Mindful analysis of Prioritising Medical Device Replacement

Authors:   Gerard Flynn, Dr. Tadgh Nagle, Dr. Ciara Fitzgerald, Prof. Mark Hutchinson    IntroductionOver the last three decades there has been a steady increase in research articles on the problem of identifying the... [ view full abstract ]

Authors:   Gerard Flynn, Dr. Tadgh Nagle, Dr. Ciara Fitzgerald, Prof. Mark Hutchinson  

Introduction

Over the last three decades there has been a steady increase in research articles on the problem of identifying the need for improvements in the strategic management of medical equipment across healthcare services. During the early 1990’s one empirical study (Larry Fennigkoh, 1992)made the observation that ‘the concept of capital equipment planning and replacement are well established but has yet to find widespread use within healthcare and in particular the planning and replacement of medical devices’. Twenty years on case studies such as Boston Hospital (Williams, 2011) indicate the problem still exists as it highlighted how a lack of a planned medical equipment replacement program affected front line clinical services in the hospital. To further emphasis the current relevance of this problem, the Irish media reported the possibility of ‘safety concerns relating to certain foetal monitors being used in Irish maternity hospitals’ (RTE, 2018) The longevity of the problem could be a function of the wickedness of the environment in which it exists. Pressures from the environment include: (i) increasing complexity and cost of devices, (ii) increasing demand for new and existing services/equipment, (iii) limited funds for device purchasing, (iv) fluctuations in replacement requirements due to past purchasing patterns, and (v) socio-political factors in device procurement. Moreover, this has led to the complex problem of effectively managing medical devices and objectively prioritising the replacement/procurement of new devices. Unfortunately, a solution often used is to satisfy those that shout loudest. With the aim of understanding the problem in depth, the paper details an exploratory case study of a front line service failure in the Irish Health care services in 2011. Analysed from the perspective of the National Clinical Head of Medical Devices for the Irish Health Services Executive (HSE), the case study utilises organisational mindfulness to uncover the degree of mindfulness/mindlessness that exists in a device replacement decision along with resulting impacts.

Research Objective: To explore the problem of prioritisation of medical device replacement from a mindful perspective.

Research Methodology

From the perspective of this research study, the following description of the appropriateness of a case study to a particular type of research seems accurate: “case research is particularly appropriate for certain types of problems: those in which research and theory are at their early, formative stages, and sticky, practice-based problems where the experiences of the actors are important and the context of action is critical” (Benbasat et al., 1987 p.369).

While an “instrumental case study” (Stake, 2000 p.437) research strategy was adopted for this study, it allowed the researchers to pursue a deep understanding of an issue (prioritisation of medical device replacement) as a primary focus, while the case itself was of secondary interest (Stake, 2000). Therefore, to fulfil the objective of this research, studying a single instrumental case facilitated uncovering and teasing out the diverse stories of those “living the case” (Stake, 2000).

The lens utilised in the case study is that of organisational mindfulness. Recognised as an antecedent to a fault free and reliable organisation, mindfulness provides a wider response portfolio, better process awareness, and stronger accountability, which can lead to superior firm performance (Thompson, 1995; Weick et al., 1999). However, so far there has been a lack of theoretical development around mindfulness, besides the conceptualisation of the components (Weick et al., 1999) and operationalisation (Mu and Butler, 2009) of the measures of mindfulness. Illustrated in Figure 1, these constructs include: (i) deference to expertise, (ii) preoccupation with failure, (iii) reluctance to simplify interpretations, (iv) sensitivity to operations, and (v) commitment to resilience.

Figure 1: Key constructs for measuring organisational mindfulness (Weick et al., 1999)

Case Study Context

During 2009, an expectant mother reported to the Irish media of an initial misdiagnosis of miscarriage in a maternity hospital but subsequently found that the pregnancy was viable following the woman seeking a second scan from her GP. Further reports of two similar cases in 2010, prompted  the Health Services Executive (HSE) to classify the situation as a Serious Incident and set up the ‘National Miscarriage Misdiagnosis Incident Review Team’ (NMMIRT) to review any similar cases. As a result, of escalating political pressure prior to the publication of the review teams report in early 2011, the Minister for Health approved the purchase of 19 ultrasound machines.

Post the 10 month review the NMMIRT produced a report ‘National Miscarriage Misdiagnosis Review, April 2011’ (HSE, 2011) which concluded that a possible 24 miscarriage diagnosis’s occurred relating primarily to the level of training of  staff in the Early Pregnancy Assessment Units (EPAU’s). The NMMR stated that ‘the majority of the ultrasound machines reviewed were properly maintained and serviced and were less than five years old at the time of misdiagnosis’ (HSE, 2011).  The NMMR requested that a review of the quality and suitability of the ultrasound equipment , according to the clinical measurement criteria outlined in the HSE clinical guidance document, (HSE, 2010) should be conducted and that a replacement should only occur in cases where the ultrasound equipment was deemed not fit for purpose. However, the Minister for Health announced to the media that ‘all ultrasound equipment over five years old will be replaced within the next few weeks’ (RTE, April 2011). This political decision including an additional 11 ultrasound machines purchases by individual hospitals, resulted in the replacement of 30 machines (at cost of circa €1.7m) in the 19 maternity sites. The quantity of machine replacements  was subsequently found to be excessive, as the NMMR identified only 6 machines in 5 EPAU’s that were over 5years old.

Findings

Having analysed the case study through the lens of organisational mindfulness, it is clear that the mindless approach taken to the problem resulted in an incorrect decision. This decision was influenced by the mindfulness factors outlined in table 1  

Table 1

Mindfulness Factors