LANDSTUHL, Germany -- As the 2018 fiscal year comes to an end Sept. 30, Landstuhl Regional Medical Center will close out its financial books with nearly $3 million in cost savings as a result of a medical equipment bottom-up review, a process that required a line item scrutiny of property that had accumulated at the hospital since 2001.

In 2017, LRMC allocated over $1.2 million for maintenance of medical items, some of which were either not being used or were being stored as back up equipment.

"For a lot of our medical equipment, over time the cost to maintain it exceeded the cost of the equipment itself," said Sgt. 1st Class Jason Dettman, the non-commissioned officer-in-charge of the LRMC Clinical Operations Division who helped spearhead the bottom-up review board. "When you consider the costs of service contracts and parts, and then multiply that by the amount of equipment we had on our property book, you're looking at millions of dollars that could be saved or spent elsewhere."

The establishment of a review board was a critical step for ensuring that an overarching perspective on the impact to the clinic was discussed. With representatives from LRMC's clinical operations, logistics, medical maintenance, clinical engineering, resource management and oftentimes a deputy commander, in addition to the subject matter expert from the clinic, the team looked at data such as how often equipment was used, if the hospital has duplicate items for backup, and if the equipment could be shared with other clinics nearby.

"We actually started the review process with like-sections such as the [Neonatal Intensive Care Unit], Labor and Delivery and the Mother-Baby Unit," said Maj. William Wiltbank, the chief of transportation at the U.S. Army Medical Material Center Europe, former chief of logistics at LRMC and the program lead of the bottom-up review process. "We were able to compare property across those like-sections and determine where we could reduce the purchase of similar types of equipment."

As part of the review process, Dettman partnered with Pia Kessler, the LRMC property book officer, and Master Sgt. Charles Sellers, the superintendent of the clinical engineering department, to meet with every single hand receipt holder in the hospital to review their current list of medical equipment and determine if it was necessary to keep each item. During their reviews, representatives from each section were able to identify and justify the need for certain pieces of medical equipment.

"We helped them to determine what items were past their life cycle and they were able to ask themselves if they really needed some things," said Kessler. "Instead of non-medical people going into clinics and telling them what they need to get rid of, the process we worked out really gave the clinics a voice as the medical experts. They know what they need for their patients and we were able to help them identify those things they could do without that would not affect the quality of our care or our patients' safety."

In addition to recognizing actual needs of clinics and care teams, Sellers helped to identify the requirements for equipment maintenance and worked with leaders to modernize their property.

"We looked at the equipment's historical maintenance report," said Sellers. "Things like operating tables didn't need to be changed out so often because they still worked; we could extend their life cycle and avoid the unnecessary cost of buying a new one."

Sellers also said that even lower cost items like lamps were reviewed. Instead of replacing a perfectly good lamp for the operating room, the clinic would simply purchase a new lightbulb. While it may seem minor, Sellers attributes the culmination of hundreds of minor work-arounds to the cost savings.

With nearly all medical equipment accounted for by the team, Dettman projects that $3 million which would have been spent on either maintaining equipment or the purchasing of new equipment for fiscal year 2019 can be allocated elsewhere.

"We can look at it as cost savings but it's really cost avoidance," said Dettman. "We avoided spending $3 million on things we just don't need any more or don't need to replace yet."

THE ACCUMULATION OF EQUIPMENT

Due in large part to Operation Enduring Freedom and Operation Iraqi Freedom, in 2007 LRMC was elevated from an American College of Surgeons verified Level III trauma center to Level II, indicating an increase in the scope of services and medical capabilities which led to the procurement of additional equipment and health care items. Again in 2011, LRMC was upgraded to a Level I trauma center; both manpower and hospital-wide property increased.

Because the number of trauma patients from forward operations decreased in 2013 as a result of the military drawdown, LRMC's trauma designation returned to level three in 2014.

Between 2001 and August 2018, LRMC cared for over 16,800 Service Members who were evacuated from forward theaters specifically due to a combat injury. In total, over 98,500 Service Members have been cared for at LRMC for both combat and non-combat related injuries and illnesses.

"After the drawdown, our patient load decreased and we had all of this excess equipment," said Wiltbank. "Fast forward to 2017 and we were still spending money on maintenance for equipment we either weren't using or for something we no longer needed."

In 2015, the Command Logistics Review Program, a U.S. Army Medical Command inspection board, identified that the percentage of equipment at LRMC that was past its life cycle-- when an item was no longer serviceable -- was 31 percent, far exceeding the MEDCOM standard of 20 percent. After an initial sweep of all hospital equipment later that year, LRMC reduced its past life cycle rate to 17 percent.

"The equipment sweep that lowered our past life cycle rate drastically reduced the equipment we had on our property book," said Wiltbank. "But that was mostly the removal of furniture and tech-related equipment. It didn't get after the real excess which was the medical equipment."

The items past their life cycle, however, were only a portion of the property issue at LRMC. In October 2017, the hospital leaders determined that the medical maintenance of such a large quantity of equipment was unsustainable due to the slow decrease of manpower in the logistics division. As positions were vacated and left unfilled to meet staffing caps and requirements, the ability to maintain medical equipment became a patient safety concern. As the new chief of logistics, hospital leadership looked to Wiltbank to downsize medical inventory in such a way that kept LRMC mission-ready with equipment that was properly maintained and safe for patients.

Wiltbank's initial goal was to decrease LRMC's property book by 10 percent, nearly $11 million worth of equipment. Through command policies and procedures to enforce the disposition of past life equipment, Wiltbank and his team exceeded their goal which resulted in the decrease of LRMC's property book by $18 million. LRMC's medical equipment inventory went from over 11,000 to around 7,000 items. By March 2018, Wiltbank was prepared to move to his second program for property book maintenance: the bottom-up review.

MEDICAL EQUIPMENT READINESS

Besides the cost savings, Wiltbank indicated that one of the biggest benefits of the bottom-up review process was the ability to forecast the disposition of equipment.

"When a clinic came in for their bottom-up review, the logistics division was able to identify an exact date for either replacement, renewal or removal on the spot," said Wiltbank. "It allowed clinics and sections to ask questions as to the best way to deal with property issues and it gave the logistics team a documented record to track turn-in progress."

The review board also cut down the time spent in the Capital Expense Equipment Program (CEEP) meetings, which was typically a lengthy discussion that required leaders to justify the need to purchase new or replacement equipment. Wiltbank noted that the review board drastically cut the CEEP meeting down by hours because leaders no longer had to justify equipment requests that were already validated during the bottom-up review.

While the bottom-up review board is about 90 percent complete with analyzing the medical equipment for the hospital, they are already looking to expand the process to the six Army health clinics throughout Europe that fall within the LRMC footprint.

"We're leaning forward," said Dettman. "Evaluating equipment needs is an ongoing process and we can anticipate actions rather than react to them."