Alternative equipment maintenance (AEM) is supposed to make the lives of healthcare technology management (HTM) professionals easier. In hospitals, where tens of thousands of devices need to be monitored and maintained, AEM strategies help busy staff save time and focus on what matters: ensuring the efficacy of devices and safety of patients. However, therein lies the rub with adapting any AEM strategy: In a busy hospital environment with countless devices, when will managers have time to build a new strategy from the ground up, let alone implement it?

At a Glance


Clinical engineering department at ChristianaCare


Newark, DE


Three hospitals and one free-standing emergency department


35 individuals, including 12 biomedical engineers, nine imaging technicians, four inspectors, three surgical equipment service technicians, one lab service technician, and one information technology/clinical engineering technician

Blake Collins, director of clinical engineering at ChristianaCare in Newark, DE, pulled off just that. The secret, he said, is to “shamelessly borrow” great ideas and, with help from the right people, make them shine even brighter.


Collins has been fascinated by alternative maintenance strategies for a long time.

“If you remember, airplanes were dropping out of the sky in the 1960s and -70s. It was alarming! So, airlines created what is called reliability centered maintenance,” he said.

In the early 1960s, airlines and the Federal Aviation Administration launched an intensive assessment of aircraft servicing practices. They discovered that many of the “lifetimes” for parts that had been outlined by aircraft manufacturers and their design engineers were wildly inaccurate. It was also suspected that much of the regularly scheduled maintenance that was being done at the time was causing more harm than good. The result was a transition to less frequent but far more informed and effective maintenance. Suddenly, far fewer commercial jets had problems.

This real-world lesson stuck with Collins, who saw parallels between the maintenance practices of yesteryear's airlines and the hospital HTM practices of today.

“A good example is an oto/ophthalmoscope,” said Collins. “There's a basic electrical safety check, which was pushed by National Fire Protection Association 99, that everyone does to ensure you don't get shocked when you pick up the device. But the thing is, there's no need to continue doing that kind of maintenance anymore because advancing technology has eliminated that risk.”

Collins pointed out that, although the result is not as dramatic as planes falling from the sky, unnecessary or excessive maintenance on a medical device takes up time and creates new risk. Every time the device is taken apart for routine maintenance, there is a risk that a part will fail or a mistake will be made.

Thankfully, risk assessment is what AEM is all about. Instead of relying solely on a manufacturer's recommendations, AEM strategies consider a hospital's unique risk factors before choosing to follow those recommendations or change the strategy for how a device is maintained.

“With enough data, you can account for your own inventory, your own environment, and your own maintenance-related failures to determine the risks you take with each device. Based on that, you come up with your unique maintenance schedules,” Collins said.

Of course, this is easier said than done. Another Collins, National Institutes of Health Director Francis Collins, pointed out that thanks to modern technologies, “we're all struggling with the wonderful problem of having too much data.”1 

When data from tens of thousands of medical devices are being generated every day, how do you distinguish the meaningful from the noise? How do you account for it all?


“I can't take credit for this part of the idea at all,” said Collins, laughing. “I went with my team to a conference sponsored by AAMI where Matt Baretich and Frank Painter were talking about AEM. Matt had recently published this new guideline, and he and Frank were answering all the questions we had been struggling with.”

Baretich, president of Baretich Engineering, has been consulting on HTM-related matters for more than three decades. Painter, a retired program director and adjunct professor at the University of Connecticut, has likewise spent decades focusing on improving the education and workflow of HTM professionals. Painter received the AAMI Foundation & ACCE's Robert L. Morris Humanitarian Award earlier this year.2  The duo spent the greater portion of 2019 running AEM workshops to help trepidatious directors like Collins make sense of AEM factors and terminology.

“When I first started thinking about AEM programs a few years ago, I was—to put it bluntly—not impressed,” Baretich, recently admitted in an AAMI blog post.3 

When he began researching AEM, Baretich quickly discovered several different interpretations for what even the acronym AEM stood for. It was a bad first impression for an already confusing topic.

“When Steve Campbell, AAMI's chief operating officer, asked me to write what became the AEM Program Guide, I agreed because I like the idea of trying to make sense out of nonsense,” Baretich said. “Then I fell in love. Not head-over-heels in love, but step by step. … I fell in love with the idea that sound AEM principles, carefully considered, really do give us tools for evidence-based maintenance—that holy grail we've been seeking lo these many years.”

After learning about it, the AEM Program Guide4  became the foundation for Collins' personal HTM holy grail.

“Matt's guide is a simple form that breaks down the whole process,” said Collins. “It frames this concept of risk assessment into a series of check boxes and a quick mathematical formula. It's pretty incredible!”

However, even with the mysteries of AEM solved, Collins and his team were still in a bind. ChristianaCare is no small entity. It consists of three hospitals and a free-standing emergency department. Collins said that he and his team manage nearly 40,000 medical devices, “and that's just a ballpark figure. We have new devices being added fairly frequently.”

“With enough data, you can account for your own inventory, your own environment, and your own maintenance-related failures to determine the risks you take with each device. Based on that, you come up with your unique maintenance schedules.”

Blake Collins, director of clinical engineering at ChristianaCare

To adapt to an AEM program, Collins and his team had to come up with classes and subclasses for every piece of equipment. Likewise, they had to repeatedly plug years of data points into Baretich's formula. They had a plan, which was an enormous step forward, but they still expected it to be many months before they would have a fully optimized AEM strategy ready for all their eligible equipment.

“We had long meetings lasting a couple of hours scheduled every week between all the supervisors and managers, just to sort through all our department's maintenance reports,” Collins said.

They were preparing for a long haul—the better part of a year. And yet, only a couple of months later, Collins and his team had a fully automated AEM system at their disposal.

A watershed moment occurred when Collins was thinking about a different workplace update.

“Timing and opportunity played a part,” Collins said. “We were in the middle of updating our computerized maintenance management system (CMMS) database when I thought, ‘Why don't I see if we can build a new risk system with them? Since we're already gathering all this data and defining asset types or model, maybe I can cascade all of that down and put it into Matt's formula with the push of a button.'”

Kyle Holetz, an advisory solution consultant for Nuvolo, was helping ChristianaCare set up its new CMMS when Collins pitched his idea.

“At first, I thought it may be a bit too much to manage as simply as Blake made it seem,” Holetz admitted. “But we were able to break each element of the AEM decision tree down into bite-sized pieces and brought them into the product in a connected and streamlined fashion.”

Holetz realized that Collins wasn't trying to reinvent the wheel. With Collins' preexisting close codes (representing the results of finished maintenance), he and the Christian-aCare team were able to prioritize the kinds of AEM decision making that could fit snugly into the configurations of Nuvolo's out-of-the-box workplace platform.

“This let us think creatively about the problem and how to operate an AEM program from the tool, while avoiding costly and hard-to-maintain custom development,” Holetz said.

The result was an extremely streamlined way to keep all of the data necessary for evidence-based maintenance decisions up to date at regular intervals—and all with the push of a button. Heidi Horn, vice president for global enablement-healthcare at Nuvolo, was particularly impressed.

“By utilizing AAMI's AEM Program Guide as an accepted process and automating the required analysis within Nuvolo, Christian-aCare was able to implement a fully compliant AEM program that requires minimal administrative work to manage,” she said. “Nuvolo also thought it was a great initiative, so with some enhancements, we've now made this functionality core in our product so that our other clients can more easily implement an AEM program.”

Results and Conclusion

For Collins, he and his team finally have the AEM “holy grail” others dream about.

“I was doing some of the legwork for the manual strategy, and I've got to tell you, it was painful,” said John Learish, a manager in the clinical engineering department at Christian-aCare. “Going through countless work orders and individually trying to understand them and categorize them was immensely time consuming. Now, it's just the click of a button and you're off and running. Then, we can monitor the decisions being made based off the system's risk scores.”

That, of course, is still an important duty. For all his love of AEM, Collins was quick to point out that it's not always appropriate for a piece of hardware. Imaging radiology devices, for instance, have strict regulations in place for how they are safely maintained. Collins' team must manually exempt these devices from being placed on an AEM schedule.

The time they're saving has also allowed the ChristianaCare HTM staff to stay at the top of their game. Lisa Carr, a supervisor in the clinical engineering department, spoke of a recent merger with Union Hospital in Elkton, MD, as a prime example of this.

“When you take a new building with new staff into a system, they have their own way of doing things. We have to translate what they're doing into our system before we can optimize their maintenance schedules,” she explained. “With everything automated, that process has become much more streamlined.”

Instead of requiring Union's staff to slowly scrub through years of data, manually making sense of their old reports in the lens of an unfamiliar AEM formula, Collins' staff was able to extract the data that were needed. They fed it wholesale into the new automated system for risk evaluation and maintenance scheduling.

“Suddenly, the new staff is facing fewer time constraints. That frees them up for training and improved performance,” said Carr. “That's how we're putting value back into the tank.”

“People always like to say that nurses have to work at the top of their license,” said Collins. “I want my folks to work at the top of their skill set, their certification, and really drive improvement for patients, physicians, nurses ... everyone.”


Francis Collins at TEDMED 2012
. Accessed Aug. 5, 2020.
AAMI Honors 2020 award and scholarship winners
Falling in love with AEM
AEM Program Guide: Alternative PM for Patient Safety.
Arlington, VA
Association for the Advancement of Medical Instrumentation

Author notes

Brian Stallard is the media relations manager at AAMI. Email: