MDM PROTOCOLS

Protocol for Work Order Notifications

AUGUST 8, 2022
DEBREBIRHAN COMPREHENSIVE SPECIALIZED HOSPITAL
Ethiopia, Amhara, Debre-birhan town
Contents
PURPOSE AND SCOPE ........................................................................................................................................................ 2
THE PURPOSE ............................................................................................................................................................................2
THE SCOPE ................................................................................................................................................................................2
PROCEDURES TO BE CARRIED OUT .................................................................................................................................... 3
MONITORING AND EVALUATION ....................................................................................................................................... 4
ANNEXES ........................................................................................................................................................................... 5
BIOMEDICAL WORK ORDER FORM.................................................................................................................................................5
DETAILS FOR THIS STRATEGIC PROCEDURE ........................................................................................................................ 6

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 Purpose and scope
The purpose
The purpose of this procedure to ensure that all medical devices are safe to use, rightly and regularly
serviced and maintained in order to enhance the quality of healthcare services in our hospital.
 Obedience to this procedure will ensure compliance with Standards intended to make
sure that the devices that are used to deliver monitoring, diagnostic, therapeutic and
treatment service:
 Have protocol for work order notification
 Are properly and safely used.
 Are properly maintained, followed, and cared for.
 Are properly and securely Stored
 All service/maintenance involvements will be recorded against the device on the
hospital Medical Devices History file/database. This will be audited and verified by the
hospital’s MEMU and MEC for compliance with this and other relevant procedures.

The scope
Who does the procedure  Authorized DBCSH Staff on monitoring, diagnostic,
apply to? therapeutic and miscellaneous medical devices
 All DBCSH-MEMU staff
 Ward/Department Managers
 MEC and SMT/DBCSH Administration
When should the  When medical devices require preventive maintenance, repair,
procedure be applied? acceptance, training, decommissioning

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 Procedures to be carried out
 Whenever there is a need of: medical device acceptance, training, corrective maintenance,
decommissioning, or Preventive maintenance alert; the user or MD Focal person of the room should
report immediately to MEMU using a Work Order Form. (Annex 1)
o In urgent cases the request for any biomedical services can be made by a phone call or other
means of reporting, however this must always be backed up with Work Order Form.
 Three copies of the Work Order Form should be filled for one request:
o The first copy, after signed by the receiver, should be kept by the user department and filed
in a ‘Medical Device Maintenance File’ folder which is divided into two halves.
 The two halves work as follows:
 The front is the pending section and is a record of all the jobs reported; organized
according to respective dates.
 The back is the completed section and is an ongoing record of all the jobs that have
been completed; organized according to respective dates.
 The ‘pending section’ should be checked regularly by users’ Team Head to ensure
that Work Orders are being carried out in a timely manner.
 When the work is completed and or the item is re/turned to service, the Form should
be signed by the users’ Team Head or equivalent
 It is then moved from the front (pending section) to the back (Completed section).
 Users’ Team Head obtains feedback regarding the status of maintenance requests
and monitors progress by reviewing ‘Medical Device Maintenance File’ monthly.
o The second is filed in a ‘Work Order Progress File’ which is divided into two halves.
 The two halves work as follows:
 The front is the pending section and is a record of all the jobs requested;
organized according to respective dates.
 The back is the completed section and is an ongoing record of all the jobs
that have been completed; organized according to respective dates.
 The ‘pending section’ should be checked regularly by MEMU Team to ensure that
Work Orders are being carried out in a timely manner.
 When the work is completed and or the item is re/turned to service, the Form is
moved from the front (pending section) to the back (Completed section).
 MEMU Head obtains feedback regarding the status of Work Orders and monitors
progress by reviewing ‘Work Order Progress File’ every week.
o The last copy is used by the service provider technician/engineer as a record of the work
undertaken.
 After completion the form then is used to create a service history for the equipment
or item concerned.
 MEMU will record all service/maintenance undertaken on the national and local history
file/inventory database; and this will be audited and verified by the hospital’s MEC for compliance
with this and relevant protocols in place.

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 Monitoring and evaluation
The hospital MEMU follows the implementation of work order protocol and timely reports to MEMC
and SMT/plan program
Reportable variables Frequency of report
# Biomedical work orders received Monthly
# Biomedical work orders completed Monthly
# Biomedical work orders pending Monthly
# Biomedical work orders outsourced Monthly

The user team head follows the status of work orders and timely reports to PMT.
Reportable variables Frequency of report
# Pending Maintenance of Medical Devices Monthly
# Completed Maintenance of Medical Devices Monthly

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 Annexes
Biomedical Work Order Form

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 Details For this Strategic Procedure
Title of The Procedure Protocol for Work Order Notification
Unique Identifier DBCSH-MEMU-PRO6-2022

State (New or Revised) Revised

Procedure for repair, planned maintenance and
Previous Title where applicable
servicing
Category Health Technology Management

Executive Director Chief Clinical officer

Lead/Author Job titles only Bio-Medical Engineer

Committee/Group responsible for the

Hospital Senior Management Team
approval
Chairman print name Hospital stamp

June-2022
Month/year consultation process completed

Month/year procedure approved

Month/year ratified and issued

Next review date

June-2024
can be disclosed to user of medical devise and public
Disclosure status
HC sectors
Medical devices, biomedical work order, requester,
Key Words maintainer, Medical Device Maintenance File, Work
Order Progress File, Pending, completed

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