Original Research

Implementation of a Multicomponent Program to Improve Effective Use

and Maintenance of Medical Equipment in Sri Lankan Hospitals

Abstract J. L. P. Chaminda1,2,
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Background: Medical equipment (ME) maintenance retains an asset’s original anticipated useful Dilantha
life and preserves its reliability and cost‑effectiveness. This study developed and implemented Dharmagunawardene1,2,
a multicomponent program to improve ME use and maintenance in nine Sri Lankan hospitals
from May 2020 to May 2021. Methods: This pre–post implementation study involved an initial Alexia Rohde1,
baseline assessment of existing ME maintenance systems, the development and implementation Sanjeewa Kularatna1,
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 08/02/2024

of a multicomponent improvement program, and a 3‑month postevaluation. Five targets ME were Reece Hinchcliff1
selected for the study: oxygen regulator, electrocardiogram (ECG) machine, suction apparatus, 1
Australian Centre for Health
blood pressure apparatus, and mini autoclave. A pretested questionnaire was administered to Services Innovation and Centre for
randomly selected nursing officers (n = 101) and health‑care assistants (n = 120) to obtain baseline Healthcare Transformation, School
ME maintenance data. Six focus group discussions and 24 key informant interviews were conducted of Public Health and Social Work,
with key stakeholders to codesign the multicomponent interventions, which included: developing a Queensland University of
Technology, Kelvin Grove,
standard operating procedure targeting preventive maintenance activities; establishing focal points
QLD, Australia, 2Ministry of
to provide technical and logistic support; staff training; and the introduction of institutional ME Health, Colombo, Sri Lanka
maintenance documents. Program effectiveness was assessed at 3 months postimplementation
using the seven predefined outcome variables. Results: Baseline assessment identified no ME
maintenance programs implemented in any of the hospitals. The highest availability was observed
for oxygen regulator (62% to 82.3%) and ECG machine (66.1% to 84.7%). The highest functionality
improvement was observed for ECG machine (40.4% to 79.7%). The positive perception of
maintenance process of ME achieved the highest (33% to 80%) improvement. Following program
implementation, improvements were noted in: the availability (P = 0.00) and functionality (P = 0.00
to P = 0.02) of all selected ME; equipment maintenance processes (P = 0.000); as well as staff
knowledge, skills, perceptions, and satisfaction. Conclusions: The program improved the use and
maintenance of ME and was widely supported by the key stakeholders. The approach is relevant
to other resource‑poor hospital settings, as inadequate ME maintenance causes health system
inefficiencies. Submitted: 02‑Jun‑2023
Revised: 20‑Nov‑2023
Keywords: Hospital, maintenance, medical equipment, quality improvement
Accepted: 21‑Nov‑2023
Published: 19-Jan-2024
Introduction and cost‑effectiveness.[4] Effective ME
maintenance management consists of
Medical equipment (ME) is vital for Address for correspondence:
adequate planning, management, and Dr. J. L. P. Chaminda,
health‑care delivery, playing an important
implementation. Australian Centre for Health
role in all aspects of diagnosis, treatment, Services Innovation and Centre
and rehabilitation.[1] ME ranges from simple ME maintenance influences the overall for Healthcare Transformation,
devices, such as sphygmomanometers, capacity, service quality, workflow, and School of Public Health and
to complex devices, such as magnetic productivity of health‑care organizations Social Work, Queensland
University of Technology, 60,
resonance imaging machines.[2] Implantable, and the health systems which encompass Musk Avenue, Kelvin Grove,
single‑use, or disposable medical devices them.[3] Effective ME maintenance has QLD, Australia.
are not considered ME.[1] been shown to reduce overall downtime, E‑mail: [email protected]
improve productivity, and increase
It is important to maintain equipment
satisfaction among staff and patients.[5,6]
efficiency to provide quality care and reduce
However, various factors, including the Access this article online
health‑care costs.[3] Maintenance is essential
unavailability of relevant Standard
work carried out to manage the original Website:
Operating Procedures (SOPs) and logbooks, https://www.who‑seajph.org
anticipated useful life of an asset and, by
have been identified as major obstacles to DOI: 10.4103/WHO-SEAJPH.
doing so, preserve its reliability, efficiency,
timely maintenance management.[7,8] Poor WHO-SEAJPH_100_23
Quick Response Code:
This is an open access journal, and articles are
distributed under the terms of the Creative Commons How to cite this article: Chaminda JL,
Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows Dharmagunawardene D, Rohde A, Kularatna S,
others to remix, tweak, and build upon the work non‑commercially, Hinchcliff R. Implementation of a multicomponent
as long as appropriate credit is given and the new creations are program to improve effective use and maintenance
licensed under the identical terms. of medical equipment in Sri Lankan hospitals. WHO
For reprints contact: [email protected] South‑East Asia J Public Health 2023;12:85-92.

© 2024 WHO South-East Asia Journal of Public Health | Published by Wolters Kluwer - Medknow on behalf of WHO Regional office for South-East Asia85
 Chaminda, et al.: Medical equipment management in low resource setting

ME maintenance culture and training in public facilities 2021. The project was developed and implemented with
have been identified as major obstacles in developing the active participation of relevant stakeholders at various
countries.[9] The implication is that ME maintenance should levels of the Sri Lankan health system.
be prioritised in daily hospital management activities in
Ethical approval for this project was obtained from the
low‑resource settings.[10]
Ethics Review Committee of the Post Graduate Institute
The Sri Lankan context of Medicine, Sri Lanka (ERC‑PGIM‑2020‑038). Written
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approval for the project was obtained from provincial

Sri Lanka is an Asian country with a rapidly aging
population of 21.7 million in the late stages of demographic and regional health authorities of Sri Lanka. A written
and epidemiological transition. The state sector remains information sheet was given before the data collection and
the key provider of inpatient care[11] with a bed strength informed written consent was obtained from all participants.
Anyone who did not wish to participate was excluded and
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of 86,589, a rate of 4 beds per 1000 population.[12]

Government spending as a share of gross domestic product their confidentiality was assured. The participants were
for health has remained < 2% for many years.[11] free to withdraw from the project at any time. Privacy and
confidentiality of the data were ensured throughout the
Divisional hospitals (DHs), earlier known as peripheral project.
units, rural hospitals, and district hospitals, were
established during the 1930s in Sri Lanka to provide Study setting
primary health‑care services. There are 483 DHs in Sri Matara is the second largest district in the Southern
Lanka comprised three types of hospitals categorized based Province of the 25 administrative districts in Sri Lanka,
on the number of beds, including Type A (75–100 beds), comprising 1283 km2 with a population of 873,000.[14]
B (50–74 beds), and C (<50).[12] There are 14 DHs in Matara, consisting of two Type‑A,
There is no well‑organized mechanism to strengthen ME seven Type‑B, and five Type‑C hospitals. Nine of these
maintenance in primary health‑care services in Sri Lanka, DHs (two Type‑A, six Type‑B, and one Type‑C) were
unlike in secondary and tertiary care settings, and this is selected to participate in this study. The rationale for
mainly due to a lack of capacity, systems, and processes. selecting the nine‑specific hospitals included in this study
The regional and provincial health authorities handle ME was based on the availability of a permanent pharmacist to
management in primary care hospitals through pharmacists coordinate the ME maintenance process.
in the respective institutions. ME maintenance at the Phase I – Initial assessment and medical equipment
district level is coordinated by the Biomedical Engineering selection
Unit (BMEU).
For phase one, an initial assessment of the existing
Few studies have been carried out in Sri Lanka to assess system of maintenance of selected ME in the project
ME maintenance.[5] One study identified that only a few settings was undertaken using questionnaires, focus group
settings had equipment maintenance registers, and all discussions (FGDs), key informant interviews (KIIs), and
available registers were reported to be deficient.[13] Given process mapping. Staff involved in ME maintenance systems
the impact of poor ME on the ability to provide safe, at the nine hospitals were invited to participate and included
cost‑effective health care, this research project aimed nursing officers (NOs), health care assistants (HCAs),
to address this gap by developing and implementing a Regional Director of Health Service (RDHS), biomedical
multicomponent program to improve the effectiveness of engineers, biomedical technicians, institutional heads of
these ME processes in Sri Lankan DHs. The results provide DHs, and pharmacists.
guidance for health‑care stakeholders in other resource‑poor
settings who similarly intend to enhance existing ME The questionnaire, FGD, and KII guides were developed
maintenance processes to improve health system efficiency. as study instruments following a desktop review of the
international and domestic literature. Detailed discussions
Methods were conducted with experts in ME management during
the development of study instruments. Face and content
This implementation research used a mixed method, pre–
validity of the project instruments were ensured through
post design that involved three distinct phases. Phase
discussions with the same individuals. Study instruments
one comprised an initial baseline assessment of ME
were pretested and revised accordingly.
maintenance systems within nine Sri Lankan hospitals.
Phase two involved the development and implementation Quantitative study
of a multicomponent program aimed at improving ME
Questionnaire survey
maintenance. Phase three involved a follow‑up assessment
to evaluate the program’s effectiveness. This project was The baseline questionnaire elicited the views of NOs and
conducted from May 2020 to May 2021, with the pre‑ and HCAs. The questionnaire included 34 questions which
post‑ assessments carried out in August 2020 and March sought feedback on ME maintenance system at the selected

86 WHO South-East Asia J Public Health | Volume 12 | Issue 2 | July-December 2023
 Chaminda, et al.: Medical equipment management in low resource setting

settings. These stakeholder groups were specifically chosen model. The project stakeholders who participated in
for inclusion due to their key role in supporting ME interviews were allocated their independent scores for the
maintenance functions. The sample size was calculated mentioned domains, followed by the average score as the
using Raosoft® online sample size calculator,[15] for 5% final score for all initially selected ME. ME with low scores
margin of error, 95% confidence level, and 50% response was assigned a low priority in maintenance management.
distribution. The required sample was 221 (NO ‑  101; ME with high scores was further reviewed and selected for
HCA ‑ 120) for 136 population of NOs and 173 population this project. Oxygen regulator, electrocardiogram (ECG)
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of HCAs. Same individuals were followed up for the machine, suction apparatus, blood pressure (BP) apparatus,
postinterventional phase, but there were six dropouts. and mini autoclave were the final ME selected for this
project.
Participants were selected using stratified random sampling
and the strata were the study settings (DHs). A five‑point Phase IIa ‑ Intervention development
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Likert scale was used in the questionnaire, and categories Process maps of the ME lifecycle were completed to
on a five‑point scale were reduced to two (satisfactory and help design appropriate interventions. Process maps are a
unsatisfactory) with expert opinion.[16] useful tool to support a better understanding of complex
Qualitative study systems and the adaptation of improvement interventions
to their local context.[19] Gaps in the existing ME use and
Focus group discussions maintenance in the project settings, identified through the
Six FGDs were conducted with purposively selected process mapping, questionnaire, FGDs and KIIs, were
groups of NOs and HCAs representing all nine DHs, presented to the project stakeholders.
using the validated guide until theoretical saturation was A strengths, weaknesses, opportunities, and threats (SWOT)
reached. FGDs were run by the lead author and involved analysis is an important tool to identify information about
groups of eight to ten participants. Each of the FGDs the internal and external environment of an organisation.
lasted approximately 90 min and were convened in meeting After completing a SWOT analysis, interventions and
rooms at the regional health office. Topics covered within strategies to remedy the deficiencies were developed using
the FGDs included the existing ME maintenance systems the (conceptual framework for identifying Threats and
in place, strengths, and weaknesses of existing systems, as Opportunities and assessing the organisations Strengths and
well as staffing and workload arrangements. Weaknesses [TOWS]) matrix, which involved consideration
Key informant interviews of administrative feasibility, acceptability, and time
availability. The TOWS matrix was developed to assist the
The RDHS, biomedical engineers, biomedical technicians, design of strategies based on logical combinations of factors
institutional heads of DHs, and pharmacists were related to internal strengths and external opportunities.[20]
approached to complete semi‑structured interviews, which
were conducted using the validated guide. Deficiencies Consultative meetings were conducted with project
of the current ME maintenance process, problems stakeholders to reach the consensus on the proposed
encountered, and suggestions for the improvements were interventions. The final selected interventions included:
discussed during the KIIs. The first author conducted the the development of a SOP, conducting hands on training
qualitative data collection with the help of trained research workshops, establishment of ME management team in DHs,
assistants. All interviews were recorded and transcribed initiation of the ME focal point in each DHs, allocation of a
verbatim following the interviews, the transcripts were nurse and a pharmacist in each DH for overall supervision
checked by the participant for accuracy. and coordination, and provision of continuous technical
and administrative support to the selected HCAs through
Qualitative data from both the FGDs and KIIs were BMEU.
analysed thematically after coding.[17] Emergent themes
were discussed and refined by the project investigators Phase IIb – Implementation of medical equipment
maintenance interventions
before being finalized.
Hands‑on training workshops were conducted at the
Selection of medical equipment
Regional Health Office run by the lead author with the
The selection of the five specific types of ME for inclusion resource of BMEU in November 2020. All staff involved
as targets for the intervention in the study was based on in hospital ME maintenance teams (Pharmacists, NOs,
initial discussion with project stakeholders, an assessment HCAs) were invited to attend the workshops. The
of available regional and hospital data, then the utilisation workshop scheduled educational sessions, discussion of the
of a multi‑criteria decision‑making model.[18,19] Frequency importance of ME maintenance, the introduction of SOPs,
of breakdown, number of needed items, importance of care, and the live demonstration of selected ME maintenance,
importance of trained staff, importance of SOPs, and wrong followed by an opportunity for participants to share
use were the domains considered for the decision‑making feedback.

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 Chaminda, et al.: Medical equipment management in low resource setting

Phase III – Follow‑up evaluation satisfied with the current processes related to ME and
poor attention was paid to these processes. No proper
Three months after the program comprising these
records were maintained and there were no established or
interventions were implemented, the effectiveness of the
coordinated maintenance mechanisms in the region.
program was assessed using the same quantitative and
qualitative methods outlined above, involving the same Results from the quantitative data
population, using outcome measures.
As per Table 1, the availability of all selected ME
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Statistical analysis significantly improved in the postintervention period. The

highest pre‑ and post‑ interventional availability were
Quantitative data analysis was conducted using Statistical
observed with oxygen regulator (from 62% to 82.3%)
Software (SPSS Version 22.0, IBM Corp., Armonk, NY,
and ECG machine (from 66.1% to 84.7%) following
USA) and McNemar’s test was performed to assess the
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the intervention [Figure 2]. The functional level of all

significance. Independent variable (Staff designation) was
ME also significantly improved at 5% level between
analysed against the dependant variables mentioned in
pre‑ and post‑ interventional stages, as illustrated in the
Annexure 1.
same Table 1. The highest improvement was achieved
Results for ECG machine (from 40.4% to 79.7%), while the BP
apparatus (82%) showed the highest functional level
Among the respondent (n = 221), the mean age was following intervention [Figure 2].
41.1 years (standard deviation 8.0), 54.3% (n = 120)
were HCAs while 45.7% (n = 101) were NOs. The The knowledge and skills of both staff categories on ME
majority (n = 172, 77.8%) of the participants were women. use and maintenance were significantly improved at the
5% level following the interventions, as illustrated in the
Fifty‑six participants (12 pharmacists, 14 NOs, and 30 Table 2. In addition, perceptions, convenient maintenance
HCAs) participated in the FGDs. There were 24 participants process, and the satisfaction of the participants on
for KIIs. maintenance process were also significantly improved at
The maintenance process of the selected ME process in the 5% level, as illustrated in Table 2.
project settings, before the implementation of the program, There was a significant improvement in all five considered
is illustrated in Figure 1. parameters. The perception of the sample on the importance
It was observed that no established ME maintenance of use and maintenance of ME achieved the highest (33%
mechanism existed for any of the nine hospitals in the to 80%) improvement. The least improvement (45.2% to
study. The FGDs and KIIs revealed the main problems 65.6%) was observed for the knowledge of the participants
to be: poor attention on preventive maintenance; frequent on the use and maintenance of ME, although the
breakdowns of selected ME; undue delays in having improvement was still significant [Figure 3].
ME repaired once broken; nonavailability of service
Discussion
agreements; nonavailability of separate maintenance
logbooks; nonavailability of ME maintenance schedules; Maintenance of equipment efficiency is vital to provide
and unavailability of trained hospital staff for ME quality care and reduce costs.[3] This project was cost
maintenance. Moreover, nonavailability of directives and neutral to implement, yet was found to significantly
assigned responsibility for regular maintenance operations, improve ME maintenance in Sri Lankan DHs, thereby
nonavailability of instructions for uniform processes and providing a template to inform action by health system
practices in ME maintenance, poor documentation process, stakeholders in comparable resource‑poor settings.
and supervision at the regional and hospital level were also
The development and implementation of SOPs are
made evident in the initial baseline assessment.
cost‑effective to deliver a high‑quality, uninterrupted
Results from the qualitative data health‑care service.[21] Development of the SOPs in this
study was completed with minimal resources but improved
Main themes that emerged from FGDs were training,
the ME availability and functionality level [Table 1]
knowledge, satisfaction, process of maintenance of ME,
significantly. ME availability and functionality have a direct
maintenance of records, and use of ME. Main themes of
effect on uninterrupted health‑care service. Nonavailability
KIIs were process of maintenance of ME, maintenance of
of maintenance registers and many deficiencies in the
records, coordination, and capacity of the regional staff.
few available registers were observed in the Sri Lankan
Thematic analysis of preintervention data indicated that health sector.[13] Registries related to ME maintenance were
there were inadequate training and knowledge among introduced and strengthened by assigning responsibilities to
institutional and regional staff on ME maintenance and use, relevant officers. They were empowered with the training
and they gained the knowledge from previous, untrained and monitored their performance by the regional health
staff, resulting in incorrect use of ME. Staff were not team by the project.

88 WHO South-East Asia J Public Health | Volume 12 | Issue 2 | July-December 2023
 Chaminda, et al.: Medical equipment management in low resource setting
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Figure 1: Process map of medical equipment maintenance in divisional hospitals of the Matara district. ME: Medical equipment, RDHS: Regional director
of health service, DHs: Divisional hospitals, BMEU: Bio medical engineering unit

Table 1: Change in availability and functionality of medical equipment following intervention

Availability Functionality
Preinterventional Postinterventional P Preinterventional Postinterventional P
(n=221) (%) (n=215) (%) (%) (%)
Oxygen regulators 62.0 82.37 0.000 48.2 71.8 0.000
ECG machines 66.1 84.7 0.000 40.4 79.7 0.000
Suction apparatus 51.1 55.8 0.001 48.7 60.8 0.000
BP apparatus 80.1 93.0 0.000 55.9 82.0 0.000
Mini autoclaves 48.4 53.0 0.002 58.9 71.1 0.029
Total n for functionality is the proportion of availability in each respective category. ECG: Electrocardiogram, BP: Blood pressure

Longer life of the equipment with minimal breakdown, functional failures among significant and critical devices.[23]
usage with a low cost, and higher personal satisfaction Development of SOPs[24] and their incorporation to improve
of the users can be achieved by excellent maintenance staff competency to ensure proper maintenance[21] was found
management combined with trained staff.[22] Lack of to be very important for ME management. Accordingly, the
maintenance mechanisms and improper use of ME were training workshops combined with the SOP had contributed
the main issues addressed through this research project, and to a significant improvement in the maintenance process
staff training with sufficient awareness resulted in improved and use of ME in the project setting and the outcomes of
satisfaction in every staff category. the project were achieved through various strategies.
Actions such as preventive maintenance, user training, Strengthening the use and maintenance of ME was
and redesigning, the devices must be taken to reduce the successfully done by the BMEU with the technical guidance

WHO South-East Asia J Public Health | Volume 12 | Issue 2 | July-December 2023 89

 Chaminda, et al.: Medical equipment management in low resource setting

Table 2: Change in knowledge and skills on medical equipment use and maintenance along with perception,
convenience of maintenance process and satisfaction before and after intervention
Satisfactory knowledge (%) Satisfactory skill (%) Positive perception (%)
Preintervention Postintervention P Preintervention Postintervention P Preintervention Postintervention P
(n=221) (n=215) (n=221) (n=215) (n=221) (n=215)
NOs 69.3 82.1 0.000 55.4 75.8 0.002 36.6 83.2 0.000
HCAs 25.0 52.5 0.000 44.2 70.0 0.000 30.0 77.5 0.000
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Satisfactory convenience of maintenance process (%) Satisfaction of participants (%)

Preintervention Postintervention P Preintervention Postintervention P
(n=221) (n=215) (n=221) (n=215)
NOs 44.6 65.3 0.000 27.7 53.7 0.000
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HCAs 35.8 66.7 0.000 31.7 74.2 0.000

NO: Nursing officers, HCA: Health care assistants

Pre intervention Post inteventional

90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Knowledge Skills Perception Maintainance Satisfaction
score
Figure 2: Radar chart of medical equipment availability and
functionality before and after intervention, ME: Medical equipment, Figure 3: Overall pre‑ and post‑ intervention knowledge, skills, perception,
ECG: Electrocardiogram, BP: Blood pressure maintenance score and satisfaction of medical equipment maintenance
among hospital staff
of a biomedical engineer in this project. According to
Ghazi, in most of the Western world, well‑established effectiveness of the intervention could further be evaluated
health‑care maintenance units are headed by a maintenance by prospective comparison of pre‑ and postcost for the
engineer to deliver excellent patient care.[25] Priority should reactive maintenance and new procurement. However,
be given to maintenance management in hospitals.[10] the cost analysis could not be performed due to resource
The managers at the regional and hospital level have the and time constraints, which can be assessed in future
responsibility to monitor the performance and to keep the studies. The improvement must be re‑evaluated after a
ME management team updated to ensure sustainability period of 6 months and necessary modifications should
and the regional leadership of the district contributed to be introduced to the processes and practices based on
the successful culmination of the project. Overall, issuing new findings. The introduced SOP must be reviewed and
instructions and SOPs on ME maintenance influenced updated to keep up with technological changes focusing
all the institutional heads and staff in DHs to follow the on essential and novel information for relevant staff
correct use and maintenance practices of ME. to improve their competency. Regular, well‑organized
training programmes must be conducted with staff
Conclusions and Recommendations turnover to ensure the sustainability of the project for
This project aimed to, and ultimately did, improve the widening the scope of implementation.
use and maintenance of selected ME in DHs in a resource Financial support and sponsorship
poor Sri Lankan setting by identifying gaps, then designing
and implementing appropriate interventions to overcome Nil.
them. The involvement of all key stakeholders in project Conflicts of interest
formulation and implementation is likely to have been a
critical enabler of the project. There are no conflicts of interest.

Although there are limitations on generalizability, the References

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 Chaminda, et al.: Medical equipment management in low resource setting

Annexure

Annexure 1: Outcome measures and their operational

definitions
Outcome measure Operational definition
Availability of ME Awareness of relevant ME in
the sub‑inventory of the unit
Downloaded from http://journals.lww.com/wsep by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW

(Section 2 of the questionnaire)

Functionality of ME Awareness of relevant ME
that were ready for routine use
within the unit (Section 2 of
the questionnaire)
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 08/02/2024

Knowledge on use and Composite measure from the

maintenance of ME Section 3 of the questionnaire
Skills of use and maintenance Composite measure from the
of ME Section 4 of the questionnaire
Convenience on the process of Composite measure from the
use and maintenance of ME Section 5 of the questionnaire
Perceptions of use and Composite measure from the
maintenance of ME Section 6 of the questionnaire
Satisfaction on the process of Composite measure from the
use and maintenance of ME Section 7 of the questionnaire
ME: Medical equipment

92 WHO South-East Asia J Public Health | Volume 12 | Issue 2 | July-December 2023