Medical Physics Operational Procedure - Main Text

1. FUNCTION
   1. Policy GP/E4 states NHS Fife’s duty to have an effective equipment management policy and organisation.  This procedure sets out the functions and internal procedures for Medical Physics to provide services in support of that policy.
   2. The Medical Physics service’s aim is to help achieve maximum availability of equipment by management and provision of a service for the initial commissioning, and routine servicing and repair, of patient connected medical equipment.
2. LOCATION
   1. Medical Physics services are based in Queen Margaret and Victoria Hospitals.  They are an integral part of the Estates Department at each of those sites, and follow their defect reporting procedures.  Services are not routinely provided outside of those two sites.  All other NHS Fife sites are currently supported by their local Estates Departments.
   2. Services will be provided Monday – Friday, 08:00 – 16:00.  There will be no service on NHS Fife specified public holidays.  There is no out of hours on call service.
3. RESPONSIBILITY
   1. The Director of Estates, Facilities and Capital Serviceshas overall responsibility for the management of the provision of technical services throughout NHS Fife.
   2. The Sector Estates Services Manager for Central and North East Fifehas responsibility for higher level management of Medical Physics.
   3. The Medical Physics Manager NHS Fifeis responsible for the day to day running of the Medical Physics services based at Victoria and Queen Margaret Hospitals.  General tasks within this function will be detailed in an internal SOP.
   4. Medical Physics Techniciansare responsible for carrying out repair and maintenance activities appropriate to their skill level and training in accordance with local test procedures that have been produced with reference to equipment service manuals.
4. OPERATIONAL SYSTEM
   1. Equipment coveredwithin Medical Physics remit is indicated in Appendix 1
   2. Defect repairrequests are reported and managed using the Apollo FM and Apollo Mobile facilities.
      1. Technicians are to monitor the Apollo planning board for defects, and allocate them to their own work list for action identifying priorities as appropriate. More detailed guidance will be in local SOPs.
      2. Standard Medical Physics response time for routine defects is 3 working days to job closed.
      3. Repaired equipment will be returned to the original registered owner and not the reporting area.
   3. Planned Servicingmay be carried out by Medical Physics staff or contractors.
      1. It will as far as practicably possible be carried out within the periodicity recommended by manufacturer documentation and other guidance or instruction published by an authoritative agency.
      2. Where manufacturer guidance indicates no routine servicing is required, appropriate PAT may be carried out within existing Estates testing schedules and policies.
      3. Detailed guidance for prioritisation and allocation of this work will be in local SOPs.
      4. All equipment will be labelled as serviced by both contractors and Medical Physics as detailed in local SOPs.
      5. Medical Physics staff will attempt to locate equipment for servicing in the clinical area that it has been assigned to in the Apollo Asset Register. They will not search a hospital in an attempt to find something that is not where it is expected to be.  After two attempts, Ward/Department Senior Charge Nurses will be requested by e-mail to locate any item that has is “not found”.  They will be asked to have these items delivered to Medical Physics at the earliest opportunity, or respond that the equipment is no longer held and can be removed from the Asset register.  A failure to respond to this request will be similarly considered as no longer having a servicing requirement.  Lists of this equipment will be presented to Capital Equipment Management Group for further consideration and the PPM task will be suspended with no future servicing scheduled.
   4. Acceptance of equipment into use.  Acceptance checks will only be completed once Asset Registration has taken place.
      1. On completion of Acceptance Checks equipment will be delivered to the clinical area and handed over to the senior Charge Nurse present.  They will be expected to sign a handover certificate.  (Appendix 2).
      2. Where a device has standard settings that can be set according to the clinical requirements of the department using the device, an authorised clinician will be requested to define these settings or acknowledge acceptance of manufacturer “as delivered” settings.  The authorised clinician will be asked to sign a written copy of these settings as a record of authorisation.  These settings will be used as the default configuration for the device until otherwise notified in writing by the same authoriser or their representative.
      3. When not done by supplier, acceptance checks by Medical Physics may include the following:-

• Confirm the equipment is safe to use and complies with all relevant standards.
• Confirm user /operator manuals are included with equipment.
• Carry out functional check according to specifications.
• Test for Electrical Safety
• Confirm maintenance requirements and place on a routine maintenance programme, (Medical Physics staff technical training may be required), or noted for contract service after warranty expiry.

1. Technical Training– To reduce the possibility of equipment malfunction following service or repair, all personnel involved in maintaining and servicing equipment must be competent to undertake this work.
   1. No one shall be allowed to carry out work on equipment considered to be “life support” equipment (ventilators, anaesthetic machines, resuscitation equipment etc.) without formal manufacturer technical training.
   2. Training on every specific model of equipment in use in the wide NHS Fife environment is impossible.  As far possible, all, but at least two of the available technical staff will receive manufacturer technical training to a level required to carry out normal service procedures on equipment that exists in large numbers.  This will be for lower risk items that still have a potential to contribute to patient harm (infusion devices, site wide patient monitoring systems etc.)  This training may also be passed on to other staff in the form of practical on job cascade training and assessment by the trained person.
   3. Where doubt exists or is it is viewed as specialised equipment, and training of in house staff is not cost effective, equipment will be referred to the manufacturer or their authorised agent for contract support.
   4. By necessity, for all other equipment, general training, experience and the capability of staff to utilise servicing manuals, has to be considered adequate.
2. Equipment Replacement Planning and Selection.  The production of equipment replacement plans is the responsibility of those indicated in Policy GP/E4.  Medical Physics Manager can provide, on request, basic Asset Register information and advice to assist the planned replacement of equipment, and its selection.

Note:- Medical Physics does not buy replacement equipment unless, in some cases, it is regarded as a routine servicing function.

1. Condemnation and Disposalof equipment may be required for many reasons, as detailed in Policy E14.6.  These will also be specified for technician guidance in Local SOPs.  Medical Physics will make condemned equipment safe for disposal and place it into the appropriate NHS Fife waste stream.  Medical Physics Manager will produce condemnation notes as required.
2. Adverse incidents and near missesinvolving the malfunction, misuse, unsuitability etc. of an item of medical equipment leading to actual or potential harm, to a patient, a member of staff, or member of the public, should be reported using the online Datix reporting system in accordance with Reference F.
   1. Where it is known a Datix incident has been, or will be, submitted, Medical Physics staff are to ensure that all equipment settings other observations and actions taken are fully recorded.
   2. Where safe to do so the following items are to be retained for possible future inspection.  If not retained, photos and all details are to be documented:-

• Machine parts removed and changed during incident investigation, either defective or contaminated.
• Any disposable accessories provided with the main equipment.

1. If equipment has been repaired and returned to user before notification of the Datix report, then any standard routine records taken should be retrieved and supplemented by observations from memory which should noted as “memory only”.
2. Incidents reported on Datix will be routinely reviewed by Capital Equipment Management Group.  Additional actions may be instigated which only supplement and do not replace the normal Datix System incident review process.

1. RISK MANAGEMENT
   1. The key risks involved in the implementation of this procedure are as follows:
      1. Lack of staff awareness of this procedure, resulting in non-compliance.  This risk is reduced by:-
      2. Procedure is published on NHS Fife Intranet policies section.
      3. Its original publication and any revision or updates will be published via the Daily Dispatch and news section on the home page of NHS Fife Intranet.

1. RELATED DOCUMENTS

Appendix 1 - EQUIPMENT MAINTAINED BY MEDICAL PHYSICS

Appendix 2 - NEW EQUIPMENT HANDOVER CERTIFICATE

EQIA