- Email: [email protected]
Clinical engineering in Canada
Chapter 8
Clinical engineering in Canada William M. Gentles BT Medical Technology Consulting, Toronto, ON, Canada
Introduction Demographics Canada is a country with a population of 36.7 million (as of 2017) distributed over an area of approximately 10 million km2 (including land and fresh water). That results in a population density of 3.67 inhabitants/km2 although the population is not distributed uniformly throughout Canada’s territory. The majority of the population lives in a fairly narrow band within 160 km (100 miles) of the US border. In 2015, the infant mortality rate was 4.9 per 1000 live births. Canada’s infant mortality rate is higher than most other developed countries except the United States. This high infant mortality rate is an indicator of inequalities in access to health care, which are most evident in indigenous populations. The territory of Nunavut in the far north of Canada has an infant mortality rate of 18.5 per 1000 live births. The average life expectancy of those born today in Canada is 82 years. Canada is experiencing an ageing population. According to Statistics Canada (2017), 15.7% of the Canadian population, nearly one person in six, was 65 or older as of July 1, 2014. This proportion has been rising steadily since the mid-1960s because fertility rates have been below the replacement level and life expectancy has been increasing. This is presenting a growing challenge to the healthcare system, as the h ealthcare needs of an elderly population include many unique challenges. There is a growing trend to deliver health care in the home, as it better meets the needs of elderly patients, and is much cheaper than hospital care. The technologies to support home health care are developing rapidly, and require clinical engineering departments to learn how to service this technology effectively.
Education of clinical engineers and clinical engineering technologists In most hospital clinical engineering departments in Canada the technical staff is a mix of engineers and technologists. The ratio of technologists to engineers is typically around 72
10:1. Technologists are usually educated in community colleges (or CEGEPs in the province of Quebec). The duration of this postsecondary education is typically 3 years. Many technologists in Canadian hospitals have a college or CEGEP diploma in electronics technology, although there are now a limited number of college programs offering diplomas in biomedical engineering technology. There are a limited number of universities offering degrees in clinical engineering or health technology management. Such clinical engineering programs typically include internships where the student works in a hospital environment. The number of educational programs is too many to list here, but may be found listed on the website of the Canadian Medical and Biological Engineering Society (CMBES, 2014) (http://cmbes.ca/schools).
The Canadian medical and biological engineering society The national society for clinical and biomedical engineering in Canada is the CMBES (www.cmbes.ca). This society was founded in 1965 by Dr. Jack Hopps. The first annual CMBES conference was held in 1966 in Ottawa. In 1977 the society hosted the first Clinical Engineering Conference in Montreal. By 1982, the CMBES conference had become an annual event, which incorporated clinical engineering as one of the main tracks, the other being devoted to research and academic topics. The CMBES secretariat is managed by a Society Management Group called “The Willow Group” which is based in Ottawa. They provide administrative support, manage the society website, and assist in organizing the annual conference. Over successive years, a number of regional clinical engineering societies were formed to provide learning and networking opportunities for clinical engineers. These included the Atlantic Canada Clinical Engineering Society (http://accesociety.org/), l’Association des physiciens et ingénieurs biomédicaux du Québec (www.apibq.ca), and the Clinical Engineering Society of Ontario (www.ceso.on.ca). Clinical Engineering Handbook. https://doi.org/10.1016/B978-0-12-813467-2.00008-0 Copyright © 2020 Elsevier Inc. All rights reserved.
Clinical engineering in Canada Chapter | 8 73
Canadian clinical engineers also participate actively in international groups such as AAMI (Association for the Advancement of Medical Instrumentation), ACCE (American College of Clinical Engineering), and IFMBE (International Federation of Medical and Biological Engineering).
The present status of clinical engineering in Canada Health care is a provincial responsibility in Canada, and each of the 10 provinces and 3 territories has a slightly different approach to the way health care is organized. There is a growing trend to organize health systems regionally within a province, with the number of regions determined by the population and size of the province. For example, the province of British Columbia, on Canada’s west coast, has a population of 4.8 million and a total area (including freshwater) of 944,735 km2. The province has five regional health authorities. Clinical engineering services are also regionalized into four regions, with a similar management structure in each region. The total number of clinical engineering staff (including engineers, technologists, and administrative staff) in the province is about 350. On a per capita basis, this is about 1 clinical engineering staff for every 14,000 people in the province. In the 2015–16 fiscal year there were 12,274 staffed hospital beds in the province (Canadian Institute for Health Information, 2017), so 1 clinical engineering staff for every 35 hospital beds. Another indicator is the number of devices per staff member. In British Columbia there are 135,000 devices in the province-wide CMMS (computerized maintenance management system). This translates into an average of 385 devices per clinical engineering staff member. Other provinces are expected to have similar indicators, although the data is not readily available.
Certification of clinical engineers There has been a certification program for clinical engineers in Canada since 1979. The program fell dormant for several years, but was revived in 2005. The certification program is administered by the Healthcare Technology Certification Commission (http://accenet.org/CECertification/Pages/Default.aspx) and the Canadian Board of Examiners for Clinical Engineering Certification. The prerequisite in Canada to become a certified clinical engineer is that you must be registered as a Professional Engineer (P. Eng.) within a provincial engineering association. The reason for this is that the title “Engineer” is protected by law, and can only be used by persons who are registered as Professional Engineers with one of the provincial Professional Engineering Associations. As of March 2017, there were 24 certified
clinical engineers in Canada. Candidates wishing to become certified must apply to the Healthcare Technology Certification Commission. If their application is accepted, they take the same written examination as all candidates in the United States; however questions specific to US codes and standards are not marked. If they pass the written examination, they are then required to take an oral examination with one question that is specific to Canadian Codes and Standards. The oral examination is administered by the Canadian Board of Examiners, and usually takes place during the CMBES annual conference. For candidates who pass the oral examination, a recommendation for certification is sent by the Canadian Board of Examiners to the Healthcare Technology Certification Commission, who issues the certificate.
Clinical engineering standards of practice for Canada In 1998 the first Clinical Engineering Standards of Practice for Canada (CESOP) was published by CMBES. Updated editions were published in 2007 and 2014. The standards were developed and revised by committees consisting of experienced members of the clinical engineering community from across the country. Each edition was presented to the membership of CMBES, and was adopted after a vote of approval by the membership. The latest edition is structured according to guidelines from the International Standards Organization (ISO/ IEC, 1994). The major sections are Service Management and Service Provision. There has been a trend for clinical engineering services in Canada to use the Standards of Practice as the basis of a Departmental Policy and Procedure Manual. The document is also used as the basis of a peer-review program in which a clinical engineering department or service can apply for an external review of their department or service by a team of their peers with expertise in the field of clinical engineering. The peer-review program is voluntary and has been offered by CMBES since 2000 and as of 2017, eight reviews have been conducted. The rationale for developing a Standard of Practice and a peer-review program was the recognition that Accreditation Canada, the Hospital Accreditation body, had little expertise in evaluating clinical engineering services in hospitals. Since the development of the Standards of Practice, we have shared these standards with Accreditation Canada, and they have incorporated references to our standards and our peer-review process in their Accreditation questionnaires that they send out to a hospital prior to an Accreditation review. This is strong evidence that a Standard of Practice document is a valuable tool for raising the profile of the profession.
74 SECTION | 2 Worldwide clinical engineering practice
The peer-review process The peer-review process is voluntary, and operated by CMBES on a cost recovery basis. Services requesting a review are only charged for the expenses of the surveyors. The surveyors volunteer their time. It is generally acknowledged that surveyors learn a great deal from participating in a survey, and so there is mutual benefit. Consequently, we have had no shortage of potential surveyors volunteering to participate in a survey. The first step that a clinical engineering service must take to initiate a survey is to submit a written request to the CMBES peer-review committee. They are then sent a presurvey questionnaire, and a request for other documents such as the policy and procedure manual and an organizational chart. The peer-review committee decides if the request is eligible for peer-review and informs the requestor. The scope of the review is confirmed including all sites, locations, and proposed dates for the survey. The peer-review committee then recruits a team of three to five surveyors that includes at least one technologist and one engineer, with experience relevant to the hospital being surveyed. The following activities take place during the site visit which lasts from three to five days (there may be several sites included in the survey): ●
●
● ●
●
An introductory meeting with the service manager to review the itinerary and the organization of the service. A meeting with the senior administration representative that the service manager reports to. A tour of the clinical engineering facilities. An audit of service documentation including completeness and accuracy of device service history, scheduled maintenance compliance, and completeness and accuracy of device inventory information. Meetings with as many service customers as possible. This is an important part of the survey. These take place in private to allow a frank discussion of the strengths and weaknesses of the service.
●
●
A private meeting of the surveyors on the last day of the survey to allow them to collect their thoughts and identify key issues, and prepare a synopsis for service staff. A wrap up meeting with the service manager and service staff to discuss the preliminary findings. This discussion is of a positive and supportive nature, and fairly brief.
The following are the activities that happen after the survey has been completed: ●
●
Findings are summarized in a written report that the service manager can present to the senior administrator. A postsurvey questionnaire is sent to the site asking for feedback and suggestions to improve the peer-review program.
Conclusions Clinical engineering in Canada has a long history. It has benefitted from a single-payer health system, where all clinical engineers work ultimately for the same boss, the Canadian taxpayer. As a result, there is a sense that we are all on the same team, and there is a willingness to work together to share best practices and other information. This has led to the strengthening of the profession and recognition of its importance by federal regulators, and Accreditation Canada.
References Canadian Institute for Health Information, 2017. Canadian MIS database (CMDB), 2015–2016, CMDB hospital beds staffed and in operation, 2015–2016. https://www.cihi.ca/en. (Accessed February 8, 2018). CMBES, Clinical Engineering Standards of Practice for Canada, 2014. Available at: http://cmbes.ca/publications-a-references. (Accessed February 8, 2018). ISO/IEC, 1994. Code of good practice for standardization. ISO/IEC GUIDE 59:1994 (E). https://www.iso.org/standard/23390.html. (Accessed February 8, 2018). Statistics Canada, 2017. Canada at a Glance. Available at: http://www. statcan.gc.ca/pub/12-581-x/12-581-x2017000-eng.htm. (Accessed February 11, 2018).
Clinical engineering in Canada William M. Gentles BT Medical Technology Consulting, Toronto, ON, Canada
Introduction Demographics Canada is a country with a population of 36.7 million (as of 2017) distributed over an area of approximately 10 million km2 (including land and fresh water). That results in a population density of 3.67 inhabitants/km2 although the population is not distributed uniformly throughout Canada’s territory. The majority of the population lives in a fairly narrow band within 160 km (100 miles) of the US border. In 2015, the infant mortality rate was 4.9 per 1000 live births. Canada’s infant mortality rate is higher than most other developed countries except the United States. This high infant mortality rate is an indicator of inequalities in access to health care, which are most evident in indigenous populations. The territory of Nunavut in the far north of Canada has an infant mortality rate of 18.5 per 1000 live births. The average life expectancy of those born today in Canada is 82 years. Canada is experiencing an ageing population. According to Statistics Canada (2017), 15.7% of the Canadian population, nearly one person in six, was 65 or older as of July 1, 2014. This proportion has been rising steadily since the mid-1960s because fertility rates have been below the replacement level and life expectancy has been increasing. This is presenting a growing challenge to the healthcare system, as the h ealthcare needs of an elderly population include many unique challenges. There is a growing trend to deliver health care in the home, as it better meets the needs of elderly patients, and is much cheaper than hospital care. The technologies to support home health care are developing rapidly, and require clinical engineering departments to learn how to service this technology effectively.
Education of clinical engineers and clinical engineering technologists In most hospital clinical engineering departments in Canada the technical staff is a mix of engineers and technologists. The ratio of technologists to engineers is typically around 72
10:1. Technologists are usually educated in community colleges (or CEGEPs in the province of Quebec). The duration of this postsecondary education is typically 3 years. Many technologists in Canadian hospitals have a college or CEGEP diploma in electronics technology, although there are now a limited number of college programs offering diplomas in biomedical engineering technology. There are a limited number of universities offering degrees in clinical engineering or health technology management. Such clinical engineering programs typically include internships where the student works in a hospital environment. The number of educational programs is too many to list here, but may be found listed on the website of the Canadian Medical and Biological Engineering Society (CMBES, 2014) (http://cmbes.ca/schools).
The Canadian medical and biological engineering society The national society for clinical and biomedical engineering in Canada is the CMBES (www.cmbes.ca). This society was founded in 1965 by Dr. Jack Hopps. The first annual CMBES conference was held in 1966 in Ottawa. In 1977 the society hosted the first Clinical Engineering Conference in Montreal. By 1982, the CMBES conference had become an annual event, which incorporated clinical engineering as one of the main tracks, the other being devoted to research and academic topics. The CMBES secretariat is managed by a Society Management Group called “The Willow Group” which is based in Ottawa. They provide administrative support, manage the society website, and assist in organizing the annual conference. Over successive years, a number of regional clinical engineering societies were formed to provide learning and networking opportunities for clinical engineers. These included the Atlantic Canada Clinical Engineering Society (http://accesociety.org/), l’Association des physiciens et ingénieurs biomédicaux du Québec (www.apibq.ca), and the Clinical Engineering Society of Ontario (www.ceso.on.ca). Clinical Engineering Handbook. https://doi.org/10.1016/B978-0-12-813467-2.00008-0 Copyright © 2020 Elsevier Inc. All rights reserved.
Clinical engineering in Canada Chapter | 8 73
Canadian clinical engineers also participate actively in international groups such as AAMI (Association for the Advancement of Medical Instrumentation), ACCE (American College of Clinical Engineering), and IFMBE (International Federation of Medical and Biological Engineering).
The present status of clinical engineering in Canada Health care is a provincial responsibility in Canada, and each of the 10 provinces and 3 territories has a slightly different approach to the way health care is organized. There is a growing trend to organize health systems regionally within a province, with the number of regions determined by the population and size of the province. For example, the province of British Columbia, on Canada’s west coast, has a population of 4.8 million and a total area (including freshwater) of 944,735 km2. The province has five regional health authorities. Clinical engineering services are also regionalized into four regions, with a similar management structure in each region. The total number of clinical engineering staff (including engineers, technologists, and administrative staff) in the province is about 350. On a per capita basis, this is about 1 clinical engineering staff for every 14,000 people in the province. In the 2015–16 fiscal year there were 12,274 staffed hospital beds in the province (Canadian Institute for Health Information, 2017), so 1 clinical engineering staff for every 35 hospital beds. Another indicator is the number of devices per staff member. In British Columbia there are 135,000 devices in the province-wide CMMS (computerized maintenance management system). This translates into an average of 385 devices per clinical engineering staff member. Other provinces are expected to have similar indicators, although the data is not readily available.
Certification of clinical engineers There has been a certification program for clinical engineers in Canada since 1979. The program fell dormant for several years, but was revived in 2005. The certification program is administered by the Healthcare Technology Certification Commission (http://accenet.org/CECertification/Pages/Default.aspx) and the Canadian Board of Examiners for Clinical Engineering Certification. The prerequisite in Canada to become a certified clinical engineer is that you must be registered as a Professional Engineer (P. Eng.) within a provincial engineering association. The reason for this is that the title “Engineer” is protected by law, and can only be used by persons who are registered as Professional Engineers with one of the provincial Professional Engineering Associations. As of March 2017, there were 24 certified
clinical engineers in Canada. Candidates wishing to become certified must apply to the Healthcare Technology Certification Commission. If their application is accepted, they take the same written examination as all candidates in the United States; however questions specific to US codes and standards are not marked. If they pass the written examination, they are then required to take an oral examination with one question that is specific to Canadian Codes and Standards. The oral examination is administered by the Canadian Board of Examiners, and usually takes place during the CMBES annual conference. For candidates who pass the oral examination, a recommendation for certification is sent by the Canadian Board of Examiners to the Healthcare Technology Certification Commission, who issues the certificate.
Clinical engineering standards of practice for Canada In 1998 the first Clinical Engineering Standards of Practice for Canada (CESOP) was published by CMBES. Updated editions were published in 2007 and 2014. The standards were developed and revised by committees consisting of experienced members of the clinical engineering community from across the country. Each edition was presented to the membership of CMBES, and was adopted after a vote of approval by the membership. The latest edition is structured according to guidelines from the International Standards Organization (ISO/ IEC, 1994). The major sections are Service Management and Service Provision. There has been a trend for clinical engineering services in Canada to use the Standards of Practice as the basis of a Departmental Policy and Procedure Manual. The document is also used as the basis of a peer-review program in which a clinical engineering department or service can apply for an external review of their department or service by a team of their peers with expertise in the field of clinical engineering. The peer-review program is voluntary and has been offered by CMBES since 2000 and as of 2017, eight reviews have been conducted. The rationale for developing a Standard of Practice and a peer-review program was the recognition that Accreditation Canada, the Hospital Accreditation body, had little expertise in evaluating clinical engineering services in hospitals. Since the development of the Standards of Practice, we have shared these standards with Accreditation Canada, and they have incorporated references to our standards and our peer-review process in their Accreditation questionnaires that they send out to a hospital prior to an Accreditation review. This is strong evidence that a Standard of Practice document is a valuable tool for raising the profile of the profession.
74 SECTION | 2 Worldwide clinical engineering practice
The peer-review process The peer-review process is voluntary, and operated by CMBES on a cost recovery basis. Services requesting a review are only charged for the expenses of the surveyors. The surveyors volunteer their time. It is generally acknowledged that surveyors learn a great deal from participating in a survey, and so there is mutual benefit. Consequently, we have had no shortage of potential surveyors volunteering to participate in a survey. The first step that a clinical engineering service must take to initiate a survey is to submit a written request to the CMBES peer-review committee. They are then sent a presurvey questionnaire, and a request for other documents such as the policy and procedure manual and an organizational chart. The peer-review committee decides if the request is eligible for peer-review and informs the requestor. The scope of the review is confirmed including all sites, locations, and proposed dates for the survey. The peer-review committee then recruits a team of three to five surveyors that includes at least one technologist and one engineer, with experience relevant to the hospital being surveyed. The following activities take place during the site visit which lasts from three to five days (there may be several sites included in the survey): ●
●
● ●
●
An introductory meeting with the service manager to review the itinerary and the organization of the service. A meeting with the senior administration representative that the service manager reports to. A tour of the clinical engineering facilities. An audit of service documentation including completeness and accuracy of device service history, scheduled maintenance compliance, and completeness and accuracy of device inventory information. Meetings with as many service customers as possible. This is an important part of the survey. These take place in private to allow a frank discussion of the strengths and weaknesses of the service.
●
●
A private meeting of the surveyors on the last day of the survey to allow them to collect their thoughts and identify key issues, and prepare a synopsis for service staff. A wrap up meeting with the service manager and service staff to discuss the preliminary findings. This discussion is of a positive and supportive nature, and fairly brief.
The following are the activities that happen after the survey has been completed: ●
●
Findings are summarized in a written report that the service manager can present to the senior administrator. A postsurvey questionnaire is sent to the site asking for feedback and suggestions to improve the peer-review program.
Conclusions Clinical engineering in Canada has a long history. It has benefitted from a single-payer health system, where all clinical engineers work ultimately for the same boss, the Canadian taxpayer. As a result, there is a sense that we are all on the same team, and there is a willingness to work together to share best practices and other information. This has led to the strengthening of the profession and recognition of its importance by federal regulators, and Accreditation Canada.
References Canadian Institute for Health Information, 2017. Canadian MIS database (CMDB), 2015–2016, CMDB hospital beds staffed and in operation, 2015–2016. https://www.cihi.ca/en. (Accessed February 8, 2018). CMBES, Clinical Engineering Standards of Practice for Canada, 2014. Available at: http://cmbes.ca/publications-a-references. (Accessed February 8, 2018). ISO/IEC, 1994. Code of good practice for standardization. ISO/IEC GUIDE 59:1994 (E). https://www.iso.org/standard/23390.html. (Accessed February 8, 2018). Statistics Canada, 2017. Canada at a Glance. Available at: http://www. statcan.gc.ca/pub/12-581-x/12-581-x2017000-eng.htm. (Accessed February 11, 2018).