management - computerized maintenance management system

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Computerized maintenancemanagement system

WHO Medical device technical series


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Computerized maintenancemanagement system

WHO Medical device technical series


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WHO Library Cataloguing-in-Publication Data

Computerized maintenance management system.

(WHO Medical device technical series)

1.Equipment and supplies. 2.Biomedical engineering. 3.Management informationsystems. 4. Biomedical technology. I.World Health Organization.

ISBN 978 92 4 150141 5 (NLM classication: WX 147)

World Health Organization 2011All rights reserved. Publications of the World Health Organization can be obtained fromWHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland(tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Requests

for permission to reproduce or translate WHO publications whether for sale or fornoncommercial distribution should be addressed to WHO Press, at the above address(fax: +41 22 791 4806; e-mail: [email protected]).

The designations employed and the presentation of the material in this publication donot imply the expression of any opinion whatsoever on the part of the World HealthOrganization concerning the legal status of any country, territory, city or area or of itsauthorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines onmaps represent approximate border lines for which there may not yet be full agreement.

The mention of specic companies or of certain manufacturers products does not implythat they are endorsed or recommended by the World Health Organization in preferenceto others of a similar nature that are not mentioned. Errors and omissions excepted, thenames of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to verifythe information contained in this publication. However, the published material is beingdistributed without warranty of any kind, either expressed or implied. The responsibilityfor the interpretation and use of the material lies with the reader. In no event shall theWorld Health Organization be liable for damages arising from its use.

Design & layout: LIV Com Srl, Le Mont-sur-Lausanne, Switzerland.

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Contents

Figures and tables 2

Preface 3Maintenance series and external guidance 4Methodology 4Denitions 5

Acknowledgements 6Declarations of Interests 6

Acronyms and abbreviations 7

Executive summary 8

1 Introduction 9

2 Purpose 11

3 CMMS structure 123.1 Fields and tables 123.2 Modules 12

3.2.1 Equipment inventory module 133.2.2 Spare parts inventory and management module 143.2.3 Maintenance module 143.2.4 Contract management module 15

3.3 Screens and reports 16

4 Implementing CMMS 174.1 Evaluation 174.2 Selection 18

4.2.1 Commercial packages 184.2.2 Open source packages 184.2.3 Locally developed packages 18

4.3 Data collection 194.4 Installation 194.5 Conguration and customization 204.6 Data entry 204.7 Training 20

4.8 Follow-up and performance monitoring 204.9 CMMS documentation and back up 21

5 Networking CMMS 22

6 Concluding remarks 23

7 References 24

8 Useful resources 25

Appendix A Common elds included in medical equipment inventory 26

Appendix B Sample CMMS screenshots 27

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Appendix C Vendor specication table 28

Appendix D Request for proposal and vendor proposal sample content 31

Appendix E Examples of CMMS vendors 34

Appendix F Examples of open source CMMS providers 35

Appendix G CMMS software design plan 36

Figures and tables

Figure 1. CMMS functionality owchart 10Table 1. Commonly used tables and related elds 12Figure 2. Table infrastructure for equipment inventory module 13Figure 3. Work order management ow chart 15Table 2. Types of reports that can be generated from a CMMS programme 16Figure 4. CMMS implementation ow chart 17Table 3. Advantages and disadvantages of a locally developed CMMS package 19Table 4. CMMS deployment solutions and related networking options 22

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Preface

Health technologies are essential for a functioning health system. Medical devices inparticular are crucial in the prevention, diagnosis, and treatment of illness and disease,as well as patient rehabilitation. Recognizing this important role of health technologies,the World Health Assembly adopted resolution in May 2007. The resolution coversissues arising from the inappropriate deployment and use of health technologies, andthe need to establish priorities in the selection and management of health technologies,specically medical devices. By adopting this resolution, delegations from MemberStates acknowledged the importance of health technologies for achieving health-relateddevelopment goals; urged expansion of expertise in the eld of health technologies, inparticular medical devices; and requested that the World Health Organization (WHO)take specic actions to support Member States.

One of WHOs strategic objectives is to ensure improved access, quality and use ofmedical products and technologies. This objective, together with the World HealthAssembly resolution, formed the basis for establishing the Global Initiative on HealthTechnologies (GIHT), with funding from the Bill & Melinda Gates Foundation. GIHTaims to make core health technologies available at an affordable price, particularlyto communities in resource-limited settings, to effectively control important healthproblems. It has two specic objectives:

to challenge the international community to establish a framework for thedevelopment of national essential health technology programmes that will have a

positive impact on the burden of disease and ensure effective use of resources; to challenge the business and scientic communities to identify and adapt innovative

technologies that can have a signicant impact on public health.

To meet these objectives, WHO and partners have been working towards devising anagenda, an action plan, tools and guidelines to increase access to appropriate medicaldevices. This document is part of a series of reference documents being developed foruse at the country level. The series will include the following subject areas:

policy framework for health technology medical device regulations health technology assessment health technology management

needs assessment of medical devices medical device procurement medical equipment donations

medical equipment inventory management medical equipment maintenance

computerized maintenance management systems medical device data

medical device nomenclature

medical devices by health-care setting medical devices by clinical procedures medical device innovation, research and development.



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These documents are intended for use by biomedical engineers, health managers,donors, nongovernmental organizations and academic institutions involved in healthtechnology at the district, national, regional or global levels.

Maintenance series and external guidance

Three documents in this technical series have been developed specically to aid a healthfacility or a national ministry of health to establish or improve a medical equipmentmaintenance programme. The documents address medical equipment inventorymanagement, maintenance, and computerized maintenance management systems.Each of these documents can be used as a stand-alone document, but together theypresent all of the factors to consider when developing a medical equipment maintenanceprogramme. Furthermore, a six-volume comprehensive series of manuals for themanagement of healthcare technology, known as the How To Manage series, existsfor people who work for, or assist, health service provider organizations in developingcountries and are publicly available. 1

Methodology

The documents in this series were written by international experts in their respectiveelds, and reviewed by members of the Technical Advisory Group on Health Technology(TAGHT). The TAGHT was established in 2009 to provide a forum for both experiencedprofessionals and country representatives to develop and implement the appropriatetools and documents to meet the objectives of the GIHT. The group has met on three

occasions. The rst meeting was held in Geneva in April 2009 to prioritize which toolsand topics most required updating or developing. A second meeting was held in Rio deJaneiro in November 2009 to share progress on the health technology management toolsunder development since April 2009, to review the current challenges and strategiesfacing the pilot countries, and to hold an interactive session for the group to presentproposals for new tools, based on information gathered from the earlier presentationsand discussions. The last meeting was held in Cairo in June 2010 to nalize thedocuments and to help countries develop action plans for their implementation. Inaddition to these meetings, experts and advisers have collaborated through an onlinecommunity to provide feedback on the development of the documents. The conceptswere discussed further during the First WHO Global Forum on Medical Devices inSeptember 2010. Stakeholders from 106 countries made recommendations on howto implement the information covered in this series of documents at the country level. 2

All meeting participants and people involved in the development of these documentswere asked to complete a declaration of interest form, and no conicts were identied.

1 Available at http://www.healthpartners-int.co.uk/our_expertise/how_to_manage_series.html2 First WHO Global Forum on Medical Devices: context, outcomes, and future actions is available at: http://www.who.int/medical_devices/gfmd_report_nal.pdf (access

March 2011)



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Denitions

Recognizing that there are multiple interpretations for the terms listed below, they aredened as follows for the purposes of this technical series.

Health technology: The application of organized knowledge and skills in the form ofdevices, medicines, vaccines, procedures and systems developed to solve a healthproblem and improve quality of life. 3 It is used interchangeably with health-caretechnology.

Medical device: An article, instrument, apparatus or machine that is used in theprevention, diagnosis or treatment of illness or disease, or for detecting, measuring,restoring, correcting or modifying the structure or function of the body for some healthpurpose. Typically, the purpose of a medical device is not achieved by pharmacological,immunological or metabolic means. 4

Medical equipment: Medical devices requiring calibration, maintenance, repair, usertraining, and decommissioning activities usually managed by clinical engineers.Medical equipment is used for the specic purposes of diagnosis and treatment ofdisease or rehabilitation following disease or injury; it can be used either alone or incombination with any accessory, consumable, or other piece of medical equipment.Medical equipment excludes implantable, disposable or single-use medical devices.

3 World Health Assembly resolution WHA60.29, May 2007 (http://www.who.int/medical_devices/resolution_wha60_29-en1.pdf, accessed March 2011).4 Information document concerning the denition of the term medical device. Global Harmonization Task Force, 2005 (http://www.ghtf.org/documents/sg1/sg1

pdf, accessed March 2011).



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Acknowledgements

Computerized maintenance management system was developed under the principalauthorship of Iyad Mobarek, Technical Ofcer, World Health Organization (WHO) CountryOfce, Amman, Jordan and under the overall direction of Adriana Velazquez-Berumen,WHO, Geneva, Switzerland as part of the Global Initiative on Health Technologies projectfunded by the Bill & Melinda Gates Foundation.

The draft was reviewed by Matthew Baretich (Baretich Engineering), Jennifer Barragan(WHO), Hashim El Zein (WHO), Victoria Gerrard (WHO), Adham Ismail (WHO), JoelNobel (ECRI Institute) and Frank Painter (University of Connecticut), and edited by InisCommunication.

Special thanks to the director, heads of departments and staff of the Directorate ofBiomedical Engineering in Jordan for sharing their data and for their support. Thanksare also due to all administrative staff at the WHO Country Ofce in Jordan, namelyMiranda Shami, Julinda Kharabsheh, May Khoury, Samia Nawas, Banan Kharabshehand Layan Al Kindi, for their administrative support.

We would like to thank Aditi A Sharma for assistance in proofreading and Karina Reyes-Moya and Gudrun Ingolfsdottir for administrative support throughout the developmentof this document.

Declarations of Interests

Conict of interest statements were collected from all contributors and reviewers to thedocument development. No conicts of interest were declared.



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Executive summary

As health facilities expand and the number of medical devices they depend on toprovide quality health care increases, a need to manage health-care technology moreeffectively and efciently becomes evident. A computerized maintenance managementsystem (CMMS) is a tool that can improve overall medical equipment management atthe facility level. The information included in a CMMS varies depending on the individualsituation but always includes the medical equipment inventory and typically includesinformation such as service history, preventive maintenance procedures, equipmentand performance indicators, and costing information.

A CMMS is made up of elds, tables and modules populated with data from the clinicalengineering or medical equipment department of a given facility. Using a CMMS, criticaldata can be accessed, manipulated and analysed using user-friendly interfaces. Reportscan be generated from the system to help policy-makers reach decisions regardinghealth technologies. However, it is important to take into consideration multiple factorswhen deciding to adopt and develop a CMMS. Factors such as nancial and technicalresources are important when determining whether to purchase a commercial product,use open-source software, or to develop a system locally. Implementation requiresproceeding through a number of phases that will allow the system to be plannedcomprehensively. By completing this multistep process, the options for deployment willbe thoroughly evaluated; a suitable package will be selected, installed and customized;data will be entered; and training on the CMMS will be provided.

For organizations with the appropriate resources to implement this tool, CMMS can bevery benecial. It is a highly exible tool that when properly implemented has the abilityto transform the management of medical equipment while also improving the availabilityand functionality of the technology required to prevent, diagnose and treat illness.



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1 Introduction

Technology plays a key role in the effectivedelivery of health care. The selection ofappropriate medical technology and theorganization of keeping that technologyin good working order fall under the remitof health-care technology management(HTM) programmes (1) . HTM is often theresponsibility of the clinical engineering (ormedical equipment) department, whichtests, repairs and maintains diagnostic andtherapeutic clinical equipment to ensurethat it can be used safely and effectively (2) .Computerized maintenance managementsystems (CMMS) have evolved to providesupport to HTM managers to maintainmedical equipment and monitor theirassociated costs automatically.

A CMMS is a software package that containsa computer database of information aboutan organizations maintenance operations.In HTM, the CMMS is used to automate

the documentation of all activities relatingto medical devices, including equipmentplanning, inventory management, cor-rective and preventive maintenanceprocedures, spare parts control, servicecontracts, and medical device recalls andalerts. The collected data can be analysedand used for technology management,quality assurance, work order control andbudgeting of medical devices (3) .

The decision to automate a HTM systemor replace an existing CMMS depends onthe individual circumstances of the healthfacility, including working procedures,information technology (IT) infrastructureand available budget. In order toeffectively assist in the managementand maintenance of medical equipment,a CMMS must comprehensively meetthe needs of the user. Although major

vendors strive to develop a system thatuniversally meets the needs of all HTM

managers, no available system presents acomplete solution. Most, however, can becustomized to meet the specic needs ofthe health facility. Alternatively, an IT rmcan be contracted to develop a CMMSpackage tailored to local requirements. Acustomized CMMS package is generallymore expensive but if well designed andmaintained will often produce a moresatisfactory solution that meets localneed.

A CMMS can be used to:

standardize and harmonize infor-mation within a HTM programme;

assist in the planning and monitoringof inspection and preventive main-tenance, and schedule and trackrepairs;

monitor equipment performanceindicators such as mean time

between failures, down time andmaintenance costs for individualor equipment groups of the samemodel, type or manufacturer;

monitor clinical engineering staffperformance indicators such asrepeated repairs by the same staffmember for the same problem,average down time associated withindividuals, and productive work timefor individuals or groups;

generate reports that can be usedto plan user training programmesbased on equipment failure trendsin certain departments or healthfacilities;

host libraries of regulatory require-ments and safety information;

generate the appropriate documen-tation for accreditation by regulatoryand standard organizations;

generate reports to assist in themonitoring and improvement of the



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productivity, effectiveness and per-formance of HTM. Examples of thesereports include: the percentage of the cost of main-

tenance compared with the totalcost of equipment in the inventory;

compliance with the inspectionand preventive maintenance pro-gramme;

mean productive working hours; identication of medical equipment

affected by hazard and recall alerts.

Figure 1 presents a owchart of CMMSfunctionality. The CMMS, whether com-mercial or customized, can be used byclinical engineers as a tool to complementtheir current HTM programme and helpthem full their departments particularobjectives. Effectively implementing agood CMMS will improve patient carethrough the efcient management andmaintenance of medical equipment toensure that it functions reliably.

Figure 1. CMMS functionality owchart

Adoption of CMMS

Selection/development of CMMSPreliminary data input and testingFinal data input and implementation

Equipment reception

Delivery and installationAcceptanceTraining (service and operation)

Equipment operation

Warranty service(if available)MaintenanceDown time monitoringLocal support evaluation

Service contract/in-house support

MaintenanceDown time monitoringSpare parts managmentPerformance of equipment and supplier

Evaluation(downtime and cost of support)Equipment performance

Supplier/manufacturer performanceProvide recommendation (procurement,decommissioning, donation, etc.)

Quality control (QC)

Performance indicatorsTechnical and administrative QC

Equipment

decommissioning orreplacement



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2 Purpose

The purpose of this document is to pro-vide a tool to guide health-care workers,particularly biomedical and clinical engi-neers, in adopting and implementing acomputerized method of managing theirmaintenance system. It is specicallyaimed at those with the technical andnancial resources to support such a sys-

tem. The reader will get an understandingof the components of a CMMS and howto select or develop a system that bestsuits their needs. High-level managersand policy-makers may wish to read thisdocument to further their understandingof managing medical equipment and toenable informed decision-making.



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3 CMMS Structure

A CMMS package integrates all medicalequipment services into a databasemade up of elds, tables, modules andscreens. The following section gives abrief introduction to this basic structure,which can be used by HTM managers tohelp choose or develop a system that issuitable for their needs.

3.1 Fields and tables

A eld is a single piece of information, forexample an equipment serial number.A table is a collection of related elds,for example an equipment location tablemight be made up of the elds building,department and room where a piece ofequipment is stored.

To avoid long descriptive text, it is usefulto develop a comprehensive, consistent

and simple coding system for the variousactivities of the database. A single codeis a eld, and a collection of elds can beorganized into tables. Coding of tables canbe developed for equipment inventory,personnel, maintenance proceduresand equipment locations. CommercialCMMS packages normally have a setof generic codes that can be adaptedor customized according to the needsof the health facility. For equipmenttype coding, standard nomenclaturesuch as the Universal Medical DeviceNomenclature System and the GlobalMedical Device Nomenclature Systemshould be considered. Implementingappropriate nomenclature can alsofacilitate the management of alerts andvigilance reports.

Appendix A provides a list of elds that are

commonly included in a CMMS inventoryfor health technology management.

Commonly used tables with their relatedelds are shown in Table 1.

3.2 Modules

A module is a collection of tables and

data screens. The inventory module, forexample, is made up of the equipment

Table 1. Commonly used tables and related elds

Table FieldsEquipmenttype

Equipment type Inspection and preventive

maintenance (IPM) procedures IPM frequency Risk level Responsible staff

Equipmentmodel

Model number Serial number Parts list Parts code and name IPM procedures

Manufacturer/seller

Manufacturer code and name Seller code and name Manufacturer email, telephone and

address Seller email, telephone and address Manufacturer contact name Seller contact name

Stores/spares Store code and name Parts code and name Parts order number

Staff Employee code Employee name Employee position Access level Training details

Maintenance Inventory number Work order number Service provider Service engineer code Fault code and name

IPM proceduresHealth facility Facility code and name

Building code and name Department code and name Type of facility



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type table, the manufacturer informationtable and the equipment location table.The following sections describe the basicmodules of a CMMS package.

3.2.1 Equipment inventory module 1 The inventory module is the core of anyCMMS and the rst to be constructed. Itis therefore very important to include allelds necessary for effective HTM. Whennew equipment is added to the inventory,the equipment is registered within theCMMS database through a data entryscreen.

Figure 2 presents a basic table infras-tructure for an equipment inventorymodule. In this gure there are threetables that contribute information to thenal inventory list. It is common practice

1 Please refer to Introduction to medical equipment inventory management in thistechnical series for more details on developing an inventory.

to use stored default values to buildinventory records for new equipment,as it reduces entry time and avoidshuman error. For example, the tableholding information about equipmenttype includes pre-stored values such asthe relevant inspection and preventivemaintenance (IPM) procedures, risklevel and responsible staff for every typeof medical equipment. It is thereforeonly necessary to enter the equipmentcode of a new piece of equipment intothe equipment table and all pre-storedvalues associated with this code willbe added to the inventory. Similarly,the other areas illustrate default valuesassociated with the equipment model,location of medical equipment andinventory number, respectively. Thisallows modules to be built with maximumefciency and maintains data integrity(3) . Although an initial time investment

Figure 2. Table infrastructure for equipment inventory module

Equipment type table

Equipment model table

Entered values

Equipment code and name

Stored values

IPM proceduresIPM frequency

Risk levelStaff responsible

Entered values

Manufacturer name and codeEquipment model number

Stored values

Safety responsibilityParts list

Trained staff names and codes

Equipment location table

Entered values

Facility name and codeBuilding code

Department name and code

Stored values

Building default valuesTrained operator

Peripheral store code

Equipment inventory module

Entered values

Inventory number (auto generated)Installation date

Seller code and nameAccessories and software

Purchase order number (purchase price)



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is required to construct coding tablesbefore the inventory data can be added,the long-term time and error savings aresignicant.

3.2.2 Spare parts inventory andmanagement moduleThe spare parts management moduleis an extension of the inventory modulethat tracks the spare parts related toequipment and helps to maintain stocklevels.

Stocked parts include those that are com-mon to a number of different pieces ofequipment such as fuses, wires, batteriesand basic electronic components, andthose parts that are more specic to aparticular model such as circuit boards,power supplies, X-ray tubes and ultra-sound probes. Fields in the spare partsinventory might include:

part description (name); stock (inventory) number; manufacturers name, serial and part

number; link to equipment model; minimum stock level; current stock level; part storage location; price and date purchased.

Depending on the maturity of the system,these data can be entered manually or byscanning a part-specic barcode, whichpopulates the appropriate elds withinthe database. The data can be used togenerate screens that:

alert the user to minimum stock lev-els for particular parts;

create reports regarding the frequen-cy of part replacement, which canhelp with predicting maintenanceschedules and future stock levels;

list all the parts required for certain

pieces of equipment; report on the consumption of reusedparts.

Some CMMS packages provide a fullyautomated operation that includes allphases of spare parts management fromprocurement to delivery, acceptancetesting and use.

3.2.3 Maintenance module 2 The maintenance module assists the userof the CMMS programme to effectivelymanage their maintenance schedule.Figure 3 provides an overview of howthe CMMS integrates with a standardmaintenance system in a hospital.As demonstrated in this figure, theCMMS can be used for both plannedpreventive maintenance and correctivemaintenance.

Planned preventive maintenanceWith the appropriate inputs, the comput-erized system can calculate when a pieceof equipment will require maintenanceand advise which parts might need to beordered and when. The package can alsomonitor the maintenance process andlog when it has been completed. Fields

required for this module may include:

equipment-specic inspection andpreventive maintenance procedures;

equipment-specic inspection andpreventive maintenance schedule;

frequency of equipment fault; estimated equipment running hours.

Corrective maintenanceWhen an equipment user reports a prob-lem with a piece of equipment, the clinicalengineering department can log the faultin the CMMS system. The programmewill automatically generate a work orderand allow the manager of the system toassign an engineer to the job. The CMMSprogramme can provide informationregarding workload, training and expertiseof individual engineers to assist with thisdecision. If an initial evaluation of the fault

identies that a specic part is required

2 Please seeMedical equipment maintenance programme overviewin thistechnical series for more information on planning, managing, and implementinmaintenance.



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to complete the job, the computerizedsystem can record this and provide theappropriate ordering information aboutthe part. When the job is complete thestatus of the equipment can be loggedin the system.

Whether preventive or corrective, prioritylevels for the maintenance to be donecan be assigned with reference to theequipment risk, the strategic value tothe health facility, and the availability ofback-up equipment. In addition, mainte-nance work order forms can be generatedin electronic or paper format to includethe relevant maintenance proceduresrequired to complete the work order (3,4) .

3.2.4 Contract management moduleThe contract management module isused to track all externally provided main-

tenance services. The main factors to

monitor are cost and performance of bothvendor and equipment.

If the medical equipment is under con-tract, either through warranty, com-prehensive service contracts or partialsupport service contracts, the vendor isrequired to provide technical support tothe equipment over an agreed period.The CMMS programme can automati-cally generate alerts addressed to vendorswhen a piece of equipment is logged asfaulty or is scheduled for inspection andpreventive maintenance. The terms andrelated costs of any contract should bestored in the system for reference.

If possible, interfacing the CMMS pro-gramme with the accounts departmentsIT system is useful. All payments to ex-ternal vendors can then be approved

electronically through the main nancial

Figure 3. Work order management ow chart

Equipment fault Clinical engineeringdept. notied

Equipment faultlogged on CMMS

IPM schedule Work order generatedInventory

Equipment historyscreen

Work order closed

IPM procedures

Pending work order(IPM or corrective)

Work order manager

Assign serviceprovider

Reporting system

Spare parts ordermanager

Stores manager

Parts received Job execution

Job Completed?

Parts available?

Parts required tocomplete job?

Yes

YesYes

NoNo

No

CMMS



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IT system of the health institution. If thisis not possible, approval forms for com-municating with the accounts departmentcould be printed from the CMMS.

3.3 Screens and reports

A screen allows the user to add, collectand analyse data from a selection offields, tables and modules through auser-friendly interface. For example, theequipment history screen is a collectionof data from various modules summarizingthe HTM activity related to a certain pieceof equipment. It is the main feature of aCMMS and includes information such asthe inventory details, service activities,work order details, spare parts used andassociated costs, and recall information.Screens can be used to generate reportsthat will assist in monitoring the activities

related to the management of medicalequipment. This helps managers toevaluate the overall performance oftheir HTM system. Appendix B presentsscreenshots from typical CMMS software,including an equipment history screen.

As with other CMMS functions, the re-ports generated can either be predenedstandards or be customized for a par-ticular application or use. An easy-to-useinterface allows the user to select theinformation they would like to extractand analyse from the database. The datagenerated can be exported into otherprogrammes for further evaluation orpresentation, such as Excel, Access andFox Pro.

Examples of the types of reports that canbe generated by CMMS are outlined inTable 2.

Table 2. Types of reports that can be generated from a CMMS programme

Report type ExamplesList Lists of equipment by health facility, department or manufacturer

Lists of faults caused by operators in a certain department or health facility Lists of work orders completed by specic clinical engineering personnel Lists of all stock received in the past month

Summary Equipment-specic reports to monitor work done on a piece of equipment, record any downexperienced and assess the general availability of the device

Dashboard report, which gives an overview of how the HTM programme is running. Informatipresented might include key performance indicators such as mean time between failures, downand response time

Activity Maintenance activities for certain selected health facilities or departments Maintenance activities for a specic piece of equipment

Workow Corrective maintenance work orders Planned preventive maintenance schedule Individual staff activity with respect to work orders that need completing Upcoming inspections, parts replacements, upgrades, etc.

Human resources Annual/monthly staff working hours Staff response time to work orders and time taken to diagnose fault Service provider details and working hours

Financial Equipment life-cycle cost Cost of service ratio, i.e. maintenance cost against equipment value

Regulatory Summary of medical device recalls Information related to equipment failures and adverse incident reports



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4 Implementing CMMS

Clinical engineering staff must be in-cluded in the entire CMMS planning andimplementation process. Figure 4 sum-marizes a basic seven-step process forimplementing a CMMS.

4.1 Evaluation

It is important to conduct a feasibilitystudy to evaluate and assess the need fora CMMS. During this phase, a completeanalysis is conducted and the scope ofthe system is dened. Decisions are made

regarding the function of the system, andthe data required to meet this functionare identied (3,4,7) . This analysis canbe used to develop a clear technicalspecication for the CMMS that includesall mandatory and optional features. Otherfactors to consider at this stage mightinclude the current IT infrastructure, thestructure of the existing HTM system,the staff skill level, the number of healthfacilities that will use the system, and thelevel of staff buy-in (3) . It is also useful toidentify any obstacles to implementingthe system that might be encountered.

Figure 4. CMMS implementation ow chart

Phase 1

Evaluation

Phase 2

Selection

Phase 3

Data collection

Phase 4

InstallationPhase 5

Conguration andcustomization

Phase 6

Data Entry

Phase 7

Training



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4.2 Selection

An HTM programme may range fromfully paperless to fully automated using aCMMS. Therefore, the amount of featuresin a CMMS can vary and selection ofthose features will be based on theneeds of the user, who may wish to fullyor perhaps only partially automate themanagement system. Once specicationsfor a system have been identied, anappropriate package can be selected. Itmay be one that is commercially available,customized to the health facilitys needsor designed specically for the user.

4.2.1 Commercial packagesThere are several commercial CMMSpackages on the market, offering a rangeof features. Most commercial CMMSinclude the option of a personal digitalassistant and barcode scanner to allowfor full automation of the HTM system.Radio-frequency identication systemsare also becoming more popular and maysoon be part of a typical CMMS package.

It is therefore important to ensure theprogramme is sufficiently flexible toaccommodate the specific needs ofthe clinical engineering departmentin which it is to be used. Selecting aCMMS package that is rigid and forcesthe user to significantly modify theirexisting workow will give poor results. Itis therefore prudent to compare currentHTM procedures with those of the CMMSbeing considered. Appendix C providesa vendor specications table that canbe used to guide the selection process.In addition to these specications, it isimportant to consider vendor reputationand experience in automation of HTMprogrammes and the number of healthfacilities that will be using the CMMS.

The nal and total cost of the CMMS is asignicant factor when selecting a CMMS.

In addition to the start-up costs, hidden

charges must be taken into account,such as annual licensing fees, extra datastorage fees, upgrade fees, password feesand technical support costs. Whethertailor-made or commercially purchased,the vendors responsibilities during allphases of CMMS implementation mustbe clearly defined and documented.Appendix D provides sample contentfor a request for proposal and a vendorproposal. A non-exhaustive list of CMMSvendors is provided in Appendix E.

4.2.2 Open source packagesThere are a number of open sourceCMMS packages developed by differentinstitutions or personnel. Appendix Fprovides a list of such CMMS packagesand their websites. The general challengeof open source CMMS is the lack oftechnical support and updates andhidden technical support charges.

4.2.3 Locally developed packages

If no commercial package meets theneeds of the user, a CMMS can be de-veloped locally by an internal softwaredevelopment team or with a contractor. Ifthe decision is to go with an internal team,it is important to recognize that a team ofprofessionals will be responsible for den-ing the requirements for the application,testing, and eventually maintaining andupdating the software. If such supportwill not be available in the long term, itis better to consider an external contrac-tor or a commercial product. In eithercase, during development, a signicantamount of staff time is required for designand testing of the system. Any additionalwork expected of staff should be plannedwith regard to their normal work activi-ties. Once designed, the institution mustensure that the source code is updatedand stored securely.



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In order to benet from the experiencesof others, a review of the literature onlocally and commercially producedCMMS is best performed before locallydeveloping a package (3) . Appendix Gpresents a proposed sequence of softwaredesign steps for the local developmentof a CMMS. Once the basic design isaccomplished, the automated procedureis operated with test data and the wholedesign is improved according to feedbackobtained from system users. This processis repeated for all activities; once allactivities are automated, the completesystem is put into operational testing untilall remarks have been considered and allproblems are solved.

The advantages and disadvantages oflocally developing a CMMS are outlinedin Table 3.

In general, the decision to develop a localCMMS is justied only when commercialpackages do not meet the specificrequirements of the health-care institution

and when major modications to HTMare required to implement commercialsystems.

4.3 Data collection

A comprehensive survey and analysis ofall available data should be conductedbefore implementing the CMMS. Thisinformation may already be available atthe health facility, but some may need tobe collected from other sources.

4.4 Installation

Before installing the system, a systemadministrator is assigned who isresponsible for the technical maintenanceof the system and for managing datasecurity.

The CMMS can be implemented as acomplete system, by individual modules,by equipment type or by location. This is

Table 3. Advantages and disadvantages of a locally developed CMMS package

Advantages DisadvantagesThe system is tailored to meet the exact needs of theinstitution without requiring any modication to thefunctions and procedures of the department.

There are limitations with regard to testing the system and collectinguser feedback. In contrast, commercial packages are able to performcomplete professional testing before they are made available to clients.In addition, they have access to a large user group and the ability tohold conferences to gather user feedback.

The system may be modied continuously accordingto new operational needs.

Source code for locally developed CMMS is sometimes poorly written,which makes the system slow.

The institution has full ownership of the source codeif properly written and updated.

Development time may be long compared with commercial packages.

New reports can be easily designed according torequests from the clinical engineering departmentor health facility managers.

The system is dependent on the IT personnel and other staff whodeveloped it. The knowledge might be lost when those staff membersleave the organization.

Staff are more familiar with the system since theyhave participated in its development.

Recurrent costs must be paid to an individual, team of individuals, orcompany to develop and regularly update the software.

Source: Cohen T et al.(2003) (3)



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the decision of the clinical engineeringdepartment and will depend on theresources available.

The software is installed on the healthfacility server or on the individual userspersonal computer. All other hardwaredevices such as line printers and scannersmust also be installed and congured.

4.5 Conguration andcustomization

Configuration and customization withexisting mechanisms and procedures areperformed before data entry. Congurationof the system could cover areas such assimple workow, access and security, anduser preferences. Customization refersto the technical functional requirementsof the system including custom screensand tables, facility-specic workow andadditional data elds (3,8) .

4.6 Data entry

This phase consists of initial data entryof common elds such as equipmentmodel number, inventory code, humanresources, equipment locations, manu-facturer information and nomenclatureclassications. User security levels andassociated passwords, access levels andaccess types are also set at this stage(3,8) . It is benecial for clinical engineer-ing staff to be assigned to populate thedatabase, as they are familiar with theterms being used.

Complete functionality of the system canbe tested with one set of data. Functionsto be tested include the creation of main-tenance requests, generation of work or-ders, completion of work orders, orderingof spare parts and generation of reports.

Data entry can be completed when theCMMS is working as required (3,7) .

4.7 Training

It is important that each staff memberof the clinical engineering departmentis fully condent and familiar with allfunctions of the CMMS. It is useful tobegin staff training in the early stagesof implementation to increase staffbuy-in and improve confidence. Inorder to manage expectations, it is alsoimportant that basic generic databasetraining is provided for key senior clinicalengineering staff. Specic user trainingfollows system installation and testing. Ifother personnel such as clinicians andnurses are expected to use the system,additional training should be providedfor them. A periodic review to assessand evaluate training needs is highlyrecommended, as there is often a steeplearning curve when using such systems.

Most vendors provide comprehensivemanuals for their CMMS and a help menuto enhance usability. Online help is alsoavailable for some systems. It is worthnoting that the implementation of CMMSis more effective if support is providedin the local language; most commercialCMMS packages are available withsupport in a range of different languages.

4.8 Follow-up and performancemonitoring

Continuous monitoring of the system isconducted to ensure that it is directlycontributing to the improvement andeffective running of the HTM programme.Elements to be monitored include:

the systems ability to effectively pro-

duce all needed performance indica-



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tors for the HTM programme, suchas down time and inspection andpreventive maintenance compliance;

evaluation of the speed of activitiessuch as generation of reports andinputting of data;

usability and user satisfaction (col-lected using a questionnaire).

In addition to this, large vendors holdannual conferences where user feedbackis collected and analysed to makeimprovements to their system.

4.9 CMMS documentation andback up

Clear, accurate and comprehensive docu-mentation for all components of the sys-tem, including full details of hardware,

software, operating procedures, upgradesand backup policies, should be kept by theclinical engineering department. For cus-tomized packages the source code shouldbe documented and updated with everyupgrade to the system. Several CMMSprogrammes use open source systems orare delivered with the source code in orderto avoid problems of ownership and codecomplications (3,7) .

It is advisable to establish a periodic back-up policy to protect data in the event of anemergency or system crash. Automaticback up to more than one storage mediacan be used; if this is not possible, a dailymanual back up is sufcient. In additionto all back up and recovery policies, itis advisable to use mirror-image serversto enhance data security, if and whenavailable.



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5 Networking CMMS

Depending on the IT infrastructure avail-able and the size of the clinical engi-neering department, the CMMS can benetworked in a variety of ways. In generalthere are two main deployment options:

the on-premise and the on-demand solu-tions (5) . Table 4 describes the featuresof these solutions and the networkingoptions available for each.

Table 4. CMMS deployment solutions and related networking options

Solution Description Features Networking optionsOn-premise CMMS installed and runs on

premises of health facility Customer responsible for the

technology infrastructure Customer pays licensing fee to use

and customize software Customer may customize

features and functions to meetrequirements

Customer has full control ofinfrastructure and data

Standalone workstation basesystem, which is useful only insmall single workshops at smallhospitals

Local area network system withinclinical engineering department

Deployment over Internet atcustomers site (self-hosted onlinesolution)

Open architecture with integrationto other applications on similar ordifferent platforms

Built using standard Microsoft WebTechnologies

On-demand Software As A Service (SAAS) Vendor provides applicationlicence to multiple customers

Infrastructure and applicationmanaged by vendor

System delivered over Internet User does not maintain hardware

or software Customer pays for access to

application

100% Internet-based applicationrequiring no installation onclients machines

Deployment over Internet (hostedonline solution)


Built using standard Microsoft WebTechnologies

Customized SAAS Customizable version of SAAS



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6 Concluding remarks

Whether it is a commercially availablepackage or a custom-designed option,a CMMS has several benefits. Muchless staff time is needed for data entry,maintenance tracking and reporting; itminimizes human errors; and it allowsmore effective monitoring of performanceindicators and staff productivity (3,6,7) . TheCMMS provides electronic documentation

of equipment inventories, tests, repairs,maintenance and equipment histories. Ifimplemented correctly, it can be used asan effective tool by health facilities andtheir clinical engineering departments tocomplement their existing programmesand improve the overall management ofthe technology, while also contributing tothe more effective delivery of health care.



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7 References

1. Cohen T. Computerized maintenance management system. Journal of ClinicalEngineering, 2001, 26:200211.

2. Duke University Health System, Clinical Engineering . Durham, NC, Duke Univer-sity Health System Department of Clinical Engineering, 2010 (http://clinicalengi-neering.duhs.duke.edu/modules/ce_pols/index.php?id=1).

3. Cohen T et al. Computerized maintenance management systems for clinical engineering. Arlington, Association for the Advancement of Medical Instrumentation,2003.

4. Barta RA. A computerized maintenance management systems requirementsfor standard operating procedures. Biomedical Instrumentation and Technology,2001, 35(1):57-60.

5. On-demand or on-premise: Understanding the deployment options for your newbusiness management system (White Paper). Richmond, Sage North America,2009.

6. ECRI Institute (http://www.ecri.org).

7. Non-published articles by the Directorate of Biomedical Engineering of the Jordan

Ministry of Health (http://www.dbe.gov.jo).

8. Data available from Maintenance Connection CMMS (http://www.maintenance-connection.com/mcv18/online/mc_home.htm).



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8 Useful resources

Medical equipment management manual. Arlington, VA, Association for the Advancementof Medical Instrumentation, 2005.

Cram N. Computerized maintenance management systems: a review of availableproducts. Journal of Clinical Engineering, 1998, 23:147223.

Kullolli I. Selecting a computerized maintenance management system. BiomedicalInstrumentation & Technology, 2008, 42:276278.

Mobarek I et al. Enhanced performance and cost-effective clinical engineering systemfor Jordan. Journal of Clinical Engineering, 2005, 30:4255.

Mobarek I et al. Fully automated clinical engineering system. Journal of ClinicalEngineering, 2006, 31:4660.

Staker T. A paperless computerized management information system for clinicalengineering. In: Cohen T et al, eds. Computerized maintenance management systemsfor clinical engineering. Arlington, VA, Association for the Advancement of MedicalInstrumentation, 2003.

Wickens CD, Sallie EG, Yili L. An introduction to human factors engineering. New York,Addison-Wesley Educational Publishers, 1998.



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Appendix ACommon elds included in medical equipment inventory

Field DescriptionEquipment inventory number Unique number assigned by a health facility to identify individual pieces of equi

Equipment description (type)and class code

Code that describes equipment in terms of relevant nomenclature system

Manufacturers name andCMMS-generated code

Name of manufacturer of equipment and code that identies the manufacturer

Model number Code assigned by manufacturer to identify equipment model

Manufacturers serial number Code assigned by manufacturer that helps to identify equipment during a recall; ato locate equipment if inventory number is removed

Current software revision Name of software device is running on; assists in identication of devices affecterecall; also used to identify equipment that needs a software upgrade

Vendor (seller) name and code Name of vendor of equipment and code that identies the vendor

Location description and code Building, department or room where equipment is installed, and code that identilocation

Purchase price Exact amount of money paid for equipment and currency used for payment

Installation date Date when equipment was ofcially accepted and put into operation by medical staffclinical engineers

Warranty expiration date Date warranty expires; usually indicated on purchase order

Inspection and preventivemaintenance procedurereference

Code that assigns specic inspection and preventive maintenance procedure for equipmeincluding frequency of procedure per year

Maintenance responsibility Name and code of institution or department, whether an external, central or peripworkshop or organization responsible for maintenance of equipment

Status ag Indicates current status of the equipment (e.g. operational, out of order, awaiting sparedue for replacement)

Other customizable elds Fields relevant to individual technical management programme



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Appendix BSample CMMS screenshots 1

1 Reproduced with permission from the ECRI Institute web site(6) .

Equipment history

Work order



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Appendix CVendor specication table

Vendors can ll in a table such as this one but may choose to include additional features.Minimum requirements are lled in by the user based on their specic situation. Thoseseen here are simply examples.

Technical specication Minimum requirements Supplier specications

Vendor information Please specify name, address and countryof origin

Is vendor specialized in CMMSdedicated to health technology?

Please answer yes or no

Name or version number of

CMMS

Required

Where marketed Please provide full list of countries,hospitals, etc.

Quality standards supportedPlease specify

Year rst sold

Please state year rst sold and locationsfor: First sold CMMS version This offered version

User-friendly with minimallearning curve

Required; please explain

Training support Required; please explain

Nomenclature system Required; please specify

Number of users Please specify maximum limit

Access groups/security levelsRequired

Document library HTML and document editor

Accounts/budgeting Preferred

PricePlease specify clearly your price, includingall components, such as annual subscriptionfee and licence cost

Automated nancial systeminterface

Preferred

Inventory management Inventory management module Barcode tracking Online recording and tracking

Spare parts managementmodule

Inventory control Minimum stock order Spares order Costing Parts exchange



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Work order module

Work order manager Scheduling Priority Service charges (e.g. labour time,

spares) Integrated elds Customized elds

Contract management Required

Project management moduleRequired

Generate purchase orders Required

Work order request over theInternet by clinical staff

Optional

Multisite asset tracking andwork orders

Required

Close work orders instantlyusing a handheld personaldigital assistant/barcodescanner

Preferred

Technical support 24 hours, 7 days a week

Remote diagnosis Required

System upgrades Please explain policy and cost Advantage given to free upgrades or

cost included in annual fee or licence

Maintenance management Scheduling Inspection and preventive maintenance

library (forms) Customizable forms

Equipment life-cyclemanagement

Tracking of purchase Evaluation Auto-receiving Full history record of equipment

Operating systems Please specify

Integrated reporting system Run quick, standard, technical and

managerial reports Create customizable reports

Invoice matching Optional

Automatic alerts and recallsRequired

Create tasks and planned eventsRequired

Print, email or fax reportsRequired

Database system Please specify

Considerations for localenvironment

Local language, currency, calendar



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Required deployment andconnection of CMMS

Local-area network 100% Internet-based application

requiring no installation on clientsmachines

Deployment over Internet (hostedonline solution) or at customers site(self-hosted onsite solution)


Scalable connection. (design andarchitecture to be used regardless ofwhether application has 10 or 10 000concurrent users?)

Network supported Please specify hardware and operatingsystems supported

Multiple site supportRequired

Use of SQL or other by CMMSPlease answer yes or no

Updating mechanisms Please specify mechanisms used to preventsimultaneous or erroneous updating

Import and export utilitiesavailable

Please specify

Other system features Please specify



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Appendix DRequest for proposal and vendor proposal sample content

The following is based on documents found on the ECRI Institute website (6) . It isintended as a reference only and should be modied to t individual requirements.

Request for proposal (RFP)

All software components of the CMMS supplied by the vendor shall be part of thevendors normal currently produced CMMS product.

All other costs such as licensing fees for the use of the vendors software componentsor database must be included within the quoted price of the CMMS or an annual fee.

All CMMS components provided according to the terms of this RFP shall be of the latestproduction.

If the vendor plans to halt production of its CMMS referenced herein and to produceimproved models before the delivery date, the vendor shall immediately notify the userin writing of this fact and provide the option of upgrading the purchase.

All support services must be provided by qualied full-time employees workingexclusively for the vendor on a continuous basis, 24 hours a day, 7 days a week.

On-site training must be provided by a qualied instructor of the vendor who is not asales representative. This training must be sufcient to ensure optimum utilization ofthe CMMS.

The order in which these selection criteria are listed is not necessarily indicative oftheir relative importance. It is expected that any vendor submitting a proposal willdemonstrate extensive and substantial qualications, capabilities and experience indeveloping, installing and supporting the CMMS, including successful provision of thesame products and services to health institutions worldwide.

The user intends to select a vendor on the basis of the proposal received in response tothis RFP and any other information it obtains from other sources regarding the CMMSand the vendor. Site visits to vendor installations may also be made by user staff. Theuser reserves the right to make its nal decision independent of any or all of the abovefactors.



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Proposals shall be delivered on or before: [date].

Offers shall be delivered to:

Attention of:

E-mail:

Telephone:

Fax:

Address:

The proposed installation date[s] for the CMMS is/are: [dd/mm/yyyy].

Vendor proposal format

PriceThe rst section of the proposal shall be a total price quotation including all systemcomponents for the purchase, including installation, start-up, training, testing andannual licensing fees of the CMMS.

Evaluation of the price shall be based on the total cost of CMMS over 10 years.

Installation and scheduleA proposed delivery and installation schedule for the CMMS shall be given, includingtime required for installation, start-up, vendor and user acceptance testing. Both vendorand user shall work together to install and operate the CMMS in pilot units identiedby the user.

PaymentProposed CMMS payment terms, including any cancellation fees and any alternativesor offers that result in a cost saving to users must be clearly stated. Full prepayment atthe time of order placement, for example, is not acceptable to the user. Furthermore,penalties for late or inadequate delivery, installation or training are included in the terms.

SubstitutionThe vendor shall supply at no extra cost the latest or any new version of the CMMSintroduced by the vendor after the award, but before delivery, that more suitably meetsthe users requirements. The vendor should specically address potential technicaldifferences.

Implementation planVendors shall submit as part of the proposal the main elements of their implementationplan. They are also expected to demonstrate their CMMS at the request of the user.



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Required IT infrastructureThe vendor shall provide a complete and detailed description of all IT requirements(hardware and software) that will be required to install and operate the system.

Upgrades and enhancementsThe vendor shall provide a copy of the vendors policy for newly developed versionsof the software, software modications for improved performance and reliability, andcorrection of design. The vendor should indicate whether such modications, upgradesand enhancements are no-charge items. Privilege shall be given to vendors with freeupgrades and enhancements.

TrainingVendors shall provide a detailed description of the training to be provided for clinicalengineering personnel specied by the user. This could include a description of theprogramme length and format, content, the qualications of the instructors, and writtenor electronic materials. The description should address the need for refresher trainingand training for new users specied by the user over the lifetime of the CMMS.

Operator manualVendors shall make available a fully descriptive operating manual online and on CD.

Technical supportA description of online, local or regional technical support capabilities, including thenumber and qualications of technical support staff, as well as their training, their baselocations, the locations of support staff, and approximate response time for emergency(both during and outside of regular business hours), shall be included.

Annual subscription feesA full description of annual subscription fees must be included. This includes the exactperiod this covers, in addition to all terms, conditions and fees, system enhancementsand upgrades, software maintenance, technical support, software licence, and anyother factors that could be of interest to the user in evaluating the vendors proposal.The price for each annual period and penalties for delayed response time to servicerequests are clearly indicated.



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Appendix EExamples of CMMS vendors

The following is a list of vendors and products offering CMMS software. This list isnot meant to be exhaustive. Inclusion on this list does not imply endorsement orrecommendation by WHO. It is meant only as a guide when searching for a databasethat best suits your organizations needs.

Vendor Website

Azzier http://www.azzier.com

Drawbase Software, Inc.http://www.drawbase.com

Eagle Technology, Inc.http://www.eaglecmms.com

ECRI Institute http://www.ecri.org.uk/ecriaims.htm

eMaint Enterprises, LLChttp://www.emaint.com

EQ2, Inc. http://www.eq2.com

Facilities TechnologyGroup

http://www.factech.com

FM Works http://www.fmworks.com

Four Rivers SoftwareSystems

http://www.frsoft.com

GE Healthcare http://www.gehealthcare.com/euen/services/asset-management-solutions/asset_plus/index.ht

ISES Corporation http://www.isescorp.com/services/operationsmaintenanceprogramming.aspx

Maintenance Connectionhttp://www.maintenanceconnection.com

MicroMain Corporationhttp://www.micromain.com/

MPulse MaintenanceSoftware

http://www.mpulsesoftware.com

Nuvek, LLC http://www.vektr.com

PEAK IndustrialSolutions, LLC http://www.cmms4hospitals.com

Phoenix Data Systems,Inc.

http://www.goaims.com

Predictive Service http://www.predictiveservice.com

Simple Solutions FMhttp://www.simplesolutionsfm.com

St. Croix SystemsCorporation

http://www.stcroixsystems.com/asset_manager.aspx

Thinkage Ltd. http://www.mainboss.com

TISCORhttp://www.tiscor.com

TMA Systems, LLC www.tmasystems.com



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Appendix FExamples of open source CMMS providers

The following is a list of open source CMMS providers. This list is not meant to beexhaustive. Inclusion on this list does not imply endorsement or recommendation byWHO. It is meant only as a guide when searching for a database that best suits yourorganizations needs.

CMMS Website Notes

Aware http://www.pninc.com/maint/aware.htm Platform-independent

Facilities Desk http://www.manageengine.com/products/facilities-desk/index.html Windows XP, 2000, Vista,Linux

Maintenance Assistanthttp://www.maintenanceassistant.com Web base and other options

Maintenance Parts Binhttp://www.nhuntsoftware.biz Windows 95/98/ME/XP/2000/NT

Maintenance Trackerhttp://www.mtrackcmms.com Windows XP, Win 98, MSAccess 2002

Mantra http://www.bmstech.com/mantra/download.htm Windows XP/2000/NT4/9x/ME/Windows 3.1x/DOS

PLAMAHS http://www.healthpartners-int.co.uk/our_expertise/plamahs.html Windows 95 or later



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Appendix GCMMS software design plan

HTM system

Activity 1IPM

Activity 2Corrective maintenance

Activity 3Quality control

Activity n

Individual procedure steps

Consult clinicalengineers

Design screen cross-referencing

Design data entryscreen

Design tables cross-referencing

Assign primary andsecondary elds

Program elds

Design database tables

Determine eldsreferred to in procedure

Program activities ofprocedure

Program activities

elds

Create screen requiredfor activities

Determine procedureactivities

Establish follow-upactivities

Determinepersonnel-

approval link

Determineneeded

approvals

Establishsecurity levels

Design reportscreens

Determineoutput data

Program reportelds



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Department of Essential Health TechnologiesWorld Health Organization

ISBN 978 92 4 150141 5

management - computerized maintenance management system

Documents