HTM Guide 1

How to Organise HTM

Anna Worm
For Engineering World Health

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 Guide 1

This presentation accompanies the book:

How to Organize: How to Manage Vol 1, Lenel et. al.,
(Ziken International: 2005).

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 What is HTM?

• Gathering information abt your equipment

• Planning technology needs and allocating
funds
• Purchasing suitable models and installing
them effectively
• Providing sufficient resources for use
• Mainting and repairing of equipment
• Ensure staff has the right skills
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 In other words:

You need skills in the management of:

• Technical problems
• Finances
• Purchasing procedures
• Stores supply and control
• Workshops
• Staff development

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 Chapter 1 introduction p6

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 Guide 1 covers

1. Regulations and Standards

2. Technical requirements
3. Models for delivery
4. Organizational structure
5. Human resource requirements
6. mornitoring

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 Chapter 2, the foundation

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 Chapter 2

2.1 Regulatory role of the government

2.2 Establish standards for your health system
2.3 Policy issues for HTM
2.4 Importantce of introducing an HTM service
2.5 Managing change

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 2.1 regulatory role of
government
Health systems can be organised in different
ways:
• Mainly public
• Mainly private for profit
• Mainly private not-for-profit
• A mix of government and private

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 2.1 regulatory role of
government
Health Systems have 4 functions:
• Financing of health services
• Provision of health services
• Creation of health resources (facilities,
equipment, training)
• Stewardship of health services (regulation and
enforcement)
BOX 4 p17
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 2.1 regulatory role of
government
• Service financing and resource creation;
– Patient pay
– Insurance pays
– Donors pay
– Government pays

Government is responsible for protection of health and

safety of health services regulations!

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 2.1 regulatory role of
government MoH
2.2 Quality standards. Accept international?
2.2 Establish system to ensure the standards are
met, so that the bodies enforcing regulations
have legal sanctions
2.3 Establish wide ranging policies covering all
aspects of use, effectiveness and safety
2.4 Establish system to ensure these policies can
be implemented
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 Discussion

• Box 5 p 18

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 2.2 establishing standards

Standards can concern:

• Manufacturing
• Safety (electrical, hygiene etc)
• Use (also maintenance)
• Disposal (also environment!)

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9-03-23 15
 Adopt international
accepted standards! P21/22
• IEC
• ISO
• EU (CE)
• FDA
• Manufacturers certificates

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 2.3 national policies

Should be developed by MoH

Very complex job

You need at least:

• A vision
• Standardization
• Provision of maintenance
• finances
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 2.3.1 vision

Look at
• Demographic data (number of inhabitants)
• Epidemiological profiles (1 disease in 1 region)
• Priority health problems (HIV, Malaria?)
• Infrastructure, finance, Human Resource

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 2.3.2 standardization

Limit wide variety of makes and models of equipment

1. Technical benefits
2. Financial benefits
3. Logistic benefits
4. Training benefits

This is why we want to involve RBC/MMC in

procurement!
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 2.3.3 maintenance

• Ensure it continues to meet standards

throughout equipment lifecycle
• For public hospitals government is responsible
for maintenance.
• For Private or Mixed hospital it depends

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 2.3.3 maintenance

• Details of how maintenance is organized

would not need to be prescribed by the
regulatory body. It’s up to your hospital how
to organise these services.
• Partnerships public/private (service)

Establish good links between workshops!!

Network to support your needs

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 2.3.4 finances

• Capital budget
• Recurrent budget

• We will talk about this in Session 5

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 2.4 HTM service/team

Benefits of HTM services:

• Clinical
• Economical

Can you explain why?

The HTM team will be discussed later in Guide 1

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 2.5 How to manage change

Ideal situation ≠ current situation

• Step by step approach!

• Do not start all over, but research current
state and start from there
• Introduce changes gradually
• Implementing everything suggesting in the
6HTM guides takes years!
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 2.5 how to manage change

Naturally human beings have a resistance to

change
Managers should motivate their people to adopt
change
Ideally employees are involved in creating
procedures-discussions, working groups etc:

Reward!
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People who are involved in developing ideas abt
their own work methods are more likely to:
• Understand objectives
• understand why necessary,
• encouraged to change their way
• See improvements

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 HTM Guide 1 Chapter 3
How to organise HTM
Anna Worm
October 3, 2012

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 C3 How to determine
technical requirements
3.1 summary of technical requirements for HTM
3.2 skill requirements
3.3 workload (time) requirements

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 3.1 summary of technical
requirements p34

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 3.1 summary of technical
requirements p34
• Providing technical advice
• Selection and procurement
• Training users and maintainers
• Maintenance and repair
• Decommissioning and disposal
• Managing staff
• Managing inventory
• Managing waste
• Managing workshops
• Record keeping
• Stock control
• Implementing safety protocols

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 Who should calculate the
needs?
Depends on centralised or decentralised system

The HTM team or senior technical staff should

study the needs. Then senior planners should
structure/design the organisation

Only works with sufficient resources

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 BioMedical Staffing plan for Rwanda
Decentralized
Ideal situation
1Msc in BME for strategy and
MoH politics . Strong relation with MMC.
Advocacy role. Evaluation role?

RBC
2 BSc with ~5yr hospital experience
for central procurement office.
I MSc ~10yr hospital experience
CAMERWA … RBC/MMC
director, 3 BSc ~5yr hospital
experience for MMC.

CHUB KMH
1 technical director in board (not
BME)
1 BSc ~3yr as BME director
3BMETs ~5yr to work on equipment
KFH CHUK etc

1BSc ~3yr hospital experience +

Northern Southern Western
Eastern Provence Kigali 4BMETs ~5yr (2 for provincial and 2
Provence Provence Provence
support district hospitals)

2 BMETs per hospital, also

~10 district ~10 district ~10 district ~10 district ~3 district
hospitals hospitals hospitals hospitals hospitals responsible for health centers
e.g. 1 senior 1 junior

~100 health ~100 health ~100 health ~100 health ~30 health
centers centers centers centers centers

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Technical Working Group September 26, 2012
 BioMedical Staffing plan for Rwanda
Centralized
Ideal situation

MoH

1Head of Division MSc ~10yr

1 director electronics BSc~5yr
12 specialists medical equipment BMET~3-5yr
1 director electro-mechanic BSc~5yr
RBC 12 specialist peripheral equipment BMET~3-5yr
1 director infra
6 civil and architecture specialists
1 project manager BSc~5yr
1 procurement specialist BSc~5yr
1 technical data analyst BSc~5yr
CAMERWA … RBC/MMC 1 MEMMS project manager BSC ~3yr
1 receptionist BSc~5yr
4 administrational staff (HR, $$, Log, AA)

-1 technical director in board -1 technical director in board

2 BMET, 1 senior 1 junior 43 District (not BME) 5 Provincial (not BME) 4 Referral
Hospital -BME director 1 BSc ~3yr Hospitals -BME director 1 BSc ~3yr Hospitals
-3BMETs ~5yr -3BMETs ~5yr

~450 health
centers hospitals

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Technical Working Group September 26, 2012
 3.2 skill requirements

For maintenance and repair we can identify 4 levels

of skills:
Level 1: basic maintenance tasks; cleaning filter
Level 2: medium level maintenance tasks: replacing
heating element autoclave
Level 3: high level maintenance tasks; troubleshoot
autoclave
Level 4: sophisticated level maintenance tasks;
repairing CT scanner
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 Other HTM skills

Level 1: keeping record of work, read manuals

Level 2: making work schedules, training other
staff, advising on procurement
Level 3: managing equipment database, financial
management, managing teams
Level 4: is normally private sector experts. You
don’t give your HTM work to a supplier!

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 3.2.2 determining your skill
requirements
• With the workshop we worked top down
• It’s also possible to work bottom up:
– Look at your inventory
– Decide work to be done (make list). Think of
common errors, PPM
– Assess other HTM needs
– Make a spreadsheet and link to level of skills

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 Workload requirements p47

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 Workload requirements p48

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 3.3.2 workload, hours

• This is a lot of work, and you don’t need to be

able to do this.
• Just try to understand the concept
• P50 example of health center
• P51 example district hospital

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 Work load hours conclusion

When you do an exercise like this you’ll see:

1. Only a small % of the time is spend on level 4
work
2. No need to have these people in the hospital
3. Service contracts are perfect
4. Many jobs can be done by technicians without
BMET degree
How much of your time do you spend on BMET
work?
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 Workload – staff numbers

• How many hours a day do we work in

Rwanda?
• How many days a year do we work?
• Travel to the job? E.g. health centers
• How long do we have to wait on spareparts?
• How much equipment do we have and what’s
the status?

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 Nice info p54

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 conclusion

Amount of work depends on:

1. Size of hospital
2. How busy it is  more wear and tear
3. Whether there is a workshop on site

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 Example questions

HTM has a relationship to everything that

happens in you health facility

A. True
B. False

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Which of the below mentions institutes is an
example of a public institute?
a. Butaro hospital
b. Siemens
c. CTB
d. Kibagabaga Hospital

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Which of the below mentions institutes is an
example of a private (for profit) institute?
a. Butaro hospital
b. Siemens
c. CTB
d. EWH

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Which of the below mentions institutes is an
example of a private (not for profit) institute?
a. Butaro hospital
b. Siemens
c. CTB
d. Kibagabaga Hospital

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• An NGO (Non Governmental Organisation) is
always a
A. private not for profit institute
B. Private for profit institute
C. Public institute
D. Mixed institute

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Which of the below mentions institutes is an
example of a mixed (private/public) institute?
a. Butaro hospital
b. Siemens
c. EWH
d. Kibagabaga Hospital

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The public and private sector together have the
responsibility to guarantee public health

A. true
B. false

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Because the government has the responsibility to
guarantee public health, they
A. Should create regulation, standards and policies
B. should check if these regulation, standards and
policies are well implemented
C. Should provide materials to be able to implement
these regulation, standards and policies
D. All of the above

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A service engineer (e.g. Oscar from Siemens)
Is a
a. Level 1
b. Level 2
c. Level 3
d. Level 4

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 The end!
Anna Worm
Sept 27

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 HTM Guide 1 Chapter 4
How to choose the model for
your HTM service
Anna Worm
October 9, 2012
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 Chapter 4. How to choose the model
for your HTM service

• different providers of HTM activities (Section

4.1)
• ways to incorporate HTM into the health
management system (Section 4.2).

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 4.1 different providers of
HTM activities
• 4.1.1 possible sources
– Individual in house skills
– Existing Technical Referral Networks in the Health
Sector
– Collaborative Arrangements
– Maintenance Services From Other Sectors
– Private Sector Companies and Individuals

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 Individual in house skills

That’s you!

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 Existing Technical Referral Networks in
the Health Sector

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 Collaborative Arrangements

• Not very much in Rwanda. More in other EAC

countries

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 Maintenance Services From Other
Sectors

Who’s responsible for

electricity, water and
telephone?

Do they have good

service?

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 Private Sector Companies and
Individuals

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 4.1.2 strategies to consider

Who’s running the health services? Normally it’s

easiest to control and run your services along the
same line
• government agencies, such as Ministries of Health
• non-government organizations, such as churches
or charities
• private sector companies, such as mines,
plantations, or health insurance companies
• a mixture of these organizations.
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 So:

if health service provision is totally dependent

on the government, it is advisable to include the
HTM Service in government services

if health service provision is run privately or by a

mixture of the private and public sector, it might
be more effective for your HTM Service to be
run privately.

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 p65

• first requirement for your HTM Service is to

have your own HTM Team at each health
facility and administrative level, whether a
workshop exists or not, to undertake technical
activities.
• The second requirement is for these in-house
teams to be linked in a referral network, which
will provide access to an increased range of
skills and support
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• third requirement for your HTM Service is to
ensure all HTM activities you require (as
identified in Section 3) take place, by using a
range of the different providers

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 4.2 incoperation HTM into
health management
• fourth requirement for your HTM Service is to
have the head of each HTM Team – the HTM
Manager – as a member of the relevant health
management team (at facility, district,
regional, or central level)

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• fifth requirement for the HTM Service is to establish
an HTM Working Group at each level (facility,
district, region, centre).
• This multi-disciplinary group should report to the
health management team, and be responsible for
reviewing the equipment situation and planning
equipment needs at that level. It should comprise all
types of stakeholders that have an important role to
play in HTM, such as administrative, medical,
finance, supplies, and technical personnel
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 p68

It is important not to decentralise responsibility

too quickly before the necessary management
skills are in place!

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 The end!
Anna Worm

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 HTM Guide 1 Chapter 5
How to develop organisation
structure
Anna Worm
October 10, 2012

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 C 5. organisational structure
for HTM service
5.1 relationship between health delivery system
and HTM service
5.2 Placement of staff at different levels
5.3 responsibilities of each level

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 5.1 recognise this?

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 We already know:

1. there are 4 levels of skills

2. At health centers there is mostly level 1 and 2 work
And The 5 requirements of c4:
3. HTM team per facility
4. Teams to be linked in referral network
5. All activities take place and are covered
6. Head of each team sit in Health mnmgt team
7. Multi disciplinary HTM work group to advise

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 5.2 placing staff at different
levels
1. Facility level
A+B Facilities without and with workshops
2. Zonal level
A+B Disctrict and regional/provincial level
3. Central or national level

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 Satff at 1A facilities without
workshop
• Make a small HTM team of people who are
suitable and interested (nurses, administrator,
store keeper) and give additional training
• Tasks:
– Oversee equipment
– Contact point for equipment and maintenance matters
– Responsible for finding solutions to problems
– Possible undertake maintenance themselves

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• So they cover all Level 1 work and communicate for any
other work

• Next to this HTM team we need an HTM Working Group,

include head of HTM team (the HTM manager) who
advises the Health management on equipment
issues/policies etc

• Sometimes too small to have a working group

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 Staff at 1B facilities with
workshop
• For Example District Hospital
• Level 1 and 2 are carried out by staff in smaller
hospitals
• Level 1, 2, 3 are carried out by staff in larger
hospitals
• HTM Manager has technical skills
• HTM Manager takes place in Management Team
and in HTM Working Group (reports to MT)

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 Staff at Zonal Level
• In Rwanda zonal level consists of:
– District hospitals
– Regional/provincial hospitals

• District level HTM team level 1 & 2. Looks after health

centers with no technical staff
• Basically only staff needed on district level:
– Equipment users with additional training
– Retrained technical staff
– Private sector artisans
– +back up from regional HTM team

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 Staff at Zonal level;
regional/provincial
• Staff in charge of level 3 jobs
• Supervises and supports district hospitals, so they
need technologists or even engineers
• Train the artisans and lower skilled technicians in
district hospitals so that
• Regional HTM team can focus on complex
equipment issues and supervision
• With help from central level
• Regional HTM Manager
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9-03-23 82
 Staff at central level

• Central HTM might have central workshop at

biggest hospital or separate site
• The engineers and engineering managers
main task is advising and supervision.
• They should be able to do all work level 1-3
• Responsible for contract management (skill
level 4) in collaboration with the central HTM
WG See p82

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 5.3 responsibilities at each
level
• Always, The HTM team and HTMWG:
– Advise management team on healthcare
technology issues
– Contact point for equipment problems
– Supervise private sector artisans
– Support and supervise equipment users
– Undertake maintenance
– Relate to higher level of HTM service

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 If there is a workshop in
district
• Skills level 1 & 2 work
• Keep stock of spare parts for maintenance
• Monitor and supervise work done by private
companies
• Undertake Quality Assurance and cost control
• Provide representation of HTM in planning
and budgeting of management team

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 Regional level

• Consultancy, management and technical advise

to districts
• Supervise and monitor
• Level 3 maintenance & repair skills
• Supervise and monitor private sector and artisans
• Advise on procurement and stock control of
accessories, spare parts, consumables for
standardized equipment

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 continues

• Centralized bulk purchasing of acc, cons, spare

parts, and working materials
• Organise training, contact training facilities
• Supervise HTM teams and HTMWG in lower
levels
• Implement policies
• Quality assurance and cost control
• Relate to central level
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 central/national level

• Advise MoH on questions of standardization

and setting up of standards
• Develop HTM policies
• Help introduce standardization in gov
equipment acquisition policy
• Supervise and support training facilities in the
country to improve training and control
quality

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 cont

• Liaise with key suppliers and encourage them

to set good quality service
• Collect and document technical information
• Liaise with other partners, like NGOs

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 And ofcourse:

• Support and supervise the regional and

referral hospitals
• Management and technical advise
• Level 3 skills in house
• Access to level 4 skills
• Set budgets and supervise
• Recruit staff
• Introduce standards in hospitals
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 The end!
Anna Worm

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 HTM Guide 1 Chapter 6
How to determine human
resources required
Anna Worm
October 10, 2012

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 Chapter 6

6.1 types of staff

6.2 number of staff
6.3 establishment posts and career
progression
6.4 terms and conditions of employment

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 6.1 types of staff

• Equipment users
• Crafts people, artisans, tachnicains
• Health service technologists and engineers
• HTM Managers
• Support staff

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 Equipment users
• Important role in ensuring that the HTM system
runs well
– First to detect problems & help to avoid problems
through correct use
– With the right training, perform level 1 skills
– Some already had training (lab, laundry) need refresher
courses?

– Other HTM activities: record keeping, stock control

– Need supervision of HTM team for HTM activities
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 Equipment users

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 Craftspeople, artisans,
technicians
• Craftspeople: skilled person who works with
their hands like plumbers, carpenters or
electricians
– Informal training: handyman
– Trade test holders: artisans
• Technician: skilled in a craft such as
mechanics, refrigeration, electricity with
certificate or diploma

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• Basic maintenance tasks
• Rwanda nationally recognized trade testing
schemes for artisans?

• Often desired to have ‘Polyvalent’ technicians,

someone with many skills in many disciplines.

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 (re)training

• You should train these people to do some HTM

activities
– Basic Training; e.g. electricity, mechanics
– On the job training; e.g. orient staff on particular HTM
activities, safety, stock control, updating inventories
– Skill development; tailor made, short term training
courses at vocational training institutes
• With this training handymen, artisans and
technicains can do most of level 1 & 2 skills

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 Technologist and engineer

• Technologist: highly skilled in a craft such as

refrigeration, electronics, electricity with a
technical (advanced) diploma. Level 3 skills
• Engineer: highly skilled in a craft such as
refrigeration, electronics, electricity with a
bachelors degree, controlling, designing, and
building equipment, develop original ideas.
Level 3 and 4 skills, Managers

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 HTM Managers

• Head of HTM team, taking place in HTM

Working Group
– In District Hospital: most senior technical person,
learn management skills on the job
– Regional and central HTM Managers: engineers
with formal management training and work
experience (more regions?)
– National HTM Manager should have skills in
human relations and bureaucracies

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 Support staff

You also need support staff like:

• Clerks
• Secretaries
• Cleaners
• Drivers
• Store personnel

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 6.2 numbers

• You need an HTM team with sufficient

technical staff with the necessary
qualifications, otherwise you be over
stretched
• No rules for the numbers, have to make
assumptions
• Guidelines in p98

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9-03-23 105
 Staff development

• It’s possible these people are not yet present

in your country, so:
– You send people for training
– You train people (start a school)
– You let juniors work with seniors
– You identify the most qualified people available

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9-03-23 107
 6.3 establish posts

• Create establishment posts for the HTM team

members.
– Means that the jobs exist in the organogram/org
chart
– Means that people can be recruited for those
posts
– Means that salaries are defined
– Helps with career progression
In Rwanda; who’s responsible for Human Resources?

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• With an organisational chart the reporting structure
becomes clear
• If technical staff is not well represented in
management bodies, it will be very difficult to do
their jobs well/be effective
•

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 Career development

• Ideally the HTM Service will be able to

develop strategies to:
– Motivate their staff
– Evaluate staff performance
– Use staff appraisal as positive tool
– Discipline staff when necessary

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• Depends on HR policies and procedures

• Enable ongoing development of technical skills

• Respond to rapid changes in equipment
design
• Provide possibility of career progression

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 p103

• Central level needs to work out training

planning and financing, scholarships, etc
• Bonding conditions
• Training should be recognized

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 6.4 terms and conditions of
employment
• You need money and take care ofavailability of
resources! Otherwise staff will get frustrated
and demoralized

• Terms and conditions: salaries, holidays,

illness, over time, insurance, …
• Or even: training, accommodation,
transportation

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 Availability of resources

• Workshop
• Tools
• Supplies if maintenance materials and
spareparts
• Office space and ways to do record keeping
• Supplies of stationary
• Techniical reference material and access to
information
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 HTM Guide 1 Chapter 7
How to set yourself goals and
monitor progress
Anna Worm
October 23, 2012

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7.1 planning process (setting goals)
7.2 review process (monitoring process)
7.3 gather data

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Planning and reviewing to evaluate your
performance (quality of your work) and the
performance of the system
= Quality Management
for client satisfaction
for cost efficiency
for compliance with laws

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 Quality management

• Management team approach

• Supervision and evaluation
• Participative leadership
• Methods of encouraging staff
• Individual responsibility and initiative
• Community participation
• Control measures: performance measures

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 Who’s responsible?

On all levels!!
Management teams, HTM teams,
HTM working Groups should
plan and
monitor progress
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 7.1 setting goals

• Opportunity for the members of each team or

group to agree on a range of activities they
want to implement, because they believe the
activities will imporve:
– Their working environment
– Their performance
– The service they provide

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 Annual planning cycle
Review past
performance,
problems, needs

Identifies solutions
Monitors
and sets specific
implementation goals for the year

Prepares an annual
action plan for
delivering
improvements next year

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 Setting goals

1. Targets
2. Recommendations
3. Longer term objectives

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 targets

• Targets guide the work of all groups involved

during the following year
• Targets should be SMART
– Specific what and who
– Measurable easy to measure
– Achievable possible with existing resources
– Relevant solve a priority
– Time-bound when should it be completed

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 P 259
target By whom How to How to Time
measure achieve table
Actions Name(s) How Resources Time
agreed in of progress required fram,
order of responsib will be start and
priority le measured completio
persons n

9-03-23 124 124

 recommendations

• Sometimes you can’t achieve something

without extra money, extra staff, or extra
supplies. Make a recommendation

• Specifically addressed to someone

• Reasonable keep it realistic
• Essential no easier
alternative
9-03-23 125 125
 Longer term objectives

• Some things can not be solved in one year.

• Try to chop it up in smaller pieces and monitor

the progress over several years

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 How to measure goals

• You need indicators to measure and you need

baseline data (not easy in developing
countries)

• Box 33 p111

• Figure 13 p112

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9-03-23 128
 7.2 monitoring progress

• Monitoring progress against goals is one of the

best ways that staff, managers and health service
provides can judge their performance, and
identify needs and problems.

• With this you will be able to give feedback to all

stakeholders. Learn from your actions!

• Review with all stakeholders/the whole team

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• Go through examples p 114-115-116-117

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 7.3 gathering data
• MIMMS/CMMS ideal tool to gather data!
• How many interventions this year?
• Which percentage of equipment is in service
• How big is the lack of spare parts?
• How long do you normally wait for spareparts
• Inventory!

• The are baseline data!!

• Look at the work of Duke
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 Citations

All images and texts clippings from:

• How to Organize: How to Manage Vol 1, Lenel
et. al., (Ziken International: 2005). Retrieved
from:
http://library.ewh.org/greenstone/collect/BM
ETDigitalLibrary/index/assoc/HASH019f.dir/gui
de%201%20How%20to%
20Organize.pdf

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 The end!
Anna Worm

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