Maintenance of Medical Equipment in Government Hospitals in Palestine

· Shocking facts of negligence and neglect ....! Not confined to the linguistic boundaries of terms such as (the negligence by the Ministry of Health in maintaining medical devices in its hospitals and health centers), but the consequences of such negligence and neglect extend to the citizen’s health… It is likely that they may lead (after affirming our mutual faith in the One God... who gives life and causes death... Glory be to Him) to a certain death, not necessarily immediate, but death may occur gradually..... through the ordeal of waiting... for the turn for this patient or that.... until spare parts for a medical device are installed.. which the Ministry failed to return to service.. to treat patients...! Which may extend to months..! due to negligence.... in maintaining a medical device... that the state purchased and purchased many others, ...to treat its citizens and not to torture them.!.. Not to mention the severe material effects borne by the citizen ...when he resorts to borrowing ...taking loans ..! to spend on his treatment bills.. services already guaranteed by the state ...which had supplied many major medical devices to the custody of the Ministry of Health warehouses...! As for the state itself... it is affected directly ...or indirectly... as a result of this negligence ...in the process of maintaining medical devices, because of the consequences of its purchased devices not being fit to serve its patients of its citizens.......! prompting transfers at the expense of its public treasury.. to private hospitals or to foreign hospitals...!

· We hope from God... that the Ministry of Health has taken the SAACB’s important recommendations contained in the report, and that it will hold accountable those who were negligent and careless...!. And that the condition of the hundreds of valuable medical devices now be other than the condition about which the SAACB issued its 37-page report...... It is a cry.. of pain and astonishment...!!

- As is known, hospitals contain many medical devices whose importance and monetary value differ from one device to another. For example, without limitation: these medical devices may be therapeutic devices, such as a cardiac resuscitation device, or diagnostic devices, such as an magnetic resonance imaging device, or analytical devices, such as blood testing devices....etc. These devices require an organized and periodic maintenance system, through a set of continuous procedures aimed at keeping the devices fit for use and operating at the required efficiency..!

- The State Audit and Administrative Control Bureau (SAACB) issued a report on the state of maintenance of medical devices in government hospitals, and on the procedures the government follows in maintaining these medical devices; the report covered the years 2015 and 2016. The Bureau issued the report in March 2017, and it was published on the Bureau’s website on 18-10-2020.....

- The SAACB reached a main conclusion, namely (the existence of shortcomings in maintenance procedures for medical devices in government hospitals in Palestine), and this conclusion arose from a set of observations and findings as follows:

- Weak policies and plans governing the maintenance work of medical devices in government hospitals, in addition to the fact that the majority of medical devices located in government hospitals operate for periods that exceed their useful life.. Moreover, hospitals lack preventive maintenance at the planning and implementation levels. There is an absence of prioritization in maintenance work, weak contract management when purchasing replacement services from medical device maintenance companies, underutilization of available resources, shortcomings in providing some necessary resources, and weak documentation and follow-up of maintenance operations...!!

- The Medical Engineering Unit, centered in the Ministry of Health and specialized in matters related to medical devices in all health centers affiliated with the Ministry of Health, performs maintenance, inspection, and calibration of medical devices in cooperation with the engineering departments in government hospitals. There are two types of maintenance: it may be (preventive maintenance), such as calibration, cleaning, lubrication, and replacement of spare parts; or it may be (corrective maintenance), where the device’s malfunction is repaired and it is returned to service.

- However, a deficiency was observed in the role of the central Medical Engineering Unit in the Ministry of Health, and in the teams working in the engineering departments of hospitals, in following up on the implementation of maintenance companies’ obligations under their signed contracts, which led to the suboptimal exploitation of these contracts.

- It was also noted that there is no periodic and accurate planning process for the maintenance of medical devices; as the SAACB observed, this does not contribute to the continuous provision of medical service to citizens. In addition, the high percentage of devices operating for periods beyond their useful life may increase the occurrence of failures for these devices, raise maintenance costs, and reduce the reliability of those devices’ operation, which negatively affects the continuity and quality of medical service delivery..

- A severe delay in the supply of spare parts was also observed, which led to the delay in maintaining many devices and leaving them out of service for long periods, and consequently delaying the provision of medical services..

- The SAACB conducted this audit to verify whether the Ministry of Health and its hospitals fulfilled their role in maintaining medical devices, given the potential economic effects on the public treasury due to weak maintenance procedures: purchasing medical devices costs huge sums of money, and requires diligence in preserving these devices and achieving maximum benefit from them; insufficient maintenance may lead to unnecessary additional expenses. Also, the delay in providing the resulting medical services due to poor maintenance of medical devices leads the state to bear additional financial burdens, because of resorting to transfers to private medical centers or foreign hospitals.

- The SAACB adds in its report other effects resulting from shortcomings in the maintenance of medical devices, aside from the economic ones, namely the effects on citizens’ health, due to weak maintenance procedures, from poor medical service provided to citizens or delays in providing it, in addition to the citizen bearing additional financial consequences as a result of his having to obtain the service from private centers.

- The SAACB also noted in its report that the audit did not include – the item of medical transfers arising from device failures – due to insufficient data on the reasons for transfers, in addition to not including in the audit – laboratory devices in hospitals –, as they are not owned by the Ministry of Health and were leased about two years ago..!

- The audit covered medical device maintenance activities during the years 2015 and 2016.

- Below we list (practical examples) of the existence of negligence in the maintenance of medical devices in government hospitals in Palestine during 2015 and 2016.

· Practical examples of manifestations of shortcomings in maintenance of medical devices in the Ministry of Health’s hospitals and other health centers in (الضفة الغربية) from Palestine...! I say in a parenthetical comment: (and I say in a parenthetical remark).... And because we are in occupied Palestine.... deliberate error is forbidden..!. Likewise, negligence and irresponsibility are forbidden.! by reason of responsibility before God, homeland, and self....!

· It was observed that about 57% of the devices located in hospitals exceeded the useful life by varying periods; of these, about 40% of the devices in hospitals operate for a period greater than the useful life and less than twice their useful life, and about 17% of the devices in hospitals operate for a period exceeding twice the useful life. For example:

· Palestine Medical Complex – Ramallah): The number of devices registered on the HIS was (1,507 devices), and their useful life was determined, with results as follows: 83 devices operate for a period greater than the useful life and less than twice that useful life. Also, there are 225 devices (15% of the total devices) that operate for a period exceeding twice the useful life, while the period of use of some devices increased fourfold.!!

· Beit Jala Hospital): The number of devices was 1,244, and their useful life was determined, with results as follows: 810 devices—65% of the total devices—operate for a period greater than the useful life and less than twice the useful life. And 274 devices operate for a period exceeding twice the useful life. !!

· Alaa Hospital - Hebron: There are 994 devices, of which 502 devices operate for a period greater than the useful life, less than twice that life, and 148 devices exceeded twice the useful life.

· Rafidia Hospital – Nablus: There are 665 devices, of which 355 devices exceeded the useful life (54%), and are less than twice the useful life, and 110 devices (17%) operate for a period exceeding twice the useful life.

- The Audit Bureau noted that the Ministry does not request a specific clause for maintenance work for the period following the maintenance year in tenders issued for the supply of devices, which later leads to eliminating competition when maintenance tenders for the device are issued and restricting them to the supplying companies only, at the cost determined by the company. We cite by way of example but not limitation, regarding the (Palestine Medical Complex), where the CT scanner at the Palestine Complex was out of service on 19-4-2016 for 21 days, whereas patients should have been transferred from the period 1-5-2016 to 10-5-2016 at the contracting company’s expense. Although the hospital was contacted by the company to transfer patients to one of the private hospitals according to the terms of the agreement, it turned out that no case was transferred during that period at the company’s expense, noting that the daily average number of patients benefiting from the device in the hospital while the device was operational equals 30 cases.!!

- The failure to perform the transfers during the above-mentioned period resulted in the loss of the opportunity to benefit from the contract signed with the company by an amount equivalent to 32 CT scans, at a rate of 600 shekel for each CT scan, and the total cost of these scans is estimated at 19,200 shekel!

- The Audit Bureau noted the unavailability of most (types of diagnostic tools required) at the Medical Engineering Unit to test medical devices, whether for preventive or corrective maintenance; however, it was found that there is also a severe shortage of these tools in the hospitals..! .

- (Spare parts) are considered one of the main resources in the work of medical device maintenance, where their unavailability in a timely manner leads to increased downtime. It was noted that there are severe delays in supplying the spare parts necessary to complete the maintenance process. The average time required to supply spare parts ranged from 152 days, as in the (Palestine Medical Complex) where 51% of its requests are not closed (i.e., not supplied), and 205 days, as in (Beit Jala Hospital) where 10% of its requests are not closed; many spare part orders have passed more than one year from the date of request and have not been supplied..!; and 280 days, as in (Princess Alia Hospital – Hebron), where 54% of its requests are not closed (not supplied). As for the average time consumed to supply spare parts in (Rafidia Hospital) it reached 157 days, and the percentage of its not-closed requests reached 18%...!

· That the delay in supplying (spare parts and repairing malfunctioning medical devices) leads to devices being out of service for long periods, increased pressure on alternative devices, and transferring patients to private hospitals at the Ministry’s expense or at the individual patient’s expense.!!

- Regarding (training courses) and the utilization of human resources and qualifying them to necessary levels of technical knowledge, it was found that the number of training courses and workshops received by maintenance staff in hospitals amounted to one employee out of every five maintenance employees having received training only once....!, during the years 2015 and 2016...!

- The total maintenance staff at the (Palestine Medical Complex) amounted to seven employees, without any training courses..! Not even a single course......!!, whereas at (Alia Hospital – Hebron), there are two employees who received only one course during the years 2015 and 2016. Likewise, at (Beit Jala Hospital), which has 3 employees, and (Rafidia Hospital – Nablus), which has 3 employees.!!

- Weak foundations of (documentation) and follow-up of maintenance operations at the Ministry of Health and its health centers, including its hospitals, in the maintenance operations of medical devices. Documentation has essential and fundamental importance in the medical device maintenance process, as it helps decision-makers in planning the maintenance process and making correct decisions whether in terms of budgeting or workforce size,..... We list below, by way of example but not limitation, some incorrect procedures in maintenance operations for medical devices due to the lack of an integrated documentation process in maintenance:

1- There is no log for each device showing the number of times it has been maintained...!

2- The cost of maintaining the device is not recorded each time, nor the spare parts that were replaced.

3- The computerized system does not issue a comprehensive report on the maintenance operations that have been carried out on all devices..

4- The Ministry does not enter all the operations it carries out into the computerized system, such as external maintenance operations.

5- Many medical devices are not registered on the computerized system at the Palestine Medical Complex.

6- There is no linkage in the computerized system between the Medical Engineering Unit and the governmental hospitals..

7- Shortcomings in the inventory process of medical devices in hospitals.

8- Incorrect entry of maintenance data into the system....! Some maintenance operations are recorded in the logs of devices different from the devices on which the maintenance work was actually performed....!

- Date: 4-2-2021