Research Article

(wileyonlinelibrary.com) DOI: 10.1002/qre.1650

Published online 9 May 2014 in Wiley Online Library

Maintenance Strategies and Failure-Cost

Model for Medical Equipment
Abdelbaset Khalaf,a* Karim Djouani,a,b Yskandar Hamama,c and Yasser Alaylid
This paper proposes a mathematical maintenance model that analyses the effect of maintenance on the survival probability
of medical equipment based on maintenance history and age of the equipment. The proposed model is simulated in Scilab
using real data extracted from maintenance history of anaesthesia machine from Draeger. The analysis using survival
approach reveals that conducting preventive maintenance on the selected medical equipment had a positive impact on
survival of equipment. The model is then used to analyse the cost of maintenance scenarios, and an appropriate scenario
is proposed for anaesthesia machine. A new failure-cost model is developed, which may be used to calculate the number
of failures of equipment and the annual maintenance cost. The proposed models may be used as a planning tool for selecting
maintenance strategies for various medical equipments. Copyright 2014 John Wiley & Sons, Ltd.
Keywords: maintenance strategies; medical equipment; survival; failure-cost

1. Introduction
ixed maintenance intervals is the most frequently used approach in the maintenance of medical equipment. Newer as needed-type
methods, such as reliability-centred maintenance (RCM) or condition-based maintenance, are not considered for application in
healthcare industry anywhere around the world, except few proposals coming from North America and Australia. Methods based
on mathematical models are hardly ever used or even considered. Yet only mathematical approaches, where component and equipment
deterioration and condition improvement by maintenance, are quantitatively linked and can determine the effect of maintenance on
reliability of medical equipment. Although more complex, probabilistic models have advantages over deterministic ones, they are capable
of describing actual processes more realistically and also facilitate optimisation for maximal reliability or minimal costs.
Recently, the American Society for Healthcare Engineering has established a Maintenance Practices Task Force to investigate
lessons that may be learned from RCM. The Maintenance Practices Task Force proposed a new parameter called RCM preventive
maintenance (PM) risk score, which requires obtaining reliable data on PM ndings. This approach may be a substantial challenge
and may require standardisation on databases and data types.1
The purpose of maintenance in general is to improve the operational availability and to extend equipment lifetime or to increase
the mean time to failure (MTTF) where, in the case of medical equipment, it serves another important purpose. A fundamental aspect
that differentiates medical equipment maintenance from similar activities in other industries is healthcare intervention and patient
safety, which are essential components of quality healthcare services. Acceptable clinical outcomes, in addition to other clinical
factors, require a high level of operational availability of medical equipment.
According to Wang et al.,2 the healthcare environment presents more challenges than most industries, and no other industries
have such a wide variety of equipment (1500 generic types) designed and made by different companies. User training and
competency remain a serious challenge, making use errors as one of the main causes of patient incidents.
According to Taghipour et al.,3 the reliability and failure patterns of a device may be affected by external factors such as operating
conditions, environmental stress, expertise level of operators and so on.
To ensure satisfactory system reliability and safe operation of medical equipment, a number of tools are used in healthcare
services. Maintenance is just one tool, and others include increasing number of equipment, leasing equipment and employing more
reliable components. However, at a time when these approaches are heavily constrained, healthcare systems are forced to obtain the
most out of the devices they already own through more effective operating policies, including improved maintenance programmes.

Tshwane University of Technology/FSATI, Pretoria, South Africa

University Paris Est UPEC/LISSI, Paris, France
University Paris Est/ESIEE, Paris, France
d
UVSQ/LISV, Versailles, France
*Correspondence to: Abdelbaset Khalaf, Electrical Engineering, Tshwane University of Technology, Pretoria Campus-Building 6-305, Pretoria, South Africa.

E-mail: khalafb@tut.ac.za
b
c

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Copyright 2014 John Wiley & Sons, Ltd.

A. KHALAF ET AL.
In 1984, the Emergency Care Research Institute4 published a recommendation to use risk as the primary criterion for deciding
which pieces of equipment should be subject to scheduled maintenance (SM) as well as the frequency of the SM and risk was
categorised as high-medium-low. Emergency Care Research Institute has developed scheduled (planned) maintenance (SM) for most
of medical equipment, which is known as health device inspection and PM. The inspection and PM includes guidelines on PM and
safety and performance inspection (SPI). In 1989, Fennigkoh and Smith5 introduced another approach. This approach classies
equipment using three parameters, that is, function, physical risk and maintenance requirements. Each parameter is assigned a score,
and the three are combined to give an equipment management score. This approach was known later as the risk-based inclusion
criterion and allowed clinical engineering (CE) professionals to focus their PM on a limited portion of medical devices (life support).

2. Maintenance strategies
Maintenance programmes range from the very simple to the quite sophisticated ones. Perhaps, the simplest plan is to adopt a rigid
maintenance schedule where predened activities are carried out at xed time intervals. Whenever the equipment fails, it is repaired
or replaced. Both repair and replacement are assumed to be much more costly than a single maintenance job. The maintenance
intervals of medical equipment are selected on the basis of manufacturers recommendation and/or long-time experience. This is
the approach most frequently adopted today in many parts of the world. Other more complicated maintenance strategies include
repair or replace, scheduled inspections and comprehensive full service programme.
Wang et al.6 summarised maintenance strategies and the types of maintenance activities applied to medical equipment.
In the last 30 years, many industries replaced their xed-interval maintenance schedules with more exible programmes based on the
analysis of needs and priorities or on the analysis of the information obtained through periodic or continuous condition monitoring
(predictive maintenance). The predictive maintenance routines include a group of programmes called RCM. In an RCM approach, various
alternative maintenance policies may be compared, and the most cost-effective one for sustaining equipment reliability is selected.
The implementation of RCM programmes represented a signicant step in the direction of getting the most out of the equipment
installed and was driven by the high-cost prole of aviation-related accidents and the critical nature of some equipment as in the
military eld.7 However, the approach is still heuristic, and its application required experience and judgment at every turn. Besides,
it may take a long time before sufcient data are collected for making such judgments. For this reason, several mathematical models
have been proposed to aid maintenance scheduling.8
Ridgway1 noted that because of the current regulatory pressures to perform PM in accordance with manufacturers
recommendations, there are currently no reliable statistics available on what increase in failure rates is expected if no PM at all
was performed on various types of medical equipment. This challenge was addressed by using a global mathematical model to
analyse the effect of PM on MTTF and failure rates of infusion pumps, ventilators and anaesthesia machines.9
Several mathematical models have been proposed to study the effect of maintenance on industrial equipment and the link to the
deterioration process of components.10 They provide the missing link in earlier approaches: a quantitative connection between
reliability and maintenance. Once a mathematical model is constructed, the process may be optimised with regard to changes in
one or more of the variables.
For a complete evaluation of the effects of a maintenance policy, one has to know by how much its application would extend the
lifetime of medical equipment, in other words, the MTTF and failure rates for each type.
According to Endrenyi et al.,8 the constant failure-rate assumption (random failures) leads to the result that maintenance cannot
produce any improvement, because the chances of a failure occurring during any future time interval are the same with or without
maintenance. This also agrees with the ndings of Ridgway,1 Dekker12 and Taghipour et al.3
The situation is quite different for deterioration processes, where the time from the new condition to failure is not exponentially
distributed even if the time between subsequent stages of deterioration is. In such a process, the hazard function is increasing, and
maintenance will bring about improvement independently of the types of distributions between stages.11 Hence the rule: conditions
cannot be improved by maintenance for random failures, but maintenance has an important role to play when failures are the
consequence of ageing.

3. Effect of maintenance on survival of medical equipment

936

In many applications, equipment failures may be divided into two categories, random failures (unpredictable) and those due to
deterioration (ageing). The processes in which medical equipment may fail may be represented by probabilistic mathematical models
and not by deterministic models.9 It is assumed that medical equipment follows a constant failure rate, and the chance of a failure
occurring in any future at time interval is the same. A constant failure rate (or hazard rate) model is a special case where the hazard
function, associated to the probability of failure in a future at time if the device is still working at the beginning of time t, is constant.
According to Troyer,7 the exponential survival and the Weibull distribution are the most widely used reliability model machines,
and the exponential survival is the most basic one with the constant failure rate or the at section of the bathtub curve. Troyer7
further claims that most industrial machines spend most of their lives in the constant failure rate (exponential), and Tarpey17 indicated
that most electronic components do not ware out, and their failure times are accurately described by an exponential distribution.
Copyright 2014 John Wiley & Sons, Ltd.

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A. KHALAF ET AL.
3.1. Model development
Many industries have developed mathematical models to optimise maintenance schedules where very little has been carried out in
medical industry. A mathematical model that analyses the survival probability of medical equipment that combines the effect of
random failures and age deterioration failures is proposed.
The survival of equipment is expressed in the following equation:
Si t Sage tettr

(1)

where t is the age of the equipment, Sage(t) is a function of the age of the equipment, tr is the last maintenance date and is the
hazard function.
The term ettr is that corresponding to the evolution of the survival after maintenance. In a similar manner to this term, let
Sage t S0 et
where S0 is the survival probability at t = 0 and is a positive constant similar to . It is assumed that the probability that the
equipment will fail at the rst use is zero; hence, S0 is equal to 1. In practice, some equipment may fail in the rst use, and the value
of initial survival probability is less than 1.
Combining the aforementioned text gives the following survival function for equipment (i).
Si t S0 et : ettr

(2)

3.2. Model simulation

The proposed global model as in Equation (2) is simulated in Scilab using real maintenance data on anaesthesia machines received
from Draeger South Africa. The data were captured from maintenance history of a specic model PRIMUS. The maintenance data
captured cover 48 units from 2007 till 2011 with history of 602 maintenance records, and PM was performed every 6 months for most
of equipment as recommended by the manufacturer. It was conrmed by Draeger South Africa that PM performed includes both
safety and performance verications (SPI) as implemented by the original manufacturer.
Table I shows a sample of the whole data set captured for the PRIMUS model of anaesthesia machine and used to test the global
model. Columns 2, 4, 5 and 6 were calculated from equipment history.
These columns correspond to the following:
[1]
[2]
[3]
[4]

The age of equipment since installation and after maintenance

Duration since any type of maintenance
Time to failures since last PM
Time to failure since last corrective maintenance (CM).

Table I. Sample of data from Anaesthesia Machine PRIMUS maintenance history, which represent one asset (ARSK-0029) installed
on 1 September 2002
Failure since
Failure
Failure
Date of
Days since
Type of
maintain
since PM
since CM
service
service
service
(days)
(days)
(days)
PM cost
CM cost
1606.00
1654.00
1882.00
1886.00
2053.00
2153.00
2468.00
2469.00
2550.00
2564.00
2766.00
2818.00
2941.00
2960.00
3186.00

PM
CM
PM
CM
PM
CM
PM
PM
CM
CM
PM
PM
PM
PM
PM

ZAR 1500.00
48.00

48.00

ZAR 1000.00
ZAR 1500.00

4.00

4.00

ZAR 8700.00
ZAR 1000.00

100.00

100.00

ZAR 1500.00
ZAR 1500.00
ZAR 1500.00

81.00
14.00

81.00
14.00

ZAR 7500.00
ZAR 3200.00
ZAR 2000.00
ZAR 3200.00

PM, preventive maintenance; CM, corrective maintenance.

Copyright 2014 John Wiley & Sons, Ltd.

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937

2007/01/24
2007/03/13
2007/10/27
2007/10/31
2008/04/15
2008/07/24
2009/06/04
2009/06/05
2009/08/25
2009/09/08
2010/03/29
2010/05/20
2010/09/20
2010/10/09
2011/05/23

A. KHALAF ET AL.
Regression analysis is used on the anaesthesia machine PRIMUS with the following situations:
1. The probability of equipment being available rst without the effect of equipment age and second with the effect of age using
a combined effect of PM and CM is presented in Figure 1 for the (Draeger Primus) model. This approach allows analysing the
effect of age on the survival of equipment and whether doing maintenance increases the survival of equipment or not. The
results in Figure 1 show that age has no apparent effect ( = 0.0000097949) on survival of equipment. This may be attributed
to the effect of maintenance where the MTTF is approximately 111 days ( = 0.0089843 and 0.0090084)
2. The probability of equipment being available rst without the effect of equipment age and second with the effect of age
considering the inuence of PM only is presented in Figure 2 for the same model. The objective is to analyse the effect of
age on the survival of equipment and whether doing PM increases the survival of equipment or not. This allows consideration
of PM in the maintenance strategy, specically because of the high cost associated with it. The MTTF is 124 days ( = 0.0080431
without the effect of age and 0.0080628 with).
3. The probability of equipment being available rst without the effect of equipment age and second with the effect of age using
effect of CM only is presented in Figure 3 for the same model. The objective is the same as in 2, but with the effect of CM on the
survival of equipment. CM is a very signicant factor affecting survival of equipment, and healthcare providers must include CM
in their maintenance strategies for at least the life span of equipment. The MTTF is 88 days ( = 0.011326) compared with
124 days for the PM effect. Clearly, this indicates that doing PM is a useful maintenance tool that may be used to extend MTTF
from 88 to 124 days and hence to increase the survival probability of anaesthetic machine.

4. Cost analysis and maintenance strategies

Financial considerations have become of major importance in hospital management. Maintenance expense is no longer looked at as a
necessary evil but is now considered to be a category of expense, which must be managed economically.
Over the last three decades, several measures dealing with productivity and cost-effectiveness of CE have been attempted.
According to Hai-Yen,13 One of the most frequent comparisons made is to contrast the costs of providing PM and repair service by
an outside agency. He adds, Studies have found that costs of in-house hourly services are approximately one-third to one-half of the
hourly cost of outside contractors.
Frize14 found that a budget level of 56% of the equipment value supported seems to be a reasonable estimate of todays needs as
a measure of CE expenses and budget needs.
In general, PM is a resource-demanding activity and may have negative impact on other important activities of CE. Therefore, it is
justiable to adopt a less resource-demanding maintenance strategy for most medical equipment excluding anaesthesia machines
and very few others.6

Global Model dealing with PM and CM:Draeger Anesthetic mc service data 2

Survival

0.8
0.6

Without the effect of the age

0.4

S0 =1, =0.0089843

0.2
0

50

100

150

200

250

300

350

400

450

Days
Global Model dealing with PM and CM:Draeger Anesthetic mc service data 2
1

Survival

0.8
0.6

With the effect of the age

0.4

S0 =1, =0.0090084, =9.7949e006

0.2
0

50

100

150

200

250

300

350

400

450

Days

938

Figure 1. Survival probability of anaesthesia machine using combined effect of preventive maintenance and CM for Draeger Primus anaesthesia machine

Copyright 2014 John Wiley & Sons, Ltd.

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A. KHALAF ET AL.
Global Model dealing with PM:Draeger Anesthetic mc service data 2
1

Survival

0.8
0.6

Without the effect of the age

0.4

S0 =1, =0.0080431

0.2
0

50

100

150

200

250

300

350

400

450

Days
Global Model dealing with PM:Draeger Anesthetic mc service data 2
1

Survival

0.8
0.6

With the effect of the age

0.4

S0 =1, =0.0080628, =1.0619e005

0.2
0

50

100

150

200

250

300

350

400

450

Days
Figure 2. Survival of anaesthesia machine using the effect of preventive maintenance for Draeger Primus anaesthesia machine

Global Model dealing with CM:Draeger Anesthetic mc service data 2

1

Survival

0.8
0.6

Without the effect of the age

0.4

S0 =0.93116, =0.011326

0.2
0

50

100

150

200

250

300

350

400

Days
Global Model dealing with CM:Draeger Anesthetic mc service data 2
1

Survival

0.8
0.6

With the effect of the age

0.4

S0 =0.92791, =0.011322, =1.6778e006

0.2
0

50

100

150

200

250

300

350

400

Days
Figure 3. Survival of anaesthesia machine using the effect of corrective maintenance for Draeger Primus anaesthesia machine

Copyright 2014 John Wiley & Sons, Ltd.

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939

Ridgway et al.15 further noted that PM is an issue of declining importance relative to several other equipment issues. Yet $300m per
year is still allocated to this in US hospitals. Ridgway et al. further indicated that there is still no good consensus on the denition of
PM or even why it is carried out, no rational process for dening a noncritical device and no good method for justifying PM intervals.
PM does not prevent all types of equipment failure and only addresses failures that result from the degeneration of a devices
nondurable parts and hidden failure.
Ridgway et al.15 further noted that some devices that appear to be very similar in their function and design have manufacturerrecommended intervals that vary by a factor of two or more. The question has been raised about the credibility of these
recommended intervals and whether it is based on meaningful test data.

A. KHALAF ET AL.
According to Wang,16 ideally PM should be performed at time intervals just below the mean-time-between-failure, as this
would allow the minimisation of resources while preventing the majority of failures. Wang16 proposed the following theoretical
ideal interval for SPIs using the formula (SPI period = 2 (1-uptime) MTBF). Uptime or operational availability of equipment for
use is measured per unit of the planned operational time. This approach reduces the annual maintenance cost and refocuses
resources from SM (SPI + PM) to higher impact tasks, for example, use error tracking, self-identied failures, repairs and regular
user training.
Debating the PM intervals with equipment manufacturers does not seem to be a practical approach as the manufacturers may be
reluctant to share the relevant information with end users if there are any documented data.
The survival analysis of anaesthesia machine PRIMUS is used with the cost data for both PM and CM to analyse maintenance
strategy. The main focus of the analysis is limited to the cost associated with both PM and CM. The cost of other activities is relatively
xed, although it has a signicant impact on availability of equipment.
To evaluate the cost of maintenance strategy of anaesthesia machine, the experimental discrete distribution is used with the cost
gures in Tables II and III and the histograms in Figures 4 and 5.
Tables II and III give the costs encountered (ZAR), their frequency and their probability for PM and CM respectively, as obtained
from maintenance history, and Figures 1 and 2 give their corresponding histograms.
Let {CP} and {CC} be discrete random variables corresponding to the PM and CM costs that take the numerical values
fC Pi ji 1; 2; ; NP g and fC Ci ji 1; 2; ; NC g
where {|NP} and {|NC} are the number of cost levels for PM and CM, respectively. The discrete probability distribution then consists of
the values of the random variables and their corresponding probabilities PPi = P(CPi) and PCi = P(CCi) with
fPPi ji 1; 2; ; NP g and fPCi ji 1; 2; ; NC g
The aforementioned distributions were used for the evaluation of the maintenance strategies.
The following scenarios are proposed for the maintenance strategy.
Scenario 1

Scenario 2

PM is carried out according to intervals, and when the equipment fails between the intervals, the next PM is carried out
with the CM related to that failure. The new PM schedule starts with the new PM carried out with CM. The maintenance
cost was simulated in Scilab using Algorithm 1 (Appendix A), and the costs of both PM and CM from the data received
and the values of for PM were being taken from Figure 2 and that of CM from Figure 3. The tted curves representing
the costs of PM, CM and total annual cost are shown in Figure 6.
PM is carried out according to xed intervals, no matter what faults occur in between any two successive PMs, and PM
is not combined with CM. The PM schedules remain unchanged. The maintenance cost was simulated in Scilab using
Algorithm 1 (Appendix A) and the costs of both PM and CM from the data received. The values of were taken from
Figures 2 and 3 for PM and CM, respectively. The tted curves representing the costs of PM, CM and total annual cost
are shown in Figure 7.

It is clear that doing PM according to manufacturers recommendation every 6 months increases total maintenance cost. Using a
longer PM interval (12 months) would reduce the total maintenance cost signicantly.

Table II. Cost and frequency of occurrence of preventive maintenance

Frequency
31
89
92
Probability
Cost

0.1123
1000

0.3225
1500

0.3333
2000

Table III. Cost and frequency of occurrence of corrective maintenance

Frequency
3
1
3
1

940

Probability
Cost
Frequency
Problem
Cost
Frequency
Problem
Cost

0.0213
400
13
0.0922
1000
10
0.0709
2300

0.0071
500
4
0.0284
1200
1
0.0071
2500

Copyright 2014 John Wiley & Sons, Ltd.

0.0213
560
2
0.0142
1270
1
0.0071
2800

0.0071
670
1
0.0071
1400
8
0.0567
3200

44

18

0.0072
2300

0.1594
3200

0.0652
4500

0.0426
780
22
0.1560
1500
8
0.0567
4700

0.0142
870
1
0.0071
1780
14
0.0993
6500

0.0071
900
9
0.0638
1800
15
0.1064
7500

0.0071
980
7
0.0496
2100
7
0.0496
8700

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A. KHALAF ET AL.

Figure 4. Number of occurrences at given preventive maintenance costs

Figure 5. Number of occurrences at given corrective maintenance costs

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Figure 6. Annual maintenance cost for scenario 1

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A. KHALAF ET AL.

Figure 7. Annual maintenance cost for scenario 2

4.1. Development of a new failure-cost model

In Section 4, simulation was used to evaluate the number of failures and the cost of maintenance strategies. In this section, a closedform model is developed and compared with the results obtained earlier.
Two failure models are encountered. The rst is the failure after PM, and the second is that after CM with p and c.
Let the rst failure after PM be during the period [t, t + dt]. The number of failures due to a rst failure after PM during this may be
obtained from
dNCM c T  t p ep t dt p ep t dt

(3)

where the rst term on the right-hand side is the differential of number of failures after the rst PM and second term corresponds to
the rst failure after PM.
Summing from 0 to T gives the number of failures between any two consecutive PM:
T

NCM c p T  t ep t dt p ep t dt

(4)

Developing this gives

T

NCM c p T ep t dt  c p t ep t dt p ep t dt c p TI1  c p I2 I3

where
T

I1 ep t dt; I2 t ep t dt and I3 p ep t dt

In what follows, the three aforementioned terms will be calculated. The rst term is
T

I1 ep t dt
0



1 p t T 1 
e

1  ep T
p

p
0

To calculate the second term, note the following well-known identity:

t ect dt

ect
ct  1
c2

With c =  p and substituting in the expression for T

"

942


ep t 
I2
p t  1
2
p

Copyright 2014 John Wiley & Sons, Ltd.

#T

T 1 



1  p t 
e
p t 1 0 2 ep T p T 1  1
2
p
p
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A. KHALAF ET AL.
Finally, the third term is
T

I3 p ep t dt 1  ep T
0

Substituting the expressions for the three terms gives the occurrence of the CM:
(
)







1
1 p T 
p T
NCM c p T
1e
e
p T 1  1 1  ep T
 c p
2
p
p






c
NCM c T 1  ep T ep T p T 1  1 1  ep T
p

c 
c T 
1  ep T 1  ep T
p



c 
1  ep T
c T 1 
p

(5)

In order to test the validity of this expression, evaluate next the limits for small and large T.
For small T


NCM




c 
c
1  1 p T c T 1 
p T c T p T  c T p T
c T 1 
p
p

For large T



c
c T
NCM c T 1 
p

This conrms the results because, for short periods, the probability of failure is governed only by PM, whereas for long periods, the
effect of PM is small compared with CM.

4.2. Failure-cost model verication

The failure model in Equation (5) is simulated in Scilab, and a comparison is obtained from the closed-form expression to that
obtained by simulation. Figure 8 in the following text shows the number of failures using the simulation and analytical methods
for the anaesthesia machine. It may be noticed that the values obtained t very well.

943

Figure 8. Number of failures PA from simulation and analytical results

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A. KHALAF ET AL.
The cost of the CM may be obtained by multiplying the mean CM cost by the number of occurrences of CM. Hence,
h


i
the cost for CM in the period of duration T is C CM C CM NCM C CM c T 1  pc 1  ep T where C CM is the mean cost
of CM.
The annual CM cost is
C aCM







365
365
c 
1  ep T
C CM NCM
C CM c T 1 
T
T
p

(6)

Furthermore, the annual PM cost is C aPM 365

T C PM where C PM is the mean cost of PM.
This leads to the following total annual cost

C aTot







365
c 
365
p T
1e

C CM c T 1 
C PM
T
T
p

(7)

The maintenance cost model in Equation (6) is simulated in Scilab, and a comparison is obtained from the closed-form expression
to that obtained by simulation. Figure 9 shows the yearly maintenance cost using the simulation and the analytical methods for the
anaesthesia machine. It may be noticed that the values obtained t very well.

5. Results
The analysis of the data for the PRIMUS anaesthesia machine has led to the following conclusions:
1. The age has no apparent effect on the survival probability of anaesthesia machine when doing both PM and CM.
This may be attributed to the effect of both PM and CM where = 0.0000097949 as in Figure 1. If we exclude PM
in the analysis as in Figure 3 where = 0.0000016778, the survival probability due to the effect of age is almost
the same.
2. PM has an effect on the survival probability of the anaesthesia machine, and this is clear in comparing results in Figure 1 with
Figure 3. The MTTF with the combined effect of PM and CM is 111 days compared with 88 days for the CM effect only, where the
MTTF is 124 days with the effect of PM alone. This analysis indicates that PM manufacturers recommended intervals have an
impact on the survival probability, but it was not possible to do the same analysis on same type and model of anaesthesia

944

Figure 9. Yearly maintenance cost from simulation and analytical results

Copyright 2014 John Wiley & Sons, Ltd.

Qual. Reliab. Engng. Int. 2015, 31 935947

A. KHALAF ET AL.
machine with no PM carried out because of unavailable maintenance data. On the other hand, one should question the validity
of PM intervals if it is based only on the annual risk associated with anaesthesia machine failures and consider doing SPI only.
However, PM should be applied to this equipment, which requires replacement of wearable parts, lubrication and so on based
on the assumption that recommended replacements are based on mean-time-between-failure studies conducted by the
component manufacturers.
3. Analysing yearly maintenance cost as a function of PM as in Figure 6 with values obtained from Figures 2 and 3 is a useful tool
in the planning of maintenance and in choosing the appropriate maintenance strategy based on available resources and
regulatory requirements. For example, hospital (A) can choose to extend PM interval to 12 or 24 months instead of 6 months,
and SPI is performed on anaesthesia machines on a scheduled base, as well as after each CM, in order to reduce the probability
of hidden and potential failures.
4. The analytical approach proposed using Equation (5) and the comparison between the simulation results and the
analytical ones as in Figure 7 show that the developed failure model is a valid one and may be generalised to analyse
number of failures of any medical equipment subject to available maintenance data and failure rates after PM and CM
with p and c.
5. The annual cost of CM may be calculated using Equation (6). The total annual cost of maintenance including both PM and CM
may be calculated using Equation (7), and the analytical results compared with the simulated results as in Figure 9 show that the
analytical method is accurate.

6. Conclusion
The analysis using the survival function and the failure-cost model has led to the following results:
1. PM has a signicant impact on the survival of anaesthesia machines and has extended the MTTF to 124 days compared with
88 days if doing CM alone.
2. The proposed scenarios for maintenance strategies is a useful tool to analyse the costs of PM, CM and annual cost of
anaesthesia machines, and similar approach may be applied to other medical equipment.
3. Applying the failure-cost model using failure rates obtained from the survival model has led to very good t compared with the
simulated result. This approach may be used with other medical equipment to calculate number of failures and maintenance
cost per annum.

References
1. Ridgway M. Manufacturer-Recommendation PM Intervals: is it time for a change. Biomedical instrumentation and technology 2009; 43:498500.
2. Wang B, Fedele J, Pridgen B, Williams A, Rui T, Barnet L, Granade C, Helfrich R, Stephenson B, Lesueur D, Huffman T, Wakeeld J, Hertzler L, Poplin B.
Evidence-based maintenance for medical equipment-part II. Journal of Clinical Engineering 2011; 36:7284.
3. Taghipour S, Deagan B, Jardine A. Reliability analysis of maintenance data for complex medical devices. Quality and Reliability Engineering
International 2011; 27: 7184.
rd
4. Emergency Care Research Institute (ECRI). Inspection and preventive maintenance system 1995, 3 edition.
5. Fennigkoh L, Smith B. Clinical equipment management. JCAHO PTSM Series 1989; 2:514.
6. Wang B, Fedele J, Pridgen B, Williams A, Rui T, Barnet L, Granade C, Helfrich R, Stephenson B, Lesueur D, Huffman T, Wakeeld J, Hertzler L, Poplin B.
Evidence-based maintenance for medical equipment-part I. Journal of Clinical Engineering 2010; 35:132144.
7. Troyer D. Strategic Plant Reliability Management Course Book. Noria Publishing: Tulsa, OK 2006.
8. Endrenyi J, Aboresheid S, Allan R. The present status of maintenance strategies. IEEE Transactions on power systems 2001; 16(4):638646.
9. Khalaf A, Hamam Y, Djouani K, Alayli Y. The effect of maintenance on the survival of medical equipment. Emerald Journal of Engineering, Design and
Technology 2013; 11(2):142157.
10. Caneld R. Cost optimization of periodic preventive maintenance. IEEE Transactions on Reliability 1986; 35(1):7881.
11. Endrenyi J, Sim S. Availability optimization for continuously operating equipment. Proceeding of the second PMAPS Symposium 1988.
12. Dekker R. Application of maintenance optimisation models: a review analysis. Reliability Engineering and Systems 1996; 51:229240.
13. Hai-Yen P. Periodic maintenance scheduling in clinical engineering. A case study, Ontario: University of Toronto 1991.
14. Frize M. Results of an international survey of clinical engineering departments. Part 2. Budget, stafng, resources, and nancial strategies. Medical
and Biological Engineering and Computing 1990; 28:160165.
15. Ridgway M, Atles L, Subhan A. Reducing equipment downtime. Journal of Clinical Engineering 2009; 34:200204.
16. Wang B. A practicum for biomedical engineering and technology management issues 2008; Chapter 14: 244.
17. Tarpey T. Statistical Models for Engineers, Lecture notes at Wright State University 2011.

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Authors' biographies

Dr Khalaf is a senior lecturer in Clinical Engineering at Tshwane University of Technology in South Africa and has 30 years of
experience in Clinical Engineering and Health Technology Management. He served at various managerial posts in industry,
government and academia. Since 2003, he has served in various honorary appointments with the National Department of Health
in South Africa, and in 2011, he was appointed as a member and deputy chair of the ministerial advisory committee on health
technology for 5 years. Dr Khalaf was born in Palestine and completed his BSc degree in Biomedical Engineering in Turkey in
1984. In 1995, he completed 2 years of postgraduate studies in medical technology in Germany, and in 2004, he was awarded his
masters degree in Clinical Engineering at the former Technikon Pretoria. In 2012, he was awarded his doctorate degree from Tshwane
University of Technology and PhD from Universite De Versailles Saint-Quentin-En-Yvelines, France in 2013.
Karim Djouani is a full professor, scientist and technical group supervisor of pattern recognition, soft computing, telecommunication,
networking systems and robotics. Since June 2012, he is the deputy director in charge of research at the IUT-CV (University Institute of
Technology) at University Paris Est-Creteil (UPEC). He is a member of the SCTIC team of the LISSI lab, University Paris Est. Since January
2011, he is a full professor at French South African Institute of Technology (FSATI) at Tshwane University of Technology, Pretoria,
South Africa, where he is presently the holder of an NRF chair in Enabled Environment and Assistance to Handicap. From July
2008 to December 2010, he seconded by the French Ministry of Higher Education to the French South African Institute of Technology
(FSATI) at Tshwane University of Technology (TUT), Pretoria, South Africa. Since June 2010, he is acting president of the French
Simulation Society and member of the board of the European Simulation Society (EuroSim).
Yskandar Hamam graduated as a bachelor of the American University of Beirut (AUB) in 1966. He obtained his MSc in 1970 and PhD
in 1972 from the University of Manchester Institute of Science and Technology. He also obtained his Diplme dHabilitation Diriger
des Recherches (equivalent to DSc) from the Universit des Sciences et Technologies de Lille in 1998. He conducted research
activities and lectured in England, Brazil, Lebanon, Belgium and France. He was the head of the Control Department and dean of
faculty at ESIEE, France. He was an active member in modelling and simulation societies and was the president of EUROSIM. He
was the scientic director of the French South African Institute of Technology (FSATI) at TUT in South Africa from 2007 to 2012.
He is currently a professor at the Department of Electrical Engineering of TUT. He has authored/co-authored about 300 papers in
archival journals and conference proceedings as well as book contributions. He is senior member of the IEEE.
Yasser Alayli received his PhD in Applied Physics from Pierre and Marie Curie University of Paris (Paris, France) in 1978. He is a
professor in the eld of engineering sciences and optronics at Versailles University (France). He was the director of LISV up to March
2013 and is currently a coordinator of a European Project Mobility Motivator and another project of charging electric cars by
induction. His research interests include precision engineering domain with sub-nanometric accuracy, optical sensors and
nanotechnologies.

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Appendix A
Algorithm 1

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