Scott James used to dread putting together his quarterly safety report. As supervisor of the clinical engineering department at McKay-Dee Hospital doing double duty as the hospital's safety officer, he found that getting timely data for the report was a struggle. Finally, tired of beating on his staff to complete reports, James came up with an innovative solution: he made them responsible for developing a monthly reporting system on preventive maintenance (PM) inspections and other key measures. Five years later, the monthly reporting process is one of the keys to his department's success.


“Clinical engineering staff members weren't getting their data to me on time,” says James. “A last-minute scramble to meet the preventive maintenance goal of a 95% completion rate would make reports late.”

Other things were bothering James, as well. While the department held regular staff meetings, staff members rarely did much talking. Contention among the staff made things tense. When they had too much or not enough work to do, staff would come to James rather than talking directly to each other. James wanted to find a way to encourage staff to complete their PMs on time without the last-minute scramble, open up during meetings, feel appreciated, and work together more efficiently.


James decided to shift responsibility for reporting to the staff, giving them ownership of the process. “I wanted the staff to feel like they're part of the whole process of reporting,” says James. “I wanted to open a dialogue between the staff and myself, and to make sure that the staff feels like they're appreciated.”

As a starting point, he gave them a template of the report he gave to the safety committee. They sat down as a group and designed individual monthly staff reports that would roll up into a department report, and feed into the hospital's safety report.

“Initially, the staff was not thrilled with the idea,” says James. “They don't like to talk about themselves. But I wanted them to receive recognition for the work they were doing, from me as their manager, and also from their peers.”

The individual monthly reports include several key performance measures, including:

  • Inventory changes and the reasons behind them,

  • Preventive maintenance totals and completion rates,

  • Service repair totals and time spent, including details on “no fault founds,” “operator errors,” and abuse or damage costs,

  • Total PM and service repair time presented as a percentage of total hours available during the month, to be benchmarked against average experience, and

  • Summaries of medical device recalls, high risk failures, and medical device reports completed.

The reporting process doesn't cost the department much time, James says. He estimates that each staff member spends a half-hour a month preparing his or her report, and 10 minutes during the staff meeting presenting the data.

Check Points

✓Monthly reports feature key performance measures, such as inventory changes, PM rates and repair time.

✓An Excel spreadsheet automates the process of reporting.

One technician created an Excel spreadsheet to automate the process of reporting. Each staff member generates reports using the department's equipment management software and enters that data into the Excel spreadsheet, which automatically generates a PowerPoint presentation for use during the staff meeting. The presentations are projected during the meeting and each staff member takes turns delivering their reports. Meetings are attended by James, his supervisor, and occasionally members from the hospital's senior management or other regions of the healthcare system.

“The presenter may be challenged by peers or management and must have the knowledge to back up what is reported,” says James. “Staff can compare data as it is presented and feel better about themselves and what they are doing. More importantly, they learn about what challenges the other team members are facing.”

Once the results have been reviewed by the group, James rolls each staff member's individual report into the CE shop monthly report. This shop report is shared with senior hospital management, and helps the clinical engineering department comply with standards set by local, state, JCAHO, and other regulatory agencies. James also uses the data to prepare and present reports to the safety committee.


James says that one of the greatest benefits of this process has been the increased communication between staff members. Hearing from each other on a regular basis helped level the playing field in the department and eliminate contention. “I want the staff to talk to each other, to feel an obligation to help each other,” he says. “Now they ask for help when they need it or offer help when they're not busy, without going through me as their manager.”

“While we've always met the 95% PM completion threshold, I no longer have to monitor that it is being done, because the staff cannot run their report until the work is completed,” says James. “Before, I would run a query to see where we were, and then go talk to those that had not yet met the threshold, to get a timeline and schedule set for completion. Today we stress that they are empowered and responsible for meeting the guidelines that they themselves had set and agreed to.”

The experience of presenting their own reports at staff meetings has improved the technicians' speaking skills, James says. It's also helped them recognize one another and realize the work that they each do. “For the staff, taking on additional work, special projects, and volunteer efforts becomes a challenge that they will be able to present to the team.”

Adam Drew, CBET, a clinical engineering technician in James' group, agrees. “Before, everyone did their own thing. We didn't know what others were doing. This process lets everyone know what you're up to.”

Dan Miller, who runs a much smaller clinical engineering shop at an affiliated hospital, has imitated some aspects of James' reporting process. “While we have a very different working environment, it has been helpful to make our staff responsible for their own compliance with PMs and their own workload,” he says. “We use a scaled-down version of this process and it's been effective.”

James also found that making staff responsible for their own reports has improved data accuracy. In one of the early reporting meetings, a staff member presented data that didn't add up. His colleagues asked him to go back and review the numbers. “It was a great learning experience for all of them,” says James. “They see the importance of accurate data entry, and know that they are accountable for it.” James is sure of the integrity of the data in his shop report because it has already been rigorously reviewed by his whole department.

Recently, James has used the accurate, timely data his department now creates on a regular basis to build the case for adding another staff member to his department. He also points out that the reporting process helps him as a manager recognize excellence among his staff.

He is proud of the process his staff has developed. “We have enhanced the mutual respect among the staff, increased the open communication, and guaranteed the participation of everyone during every meeting. Since implementation, no staff member has failed to meet the requirements they themselves have established.”

Subject: McKay-Dee Hospital Center

Location: Ogden, UT

Size: 317-bed, full-service tertiary and acute care hospital with 17 affiliated clinics, part of the 21-hospital Intermountain Healthcare System

Staff: In-house clinical engineering department includes six staff members

Subject: McKay-Dee Hospital Center

Location: Ogden, UT

Size: 317-bed, full-service tertiary and acute care hospital with 17 affiliated clinics, part of the 21-hospital Intermountain Healthcare System

Staff: In-house clinical engineering department includes six staff members

Author notes

Jill S. Williams is a freelance writer who lives in Herndon, VA.