Michele Manzoli§ °, Stefano Bergamasco§ *, Roberto Belliato§ * § Università degli Studi di Trieste, ° Dipartimento Servizi Condivisi dell’A.O.U. di Udine, * TBS Group SpA 1
Stages of diffusion and maturity : • Future • Experimental • Tested • Established • Obsolete 2
Identifying existing health care services that do not provide value for money (Med J Aust 2009) Exploring policy- makers’ perspectives on disinvestment from ineffective healthcare practices (IJTAHC 2008) Building the evidence base for disinvestment from ineffective health care practices: a case study in obstructive sleep apnea syndrome (Ph.D. thesis - University of Adelaide 2007) 3
Route 1. To investigate the topic 2. To study in deep the HTA approach 3. To state an applicable methodology 4. To «close the loop» 4
Renewal Plan? …not really! Equipment Intended purpose Diagnostic-therapeutic pathway 5
Methodology 0. Group formation 1. Clinical specialty identification 2. Data collection and «equipment-procedure» pairs identification 3. Prioritization 4. Evidence Collection, Selection and Synthesis 5. Assessment of economic-organizational implications 6. Conclusions, Discussion and Recommendation 7. Dissemination, Implementation and Update 6
A) Analysis of Costs associated with the use B) Reimbursment according DRG C) Economic return of disposal «Total disinvestment» D) Available human resources analysis E) Hospital length of stay F) Operating theatre use Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Costs - A - A - A - A - A - A Do not change anything DRG + B + B + B + B + B + B Amortization - X - X 0 0 0 - X (last depreciation charge ) Costs 0 0 0 0 0 0 Disinvest DRG 0 0 0 0 0 0 Disposal ± C 0 0 0 0 0 Amortization - 3X 0 0 0 0 0 7
Literature: 4 kinds of economic assessment: 1) Cost-minimization analysis Disinvestment with 2) Cost-effectiveness analysis 3) Cost-utility analysis immediate use of resources 4) Cost-benefit analysis FAIL END OF THE STORY PASS Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Old costs - A - A - A - A - A - A Do not Old DRG + B + B + B + B + B + B change Old amortization - X - X 0 0 0 anything - X (last depreciation charge ) New costs - G - G - G - G - G - G New DRG I I I I I I Disposal ± C 0 0 0 0 0 Disinvest + new Old amortization - 3X 0 0 0 0 0 equipment New amortization - H - H - H - H - H - H 8
[workflow based on the one created by Policlinico Gemelli’s UVT] 9
«Closing the loop» Assets disposal from an accounting point of view - Alienation - Scrapping - Donation - Waste disposal - Refurbishing - Transfer to Developing Countries 10
…back to basics! 1) Equipment suitability for donation 2) Recipient’s active engagement 3) Evaluation of potential recipients 4) Pre-donation planning 5) Donation implementation 6) Follow-up evaluation 11
Non profit social cooperative based in Brescia http://www.memua.it/ Donor Recipient hospital Donor hospital hospital Recipient hospital Donor Medicus Mundi hospital Attrezzature Recipient Donor hospital hospital Recipient hospital Donor hospital 12
Main managed activities: • collection, recovery and restoration of medical equipment and plants; • provision of equipment for international cooperation projects; • installation and startup of equipment and plants, as well as post-installation support; • service, update or modification of equipment in order to impart efficiency, quality and safety; • consultancy, design and management of cooperation projects in the social-health field. "Through a virtuous circle that allows the recovery of otherwise discarded materials and equipment with high costs for public and private health institutions and consequent social costs imposed on all citizens, MEDICUS MUNDI ATTREZZATURE's objective is to ensure the promotion of human dignity, assuring the inalienable right to health and to life and the social integration of socially disadvantaged people through a rehabilitation and reintegration project" 13
From Theory... 1. Equipment suitability for donation Simplicity of operation Accessories and supplies Operating and service manuals Safety 14 Technical support from the OEM …to Practice Volunteers and employees, with critical thinking, understand the extent to which they can restore and refurbish the more complex equipment. The manuals often can not be found, and the good is taken without documentation "technical library" of the Cooperative In absence of adequate testing equipment, safety testing is done by third parties The Cooperative remains the interlocutor of the recipient
from Theory... 2. Recipient’s active engagement Preparing and using checklists to ensure that donations are appropriate Sharing with potential donors the priority lists, policies and checklists Providing feedback to the donor during the donation process as well as final outcomes of the donation Refusing unsolicited or inappropriate donations …to Practice Donation recipients are associations, religious congregations, NGOs, Caritas, International Cooperation Organizations. These subjects take care of health facilities in developing countries and promote projects for this purpose They address subjects like MeMuA in order to get equipment and establish collaborative arrangements Once the donation process is over, the give a feedback in order to improve future collaborations 15
from Theory... 3. Evaluation of potential recipients The donor should demand from the potential recipient the following information: which and how many procedures will be performed (clinical need) properly trained physicians, nurses and technicians available facilities to install and operate the requested equipment human, material and financial resources available to service and maintain the requested equipment …to Practice The Cooperative assures that the recipient really needs the equipment required for the project it aims to achieve, and has the means to use and maintain it. It can be useful - in the case of major installations - to organize an inspection tour In addition to equipment, it is often necessary: to install photovoltaic panels for electricity, pumps for water, voltage stabilizers, and to know the type of sockets used and obtain appropriate adapters 16
from Theory... 4. Pre-donation planning The donor needs to provide detailed information regarding: the installation (e.g. floor loading capacity, space and power requirements) the operation requirement (e.g. cables, reagents, test equipment) required training for operation and maintenance maintenance requirement (e.g. special tools, PM frequency and materials) who will cover the costs of international and local transport, freight and insurance, warehousing, customs clearance, storage and handling, installation and ongoing support costs …to Practice Much information can be found on the manuals All arrangements are made before the equipment shipment 17
from Theory... 5. Donation implementation Decontaminated equipment, fragile parts packaged with great care. If available, procedures or recommendation for periodic inspection, maintenance and calibration should be provided The recipient inspects all containers and content for damage and verifies that nothing is missing; any irregularities is reported immediately to the donor Installation is performed; after that, verification of proper and safe operation must be performed A program of periodic inspection, maintenance and calibration is implemented …to Practice The packaging for shipping is a critical step because, if done not properly, may affect the success of the project If the equipment has been disassembled, the assembling should not be too difficult and there should be all the necessary hardware components (since it is often difficult to find them) 18
from Theory... 6. Follow-up evaluation The donor and the recipient assess the level of operational success or failure of the equipment donated; this assessment encourages the continued support of the donor and allows both parties to learn to improve from previous experience …to Practice MeMuA and the recipient confront each other with respect to the success of the project and will keep in touch for any technical and organizational requirement 19
Examples of adaptation of disused equipment 1. Low-cost voltage stabilizer Components n. € Notes 1 290,00 Stabilizer control group 380V 30V 1 0 Reclaimed Rack cabinet with two doors 2 130,00 Painted doors 1 0 Reclaimed Transformer 30 KVA 1 15,60 Cuttable fuse box 3 3 2,04 Cylindrical Fuse GG BRC 10,3x38 32 A 2 147,80 Circuit breaker 24-32 1 5,00 Seq. Relay 3 x 208 1 3,00 Neutral terminal 10 sq.mm 6 18,00 Standard terminal 10 sq.mm 1 3,00 Protection terminal 10 sq mm 1 0 Reclaimed Insulation tube 1 13,00 Cable 1.5 m 1 10,00 Consumables 1 43,00 Design 1 100,00 Labor Total 780,44 20
2. Reports management 3. Portable ceiling surgical and ultrasound images light storage 21
michele.manzoli@gmail.com stefano.bergamasco@tbsgroup.com roberto.belliato@tbsgroup.com « Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime » (Chinese proverb) 22
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