‘‘Practices and factors affecting on-site medical equipment maintenance at Wau Teaching Hospital, South Sudan’’

Abstract

Background of the study

Along with developments in the clinical domain, medical equipment is becoming more sophisticated, and it needs to function at peak efficiency. In this case, hospitals should priorities the prompt and effective maintenance of life-saving equipment. The purpose of the study was to determine medical equipment maintenance practices, to find out an important factor that influences on-site medical equipment maintenance practices and to suggest possible areas for improvement.

Method

This was a cross-sectional descriptive quantitative research design conducted from November 2022 to February 2023. Data were collected using self-administered structured questionnaires. A sample size of 212 respondents was determined using Slovin’s Formula (N/ 1+ Ne²) from a population size of 450. A convenience sample technique was used to select the participants. An exploratory factor analysis was performed to test the inter-relationship between variables, Bartlett’s test of sphericity(p = 0,000) indicated a significant correlation, The Kaiser-Meyer- Olkin measure of sample adequacy was 0.800, and this value indicated the appropriateness of the data. A desk review and observational checklist were used.

Results

In this study, a descriptive statistic was performed under three objectives: the overall grand mean value of medical equipment maintenance practice was 2.11, and it showed the practices were uninfluential; the overall grand mean value of factors influencing medical equipment maintenance practices was 3.61, and the identified factors were influential; and lastly, the overall grand mean value of root causes of medical equipment maintenance failures was 3.565, and the identified factors were found to be influential factors.

Conclusions

The findings showed that medical equipment maintenance practice was a weekly practice; factors influencing medical equipment maintenance practice and the root causes of medical equipment maintenance failure were identified as influential factors. Corrective maintenance and outsourcing were the main maintenance practices observed, along with a lack of biomedical personnel, inadequate information aboutdevices, a lack of periodical inspection and prevention, design and implementation, and inappropriate medical equipment.

Background of the study

With improvements in the clinical field, hospital medical equipment is becoming more sophisticated and requires perfect operating conditions [1]. In this context, it is important for hospitals to focus on the effective and fast repair of life-saving equipment [1], so it is necessary to ensure that they are working under ideal conditions as clinical advancements progress. Constant maintenance ensures that each piece of equipment provides the required performance and has the estimated effective life cycle, which minimizes operating expenses for the hospital. Healthcare device repair processes have various categories ranging from inspection, preventive maintenance, and repair after the device has failed to operate [2]. Improper repair of healthcare devices results in equipment breakdown, reduces their function, and wastes resources. The availability of services is crucial for the operation of medical technology [3]. A study conducted in Kenya [3], information gathered through a case study from hospital managers and biomedical engineers, the findings revealed factors that hampered device maintenance practices including a lack of a preventive maintenance plan, which leads to frequent device failures; inadequate inventory documentation, which results in poor medical device selection and procurement; and a shortage of spare parts, which results in most devices not working. Based on a World Health Organization (WHO) survey (2006), approximately half of medical instruments in underdeveloped nations have been underutilized, improperly used, or inadequately maintained as a result of a lack of proper maintenance management processes [4]. World Health Organization has found out that, approximately half of the medical equipment in developing countries is used incorrectly or is not adequately maintained due to ineffective management policies; on the other hand, these countries’ ability to handle and maintain medical equipment remains limited [5]. As reported by the WHO, 70% of all medical devices introduced from advanced countries do not function well in lower-income countries, and more than 95% of the healthcare devices in the public sector are imported and of low quality, where 96% would not work well over 5 years after donation, and 39% did not function due to a lack of trained personnel, manufacturer manuals, or accessories [6]. Constant maintenance ensures each piece of equipment provides the required performance and has an estimated effective life cycle, which minimizes operating expenses for the hospital. Healthcare device repair processes have various categories ranging from inspection, preventive maintenance, and repair after the device has failed to operate [2]. A study conducted in Iran [2], revealed seven main themes influencing medical device maintenance and management, such as physical resources, no dedicated area in the hospitals where the maintenance process can take place, limited trained human resources to handle the device operations and services, and inadequate funding for the healthcare device maintenance process. Moreover, the same study indicated that, there were frequent medical equipment break downs due to an irregular power supply to the hospital, which affected the quality control of the devices. A computerized data system to keep records was not well implemented, no operation manuals necessary to assist the biomedical engineering units were available, and there were records of poor documentation maintenance of medical equipment. Gaps in the literature have shown the scarcity of information about medical equipment maintenance practices and the factors that affect them in South Sudan.

WAU Teaching Hospital lacks records and information, which are key for every movement for equipment maintenance practices. There is no real system to maintain data so that someone can retrieve the information successfully for efficient management. It has been observed that; most of the patients were referred to nearby countries for further medical checkups, which incur enormous cost for the patients, and those who cannot afford the travel expenses end-up untreated. In the present study, it was found that maintenance practices are outsourced to a third-party logistics company, corrective maintenance is the main practice observed, lack of biomedical engineering and highly trained technicians, lack of a designated area to repair medical devices, lack of documentation and information about the medical devices and lack of periodical inspection and prevention.

The main purpose of the study was to determine medical equipment maintenance practices, to find out an important factor that influences on-site medical equipment maintenance practices. The researcher was interested in determining the maintenance practices taking place, and the factors affecting them and to proposing a better planning intervention at Wau Teaching Hospital South Sudan. This paper had questioned, how was medical equipment maintenance being practiced at WAU Teaching Hospital? What were the major factors affecting medical equipment maintenance practices at WAU Teaching Hospital? And what were the major causes of medical equipment failure at WAU Teaching Hospital?

Method

Description of the study area

The data were collected at WAU Teaching Hospital, a regional referral hospital serving the entire greater Bahr EL-Ghazal states, namely: - Aweil, Rumbek, Warrap, and Western Bahr el-Ghazal States, South Sudan. This site was chosen due to its centrality, being a referral point, having well-experienced and knowledgeable personnel, and being equipped with sophisticated medical equipment.

Research design

This is a quantitative research design, in which a descriptive cross-sectional research design uses a quantitative approach to examine medical equipment maintenance practices, with the aim of determining the factors that affect medical equipment maintenance practices and the major causes of medical equipment maintenance failure. A convenience sampling of 212 willing respondents gave consent, and self-administered structured questionnaires were used to gather information from the healthcare workers and stakeholders, who are knowledgeable and have ideas regarding medical equipment maintenance practices, Table 1.

Table 1.

Demographic profile of the respondent

(N = 195)	Frequency	Percent(%)
Sex
Male	87	44.6
Female	108	55.4
Age
21–25 Years	12	6.2
26–30 Years	26	13.3
31–35 Years	37	19
36–40 Years	41	21
Above 41 Years	79	40.5
Occupation
Medical doctor	14	7.2
Equipment operator	10	5.1
Storekeeper	3	1.5
Nurse	140	71.8
Mid-wife	14	7.2
Help pooled fund area coordinator	1	0.5
Care international organization coordinator	1	0.5
Theatre attendance	7	3.6
Anaesthetist	5	2.6
Education levels
Primary school	3	1.5
Secondary school	72	36.9
Diploma	88	45.1
Bachelor	29	14.9
Master	3	1.5
Working experience
1–5 Years	36	18.5
6–10 Years	27	13.8
11–20 Years	60	30.8
Above 21 years	72	36.9
Marital status
Single	26	13.3
Married	150	76.9
Divorced	4	2.1
Widow/Widower	14	7.7

Study population

The target population was healthcare workers and stakeholders, Director General of Wau Teaching Hospital, Medical Director of Wau Teaching Hospital, Supply Chain Experts, Pediatrician, Obstetrician, Equipment Operators, Medical Doctors, Anesthetists, Theatre Attendance, Matrons, Nurses, Midwives, Storekeepers, Donors, and Implementing Partners who are supporting health service delivery in the hospital.

Inclusion criteria

The inclusion criteria were healthcare workers who operate the equipment and have knowledge and experience regarding medical equipment maintenance practices.

Exclusion criteria

Non equipment operators.

Sample size

Sample size was determined using Slovin’s formula, with a population size [7] of 450 people, a confidence level of 95% and a margin of error of 5%.

Slovin’s formula = N/1 + Ne², where: - N is the population size and e is the margin error.

450/1 + 450 (0.05) ² = 450/1 + 450 (0.0025) = 450/1 + 1.125 = 450/2.125 = 211.7 = 212.

Sampling technique

This study used a convenience sampling technique for quantitative data, where the respondents were chosen based on their working relationship. The participants from various departments were asked, if they would voluntarily sign a consent form and participate in the study. The researcher identified categories of respondents who agreed to participate in the study Table 1. Questionnaires were distributed with the help of the recruited research assistants.

Data collection instruments

The data collection tools were self-administered questionnaires, five (5) Likert scale template was used for the data collection whereby the respondents were asked to tick an appropriate statement, strongly disagree, disagree, neutral, agree and strongly agree. Desk reviews and observation checklists was used, Table 2).

Table 2.

Observation Checklist: the table shows three types of scores. If the element meets the standard, it scores 2; in case of half-done, it scores one; and in case of incompatibility, it scores zero

Maintenance practices	Standards	Data collection method	Data collection source	Score 0 1 2
Inspection and Preventive	To assess and treat the equipment on the routine basis.	Observation and record review	Head Equipment operator	0
Corrective	To restore device back to its normal function after it fail to operate.	Observation and Record Review	Head Equipment operator		1
Predictive	A forecasting technique to determine the rate of failure of certain types of replaceable component, and then the interval is set to repair the device	Record Review	Head Equipment operator	0
Proactive	The process of maintaining the exact part of the device that had fail to operate.	Record Review	Head Equipment operator	0
In-house Outsourcing	Staff do maintain the device in the health facility Third Party logistic contracted to repair the equipment	Observation & Interview Record Review	Head Equipment operator Head Equipment operator	0 2

Data collection procedure

The University of Rwanda issued a letter for the collection of data in the respective country, and ethical approval was obtained from the South Sudan Ministry of Health Research Ethics Review Board. The director of Wau Teaching Hospital was brief on the aim of the study. The research assistants were trained, and the questionnaire was pretested at Wau Military Hospital.

Data management and analysis

Data were coded, cleaned, and data analysis was performed using the Statistical Package for Social Sciences (SPSS) version twenty-three (23). Exploratory factor analysis was performed to test the interrelationship between variables. Overall grant mean values were performed to test influences under three objectives: medical equipment maintenance practices, factors affecting medical equipment maintenance, and major root causes of medical equipment failures. The descriptive statistical results are shown in the tables and figure.

Analysis of Scales’ Reliability and Validity:

The coefficient was used to measure a scale of multiquestions frequency and measure the degree of compliance between 0 and 1. As the coefficient approaches 1 Cronbach’s alpha is assumed to be very high.

Generally, the following evaluations are made on the Cronbach alpha coefficient of studies in the social sciences:

• 0.0alpha < 0.40, the scale has no reliability, Weak.

If 0.41 < < alpha < 0.60, the scale’s reliability is low, Good.

For 0.61 < alpha < 0.80, the scale has an acceptable reliability level, Very good.

If 0.81 < alpha < 1.00, the scale’s reliability is very high, Perfect.

Primary source

The statistical reliability of the study (Table 3) is evaluated to be perfect because it ranges between 0.81 < alpha < 1.00 and the scale’s reliability is very high, Perfect.

Table 3.

Statistical reliability

Cronbach Alpha	Number of Items
0.889	30

Factor analysis results

An exploratory factor analysis was performed using a principal component analysis and varimax rotation for medical equipment maintenance practices. The minimal factor loading criterion was set to 0.5 [8]. Bartlett’s test of sphericity measure (P = 0.000) indicated that the correlation matrix was significant (Table 4). The Kaiser-Meyer- Olkin measure of sample adequacy was 0.800, and this value indicated the appropriateness of the data for factor analysis. The communalities of the scale which indicate the amount of variance in each dimension, were assessed to ensure an acceptable level of explanation. The results showed that all the communalities were over 0.5, with the exception of one variable whose value was less than 0.5 and was deleted (Table 5). Factor solution derived from this analysis yielded 3 factors for the scale (Fig. 1), and account for 55.010% of the variance in the data (Table 6). Finally, factors loading related to maintenance practices were grouped into three factors (Table 7).

Table 4.

KMO and Bartlett’s test

Kaiser-Meyer Measure of Sample Adequacy Bartlett’s Test of SphericityApprox. Chi-Square df Sig.

0.800 603.123 66 0.000

Table 5.

Communalities

	Initial	Extraction
The Hospital has someone or in-house person mandated to repair the equipment	1.000	0.571
This is an area in the hospital where the maintenance process can take place	1.000	0.648
The hospital has the Bioengineer or technical person who can maintain the equipment	1.000	0.647
There is a regular check up on medical equipment in the hospital	1.000	0.577
There is a policy for the equipment practices in the hospital	1.000	0.606
The hospital has the standard operating procedure	1.000	0.618
The hospital repair the equipment by bringing an expert (Thirty-Party) from outside using outsourcing strategy	1.000	0.587
The hospital procure in-house medical equipment maintenance practices	1.000	0.576
Preventive Maintenance as it assess and treat the equipment on routine basis and repair process take place on the regular interval become the most preferred maintenance practices in Wau Teaching Hospital	1.000	0.633
Corrective Maintenance as it a process of restoring device back to its normal function after it fails to operate, is the most preferred maintenance practice in Wau Teaching Hospital	1.000	0.609
Predictive Maintenance is the most preferred maintenance practice in Wau Teaching Hospital	1.000	0.728
Pro-active Maintenance being the process of maintaining the exact of the device that had failed to operate is the most preferred maintenance practices in Wau Teaching Hospital	1.000	0.626
Resource related factors (such as lack of adequate human resource, physical infrastructure, limited funding) affects medical equipment maintenance practice	1.000	0.651
Lacking of training to the equipment operators affects medical equipment maintenance practices	1.000	0.718
Documentation/Information bank factors (such as local and global policies, standard operating procedure, lack of inventory and language barrier) affects medical equipment maintenance practices	1.000	0.698
Miss- appropriateness factors (such as lack of frequent cleaning and use of device by a person not skillful) affects medical equipment maintenance practices	1.000	0.637
Planning and Action factors (such as procurement determination policy to access medical equipment and culture of managers to decision-making) affects medical equipment maintenance practices	1.000	0.675
Infrastructure factors(such as narrow space and power disruption affects medical equipment maintenance practices).	1.000	0.630
Quality and Safety factors (such as testing the device commissioning, adjustment and calibration) affects medical equipment maintenance practices	1.000	0.538
Improper storage and transportation are the major root causes for medical equipment maintenance failure	1.000	0.610
Initial failure is the major root cause for medical equipment maintenance failure	1.000	0.532
Inappropriate handling is the major cause for medical equipment maintenance failure	1.000	0.691
Inadequate maintenance is the major root cause for medical equipment maintenance failure	1.000	0.611
Environmental stress is the major root cause for medical equipment maintenance failure	1.000	0.616
Random failure is the major root cause for medical equipment maintenance failure	1.000	0.684
Inappropriate repair technic is the major root cause for medical equipment maintenance failure	1.000	0.624
Wear-out failure is the major root cause for medical equipment maintenance failure	1.000	0.743
Poor maintenance culture is the major root cause for medical equipment maintenance failure	1.000	0.782
Lack of highly trained technicians are the major root causes for medical equipment maintenance failure	1.000	0.526

Extraction Method: Principal Component Analysis

Fig. 1.

The three factors extracted

Table 6.

Total variance explained

Component	Initial Eigenvalues			Extraction Sums of Squared Loadings			Rotation Sums of Squared Loadings
	Total	% of Variance	Cumulative %	Total	% of Variance	Cumulative %	Total	% of Variance	Cumulative %
1	3.911	32.595	32.595	3.911	32.595	32.595	2.617	21.807	21.807
2	1.500	12.499	45.094	1.500	12.499	45.094	2.084	17.367	39.174
3	1.190	9.916	55.010	1.190	9.916	55.010	1.900	15.836	55.010
4	0.968	8.063	63.073
5	0.891	7.424	70.497
6	0.700	5.835	76.332
7	0.650	5.420	81.752
8	0.567	4.727	86.479
9	0.470	3.918	90.397
10	0.432	3.599	93.996
11	0.396	3.303	97.299
12	0.324	2.701	100.000

Extraction Method: Principal Component Analysis

Table 7.

This showed factors loading related to maintenance practices

Types of practices	Component 1	2	3
Human Resource	0.775 0.736 0.704 0.696
Policy and SOP		0.723
		0.665
		0.636
Types of Maintenance Practices		0.604	0.741
			0.690
			0.689
			0.560

Factor 1: Indicates the expertise and infrastructure where the repair process can take place

Factor 2: It loaded the policy and standard operating procedure together

Factor 3: It loaded the types of maintenance practices

Table (8) located at the end of the document, shows Descriptive Statistics under Objective 1, Medical Equipment Maintenance Practice, and the overall grand mean value of Medical Equipment Maintenance Practice was 2.11, which can be interpreted as weakly practiced (the practices are uninfluential), as the weighted average mean value falls between a mean range of 1.80 and 2.59.

Table 8.

Weighted average values for 5 point likert scales

Weighted Average	Result	Result interpretation
1.00-1.79	Strongly disagree	Very uninfluential
1.80–2.59	Disagree	Uninfluential
2.60–3.39	Neutral	Neutral/do not know
3.40–4.19	Agree	Influential
4.20-5.00	Strongly agree	Very influential

In the descriptive data analysis, mean values were calculated for each construct in the Likert scales, from Strongly Disagree = 1 to Strongly Agree = 5, and the associated standard deviation was also calculated. The mean responses given for each construct of variables under investigation were averaged to obtain the composite mean for variables. For objective interpretation and comparison of the results, the composite mean was interpreted by dividing the distances between the scale values (4) by the number of values (which is 5 on a 5-point Likert scale). Thus the distance is 4/5 = 0.80, which is used to calculate the weighted averages (1 + 0.8 = 1.8, 1.8 + 08 = 2.6, 2.6 + 0.8 = 3.4, 3.4 + 0.8 = 4.2, 4.2 + 0.8 = 5). The weighted average categories (mean score) were interpreted with the level of agreement for each factor calculated, and its interpretation was aligned with an equal level of degree to explain the objectives. A weighted average between 1.00 and 1.79 interpreted as “very low/very weak”, 1.80–2.59 as low, 2.60–3.39 as neutral/do not know, 3.40–4.19 as moderate, and 4.20-5.00 as a high level of practice or performance or effect (Table 9).

Table 9.

Showed descriptive statistics under objective 1, medical equipment maintenance practice

Item: Medical equipment maintenance practice	Scalea					Mean		Std. Dev.
	1	2	3	4	5
The hospital has someone or in-house person mandated to repair the equipment	140	29	7	12	7	2.86		1.11
There is an area in the hospital where the maintenance process can take place	100	55	9	22	9	1.55		1.06
The hospital has the bioengineer or technical person who can maintain the equipment	120	44	17	11	3	1.90		1.19
There is a regular check up on medical equipment in the hospital	101	58	15	13	8	1.63		0.97
The hospital has regular electric power supply	92	52	15	22	14	1.82		1.10
There is a policy for the equipment maintenance practices in the hospital	94	56	20	17	7	2.05		1.29
The hospital has the standard operating procedure	90	51	17	25	12	1.90		1.12
The hospital repair the equipment by bringing an expert (Third Party) from outside using outsourcing strategy	74	43	15	44	19	2.07		1.27
The hospital procures in-house medical equipment maintenance practices	94	58	28	8	7	2.44		1.43
Preventive maintenance as it assess and treat the equipment on the routine basis and repair process take place on the regular interval become the most preferred maintenance practice in WAU teaching hospital	81	47	24	25	18	1.85		1.05
Corrective maintenance as it is a process of restoring device back to its normal function after it fails to operate is the most preferred maintenance practice in WAU teaching hospital	45	55	13	25	57	2.24		1.35
Predictive maintenance is the most preferred maintenance practice in WAU teaching hospital	77	56	24	22	16	2.97		1.59
pro-active maintenance being the process of maintaining the exact part of the device that had failed to operate is the most preferred maintenance practice in WAU teaching hospital	77	53	18	33	14	2.20		1.29
Grand mean for Medical equipment maintenance practice							2.113

^aWhere 1 = Strongly Disagree, 2 = Disagree, 3 = Neutral, 4 = Agree 5 = Strongly Agree

Table (10) located at the end of the document, the overall grand mean value of factors influencing medical equipment maintenance practices was 3.61, and it can be interpreted that all the identified factors were influential factors, as the weighted average mean value as well as the individual factor mean value fall between a mean ranges of 3.40–4.19.

Table 10.

Descriptive statistics under objective two (2), factors influencing medical equipment maintenance practices

Item: Factors influencing medical equipment maintenance practices	Scalea					Mean	Std. Dev.
	1	2	3	4	5
Resources Related factors (such as lack of adequate human resource, Physical infrastructure) affects medical equipment maintenance practices	41	14	14	54	72	3.52	1.55
Lack of training to the equipment operators affects medical equipment maintenance practices	31	22	12	55	75	3.62	1.48
Documentation/Information bank factors (such as Local and global policies, Standard operating procedure, Lack of inventory and Languages Barrier) affects medical equipment maintenance practices	23	27	13	56	76	3.53	1.48
Miss- appropriateness factors (such as Lack of frequent cleaning and Use of device by a person not skilful) affects medical equipment maintenance practices	32	22	22	48	71	3.69	1.41
Planning and Action factors (such as Procurement determination policy to access medical equipment and Culture of managers to decision-making) affects medical equipment maintenance practices	32	22	22	48	71	3.57	1.42
Infrastructure factors (such as Narrow space and Power disruption) affects medical equipment maintenance practices	30	16	26	58	65	3.71	1.43
Quality and Safety factors (such as Testing the device commissioning and Adjustment and calibration) affects medical equipment maintenance practices	26	24	8	60	77	3.68	1.34
Grand mean of factors influencing medical equipment maintenance practices						3.61

^aWhere 1 = Strongly Disagree, 2 = Disagree, 3 = Neutral, 4 = Agree 5 = Strongly Agree

Source: Own survey, 2022

Table (11) situated at the end of the document, the overall grand mean value of Root causes of medical equipment maintenance failures was 3.565, and it can be interpreted as identified factors found to be influential factors, as the weighted average mean value falls between mean range of 3.40 and 4.19.

Table 11.

Showed descriptive statistics under objective three (3), Root causes of medical equipment maintenance failures

Item: Root causes of medical equipment maintenance failures	Scalea					Mean	Std. Dev.
	1	2	3	4	5
Improper storage and transportation is major root cause for medical equipment maintenance failures	29	21	15	62	68	3.61	1.43
Initial failure is major root cause for medical equipment maintenance failures	29	22	20	71	53	3.50	1.39
Inappropriate handling is major root cause for medical equipment maintenance failures	29	16	13	69	68	3.67	1.41
Inadequate maintenance is major root cause for medical equipment maintenance failures	27	16	10	69	73	3.74	1.39
Environmental stress is major root cause for medical equipment maintenance failures	35	25	19	58	58	3.41	1.48
Random failure is major root cause for medical equipment maintenance failures	27	20	25	60	63	3.57	1.39
Inappropriate repair technique is major root cause for medical equipment maintenance failures	31	12	16	69	67	3.66	1.41
Wear-out failure is major root cause for medical equipment maintenance failures	35	20	24	58	58	3.43	1.46
poor maintenance culture is major root cause for medical equipment maintenance failures	42	16	13	54	70	3.48	1.56
lack of highly trained technicians is major root cause for medical equipment maintenance failures	41	16	11	43	84	3.58	1.59
Grand mean of Root causes of medical equipment maintenance failures						3.565

^aWhere 1 = Strongly Disagree, 2 = Disagree, 3 = Neutral, 4 = Agree 5 = Strongly Agree

Source: Own survey, 2022

Desk review

In the current study, there was a lack of available papers on medical device maintenance process and a scarcity of local and global policies and protocols in the Wau Teaching Hospital.

The observation checklist was carried out, in which head of equipment operator was interviewed. The results are shown in (Table 2) at the end of document.

Positionality

The principal investigator was complete aware about the situation in the hospital; he has noticed that; there was no biomedical engineering department and no biomedical engineering experts in the hospital; and most of the equipment observed was not functioning and the reason behind that remains unclear.

The results

Response rate

The study had a total sample size of 212; only 195 (92%) questionnaires were completed, 12 (6%) were incomplete, and 5 (2%) were not retrieved. A total of 195 questionnaires were analyzed using SPSS version Twenty-Three (23). The Five (5) Likert scale template was used for the data collection, whereby the respondents were asked to tick an appropriate statement: strongly disagree, disagree, neutral, agree, and strongly agree.

Demographic profile of the respondent

Based on this research, there were more females (108,55.4%) than males, and study covered most of the age group ranging between 36 and 40 years and above (41,21%). While observing their occupation, the study indicated that most of the respondents who participated proficiently were nurses (140,72%) rather than any other professional located at the end of the document (Table 1). The study showed that most of the respondents were in standard stage with good experiences. Thus, the study went further to educational background, and the findings were that most of the respondents (88,45%) who participated had a Diploma degree. With regard to marital status, (150,77%) were married, while on working experience research specified that most of the respondents had more than 20 years of experience (72,40%). The descriptive statistics are shown in (Tables 8, 10 and 11) situated at the end of the document.

Health care apparatus repairs exercise

In the present study, it was found that maintenance practices are outsourced to a third-party logistics company, corrective maintenance is the main practice observed, lack of biomedical engineering and highly trained technicians, lack of a designated area to repair medical devices, lack of documentation and information about the medical devices and lack of periodical inspection and prevention.

Factors influencing medical equipment maintenance practice

In the current study, the majority of respondents strongly agreed that lack of biomedical engineering, scarcity of funding support, lack of training for equipment operators, lack of documentation and information, inappropriateness of medical devices, lack of planning and action by top management, lack of a place designated to maintain equipment, and lack of quality and safety practices such as testing and calibration are the major growing factors affecting medical equipment maintenance practices in Wau Teaching Hospital. The study also documented that most of the donated equipment to the hospital was lying unused because the implementing partner supporting the hospital hired a consultant to operate the devices, and upon completion of the project, the equipment remained unused. Comparing these results to the other world, there were some cornerstones on which they built. In the current study, it was documented that patients were seeking treatment further in nearby countries and that they incurred enormous cost for the treatment.

Root causes of medical equipment maintenance failures

In the current study, there was no single biomedical engineer, no periodic inspection of medical devices, lack of equipment spare parts in Wau Teaching Hospital.

Discussion

Health care apparatus repairs exercise

In the present study, it was found that maintenance practices are outsourced to a third-party logistics company, corrective maintenance is the main practice observed, lack of biomedical engineering and highly trained technicians, lack of a designated area to repair medical devices, lack of documentation and information about the medical devices and lack of periodical inspection and prevention.

In a study conducted in Canada [1], almost all service delivery units used their manufacturers’ guiding manuals to maintain their medical instruments, and the hospital outsourced maintenance services to a third-party logistics company. In this current study, maintenance practices were outsourced to a third-party logistics company, and corrective maintenance is the main practice observed when medical equipment breaks down due to a lack of biomedical engineering and language barriers for the equipment operators, which have contributed to the inability to maintain the devices.

In Malaysia, five maintenance practices were noted (preventive, proactive, corrective predictive, and breakdown maintenance), and the most commonly used practices were preventive and breakdown maintenance [9].

In this study, preventive, predictive, and proactive maintenance practices were rarely implemented in the hospital, due to a complete lack of biomedical engineering, highly trained technicians, and a lack of a designated area to repair medical devices; rather, medical equipment was being maintained where it was located. This has shown that Wau Teaching Hospital is still far behind. The repair of healthcare devices is essential for lowering output costs, decreasing client frustration, treating clients on time, and hence decreasing complications, mortality, and danger during service delivery [10].

In this study, the repair process was outsourced to a third-party logistics company, which incurs enormous costs for the institution. On the other hand, treatment was delay, which was also risky for patients.

A study conducted in Iran found that two practices, corrective and preventive maintenance, were used [2].

In the present study, corrective maintenance was the only repair practice seen in the hospital. The majority of the respondents pointed out that, for effective maintenance practices, there should be a guiding policy, standard operating procedure, adequate space and biomedical engineering; in fact, these are not being observed in the hospital. In the present study, the situation is of great concern since no single document was seen during desk review.

Factors influencing medical equipment maintenance practice

A study conducted in Kenya found out that most of the factors that affect medical equipment maintenance practices were a lack of preventive maintenance plans, inadequate inventory documentation and a shortage of spare parts [3]. One study showed that most of the factors affecting medical equipment maintenance practice were limited to qualified human resources, irregularity in servicing medical devices and workload on a limited number of pieces of equipment [11].

A study revealed that, factors that lead to ineffective performance of medical equipment maintenance practices were linked to qualified candidates to operate the machine, inadequate infrastructure, limited knowledge about the devices and lack of individual accountability [12].

In the current study, the majority of respondents strongly agreed that lack of biomedical engineering, scarcity of funding support, lack of training for equipment operators, lack of documentation and information, inappropriateness of medical devicesn, lack of planning and action by top management, lack of a place designated to maintain equipment, and lack of quality and safety practices such as testing and calibration are the major growing factors affecting medical equipment maintenance practices in Wau Teaching Hospital. The study also documented that most of the donated equipment to the hospital was lying unused because the implementing partner supporting the hospital hired a consultant to operate the devices, and upon completion of the project, the equipment remained unused. Comparing these results to the other world, there were some cornerstones on which they built. In the current study, it was documented that patients were seeking treatment further in nearby countries and that they incurred enormous cost for the treatment.

Root causes of medical equipment maintenance failures

In a study carried out by the WHO, it was revealed that 80% of health care instrument failures occurred due to preventable factors, 60% occurred due to inadequate repair, and approximately 20% occurred due to inappropriate handling [12]. In Ghana, it was found that the causes of the health care instrument were attributed to improper storage, transportation, insufficient upkeep of the devices, environmental diversity failure at random, an incorrect repair process, failure due to wear out of the devices, and a limited number of highly trained and skilled personnel [12].

In the current study, the situation was similar and even more complex compared to the study carried out in Ghana. All the root causes of medical equipment maintenance failures looked the same, but there was a limited number of skilled personnel in the study conducted in Ghana. On the other hand, there was no single biomedical engineer in Wau Teaching Hospital, which has raised an alarming situation of great need in Wau Teaching Hospital compared to the study conducted in Ghana.

Best practice for medical equipment maintenance planning interventions for medical equipment failures

The World Health Organization recommends the introduction of Computerized Maintenance Management System software. The software is very important in keeping information about the devices, tracking previous records, and assisting in scheduling inspection prevention maintenance dates [13]. Equipment donation should conform to country policy and is the best practice to avoid equipment failure and damping [14].

The best practices were also seen in Ghanaian hospitals, where effective maintenance records were established to track all maintenance activities [12]. The researcher also agreed with the five maintenance practices seen in Malaysia: such as preventive, proactive, corrective, predictive, and breakdown maintenance. These will enhance service delivery by prolonging the life of the equipment and saving management money.

In this current study, since the hospital does not own the maintenance practices on the ground but rather depends on the donor’s expertise to repair the medical devices, it is of great concern that the hospital avails resources such as biomedical engineers who will be concerned with equipment, infrastructure to ensure adequate space and ventilation, financing, and adopting local and global policies and protocols. At the current level of Wau Teaching Hospital, inspection-preventive and corrective maintenance should be adopted as the starting best practices.

Limitations of the study

The scarcity of access to full texts of medical equipment maintenance practice articles published in South Sudan. Some participants refused to cooperate because they feared jeopardizing the confidentiality of the information they provided.

Conclusion

The findings showed that medical equipment maintenance practice was a weekly practice; factors influencing medical equipment maintenance practice and the root causes of medical equipment maintenance failure were identified as influential factors. Corrective maintenance and outsourcing were the main maintenance practices observed, lack of biomedical personnel, inadequate information about devices, lack of periodical inspection and prevention, design and implementation and inappropriate of medical equipment.

Recommendations

Medical equipment maintenance practice

For effective maintenance practices, the Ministry of Health, donors and hospitals have to avail themselves of resources particularly biomedical engineering, financial allocation and the establishment of an infrastructure mandated to repair medical equipment, and long and short term capacity building in the field of biomedical engineering. The treating institution has to adopt the best practices of inspection and prevention maintenance which will allow the managers to detect any defect and allow the institution to plan early for repair or replacement of the device, and the practices will lead to a long life span of the equipment.

Factors influencing medical equipment maintenance practice

It is recommended that the Ministry of Health has to plan, forecast and procure of medical equipment which should be based on the need and expertise in the treating institution. The Ministry of Health has to formulate policies, protocols and standard operating procedures in the area of equipment maintenance processes and cascade them down as guiding principles to the tiers. The Ministry of Health has to introduce computer database and that will help managers store and retrieve information quickly about medical devices. Moreover. The MOH has to adopt inspection- prevention maintenance and will allow fault detection and quick management decisions to either repair and replace the device. Hospital must adopt the WHO recommendation to introduce a computer database for storing and easily retrieving information about medical equipment maintenance practices.

Abbreviations

HPF

Health Pooled Fund

HIMP

Healthcare Instrument Maintenance Practice

MEMP

Medical Equipment Maintenance Practice

SMOH

State Ministry of Health

MOH

Ministry of Health

SOP

Standard Operating Procedure

WHO

World Health Organization

W.T.H

Wau Teaching Hospital

Authors’ contributions

1. NM: Have initiate the proposal planning, writing, involve in data collection and analysis. 2. MM & SM: Involved in the planning and study writing procedure. 3. MN and SM have contributed in to manuscript writing procedure.

Funding

No funding was given for this research.

Data availability

The data sets used in this study can be accessed from the corresponding author.

Declarations

Ethics approval and consent to participate

Ethical approval No. MOH/RERB 60/2022 of this study was obtained from the National Ministry of Research Ethical Review Board, Juba South Sudan. The health facility respondents agreed to participate in the study by signing the informed consent forms. The respondents were assured that the information they were given would be treated as confidential.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.