UNIT 4 EQUIPMENT MANAGEMENT - MAINTENANCE, REPAIR AND DISPOSAL

Structure Objectives Introduction Definition Existing Situation Maintenance and Repair Facilities 4.4.1 Need for Repair and Maintenance Centre 4.4.2 Outline of the Plan of Biomedical Engineering Operations for Maintenance 4.4.3 Maintenance and Repairs Condemnation and Disposal Let Us Sum Up Answers to Check Your Progress

4.0 OBJECTIVES After studying this unit, you should be able to:

discuss the existing situation of hospital equipment; a describe the essential features of timely maintenance and repair procedures; and a mscuss condemnation (discard policy) and disposal of equipment.

4.1 INTRODUCTION Hospital equipment are based on sophisticated and high cost technology involving huge- funds. An average hospital administrator/clinician'is least aware about the complexities and technicalities lnvolved in the right selection, procurement, specifications, installation, utilisation, maintenance and repair of these equipment. The situation is even worse wheh it comes to condemnation and disposal of hospital equipment. As a result of the same, the hospitals end up procuring equipment which may not be the best. Besides, we also end up paying more. The aggressive marketing by the equipment suppliers and agents may lead to various malpractices.

Maintenance and repair of these sophisticated equipment becomes the biggest casualty. Most of the hospitals are ill equipped for any organised and systematic maintenance and repair facility. In fact, even the basic facilities for rnaintenance and repair of hospital equipment are non-existent. This not only leads to long down time but also gross under utilisation and inefficiency, thus affecting the patient care adversely. Some surveys and studies have indicated that non-funcional equipment is a major contributory factor for wastefbl expenditure in hospitals.

Optimum utilisation of equipment requires that the equipment remain in good working conditions for most of their life. Timely maintenance and repair of the hospital equipment, therefore, assumes vital importance. This unit will offer some guidelines on this complex probiem and also on the condemnation and disposal of the equipment.

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4.2 DEFINITION Management, per se, is defined as the purposeful and effective utilisation of resources for accomplishing a pre-determined objective. Extending the same to equipment management, it would mean that we not only ensure greater utilisation of the hospital equipment, but also maximise their uptime and ensure the reliability, validity, efficiency and safety in their day to day functioning.

Essentials of Logistics Equipment Manigeme 4.3 EXISTING SITUATION

The existing situation of the hospital equipment particularly their maintenance and repair is rather gloomy. Hospitals seldom have 50-60 per cent equipment in usable conditions. According to a survey by the Department of Electronics (DOE), Government of India, hightech medical equipment worth Rs. 50 crore are lying idle in government hospitals in Delhi and nine other States due to lack of spares, and non-availability of funds.

The survey was done in 132 government hospitals in nine states-Delhi, Madhya Pradesh, Orissa, Bihar, Punjab, Uttar Pradesh, Maharashtra, Assam, Haryana, TamilNadu. It disclosed that electro-medical equipment worth 48.61 crore out of the total cost of 180.58 crore were not in working conditions. As the survey did not cover all hospitals, except in Punjab, it extrapolated the result to conclude that equipment worth at least Rs. 50 crore may not be in working condition in these states. While presenting the findings of the survey, the then Secretary, Electronics identified some of the reasons for the non-working conditions as a) lack of maintenance policy by the hospitals and lack of provision of budget on this account, b) the non-availability of technical documents for installation, maintenance and safety since these equipment were either received as donations from various developed nations or purchased without having adequate purchase policies. The survey also found that lack of availability of spare parts, particularly for imported equipment, was also creating problems. In addition, the support for maintenance of such equipment was also grossly inadequate. "As imported equipment were also being handled through co'mission agents and local manufacturers had limited capabilities of providing after-sale services beyond the warranty period particularly in remote locations", the report said.

Table 4.1: Nation-wide Survey of Status of Medical Equipment

The most common factors contributing to this wastage are:

Purhase of sophisticated equipment which is under-utilised or never used due to lack of technical expertise to maintain and use it.

Reduced lifetime of equipment due to mshandling and lack of maintenance and repau.

Additional purchases of accessories, extra spares and modification to facilities initially unforeseen due to lack of expertise in choosing appropriate equipment.

Estimated wastage 20-24 per cent

Estimated to affect 50-60 pc ,,o:of equipment value.

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Estimated to affect 10-30 per cent of equipment value.

and extra workload on limited cot~petent

e in repairs and lack of

Check Your Progress 1

What were the important findings of the survey conducted by DOE? .......................... __.l ........................................................... ............................................................................. ....................................................................................................................................................................

4.4 MAINTENANCE AND REPAIR FACILITIES Once a hospital has been planned and provided with required equipment, there comes the need to manage/maintain them scientifically so that the quality service is provided to patients on a continued basis. .

There is a large variety and diversity of equipment in a hospital. The nature and type of equipment vary in different hi-techfmid-tech hospitals depending upon the competence, sue, type of hospital. To illustrate, the range varies from a simple B.P. apparatus to highly sophisticated diagnostic and therapeutic gadgets, laboratory equipment, imaging equipment, anaethesia, O.T. equipment etc. This is only to name a few, hospital equipment also include those used in various other services viz., CSSD, mechanised laundry, kitchen, stores, and housekeeping.

In order to provide and establish efficient equipment maintenance service in hospitals, it is important that a written plan be developed, right from procurement and up to disposal of equipment. More so, for the reasons that the equipment are based on high cost and sophsticated technology.

4.4.1 Need for Repair and Maintenance Centre In order to mitigate the long standing problems of hospital equipment maintenance (preventive and breakdown) which results in non-utilisation or under-utilisation of vast national resources thereby adversely affecting quality of health care delivery. Department of Electronics, Government of India has started a national programme through decentralised repair and maintenance centres in 12 States of the country. These centres are joint venture of DEO with State Electronics Corporations. At present, there are 13 such Electro Medical Maintenance (EMM) Centres in the country. Objectives The objectives of setting up of these centres are: - to render repair and maintenance facility to hospitals, medical institutions and

dispensaries in the State; - to provide consultancy service to hospitals and medical institut~ons on electro-medical

equipment in the area oQre-installation and operation of equipment; and ,

- to conduct training course for medical and paramedical personnel.

It was proposed to establish regional workshops on equipment maintenance in 6th Five Year Plan. First regional workshop was established at Medical College, Cuttack immediately after the 6tb Five Year Plan.

Equipines~t Manngenrent- Maintenance, Repnir

and Disposal

Evserttials o f Logist ics a n d E q u i p m e n t M a n a g e m e n t

4.4.2 Outline of the Plan of Biomedical Engineering Operations for Maintenance

There are enormous variations between hospitals according to different climate, location, the States size, the form of care provided and the type of patients seeking care. Still there are number of parameters common to almost every institution. In order to provide efficient maintenance services, it is important to develop a routine plan and guidelines. This plan should focus the attention on the common elements in the organisation, related to procurement and maintenance of the medical equipment in order to optirnise and get the most out of the limited amount of money and other scarce resources. In planning of the biomedical engineering equipment for use in health institutions the elements involved are discussed below:

a) Requirement of equipment: At the every outset a realistic estimation of the requirement of equipment for different medical institutions would be the most important step for all future activities related to equipment. This exercise has not only to identify the bio- medical equipment, but also assess the quantity in which they are required based on estimated patient load needing the equipment. Give the specification of the same and also the sources of procurement of these equipment. Secondly, the bed strength of the hospital and type and range of services provided in the hospital would be other guiding factors for assessing requirements.

b) Workload in terms of patients: The need of these equipment would be directly related to the workload i.e. inpatients, outpatients, those attending the emergency services and Intensive care units. The workload of patients would also help in assessing the requirement of the equipment m the other diagnostic, therapeutic, supportive and ancillary services.

C ) Budget The hospital and health care equipment are based on high-tech and ' are expensive. The meagre resources should take into account not only the purchase of equipment but its maintenance as well. Often ad-hoc grantstdonor agency grants are used for the purpose without taking into account the maintenance which causes problem later on. Every hospital should have a part of budget allocated for maintenance of equipment.

d) Preventive maintenance: The preventive maintenance is an important aspect of equipment management. It is essential for efficient and effective functioning of equipment as well for increasing the life of equipment. As regards the preventive maintenance is concerned, care should be taken that new equ~pment are under warranty for a sufficient period to test its performance. Adequate steps should be taken for preventive maintenance of equipment while outlining the plan for equipment operations for maintenance.

4.4.3 Maintenance and Repairs 4

Maintenance as yell as repairs are the two terms which are closely relatcd to each other and also used combinedly. Broadly classifying, the equipment maintenance and repairs would ~nclude the following: 1) Preventive Maintenance 2) Master maintenance plan 3) Repair of equipment a) As regarding the preventive maintenance of all expensive and sophisticated equipment

is concerned, care should be taken that the new equipment/machines are under warranty for a sufficient period to test its performance. The essential spares should be obtained along with the equipment as a part of the configuration and the integral part of the purchase contract, to last for sufficiently long period say 5- 10 years. The equipment should also be under service contract after 5 years also. Some penalty clause may be included in the purchase contract to this effect. For electronic equipmen1 necessary safeguards should be carefully observed which may include: - Voltage stabilizers, built in or othewise

In high priority areas like operation theatre, ICU, ICCU, diagnostic servlces etc. voltage stabilization should be done areawise preferably through an uninterrupted power supply (UPS) system.

- Separate line should be laid where voltage fluctuation is considerable

- Automatic switchover for emergency should bt provided with a generator. The requirements of electric1 , water, spade and atmospheric conditions should also be taken into account. For exa ,I? ple, for certam life saving equipment, a three-phase supply of electricity should be provided. Such equipment should also be protected from the vagaries of weather in order to minimize the breakdown and also enhance the life of equipment.

b) As regard the routine equipmentJinstrurnents such as sphygmomanometer, suction apparatus, centrifuges, mcubator, hot air ovens, ECG machine, etc. the maintenance cell (workshop) should have the required fqcilities in term of skilled and trained manpower, adequate spares and infrastructural facilities.

c) The preventive maintenance will give rise to the following advantages: - Reduction in down-time of the equipment - Safety of equipment - Effective and economic functioning - Increased life of the equipment

The advantages of preventive maintenance can best be illustrated by following two examples.

Illustration I The illustrat~on is presented from the experience of a medium size trust hospital in Gujarat. Recently, because of non-functioning of simple equipment in the pathology department some very important investigation could not be carried out in time. Following a number of surgical operations a few specimens/excised tissues were sent to laboratory for histopathological reports. The histopathological test could not be carried out for the reasons that the microtome, an equipment which cuts out thin slides of excised tissue matter for microscopial examination, was not in a working order. It was found to be rusted and its blades could not be opened due to the rusting. This happened because this microtome was '

not washed, cleaned and oiled after its last use. This resulted in delay in reporting and more costs for getting reports from outside.

Nustration I1 In another case the ultrasonography used in various departments for getting the image of different body organs could not be used for want of simple maintenance. The transducer (the rounded portion which is placed on the body) of this sonography equipment is always applied on the vairous parts of the body with the help of lubricating jelly. After a couple of months use this equipment stopped working. The reason was that the jelly which was repeatedly applied on the transducer before each use, formed a thick coating all around its surface which transmits the ultrasounds into thk human body for getting an image (resolution) of that pmcular organ for helping in diagnosing the problem. This thick coating interfered with this transmission and gave a very poor resolution. All this could have been prevented if after each use the jelly was cleaned off the transducer with the help of simple normal saline solution and dried with muslin cloth.

Check Your Progress 2

1) What are the four elements of the Plan of Bio-medical engineering operations for maintenance?

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2) Discuss advantages of preventive maintenance? ...........................................................................................................................................................

.. " ... "....... y........... ....... ' ..................................................................................................................

3) What w p t wrong with the Ultrasonography equipment? ...........................................................................................................................................................

quipm M

lent aint

Manrgement- enance, Repair

and Disposal

E \ s c ~ ~ t i a l s of Logistics Equipment Manayemc

Master Maintenance Plan

The master maintenance plan should be drawn in consideration of the load of the use1 departments including the following aspects of equipment maintenance and repairs: - , Recruitment of skilled manpower - Ananging regular training programmes on maintenance and repairs of equipment of the

technicians and other concerned personnel - Establishhg a bank of spare parts and crucial components - Establishing detailed records of the purchase, procurement and maintenance of

equipment - Periodic checks and repairs - Monitoring of the annual maintenance contract for expensive and sophisticated

equipment - Developing a 'maintenance cell' for maintenance and repair - Establishing a nucleus of communication between this cell and the supplier of

equipment - Follow up of the maintenance and repair services.

Repair of Equipment It is necessary to have basic in-house facilities for the routine repairs of the common equipment. It has been generally seen that many a times the hospital equipment are not working for want of simple repairs, such as faulty switches and plugs, loose wiring and sparking, fuse problems, lack of spare parts, lack of training in handling the sophisticated equipment and many other factors.

The in-house repair facility should be organized keeping the following in mind: - Head of maintenance cell (workshop) should be completely accountable and

responsible for the task under his control. - The availability of skilled manpower for the repairs. - Provision for a bank of spare parts and crucial components. - All technicians and other workers handling important equipment should be provided

with a separate tool kit consisting of a4 essential items required for repairs and maintenance.

The repair proceduresinhst underline the following: a) ' Repairing and servicing of sophisticated equipment only under the guidance of a

skilled person.

b) This cell should also evolve and develop the procedures for requisitioning repair services as and when a particular equipment breaks-down or stops working.

c) If in-house facilities cannot repair a particular equipment, then the procedure for its repair from outside agencies should also be developed.

4) The downtime of each equipment should be specified and adhered to by the rnaintenince cell.

e) The technical personnel involved should be trained either by the established institutions or by the company supplying those equipment.

Staff and Organisational Structure The staff and organisational structure for equipment management would vary depending on the nature, type size of a hospital. However, for a large district hospital following staff may be recommended:

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1) A J k Engineer (El&cal/MeCli&ical) 2) Two Technologists (ElectricaVMechanical) 3) . Engineering Aids

The organisational structure is given below:

Hospital Superintendent I

Head - Maintenance Cell , (Junior y) ,

Technologists Electrical&fechanical

Engineering Aids

In large hospital the staff working in the maintenance cell would be the integral part of the hospital engineering services which should be under the direct supervision of the designated medical officer or the hospital superintendent.

4.5 CONDEMNATION AND DISPOSAL It becomes imperative that every hospital must develop proper maintenance and repair facilities for hospital equipment in the manner suggested above to minimize the periodic breakdowns as well as increase the up time of the equipment to its maximum. However, over a period certain equipment either become obsolete or beyond economic repair and occupy precious space in the respectwe departments or in the hospital on the whole. These equipment need to be condemned and disposed off at regular intervals.

Continuous use alid exploitation of equipment and various other factors i ~ ~ l u d i n g environment cause its progressive wear and tear and finally render it unserviceable. Lack of trade support for old equipment and rapid pace of technological development fbrther influence the expected useful life of the equipment.

At present no provisioning action of non-expendable stores can take place unless these are declared unserviceable/BER (Beyond Economic Repair). As the process of provisioning takes at least 2 years, this often leads to serious deficiencies of vital equipment at unit level. It is proposed to remedy this lacuna by initiating programme of periodical phasing out of all equipment in relation to its anticipated life.

AnticipatedJexpected life of equipment is to be used only as a guide. It is neither a Death Warrant nor an insurance for the life of the equipment. While proper and careful use may prolong the useful life of an equipment, certain unforeseen factors may render it BEW unserviceable within a few weeks of its procurement. Therefore, the concept of anticipated life and dscard policy is to be used wlth utmost discretion by repair and maintenance agencies.

Frequent and recurring defect, failure of equipment, unreliability of its performance and reduced and unacceptable levels of accuracy in certain cases may lower the confidence of the user in its employability. Unreliable performance and frequent failures may thus render it unusable and necessitate its replacement. Depending upon the nature of the equipment the state of its fitness should be we11 known to the repair/maintenance agency. When the repair agency is convinced that the equipment is beyond economic repairs, discard action should be initiated. In the meantime a11 attempts to repair the equipment must be made. The equipment must bq declared as unservlceableA3ER after all attempts to repair it have failed.

It has also been seed that the condemnation procedures are not being undertaken on a regular and periodical basis for the following reasons:

a) lack of adequate record and other details with respect to date of procurement, purchase cost, source, and cost incurred on maintenance, repau etc.

b) The unwillingness and reluctance on the part of the senior hospital authorities to take decision for condemnation and disposal of equipment.

In view of the above, it is essential that the proper procedures should be laid down for condemnation and disposal of hospital equipment. It is also essential that proper records with respect to every expensive equipment should be maintained to facilitate their effective and efficient use and ultimately justify their condemnation and disposaI.

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Equipment Mmnmgernent- Mmintenmmce, 'Repmir

mnd Disposml

E s s r ~ ~ t i n l s of L o g i s t i c s and Minimum criteria to be followed for condemnation and disposal of equipment is given Equipment Management below:

The equipment has become:

a) non-functional and beyond economical repair b) non-functional and obsolete 'L c) functional but obsolete d) functional but hazardous e) functional but no longer required. Procedure for Condemnation Purchase and maintenance records of all costly and sophisticated equipments should be maintained in the form of a separate history sheet and logbook for each equipment. The contents and format of the history sheet are given here under:

Histoiy Sheet of Equipment to be maintained for every equipment and should incorporate Identification data i.e. make, model and date purchased Details of sources and reputation of suppliers Availability of spares Purchase cost Details of breakdown and down time Repairs undertaken and expenditure incurred If imported details thereof (custom clearance) Details of procurement procedure.

The History sheet may have the following tabular format:

I A column may be added for determining the life of equipment at purchase Items like disposables and I.V. sets, h en , patient cot, and related furniture items. bowels and trays etc. can be condemned on the recommendation of the user department.

Condenination Committee A Condemnation Committee should be constituted for assessing whether or not an equipment should be condemned and disposed off based on the history sheet and the recommendations of the user department. This coinmittee should meet periodically at regular intervals, at least twice a year. The condemnation committee may consist of: 1) Designated Medical Officer-in-charge 2) Concerned Head of Department 3) Technologist in-charge of Maintenance Cell 4) Stores-in-charge

Date of Repair

8

However, for condemnation of costly hospital equipment, a special condemnation board

Remarks

9

Date of Receipt

(i

SI. Name of No. Firm with

Address & Tel. No. '

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may be constituted as per rules of the organisation. Any of the following procedures can adopted for disposal of equipment after condemnation.

Quantity

4

Date of Breakdown

7

Name of Local Servicing Agent

3

a) Circulate within the hospitals, wards and OPD b) Return to vendor if he is willing to accept c) Sell to other hospitals d) Sell to scran dealers

Cost

5

e) Local destruction f j Auction

Check Your Progress 3

1) Fill in the blanks: a) History Sheet gives details of ....................................... time. b) History Sheet gives details of ..................................... incurred.

2) Describe composition of Condemnation Committee.

Equipment Audit

Another requisite for an efficient system of equipment management is to carry out the equipment audit. In other words, there is a need for periodic evaluation of the quality of performance of equipment in a hospital. It is hoped that if such an audit is performed, it will be advantageous to all concerned viz., hospital, professionals, Government and the management so that, better utilisation of scarce resources is ensured and it will also contribute to the improvement of quality of hospital care.

The stages involved in equipment audit are as under:

a) Procurement: The steps involve the checking for: - Justification for the purchase of equipment including the technical specifications

provided, with the help of indents received for the purpose from the user department.

- Suitability of the specification in the supply order the choice of supplier to whom the order has been placed through tenders floated and quotations received.

- Receipt of equipment as per the specification in the supply order, and - Ensuring availability of the essential spares, after sales maintenance service and

the training to be provided by the supplier to the hospital staff for efficient use of the equipment wherever required.

b) Installation and commission involves checking with the he5 of history sheet whether the installation instruction viz. Safety, electrical instructions, etc. has been followed.

c) Performance: After having gone through the above steps, the performance aspect of the equipment audit should be checked with the help of the history sheet and logbook. The user department itself should also review the history sheet and logbook periodically.

Equipment Audit Committee

The equipment audit committee may consist of medcal officer-in-charge, user department, head of maintenance cell and the matron. The equipment audit committee shall elect its own Chairman and the Secretdry from amongst the members in the first meeting and then meet period~cally - rmnunum'once in a x inonths -to perform equipment audit based on the hisf* sheet of the equipment., Maintenance of history sheet and its subsequent write-up is esserihal for performance of equipment audit by the Committee.

Some of the advantages of equipment audit are as under:

a) To evaluate the concurrent performance and utilisation. b) It provides a satisfactory mechanism to assist the process of condemnation. c) The equipment audit reports provide an objective method for procurement of

equipment in future.

d) To identify inadequacies and recommend remedial measures. e) Cost per reportable result and cost effectiveness can be evaluated. Trainhg and Development There is an urgent need for developing and conducting regular inservice training programmes for technicians'and other parwedical personnel who are engaged in the day-

quipment Main1

Management- tenance, Repair

and Disposal

I Essentials o f Logistics and to-day operation of hospital equipment in various departments. Equipment Mnnagement Training in hospital equipment can be broadly classified under the following categories: 1) Training by the supplier of the equipment dealing with its operation. 2) Training within the hospital dealing with routine maintenancelrepairs. 3) Training outside the hospital in a recognised institution dealing with maintenance1

repairs for electronic equipment.

lmportant elements in the training and development of the technicians include:

a) Training the technicians in quality management. b) Education of technicians on the repairlmaintenance policy, objectives and concepts of

patient satisfaction.

C ) Awareness programmes for new entrants (induction training programme). d) Procedures for specifying and verifying that technicians received suitable training. e) Teamwork and communication methods. t) Assessing carefully the technicians requirements and subsequently providing

assistance and encouragement.

g) The performance evaluation of technicians to assess their development needs and potential.

This training may be provided in different modules. Some of which may be of the following types:

a) Use and practice of equipment including proper handling of the equipment. b) Preventive maintenance and trouble shooting. c) Following the instructions manual in day to day use of the equipment d) Use of tool kit e ) Knowledge about common and recurrent causes of breakdown. Q Identification of common spare parts which are responsible for frequent breakdowns

such as fuses. washers, nuts and bolts etc.

g) Inspection and routine maintenance: Dailylperiodic checklservicing schedule with information on all aspects of inspection - removing, dismantling, cleaning, examining, lubricating, assembling, adjusting, testing and reassembling of equipmentisystem where required.

h) Calibration i) Testing and safety guidelines j) Basic concepts of physics and electronics as relevant to hospital equipment. k) Technology upgradation.

To sum up, suitable mechanism should be developed with requisite infrastructure for evaluating the performance of the maintenance cell and other departments relating to procurement, utilisation, maintenance, repair and condemnationidisposa1 of the equipment. The feedback arising out of such evaluation should be recorded and made use of in impi-oving the quality-related activities of equipment management in future.

Check Your Progress 4

I ) List the advantages of Equipment Audit.

.........................................................................................................................................................

2) Fill in the blanks: a) The Equipment Audit Committee should meet for a minimum of

in six months.

b) Proper maintenance of ...................................... is essential for the proper functioiiing of Equipment Audit Committee.

4.6 LET US SUM UP Equipment Mnnngcment- Maintenance, Repair and Disposal

In this unit, you have learnt about the existing status of hdspital equipment in the governmental set-up. The non-functioning of a good percentage of the equipment for want of timely and proper repair and maintenance leading to blockage of funds and idle equipment has been explained. This has been used to emphasize the necessity of planning timely and proper preventive maintenance and maintenance in respect of costly equipment in the hospitals.

The need of timely proper condemnation and disposal thereafter of equipment to facilitate early replacement has also been discussed. The necessity of proper training for the staff to improve equipment utilisation has also been touched upon. You have also been exposed to the growing awareness in the use of equipment audit as a management tool.

4.7 ANSWERS TO CHECK YOUR PROGRESS Check Your Progress 1

a) Hospital equipment maintenance and repair situation is gloomy. b) Hospitals seldom have 50-60 per cent equipment in usable condition. c) High-tech medical equipment worth Rs. 50 crores are lying idle in government hospitals

in Delhi and 9 other states.

Check Your Progress 2

1) a) Requirement of Equipment b) Workload in terms of patients c) Budget plannlng d) Preventive maintenance

2) a) Reduction in down-time of the equipment b) Safety of equipment c) Effective and economic functioning d) Increased life of the equipment

3) The transducer got a thick coating of the jelly. It was not cleaned properly after each use.

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Check Your Progress 3

1) a) down , i ,

b) expenditure 2) a) Designated Medical Officer-in-charge

b) Concerned Head of Department c) Technologist i n - chde of Maintenance Cell d) Stores-in-chargg

Check Your Progress 4 1) ,a) To evaluate the concurrent performance and utilisation.

b) It provides a satisfactory mechanism to assist the process of condemnation. c) The equipment audit reports provide an objective method for procurement of

equipment in future.

d) To identify inadequacies and recommend remedial measures. f e) Cost per reportable result and cost effectiveness can be evaluated.

2) a) Once b) History Sheet