Andrew Bennett Bruce A. Brasser
Frank Hyland Jim Liston

With an eye toward a new fiscal year, many purchasing decision-makers get an early start, as they consider improvements and updates of equipment their facilities use on a day-to-day basis. Rehab Management arranged a roundtable-style interview with the following individuals to discuss how decisions for purchasing capital equipment are made for their respective institutions. Guests at the “table” include: Bruce A. Brasser, RN, MSN, MBA, vice president of clinical services and risk manager, Mary Free Bed Rehabilitation Hospital, Grand Rapids, Mich; Frank Hyland, MSPT, vice president, rehabilitation services administrator, Good Shepherd Rehabilitation Hospital, Allentown, Pa; Andrew Bennett, DPT, OCS, FAAOMPT, of Texas Physical Therapy Specialists (or TexPTS), New Braunfels, Tex; and Jim Liston, PT, MEd, CSCS, founder and president of the Competitive Athlete Training Zone (CATZ) and Physical Therapy Institute, Pasadena, Calif.

Rehab Management (RM): How many physical medicine and rehabilitation professionals (OTs, PTs, and SLPs) practice at your facility?

Brasser: Mary Free Bed Rehabilitation Hospital (MFB) employs approximately 60 physical therapists, 40 occupational therapists, and 20 speech and language pathologists in a variety of full-time and part-time positions.

Hyland: We have 100 physical therapists, 45 occupational therapists, and 32 speech and language therapists. We also have 10 recreational therapists, 45 COTAs, and 70 PTAs.

Bennett: We have a total of 15 licensed physical therapists employed by TexPTS.

Liston: We currently employ six full-time—and one part-time—physical therapists.

RM: What programs does your facility offer?

Brasser: [Our facility] provides comprehensive rehabilitation services for customers in our market areas, with a full range of programs. Inpatient programs include spinal cord injury, brain injury, stroke, bariatrics, amputee, orthopedics, and pediatrics. Outpatient therapy programs provide these same patient populations with a number of therapy options, and coordination of inpatient and outpatient care is a priority for our team. Physician and nursing services also are provided to our patients through our outpatient medical center, effectively meeting the clinical needs of the patients who require rehab-related physician and nursing services.

The Motion Analysis Center provides state of the art assessments of gait, with physical therapy and physician interpretation of findings and recommendations for treatment. Our drivers’ rehabilitation program provides valuable assessment and training for patients with disabilities throughout the Midwest. The MFB orthotics and prosthetics division serves patients within the campus, and at a number of other locations throughout West Michigan.

Hyland: We offer specialized programs in stroke, orthopedics, brain injury, spinal cord injury, pediatrics, amputation, speech and language, multiple sclerosis, and hand rehabilitation, among others. These are offered at 18 outpatient sites, four inpatient sites, a long-term acute care hospital, and two long-term care homes for people with severe disabilities.

Bennett: Like most PT clinics, we have some peripheral programs for patients such as aquatics or wellness and fitness assessments, but our focus is placed heavily on high-quality, evidence-based, orthopedic physical therapy. We do provide EMG/NCV diagnostic testing as part of our services when requested by one of our referring physicians.

Liston: Youth fitness programs, sports performance training, adult fitness, senior exercise classes, fall prevention programs, and aquatic therapy.

RM: Does your practice have a niche?

Brasser: As a provider of a comprehensive set of rehabilitation services, MFB has developed a number of specialty programs that meet the unique needs of the broader populations that are served. For example, our Intensive Therapy for Motor Recovery Program provides patients with spinal cord injuries with focused, intensive therapy services to maximize recovery. Focused outpatient physician and nursing services are available for a broad range of patient populations, including muscular dystrophy and ALS. The MFB Center for Limb Differences provides pediatric patients with amputations with an extensive array of services. A partnership with the Helen DeVos Children’s Hospital enables children with severe feeding limitations to receive treatment from a multidisciplinary team of feeding experts. Finally, the MFB Spasticity Management Program for both adults and pediatrics offers a range of therapy and treatment approaches, including a thriving Intrathecal Baclofen program that has earned national recognition.

Hyland: As a leading rehabilitation network, we have several key disciplines: neurorehabilitation, assistive technology, musculoskeletal, pediatric, industrial rehabilitation, and aquatic therapy.

Bennett: Yes. We provide outpatient orthopedic physical therapy services with a high specialization in manual therapy. Of our 15 PTs, seven are board certified in orthopedics, two are board certified in electromyography, four are fellowship trained, one is a certified hand therapist, and we currently have seven of our staff members enrolled in either an orthopedic residency or a manual therapy fellowship.

Liston: CATZ provides outpatient orthopedic therapy in a vibrant healing environment. We work with children, adults, and seniors. Our niche: youth athletes and sports enthusiasts.

RM: What is your primary buying cycle regarding the purchase of capital equipment (fiscal, yearly, quarterly, or as needed)?

Brasser: Capital expenditures are planned during the development of the annual operating budget, using a flexible long-range capital equipment improvement plan as a starting point. Each quarter, the specific capital equipment proposals (all equipment items exceeding $500) are reviewed by the hospital’s executive leadership team. Final approval for capital equipment purchases is provided by the board of trustees. A rapid approval process is used for purchases of capital equipment that is critical to the provision of therapy and nursing services. The hospital CEO approves these urgent requests, providing the organization with a valuable means for responding to changing needs in the hospital.

Hyland: It is fiscal—our year runs from July 1 till June 30 and we make budget decisions in February for the coming year.

Bennett: As needed.

Liston: We budget for capital equipment at the end of each calendar year. Smaller purchases are made on an as needed basis.

RM: What process do you follow when making purchasing decisions? How is the rehabilitation staff involved?

Brasser: Ideas and requests for equipment that can improve services are encouraged from all employees, and many of the capital equipment ideas are generated from the nurses, therapists, and physicians who work with patients each day. This includes replacement equipment as well as new equipment or technology that can enhance the rehabilitation care provided at MFB.

Program and department managers are responsible for developing a request for the equipment that is needed. For replacement equipment, this is often a routine request and requires little research by the responsible manager. However, the most expensive requests and many new equipment requests require a more detailed plan and justification. This analysis addresses the projected use of the equipment, the opportunity to share equipment between multiple programs, feedback from the physicians and staff, and the manager’s research on alternative products or vendors that is completed to secure the best service and price. Once this business plan is developed, the manager reviews this information with the director or vice president, who presents the request at the executive leadership team’s quarterly review.

Hyland: The basic decision is whether the purchase is going to be for replacement of existing equipment or if it is for a new piece of equipment. Each manager of an area submits a request for either new or replacement equipment and senior management makes the purchase decision on a priority basis.

Bennett: The therapists identify when an equipment item is needed and discuss it with the local clinic director. Each clinic has a semiannual internal budget to assist the director in making any equipment purchases on an as-needed basis. Items over a predetermined dollar amount require authorization from the executive staff before purchasing.

Liston: We discuss equipment needs at our monthly staff meetings. We are always looking for ways to better serve our customers and to meet their needs, and feedback from our therapists helps us better understand the pulse of each of our facilities.

RM: How do you determine whether to purchase new equipment?

Brasser: The decision to purchase new equipment is driven by patient needs, cost, and timing. The justification process at MFB begins with a review of the expected use of the equipment. Managers evaluate questions such as: How will this equipment help our patients and staff?”, “Is there another department that is currently using this equipment,and is there an opportunity to collaborate?”, and “Is there an equivalent alternative that would be less expensive?”.

Next, a cost/benefit analysis is completed for the most expensive equipment items, to ensure that the demand for the equipment is great enough to justify the purchase. Finally, timing of the purchase is determined, with urgent requests for critical replacement equipment taking priority over routine requests.

Hyland: This determination is based on three criteria—program needs, patient demand, and, very importantly, ROI (return on investment).

Bennett: I’m sure our approach to this isn’t much different than others: Does the equipment address an unmet, unique need? Are we losing by not having the equipment (in clinical care or customer service)? What is our ROI (whether clinical or customer service)? Is it in the budget? Is there an alternative that will meet the need adequately?

Liston: There is a certain standard and quality we need to maintain when it comes to function and appearance of our equipment. Our customers expect state-of-the-art equipment and we deliver it. We get rid of the older pieces that don’t meet our standards.

RM: What pieces of equipment are you planning to purchase this year (for example: beds, computer equipment, gait and balance equipment, aquatic therapy devices, lifts, and transfer equipment)?

Brasser: [We have] added some outstanding new equipment in the past 3 years, and 2008 will be no different. Current plans for capital equipment include the expansion of ceiling-mounted patient lift systems within patient rooms. These are currently in place for each room on the spinal cord injury team; these lifts have significantly reduced employee injuries, have added efficiency for the staff, and are appreciated by the patients.

Expected therapy equipment purchases include additional FES devices for both upper and lower extremities and expanded patient education materials using Internet-based technology. MFB therapists will also be evaluating commercially available devices, such as the Nintendo® Wii™ system, to determine if this equipment can enhance the rehabilitation services provided for certain patients.

Hyland: We are primarily looking at replacing hospital beds and acquiring additional gait and balance equipment for our neurorehabilitation outpatients.

Bennett: As we expand and open additional clinics, we have a basic “package” of sorts with the clinical equipment and office equipment that is needed to sufficiently support a start-up. Most of the large cost items can be attributed to cardiovascular equipment, hi-lo tables, and computers.

Liston: We will be purchasing new therapy tables, two new computer stations, a cross cable machine, and various smaller pieces of equipment.

RM: What is the most common new piece of equipment that your rehabilitation department is planning to purchase?

Brasser: MFB maintains a fleet of wheelchairs that are used by patients and therapists in all programs when selecting the most appropriate wheelchair for the patient. Each year, one or more new wheelchairs are purchased to provide patients and caregivers with the best choice.

Hyland: Hospital beds—we are going into a new cycle where beds need to be replaced.

Bennett: More hi-lo tables.

Liston: More towels and lightweight dumbbells.

RM: There are many different factors to consider when making capital purchases, such as vendor visits, site visits, price points, and service agreements that play into a purchasing decision. What are those considered most important by your facility?

Brasser: MFB completes a thorough analysis of a number of key factors prior to any capital equipment purchase. This scrutiny is time-intensive but significantly reduces the chance that equipment purchased in the last year is rarely used or, worse yet, hidden in a closet and covered with dust. The MFB leadership team accepts the responsibility for completing this analysis,and the staff members understand this and regularly participate in the review process.

MFB routinely uses vendor demonstrations and site visits, as well as reference contacts with rehabilitation hospitals that are already using the equipment or working with the vendor. Whenever possible, MFB uses a trial period for the equipment, which allows staff members to learn about the equipment and use this with patients after training is completed. This was a very important part of the selection process for a ceiling-mounted lift system in 2006.

Hyland: Good Shepherd has developed a reputation as an early adopter of technology, and we take great care to live up to our promise for advanced care and rehabilitation supported by technology. This has led us to being asked by manufacturers to be a beta site for testing new equipment. A recent example was the Bioness L300, which is used to treat foot drop. In other instances,we have taken equipment on trial or called other hospitals to do reference checks on the effectiveness of new equipment.

Bennett: Although the cost is a large part of the decision making, we also highly value the relationships we have with our vendor reps. Having the ability to send a single e-mail or make a single phone call to have a replacement part shipped or equipment item serviced is key. Bottom line: customer service and cost.

Liston: This is in order of importance: site visits, referrals from fellow therapists, a fair price, and a good service agreement.

—Rogena Schuyler Silverman