ staff do not like it
◆ a newer model has arrived on the market.


7.5 Decommissioning, disposal, and replacement of equipment




151


Maintenance technicians and engineers are required to judge these issues, and
procedures are required for the following steps:
i. assessing whether equipment has reached the end of its life, and condemning it
ii. physically disposing of the equipment safely and promptly
iii. taking it off the health service records
iv. triggering its replacement, so that the service it provided can continue.
Currently, equipment in the health service is seen as the property of the controlling
body of the health service provider organization. In other words, Ministry of Health
equipment is the property of the national government, and equipment in a private
hospital is the property of the business firm that runs the health service. These
controlling bodies require the equipment to be officially written off by a relevant
authority (for example, in the government sector the Ministry of Finance will have
some form of Board of Survey). These decommissioning authorities may be based
nationally, at the district/region, or even at the health facility level.
These authorities must be told when equipment reaches the end of its life. They will
then officially condemn it, and arrange for its disposal and any auctioning of viable items
or scrap to recover money for the controlling body (the treasury in the government
sector, for example). This process can take a long time, but should occur regularly in
order to avoid large and dangerous graveyards of old equipment dotted around the
facility site. Health facilities must be able to cope with the stocks of condemned
equipment in the meantime, and must create special storage sites within their grounds.


The Condemning, Disposing, and Replacement Process
Figure 19 shows the likely steps in a typical decommissioning process.
The Health Management Team might have to chase the Board of Survey to visit the
health facility promptly in order to officially condemn the equipment, and arrange
for it to be auctioned off.
Ideally, condemned equipment is only disposed of once the official condemning
process has occurred. However, if this does not happen regularly, the health facility
cannot afford to become choked with old and scrap items, and should start a process
of cannibalizing the equipment in order to reduce the impact of the stockpile and to
gain as much use as possible from the old items. Hazardous components should be
properly disposed of, as described in Section 5.4.
The Health Management Team should pursue with the health service provider the
possibility of:
◆ establishing their own facility-level Board of Survey as soon as possible (if one


does not already exist)
◆ being able to sell off metal items for scrap
◆ returning any money raised from the sale of condemned items to the budget of


the health facility.


7.5 Decommissioning, disposal, and replacement of equipment




152


Figure 19: Steps in a Typical Decommissioning Process


7.5 Decommissioning, disposal, and replacement of equipment


Steps Activities


Timing


Judgement


Technical action


Senior maintenance staff technically evaluate equipment to assess its fitness to continue in service. This can
happen at any time:
• when there is a fault (see Guide 5)
• during the annual Equipment Inventory updating process (see Guide 2)
• during the Equipment Development Planning (EDP) process (see Guide 2).


Senior maintenance staff from your local workshop consider four issues and judge:
• whether the equipment fulfils any of the valid replacement criteria defined in the Replacement Policy (as
described in Box 55)
• what the internationally advised typical life-time is for the equipment (see Annex 8)
• the equipment's track record and state of health as documented in its service history records (see Guide 5)
• whether it will be necessary to override the average expected lifespan and condemn early, or even to extend
the lifespan.
For expensive equipment, it may be helpful to obtain an evaluation from the supplier.


If the equipment is condemned because it is unreliable, damaged, or in any way unsafe, the maintenance staff:
• take it out of service immediately for safety reasons and to prevent its return to use
• inform the Head of the User Department
• take unsafe moveable items to the maintenance workshop, or arrange for unsafe fixed equipment to be
disassembled
• if there is to be a delay with either of these actions, leave notices on the equipment and make them
inoperable (for example, by removing the accessories, or the mains connection).


Administration
The Purchasing and Supplies Manager completes a form, such as a List of Expendables to be Written Off form
(see Annex 9), and submits it to the relevant:
• financial head office of your organization (for example, the Ministry of Finance)
• local Board of Survey, whether it is a facility or district branch (Section 1.2)


Official response The Board of Survey scrutinizes the report, visits the facility, and condemns the equipment, thereby providing the HTM Service with authority to remove the equipment from service.


Technical action


The HTM Team from your local workshop cannibalizes the equipment by:
• removing any useful components and parts from the condemned equipment, for use on other equipment
• storing these components and parts in the facility stores and maintenance sub-stores (depending on their
size and number)
• ensuring that any hazardous components or parts (such as radioactive sources, asbestos, mercury, etc) are
disposed of in a safe manner according to the Waste Management & Hygiene Plan (Section 5.4), taking
advice from the Infection Control Committee and any other relevant safety sub-group of the HTMWG
• placing the remaining (unusable) parts of the equipment outside at a specially designated site
within the grounds of the health facility or workshop, which is a secure site that is fenced-off and locked.


Record-keeping
The HTM Manager ensures that the record of the written-off items:
• is removed from the Equipment Inventory (see Guide 2)
• is removed from the maintenance files (see Guide 5)
• is used to update the Equipment Development Plan (see Guide 2).


Official action
The local Board of Survey auctions off:
• only the remaining equipment items which are safe to reuse
• any remaining materials for which scrap value can be obtained (for example, scrap metal).


Reporting


The HTM Manager of your local workshop:
• writes a technical report explaining why the equipment should be officially condemned
• submits this report to:
– the Health Management Team and relevant User Department, for information and discussion at
management meetings
– the Purchasing and Supplies Manager, who starts the official process
– the HTMWG, in order that the condemnation triggers a replacement in the annual Equipment
Development Planning process (see Guide 2).




153


Section 7 summary


Box 58 contains a summary of the issues covered in this Section.


BOX 58: Summary of Procedures in Section 7 on Ensuring Continuous Operation
Health Service Provider
and Health Management
Teams


Section Heads


All Staff
Health Management
Teams
Heads of Department


User Staff


HTM Team


Health Service Providers
All Staff


HTM Teams
Equipment Users
Section Heads


◆ address the practical issues involved in implementing the equipment
security strategies (see Box 53)


◆ introduce the security strategies to Section Heads and explain their
implications


◆ introduce the security strategies to their staff and train them in their
application


◆ monitor that their staff are adhering to the equipment security procedures
◆ make it their responsibility to guarantee the security of equipment
◆ allocate the user departments sufficient resources to undertake user PPM


(materials, funds, training, etc)
◆ liaise with the HTM Service to develop the user PPM system
◆ plan these activities and implement them according to the written


guidelines and timetables
◆ monitor to ensure that their staff are adhering to correct PPM techniques


and timetables for equipment
◆ report any problems to the Health Management Team so that training


needs can be addressed
◆ only undertake the sorts of procedures that do not require the intervention


of the maintenance department
◆ undertake the user PPM activities regularly according to a timetable, and


the training received
◆ refer to the training resources and posters provided (Section 3.5) and


manufacturers’ manuals (Section 3.4) for guidance
◆ report any problems identified with user PPM to the Head of Section and


Health Management Team, so that training needs can be addressed, or
disciplinary action can take place


◆ plan and implement the more technical PPM tasks (see Guide 5 on
maintenance management)


◆ ensure the HTM Service has sufficient safety testers (see Annex 6)
◆ undertake visual checks to monitor whether equipment is electrically and


mechanically trustworthy
◆ undertake regular safety tests with the necessary test instruments
◆ report any faults to their Section Head immediately they occur
◆ report any faults to their HTM Team immediately using the correct Work


Request/Job Form (see Guide 5 on maintenance management)
◆ use the User Department Maintenance File to review progress on


maintenance work (see Guide 5)


Fa
ul


t R
ep


or
tin


g
T


es
tin


g












U


se
r P


PM














S
ec


ur
ity


Continued overleaf




154


Section 7 summary


BOX 58: Summary of Procedures in Section 7 on Ensuring Continuous Operation (continued)
HTM Service


Purchase and Supplies
Officers
Health Management
Teams


Boards of Survey


◆ undertakes the technical judging activities to identify when equipment
should be decommissioned


◆ undertakes the necessary reporting, dismantling, cannibalizing, and storage
activities to ensure equipment is taken out of service and does not return
to use


◆ administer the official communication with the Board of Survey and the
finance head office of the health service provider


◆ chase the Board of Survey to act so that large graveyards of scrapped
equipment do not gather on health facility grounds


◆ ensure that disposal of equipment and parts is undertaken according to the
Waste Management and Hygiene Plan (Section 5.4)


◆ ensure that decommissioning of equipment triggers the purchase of a
replacement item (when applicable)


◆ officially write-off equipment promptly
◆ organize the auction of only those pieces of equipment which are safe for


reuse, and any materials for which a scrap value can be obtained.


De
co


m
m


iss
io


ni
ng





155


8. HOW TO UNDERTAKE ACTION PLANNING
AND MONITORING OF PROGRESS


Why is This Important?
Managing the activities described in this Guide will involve a cycle of actions.
You need to monitor your performance, and set yourself goals so that you can
improve. Then you monitor your progress, revise your goals, and review your
progress again – thus undertaking a continuous cycle of planning and review.
Such evaluation helps you to ensure the quality of your work. This is one
element of quality management – an important goal for managers.


The planning and review activities are interlinked in a cycle as shown in Figure 20, but
it is necessary to start the discussion at some point in the cycle. This Section discusses:
◆ the planning process (setting goals) in Section 8.1
◆ the review process (monitoring progress) in Section 8.2.


Figure 20: The Planning and Review Cycle


All staff involved in equipment operation and safety should be involved in planning and
reviewing their progress with this work. Thus, this Section is relevant for all different
types of staff in:
◆ the user departments and committees
◆ HTM Teams
◆ HTM Working Groups
◆ their various safety sub-groups.


8 How to undertake action planning and monitoring of progress


Set/Revise
Goals Monitor Performance/Progress


action


feedback




156


The main outcome of the planning and review process is that you are able to evaluate
your performance. This is important for ensuring the quality of your work (quality
assurance), which is an essential component of quality management.


Aims of Quality Management
◆ client satisfaction
◆ cost efficiency
◆ compliance with laws


We recommend that quality management is introduced into the health management
systems of all the decentralized levels of the health service. It can help to improve
staff attitudes, and this, in turn, can help staff handle the challenges connected with
the many reforms and new management tasks they face (such as those described in
this Guide). Important elements of quality management are:
◆ a management team approach
◆ supervision and evaluation
◆ participative leadership
◆ methods for encouraging staff
◆ individual responsibility and initiative
◆ control measures such as performance measurements and impact analysis
◆ community participation.


8.1 SETTING GOALS (ANNUALLY) FOR EQUIPMENT
OPERATION AND SAFETY


Purpose
It is necessary for each user department/safety sub-group to have goals and plans
which set out their priority activities. The goals and plans must be clearly defined so
that they guide the work of:
◆ the department/sub-group
◆ its staff
◆ the health facility
◆ the health service as a whole.
The goals and plans will also enable staff and managers to monitor their own
performance and progress with regard to the operation and safety of equipment (as
well as their wider range of clinical activities).


8 How to undertake action planning and monitoring of progress




157


Every department or team can benefit from an Annual Action Plan which contains
clear, specific goals relating to its key activities. An action planning process should
take place once a year, as standard practice. This is an opportunity for the members
of the team to agree the range of activities (initiatives and changes) they want to
implement, because they believe the activities will improve:
◆ their working environment
◆ their performance
◆ the service they provide.
There are boundaries and limitations to this planning process. The need for major
investments in equipment should be discussed outside the annual action planning
process, through activities such as the Equipment Development Planning exercise
(see Guide 2 on planning and budgeting). Similarly, ongoing shortages of staff or
money are usually excluded from the annual action planning process, and should be
addressed instead by higher authorities who can influence such issues.
Instead, we suggest that annual action planning should focus on improvements and
changes that staff can undertake themselves, and that can be achieved with existing
staff, equipment, facilities and other resources. Staff involved in the use and safety of
equipment should devise a wide range of initiatives and goals for all aspects of their
work, such as:
◆ obtaining information about new products
◆ improving operator skills in using equipment
◆ establishing safety guidelines
◆ improving stock control of accessories and consumables
◆ improving user PPM.
The planning process, and the plans themselves, should be clear and straightforward.
This assists participation and produces goals that can be understood and used by all
staff. Staff who are involved in setting goals and preparing plans are more likely to be
committed to carrying them out. Thus, the planning process should incorporate
representatives of all different types of staff, from all relevant disciplines.
We suggest that you hold an action planning seminar once a year. Such seminars can
be held in various ways:
◆ Either across a ‘horizontal’ level of the health service, in other words, planning


for the health service as a whole with participation from all disciplines,
undertaken by your health facility or by your district health authority.


◆ Or across a ‘vertical’ professional programme within the health service (such as
the laboratory service, or maintenance service). In this case, representatives
would meet from all the laboratory departments, for example, in your
district, or region, or throughout the health service as a whole.


8.1 Setting goals (annually) for equipment operation and safety




158


The main purpose is to establish an annual planning cycle which:
◆ reviews past performance, problems, and needs
◆ identifies solutions and sets specific goals for the year
◆ prepares an annual action plan for delivering improvements in the coming year
◆ monitors implementation
◆ starts back at the beginning again with another review the following year.


Setting Goals
Three types of goals are required: targets, recommendations, and longer-term objectives.
i. Targets
Targets guide the work of the user department, HTM Working Group (or its
sub-groups), and HTM Team during the following year. They help to improve
services and make sure that the most important work gets done. Targets are one of
the best tools for judging progress and work performance. We suggest that each
department /group should have between five and 10 targets, following the ‘SMART’
target-setting process:
Specific state what should be done and who will do it
Measurable easy to measure, or easy to decide that the target has been achieved


or if progress is being made
Achievable possible to carry out with existing staff, equipment and money
Relevant cover a priority problem or improvement
Time-bound state when the activity should be completed by.
It will be clearer if targets are written down using the following headings, which can
be used when the final plans are produced:


Target By whom How to measure How to achieve Timetable
Actions agreed,
listed in order
of priority


8.1 Setting goals (annually) for equipment operation and safety


Names of
persons who will
be responsible


How progress will
be determined
(see indicators
below)


Resources
required


Time-frame for
start and
completion




159


ii. Recommendations
You will discover that some important problems cannot be overcome or
improvements achieved unless extra supplies, staff, or funds are provided, or unless
assistance is obtained from outside. In such cases, recommendations are required.
These should be:
Specifically addressed to the person, official, department, organization, etc that


is able to carry out the recommendation.
Reasonable there is no point in asking for the impossible, such as


10 times more staff.
Essential there should be no easy way for the user department to


achieve the same results on their own.
iii. Longer-term objectives
You will also discover some problems which cannot be solved in one year. Maybe they
need large amounts of money, longer preparation, or plenty of time to achieve. Or
maybe it is simply not possible to do everything at once. In such cases, longer-term
objectives are required which will be carried forward to the next year, or for
implementation later on.


How to Measure the Goals
Each goal must be easily measured, so that you can see if it has been achieved or if
progress is being made:
◆ You need a way of determining if you are moving towards your goal – this is called


an indicator. There will always be several possible indicators for each goal, and
more than one way of measuring them.


◆ You need to know where you are starting from, in other words, what the situation
is now – this is called the baseline data. The data chosen must be relevant to
the indicator.


Box 59 provides an example of different ways of measuring a goal using indicators
and baseline data.


8.1 Setting goals (annually) for equipment operation and safety




160


8.1 Setting goals (annually) for equipment operation and safety


BOX 59: Example of How to Measure a Goal
Goal: Let’s make the health facility a cleaner place
An indicator: Increase the number of equipment cleaning schedules implemented


One way of measuring this:
Calculation required: Percentage of available cleaning schedules implemented per month


= Number of equipment cleaning schedules carried out x 100 %Number of equipment cleaning schedules should have been done


Baseline data: All 10 departments have been given equipment cleaning schedules, but in July
only two were found to be following them.
Therefore your baseline data is 20%.


Your aim is to improve this situation and increase this percentage.


Alternative way of measuring this:
Baseline data: In a study of the current situation you find that equipment cleaning schedules


have only been written for four departments, and you plan to help them to start
implementing these over the next three months. Additional equipment
cleaning schedules need to be written for the remaining six departments, and
you plan to write them all in the next three months.


Calculation required: Percentage of available cleaning schedules implemented


= Number of equipment cleaning schedules carried out in a time period x 100 %Number of equipment cleaning schedules should have been done in that time period


and percentage of equipment cleaning schedules developed


= Number of equipment cleaning schedules written in a time period x 100 %Number of equipment cleaning schedules planned to write in that time period


After three months you find that, in fact, you only managed:
◆ to get three out of the four departments to implement their equipment cleaning schedules,


that is, 75% of your first target
◆ to write equipment cleaning schedules for three of the remaining departments,


that is, 50% of your second target.




161


It is necessary to choose suitable indicators that are specific to all your annual goals.
There are many possible indicators for user departments, safety sub-groups, and the
health service as a whole, so staff and managers should decide upon the most important
activities (or statistics and results) to measure. Examples of the types of indicators
which can be used for equipment operation and safety are those describing:
◆ the existing situation - numbers of user-created faults and breakdowns


- key accessories and consumables available and used
- number of X-rays taken
- numbers of equipment accidents/hazardous


incidents
◆ improved performance - number of accident-free driver days


- waiting time to receive results of laboratory tests
- numbers of equipment operators attending


training courses
- increase in the number of user PPM interventions


◆ cost-benefits - number of patients seen per piece of equipment
owned (for certain departments)


◆ efficiency and effectiveness - equipment availability per year (for different types
of equipment).


The user departments, safety sub-groups, HTM Working Group, etc should meet to
agree on a few suitable indicators that can be measured easily and quickly (if
possible). Positive indicators are preferable as they motivate staff. Sometimes it is
useful to use common indicators for different teams, groups, and staff, so that their
progress can be compared.
Once the indicators have been agreed, they need regular measuring and charting.
The relevant Health Management Team will need to decide:
◆ how records of these indicators will be kept, for example, in a register, with a form,


or on a chart (Section 8.2)
◆ who will be responsible for keeping them
◆ how regularly the results will be summarized (each month, for example)
◆ what form of charts and displays you will use to display the monthly summarized


results (so that it is easy for people to see how they are progressing).


The Annual Planning Process
In preparation for the annual action planning process, every user department, HTM
Team, and safety sub-group should be involved in carrying out a review of:
◆ their performance and progress in the previous year
◆ their targets, plans, and needs for the coming year.


8.1 Setting goals (annually) for equipment operation and safety




162


Department Heads or Chairs of Sub-Groups should involve their staff through
regular meetings. Alternatively, if the team is large, they can nominate a small
review group to prepare material for the action planning process. It is useful for each
group to undertake an exercise which involves asking a selection of their ‘clients’
about the department’s work. Thus a user department or sub-group will ask their
clients what they think are the five most important problems regarding equipment
operation and safety.
These clients should be a mixture of:
◆ staff in the health facility served by the user department or sub-group
◆ members of the Health Management Team at their facility or district
◆ the HTM Team
◆ patients.
If targets were prepared the previous year, they should be assessed to see how well
they were implemented. This helps the user department or sub-group to identify
and study the successes and problem areas for the team, and agree on which
problems are priorities for tackling in the coming year.
The user department or sub-group should now have prepared sufficient information
to take to the annual action planning seminar. If the seminar is a large one (in other
words, it covers many health facilities, or many departments in a professional
service), the Department Head or Chair of Sub-Group may have to nominate a
couple of senior, knowledgeable and responsible members of staff to be their
representatives at the meeting.
Depending on the number of people attending, the seminar may be a one- or two-
day event, as described in Box 60. For each priority problem area identified,
delegates at the seminar will consider and discuss the issues raised and come up with
suggestions for solutions. For each solution or improvement, representatives write
new targets, recommendations, and longer-term objectives, as well as indicators for
the coming year (as described above).
The Annual Action Plan developed should state the agreed goals, who is responsible for
achieving these goals, how they will be measured, the resources required, and the
timescale by which they should be achieved. Once the plan is ready, it needs to be
communicated to all staff.


8.1 Setting goals (annually) for equipment operation and safety




163


8.1 Setting goals (annually) for equipment usage and safety


BOX 60: Strategies for Running an Annual Action Planning Seminar in the Health Service
All managers (including Heads of Department and Chairs of Sub-Groups) ensure that their nominated
representatives attend the annual action planning seminar.
Process
The first half day to one full day
Participants are divided into
working groups.
Each working group is given different
departments or areas of the health
service to consider.
Each working group analyzes their
department/area under study.


Each working group prepares a list of:
◆ between five and 10 most important


difficulties or problems for the
department/area;


◆ their five to 10 targets, recommendations,
and longer-term objectives.


The second half day to one full day
The participants are brought together in
a plenary session.
Each working group presents its findings
in turn.
Participants from other groups
provide input.
The Chair oversees an end-result of the
plenary session.
After the seminar
The Health Management Team reviews
and finalizes the material from the seminar.


The Health Management Team
distributes the Annual Action Plan.


Heads of Department/Chairs of
Sub-Groups display their goals.


Actions
No more than 10 people in each group (with a mix of nurses,
doctors, and other staff), in order to improve participation.


They are given the material prepared by those departments
(as described earlier in this Section).


They: ◆ review performance over the past year
◆ assess how well targets were implemented
◆ consider the lists of problems and solutions provided
◆ identify successes
◆ carefully examine problem areas.


They take large sheets of paper, with the name of the working
group on top, and from their analysis they clearly list:
◆ the priority problems
◆ the targets, recommendations, and longer-term objectives.


The purpose is to reach agreement on all proposed targets,
recommendations, and longer-term objectives by the end of
the seminar.
They display and briefly explain their list of problems, targets,
recommendations, and longer-term objectives.
They put forward questions, advice, and suggestions for
amendments.
He or she ensures that agreement is reached for all goals.


It ◆ reviews the materials generated at the seminar
◆ arranges them appropriately in order to produce the


Annual Action Plan
◆ combines duplicated suggestions from different


working groups
◆ writes any additional goals required
◆ makes revisions as necessary
◆ groups together all targets, recommendations, and longer-


term objectives by team/department and subject.
It ensures that the Annual Action Plan is reproduced quickly
and distributed widely around the service, so that all staff have
access to it.
They ensure the goals are displayed in suitable locations, to
ensure that staff are aware of them.




164


8.2 MONITORING PROGRESS WITH EQUIPMENT
OPERATION AND SAFETY
Part of the management of equipment-related activities is the identification of
problems and needs. All equipment-related activities should be monitored and
evaluated, and the performance of equipment, staff, and departments should be
supervised (this applies to all clinical, technical, and support departments). The
results of such monitoring are useful for providing feedback to staff, Health
Management Teams, and the Healthcare Technology Management Service.
Monitoring progress involves a number of different activities. The following
monitoring activities are described in this Section:
◆ Monitoring progress against the annual goals (as set in Section 8.1).
◆ Monitoring progress in general, using statistics, incident reports and staff appraisal.


Monitoring Progress Against Annual Goals
Monitoring progress against goals is one of the best ways that staff, managers, and
the health service provider can judge their work performance. Thus, it is necessary to
follow up the plans and goals set, in order to ensure that they are put into practice. If
this is not done and goals sit on a shelf gathering dust, then all the time spent
planning will have been wasted.


Regular monitoring of progress against goals is essential throughout
the year. This should be done using the measuring and charting
methods introduced in Section 8.1. Displaying annual goals and
progress towards them can be helpful to staff.


At the end of each year, it is essential to review and carefully analyze the results
achieved on all the department goals, before starting to develop the Annual Action
Plan for the following year. This step is the most important – to review results on a
regular basis with the people who are doing the work.
This is the time to give praise for good progress, or to find out what might be causing
shortcomings or problems, and then seek a solution. If solutions are quite impossible
it may be necessary to change the plans. If common indicators were used for
different departments, groups, and staff, it will be possible to compare their progress.
Once planning and financial systems are established, it is also possible to link annual
planning with the process of setting the health facility’s budget. For example, the fact
that a department achieves its goals could play an important part in justifying the
budget allocations they request from the Health Management Team (see Guide 2 on
planning and budgeting ).


8.2 Monitoring progress with equipment operation and safety




165


Monitoring Progress in General
Monitoring equipment-related activities can help to identify problems and needs.
Thus the results of monitoring are useful for providing feedback to staff and senior
management. By receiving feedback on their activities and answers to their queries,
staff benefit from experience, and feel a part of the system as a whole. In this way staff:
◆ will be informed
◆ can obtain support
◆ will feel involved and empowered
◆ can be encouraged to take responsibility.
Regular monitoring of activities and services is also essential for improving the quality
of healthcare. Management need facts so that they can plan effectively, and need to
know how equipment-related activities are performed. Thus, it is important to have
some method of collecting information, such as:
◆ the numbers of equipment not functioning
◆ consumable usage rates
◆ equipment shortages
◆ training deficiencies.
It may be possible to incorporate this data gathering into any existing Health
Management Information System (see Guide 1 on organizing HTM). This will
enable ‘evidence-based’ planning to take place.
i. Statistics
Heads of Department/Chairs of Sub-Groups need to gather and compile statistics
regularly. These will provide information on the progress of their team and its work
performance in relation to equipment. They need to gather this data in order to:
◆ be better managers
◆ improve the running of their departments
◆ provide information to other people and bodies who need to know how their


department is functioning.
Thus the Head of Department/Chair of Sub-Group needs to:
◆ analyze any incident report forms (see below), in order to extract information


about problems with equipment, procedures, or staff
◆ use data from attendance records and departmental work records to compile


statistics about equipment use and availability
◆ review the User Department Maintenance File to obtain feedback on progress


with maintenance requests (Section 7.4)
◆ produce brief, informed and accurate written reports for the Health Management


Team on pertinent equipment operation issues.


8.2 Monitoring progress with equipment operation and safety




166


Statistics should be gathered regularly, for example on a monthly or quarterly basis.
Box 61 shows the sort of statistics that can be gathered. You will need to decide
which are the most useful ones for your health service.


BOX 61: Examples of Statistics Which Can be Gathered Regularly
Type of statistics Examples
Statistics obtained by counting numbers


Statistics obtained by doing calculations


Statistics obtained by doing analysis


8.2 Monitoring progress with equipment operation and safety


The workload and performance of different types of equipment,
such as:
◆ how many times the equipment is used
◆ how many times patients (or samples, etc) are sent away


because the equipment was unavailable.
The number of times work with equipment is cancelled due to
different causes, such as:
◆ consumables not being available
◆ no money to buy cleaning materials
◆ low staffing levels
◆ equipment broken
◆ specific accessories unavailable.
The number of adverse incidents due to different causes, such as:
◆ poor safety procedures
◆ no cleaning taking place
◆ no user PPM
◆ untrained staff.


Use of internal resources, for example the cost of
running equipment.
This method is used for things that are more difficult to
measure or assess and refers to the quality of performance and
user satisfaction rather than quantities.


The compilation of these statistics is made easier if you design relevant and useful
Statistics Forms to enter the data into. We suggest that you file these Statistics Forms
in Statistics Folders, and that you use them for creating reports for management.
Staff such as the In-Service Training Coordinator and the Infection Control Officer,
can also play a role in monitoring equipment skills and issues across the health
facility as a whole. This helps them to identify where problems are occurring which
they could follow up with in-service training or other measures (Section 3.5). In
addition, Department Heads should regularly report to the Purchasing and Supplies
Officer regarding the quality of materials purchased (Section 6.3).




167


ii. Incident reports
Each health facility should have some formal method of reporting problems, accidents,
and adverse incidents in all equipment-related safety areas (Section 5). Some type of
Accident Record Book or Incident Form can be used so that staff can report whenever
any type of incident occurs. These should be submitted to the HTM Working Group
(or its safety sub-groups).
The HTMWG should monitor the incidents, and discuss the most appropriate
solution in each case. It will need to report to the Health Management Team, and
address the problems using a combination of strategies such as:
◆ changing operating procedures
◆ introducing further safety measures
◆ training staff
◆ penalizing or rewarding the behaviour of staff
◆ redistributing equipment until such time as the necessary human skills are in place.
iii. Staff appraisal
Another form of reporting and feedback is staff appraisal by managers. Informal
methods include activities such as sharing information, support, and supervision.
A formal method is a staff appraisal process which monitors the work performance of
individuals, and identifies areas for goal-setting for both the individual and their
manager. The purpose of the interaction is to:
◆ guide the individual in their job
◆ evaluate their performance
◆ take corrective action to improve job performance
◆ agree required training, development, and other strategies by the employer, which


would assist the employee to become more effective in their job.
Regular monitoring of equipment-related activities will also mean that instances of
good or bad work performance, in relation to equipment, can be incorporated into
the staff appraisal system.
For a fuller description of staff appraisal strategies, see Guide 5 on maintenance
management.
Box 62 contains a summary of the issues covered in this Section.


8.2 Monitoring progress with equipment operation and safety




168


Section 8 summary


BOX 62: Summary of Procedures in Section 8 on Action Planning and Reviewing Progress
Health Service
Provider


Heads of Department,
HTM Teams and
HTM Working Groups


Health Service
Provider


Heads of Department
and Safety
Sub-Groups


Health Management
Teams


Mo
ni


to
rin


g
Pr


og
re


ss









Se


tti
ng


G
oa


ls


◆ ensures there is an annual action planning process whether across ‘horizontal’
levels (within a health facility or district), or within a ‘vertical’ programme (for
example, for the laboratory service as a whole)


◆ set their targets, recommendations, and longer-term objectives each year, in
order to improve their performance (after reviewing the previous year’s
performance)


◆ develop suitable measurement indicators for these goals and gather
baseline data


◆ participate in the annual action planning seminar


◆ ensures the Health Management Information System is developed to include
factors which measure progress with equipment


◆ ensure progress against annual goals is monitored, displayed, and used to
provide feedback to department/group staff, as well as to develop improved
goals for the following year


◆ decide on suitable equipment-related statistics which are informative and easy
to gather


◆ use incident reports, attendance figures, and departmental records to gather
and compile statistics, enter them on Statistics Forms, and file them in
Statistics Folders


◆ use the statistics when reporting to management
◆ monitor staff ’s good and bad performance in relation to equipment, and feed it


into the staff appraisal system


◆ ensure that progress against any goals (annual or regular) is used to prompt the
correct response, such as training, better budgets, different suppliers, career
progression, etc


◆ analyze the information in the Accident Record Book or Incident Forms to
develop a combination of strategies which will address any equipment-
related problems




ANNEX 1: GLOSSARY
Acceptance process: Activities undertaken when equipment arrives at an health facility, at


the end of which the equipment will be operational and officially belong
to the facility, such as receipt, unpacking, installing, commissioning,
initial training, entering into stores and onto records, payment.


Administrative level: See decentralized authorities.
Central level: Highest authority of your health service provider, such as Ministry of


Health or Board.
Cleaning: Removal of visible dirt and reduction of the number of some


infectious micro-organisms.
Commissioning: A series of tests and adjustments performed to check whether, and


ensure that, new equipment is functioning correctly and safely before
being used.


Communication equipment: Any equipment that is used for sending or receiving information, such
as telephones, two-way radios, nurse-call systems, paging systems.


Decentralized authorities: Local units of an organization which have had authority transferred to
them from the central level of the organization. For example, district,
regional, provincial, or diocesan health authority.


Decommission: Take out of service; dismantle and make safe; board. The process of
condemning or writing off equipment and disposing of it.


Depreciation: The amount by which the monetary value of an asset is reduced over a
period of time due to its everyday use (‘wear and tear’) or due to the
fact that it could not be sold second hand for as much as it originally
cost; the asset is said to depreciate in value.


Decontamination: The process of making items safe for handling and reuse.
Dioxins: A pollutant that is emitted from burning/incineration of healthcare


waste which is hazardous to people and the environment.
Disinfection: The reduction of a population of harmful micro-organisms on any


surface without achieving sterility (in other words, not all bacterial
spores present are destroyed).


Donor: See external support agency.
Earth: Provide an electrical connection from electrical devices to the ground,


which is regarded as having zero electrical potential.
Electrical safety: The guidelines, practices and procedures to ensure that people are


protected from the fatal electrical risks posed by electrical supplies,
installations, and equipment.


Energy sources: A source of energy or power, such as generating sets, solar panels
or transformers.


Equipment-related supplies: Items which are essential for equipment use, such as consumables,
accessories, spare parts, and maintenance materials used
with equipment.


Equipment users: All staff involved in use of equipment, such as clinical staff (eg. doctors
and nurses), paramedical staff (such as radiographers and
physiotherapists) and support services’ staff (such as laundry and
kitchen workers).


Annex 1: Glossary


169




External support agency: A body responsible for providing money, equipment, or technical
support to developing countries on various terms, such as
international donors, technical agencies of foreign governments, non-
governmental agencies, private institutions, financial institutions,
faith organizations.


External support agency staff: People working for external support agencies that health workers
come into contact with, such as a country representative, desk officer,
consultant, coordinating agency, director.


Fabric of the building: Items which are part of the integral structure or framework of a
building, such as doors, windows or roofs.


Facility: See health facility.
Fire fighting equipment: Equipment used to put out fires, such as fire blankets, buckets,


extinguishers, hose and sprinkler systems.
Fixtures built into the building: Items which are not part of the integral structure of a building but are


installed into the fabric of the building, such as ceiling-mounted
operating theatre lights, scrub-up sinks and fume cupboards.


Furans: A pollutant that is emitted from burning/incineration of healthcare
waste which is hazardous to people and the environment.


Head of section: Departmental manager, such as head of department, group leader,
officer in-charge, senior operator.


Health facility: Buildings where healthcare is delivered, ranging from small units
(clinics, health centres), and small hospitals (rural, district, diocesan),
to large hospitals (regional, referral).


Health facility furniture: Furniture with a specific clinical use in health facilities, such as beds,
cots, trolleys, infusion stands.


Health management team: Health management body, such as facility management committee,
district/regional/diocesan/central health management team, Board.


Health service provider: A provider of health services, such as Ministry of Health or Defence,
non-governmental organization, private institution, employer
organization or corporation (for example, mine ), faith organization.


Health system: Comprises all organizations, institutions, and resources devoted to
health actions (defined as any effort, in personal or public health
services or through intersectoral action), whose primary purpose is to
improve people’s health. (Source: WHO).


HTM Manager: Head of the HTM Team; ranging from a general member of health
staff with some management skills in the smallest HTM Teams, to an
engineering manager in the highest level of HTM Team.


HTMS: Healthcare technology management service made up of a network of
HTM Teams and HTM Working Groups.


HTM Team: A body responsible for the management of equipment, such as,
equipment management team, maintenance management team,
physical assets management team; Part of the HTM Service.


HTM Working Group: A working group, or standing committee responsible for making
decisions on healthcare technology management issues; part of the
HTM Service.


Annex 1: Glossary


170




Infection control: Internationally this term means control of a wide range of practices,
processes and procedures in the clinical work of the health facility as a
whole; in this Guide the discussion only covers the equipment issues
which contribute to infection control.


Installation: The process of fixing equipment into place; can range from building
equipment into the fabric of a room to simply plugging it into an
electrical socket.


Inventory: A systematic listing of stock (or assets) held. An annual inventory is
prepared at the end of each year following a physical inspection and
count of all items owned by an organization. The list gives details,
such as location, reference number, description, condition, cost, and
the date the inventory was taken.


Laundry and Equipment required for kitchen or laundry activities, such as cookers,
kitchen equipment: cold rooms, washing machines, hydro-extractors, roller-ironers.
Life-cycle cost: The recurrent cost required to keep equipment going throughout its


life (for example, fuel, consumables, maintenance, training, disposal).
Lifetime: Lifespan, life expectancy. For equipment, the likely length of time


that an item will work effectively, dependent on the type of
technology and parts used in its manufacture.


Maintainers: See maintenance staff.
Maintenance staff: Staff responsible for maintenance of equipment, such as craftspeople,


artisans, technicians, technologists, engineers.
Manager: Any staff involved in the management of equipment-related


activities. This could include administrator, nurse-in-charge, medical
superintendent, chief executive, director, health secretary, medical
practitioner, maintenance manager, policy-maker.


Medical electrical safety: The guidelines, practices and procedures to ensure that people are
protected from the fatal electrical risks posed by medical equipment;
stricter requirements than for electrical safety, as medical equipment
comes into direct contact with patients’ bodies.


Medical equipment: Equipment used for medical purposes, including X-ray units,
diathermy units, suction pumps, foetal doppler, scales, autoclaves,
infant incubators, centrifuges.


Office equipment: Equipment used in an office, such as computers, photocopiers,
calculators, record systems.


Office furniture: Furniture used in an office, such as desks, chairs or filing cabinets.
Operative: A skilled worker; a skilled equipment user.
Pending: Awaiting an outcome; waiting for something to take place.
Plant, general: Machinery such as boilers, lifts, air-conditioners, water pumps


or compressors.
PPM schedule: Planned preventive maintenance protocol, or list of activities,


describing the work to be carried out on equipment at specified
regular intervals, in order to prevent breakdowns and ensure the
equipment is operational and safe.


Annex 1: Glossary


171




PPM timetable: A calendar showing the days when PPM tasks should be performed
according to the PPM schedules, in order to ensure that they occur at
the required frequency.


Quality control: A system of maintaining standards; testing a sample
against specifications.


Service supply installations: Supply installations such as electrical installations, water and sewage
pipelines, gas supplies.


Standard: A required or agreed level of quality or attainment set by a recognized
authority, used as a measure, norm, or model for all aspects of health
services and healthcare technology.


Standardization: Rationalization, normalization, and harmonization. In other words,
reducing the range of makes and models of equipment available in
stock, by purchasing particular or named makes and models.


Sterilization: The destruction or removal of all living organisms on any surface to
produce an absolute – a sterile object (an item cannot be ‘nearly’ sterile).


Stock: In stores, this is the goods held by an organization for its own use. The
‘equipment stock’ is all the equipment assets owned by an organization.


Supplier: Someone who provides equipment, such as manufacturer,
manufacturer’s representative, wholesaler, salesman.


Support staff: Additional types of staff in the health service besides medical
personnel such as planner, finance officer, procurement officer, stores
controller, human resource officer.


Training equipment: Equipment required when running training courses, such as overhead
and slide projectors, video and tape recorders.


Users: See equipment users.
Vehicles: Any conveyance used for transporting people, goods, or supplies in


the health service, such as ambulances, cold-chain motorbikes, mobile
workshops, lorries, buses.


Walking aids: Items used to aid mobility, such as wheelchairs, zimmer frames, crutches.
Waste treatment plant: Any plant used to treat waste, including incinerators, septic tanks or


biogas units.
Working group: A group of people set up to be responsible for a particular subject area,


such as a standing committee, select committee, or sub-committee.
Workshop equipment: Equipment used in a workshop, such as hand tools, bench tools,


test instruments.
Your organization: See health service provider.


Annex 1: Glossary


172




BOX 63: WHO’s Definition of the Technology Management Hierarchy
Equipment support: undertaking maintenance and repair.
Equipment management: using the equipment database (inventory and maintenance history)


to help you make decisions for improving equipment support.
Asset management: including cost and utilization information (life-cycle cost analysis) in


the equipment database to help you make decisions on replacement
and acquisition.


Technology assessment: reviewing past, current, and future technologies to determine their
efficacy and effectiveness, and to help you make decisions for capital
planning and acquisition.


Technology management: using: equipment
equipment support
equipment management
asset management
technology assessment


to manage technology in health care from conception to retirement.
Source: Department of Health Service Provision, World Health Organization, 2000


Annex 1: Glossary


173




ANNEX 2: REFERENCE MATERIALS AND CONTACTS
This Annex is in two parts, and provides information about:
Part i. Books, guidelines, databases, and websites
Part ii. Organizations, sources of publications in part i, resource and information centres.


i. Books, Guidelines, Databases, and Websites
The following books, guidelines, videos, databases, and websites are listed in subject categories
according to the topics found in Sections of this Guide. For each publication, a brief description of
the content and the main source(s) are included. Contact details for the source organizations are
included in Part ii. Readers should note that many of the publications are available at low cost. In
some countries it may also be possible to obtain these publications from local bookstores, as
publishers and distributors increase efforts to ensure wider availability. Published prices may be
flexible depending on the order size, discounts available and distribution method.


Tip • Many books and documents cover a variety of topics that appear in several Sections of this Guide.
The first time they appear in this list they are described in full. For each subsequent entry only the
basic details are provided.


Healthcare Technology Management Framework Issues
This material covers issues in Sections 1 and 2, such as healthcare technology management
definitions, policy, regulations, guidance, and services. It is listed alphabetically by title. Further
detailed information on this topic is provided in Guide 1.


Developing healthcare technology policy
Health care technology management No.1: Health care technology policy framework
Kwankam Y, Heimann P, El-Nageh M, and M Belhocine (2001). WHO Regional Publications,
Eastern Mediterranean Series 24. ISBN: 92 9021 280 2
This booklet is the first in a series of four titles. It introduces the ideas of and behind health care
technology management, defines terms relating to and sets objectives for health care technology
management policy. It examines what should go in to such a policy, and the national policy
framework and organization. Capacity-building and human resources issues are considered, as well as
economic and financial implications. Attention is also given to legislation, safety issues, cooperation
nationally and between countries, implementation, monitoring, and evaluation. See Guide 1 for
information on the three further titles in this Series covering regional strategies, policy formulation
and implementation, and country situation analysis.
Available from: WHO
Interregional meeting on the maintenance and repair of health care equipment: Nicosia,
Cyprus, 24-28 November 1986
WHO (1987). WHO document WHO/SHS/NHP/87.5
This document provides a comprehensive discussion of the problem of non-functioning equipment
and of proposed solutions. The major policies, recommendations, and strategies proposed by the
conference on the issue of maintenance and repair of health care equipment are presented. It
includes four Working Papers which cover in detail: maintenance and management of equipment,
the proposed health care technical service, manpower development, and training.
Available from: WHO


Annex 2: Reference materials and contacts


174




Management of equipment
DHSS, UK (1982). Health Equipment Information No. 98
The aim of this booklet is to recommend a system of equipment management that, if fully
implemented, would ensure that all equipment used in the British National Health Service was suitable
for its purpose, was maintained in a safe and reliable condition, and was understood by its users. Its
recommendations and procedures are structured into sections on equipment selection, acceptance
procedures, training, servicing (maintenance, repair, and modification), and replacement policy. It also
covers the management of inventories, equipment on loan, servicing, long-term commercial contracts,
and infection hazards.
Available from: Her Majesty’s Stationery Office (HMSO).
Medical equipment in sub-saharan Africa: A framework for policy formulation
Bloom, G and C Temple-Bird. (1988). IDS Research Report Rr19, and WHO publication
WHO/SHS/NHP/90.7. ISBN: 0 903354 79 9
This book provides a good overview of the situation of medical equipment in Africa. Its approach to
the analysis is to unpackage medical equipment technology into its component activities, such as
planning, allocating resources, procurement, commissioning, operation, maintenance, training, etc.
It provides good general policy formulation strategies to address the problems discussed.
Available from: WHO
Practical steps for developing health care technology policy: A manual for policy-makers
and health service managers in developing countries
Temple-Bird, C (2000). Institute of Development Studies, University of Sussex, UK.
ISBN: 1 85864 291 4
This book is a practical step-by-step guide for developing health care technology policy. It can be
used by health service providers, regional and district health authorities, health facility managers,
and external support agencies. It describes a process for developing health care technology policy
which is collaborative, participatory, iterative, and involves community stakeholders. Guidance is
provided on underlying management concepts, undertaking a situation analysis, running a ideas
workshop, formulating policy, developing an implementation plan and procedures manual, as well as
the resources required to complete these tasks.
Available from: Ziken International Consultants Ltd
See Guide 1 for further resources on, and examples of, developing healthcare technology policy.


Regulating relationships with external support agencies that provide equipment
Guidelines for health care equipment donations
WHO (1997). WHO document WHO/ARA/97.3
This document presents guidelines that aim to improve the quality of equipment donations, not to
hinder them. They are not an international regulation, but intended to serve as a basis for national or
institutional guidelines, to be reviewed, adapted and implemented by governments and
organizations dealing with health care equipment donations. They provide detailed guidance and
checklists for both the potential donor and recipient. The guidelines are based on extensive field
experience and consultations with many experts internationally. They also merge together several
earlier documents, including the one listed below.
Available from: WHO
Guidelines on medical equipment donations
Churches’ Action for Health (1994). World Council of Churches’ publication
This paper is a guide for those accepting and making donations, and is also useful for those planning
to buy equipment. It clearly lays out in point form the responsibilities of the recipient and the
responsibilities of the donor.
Available from: WCC


Annex 2: Reference materials and contacts


175




Understanding healthcare technology management
Health and disease in developing countries
Lankinen, K et al (eds) (1994). MacMillan Press. ISBN: 0 333 58900 9
This comprehensive book covers health and disease from the wider perspective of development in
general. It is of particular interest to medical and other professionals working in developing countries
or for international cooperation agencies. It is a valuable resource for district medical officers, and
students taking courses in public health and tropical medicine. Besides sections on: society,
economy and health; infectious diseases; and challenges for health care, there is a section on health
services to meet the challenges. This section contains chapters of particular relevance to equipment,
such as:
◆ Medical equipment management. Temple-Bird, C, Chapter 52
◆ Essential laboratory services. Willcox, W, Chapter 51
Available from: major internet bookshops
Health in the commonwealth: Challenges and solutions 1998/1999
Commonwealth Secretariat (1999). Kensington Publications Ltd, London
This digest of articles covers a wide range of health issues, such as: resources and planning; equity of
access; medical technology and equipment; health promotion; mother and child health; community
health; communicable and non-communicable diseases, etc. The content is aimed at policy-makers
and planners. There is a range of technology articles on equipment, telemedicine, hospital design,
sanitation, vector control, water and air supplies, including:
◆ Managing healthcare technology. Temple-Bird C, pp 57-60
Available from: Commonwealth Secretariat
International seminar for hospital technicians/engineers: February 1998, Moshi, Tanzania
Clauss J (ed) (1998). FAKT
This document reports the results of intensive work by 38 national and international experts brought
together from faith, public, and private agencies to strengthen equipment management measures in
the health sector. It includes papers, with country examples, on healthcare technology management,
financing maintenance, workshops and tool requirements, cash control, equipment standardization,
networking, structures of health care technical services, training, communication technologies,
modification of medical and hospital equipment, and energy supply and photovoltaics.
Available from: FAKT
International workshop on healthcare technology management: 2-6 October 2000,
Catholic Pastoral Centre, Bamenda, Cameroon
Clauss, J (compiler) (2000). FAKT
This document reports the results of intensive work by 35 national and international experts
involved in setting up and operating systems for the sustainable management of healthcare
technology. It includes papers, with country examples, on healthcare technology management, the
role of stakeholders, public/private partnerships for providing HTM, cost-effective maintenance and
repair services, and acquisition and utilisation of healthcare technology.
Available from: FAKT
Medical equipment in Botswana: A framework for management development
Temple-Bird C L, Mhiti R, and G H Bloom (1995), WHO publication WHO/SHS/NHP/95.1
This book reports on the results of a study of the healthcare technology sector in Botswana, and the
lessons learnt are of relevance to many other countries. The study was undertaken by unpackaging the
sector into its component activities, such as planning, allocating resources, procurement, commissioning,
operation, maintenance, training, etc. In this way the book provides good general healthcare technology
management strategies to address the problems discussed. This book discusses many of the common
operation and safety problems found in health facilities.
Available from: WHO


Annex 2: Reference materials and contacts


176




Physical assets management and maintenance in district health management
Halbwachs H (2000). GTZ document
This paper provides practical guidance to health workers involved in district health systems
concerning health technology – one of the critical areas in managing health service delivery at district
level. It presents the physical assets management approach, and elaborates on key strategies for
maintenance, financing, quality control, monitoring indicators, and a basic paper-based maintenance
information system. It also has an example of a maintenance job card.
Available from: GTZ
The effective management of medical equipment in developing countries: A series of five papers
Bastiaan Remmelzwaal (1997). FAKT, Project Number 390
This document is aimed at the health workers, administrators, maintainers, and overseas aid workers
who are involved in medical equipment management in developing countries. It examines the
variation in performance with management of medical equipment in different countries, with the
objective of identifying successful approaches. It addresses some of the managerial issues related to
the conservation of equipment; allocation of human, financial and material resources; and acquisition
and use. It looks at the structure for the HTM Service, and the HTM cycle.
Available from: FAKT
See Guide 1 for more information on further relevant issues, such as health service definitions, the
place of HTM in health systems, regulations, and standards.


Developing Skills, Managing Change, and Monitoring Progress
This material covers issues in Section 2.1 on managing change, Section 3.1 on accountability,
Section 3.5 on training, and Section 8 on target-setting and monitoring progress. It is listed
alphabetically by title.
A book for midwives
Klein, S (1996). Hesperian Foundation. ISBN: 0 942364 23 6
This book provides practical information on antenatal care, labour, birth and post-partum care. It also
includes a section on making teaching materials and low-cost equipment.
Available from: TALC
Diagnosis and treatment: A training manual for primary health care workers
Birrell, K and G Birrell (2000). VSO. ISBN: 0 333 72211 6
This is a practical training manual for all first line PHC workers. It gives guidance on how to diagnose
and treat the most common illnesses, how to prescribe rationally and deliver good patient care with
scarce resources. It is based on a series of training courses developed by VSO, national doctors and
health workers. It can be used as a self-study guide and as a reference manual.
Available from: TALC
District health care: Challenges for planning, organization and evaluation in developing
countries (2nd edition)
Amonoo-Larston R, Ebrahim G, Lovel H, and J Rankeen (1996). MacMillan. ISBN: 0 333 57349 8
This book contains practical support and advice intended for those in the planning, management
and evaluation of health services at district level. It covers a wide range of topics based on country
experience, including: staff motivation, teamwork, developing management skills, managing change,
managing conflicts, and staff development; managing finances; monitoring and evaluation; as well as
district health needs, plans, organization and management.
Available from: TALC
Healthcare technology: Training skills for hospital technicians and engineers
FAKT (1999). FAKT Technical Library Data Sheet
This paper discusses the major objectives of training both on- and off-the-job. It then provides
practical guidance on how to undertake on-the-job training effectively by using the PESOS
procedures (prepare, explain, show, observe, supervise). It explains each step in detail. Although
written for maintenance staff, its advice is just as useful for any other types of staff.
Available from: FAKT


Annex 2: Reference materials and contacts


177




Hospital technology: Communication – a vital skill for successful healthcare technical
service management
FAKT (1999). FAKT Technical Library Data Sheet
This paper discusses the importance of communication for both working in a team and working in an
organization/network. It provides advice on how to communicate effectively, its importance, the
barriers that exist, how to promote effective communication, the role of the head of department,
methods to use, and related reading. Although written for maintenance staff, its advice is just as
useful for any other types of staff.
Available from: FAKT
How to make and use visual aids
Harford, N and N Baird (1997). VSO. ISBN: 043592317X
This booklet describes a number of useful and practical methods for making visual aids quickly and
easily, using low cost materials.
Available from: TALC, VSO
Management support for primary health care: A practical guide to management for health
centres and local projects
Johnstone P, and J Ranken, (1994). FSG Communications Ltd, Cambridge, UK. ISBN: 1 87118 02 4
This practical user-friendly book gives support and guidance to leaders in health centres and other
local projects to help stimulate and maintain primary health care (PHC) in their surrounding
communities. Aid workers, and others unfamiliar with PHC and basic management techniques may
also benefit. Includes sections which will assist with staff motivation, such as teamwork and team
effectiveness; managing oneself, others and tasks; and managing change, as well as sections on
planning and monitoring progress.
Available from: TALC
Medical administration for frontline doctors: A practical guide to the management of
district-level hospitals in the public service or in the private sector (2nd edition)
Pearson C (1990). FSG Communications Ltd, Cambridge, UK. ISBN: 1 871188 03 2
This book provides information for doctors who combine wide clinical responsibilities with
administration and support for primary health care services. It covers a wide range of topics, with
country examples, including: management structures; infrastructure and maintenance; buildings,
support services, and equipment; hospital supplies; training; outreach programmes; and wider
responsibilities in the district and above. It includes advice on many safety topics such as cleaning
procedures, linen handling, earthing, lightning protection, and fire prevention.
Available from: TALC
On being in charge: A guide to management in primary health care (2nd edition)
McMahon R, Barton E, and M Piot (1992). ISBN: 9241544260
This practical guide aims to improve the managerial skills of middle level health workers. The text is
reinforced with practical examples, questionnaires and illustrations that help relate the information
to health workers’ own experiences. Topics include identifying health problems, assigning priorities
to their solution, planning and implementing programmes, and evaluating results. Also serves both as
a training and reference guide, covering all aspects of primary health care management including
equipment and drugs.
Available from: WHO
Physical assets management and maintenance in district health management
Halbwachs H (2000). GTZ document


Annex 2: Reference materials and contacts


178




Setting up community health programmes: A practical manual for use in developing
countries (2nd edition)
Lankester, T. (2000). ISBN: 0333679334
A practical ‘how-to’ manual designed for a wide range of health workers working with community
health programmes. With revised and updated material on planning, management and evaluation of
health programmes ranging from choosing and training a team through the setting up of clinics and
advising village health workers. Includes new information on community-based approaches to safe
motherhood, immunisation, malaria and TB, based on WHO guidelines.
Available from: TALC
Training health personnel to operate health-care equipment: How to plan, prepare and
conduct user training – A guide for planners and implementors
Halbwachs H, and R Werlein, (1993). GTZ, Eschborn
The aim of this book is to ensure that users are in a position to operate equipment and plant without
causing failure or malfunction. Part one addresses the planner/administrator developing user courses
and gives information about methods, course organization, finances, etc. Part two discusses
interesting issues for the implementers i.e. how to design a course, teaching methods and teaching
aids, conducting a course, etc. This practical guide provides sample checklists, questionnaires,
worksheets, tests, certificates, etc.
Available from: GTZ
Transfer of learning: A guide for strengthening the performance of health care workers
Intrah/PRIME II/JHPIEGO (March 2002)
This book is for health care workers involved in training and learning interventions and enables them
to transfer their newly acquired knowledge and skills to their jobs, resulting in a higher level of
performance and sustained improvement in the quality of services at their facilities.
Available from: free online at http://www.prime2.org/prime2/section/70.html


Efficient Use of Equipment
This material covers issues in Section 3.3 such as equipment utilization, building design, and cost-
effectiveness. It is listed alphabetically by title.
Approaches to planning and design of health care facilities in developing areas: Vol 3
Kleczkowski B, and R Pibouleau (eds) (1979). WHO Offset Publication No 45. ISBN: 92 4 170045 9
This volume addresses the issue of hospital design in terms of the building structure itself. It
discusses inpatient areas, outpatient department, surgery, radiology department, equipping and
mobile facilities. Equipment issues are covered in the section on equipping by Cooper-Poole, and
radiology by Palmer.
Available from: WHO
Approaches to planning and design of health care facilities in developing areas: Vol 4
Kleczkowski B, and R Pibouleau (eds) (1983). WHO Offset Publication No 72. ISBN: 924 170072 6
This volume addresses the issue of hospital design in terms of the building structure itself. The
design of a hospital is discussed in the context of geographic and demographic data, utilisation, costs
and available resources. It is a useful resource for planners, architects and administrators. This
volume covers small health care facilities, laboratory facilities, transport systems, local construction
materials, health service management, training, commissioning, and engineering and maintenance
services. Medical equipment is covered in the sections on commissioning by Steele, and on
engineering and maintenance services by Mehta.
Available from: WHO


Annex 2: Reference materials and contacts


179




Design for medical buildings (4th edition)
Mein P, and T Jorgnesen (1988). University of Nairobi, Housing Research and Development Unit;
African Medical and Research Foundation
Construction guidelines for medical buildings with special reference to appropriate designs for
developing and tropical countries. Relationship diagrams, flow of patients, linkages between
different units and services.
Available from: WHO, AMREF
District health facilities: Guidelines for development and operation
WHO Regional Publications: Western Pacific Series No 22 (1998). ISBN: 92 9061 121 9
This revised and expanded book presents detailed, richly illustrated guidelines for the planning
and design of district hospitals including the efficient utilization of space and easy movement of
people, equipment, and supplies. It also provides extensive information on the selection and
maintenance of medical and laboratory equipment. Additional material covers sanitation and waste
management, emergencies and disasters, the procurement of essential drugs, and safety testing and
calibration instruments.
Available from: WHO
Medical equipment in developing countries: Two neglected issues – planning and financing
Berg H (1992). WHO Document WHO/SHS/CC/92.2
This document is aimed primarily at health planners. It describes planning problems, and outlines
the procedures that should occur before equipment is purchased in order to ensure that the
implications of ownership are known. It looks at the recurrent cost implications of equipment, and
presents a method for unit costing and shows the consequences through examples.
Available from: WHO
See Guide 2 on planning and budgeting, for more material on planning and designing health
facilities and their equipment, as well as the life-cycle costs of equipment.


Operation, Care, and User Maintenance
This material covers issues in Section 3.2 on equipment handling, Section 4 on operation, care and
cleaning of equipment, and Section 7.2 on user maintenance. It is listed alphabetically by title.
Anaesthesia at the district hospital (2nd edition)
Dobson MB (1988). Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK.
ISBN: 92 4 154527 5
A practical manual designed to help medical officers in small hospitals acquire competence in the
use of essential techniques for inducing anaesthesia for both elective surgery and emergency care of
the critically ill. Addressed to doctors having at least one year of postgraduate clinical experience, the
book concentrates on a selection of basic techniques, procedures, and equipment capable of
producing good anaesthesia despite the limited resources usually found in small hospitals. The
manual was prepared in collaboration with the World Federation of Societies of Anaesthesiologists.
Available from: WHO
Anaesthetic equipment: Physical principles and maintenance (2nd Edition)
Ward C (1985). Baillière Tindall. ISBN: 0 7020 1008 1
This book provides a comprehensive and practical coverage of the wide range of equipment used
in anaesthetic practice. It allows the reader to understand the mode of operation and maintenance of
equipment, and how to cope with common causes of mechanical failure. Suitable for trainee
and established anaesthetists, intensive care specialists, anaesthetic nurses, and theatre and
maintenance technicians.
Available from: book suppliers


Annex 2: Reference materials and contacts


180




A pocket book for safer IV therapy (drugs, giving sets and infusion pumps)
M Pickstone (ed.) (1999). ISBN: 094 867232 3
This pocket book has been written to help clinical staff deliver safe IV therapy. It covers the
calculation of drug dose, the make-up of drug solutions and the selection of infusion devices and
associated equipment.
Available from: major internet bookshops
Basics of light microscopy (training video)
Olympus Microscopes. Code 30892
This video is both suitable for beginners or for those wishing to refresh existing knowledge. It
provides information about various objectives, proper illumination, magnification scales, and imaging
quality. Based on combined technical know-how and experience, this video is an easily
understandable and interesting teaching tool for microscopists and anyone who would like to
become one.
Available from: Olympus Microscopes
Blood pressure measuring equipment: Principles, use, maintenance, repair
Huys J (1992). TOOL, Amsterdam. ISBN: 90 70857 26 X
This book is for medical technicians in rural hospital and clinics. It covers the principles of common
BP equipment, how to use BP measuring equipment, advice about its use, and instructions for
maintenance and repair.
Available from: Medical and Health Library, free at http://media.payson.tulane.edu:8086/cgi-
bin/gw?e=t1c11copyrigh-mhl-1-T.1.B.21.1-500-50-00f&q=&l=e&g=00
Care and safe use of hospital equipment
Skeet M and Fear M. (1995). VSO. ISBN: 0 9509050 5 4
This book provides practical advice for health service staff about proper management of the type of
equipment found in district hospitals or health centres. It includes guidelines on preventive maintenance
and servicing, simple user instructions, checklists for correct and safe use of equipment, and basic
technical information for training of first-line maintenance staff. The information is easily accessible to
those without a technical background. It includes advice on many topics relating to safety and testing
such as checking power supplies, gas cylinders, disinfection and sterilization, as well as a basic tool list.
Available from: TALC, VSO
District laboratory practice in tropical countries (part 1)
Cheesbrough M (1998). Tropical Health Technology. ISBN:0 9507434 4 5
A valuable resource aimed at those responsible for the organization and management of district laboratory
services but can also be adapted for use by health centres. Covers selection and procurement of
laboratory equipment and supplies, as well as their use, care, and maintenance. It covers parasitological
tests, clinical tests and training of personnel, as well as all types of safety issues for laboratories.
Available from: TALC, THT
District laboratory practice in tropical countries (part 2)
Cheesbrough M (2000) Tropical Health Technology. ISBN:0 9507434 5 3
Covers microbiological, haematological and blood transfusion techniques required at district level.
Available from: TALC, THT
Emergency Care Research Institute (ECRI, USA) products
This organization produces a variety of products on healthcare technology. They are available as hard
copy and as software regularly renewed by subscription, with special rates for developing countries.
They cover various issues, such as:
◆ Inspection and preventive maintenance system
◆ Health devices alerts database (international database of medical hazards, problems and


recalls of equipment)
◆ Health technology monitor newsletter
◆ Healthcare product comparison system
◆ Health devices source book
◆ Health devices system
Available from: ECRI


Annex 2: Reference materials and contacts


181




General surgery at the district hospital
Cook J, Sabkaran B, and A Wasunna (eds) (1998). Dept. of Surgery, Eastern General Hospital,
Edinburgh, Scotland. ISBN: 92 4 154235 7
A richly illustrated guide to general surgical procedures suitable for use in small hospitals that are
subject to constraints on personnel, equipment, and drugs. The book presents an overview of basic
principles, and detailed information on simple but standard surgical techniques for the face and
neck, chest, abdomen, gastrointestinal tract, urogenital system, and paediatric surgery. Lists of
essential surgical instruments, equipment and supplies are included.
Available from: WHO
How to look after a refrigerator
Elford J, (1992). Healthlink (formerly AHRTAG). ISBN: 0 907320 07 4
Provides practical guidelines for care and maintenance of a range of kerosene, gas, electric and solar
refrigerators.
Available from: Healthlink Worldwide
Instrumentation for the operating room: A photographic manual (5th edition)
Brooks Tighe S (1999). ISBN 0323003508
Colour photographic reference manual illustrating in detail a range of instruments for major surgical
procedures: endoscopic, neurosurgery, ophthalmic, orthopaedic, and oral, maxilla and facial surgery.
Also includes a section describing the care and handling of instruments from cleaning to sterilization,
inspection and testing.
Available from: major internet bookshops
La maintenance dans les systemes de santé/ Maintenance for health systems: 4th GTZ
Workshop, Dakar, Senegal, September 1993
Halbwachs H, and R Schmitt (eds) (1994). GTZ
This document reports the results of intensive work by 67 national and international experts brought
together from health services and support agencies to strengthen equipment maintenance measures
in the health sector. It includes papers, with country examples, on the benefits of maintenance, the
place of maintenance in the district health system, maintenance management and organization,
energy management, photovoltaic systems, networking and computers, and training. This document
has sections written in both French and English.
Available from: GTZ
Maintenance and repair of laboratory, diagnostic imaging, and hospital equipment
WHO (1994). ISBN: 92 4 154463 5
A practical manual for maintenance and repair of basic laboratory and diagnostic equipment, as well
as anaesthetic machines, operation room equipment, and ultrasound and X-ray generators. Intended
for use in settings that do not have technicians or engineers with specialist expertise. The manual
uses line drawings and numerous checklists for inspection and cleaning, good working practices,
routine operation and maintenance. It is also useful as a training aid. It includes advice on many
topics relating to safety and testing such as disinfection, gas cylinders, laboratory hazards, radiation
hazards, and hazards from other types of equipment.
Available from: WHO
Manual of darkroom technique
Palmer P (1985). WHO Basic Radiological System: ISBN: 92 4 154178 4
This manual is intended for use by operators working with the WHO Basic Radiological System
(WHO-BRS), but the principles and methods described can be used in the processing of X-ray films
taken with any type of X-ray equipment. The manual provides a step-by-step illustrated guide to
darkroom technique, and outlines all the basic requirements for the storage and handling of X-ray
films and processing equipment. It contains sections covering the maintenance of the processing
tank (non-electric) and the cassettes and screens. This is in the form of schedules of cleaning to be
undertaken daily, weekly and monthly.
Available from: WHO


Annex 2: Reference materials and contacts


182




Medical supplies and equipment for primary health care: A practical resource for
procurement and management.
Kaur M, and S Hall (2001). ECHO International Health Services Ltd. ISBN: 0 9541799 0 0
This book is intended for health workers and those responsible for the procurement and management
of medical supplies and equipment at primary healthcare level. It covers guiding principles for
selecting supplies and equipment, provides guidelines for ordering and procurement, storage and
stock control, care and maintenance, and considers decontamination and safe disposal of medical
waste. The manual also discusses the use of standard lists as a tool for encouraging good procurement
practice and includes model lists of medical supplies and equipment required for primary health care
activities in both health facilities in the community, and basic laboratory facilities.
Available from: TALC
Physical asset planning and management software (PLAMAHS)
HEART Consultancy
This software package holds information, and supports analysis, on: the equipment inventory,
equipment models and standards, existing and planned facilities, procurement support, and
maintenance support. The software holds various digital images, standard lists and templates for forms,
etc, and has a security system. It has been designed especially with developing countries in mind, is
available at special rates for developing countries, and HEART can assist with training requirements.
Available from: HEART Consultancy
Refrigerators use, maintenance and repair series
Expanded Programme on Immunisation (EPI) (1984-1987). WHO
EPI/LOG/84/14 - 19, 21, 22, 25, 26 and EPI/TECH.HB/A - H
This series is grouped into two sub-series: i) User and ‘how to look after’ handbooks, and ii) Repair
technicians handbooks. The user’s handbooks are comprehensive illustrated guides that contain
information on installation, the components, operation, schedules for daily/weekly/monthly care,
fault-finding, basic maintenance procedures, and conversion to electric operation. The ‘how to look
after’ handbooks contain task sheets for different maintenance tasks, with information on the tools
and materials required, and step-by-step action required for the tasks (written as training modules).
The technician’s handbooks have the same format as the user material but cover much more
complicated maintenance procedures. They are meant to be used in conjunction with the
manufacturers’ own maintenance and repair manuals.
Available from: WHO
Selection of basic laboratory equipment for laboratories with limited resources
Johns ML and ME El-Nageh (2000). ISBN: 9290212454
This book provides a framework to help laboratory workers, supply officers and decision makers to
choose and buy laboratory equipment and consumables. Includes information on maintenance and
energy requirements for laboratory equipment, quick reference buyer’s guides and equipment data
specification sheets provide easy reference for equipment buyers. The framework can be adapted to
guide general equipment purchasing.
Available from: WHO
Surgery at the district hospital: Obstetrics, gynaecology, orthopaedics and traumatology
Cook J, Sabkaran B, and A Wasunna (eds) (1991). Dept. of Surgery, Eastern General Hospital,
Edinburgh, Scotland. ISBN: 92 4 154413 9
An illustrated guide to essential surgical procedures in small hospitals for treating the major
complications of pregnancy and childbirth, common gynaecological procedures, and managing
traumatic injuries, including fractures and burns. Emphasis is placed on standard surgical protocols
that represent the safest line of action in hospital settings where equipment may be primitive, drugs
limited, and specialist services sparse – these requirements are discussed.
Available from: WHO


Annex 2: Reference materials and contacts


183




Surgical instruments: A pocket guide (2nd edition)
Papanier Wells M, and M Bradley (1998). ISBN: 00721678017
A pocket guide listing and describing surgical instruments: sharps/dissectors, forceps, clamps,
retractors, suction tips, dilators, endoscopic instruments, internal stapling devices, and most
commonly used instrument sets for a variety of surgical procedures. Includes a picture of the
instrument with a brief description explaining the uses, varieties, and alternative names.
Available from: major internet bookshops
Training manual for central service technicians (4th edition)
American Society for Healthcare Central Service Professionals (2001). ASHCSP, USA.
ISBN: 0 7879 5947 2
This manual is an introductory text developed to acquaint entry-level aides and technicians with the
scope of the central service (central sterile supply department) profession and with the scientific
principles that underlie their daily work. Updated materials include easy-to-read graphs, new
photographs, and updated information on regulation, governing agencies, and web links. Other
publications are available linked to this manual, such as a workbook, an instructor’s guide, a
manager’s manual, and so on – see ASHCSP website.
Available from: ASHCSP
Where there is no technician: A practical guide for users of medical equipment
Remmelzwaal B, and E de Villiers (eds) (2002). MOHSS, Namibia
This manual aims to cover situations where the nearest knowledgeable maintenance technician or
private company is hundreds of kilometres away, and health workers must develop basic skills related
to maintenance, calibration, and safe operation of equipment. In a modular style, it covers 10 pieces
of medical equipment commonly found in district health facilities. The manual intends to serve both
as a training manual and as a practical reference guide for individual health workers.
Available from: Ministry of Health and Social Services, Namibia


Safety Issues
This material covers issues in Section 5, such as operator safety, decontamination issues, waste
management, electrical safety, medical equipment safety, and accidents. The material is listed
alphabetically by title in each sub-section.


Tip • Some sources cover many topics and are listed in the first sub-section. Sources that cover a single
topic are listed in the sub-sections dedicated to that topic. When looking for a specific topic, always
check the first sub-section to see if any sources also cover the subject matter you are interested in.


Sources covering many safety topics
Care and safe use of hospital equipment
Skeet M and Fear M. (1995). VSO. ISBN: 0 9509050 5 4
Emergency Care Research Institute (ECRI, USA) products
ECRI
Enhancing patient safety: The role of clinical engineering
American College of Clinical Engineering (2001). ACCE White Paper, ACCE, Plymouth Meeting, USA
This paper discusses the problem (in the USA) of the level of adverse incidents occurring in
healthcare due to user error, and the important role clinical engineers need to play in patient safety. It
contains information on other papers, websites, and organizations that deal with patient safety issues.
Available from: ACCE website: www.accenet.org
Essentials of health and safety at work
Health and Safety Executive (HSE) (1989). ISBN 0 11 885494 1
This practical, easy to use guide helps you to prevent workplace accidents and comply with UK HSE
law without major disruption or expense. It is full of good advice to help you start planning for safety,
and contains checklists, diagrams, and case studies covering a wide range of workplace hazards.
Available from: HMSO Books, UK


Annex 2: Reference materials and contacts


184




Gas safe with medical gases (training video)
BOC Medical. Code 888859
This video includes information on the storage and handling of cylinders, identification, and
procedures in the event of fire, etc.
Available from: BOC Medical
Infusion systems
Medicines and Healthcare Regulatory Authority (1995). MDA Device Bulletin, No. DB 9503
(May 1995)
This publication addresses many aspects of the use and selection of infusion systems. Its purpose is
to raise awareness of the nature of infusion systems, their advantages and their potential risks, with a
view to reducing the number of adverse incidents that arise from their use. It describes the different
types of infusion devices, risks and applications, training programmes, safety recommendations,
purchasing, and management responsibilities.
Available from: MHRA
Maintenance and repair of laboratory, diagnostic imaging, and hospital equipment
WHO (1994). ISBN: 92 4 154463 5
Medical administration for frontline doctors: A practical guide to the management of
district-level hospitals in the public service or in the private sector (2nd edition)
Pearson C (1990). FSG Communications Ltd, Cambridge, UK. ISBN: 1 871188 03 2
Medical equipment in Botswana: A framework for management development
Temple-Bird C L, Mhiti R, and G H Bloom (1995), WHO publication WHO/SHS/NHP/95.1
Medical supplies and equipment for primary health care: A practical resource for
procurement and management.
Kaur M, and S Hall (2001). ECHO International Health Services Ltd. ISBN: 0 9541799 0 0
Medicines and Healthcare Regulatory Agency (MHRA, UK) products
This agency of the UK government (formerly the Medical Device Agency) ensures medical devices
and equipment meet appropriate standards of safety, quality, performance, and effectiveness, are
used safely, and that they comply with relevant Directives of the European Union. The MHRA
provides a variety of publications, such as:
◆ Medical device alerts (replacing former hazard notices, safety notices, device alerts,


advice notices, etc)
◆ Device bulletins (replacing former evaluation reports)
◆ Device evaluations
◆ Advice on a wide variety of safety topics (visit the website, click on contacts, then medical


devices, then search under a subject area such as decontamination, or laundry for example).
Available from: MHRA
Safety at work (training video and interactive CD)
RS Components Ltd.(1994). Codes 446-2446 and 446-2452 (catalogue page 1-196 Sept 2003)
This video/CD covers the important safety issues that every electrical apprentice needs to know. It
includes sections on the range of hazards and risks of working in the electrical industry, health and
safety law, portable appliance testing, keeping an eye out for hazards, using equipment properly,
accessing and handling equipment, what to do in an emergency, and recognizing the signs.
Available from: RS Components Ltd
Safety in clinical and biomedical laboratories
Collins C (ed) (1988). Chapman and Hall Medical. ISBN: 0 412 28370 0
This book is a concise guide to proper practice in a clinical environment, to achieve safety at work. It
covers chemical, electrical, mechanical, microbiological, and radiation hazards, laboratory first aid,
and safety checklists.
Available from: major internet bookshops


Annex 2: Reference materials and contacts


185




Equipment-related infection control
A handbook for managers: Insecticide treated net projects
Chavasse D, Reed C, and K Attawell (1999). Malaria Consortium.
Designed to be a practical decision-making tool for project managers, the handbook covers planning,
implementing and monitoring treated net projects, illustrated with examples from more than 30
projects in 16 countries.
Available from: http://www.liv.ac.uk/lstm/malaria/mcpubns.htm
Chemical disinfection in hospitals (2nd edition)
G Ayliffe, D Coates and PN Hoffmann (1993). ISBN: 0901144347
This book is a guide to disinfection in hospitals and laboratories. It covers the principles, properties and
safety of chemical disinfection and disinfectants. There are chapters on disinfection policy and cleaning
and disinfection of the environment, skin, and medical equipment including endoscope disinfection.
Available from: major internet bookshops
Hygiene promotion: A practical manual for relief and development
Ferron S, Morgan J and M O’Reilly (2000). ISBN: 1853395056
This manual has been written for fieldworkers aiming to reduce the incidence of water and
sanitation related diseases in relief and rehabilitation programmes. Also useful for other
development workers, particularly those working in the fields of community development, health
and engineering.
Available from: TALC
Hospital hygiene (3rd Edition)
Maurer I (1990). Edward Arnold, London. ISBN: 0 7131 4443 2
This book makes an important contribution to the understanding of infection and methods of
infection control worldwide. It deals with the subject in an entertaining and stimulating manner and
provides direct advice and guidance in a difficult area of hospital administration. It provides any
health service worker who deals with hospital hygiene with information and illustrations so that
informed decisions can be made, priorities assessed, and training programmes organized. It covers
hospital infection, sterilization, disinfection, dust control, cleaning with water, chemical disinfection,
and hygiene policies.
Available from: major internet bookshops
Immunisation in practice: A guide for health workers who give vaccines
WHO (1996). MacMillan. ISBN: 0 333 63095 5
A guide for health workers giving immunisations. Explains about vaccinations and provides practical
information on how to carry out immunisation, look after vaccines and on methods of sterilisation
and boiling.
Available from: TALC, WHO.
Optimalization of the process for manually operated jacket steam sterilizers
Muis B, Bruijn ACP de, Drongelen AW van, and J Huys (2001). RIVM report 318902011
This report describes research to find the optimal process for manually operated jacketed steam
sterilizers that are mainly used in developing countries. It looks at various test packs, the use of
thermocouples, and test cycles to find the optimal process profile.
Available from: RIVM/Dutch Institute for Public Health and the Environment
Sterilization of medical supplies by steam, volume 1: General theory (2nd edition)
Huys J (2003). HEART Consultancy. ISBN: 90 75829 04 3
This book focuses on the most common and most safe method used for sterilization in the Central
Sterile Supplies Department in healthcare institutions – sterilization by pressurised high
temperature steam. Originally intended to educate technical service personnel in remote health
institutions, it has grown into a textbook that can be used by anyone interested in sterilization.
Contains information on steam pulsing, monitoring sterility, self-made test packs, use of
thermocouple testing kits, and process profiles. Available in several languages.
Available from: HEART Consultancy


Annex 2: Reference materials and contacts


186




Vector control: Methods for use by individuals and community
Rozendaal J (1997). WHO. ISBN: 92 4 154494 5
Provides practical information on all major disease vectors and pests, and on effective control
methods suitable for rural and urban environments. Intended for health workers and auxiliary staff as
well as health planners and aid organizations.
Available from: WHO


Waste management
De Montfort medical waste incinerators
Information on the De Montfort University incinerators designed by Prof. DJ Picken can be obtained
from a website. It contains copies of drawings and instructions for the building, operation and
maintenance of various incinerator models. The range of DMU incinerators has been developed for
use by rural PHC facilities, and designed to be constructed on site using local materials. There may be
a small charge to cover the cost of printing and postage of the plans.
Available from: website: www.mw-incinerator.info/en/101_welcome.html
How are we managing our health care wastes?
Coad A, and J Christen (1999). SKAT
This document looks at management of health care waste in low-income and middle-income
countries using case studies from 6 cities in Africa, Asia and the Middle East. Consists of a series of
questions with comments to guide health care waste management.
Available from: ITDG Publishing
Management of solid and liquid waste at small healthcare facilities in developing countries.
Jantsch F, and H Vest, (1999). GATE-Information Service, Division 44: Environmental Management,
Water, Energy, Transport, GTZ, Eschborn, Germany
This book aims to raise awareness and provide advice for healthcare waste management in order to
improve the overall environmental conditions at health facilities. Part one of this practical guide
provides advice on healthcare waste generation and related hygiene risks, waste management and
factors influencing its effectiveness at health facilities in developing countries. Part two presents a
series of detailed worksheets with illustrations to provide the reader with practical solutions suitable
for immediate implementation.
Available from: GTZ, GATE
Safe management of wastes from health-care activities
Pruss A, Giroult E, and P Rushbrook (1999). ISBN: 9241545259
A comprehensive and practical guide covering all aspects of the management of health care waste.
The book defines waste categories and characteristics, describes the planning needed, collection,
segregation, storage, transport, and disposal of waste. There is also chapter on training and a section
on simple and safe waste management techniques for emergencies and small rural facilities. It is
relevant to hospitals in developing countries and health centres.
Available from: WHO


Electricity supplies and safety
A guide to power conditioning and power back-up
Huys J (1996). FAKT, Basler Mission, and HEART Consultancy
This document is an introduction to guide you through the terminology and information regarding
power conditioning and power back-up. It is aimed at health workers facing problems with ensuring
power quality for any electrical equipment, and ensuring power is available when you need it. It
deals with the problems which can occur in the mains supply, and an explanation about the main
measures which can be taken for power conditioning and power back-up (including advice on
suppressing electro-magnetic interferences and radio frequency interference, and advice on
different types of uninterruptible power supplies). It is meant for anyone involved in the decision-
making process for the procurement and installation of such equipment.
Available from: FAKT


Annex 2: Reference materials and contacts


187




Electricity at work (training video)
RS Components Ltd.(1990). Code 446-2238 (catalogue page 1-201 Sept 2003)
This video examines electricity at work regulations. It includes sections on the need for regulations,
the dangers of electricity, safe construction and maintenance of electrical systems, strength and
capability of electrical equipment, equipment exposed to adverse conditions, prevention of danger,
earthing and protective devices, electrical continuity, joints and sockets, excess current protection,
isolation of equipment, live working, access for work, and suitable personnel and training.
Available from: RS Components Ltd
IEE wiring regulations (16th edition)
William Ernest (amended 2004). RS Components Ltd
This is the latest edition of the IEE wiring regulations which describes how to plan and implement
electrical installations safely in accordance with international wiring rules. (Guidebooks for
implementing the IEE wiring regulations are also available).
Available from: RS Components Ltd
If not in use – switch off!: Guidelines and key recommendations for a sustainable and cost-
effective energy supply for health facilities in remote locations
Röttjes M (1995) FAKT, Stuttgart, Germany
This practical document aims to provide a variety of courses of action that medical and
administrative staff can pursue when health facilities are hit by energy problems. It covers
sustainable and cost-effective energy supplies, the different energy requirements, possible energy
sources, and suggestions for a hospital energy supply. It includes PPM schedules for air-cooled diesel
power plants.
Available from: FAKT
International seminar for hospital technicians/engineers: February 1998, Moshi, Tanzania
Clauss J (ed) (1998). FAKT
La maintenance dans les systemes de santé/ Maintenance for health systems: 4th GTZ
Workshop, Dakar, Senegal, September 1993
Halbwachs H, and R Schmitt (eds) (1994). GTZ
Testing to the 16th edition (training video)
RS Components Ltd.
This video describes how to test electrical installations according to the latest IEE wiring regulations
(16th edition).
Available from: RS Components Ltd


Laboratory safety
District laboratory practice in tropical countries (part 1)
Cheesbrough M (1998). Tropical Health Technology. ISBN:0 9507434 4 5
District laboratory practice in tropical countries (part 2)
Cheesbrough M (2000) Tropical Health Technology. ISBN:0 9507434 5 3
Practical laboratory manual for health centres in East Africa,
Carter J and Olema O (1998). AMREF.
Practical laboratory manual providing information necessary to establish, select and use laboratory
tests for patient management. Also includes material on implementation of safe working practices,
reporting and recording test results, keeping an inventory of supplies and equipment, ordering
supplies and maintaining equipment.
Available from: AMREF


Annex 2: Reference materials and contacts


188




Supplies and Stores Management
This material covers issues in Section 6, such as supplies management and stock control. It is listed
alphabetically by title.
How to manage a health centre store
Battersby A (1994). Healthlink Worldwide (formerly AHRTAG).
Describes in detail the structure and organization of a store or dispensary, methods of arranging
stocks, stock control, and basic dispensing.
Available from: Healthlink Worldwide
Medical supplies and equipment for primary health care: A practical resource for
procurement and management.
Kaur M, and S Hall (2001). ECHO International Health Services Ltd. ISBN: 0 9541799 0 0
Spare parts and working materials for the maintenance and repair of health care
equipment: Report of workshop held in Lübeck, August 1991
Halbwachs H, and C Temple-Bird (eds) (1991). GTZ, Eschborn, Germany
This book, mainly aimed at maintenance technicians, covers the maintenance requirements for
common items used at district level (anaesthesia equipment, infant incubators, X-ray equipment,
suction pumps, autoclaves and laundry equipment) including some advice on safety testing and test
instruments. It also includes information on workshops and stock control of parts.
Available from: GTZ
Stock control software
Stock control of items in stores is an area where simple computer software programs can be of
assistance once you have mastered a manual paper system, have a large enough store (for example, at
central level), and can obtain sufficient training of staff. The following products can be viewed on
the internet and should provide either a full demonstration CD of the software to study, or use of a
shareware program free of charge for a set period of time:
◆ Website: www.easy4you.net/EN/stock.htm


Low cost stock control and invoicing package for small to medium size businesses, provided as
shareware software.


◆ Website: www.microsoft.com/BusinessSolutions/Navision/supplychain.aspx
Navision sales and stock management software is suitable for medium to large scale businesses,
and is available in various building blocks. Navision is used by several central/national medical
stores in Africa, but requires a lot of training


◆ Website: www.requisoft.com/stock/stock.html
Requisoft Stock software controls and manages an organization’s stock, and allows you to browse
through your stock records. It can be used on its own or as a module of the Requisoft
Procurement system.


◆ Website: www.artisan.co.uk/products/index.php?p=Stock
Artisan stock management and control software is comprehensive, and includes complex
assembly component and works order systems.


Technician’s handbook for compression refrigerators – Part D: How to keep stocks of
spare parts
WHO Expanded Programme on Immunization (1984). EPI/TECH.HB/D, Document
EPI/LOG/84/20 in Refrigerators use, maintenance and repair series, WHO, Geneva.
This booklet contains a series of case studies to help the reader learn about spare parts management.
Although designed for vaccine refrigerators, it can be applied to any spare parts. It has sections
covering how to choose and order spare parts, how to keep track of stocks of spare parts, how to
decide who should keep the stocks, and how many parts should be kept at each level of the health
service. It contains exercises and case studies for each topic.
Available from: WHO


Annex 2: Reference materials and contacts


189




Testing and Decommissioning
This material covers issues in Section 7.3 on safety testing and test instruments, and Section 7.5 on
decommissioning. It is listed alphabetically by title.
Care and safe use of hospital equipment
Skeet M and Fear M. (1995). VSO. ISBN: 0 9509050 5 4
District health facilities: Guidelines for development and operation
WHO Regional Publications: Western Pacific Series No 22 (1998). ISBN: 92 9061 121 9
Estimated useful lives of depreciable hospital assets (revised 2004 edition)
American Society for Hospital Engineering (2004). American Hospital Association.
ISBN: 1 55648 319 8
One of the organizations which have tried to estimate typical equipment lifetimes for healthcare
technology. The AHA’s extensive list reflects how equipment lasts within the United States’ health
care system whether it was manufactured in the US or abroad. It covers buildings, estate, fixed
equipment, and individual items of movable equipment. The list was compiled after discussions
with manufacturers of healthcare equipment, discussions with various hospital department
managers, and analysis of actual retirement practices for actual hospital assets.
Available from: AHA
Maintenance and repair of laboratory, diagnostic imaging, and hospital equipment
WHO (1994). ISBN: 92 4 154463 5
Maintenance and the life expectancy of healthcare equipment in developing economies
Hans Halbwachs, GTZ. In Health Estate Journal (March 2000) pp 26-31
This article comes from one of the organizations that have tried to estimate typical equipment
lifetimes for healthcare technology. The GTZ estimates are for 16 types of medical equipment and
plant, and tries to more closely reflect the realities in developing countries. The article describes the
Delphi survey used to obtain feedback from 23 experts from 16 different country backgrounds.
Rather than providing exact lifetimes, this approach provides a range for the lifetime which depends
on the quality of the initial equipment and how well it has been maintained.
Available from: GTZ
Spare parts and working materials for the maintenance and repair of health care
equipment: Report of workshop held in Lübeck, August 1991
Halbwachs H, and C Temple-Bird (eds) (1991). GTZ, Eschborn, Germany


See Guide 5 on maintenance management for more information on maintenance schedules that
include safety tests.


Annex 2: Reference materials and contacts


190




Accessing Information
These websites are sources of information concerning many aspects of health service delivery. They
are locations where there is, or may be, information about healthcare technology management and
equipment operation and safety.
Africa online: Health website: http://bamako.africaonline.com/afol/index.php
Provides links to health information sites related to Africa. The links are organized into the following
categories: health information, health news, events, African organizations, international
organizations, schools and hospitals in Africa, projects, publications and health services
AFRO-NETS (African networks for health research and development) website:
www.afronets.org
Forum for exchanging health research information in and between East and Southern Africa.
AJOL (African journals online) website: www.inasp.org.uk/ajol
Offers free online access to tables of contents and abstracts of over 70 journals published in Africa.
Blood transfusion safety (BTS) website: www.who.int/bct/Main_areas of work/BTS/BTS.htm
WHO site covering blood safety issues from access to safe blood and blood products to evaluations of
HIV testing kits.
British medical journal website: http://bmj.bmjjournals.com/
Free worldwide access to BMJ and the student BMJ and wide range of specialist journals to users in
low-income countries.
CEN website: www.cenorm.be
The European Committee for Standardisation website lists the essential European Standards they
publish regarding sterile supplies. They include standards for different sorts of sterilizers and Bowie
& Dick tests (e.g EN285, EN13060), validating sterilization techniques (e.g. EN554), chemical
disinfection (e.g. EN1499), testing systems (e.g. EN866, EN877), packaging and labelling
(e.g. EN868, EN556).
Centers for Disease Control and Prevention (CDC) website: www.cdc.gov
This agency of the US government is a leading centre for providing up-to-date information on
disease prevention and control, health promotion, and education activities. The website has a wide
range of information. For example, discussions on:
◆ the correct laundering of linen at www.cdc.gov/ncidod/hip/STERILE/laundry.htm
◆ how laundries should wash infected material at www.cdc.gov/ncidod/hip/Blood/worker.htm
◆ laundering for patients with AIDS at www.cdc.gov/hiv/pubs/brochure/care6.htm#Laundry.
Deliver website: www.deliver.jsi.com
USAID funded project focusing on supply chain logistics for health products in developing countries from
estimating demand for supplies, and maintaining optimal supply levels, to proper storage guidelines.
Eurasia health knowledge network (EHKN) website: www.eurasiahealth.org
Specialises in the health information needs of the Former Soviet Union (FSU) and Central and
Eastern Europe (CEE). Site links to clinical practical guidelines, medical textbooks, and other
educational materials, many in Russian and other regional languages
European forum for hospital sterile supply website: www.efhss.com
The forum runs a website hosting most European associations related to sterile supply. It is a useful
resource with a question and answer page, discussion forum, training and other useful information
on sterilization.


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191




FIN: Free international newsletters: www.healthlink.org.uk
Healthlink produces this publication that lists over 130 print and electronic health-related
newsletters and magazines which are available free to readers in developing countries.
Free medical journals website: www.freemedicaljournals.com
This site is a comprehensive, up to date list of medical journals available free on the internet.
GATE (German Appropriate Technology Exchange): www5.gtz.de/gate/
The GATE Information Service seeks to improve the technological knowledge of organizations and
individuals involved in poverty alleviation projects and to develop information and knowledge
management systems of organizations.
Global alliance for vaccines and immunization (GAVI) website: www.vaccinealliance.org
This global alliance produces a wide range of information including factsheets and the Immunization
FORUM newsletter providing updates and topical debate about key immunisation issues.
Healthcare waste website: www.healthcarewaste.org
WHO site for health care waste management
Health exchange website: www.healthcomms.org
Explores issues, ideas and practical approaches to health improvement in developing countries and
provides a forum for health workers and others to share viewpoints and experiences in this area.
HealthNet news website: www.healthnet.org/medpub
Weekly newsletter distributed to health professionals in Africa, Asia and Latin America. Features
current, practical, clinical and public health information.
HIF-net at WHO discussion group
Discussion list dedicated to issues of improving access to reliable health information in resource-poor
settings. To join, email your name, affiliation and professional interests to: health@inasp.info
HINARI (Health inter-network access to research initiative) website: www.healthinternetwork.net
WHO initiative offering free/discounted access to journals from six leading publishers.
HNP flash website: www.worldbank.org/hnpflash
A free monthly electronic newsletter dedicated to sharing knowledge regarding the latest technical
developments in the fields of health, nutrition, population, and reproductive health.
ID21 health website: www.id21.org/health
An internet based development research reporting service for health policy makers and development
practitioners on global health issues. Latest research summaries are provided on a searchable
website, by email and in a quarterly publication.
IEC website: www.iec.ch
International Electrotechnical Committee, which sets standards for the safe manufacture of
electrical healthcare technology. There is a wide range of specific standards for medical electrical
equipment falling under the standard numbers IEC 60101–1,2, and 3.
IEE healthcare technologies professional network website: www.iee.org/pn/healthtech
The Institution of Electrical Engineers of the UK provides internet sites for a wide variety of
engineering professions, with the aim of enabling people to communicate with their peers around
the world and access the latest global industry news and key information sources. One of their
professional networks focuses on healthcare technologies. It has also hosted a series of seminars on
Appropriate medical technology for developing countries, and their reports can be obtained
from the IEE.
INFRATECH discussion group
WHO forum for global exchange of information on infrastructure and healthcare technology issues.
To subscribe, send an email to listserv@listserv.paho.org. Enter in text: subscribe infratech ‘your full
name’.
International health exchange website: www.ihe.org.uk
Provides training, information and advice to health workers in emergency aid and development
situations. This site also provides information about jobs and health development issues.


Annex 2: Reference materials and contacts


192




Joint Commission on Accreditation of Healthcare Organizations (JCAHO) website:
www.jcaho.org
This American body has published new patient safety standards that cut across disciplinary
boundaries in an attempt to make safety a fundamental principle of patient care. These standards
cover infection control, the environment of care, and other disciplines.
KAR (Knowledge and research programme on disability and healthcare technology) website:
www.kar-dht.org, and for the latest projects being funded use website: www.disabilitykar.net/
This is the Knowledge and Research Programme on disability and healthcare technology of the UK
government's Department for International Development (DFID). It supports a range of projects on
development and use of appropriate disability and healthcare technologies in developing countries.
The website also provides links to:
i. Disability and healthcare technology newsletter produced every six months describing the


progress and findings of the projects funded;
ii. KaR global database on healthcare technology publications, organizations, manufacturers,


training institutions, etc.
NICE (National Institute of Clinical Excellence) website: www.nice.org.uk
Provides guidance to the UK National Health Service (NHS) on current best practice covering both
health technologies (from medicines to diagnostic techniques) and the clinical management of
specific conditions.
Programme for appropriate technology in health (PATH) website: www.path.org
PATH identifies, develops and applies appropriate technologies to public health problems in
developing countries.
Public health care laboratory website: www.phclab.com
Global forum of information exchange and resource centre for laboratory personnel and those
concerned with PHC laboratory services in developing countries.
Safe injection global network (SIGN) alliance website: www.who.int/injection_safety/sign/en
This is a network/discussion group for safe injection issues from technical, managerial, and
operational issues to policy development, consensus formation and advocacy. It covers a wide range
of topics, such as whether to use reusable or disposable items. The alliance produces the electronic
newsletter SIGNpost. The site is hosted by WHO.
TechNet (Technical network for strengthening immunisation services) website:
www.technet21.org
Forum focusing on improving management and operational logistics for health service delivery in
developing countries, in particular, immunisation services.
The manager’s electronic resource center website: http://erc.msh.org
The ERC website is an electronic information resource and communication service for health managers,
containing more than 150 ready-to-use management tools in various languages. A key feature is:
◆ The health manager’s toolkit, includes spreadsheet templates, forms for gathering and


analyzing data, checklists, guidelines for improving organizational performance, and self-
assessment tools that allow managers to evaluate their organizations. Tools cover areas such as
strategic planning, developing information systems, cost and revenue analysis, and sustainability.


WHO: Health technology and pharmaceuticals website: www. who.int/technology
This WHO site provides information on pharmaceutical and health technology developments with a
particular focus on developing countries. It includes links to blood transfusion safety and clinical
technology, essential drugs, medicines, vaccines and biologicals.
WHO: Injection safety website: www.injectionsafety.org
This WHO site focuses on safe injections and the elimination of injection-associated transmission of
blood-borne pathogens.
WHO: Management of health services (MAKER) website: www. who.int/management
This WHO site provides information, publications, and country experiences on all types of management
issues for health services, such as facility management, resource management, and district management.


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193




ii. Organizations, Sources of Publications in Part i, Resource and
Information Centres


For the following institutions we have included the name, address, contact details, a brief description
of the various services they offer, and additional contact details for further relevant activities.
AfriAfya
AMREF Building, PO Box 30125, Nairobi, Kenya
Tel: 254 2 609520, fax: 254 2 609518, email: info@afriafya.org, website: www.afriafya.org
Established by Kenya-based health agencies, AfriAfya provides community access to relevant and
appropriate health knowledge and information in an interactive manner. As well as a section on
HIV/AIDS there is a news centre, message board and discussion forum on their website.
AFTH (African Federation of Technology in Healthcare)
PO Box 19070, Tyberg 7505, South Africa
Email contacts: ykwankam@cht.uninet.cm and pheimann@mweb.co.za
For information use website: http://ifmbe-news.iee.org/ifmbe-news/may1998/mrc.html, and look up
the South African Medical Research Council (SA MRC).
Albert Browne (International) Ltd
Chancery House, 190 Waterside Road, Hamilton Industrial Park, Leicester, LE5 1QZ, UK
Tel: 44 116 276 8636, fax: 44 116 276 8639, website: www.thebrownegroup.co.uk
This company manufactures sterilization monitoring systems, and is a source for a wide range of
ready-made Bowie & Dick tests in different forms using TST technology.
Amazon Bookshop
PO Box 81226, Seattle, Washington 98108-1226, USA
Website: www.amazon.com or www.amazon.co.uk
Internet bookshop
American Hospital Association
Clinical Engineering Section, 840 North Lake Shore Drive, Chicago, Illinois 60611,USA
Website: http://aharc.library.net/
Their documents are published by HealthForum, use website:www.ahaonlinestore.com
American Society for Healthcare Central Service Professionals (ASHCSP)
One N Franklin Avenue, Chicago, Illinois 60606-3421, USA.
Tel: 1 312 422 3700, fax: 1 312 422 4577, website;
www.ashcsp.org/ashcsp/education/publications.html
This society is for healthcare workers working in the central service and sterile processing field
(central sterile supply departments). They produce a wide range of publications covering the
training of technicians, advice for managers, continuing education for central service staff, different
sterilization techniques, reusables, decontamination, assembly and packaging, administration and
organization, cost analysis, and total quality management.
AMREF International (African Medical and Research Foundation)
Resource Centre, AMREF Headquarters, Langata Road, PO Box 00506 – 27691, Nairobi, Kenya
Tel: 254 2 501301/2/3, fax: 254 2 609518, e-mail: amref.info@amref.org, website: www.amref.org
Publishes practical books, journals and other literature for health workers, and provides advice on
primary health care. Runs training courses and seminars.
BMA (British Medical Association) and BMJ Bookshop (British Medical Journal)
BMA House, London, WC1H 9JR, UK
Tel: +44 (0)20 7383 6244, fax: +44 (0)20 7383 6455, e-mail: orders@bmjbookshop.com,
website: www.bmjbookshop.com
BOC Medical
Customer Service Centre, Priestley Road, Worsley, Manchester, M28 2UT, UK
Tel: 44 800 111 333, fax: 44 800 111 555, email: bocmedical@uk.gases.boc.com,
website: www.boc.com or bocmedical.co.uk


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194




BOND (British Overseas NGO’s for Development)
Website: www.bond.org.uk
A network of more than 260 UK based voluntary organisations working in international development and
development education. BOND works to promote the exchange of experience, ideas and information by
acting as a broker for a variety of relationships and by collating and distributing information.
Commonwealth Secretariat
Marlborough House, Pall Mall, London, SW1Y 5HX, UK
Tel: 44 207 747 6500, fax: 44 207 930 0827, website:
www.thecommonwealth.org/publications/html/contactus.asp
This website provides access to the publications produced by the Commonwealth Secretariat.
DFID (Department for international development)
Website: www.dfid.gov.uk
UK government’s department for international development assistance.
Eastwood Park Training and Conference Centre
Falfield, Wotton-under-Edge, Glos, GL12 8DA, UK
Tel: 44 1454 262777, fax: 44 1454 260622, email: training@eastwoodpark.co.uk, website:
www.eastwoodpark.co.uk
This centre offers:
◆ a wide range of scheduled and tailor-made short courses in healthcare engineering, estates and


facilities, at certificate level accredited with known bodies (such as BTEC, City and Guilds)
◆ specific equipment courses, such as sterilization technology courses.
ECHO International Health Services Ltd
ECHO International Health Services is no longer trading as it used to. Its services can be accessed as
follows:
i. the charitable foundation can be contacted at:


ECHO, Ullswater Crescent, Coulsdon, Surrey, CR5 2HR, UK
Tel: 44 208 6602220, fax: 44 208 6680751, website: www.echohealth.org.uk/intro2.html


ii. the trading branch of the business (wholesale providers of medical supplies and equipment) is now:
Durbin PLC, 180 Northholt Road, South Harrow, Middlesex, HA2 0LT, UK
Tel: 44 208 8696500, fax: 44 208 8696565, email: cataloguesales@durbin.co.uk, website:
www.durbin.co.uk


iii. ECHO publications are still available from TALC (see below).
ECRI (Emergency Care Research Institute)
5200 Butler Pike, Plymouth Meeting, Pennsylvania 19462-1298, USA
Tel: 1 610 825 6000 ext 5368, fax: 1 610 834 1275, website: www.ecri.org
Offers guidance and advice on healthcare technology, planning, procurement and management; and
health technology assessment and assistance.
Elsevier Health Science
Elsevier Books Customer Services, Linacre House, Jordan Hill, Oxford, OX2 8DP, UK
Tel: 44 1865 474110, fax: 44 1865 474111, email: eurobkinfo@elsevier.com, website:
www.us.elsevierhealth.com
Books published by WB Saunders, Mosby, Churchill Livingstone, and Butterworth-Heinemann are
now all members of the Elsevier Science, Health Sciences Division.
European Union (EU)
http://europa.eu.int/comm/development/index_en.htm
EU site for international development and aid.
FAKT (Consultancy for Management, Training, and Technologies)
Gansheidestrasse 43, D-70184 Stuttgart, Germany
Tel: 49 711 21095/0, fax: 49 711 21095/55, email: fakt@fakt-consult.de, website: www.fakt-consult.de
Non-profit consultancy firm, that provides information on appropriate hospital and medical
equipment and training in healthcare technologies. FAKT is not a supply organisation.


Annex 2: Reference materials and contacts


195




Global Directory of Health Information Resource Centres.
Health Information for Development (HID) Project, PO Box 40, Petersfield, Hants, GU32 2YH, UK
Tel: 44 1730 301297, fax: 44 1730 265398, email: iwsp@payson.tulane.edu,
website: www.iwsp.org/directory.htm
This is a directory of health information resource centres that is arranged alphabetically by country.
Between January 2000 and May 2001, Health Information for Development (HID) compiled a
Global Directory of Health Information Resource Centres (HIRCs). This is available from their
website. The Directory is updated on an ongoing basis.
GTZ (Deutsche Gesellschaft für Technische Zusammenarbeit – German government
technical aid agency)
Division of Health and Education, PO Box 5180, D-6236, Eschborn, Germany
Tel: 49 6196 791265, fax: 49 6196 797104, email: Friedeger.Stierle@gtz.de
Website: http://www.gtz.de/de/4030.htm
Friedeger Stierle is the contact for the GTZ’s healthcare technology management programme, and
any articles or documents on HTM.
Healthlink Worldwide
Cityside, 40 Adler Street, London, E1 1EE, UK
Tel: 44 20 7539 1570, fax: 44 20 7539 1580, email: info@healthlink.org.uk, website:
www.healthlink.org.uk
Publishes a range of free and low-cost newsletters, resource lists, briefing papers and manuals about
health and disability. Publications include HIV testing: a practical approach which is a briefing
paper on HIV counselling and laboratory testing.
HEART Consultancy
Quadenoord 2, 6871 NG Renkum, The Netherlands
Tel: 31 317 450468, fax: 31 317 450469, email: jh@heartware.nl, website: http://www.heartware.nl
Consultancy firm working in all aspects of healthcare technology management in developing
countries. It also produces and supplies the PLAMAHS software package for managing the inventory,
model lists, maintenance, and procurement needs for your healthcare technology stock. HEART also
undertakes research and training, and produces publications on many aspects of sterilization for
developing countries. It has developed a basic testkit for performance testing of sterilizers, and can
identify suppliers that still manufacture basic sterilizers (manually operated/fuel heated).
HMSO (Her Majesty’s Stationery Office)
Website: www.hmso.gov.uk
Publishers of material produced by departments of the UK government.
Humanitarian Information for All
c/o Human Info NGO vzw and Humanity CD Ltd, Oosterveldlaan 196, B-2610 Antwerp, Belgium
Fax: 32 3 449 75 74, email: humanity@humaninfo.org, website: www.humaninfo.org
The goal of this organization is to disseminate health care information free-of-charge in developing
countries. Thus, their Medical and Health Library makes publications available on the internet.
Refer to their homepage to find the large list of publications available.


Annex 2: Reference materials and contacts


196




Institute of Decontamination Services, UK
Website: www.idsc-uk.org
Formerly the Institute of Sterile Services Management. Publishes the ISSM Journal.
Intermediate Technology Development Group (ITDG) and ITDG Publishing
The Schumacher Centre for Technology and Development, Bourton Hall, Bourton-on-Dunsmore,
Rugby, CV23 9QZ, UK
Tel: 44 1926 634400, fax: 44 1926 634401, email: enquiries@itdg.org.uk, website: www.itdg.org
The Development Group is a charity concerned with the research and development of ‘appropriate’
technologies for application in developing countries. It has worked on topics such as, alternative
electrical supplies, access to water, disability aids, medical supplies. It also undertake consultancies.
The Publication Division produces and disseminates books and journals covering aspects of health,
development, and appropriate technology. It can be contacted at: Tel: 44 1926 634501, fax: 44 1926
634502, email: itpubs@itpubs.org.uk, website: www.itdgpublishing.org.uk.
International Atomic Energy Agency (IAEA)
Wagramerstrasse 5, PO Box 100, A-1400, Vienna, Austria
Tel: 43 222 2360, fax: 43 222 230 184, website: www.iaea.org
Offers regionally-based training courses in the field of nuclear medicine.
International Centre for Eye Health (ICEH)
International Resource Centre, Institute of Opthalmology, University College London,
11–43 Bath Street, London EC1V 9EL, UK, website: www.iaea.org/
Tel: 44 20 7608 69 23/10/06, fax: 44 20 7250 3207, email: eyeresource@ucl.ac.uk, website:
www.ucl.ac.uk/ioo
Advises and publishes information on all aspects of eye care including prevention of blindness.
Produces the Community eye health journal distributed free to developing countries, an annual
standard list of medicines, equipment, instruments and optical supplies for eye care for developing
countries, and teaching slides/text sets and videos.
International Federation of Hospital Engineering (IFHE)
Website: http://home.enter.vg/ifhe/main.html
This body enables national engineering professional organizations to join in a world-wide federation.
It encourages and facilitates exchange of information and experience in the broad field of hospital
and healthcare facility design, construction, engineering, commissioning, maintenance, and estate
management. It arranges an International Congress every two years at different locations, in
conjunction with a healthcare trade exhibition. The reports of the papers presented at these
congresses are sources of information on many topics, such as sterilization, air flow control, waste
management, equipment safety, etc. The IFHE also publishes a newsletter.
International Federation of Infection Control (IFIC)
North Manchester General Hospital, Delaunays Road, Crumpsall, Manchester, M8 6RB, UK
Website: www.ific.narod.ru/
International Federation of Sterile Supply (IFSS)
7 Kendal Drive, Beeston Fields, NG9 3AW, UK
Tel: 44 115 9256364, fax: 44 115 9256364, email: GillianSills@aol.com, website: www.ifssonline.com
Isopharm Sentry Ltd
The Validation Centre, Millindale, Rotherham, South Yorkshire, S66 7LE, UK
Tel: 44 1709 811460, fax: 44 1709 813535, email: sales@isopharm-sentry.com,
website: www.sentry-products.co.uk
Supplier of a wide range of validation, testing, and commissioning equipment used with items such
as sterilizers, washer/disinfectors, and medical gas pipelines.


Annex 2: Reference materials and contacts


197




Malaria Consortium
The original Malaria Consortium (the joint partnership between the Liverpool School of Tropical
Medicine and the London School of Hygiene and Tropical Medicine) is no longer operating under
that name. However, the report of its programme, its publications, and continuing projects can be
accessed on website: www.liv.ac.uk/lstm/malaria/. There is a new NGO called the Malaria
Consortium, which is pursuing similar issues, such as insecticide treated net projects. It can be
accessed on website: www.malariaconsortium.org.
Medical Research Council South Africa (MRC-SA)
PO Box 19070, 7505 Tygerberg, South Africa
Tel: 27 21 9380911, fax: 27 21 9380200, email:info@mrc.ac.za, website: www.mrc.ac.za
The MRC-SA’s mission is to improve the nation’s health status and quality of life through relevant
and excellent health research aimed at promoting equity and development. They have a WHO
Collaborating Centre for Essential Technologies in Health, at website:
www.mrc.ac.za/innovation/whocollaborating.htm
Medicine-hygiene-prevention publishing house (mhp Verlag GmbH)
Wiesbaden, Germany
Website: www.mhp-verlag.de
Produces a number of publications including the Central service/Zentral sterilization bilingual journal.
Medicines and Healthcare Regulatory Agency (MHRA)
Hannibal House, Elephant and Castle, London, SE1 6TQ, UK
Tel: 44 0207 972 8000, email: devices@mhra.gsi.gov.uk, website: www.mhra.gov.uk
Offers guidance, advice, and regulations on medical device quality, safety, performance, use,
and standards.
Ministry of Health and Social Services, Namibia
Dr N Forster, Under Secretary: Health and Social Welfare Policy, Private Bag 13198, Windhoek, Namibia
Email: nforrster@mhss.gov.na
MSc Envirohealth Products
25 Reedbuck Crescent, Corporate Park, PO Box 506, 15 Randjesfontein, Midrand 683, South Africa
Tel: 27 11 314 7540, fax: 27 11 314 7535, email: scaine@mweb.co.za
Contact for further information about the Medcin 400 Gas Incinerator, a pre-assembled incinerator
designed for rural and small-scale healthcare waste management.
Olympus Microscopes, UK
Scientific Divisions, Great Western Industrial Park, Dean Way, Southall, Middlesex, UB2 4SB, UK
Tel: 44 207 253 2772, fax 44 207 251 6330, email: info@olympus.uk.com, website:
www.olympus.co.uk
Manufacturer of microscopes and other optical equipment with bases around the world. Source of
microscope training video.
PAHO (Pan American Health Organization)
Pan American Sanitary Bureau, Regional Office of the World Health Organization, 525 Twenty-third
Street, N.W. Washington, D.C. 20037, USA
Tel: 1 202 974-3000, fax: 1 202 974-3663, website: www.paho.org/
The Pan American Health Organization (PAHO) is an international public health agency working to
improve health and living standards of the countries of the Americas. It also serves as the Regional
Office for the Americas of the World Health Organization.Antonio Hernandez is the contact for
healthcare technology issues, email: 1hernana@paho.org
RIVM (Dutch Institute of Public Health and the Environment)
Laboratory for Medicines and Medical Devices, Dept. LGM, Postbak 50, Postbus 1, 3720 BA,
Bilthoven, The Netherlands
Tel: 31 30 2749111, fax: 31 30 2742971, email: info@rivm.nl,
website: www.rivm.nl/sector4/lgm/index.html
Amongst other topics, this organization has undertaken research on the performance of manually
operated sterilizers.


Annex 2: Reference materials and contacts


198




RS Components Ltd.
Birchington Road, Corby, Northants, NN17 9RS, UK
Tel: 44 1536 201234, fax: 44 1536 405678, email: general@rs-components.com, website: rswww.com
Supplier of equipment, supplies, parts, and components for a wide range of engineering professions
such as electrical, electronic, mechanical, heating, ventilation, air-conditioning, plumbing, welding,
pneumatics, computing, automotive. Also a source of textbooks, technical data books, technical
literature, and training videos for all these engineering fields.
Source (International Information Support Centre)
The Wellcome Trust Building, Institute of Child Health, 30 Guildford Street, London, WC1N 1EH, UK
Tel: 44 20 7242 9789 ext 8698, fax: 44 20 7404 2062, email: source@ich.ucl.ac.uk, website:
www.asksource.info
The Source Centre has a unique collection of over 20,000 health and disability related information
resources. These include books, manuals, reports, posters, videos, and CD-Roms. Many materials are
from developing countries and include both published and unpublished literature.
Swiss Centre for Development Cooperation in Technology and Management (SKAT).
Website: www.skat.ch/dc/publ/publ.htm
SKAT works internationally in the areas of water and sanitation, architecture and building, transport
infrastructure, and urban development. They also publish the SKAT newsletter.
Swiss Centre for International Health (SCIH)
Swiss Tropical Institute, Socinstrasse 57, PO Box, CH-4002 Basle, Switzerland
Tel: 41 61 284 82 79, fax: 41 61 271 86 54, email: martin.raab@unibas.ch,
website: www.sti.ch/francais/scih/scih.htm
Undertakes consultancies in healthcare technology management in developing countries and
countries in transition.
TALC (Teaching Aids at Low Cost)
PO Box 49, St. Albans, Herts, AL1 5TX, UK
Tel: 44 1727 853869, fax: 44 1727 846852, email: talc@talcuk.org, website: www.talcuk.org/
UK registered non-profit charity specialising in supplying affordable books, slides and teaching aids
on health and community issues in developing countries, with a particular focus on materials for
PHC and district levels.
Third World Network
Email: twnet@po.jaring.my, website: www.twnside.org.sg
The Third World Network is an independent non-profit international network of organizations and
individuals involved in development issues. Its website offers articles and position papers on a variety
of subjects related to developing countries, including trade, health, biotechnology and bio-safety.
Transaid (Transport for Life)
137 Euston Road, London, NW1 2AA, UK
Tel: 44 20 7387 8136, fax: 44 20 7287 2669, email: info@transaid.org, website: www.transaid.org
A charity working in the field of international transport management. Thus unique organization works
with many sectors, including health, to ensure that transport resources are efficiently and effectively
used. Their aim is to develop local capacity in transport and logistics management. They produce a
newsletter Hub and spoke, and have developed the Transaid transport management handbook.
Tropical Health Technology (THT)
14 Bevills Close, Doddington, March, Cambridgeshire PE15 OTT, UK
Tel: 44 1354 740825, fax: 44 1354 740013, email: thtbooks@tht.ndirect.co.uk,
website: www.tht.ndirect.co.uk
Charity concerned with supporting and improving laboratory services in the developing world.
Primary focus is laboratory services, information and technology. Specializes in supply of laboratory
equipment, books, bench aids, slide sets and microscopes.


Annex 2: Reference materials and contacts


199




UNAIDS
20 Avenue Appia, CH-1211 Geneva 27, Switzerland
Tel: 41 22 791 3666, fax: 41 22 791 4187, email: unaids@unaids.org, website: www.unaids.org
The joint UN programme on HIV/AIDS, publishes an extensive range of materials, including
practical and technical guidelines. For information about programmes and activities and materials,
contact country-based staff.
UNICEF (United Nations Children’s Fund)
UNICEF House, 3 UN Plaza, New York 10017, USA
Tel: 1 212 326 7000, fax: 1 212 887 7454, email: jando@unicef.org, website: www.unicef.org
It provides a wide range of resource materials, journals, books, videos, games and posters for
children’s programmes. Your regional or field office will offer advice on all aspects of child health care
and UNICEF materials – contact details are on the website. UNICEF’s Supply Catalogue
(formerly the UNIPAC catalogue) lists products with their specifications under categories such as:
immunization and cold chain; medical devices and kits; water, environment, sanitation and
engineering; education, communication; etc. View it online at www.supply.unicef.dk/Catalogue. The
goods are supplied by the UNICEF Supply Division, UNICEF Plads, Freeport, 2100 Copenhagen
OE, Denmark. Tel: 45 3527 3527, fax: 45 3526 9421, email: supply@unicef.org.
Voluntary Service Overseas (VSO), and VSO Books
317 Putney Bridge Road, London, SW15 2PN, UK
Tel: 44 20 8780 2266, email: webteam@vso.org.uk, website: www.vso.org.uk
A UK-based charity with worldwide experience of providing skilled volunteers for work overseas,
including workers in the fields of medicine, hospital engineering, and associated technical services.
VSO Books publishes practical books about specific areas of development, using the professional
experience of volunteers.
World Bank (WB)
www.worldbank.org
One of the world’s largest sources of development assistance including health, nutrition and
population projects
World Council of Churches (WCC)
PO Box 2100, 1211 Geneva, Switzerland
Tel: 41 22 791 6111, fax: 41 22 791 0361, email: info@wcc-coe.org, website: www.wcc-coe.org
International fellowship of churches that produces publications and newsletters.
Recent publications include Guidelines on medical equipment donations.


Annex 2: Reference materials and contacts


200




World Health Organization (WHO)
20 Avenue Appia, CH-1211 Geneva 27, Switzerland
Tel: 41 22 791 2476 or 2477, fax: 41 22 791 4857, website: www.who.int/en/
WHO offers advice, and undertakes programmes, on all aspects of health care. Contact your regional
or field office for advice on all aspects of health care and WHO materials – the addresses of the
regional offices worldwide are available on the website.
i. WHO has programmes and literature on many aspects of healthcare technology management.


Andrei Issakov, Coordinator of Health Technology and Facilities Planning and Management, is
the contact, and source of WHO literature on healthcare technology management that is not
available as published documents, email: issakova@who.int.


ii. WHO produces and distributes books, manuals, journals, practical guidelines and technical
documents, several include aspects of healthcare technology management. The Distribution and
Sales Office is the contact point for information on WHO publications, email:
publications@who.ch, website www.who.int/publications/en. To order WHO publications use
email: bookorders@who.int.


iii. WHO has a comprehensive library and information service on international public health
literature. Contact email: library@who.int. The WHO library catalogue has electronic access to
more than 4000 technical documents, use website: www.who.int/library.


iv. WHO produces many newsletters, for a list contact website:
www.who.int/library/reference/information/newsletters/index.en.shtml


Ziken International Consultants Ltd
Causeway House, 46 Malling Street, Lewes, East Sussex BN7 2RH, UK
Tel: 44 1273 477474, fax: 44 1273 478466, email: info@ziken.co.uk, website: www.ziken.co.uk
A consultancy organization working worldwide in many aspects of health care development,
including healthcare technology management.


For information on the wide range of international professional bodies representing different aspects
of clinical and hospital engineering, see Guide 1 or 5.


Annex 2: Reference materials and contacts


201




ANNEX 3: PROCESS PROFILE FOR
COMMON STERILIZERS


Figure 21: Example of a Process Profile Common to Many Sterilizers


Notes:
1. Typical profile for a sterilization process by steam for porous loads.
2. The sterilizer should be equipped with a vacuum system for creating the pre- and post-vacuum.
3. Timing: air-removal by pre-vacuum (5 minutes), then three pulses, followed by 10 minutes


sterilization, and post-vacuum for drying (15 minutes).
4. It will be necessary to validate the process in your own sterilizer, with the most difficult load and


packaging material.


Source: Huys J, 2003, ‘Sterilization of medical supplies by steam, volume 1: General theory’, 2nd edition,
HEART Consultancy, Renkum, The Netherlands, ISBN: 90 75829 04


Annex 3: Process profile for common sterilizers


202


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Figure 22: Sample Store Requisition and Issue Voucher


Annex 4: Example of a supplies order form


203


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Figure 22 shows a form that can be used when ordering supplies. It acts as both a requisition
voucher for goods from stores and a record of the items issued. If the voucher is produced as a
standard duplicate order book, then the information can be used both by the user department as a
record of the goods ordered and by stores staff for stock management purposes.




ANNEX 5: ENTERING ITEMS INTO THE STOCK
CONTROL SYSTEM


Guide 3 on procurement and commissioning describes the procedures involved when you receive
equipment supplies on site and undertake the Equipment Acceptance Process. The information
here summarizes the steps involved:
◆ During the acceptance process, the Commissioning Team compiles the following information


from the available contracts, packing lists, or invoices, in order to complete a ‘Register of New
Stocks’ form for each new piece of equipment received, according to a standard format (see
example in Figure 23):
- Type of equipment.
- Equipment name/model.
- Name and address of manufacturer.
- Name and address of supplier/agent if relevant.
- Price of equipment.
- Manufacturer's part numbers for ordering purposes.
- Lists of all consumables, accessories, and spare parts received, including the quantity of each,


the part numbers for ordering purposes, and the price of each.
◆ At the successful completion of the initial training sessions (this is the training of users and


maintainers undertaken when new equipment arrives), the Commissioning Team issues the
accessories and consumables for immediate use to the relevant user department, together with
the new equipment.


◆ The Commissioning Team gives a copy of the Register of New Stocks form, and the remaining,
unissued, items to the Stores Controller so that they can be entered into the stores system
according to the standard procedure (Section 6.2).


◆ The Stores Controller sets up the correct stock cards (bin cards) so that the stores reordering
system can come into effect automatically.


◆ The Stores Controller enters the stores code for each item on the Register of New Stocks form,
and provides the relevant user departments and the HTM Manager with lists of the new items
received and their stores codes for ordering purposes.


◆ The HTM Manager files the Register of New Stocks form with the stores codes in the relevant
equipment files (see Guide 5 on maintenance management), and provides this information to
the Specification Writing Group if they need assistance with updating specifications and
detailing future purchase contracts (see Guide 3 on procurement and commissioning).


◆ The stocks of equipment accessories, consumables, and spare parts should be issued and
reordered according to the procedures given in Sections 6.2 and 6.3.


Annex 5: Entering items into the stock control system


204




Figure 23: Example of a ‘Register of New Stocks’ Form


Annex 5: Entering items into the stock control system


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ANNEX 6: SAFETY AND CALIBRATION
TESTING INSTRUMENTS


Some instruments provide basic tests, while others are designed for more complex procedures. Box 64
provides some advice on the types of test instruments required, which are bench-top instruments.
Not every HTM Team or workshop needs all of them: it will depend on the skill levels of the staff.
However, anyone maintaining or repairing medical equipment needs some form of medical
equipment safety tester – either a basic one made from common bench tools or a commercially
available product for comprehensive testing. Other smaller hand tools used for testing purposes are
included in the regular tool kits for maintenance staff – see Guide 5 on maintenance management.


Annex 6: Safety and calibration testing instruments


206


BOX 64: Example of Safety and Calibration Testing Instruments by Type of Work and
Skill Level


Type of work Instrument Skill level
Electrical


Electronic


Medical equipment


insulation tester (‘megger’ meter)
mains socket wiring tester
phase tester
continuity tester
three-phase tester
multimeter
bench-top power supply
counter/timer
function generator
oscilloscope
ammeter and earth break box (instead of MES tester)
electronic thermometer
standard mercury BP apparatus
defibrillator analyzer/tester
ECG simulator
electro-surgical unit (ESU) analyzer
medical electrical safety (MES) tester/analyzer1, 2
non-invasive BP monitor tester
oxygen analyzer
oxygen flow meter monitor
patient simulator, multi-parameter, two-channel
pH meter standards
phosphorescent strip
pressure/vacuum meter
spectrophotometer standards
X-ray line resistance meter
X-ray mAs meter
X-ray phantoms


Basic


Specialist


Basic
Specialist


Basic


Specialist


Continued opposite




Note:
1. The medical electrical safety (MES) tester/analyzer should include an IEC 60101-1 test load
2. A portable appliance tester (PAT) could possibly be used instead of an MES – something is better than


nothing. However, it cannot necessarily go down to the correct sensitivity for medical equipment or check
for patient probe leakage. Use of a PAT requires specialist advice in order to be aware of its limitations.


Annex 6: Safety and calibration testing instruments


207


BOX 64: Example of Safety and Calibration Testing Instruments by Type of Work and
Skill Level (continued)


Type of work Instrument Skill level
Medical equipment gas analyzer


ultrasound therapy unit output (precision) test balance
ventilator tester


Advanced specialist –
very expensive and only
required in the largest
workshops




ANNEX 7: MAINTENANCE WORK REQUEST/JOB FORM
Figure 24 shows an example of a form that can be used both to request maintenance work (by the
user department or the HTM Manager), and to record the work undertaken (by the maintenance
staff). Thus it keeps together the records of the request and the response made. Its multiple copies
are filed by the user department and the HTM Team so that each can monitor progress with
requests (see Guide 5 on maintenance management).


Annex 7: Maintenance work request/job form


208


Figure 24: Example of a Work Request/Job Form


For User Department Only
Facility: Date:
Location:
Person making request/In-charge (Full name, Position, Contact):


Equipment task: Inventory no.
Fault description:


Equipment/Work order received by: Date:
Equipment returned to (Full name): Date:
For HTM Team Only
Allocated to: Section:
Type of service: PPM Repair
Serial no.
Work undertaken:


Reasons for failure: wear and tear: mains unstable: dirt:
contamination (water, oil): user error/handling: faulty installation:
other (specify):
Materials used: Quantity/Cost:


Test results:
Work time: Travel time:


Why not completed:


Completed by:
Maintainer's signature: Date:


Note: this is a triplicate form – 1st sheet is the User File copy
2nd sheet is the Maintenance Progress File copy
3rd sheet is the Equipment/Section History File copy


Work Request/Job Form




ANNEX 8: TYPICAL EQUIPMENT LIFETIMES
Different organizations have tried to estimate typical equipment lifetimes for healthcare technology.
This annex contains the results from two different sources – the American Hospital Association, and
the GTZ (German Government Technical Aid Agency).


LIST 1: The American Hospital Association (AHA)
Source: American Hospital Association, 1998, ‘Estimated Useful Lives of Depreciable Hospital Assets’,


American Hospital Association, Chicago, USA


The AHA’s extensive list reflects how equipment lasts within the United States’ healthcare system,
whether it was manufactured in the US or abroad.
Their list was compiled following:
◆ discussions with manufacturers of healthcare equipment
◆ discussions with various hospital department managers
◆ analysis of actual retirement practices for actual hospital assets.
Their list is made up of a series of tables of different categories of equipment determined by the
equipment’s role in the health facility.


Annex 8: Typical equipment lifetimes


209


Part One: Estimated Useful Lives of Land Improvements, Buildings, and
Fixed Equipment


Table 1: Land Improvements
Land improvements are assets of an above-ground or below-ground nature, found in the land area contiguous to
and designed for serving a health care facility. The asset cost would include a proportionate share of
architectural, consulting, and interest expense for newly constructed or renovated facilities.
Item Years Item Years
Bumpers 5
Culverts 18
Fencing


Brick or stone 25
Chain-link 15
Wire 5
Wood 8


Flagpole 20
Guard rails 15
Heated pavement 10
Landscaping 10
Lawn sprinkler system 15
Parking lot, open-wall 20
Parking lot gate/s 3
Parking lot striping 2
Paving (including roadways, walks,and parking)


Asphalt 8


Paving (including roadways, walks,
and parking) (continued)


Brick 20
Concrete 15
Gravel 5


Retaining wall 20
Shrubs and lawns 5
Signs, metal or electric 10
Snow-melting system 5
Trees 20
Turf, artificial 5
Underground utilities


Sewer lines 25
Water lines 25


Waste water treatment system 20
Water wells 25
Yard lighting 15




Table 2: Buildings
Buildings are structures consisting of building shell, exterior walls, interior framings, walls, floors, and ceilings.
The asset cost would include a proportionate share of architectural, consulting, and interest expense for newly
constructed or renovated facilities. In assigning the estimated useful lives in this table, the following factors
were considered: the type of construction, the functional utility of the structure, recent regulatory or
environmental changes, and the general volatility of the health care field.
Item Years Item Years
Boiler house 30
Garage


Masonry 25
Wood frame 15


Guardhouse 15
Masonry building, reinforced
concrete frame 40
Masonry building, steel frame
Fireproofed 40
Nonfireproofed 30
Masonry building, wood/metal frame 25


Table 3: Building Components
Building components are assets that are a part of the building shell or interior construction. The asset cost would
include a proportionate share of architectural, consulting, and interest expense.
Item Years Item Years
Canopies 15
Carpentry work 15
Caulking 5
Sealants 5
Ceiling finishes


Acoustical 8
Gypsum 10
Plaster 12


Computer flooring 10
Corner guards 10
Cubicle tracks 10
Designation signs 5
Doors and frames


Automatic 10
Hollow metal 20
Wood 15


Drapery tracks 10
Drilled piers 40
Floor finishes


Carpet 5
Ceramic 20
Concrete 20
Hardwood 10


Annex 8: Typical equipment lifetimes


210


Metal-clad building 20
Multilevel parking structure 25
Reinforced concrete building,
common design 40
Residence


Masonry 25
Wood frame 25


Storage building
Masonry 25
Metal garden-type 10
Wood frame 20


Floor finishes (continued)
Quarry 20
Sealer 5
Terrazzo 15
Vinyl 10


Folding partitions 10
Loading dock bumpers and levelers 10
Magnetic/MRI shielding 10
Millwork 15
Overhead doors 10
Partitions, interior 15
Partitions, toilet 15
Railings


Freestanding (exterior) 15
Handrails (interior) 15


Roof covering 10
Skylights 20
Storefront construction 20
Wall covering


Paint 5
Wallpaper 5


X-ray protection 10




Table 4: Fixed Equipment
Fixed equipment includes assets that are permanently affixed to the building structure and are not subject to
movement but have shorter useful lives than that of the building. The asset cost would include a proportionate
share of architectural, consulting, and interest expense.
Item Years Item Years
Benches, bins, cabinets, counters,
and shelving, built-in 15
Cabinet, biological safety 15
Canopy-ventilating for laundry ironer 15
Central dictation system 10
Coat rack 20
Conveyor system, laundry 10
Cooler, walk-in 15
Curtains and drapes 5
Emergency generator set 20
Generator controls 12
Hood, fume 15
Fire protection in hoods 10
ICU and CCU counters 15
Illuminator


Multifilm 10
Single 10


Table 5: Building Services Equipment (overleaf)
Building services equipment refers to mechanical components or systems designed for the building(s), including
air conditioning, electrical elevators, heating lighting plumbing sprinklers, and ventilating. The asset cost would
include a proportionate share of architectural, consulting and interest expense for newly constructed or
renovated facilities.


Annex 8: Typical equipment lifetimes


211


Laminar flow system 15
Lockers, built-in 15
Mailboxes, built-in 20
Medicine preparation station 15
Mirrors, traffic and/or wall mounted 10
Narcotics safe 20
Nurses’ counter, built-in 15
Pass-through boxes 15
Patients’ consoles 15
Patients’ wardrobes and vanities, built-in 15
Projection screens 10
Sink and drainboard 20
Sterilizer, built-in 15
Telephone enclosure 10




212


Item Years Item Years
Air-condition equipment


Centrifugal chiller 15
Compressor, air 15
Condensate tank 10
Condenser 15
Controls 10
Cooler and dehumidifier 10
Cooling tower, concrete 20
Wood 10
Duct work 20
Fan, air-handling and ventilating 20
Metal 20
Piping 20
Precipitator 10
Pump 10


Air-conditioning system
Large (over 20 tons) 10
Medium (5-20 tons) 10
Small (under 5 tons) 5


Air curtain 15
Antenna system 10
Boiler 20
Deaerator system 15
Boiler smokestack, metal 20
Clean-air equipment 15
Clock system, central 15
Co-generation plant, generator powered 15
Door alarm 10
Door-closing devices, for fire alarm system 15
Electric lighting and power


Composite 18
Conduit and wiring 20
Emergency lighting system 15
Feed wiring 20
Fixtures 10
Switch gear 15
Transformer 30


Elevator
Dumbwaiter 20
Freight 20
Passenger, high-speed automatic 20
Passenger, other 20


Emergency generator 20
Controls 12
Energy management system, computer based 10
Escalator 20
Fans, ceiling-mounted 10


Annex 8: Typical equipment lifetimes


Fire protection system
Fire alarm system 10
Fire pump 20
Smoke and heat detectors 10
Sprinkler system 25
Tank and tower 25


Furnace, domestic 15
Heating, ventilating, and air conditioning
(composite system) 15
Heat pump system 10
Humidifier 15
Incinerator, indoor 10
Insulation, pipe 15
Intercom system 10
Laboratory plumbing, piping 20
Magnetic door holders 10
Medical gas system (composite system) 15
Nurse call system 10
Oil storage tank 20
Oxygen, gas, and air piping 20
Paging system 20
Physicians’ in-and-out register, built-in 10
Plumbing, composite 20
Fixtures 20


Piping 25
Pump 15


Pneumatic tube system 15
Radiator


Cast-iron 25
Finned tube 15


Sewerage, composite 25
Piping 20
Sump pump and sewerage ejector 10


Solar heating equipment 10
Surge suppression system 15
Telephone system 10
Television antenna system 10
Television satellite dish 10
Temperature controls, computerised 10
Unit heater 10
Vacuum cleaning system 15
Water fountain 10
Water heater, commercial 10
Water purifier 10
Water softener 10
Water storage tank 20
Water wells 25




Annex 8: Typical equipment lifetimes


213


Part Two: Estimated Useful Lives of Major Movable Equipment
Major movable equipment is defined as assets that are generally assigned to a specific department within the
health care facility, but with the capacity of being relocated. The assets have a minimum useful life of at least
three years and a unit cost sufficiently large to justify the expense of maintaining an equipment ledger.
Note: Included within the departmental listings are assets that may be considered to be minor equipment (for
example, surgical instruments with a three-year life assignment). Minor equipment may be defined as assets
that are relatively small in size and unit cost and have high usage. They are generally found in the obstetrics,
surgery, and dietary departments.


Table 6: Administrative Departments
Administrative Departments consist of administration, barber shop, board room, admitting, business office,
communications, data processing, education, facilities management, finance, foundation, graphics, home health,
human resources infection control, library, lobby, marketing, medical education, medical records, medical staff
facilities, nursing administration, pastoral care, patient education, physician on-call rooms, public relations,
quality assessment and improvement, social services, and volunteer services departments.
Item Years Item Years
Beepers, paging 3
Bench, metal or wood 15
Binder, punch machine 10
Bookcase, metal or wood 20
Bulletin board 10
Cabinet file, metal or wood 15
Camera 5
Cathode-ray tube (CRT) 3
Chair


Arm 15
Conference 15
Executive 15
Folding 10
Guest 15
Side 15


Check signer 10
Clock 10
Collator, electric 10
Computer


Laptop 3
Large 5
Micro 5
Mini (personal) 3


Computer disk drive 5
Computer networking equipment


Controller 5
Hub 5
Modem 5
Mux unit 5
Server 5
Token ring 5


Computer printer 5
Computer software 3
Computer terminal 5
Credenza 15
Data printing unit 5
Data storage unit
Mechanical 10


Nonmechanical 15
Data tape processing unit (including
controller, drive, and tape deck) 5
Desk, metal or wood 20
Dictating equipment 5
Display cases 20
Duplicator 5
Facsimile transmitter 3
Files 15


Electric rotary 15
Legal 15
Regular 15


Filing system, portable 20
Imprinter


Address 5
Embossed plate 10


Integrator 10
Intercom 10
Label maker 10
Library furniture 20
Mailing machine 10
Microfilm unit 10


Continued overleaf




Table 6: Administrative Departments (continued)
Item Years Item Years
Microphone 5
Microprojector 10
Organ 10
Paper burster 8
Paper cutter 10
Paper shredder 5
Paper shredder 5
Partitions, movable office 10
Photocopier


Small 3
Large 5


Piano 20
Projector


Overhead 10
Slide 10
Video 5


Recorder, tape 5
Safe 20
Scale, postal 10
Screen, projector 10
Settee 12


Table 7: Nursing Departments
Nursing departments consist of cardiac care, chemical dependency, intensive care, medical/surgical care,
neonatal intensive care, nursery, pediatrics, pediatric developmental disabilities, and psychiatric units.
Item Years Item Years
Bassinet 15
Bath


Sitz 10
Whirlpool 10


Bed
Birthing 15
Electric 12
Flotation therapy 10
Hydraulic 15
Labor 15
Manual 15
Orthopedic 15


Bench, metal or wood 15
Bin, metal or wood 15
Blood pressure device, electronic 6
Bookcase, metal 20


Annex 8: Typical equipment lifetimes


214


Shelving, portable, steel 20
Sofa 12
Stamp Machine 10
Stapler, electric or air 10
Stencil machine 10
Stereo equipment 5
Table


Folding 10
Metal or wood 15


Television receiver 5
Time recording equipment 10
Transcribing equipment 5
Typewriter, electric 5
Valet, office 15
Video cassette recorder/player 5
Walkie-talkie 5
Water cooler, bottle 10
Word processor


Large 5
Small 5


Work station 10


Cabinet
Bedside 15
File 15
Instrument 15
Metal or wood 15
Pharmacy 15
Solution 15
X-ray 15


Central supply furniture 15
Chair


Blood drawing 10
Dental 15
Executive 15
Folding 10
Geriatric 10
Hydraulic, surgeon’s 15


Continued opposite




Operating stool 15
Ophthalmoscope 10
Osmometer 7
Otoscope 7
Ottoman 10
Patient monitoring equipment 10
Phototherapy unit 10
Physicians’ in-and-out register, portable 10
Physiological monitor 7
Pump, breast 10
Scale, baby 15
Settee 12
Shelving, portable, steel 20
Sofa 12
Stall Bars 15
Table


Anaesthetic 15
Autopsy 20
Electrohydraulic tilt 10
Examining 15
Folding 10
Food preparation 15
Fracture 15
Instrument 15
Light 15
Metal 15
Obstetrical 20
Operating 15
Orthopedic 10
Overbed 15
Pool 10
Refrigerated 10
Therapy 15
Traction 10
Urological 15
Wood 15


Telemetry unit, cardiac 5
Thermometer, electric 5
Ultrasonic fetal heart monitor 7
Work station 10


Annex 8: Typical equipment lifetimes


215


Table 7: Nursing Departments (continued)
Item Years Item Years
Chair (continued


Kinetron 15
Podiatric 15
Shower/bath 10
Specialist’s 15


Chart rack 20
Chart recorder 10
Clothes locker
Fibreglass or metal 15
Laminate or wood 12
Computer, caridial output 5
Credenza 15
Crib 15
Croupette 10
Defibrillator 5
Desk, metal or wood 20
Doppler 5
Dresser 15
Food service furniture 15
Frame, turning 15
Housekeeping furniture 15
ICU and CCU furniture 15
Infant care center 10
In-service education furniture 15
Insufflator 5
Labor and delivery furniture 15
Laboratory furniture 15
Lamp


Bilirubin 10
Emergency 10


Lawn and patio furniture 5
Light


Delivery 15
Examining 10
Portable, emergency 10


Natural childbirth backrest 10
Nursing service furniture 15
Operating room furniture 15




Table 8: Diagnostic and Treatment Departments
Diagnostic and treatment departments consist of ambulatory surgery, anesthesia, cardiac rehabilitation,
catheterization laboratory, CT scan, ECT, EEG/EMG, emergency, employee health, enterostomal therapy, GI
laboratory, hemodialysis, hyperbaric medicine, in vitro medicine, IV therapy, inpatient pharmacy, laboratory,
lithotripsy, mobile air care, medical oncology, MRI, noninvasive cardiology, obstetrics, occupational therapy,
physical therapy, postanesthesia care unit, radiation therapy, radiology, respiratory therapy, speech therapy, and
surgery departments.
Item Years Item Years
Accelerator 7
Alternating pressure pad 10
Amino acid analyzer 7
Amplifier 10
Anaerobe chamber 15
Analyzer, haematology 7
Anatomical model 10
Anesthesia unit 7
Ankle exerciser 15
Apnea monitor 7
Apron, lead-lined 47
Arthroscope 5
Arthroscopy instrumentation 3
Aspirator 10
Audiometer 10
Autoclave 10
Autoscaler, ionic 10
Bacteriology analyzer 8
Baci incinerator 5
Balance


Analytical 10
Electronic 7
Precision mechanical 10


Basal metabolism unit 8
Bath


Fluidotherapy 7
Paraffin 7
Serological 7
Water 7


Biochemical analysis unit 7
Biochromatic analyzer 7
Biofeedback machine 8
Biomagnetometer 7
Bipolar coagulator 7
Blood cell counter 5
Blood chemistry analyzer, automated 5
Blood culture analyzer 8


Annex 8: Typical equipment lifetimes


216


Blood gas analyzer 5
Blood gas apparatus, volumetrics 8
Blood transfusion apparatus 6
Blood warmer 7
Blood warmer coil 7
Bone surgery apparatus 3
Breathing unit, positive-pressure 8
Bronchoscope


Flexible 3
Rigid 3


Carbon monoxide recorder/detector 10
Cardiac monitor 5
Cardioscope 8
Cart


Emergency-isolation 10
Medicine 10


Caspar ACF instrument and plate system 7
Cassette changer 8
Cautery unit


Dermatology 7
Gynecology 7


Cell freezer 7
Cell washer 5
Centrifuge 7
Centrifuge, refrigerated 5
Cerebral function monitor 7
Child immobilizer 15
Chloridiometer 10
Chromatograph, gas 7
Clinical analyzer 5
Clopay wrapping machine 10
Coagulation analyzer 5
Cold-pack unit, floor 10
Colonoscope 3
Colorimeter 7
Colposcope, with floor stand 8
Computer, clinical 5


Continued opposite




Table 8: Diagnostic and Treatment Departments (continued)
Item Years Item Years
Computer-assisted tomography (CT) scanner 5
Conductivity tester 5
CO-oximeter 10
Cryoopthalmic unit, with probes 7
Cryostat 7
Cryosurgical unit 10
Cyclotron 7
Cystic fibrosis treatment system 10
Cystometer 10
Cystometrogram unit 10
Cystoscope 3
Decalcifier 10
Deionized water system 7
Densitometer, recording 5
Dental drill, with syringe 3
Dermatome 10
Diagnostic set 10
Diathermy unit 10
Digital fluoroscopy unit 5
Digital radiography unit 5
Diluter 10
Dispenser, alcohol 10
Distilling apparatus 15
Doppler 5
Dose calibrator 5
Dryer, sonic 10
Duodenoscope 3
Echocardiograph system 5
Echoview system 5
Electrocardiograph 7
Electrocardioscanner
(Holter monitor scanner) 7
Electroencephalograph 7
Electrolyte analyzer 5
Electromyograph 7
Electrophoresis unit 7
Electrosurgical unit 7
Ergometer 10
Evacuator 10
Evoked potential unit 10
Exercise apparatus 15


Annex 8: Typical equipment lifetimes


217


Exercise equipment, outdoor 10
Exercise system, computer assisted 5
Exerciser, orthotron 10
Eye surgery equipment (phacoemulsifier) 7
Fibreoptic equipment 5
Fibrometer 7
Film changer 8
Film viewer 10
Flow cytometer 5
Fluid sample handler 5
Fluorimeter 10
Fluoroscope 8
Frame, turning 15
Furnace, laboratory 10
Gamma camera 5
Gamma counter 7
Gamma knife 10
Gamma well system 7
Gas analyzer 8
Gastroscope 3
Geiger counter 10
Generator 5
Gloves, lead-lined 3
Hand dynamometer 10
Heart-lung system 8
Heat sealer 5
Hemodialysis unit 5
Hemoglobinometer 7
Hemophotometer 10
High-density mobile film system 10
Holter


Electrocardiograph 7
Electroencephalograph 7


Homogenizer 10
Hood, exhaust or Bacti 10
Hydrocollator 10
Hydrotherapy equipment 15
Hyfrecator 10
Hyperbaric chamber 15
Hypothermia apparatus 10
Image analyzer 5


Continued overleaf




Table 8: Diagnostic and Treatment Departments (continued)
Item Years Item Years
Image intensifier 5
Immunodiffusion equipment 10
IMX analyzer 7
Incubator, laboratory 10
Inhalator 10
Intraarterial shaver 10
Iontophoresis unit 8
Isodensitometer 7
Isolation chamber 12
Isotope equipment 7
Isotope scanner 7
Kiln 10
K-pads 5
Kymograph 10
Lamp


Deep-therapy 10
Infrared 10
Mercury quartz 10
Slit 10


Laparoscope 3
Laryngoscope 3
Laser, coronary 2
Laser, surgical 5
Laser positioner 5
Laser smoke evacuator 5
Lifter, patient 10
Linac scalpel 5
Linear accelerator 7
Lithotripter, extracorporeal shock-wave (ESWL) 5
Magnetic resonance imaging (MRI) equipment 5
Mammography unit
Fixed 5
Mobile (van) 8
Marograph 7
Mass spectrophotometer 7
Microbiology analyzer 8
Microscope 7
Microtome 7
Microtron power system 7
Mirror, therapy 15
Muscle stimulator 10


Annex 8: Typical equipment lifetimes


218


Nebulizer
Pneumatic 10
Ultrasonic 10


Nephroscope 7
Neurological surgical table headrest 10
Neutron beam accelerator 8
Noninvasive CO2 monitor 7
Optical readers 5
Orthotron system 10
Orthourological instruments 10
Oscilloscope 7
Oven


Paraffin 10
Sterilizing 10


Oximeter 10
Oxygen analyzer 7
Oxygen tank, motor, and truck 8
Pacemaker, cardiac (external) 5
Pacing system analyzer 7
Panendoscope 10
Parallel bars 15
Pelviscope 7
Percussor 5
Perforator 10
Peripheral analyzer 10
pH gas analyzer 10
pH meter 10
Phonocardiograph 8
Photocoagulator 10
Photography apparatus, gross pathology 10
Photometer 8
Physioscope 10
Pipette, automatic 10
Plasma freezer 10
Platelet rotator 20
Positron emission tomography
(PET) scanner 5
Proctoscope 3
Prothrombin timer, automated 8
Proton beam accelerator 7
Pulmonary function analyzer 8


Continued opposite




Table 8: Diagnostic and Treatment Departments (continued)
Item Years Item Years
Pulmonary function equipment 8
Pulsed oxygen chamber 10
Pulse oxymeter 7
Pump


Infusion 10
Stomach 10
Suction 10
Surgical 10
Vacuum 10


Radiation meter 8
Radioactive source, cobalt 5
Radiographic duplicating printer 8
Radiographic-fluoroscopic combination 5
Radiographic head unit 5
Rate meter, dual 10
Refractometer 10
Refrigerator, blood bank 10
Resuscitator 10
Retractor 5
Rhinoscope 3
Rinser, sonic 10
Rotoosteotome unit 10
Saw


Autopsy 10
Neurosurgical 10
Surgical, electric 10


Scale
Bed 10
Chair 10
Clinical 10


Scale, metabolic 10
Scintillation scaler 8
Sensitometer 10
Seriograph, automatic 8
Shaking machine (vortexer) 8
Sharpener, microtome knife 10
Sigmoidoscope 3
Signal-averaged EKG 5
Simulator 5
Single-photon emission computed tomography
(SPECT) Scanner 5
Sinuscope 7
Skelton 10


Annex 8: Typical equipment lifetimes


219


Slide stainer, laboratory 7
Spectrophotometer 8
Spectroscope 10
Sphygmomanometer 10
Spirometer 8
Stand


Basin 15
Intravenous 15
Irrigating 15
Mayo 15


Steam-pack equipment 10
Stereo tactic frame 5
Sterilizer, movable 12
Steris sterilization system 7
Stethoscope 5
Stress tester 10
Stretcher 10


Hydraulic 7
Surgical shaver 5
Tank


Cleaning 10
Full-body 15
Hot-water 10
Therapy 15


TDX analyzer 7
Telemetry unit, cardiac 5
Telescope, microlens 10
Telescopic shoulder wheel 15
Telethermometer 10
Tent


Aerosol 8
Oxygen 8


Thyroid uptake system 5
Tissue-embedding center 8
Tissue processor 7
Titrator, automatic 10
Tonometer 10
Totalap 10
Tourniquet, automatic 10
Tourniquet system 7
Traction unit 10
Transcutaneous nerve stimulator system 5
Transesophageal transducer 5


Continued overleaf




Wheelchair 5
X-ray equipment


Developing tank 10
Film dryer 8
Film processor 8
Furniture 15
Image intensifier 5
Intensifying screens 5
Silver recovery unit 7


X-ray unit
Fluoroscopic 5
Mobile 5
Radiographic 5
Superficial therapy 5
Tomographic 5
Wiring 5


Cart
Food/tray, heated-refrigerated 10
Linen 10
Maid 10
Supply 10
Utility 10


Cash register 5
Central data processing unit 10
Clock 10
Coffee maker 5
Compactor, waste 10
Compressor, air 12
Conveyor, tray 10
Cooker, pressure, for food 10
Cooler, walk-in, freestanding 15
Cutter, cloth, electric 10
Cutter, food 10
Dish sterilizer 10
Dishwasher 10
Disinfector 15


Table 8: Diagnostic and Treatment Departments (continued)
Item Years Item Years
Treadmill, electric 8
Tube dryer 10
Tube tester 10
Ultrasound, diagnostic 5
Ultrasound unit, therapeutic 7
Vacuvette 10
Ventilator, respiratory 10
Vial filler 10
Vibrator 10
Video


Camera 5
Light source 5
Monitor 5
Printer 5


Table 9: Support Departments
Support departments consist of biomedical engineering, central sterile supply, dietary, engineering/maintenance,
housekeeping/environmental services, laundry, materials management, security, and staff facilities departments.
Item Years Item Years
Air conditioner, window 5
Ambulance 4
Automobile


Delivery 4
Passenger 4


Battery charger 5
Bedpan washer 15
Blanket dryer 15
Blanket warmer 15
Bottle washer 10
Broiler 10
Burnisher, silverware 15
Cage, animal 10
Camera, identification 5
Camera, surgical 5
Camera, television monitoring,
color or black-and-white 5
Camera, videotape, color or black-and-white 5
Can opener, electric 10
Capsule machine 10


Annex 8: Typical equipment lifetimes


220


Continued opposite




3.3 Planned Preventive Maintenance


221


Table 9: Support Departments (continued)
Item Years Item Years
Dispenser
Butter, refrigerated 10
Milk or cream 10
Drill press 20
Dryer
Clothes 10
Hair 5
Drying oven, paint shop 10
Enlarger 10
Extractor, laundry 15
Floor-buffing and polishing machine 5
Floor-scrubbing machine 5
Floor-waxing machine 5
Folder, flatwork 15
Food chopper 10
Freezer, ultracold 10
Fryer, deep-fat 10
Garbage disposal, commercial 5
Glassware washer 8
Griddle 10
Grinder, food waste 10
Helicopter 4
Hoist, chain or cable 15
Hot-food box 15
Hotplate 5
Humidifier 8
Ice cream freezer 10
Ice cream (soft) machine 10
Ice cream storage cabinet 10
Ice cube-making equipment 10
Indicator, remote 10
Intercom 10
Ironer, flatwork 15
Kettle, steam-jacketed 15
Key machine 10
Laminator 10
Lathe 15
Lawn mower, power 3
Linen press 15
Linen table 15
Linen washer 15


Lint collector 15
Loom 15
Lowerator 10
Mannequin 10
Marking machine 10
Meat chopper 10
Mixer, commercial 10
Nourishment ice station 8
Oven


Baking 10
Microwave 5
Roasting 10


Packaging machine 10
Platform 12
Paint spray booth 15
Paint-spraying machine 10
Paper baler 15
Parking lot sweeper 5
Pipe cutter-threader 10
Planer and shaper, electric 10
Plate-bending press 10
Platemaker


Computerized 5
Noncomputerized 10


Popcorn machine 8
Power supply 10
Press, laundry 15
Printing press 10
Range, domestic 10
Refrigerator


Domestic 8
Commercial 10
Undercounter 10


Remote control receiver 10
Rotary tiller 10
Sanitizer 10
Saw
Band 10
Bench, electric 10
Meat-cutting 10
Scaffold 10
Scale, laundry
Movable 10
Platform 15


Continued overleaf




Table 9: Support Departments (continued)
Item Years Item Years
Sewing machine 15
Shears, squaring, floor 12
Shoulder wheel 20
Simulator 5
Slicer
Bread 10
Meat 10
Snowblower 5
Steamer, vegetable 10
Telephone, cordless 5
Telephone equipment for deaf 5
Telephone monitors 10
Telephone system 10
Television monitor 5
Television receiver 5
Toaster, commercial 10
Tractor 10
Truck (automotive)


Forklift 10
Multipurpose filling 15
Pickup 4
Van 4


Annex 8: Typical equipment lifetimes


222


Truck (hand)
Hot-food 10
Tray 12


Ultrasonic cleaner 10
Urn, coffee 10
Vacuum cleaner 8
Vegetable peeler, electric 10
Vending machine 10
Vise, large bench 20
Warmer


Dish 10
Food 10


Washing machine
Commercial, small 10
Domestic 10
Linen, large 15


Welder 10
Wire tightener-twister 10




LIST 2: The GTZ (German Government Technical Aid Agency)
Source: Halbwachs, H (GTZ), 2000, ‘Maintenance and the Life Expectancy of Healthcare
Equipment in Developing Economies’, in Health Estate Journal, March 2000, pp 26-31


The GTZ list contains estimates for fewer equipment items, but it more closely reflects the realities
in developing countries.
The GTZ used a particular research method (a Delphi survey – see source paper) to obtain and
analyze feedback from 23 experts from 16 different country backgrounds. The experts were made up
of hospital engineers, bio-medical engineers, a public health doctor/manager, health physicists, and
an health economist. Rather than providing exact lifetimes, this approach provides a range for the
lifetime that depends on the quality of the initial equipment and how well it has been maintained.
Reproduced here is a table containing a summary of their findings.


Table Summarizing GTZ’s Findings


Equipment type
Poorly Well Poorly Well


maintained maintained maintained maintained
Air-conditioner
(window type) 3 5 – 7 5 – 6 10 – 12
Anaesthetic machine
(Boyles) 2 – 5 5 – 10 5 – 10 10 – 15
Centrifuge 3 – 4 7 – 8 6 – 9 10 – 12
Generator (diesel) 3 – 6 9 – 10 10 – 12 18 – 20
Generator (petrol) 2 – 5 5 – 10 6 – 15 10 – 20
Microscope 3 – 6 5 – 10 6 – 10 10 – 20
Oven, hot air (laboratory) 2 – 6 5 – 8 6 – 10 10 – 15
Refrigerator (electrical) 3 – 5 5 – 8 5 – 8 10 – 15
Refrigerator (kerosene) 4 4 – 8 5 – 10 10 – 17
Sphygmomanometer
(aneroid) 1 – 3 2 – 3 2 – 5 5 – 10
Sphygmomanometer
(mercury) 1 – 2 3 – 5 3 - 5 8 – 10
Sterilizer, bench-top
(horizontal) 3 – 5 5 – 8 6 – 10 10 – 14
Sterilizer, floor-standing
(vertical) 3 – 6 5 – 12 8 14 – 15
Suction pump (electrical) 1 – 3 5 – 7 5 – 8 10 – 15
Truck, pick-up 2 – 4 3 – 6 4 – 8 7 – 12
Washing machine
(electrical) 2 – 4 5 6 8 – 11


Annex 8: Typical equipment lifetimes


223


Lifetime in years
Poor quality makes Good quality makes




ANNEX 9: FORM FOR REGISTERING WRITTEN-OFF
EQUIPMENT


Figure 25 shows a form that can be used to register when equipment is condemned and written-off.
It acts as both a record for the health facility to take the item off their inventory, and a record for the
Board of Survey to organize the destruction or disposal of the item in an appropriate way.


Figure 25: Example ‘List of Expendables to be Written Off’ Form


Annex 9: Form for registering written-off equipment


224


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ANNEX 10: SOURCE MATERIAL/BIBLIOGRAPHY
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229






‘How To Manage’ Series for Healthcare Technology
This Series of Guides helps you to get the most out of your investment in healthcare
technology. You need to manage your assets actively, ensuring that they are used optimally
and efficiently. This series shows you how.
Physical assets such as facilities and healthcare technology are the greatest capital
expenditure in any health sector. Thus it makes financial sense to manage these valuable
resources, and to ensure that health care technology:
◆ is selected appropriately
◆ is used correctly and to maximum capacity
◆ lasts as long as possible.
Such effective and appropriate management of healthcare technology will contribute to
improved efficiency within the health sector. This will result in improved and increased
health outcomes, and a more sustainable health service. This is the goal of healthcare
technology management – the subject of this Series of Guides.


The Guides
Guide 1: How to Organize a System of Healthcare Technology Management
Guide 2: How to Plan and Budget for your Healthcare Technology
Guide 3: How to Procure and Commission your Healthcare Technology
Guide 4: How to Operate your Healthcare Technology Effectively and Safely
Guide 5: How to Organize the Maintenance of your Healthcare Technology
Guide 6: How to Manage the Finances of your Healthcare Technology


Management Teams




Copyright 2016, Engineering World Health