Medical device maintenance outsourcing: Have operation management research and management theories forgotten the medical engineering community? A mapping review

doi:10.1016/j.ejor.2012.02.043

European Journal of Operational Research

Volume 221, Issue 1, 16 August 2012, Pages 186-197

https://doi.org/10.1016/j.ejor.2012.02.043 Get rights and content

Abstract

In this paper, we examine the large body of existing research on outsourcing, and assess the status of research on outsourcing the maintenance of medical devices. Because so little research in this area currently exists, the study was broadened to include other fields that outsource maintenance services, and considers possible applications to the field of medical device maintenance. In all, this paper examines 55 articles spanning various dimensions, including: mathematical models, empirical studies, and conceptual papers. We conclude that research into the outsourcing of medical device maintenance services in hospitals is still in its infancy stages, and that further progress in this field would benefit from additional empirical study grounded in management theory.

Highlights

► The outsourcing of maintenance services in hospitals is still in its infancy stages. ► None mathematical model papers were applied to medical device maintenance outsourcing. ► The majority of mathematical model proposals were not applied to any industry. ► Proposals are weighed in favor of cross-sectional surveys rather than longitudinal studies. ► The distribution of the industry application of research is weighed heavily in favor of the information technology systems field.

Introduction

Medical technology management is a systematic process that begins with strategic planning, technology assessment, and facilities planning. Once the institution has determined its technological needs, the process proceeds with technology procurement, and concludes with maintenance management (Judd, 2004: p. 159). When a health care institution lacks the technical skills or specialized assets needed for the maintenance of its medical technology, maintenance should be outsourced.

Yet while outsourcing has grown in popularity, research on maintenance outsourcing in academic literature remains scarce. Our review of the literature confirms the findings of Jackson and Pascual (2008) that there is no study on maintenance service outsourcing that deals with the problems of service provider selection, evaluation, and performance measurement in an integrated manner. In the healthcare environment these problems are worthy of study, as healthcare institutions lacking the capacity to deal with these issues may face significantly higher costs. For example, it has been reported that some maintenance service providers-in most cases the original equipment manufacturer (OEM)-have created barriers to service competition by denying training or documentation to potential competitors, and withholding replacement parts (Blumberg, 2004: p. 138). For healthcare institutions in developing countries, where contracting maintenance services is often inevitable because hospitals have fewer properly trained employees on staff and less material resources are available to handle in-house maintenance, opportunistic behavior and anticompetitive practices can be even worse. These findings suggest a gap between client needs and contractor performance, prompting many studies to tackle the problem of critical elements related to maintenance outsourcing processes in general, although little research exists examining the particular case of medical device maintenance outsourcing.

Thus, this paper is the first stage of research to answer the three questions formulated below. The overall goal of this study is to identify representative research measuring the performance of outsourced medical device maintenance in the hospital environment, using management theories and/or strategic management theories,² or mathematical models. Since little research currently exists in the field of medical device maintenance outsourcing, we also identify literature on maintenance outsourcing in general that could be applied to the medical devices field. The specific research questions of this review are therefore:

1.
Which are the most common dependent and independent variables for evaluating maintenance performance and outsourcing decision problems, both in the hospital environment and other technical fields?
2.
What are the existing research gaps, and what future studies can be done in the field to evaluate the performance of medical device maintenance services?
3.
How does a paper’s methodology, outsourcing problems tackled, area subject,³ percentage of self citations, management theories used to ground its hypothesis, the percentage of review papers appearing in the journal, and the industry research was conducted in affect the article’s impact, as measured by the Source Normalized Impact per Paper (SNIP)⁴ the article receives?

Section snippets

Motivation

The assessment of maintenance service provider performance is an intriguing and timely research topic that deserves more comprehensive study. Within this topic, two particular problems stand out. First, the two key elements in managing a maintenance service supplier are supplier selection and performance assessment. However, performance assessment has received less scholarly attention (Kannan and Choon, 2003). For example, there is still little knowledge about the relationship between selection

Data sources

We consulted a range of academic archives to identify relevant research measuring the performance of medical device maintenance outsourcing and other outsourced services. The archives consulted included PubMed,⁷ Proquest-AB I/Inform Global, ScienceDirect, JSTOR, and EconLit. The range of archives we selected was suitable because of its multidisciplinary nature, including extensive coverage of economics and other

Results

After the search and final selection processes, 15 papers from PubMed met the inclusion/exclusion criteria, one of which (6.67%)¹⁵ was conceptual (Barney, 1999, Quinn and Hilmer, 1995, Bahli and Rivard, 2003, Aron et al., 2005, McIvor, 2000, Martin, 1997, Dranove and White, 1994), and 14 of which were empirical (93.33%). Of the empirical papers, eight (53.33%) included an empirical component related to outsourcing

Discussion and conclusions

This paper has attempted to provide a mapping review and assessment of the status of research dealing with the maintenance outsourcing of medical devices. Because so little research currently exists, the study was broadened to include other fields that outsource maintenance services, using research on outsourcing in other industries that could be applied to the field of medical device maintenance. We looked at scholarly papers tackling the problem of outsourcing performance and outsourcing

Implications for future research

Perhaps the most significant finding of this review is the need for further research in the field of maintenance outsourcing of medical devices, as indicated by the gaps in existing research detailed above. Future research question priorities should include:

•
Which capabilities and characteristics of medical device maintenance service providers affect their performance and the service of healthcare institutions?
•
Which capabilities and characteristics of medical device maintenance service providers

Acknowledgments

Thanks to our three anonymous reviewers for their indirect help and collaboration in preparing this paper. Thanks also to Gregory L. Haugan for his assistance with the translation and review of this paper.

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We analyze the joint optimization of spare parts inventories and workforce allocation in a single-site maintenance system. In this system, for each failure, a service engineer with a necessary replacement part has to be allocated. If one of the required resources is not available, the incoming failure request is routed to an external provider, such as a centralized repair facility or a sub-contractor. We study multiple failure types (related to failing components) with exponentially distributed inter-failure times. The system repair times and the replenishment times of the spare parts inventory are also exponentially distributed. The inventory replenishment is done according to a Base-Stock policy. The objective is to minimize the total system cost consisting of annual holding costs of the spare parts and the service engineers, and incidental outsourcing costs. For the joint optimization of the resources, we propose a Mixed-Integer Programming (MIP) formulation using the balance equations of the Markov Chain representation of the system. Furthermore, we provide a simple and efficient heuristic that produces close-to-optimal (< 0.3% difference) results, for solving larger instances. Using the proposed optimization methods and real-life data, we analyze the optimal balance between the costs of the resources and the outsourcing costs and show how the outsourcing rates and the total costs behave for different system parameters.
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As pointed out by De Vivo et al. [6], a significant amount of medical equipment is so complex that performing in-house maintenance becomes uneconomical, and hiring independent service agents is difficult as they may not be familiar enough with the equipment and may not have access to all necessary information such as manuals or complementary documentation, which are detained by the Original Equipment Manufacturer (OEM). Indeed, in order to maintain market share, the OEM generally adopts protectionist actions such as not training possible external providers and not providing sufficient parts for the market, which makes it difficult for third-party providers to repair failed units, as mentioned by Cruz & Rincon [7]. In this context, OEMs become the only agents able to execute maintenance services adequately, granting them monopoly power.
Healthcare institutions make use of technology-intensive equipment that follows tight quality standards. These companies aim at ensuring service continuity and safety of patients. In this context, maintenance services are generally performed exclusively by the Original Equipment Manufacturer (OEM) because it detains the required expertise, tools and spare parts. Then, we here propose a model to analyze the interaction among hospitals and OEM. We consider the OEM can provide maintenance services for two different classes of hospitals, which have the option of either hiring an Extended Warranty (EW) or paying for each maintenance intervention on demand with or without priority. Class 1 customers are often large hospitals, whereas institutions of class 2 are generally small/medium ones, which have shorter budgets, and thus would choose a non-priority option. To that end, we adopt a Stackelberg game, where the OEM is the leader and the customer is the follower. Failures and repairs follow a 2-class G/M/1 priority queuing system. The OEM maximizes its expected profit by setting the EW and repair intervention prices, and selecting the optimal number of customers in each class. An application example is used to demonstrate the proposed model; a sensitivity analysis is also performed.
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A Coxian phase-type distribution was fitted to the length of time from admission until discharge readiness, and some hypothetical scenarios were considered and compared on the grounds of a number of performance measures and cost implications. Cruz and Rincon [13] examined the large body of existing research on outsourcing, and assessed the research status on outsourcing the maintenance of medical devices such as the magnetic resonance imaging (MRI) used in diagnosing TBI. The authors concluded that, “research into the outsourcing of medical device maintenance services in hospitals is still in its infancy stages, and that further progress in this field would benefit from additional empirical study grounded in management theory.”
Entering medical encounter data by hand is time-consuming. In addition, data are often not entered into the database in a timely enough fashion to enable their use for subsequent mission planning. The Patient Informatics Processing Software semi-automates the data collection process onboard ships. Then data within these images are captured and used to populate a database, after which multiple ship databases are used for reporting and analysis. In this paper, we used the Patient Informatics Processing Software Hybrid Hadoop Hive to orchestrate database processing via various ships, by marshaling the distributed servers, running the various tasks in parallel, managing all of the communications and data transfers between the various parts of the system, and providing for redundancy and fault tolerance. Then we employed the Apache Hive as a data warehouse infrastructure built on top of Hadoop for data summarization, query, and analysis to identify traumatic brain injury (TBI) as well as other injury cases. Finally, a proposed Misdiagnosis Minimization Approach method was used for data analysis. We collected data on three ship variables (Byrd, Boxer, Kearsage) and injuries to four body regions (head, torso, extremities, and abrasions) to determine how the set of collected variables relates to the body injuries. Two dimensions or canonical variables (survival vs. mortality) were necessary to understand the association between the two sets of variables. Our method improved data classification and showed that survival, mortality, and morbidity rates can be derived from the superset of Medical Operations data and used for future decision-making and planning. We suggest that an awareness of procedural errors as well as methods to reduce misclassification should be incorporated into all TBI clinical trials.
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The problem is not exclusive to the healthcare industry – according to a survey performed by Deloitte Consulting, 44% of respondents2 indicated that they saw no cost savings in their outsourced activities, while only 34% of respondents were satisfied with the supplier’s service quality (Landis, Mishra, & Porrello, 2005). This problem is compounded by the fact that maintenance outsourcing studies appear contradictory and incomplete (Assaf, Hassanain, Al-Hammad, & Al Nehmi, 2011; Benaroch, Webster, & Kazaz, 2012; Berradea, Cristiano, & Scarf, 2012; Garg & Deshmukh, 2006; Miguel & Rios, 2012; Shafiee & Chukova, 2013; Simoes, Gomes, & Yasin, 2011). For example, Miguel and Rios (2012) found particular deficiencies in the few existing studies on medical device maintenance outsourcing.
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Decision SupportMedical device maintenance outsourcing: Have operation management research and management theories forgotten the medical engineering community? A mapping review

Abstract

Highlights

Introduction

Section snippets

Motivation

Data sources

Results

Discussion and conclusions

Implications for future research

Acknowledgments

Information & Management

Journal of Economic Behavior and Organization

Journal of Operations Management.

Journal of Corporate Finance

Journal of Management

European Journal of Operational Research

Journal of Operations Management

European Journal of Operational Research

Mathematical and Computer Modelling

European Journal of Operational Research

European Journal of Operational Research

Multicriteria decision making on maintenance: spares and contracts planning

European Journal of Operational Research

Multicriteria modelling of repair contract based on utility and ELECTRE I method with dependability and service quality criteria

Annals of Operations Research

Production and transaction economies and IS outsourcing: a study of the U.S. banking industry

MIS Quarterly

Just right outsourcing: understanding and managing risk

Journal of Management Information Systems

Service contracts: a stochastic model

Mathematical and Computer Modelling

A Transaction cost approach to outsourcing behavior: some empirical evidence

Information and Management

Evidence on the role of firm capabilities in vertical decisions

Strategic Management Journal

The information technology outsourcing risk: a transaction cost and agency theory-based perspective

Journal of Information Technology (Routledge, Ltd.)

The Eigen factor metrics

The Journal of Neuroscience

A Resource-based perspective on information technology capability and firm performance: an empirical

MIS Quarterly

How a firm’s capabilities affect boundary decisions

Sloan Management Review

Technology choice, transaction alignment and survival: the impact of sub-population governance structure

Advances in Strategic Management

Supplier performance measures and practices in JIT companies in the US and UK

International Journal of Purchasing and Materials Management

New trends in high-technology health care support services

Biomedical Instrumentation & Technology

Systematic search and review procedures: results of the WHO Collaborating Centre Task Force on mild traumatic brain injury

Journal of Rehabilitation Medicine

Benchmark indicators for medical equipment repair and maintenance

Biomedical Instrumentation & Technology

The impact of firm-specific assets and the interaction of uncertainty: an examination of make-or-buy decisions in public and private hospitals

Journal of Economic Behavior and Organization

Clustering techniques: measuring the performance of contract service providers

IEEE Engineering in Medicine and Biology Magazine

A comparative study of maintenance services using the data-mining technique

Revista de Salud Publica (Bogota)

A fuzzy inference system to evaluate contract service provider performance

Biomedical Instrumentation & Technology

A study on facilitators and inhibitors to the introduction of outsourcing in the hospital information systems in Korea

Journal of Preventive Medicine and Public Health

A systematic assessment of the empirical support for transaction cost economics

Strategic Management Journal

Factors influencing publication of research results

JAMA

Recent theory and evidence on competition in hospital markets

Journal of Economic and Management Strategy

Citation analysis as a tool in journal evaluation

Science

A topology of reviews: an analysis of 14 review types and associated methodologies

Health and Information and Libraries Journal

Systematic reviews and the Cochrane collaboration: combining studies to enhance power

Decision Support
Medical device maintenance outsourcing: Have operation management research and management theories forgotten the medical engineering community? A mapping review