








































J Global Clinical Engineering Issue 2:4-16; 2019  4

Received November 18, 2018, accepted March 02, 2019, date of publication March 21, 2019

Evaluation of Medical Equipment Technology 
Management Performance Outcomes Related 
with Patient Safety: A Mathematical Analysis of 
Advanced Clinical Engineer

By M. A. Hossain1, M Ahmad2, M R Islam2, and Y David3

1 National Electro- Medical Equipment Maintenance Workshop & Training Center, Dhaka under the Ministry of Health & Family 
Welfare, Government of the People's Republic of Bangladesh
2 Department of Electrical and Electronic Engineering,  Khulna University of Engineering & Technology (KUET), Khulna-9203, 
Bangladesh
3 Principal, Biomedical Engineering Consultants, LLC, USA 

ABSTRACT

With the rapid development of medical equipment technology, the quality of patient care becomes under the spotlight of 
clinical engineering management of medical equipment since the past 4 decades and it is continually. Researchers give 
in-depth attention to minimize undesired incidents which are associated with medical and surgical equipment such as 
patients' unnatural deaths and injuries. This proposed research work investigates the relationship between performance 
outcomes of medical equipment technology management/patient-care technology and the reduction in undesired events 
like injury and even unnatural deaths. This proposed research work investigates the effect of varying levels of performance 
on quality of patient care and uses an indicator such as patient safety (PS) and cost-effective care by applying mathemati-
cal modeling of clinical engineering approach methodology to medical equipment technology management. In this study 
the quality model of Clinical Engineering Departments is determined by educational qualification, Clinical Engineering 
(CE) certification, training, and duration of experiences in this field. The standard performance of patient-care technology 
management is determined by the parameters of medical devices and the outcomes performance of medical equipment 
is determined. Data for this study was collected from 18 countries including from high, upper and lower-middle income 
regions. We were able to collect and analyze data of different performance levels of CE and biomedical engineering pro-
grams. The analysts' report measures the performance outcomes of Medical Equipment Technology Management System 
(METMS) and its impact on patient-care outcomes specifically impact on the reduction of patient risk factors associated 
with medical and surgical equipment. The findings should encourage researchers and healthcare stakeholders to better 
integrate the clinical engineering professionals in a hospital in order to achieve a safe functional condition of medical 
equipment to keep its scheduled life span in compliance with recommended span declared by manufactures. Cost-effective 
Clinical Engineering Department (CED) model can be designed and monitored through the methodology of this study. We 
hope that this study will motivate the deployment of senescence methodology for conventional electro-medical assets, by 
biomedical engineering and medical professionals, healthcare policymakers, equipment users, and vendors to improve 
outcomes as proposed by the research work described in this paper. 

Keywords – clinical engineer, Clinical Engineering Department, medical equipment technology, hospital, quality of patient care



5 J Global Clinical Engineering Issue 2:4-16; 2019

Hossain, Ahmad, Islam, David: Evaluation of Medical Equipment Technology Management Performance Outcomes 
Related with Patient Safety: A Mathematical Analysis of Advanced Clinical Engineer

INTRODUCTION
Ensuring the quality of patient care when medical 

equipment is deployed becomes a global issue and must be 
addressed in order to avoid unintended patient outcomes. 
Qualified clinical engineer's knowledge and methodologies 
are used as an approach to reduce risk factors associated 
with the use of medical and surgical equipment.1,2 This 
proposed research work investigates the relationship 
between performance outcomes of medical equipment 
technology management/patient-care technology and 
the reduction in undesired events like injury and even un-
natural deaths. Despite the continuous necessity to ensure 
the quality performance and impact on patient outcomes 
of medical equipment technology the establishment of the 
standardized ratio of Clinical Engineering Department 
(CED) in hospitals under public healthcare system, many 
countries could not fully accept it. As a result, every year, 
many patients have been subjected to serious risks and 
even unnatural death which was not reported to agen-
cies in many countries. For lower- and middle-income 
counties, this data is often hidden and frequently, both 
the doctors and patients were not aware of the cause.3–5

 This proposed research work investigates the effect 
of varying levels of performance on quality of patient 
care and uses indicators such as patient safety (PS) and 
cost-effective care by applying mathematical modeling 
of the CE approach methodology to medical equipment 
technology management. In this study quality model 
of CED's is determined by educational qualification, CE 
certification, training and duration of experiences in this 
field. The standard performance of patient-care technol-
ogy management is determined by the parameters of 
medical devices and the outcomes performance of medi-
cal equipment is determined.6–8  Data for this study were 
collected from 18 countries including from high, upper 
and lower-middle income regions.9 

While technology reliant patient-care services can vary 
widely in their dependency, the ratio of clinical engineering 
professionals serving the population can be one indicator 
that is common to many regions. One Clinical Engineering 
Professional (CEP) can adequately service technologies 
supporting a population of 10,000 persons, and one CED 
can manage CE service program for region with a popula-
tion of 10,000.9 Quality performance of CEP and Medical 

Equipment Technology Management System (METMS) 
can be standardized by adopting parameters that relate 
to equipment performance such as unintended incidents, 
downtime, cancellation of patient examinations due to 
equipment issue, and similar known indicators.10,11 By 
using mathematical analysis, the performance outcomes 
of METMS can be benchmarked and compared with other 
facilities.10 It must be remembered that even a 100-bed 
modern hospital operation is ensuring the quality and 
safety of patient-care in any zone of a country.10 The per-
formance outcomes thus relate to patient-care outcomes 
and the status of patient safety (PS) can be measured by 
tools such as laptops, pen drives, Internet modems, cell 
phones, and testing analyzer use for data collection. This 
investigation interpreted correctly, can contribute to the 
development of voluntary guidelines for adopting and 
improving performance reporting. Similarly, patient-care 
organizations and groups actively involved in furthering 
measurement, management and reporting may use this 
methodology in assessing the impact of work carried out 
by them in adopting the CED model in hospitals to evaluate 
and enhance the performance of patient care like PS and 
educating them for ensuring the standard performance 
of MEMTS.11

We were able to collect and analyze data of different 
performance levels of CE and biomedical engineering 
programs. The analyst’s reports measure the performance 
outcomes of MEMTS and its effect on patient-care out-
comes specifically on the reduction of patient risk factors 
associated with medical and surgical equipment. The 
findings should encourage researchers and healthcare 
stakeholders to better integrate the CEPs in their hospitals 
in order to achieve a safe functional condition of medical 
equipment and to keep its scheduled lifespan in compli-
ance with those recommended by the manufactures.12 A 
cost-effective CED model can be designed and monitored 
through the methodology of this study.

Despite barriers including low willingness, competing 
business group interests, and unethical pressure from 
some personnel within the healthcare system,13 it is for 
the benefits of the patients, their relatives, and taught 
stakeholders that well-managed healthcare technology 
has a positive impact on care outcomes and on the optimal 
use of limited healthcare resources. This investigation, if 



Hossain, Ahmad, Islam, David: Evaluation of Medical Equipment Technology Management Performance Outcomes 
Related with Patient Safety: A Mathematical Analysis of Advanced Clinical Engineer

J Global Clinical Engineering Issue 2:4-16; 2019  6

interpreted correctly, can contribute to the development 
of voluntary guidelines for adopting and improving per-
formance reporting. Similarly, patient-care organizations 
and groups actively involved in furthering measurement, 
management and reporting may use this methodology in 
assessing the impact of work carried out by them in adopt-
ing the CED model in hospitals to evaluate and enhance 
the performance of patient care like PS and educating 
them for ensuring the standard performance of METMS. 
But, in spite of some challenges, the need for this pro-
posed research work cannot be denied.13,14 We hope that 
this study will motivate the deployment of senescence 
methodology for conventional electro-medical assets, 
by biomedical engineering and medical professionals, 
healthcare policymakers, equipment users, and vendors 
to improve outcomes as proposed by the research work 
described in this paper. While an analytical approach to 
PS and cost-effective care has become the expectations of 
patients, this topic is starting to be explored in the litera-
ture, mostly concluding that additional data is needed.

RELATED DEFINITIONS AND TERMINOLOGIES 
While it is unreasonable to assume that clinical engi-

neeThis section uses definitions and terminologies related 
to the proposed research with subsequent subsections 
presenting different definitions and terminologies.

Evaluation
Evaluation is a systematic determination of a subject's 

merit, worth, and significance using criteria governed by 
a set of standards. It can assist an organization, program, 
project, or other intervention or initiative to assess any 
aim, realizable concept/proposal, or alternative that would 
help in decision-making, or to ascertain the degree of 
achievement or value in regard to the aim and objectives 
and results of any such action that has been completed. 
The primary purpose of evaluation, in addition to gaining 
insight into prior or existing initiatives, is to enable reflec-
tion and assist in the identification of future changes.15–17 

In this study, we evaluate the performance outcomes of 
METMS to understand the situation of PS.

Medical Equipment Technology Management
Confusion is often seen in research with the use of 

some of the terminology such as Healthcare Technology 
(HT), Medical Technology (MT), Medical Devices Technol-
ogy, Medical Equipment Technology (MET). For better 
understanding, we submit an explanation in this section. 
The World Healthcare Organization (WHO) has defined 
HT as the “application of organized knowledge and skills 
in the form of devices, medicines, vaccines, procedures, 
and systems developed to solve a health problem and 
improve quality of life.18” The International Network of 
Agencies for Health Technology Assessment has stated 
that HT includes pharmaceuticals, devices, procedures, 
and organizational systems used in the healthcare industry, 
as well as computer-supported information systems.19 
But our proposed study deals with MET which is one 
of the major elements of HT. In the United States, these 
technologies involve standardized physical objects, as well 
as traditional and designed social means and methods to 
treat or care for patients.20 

Wikipedia has stated that HTM sometimes referred to 
as CE, CE management, clinical technology management, 
HT management, medical equipment management, bio-
medical maintenance, biomedical equipment management, 
and biomedical engineering.21 MT may broadly include 
medical devices, information technology, biotech, and 
healthcare services.21 Alternatives terms have mentioned in 
2 statements. Among them, the term “clinical engineering 
management” is appropriate for the proposed research 
work. The justification for the selection of MET manage-
ment for this proposed study has given as the statement 
in the next paragraph.

The synonym of clinical engineering is medical en-
gineering and besides technology is one of the parts of 
engineering and clinical engineering role is to maintain 
the management of medical equipment. So according to 
references and discussions, the term clinical engineering 
management" can be used as "medical equipment technol-
ogy management." For the entire proposed research work, 
the term medical equipment technology management is 
to be used. METMS can be defined as the mechanisms for 
interaction and oversight of the medical equipment used 
in the diagnosis, treatment, and monitoring of patients. 



7 J Global Clinical Engineering Issue 2:4-16; 2019

Hossain, Ahmad, Islam, David: Evaluation of Medical Equipment Technology Management Performance Outcomes 
Related with Patient Safety: A Mathematical Analysis of Advanced Clinical Engineer

The related policies and procedures govern activities from 
selection and acquisition to incoming inspection and main-
tenance of medical equipment. The main goal of METMS 
is to ensure that the equipment used in patient care must 
be safe, available, accurate, and affordable. This article 
deals with the evaluation of the performance outcomes of 
medical equipment technology management system that 
are related to patient safety.

ADVANCED CLINICAL ENGINEER'S APPROACH 
Although procedures can vary from one field of inquiry 

to another they are often quite similar. The process of a 
skilled CE method involves making hypotheses, deriving 
predictions from them as logical consequences, and then 
carrying out experiments or empirical observations based 
on those predictions such as quality of CED models and 
their contributions for appropriate controlling of MET 
to ensure the PS.24

Methodology
The safe functional condition of medical equipment 

ensures it reaches its scheduled life span in compliance 
with manufacturers recommendations. These are the 
outcomes of HT management and it is actively related to 
patient satisfaction parameters such as PS, quality, and 
cost. However, this can not be ensured by many countries 
due to a lack of a skilled clinical engineer's approach. 
While the global CE forum has been trying to improve 
the quality of CEPs in many higher, upper-middle income 
countries, lower-middle-income countries have not yet 
implemented the conventional engineering approach 
for managing the medical equipment in their countries. 
Authors have stated that a conventional CEP is 14% of 
the skills on METMS. Investigation reports show that the 
PS of these countries has become questionable and it is 
continually.25 Subsequent studies provided additional 
quantitative data. In a landmark report, “To Err is Hu-
man: Building a Safer Health System,” the Institute of 
Medicine estimated that medical errors cause 44,000 
to 98,000 deaths annually in U.S. hospitals.26 We did not 
find any articles regarding MET assessment in lower-
middle income countries such as Bangladesh due to a 
chronic lack of a CE approach. Investigation reports by 
the WHO in 2017 report that the density of biomedical 

engineering professionals and density of hospitals with 
biomedical engineering department unit/service are very 
poor to negligible in lower-middle income countries like 
Bangladesh, Bhutan, Pakistan, Nepal, Sri-Lanka and so 
forth.9 As a result, the performance outcomes of METMS 
in these countries have not been good. The investigation 
report of the World Bank has stated that more than 65% 
of medical and surgical equipment were not functioning 
in Bangladesh public hospitals.27 Functional equipment in 
the intensive care units of Bangladesh hospitals provided 
much error-filled data. From the investigation report, we 
have observed that PS is very poor in the intensive care 
units of 6 modern hospitals in Bangladesh due to the 
absence of hospital CEDs.28 

Some of the issues are outlined below:

a. The staffing model of the CED could not design and 
develop to match the workload and activities of the 
hospitals.

b. The message of modeling a CE approach for evaluat-
ing the quality of patient care could not be properly 
disseminated among healthcare stakeholders properly 
thus eliminating the conventional engineering approach 
by the research.

c. The concept regarding the importance of modeling 
of CEDs and their relation to obtaining safe outcomes 
performance of METMS as well as its relation with 
parameters of quality of patient have yet to be unex-
plored in the literature. 

d. Both patients and medical doctors are not yet aware 
of the benefits of introducing quality CED models in 
the hospitals. 

Objectives of this study are as follows:

1. To define the outcomes of METMS and its impact to 
ensure PS

2. To investigate the present densities of CEP and CED 
per 10,000 population 

3. To analyze the outcomes of METMS related to CED
4. To specify densities of CEP and CED and their quality 

related to outcomes of METMS
5. To evaluate the performance outcomes of METMS to PS

6. To submit a recommendation for improving the pres-
ent poor conditions



Hossain, Ahmad, Islam, David: Evaluation of Medical Equipment Technology Management Performance Outcomes 
Related with Patient Safety: A Mathematical Analysis of Advanced Clinical Engineer

J Global Clinical Engineering Issue 2:4-16; 2019  8

The purpose of this section is to undertake a literature 
review focusing on PS by applying the quality model of 
CED. Shaffer has submitted a statement regarding the 
selection criteria of one clinical engineer professional 
based on population and bed numbers of the hospital.26 
The author stated “the recent history of this sub-discipline 
is somewhat erratic. In the early 1970s, CE was thought 
to be a field that would require many new professionals. 
Estimates for the U.S. ranged as high as 5,000 to 8,000 
clinical engineers or 5 to 10 clinical engineers for every 
250,000 of the population, or one clinical engineer per 
250 hospital bed.”26 

From this statement, it is found that one CEP was 
needed per 31,250 people in the U.S. The WHO litera-
ture has suggested that one CEP is required per 10,000 
people in general regions.9 From this statement, we have 
observed that the current demand for biomedical engineer-
ing professionals has significantly increased more than 
threefold over the past 48 years. This has been revealed 
by the earlier publication by Shaffer.26 Besides the den-
sities of CEP/BEMP and hospital with CED/biomedical 
engineering unit/service were presented for per 10000 
population of WHO enlisted countries respectively. The 
data are very much helpful for this study. 

Pietro et al stated that an HT or MET assessment 
process is conducted by interdisciplinary groups using 
explicit analytical frameworks drawing from a variety 
of methods.2 Given the variety of impacts addressed and 
the range of methods that may be used in an assessment, 
several types of experts are needed in HTA. Among them, 
clinical and biomedical engineers are considered the key 
components for the HTA. ACCE defines, the clinical engi-
neer as a professional, who supports and advances patient 
care by applying engineering and managerial skills to 
HT.23 The performance of METMS is very much important 
and related to the outcome of patient care and safety.9 
Eighty percent of METMS is maintained by the hospital 
in-house CED, and clinical departments are responsible 
for maintaining the remaining 20% of METMS.23 Hossain 
et al have stated that a skilled clinical engineer maintains 
52% of METMS in the modern hospital and subsequently, 
a typical METM cycle is represented in Figure 1.28

The WHO has stated that introducing quality bio-
medical/clinical engineering department unit/service 
is compulsory in modern hospitals to obtain the quality 
outcomes of METMS.9 From a comprehensive literature 
review,11 it was found that it is very important to develop a 
model of CED which consists of a skilled clinical engineer, 
a CE technologist, and a biomedical equipment techni-
cian. Their performances can be determined by basic 
education, accredited certificate on MET, and length of 
services in this field. Regardless of the necessity to design 
and introduce a quality CED model to optimize the use of 
MET, many countries could not yet do so. As a result, the 
lower performance outcomes of patient-care technology 
reduced the quality of patient outcomes. A group of search 
results explored that PS has been reduced with rapid 
increases of complex medical devices in lower-middle 
income countries. This study investigated the quality 
model of a CED and its performance outcomes related to 
PS.6,11 It has also been shown common models of CED for 
HT management system for the hospitals. For example, a 
CED model is shown n Figure 2.

Figure 2. does not include a clinical engineering tech-
nologist (CET) to ensure the safe operation of critical 
equipment such as a heart-lung pump machine. Whereas, 
a group search results suggested that 3 types of engineer-
ing professionals must be considered such as engineers, 
technologists, and technicians.29 Other studies (e.g., Ja-
pan, Malaysia) have also emphasized this to ensure safe 

FIGURE 1. Roles of the Clinical Engineering Department to 
ensure the performance of Medical Equipment Technology 
Management Systems parameters.



9 J Global Clinical Engineering Issue 2:4-16; 2019

Hossain, Ahmad, Islam, David: Evaluation of Medical Equipment Technology Management Performance Outcomes 
Related with Patient Safety: A Mathematical Analysis of Advanced Clinical Engineer

operation and preventive maintenance tasks.9,23 Recent 
publications note that CETs are very much important 
human resources to ensuring the safe operation of life 
support, therapeutic, and monitoring equipment in the 
critical care departments in a hospital.22 Other studies 
suggest that CETs are the best operators of life support, 
therapeutic, and monitoring equipment in the Critical Care 
Unit, the Intensive Care Unit, the Operating Theatre, and 
the Dialysis, Anesthesia, and Emergency Departments as 
well.29,30 Integration of CEs, CETs, and biomedical equip-
ment technicians (BMETs) are shown in Figure 3.

METMS are very much closed to CEDs for patient care. 
Certified staff from CEDs are much better than Conven-
tional Engineering Department in hospitals. But, it is 
not possible to ensure all parameters of METMS by CEs 
because some parameters of METMS are actively related 
to CETs and BMETs. The overdependence on the use of 
technology in every treatment step can result in severe 

FIGURE 2. Clinical Engineering Department model for a hos-
pital in the U.S.

FIGURE 3. A basic model of a Clinical Engineering Department 
for a hospital.

CE = clinical engineer; CET = clinical engineering technologist; BMET = biomedical 
equipment technician.

economic burdens for families and individuals. However, 
the cost can be minimized by ensuring the desired life-
cycle of the medical equipment. From literature review 
results it was observed that the model of a CE approach 
can ensure the safe use of equipment up to the expected 
life span.22 The World Health Organization noted that one 
CEP can be considered per 10,000 population. From the 
literature review results,22 the performance of AP can be 
considered as 100% subject to accessibility of the density 
of CEP=1, per 10,000 people and the performance of GP 
can be considered as 100% subject to density of hospital 
with CED unit/service of 3.00 per 10,000 people to ensure 
24-hour services. So, the performance of Ap = 1 @ density 
of CEP=1, and GP=100%. @ hospital density with CED unit/
service CED= 3 for per 10,000 population in a country.

RESEARCH METHODOLOGY

Goal of the Prospective Research
The main aim of the proposed study is to evaluate the 

performance outcome of METMS by applying skilled a CE's 
approach to enhance the present PS. The sub-objectives 
of this proposed study are explained below:
1. To investigate and standardize the performance of 

CEPs per 10000 people in a country.
2. To investigate and standardize the performance of 

CEDs per 10000 people in a country.
3. To control the performance of CEDs by CEPs to obtain 

a standard output of METMS for ensuring PS.

Research methodology and materials
Let Rp and CP are the desired input and actual output 

METM that depends on the standard performance of CED. 
From the literature review results,3-5 it has seen that the 
performance of METMS is dependent on the quality of the 
performance of the CEDs. The CEPs are the controller or 
regulator of the CEDs and which control the performance 
of the CED (i.e., CEP controls the performance of METMS). 
Here, CEP is defined as the clinical engineering manager 
who monitors and evaluates the performance output of 
the CED. According to the basic argument in the literature 
review results and discussions, the methodology of the 
proposed study can be presented by Figure 4.17



Hossain, Ahmad, Islam, David: Evaluation of Medical Equipment Technology Management Performance Outcomes 
Related with Patient Safety: A Mathematical Analysis of Advanced Clinical Engineer

J Global Clinical Engineering Issue 2:4-16; 2019  10

FIGURE 4. Proposed research methodology to evaluate the 
performance outcomes of METMS that is with patient safety.

Based on the desired input quantity being improved, 
and on the actual output condition, the input and output 
variables can be modeled as safe functionality of medical 
devices up to their standard life span. According to Fig.4 
& basic feedback control theory, the output performance 
of GP can be measured by the following Eq. (1)

From Eq. (1), it is seen that the value of CP is dependent 
on the value of AP and GP. So, this is needed to standardize 
the performance of AP and GP and thus from Eq. (1), the 
value of CP can be measured.

Basic analysis of the proposed study
The value of CP is dependent on GP and Ap. Figure 4 

shows that AP works as a sensor for the system. So, for 
an enhancing output and stability of the system, the per-
formance of AP must be kept in a standard setting point. 
Besides, it is needed to keep the performance of GP as 
standard. We can consider the desired input or reference 
input such as the safe functional condition of medical 
devices up to their standard life span= RP=100%. As it 
is related to the PS and desired by the patient, 100% can 
be considered. It is obvious that patients do not expect 
to suffer unintended outcomes including accident, injury, 
or other harm from medical devices. For any value of GP, 
the value of (1+AP.GP) should be greater than GP and the 
value of Cp/Rp  will be less than 1 or the value of CP will 
be less than 100%. 

For testing the proposed work methodology, let us 
consider AP=1 and GP=100% and by the calculated of CP 
will be 99%. From a group of search results it is found 
that the sensor's setting point 1 is standard.8,9,11 To set 
the standard value of Ape=1, it is needed to standardize 
the performance of AP. Besides, the performance of GP is 
needed to standardize.

Standardize performance of AP and GP

The performance of AP of GP can be standardized by 
the following Eq. (2) and Eq. (3).

From the literature review results, the performance 
of AP can be considered as 100% subject to accessibil-
ity of density of CEP=1, per 10,000 population and the 
performance of GP can be considered as 100% subject to 
the density of hospital with a CED unit/service of 3.00 
per 10,000 population to ensure 24-hour services.17 

So, the performance of Ape= 1@density of CEP=1, and 
GP=100%. According to the literature it is observed that 
the density of a hospital with a CED is 3. 5 per 10,000 
people in Japan.9 It can also be considered that the den-
sity of a hospital with a CED service is 1 for 8 hours per 
10,000 people. For ensuring 24-hour CED services with 
a minimum density of a hospital with a CED per 10,000 
people can be considered as 3. According to a statement 
by Hiroki Igeta from the Clinical Engineering Bank,9,31,32 
it was observed in staff for a CE service structure that the 
quality of patient care was related to the number of the 
skilled human workforce.  For example; the optimal ratio 
for medical doctors to population are 1:1000. Available 
statistics show that over 45% of WHO Member States 
report to have less than 1 physician per 1000 population. 
CEPs and CEs are not at the same levels. A CEP is defined 
as a senior skilled CE. So, one CEP can be considered for 
10,000 people a standard setting point of AP. From a 
group of literature review results, it was observed that 
24 hours of equipment services are required to ensure 
PS in the Critical Care Unit.7–9,11 So, the CEDs services are 

(2)

(3)

(1)

CED = Clinical Engineering Department; METMS = Medical Equipment Technology 
Management System.



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Hossain, Ahmad, Islam, David: Evaluation of Medical Equipment Technology Management Performance Outcomes 
Related with Patient Safety: A Mathematical Analysis of Advanced Clinical Engineer

considered as 3 times for 24 hours. Staff duty is consid-
ered as 8 hours and regarded as fulltime employ (FTE). 
Therefore, the density factor has considered as “3”. From 
the discussions, the value of AP and GP can consider as 
Ap=1, to ensure 100% performance and CED= 3 to ensure 
the 100% performance of GP. So, the value of the sen-
sor can be determined by the density of CEP for 10000 
population (D1). So, the relation between Ape and D1 is 
inversely proportional. Standard performance of D1 is set 

TABLE 1. Standard Data Related to the Proposed Study

Integer D1 AP D2 Gin  

1. 1 1 3 100% 99%

2. 0.9 1.11 2 66.67% 88.88%

3. 0.8 1.25 1 33.34% 78.12%

4. 0.7 1.43 0.9 30% 68. 34%

by D1=1 and its inverse corresponding values are shown 
as AP. Standard performance of D2 is set by D2=3 and its 
proportional values are shown by GP. For validation, the 
proposed work methodology the values of CP are shown. 
The standard data of AP and GP and their corresponding 
values CP are shown in Table 1.

Table 1 shows the validity of the prospered research 
work methodology. Next section uses for data collections 
and data analysis related to AP and GP.

Data collection to standardize the performance 
of AP and GP

Data collection has been accomplished by a survey 
conducted by the WHO in 2017. Global dimensions of 

biomedical engineers,9 has submitted a survey report on 
D1 and D2. Based on data and the basic theme, the exist-
ing data were analyzed and as AP and GP and outlined in 
Table 2. 

TABLE 2. Present Data of AP and GP for 18 Countries

Country code The density of CEP per 
10,000 people (D1) AP

Density hospital with CED unit 
per 10,000 people (D2) GP in%

Any country 1 1 3 100

JPN 1.58 0.64 3.5 116

SVN 0.84 1.2 1.35 45

BEL 0.87 1.5 1.25 42

IRL 0.7 1.42 1.21 41

KIR 0.27 3.7 2.93 97

MYS 0.82 1.2 0.84 28

PAN 0.83 1.22 0.74 25

MNG 0.81 1.18 0.74 25

FIN 2.73 0.37 0.09 3.9

ISR 2.48 0.42 0.09 3.9

ROU 0.64 1.56 0.30 10



Hossain, Ahmad, Islam, David: Evaluation of Medical Equipment Technology Management Performance Outcomes 
Related with Patient Safety: A Mathematical Analysis of Advanced Clinical Engineer

J Global Clinical Engineering Issue 2:4-16; 2019  12

Country code The density of CEP per 
10,000 people (D1) AP

Density hospital with CED unit 
per 10,000 people (D2) GP in%

JOR 0.67 1.49 0.16 5.33

AUS 0.13 7.69 0.43 14.33

IND 0.34 2.94 0.12 4.00

ZAF 0.06 16.67 0.34 11.33

MDS 0.03 33.34 0.037 1.23321

BTN 0.08 12.5 0.047 1.56651

PAK 0.02 50 0.1 3.333

Data collection and statistical analysis
Based on the analysis, the value of Cp can be evaluated 

using Eq.(4) below.

So, the standard value of CP=99% and it is the output 
of METMS(GP). Cp=Safe functional condition of medical 

(4)

TABLE 3. Statistical Data Analysis of CP of 18 Countries

Country code AP GP % Cp

JPN 0.64 116 178.841

SVN 1.2 45 36.82

BEL 1.5 42 27.60

IRL 1.42 41 28.40

KIR 3.7 97 26.14

MYS 1.2 28 22.62

PAN 1.22 25 19.84

MNG 1.18 25 20.50

FIN 0.37 3.9 6.25

ISR 0.403226 3.9 5.92

ROU 1.5625 9.999 6.01

JOR 1.492537 5.3328 3.18

Country code AP GP % Cp

AUS 7.692308 14.3319 1.85

IND 2.941176 3.9996 1.25

ZAF 16.66667 11.3322 0.68

MDS 33.33333 1.23321 0.037

BTN 12.5 1.56651 0.12

PAK 50 3.333 0.067

equipment to reach its scheduled life span in compliance 
with the manufacturer’s recommendations. But, this factor 
is related to PS and thus the values of Cp are proportional 
to PS. This research methodology can be used as the 
standard for any country. 

The analyst’s data in Table 3 regarding AP & GP were 
used to evaluate the values of CP using Eq.(1) and these 
values are shown in Table 3. 

Results and discussion
The maximum value of CP has found as 178.84% in 

Japan and the minimum value of CP has found 0.067% in 
Pakistan. For authentication of the results, we examined 
the in-house CE models of Japan and Pakistan. Accord-
ing to the standard guideline of the WHO, we have seen 
that the maximum 12 CEs were necessary for the Aso 
Hospital in Japan.28 But Igate and colleagues suggested 
63 CEs under the CED in Aso Hospital.32 He has stated 



13 J Global Clinical Engineering Issue 2:4-16; 2019

Hossain, Ahmad, Islam, David: Evaluation of Medical Equipment Technology Management Performance Outcomes 
Related with Patient Safety: A Mathematical Analysis of Advanced Clinical Engineer

that improvement to the level of service for patients was 
a result of standardized clinical techniques ensuring the 
efficient and safe use of medical equipment. 

The performance of the Ap has found as more than 1 
and its corresponding sensor setting point of the feedback 
controller is 0.64 and is shown in Table 2. On the other 
hand, the value of D2 is 3.5 and it is more than 3. This in-
dicates that the performance of GP is higher than 100%. 
From the data of CEP and CED, we have seen that Japan has 
introduced more CEs to cover 24-hours of services such 
as other Intensive Care Unit professionals. Besides, it is 
found that common medical equipment such as ventilators, 
defibrillators, hyperbaric oxygen therapy, hemodialysis, 
cardiac pacemakers, and surgical equipment have been 
operated by the CETs. Therefore, the performance output 
value of MEMTS in Japan is (1.80×99%) = 178.84% and that 
is 1.8-times higher than that of the standard actual value 
of CP. From the data, it was found that 10% of hospitals 
of Pakistan have introduced the biomedical engineering 
department and the number of biomedical engineers 
was 0.02 per 10,000 people. Therefore, the measuring 
feedback sensor setting point of this country was 50. The 
values of CP was found as 0.07% which is quite poor.9,32

Analysis and discussion
Despite being developed countries, FIN, ISR, and AUS, 

showed poor values of CP. The evaluated value of CP in 
Japan was found to be much higher than the standard 
among the 18 countries. Although the performance out-
comes of METMS of 7 countries were found to be less 
than that of the actual standard value of CP, it can still be 
considered. The analysts' reports also show that the CP 
values of 10 of the 18 countries were much poorer than 
that of the standard.

Limitation of data collection and analysis
It is complex to get the data of CED models including 

staff numbers and hence we consider only the data of 
hospital with a CED. Our proposal was to skilled CE’s 
approach and for this reasons CET and BMET data could 
not be collected due to a lack of secondary data in the lit-
erature. And thus, we evaluated the CP on combined data. 
But Hossain et al stated that a skilled CE is responsible 
for ensuring 52% of the outcomes of the METM cycle.33 

Based on data, the standard CP and actual evaluated CP 
are shown in Table 4.

Table 4 shows a comparative statement between stan-
dard and evaluate CP according to skilled CE’s approach 
and the data was validated by the secondary research 
method.9,30

Patient safety and outcomes of METMS
Summary of the literature review results confirms that 

patient safety is proportional to the outcomes of METMS.34 

TABLE 4. Standard and Evaluated Performance of Outcomes 
of Medical Equipment Technology Management Systems in 
18 Countries

Country code Standard CP as 
published

Evaluated CP according 
to present data

SVN 52 36.82

BEL 52 27.60

IRL 52 28.40

KIR 52 26.14

MYS 52 22.62

PAN 52 19.84

MNG 52 20.50

FIN 52 6.25

ISR 52 5.92

ROU 52 6.01

JOR 52 3.18

AUS 52 1.85

IND 52 1.25

ZAF 52 0.68

MDS 52 0.037

BTN 52 0.12

PAK 52 0.067



Hossain, Ahmad, Islam, David: Evaluation of Medical Equipment Technology Management Performance Outcomes 
Related with Patient Safety: A Mathematical Analysis of Advanced Clinical Engineer

J Global Clinical Engineering Issue 2:4-16; 2019  14

We note patient safety as PS and the outcomes of METMS 
as CP. So, the relation between PS and CP can be explained 
by the relationship below in Eq.(5). 

PS α CP

The data from Table 4 shows that PS is very much 
negligible in lower-middle income countries although 
the PS of some higher income countries was found to be 
poor as well. Also, employing an outsourced CED is very 
expensive and risky for the patient.

CONCLUSION
The goal of this paper was to understand the current 

performance outcomes of METM that are related to PS in 
18 high, upper and lower-middle income countries. Most 
of the developed countries have introduced a BMED ser-
vice unit for their hospitals without studies which has led 
to overstaffing and understaffing models of CED/BMED 
that are not what is best for the patients. Overstaffing can 
be expensive while understaffing models of CED are very 
inefficient when it comes to ensuring outcomes perfor-
mance of METM and puts the patient at risk. 

While high and upper middle-income countries have 
been aware of CE issues, healthcare stakeholders in 
lower-middle income countries are generally not aware 
of this subject. This study brings effective results to raise 
the awareness of the present healthcare stakeholders to 
introduce one CED in the modern hospitals according 
to the workload and complexity of the MET. This will 
improve the present undesired outcomes of METM and 
the associated patient risks. Necessary recommenda-
tions to improve the present undesired conditions are 
included below.

RECOMMENDATIONS 
Based on results and discussions, the following sug-

gestions/recommendations have submitted to improve 
the present undesired conditions.
1. It is necessary to establish a CE association in each 

country under the umbrella of the Global Clinical 
Engineering Forum to disseminate the Global Clinical 
Engineering Issue. 

(5)

2. It is necessary to evaluate the performance of METM 
by utilisation of an advanced CE as the representative 
in countries that have not yet introduced models of 
CED in their hospitals.

3. The assigned advanced CE in a position to measure the 
performance outcomes of METM and publish reports 
in a yearly “Health System Review” of their concerns 
to motivate and to raise awareness among healthcare 
stakeholders. Online course can be started to ensure 
certified globally CEPs are available.

4. The local office of WHO in each country can invite 
workshop/seminar/national conference/quarterly 
meetings with healthcare stakeholders by lead by an 
advanced CE.

5. A member or country ambassador should be selected 
by the CED of the International Federation of Medi-
cal and Biological Engineering to further and share 
updated enhancements in CE.

6. More case studies should be published in GCEJ to 
promote the advantages and benefits of having an in-
house CED such as the reduction of patient risks and 
the reduction in healthcare operating costs associated 
with medical and surgical equipment management. 

7. It is necessary to invite academic biomedical engi-
neering departments from lower and middle-income 
countries to submit of research articles in this field.

8. There should be an effort to encourage the representa-
tives from the WHO, JICA, World Bank, CIDA, USAID, 
and UNICEF to help in disseminating the message 
of “Global Clinical Engineering” in their respective 
countries.

ACKNOWLEDGMENTS
We acknowledged this research work to the Ministry 

of Health & Family Welfare, Government of Bangladesh, 
Biomedical Engineering Department, Khulna University 
of Engineering &Technology, Khulna-9203, Bangladesh, 
NEMEMW& TC, Ministry of Health & Family Welfare, 
Dhaka, and Global Clinical Engineering Leaders.

CONFLICT OF INTEREST
The author declares that there is no conflict of interest regarding the pub-

lication of this paper.



15 J Global Clinical Engineering Issue 2:4-16; 2019

Hossain, Ahmad, Islam, David: Evaluation of Medical Equipment Technology Management Performance Outcomes 
Related with Patient Safety: A Mathematical Analysis of Advanced Clinical Engineer

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AUTHOR’S BIOGRAPHY
Anwar Hossain has completed BSc in Electrical & 

Electronic Engineering since 1990 from Khulna Univer-
sity of Engineering & Technology (KUET), Bangladesh. 
He joined as an electro-medical engineer at the National 
Institute of Cardio-Vascular Disease & Hospital, Dhaka, 
Bangladesh since 1991 and then was moved to National 
Electro-Medical Equipment Maintenance Workshop & 
Training Center, Dhaka under the Ministry of Health & 
Family Welfare, Government of the People's Republic of 
Bangladesh. as an assistant medical electronics engineer. 
Currently, he is working in the same organization as the 
technical manager (repair) cum chief training counselor. 
He has obtained 10 fellowships such as WHO, JICA, FRG, 
GOB, World Bank, 2nd FACE. He completed his MSc in 
Biomedical Engineering from KUET and is a PhD candi-
date in the Biomedical Engineering Department of KUET, 
Bangladesh. He has published research articles in differ-
ent renowned journals and conference proceedings. His 
research interests include advance clinical engineering 
management to enhance the quality of healthcare.


