Table 1

Included studies under study type ‘descriptions of processes taking place within or across hospitals’ (n=14)

Study name	Type of article	Journal	Year	Country	Setting	Device/equipment	Main aim of paper	Research methods	Intervention/approach	Lessons/outcome	Limitations
Eagle et al44	Journal article	The American Journal of Managed Care	2002	USA	1 hospital	Defibrillators, pacemakers, coronary stents and coronary balloon catheters	To assess the magnitude of savings and develop concepts for ‘best strategies’ in reducing costs in the purchasing of high-technology, high-cost materials used in coronary interventions and electrophysiological treatments.	Description of process (with reported cost savings): case study reporting on experience.	Iterative negotiation following a broad request for proposal sent to a diverse group of vending organisations in high-technology areas of cardiology. Product costs and volume usage were assessed before and after the process to estimate annualised cost reduction achieved. Collaborative consensus among physicians, administration, materials management, purchasing and vendors.	Aggressive, collaborative, fair and competitive bidding for high-cost products used for coronary interventions and electrophysiological treatments leads to substantial cost savings and can promote provider–industry partnerships that further enhance product use, provision and tracking.	None listed.
Greenwood et al27	Journal article	Journal of Clinical Engineering	2014	Canada	1 hospital	Capital equipment (examples given: table, examination; scanner, ultrasonic, bladder)	To examine the effect of a clinical engineering role change (from equipment maintenance to health technology management).	Description of process (with reported cost savings): case study using experience and data from the previous three 5-year clinical capital equipment plans were collected and analysed.	Development of in-house clinical engineering expertise who develops risk ranking system and long-range technology plan: (1) a theoretical replacement plan, (2) an emerging technology plan, and (3) a fleet equipment plan.	Developing in-house clinical engineering (CE) expertise enables the facility to keep its capital equipment current and keep clinician acceptance high by maintaining a fair and methodical process. Hospital has made its clinical environment safer through the use of planning tools such as fleet management, equipment standardisation and a balanced request scoring system while keeping within its long-range capital equipment budgetary limits. The average age of clinical equipment has dropped substantially to just over 5 years as of the 2011 plan. Annual contingency fund expense for clinical capital equipment no longer absorbs between 15% and 25% of the overall CE budget. It has now been fixed at the relatively small amount of 5% of the overall budget, and this threshold has been reached in only 1 of the last 5 fiscal years.	None listed.
Langenburg et al30	Journal article	Pediatric Endosurgery & Innovative Techniques	2003	USA	1 hospital	Surgical robotics	To describe experiences in developing and implementing a programme for computer-assisted, robot-enhanced surgery.	Description of process: case study based on experience.	Defined a core group of individuals who shared vision: paediatric surgeons, our institutional research director, a biomedical engineer and physicist, and hospital chief executive officer. Partnership developed to continue research and development of equipment and surgical techniques. Developed short-term and long-term educational, research and business plans; shared with hospital administration and hospital board of trustees to garner support. The staff of the hospital development office was also involved in generating financial support.	Institutional and private donor support has allowed implementation of a robotic minimally invasive surgical suite in operating room and in research building. Within 1 year of embarking on programme the team performed our first robot-assisted minimally invasive surgery on a patient. Many of paediatric subspecialty colleagues have been using suites for procedure development in their areas of interest. The key elements in developing a new programme are to define a core group of committed individuals, define your vision, create corporate partners and garner financial support with a sound educational, research and business plan.	None listed.
Licona et al29	Journal article	International Journal of Technology Assessment in Health Care	2009	Mexico	1 hospital	CT scanner	To demonstrate the experience of a managed network of professionals inputting into equipment management in one institution.	Description of process: case study reporting on experience.	Involvement of a multidisciplinary group (drawn from researchers, undergraduate and graduate students in fields that range from architecture to civil and biomedical engineering) to deal with large and complex issues within the field of hospital engineering. Steps involved specifically in the equipment planning phase include: assessing availability of similar equipment at locations in the vicinity; cost-effectiveness planning; incorporation of data on equipment availability at the state-wide level combined with morbidity and mortality figures, incorporation of information regarding ‘plant’ installations including electrical, hydraulic and telecommunications. Specifically for the case of the CT scanner purchase: the BME branch of this group analysed the bidding procedures, the contracts, and asked several questions that needed to be answered before the formalisation of the reception could be signed.	During this study, several anomalies were discovered: the equipment being bought was constructed by one of the three major vendors of imaging equipment worldwide. However, they did not participate in the bidding process. A local company won the bid and then proceeded to subcontract the equipment from the major vendor. The questions arose as to who was installing the equipment, because it appeared that the major vendor was providing the technicians, which was a breach of contract (bid-winning companies should provide training and do installations themselves). A second question arose regarding the existence of replacement parts within the winning company’s warehouses, and finally, there was a major question posed as to the adequacy of the equipment being bought (64-slice CT specially built for cardiac studies) for a general hospital with no cardiac specialties, as well as the elevated sale price (as much as a MRI scanner). The hospital took these results in hand and acted in accordance with its administrative procedures to correct the anomalies.	None listed.
Madhlambudzi and Papanagnou12	Journal article	International Journal of Healthcare Technology and Management	2019	UK	2 hospitals	Diagnostic equipment	To describe analysis of decision-making processes when the public hospitals purchase diagnostic equipment and it discovers how the hospitals use stakeholder identification and salience during the purchase of diagnostic equipment.	Description of process: case studies and semistructured interviews (n=121, narratives of people involved in decision-making on outsourcing laboratory diagnostic equipment), document analysis.	N/A	NHS hospitals fail to identify key stakeholders resulting in possible delays and conflicts. Throughout our research, it was ascertained that NHS hospitals do not tend to apply stakeholder analysis as a part of their project planning process. This has in some cases resulted in leaving out key stakeholders and thereby bringing about conflict and delays in the process. NHS hospitals are bound by strict guidelines in their procurement processes to avoid bias and ensure competition among potential suppliers and get the best deal. Technical personnel, however, came up with some valid reasons why it would be more suitable to upgrade the present equipment than to undertake radical adjustments or changes. It is, therefore, important that at any stage of the process the weight of the stakeholders should be considered in deciding whether their input is acceptable or not.	None listed.
Mitchell et al40	Journal article	International Journal of Technology Assessment in Health Care	2010	USA	1 hospital in 1st case; 3 hospitals in 2nd case	Cardiac catheterisation laboratory; ICU telemedicine services	To describe two evidence reports from our hospital-based HTA centre which required the integration of local data. Both cases illustrate how local evidence can be used at the institutional level to support the quality, safety and cost-effectiveness of patient care.	Description of process: two case studies (one using qualitative and one using quantitative data); 1st case: equipment service records, and interviews with physicians, technicians and administrative staff. 2nd case: systematic review of effectiveness of service, the hospital’s administrative and claims databases (including mortality and length of stay).	Integration of local qualitative and quantitative data into hospital-based HTA to select a new technology or inform a decision on whether to continue services.	Hospital-based HTA using local data can fill gaps in the published evidence, and also improve the generalisability of evidence to the local setting. To take advantage of local evidence, health systems should encourage the development of hospital-based HTA centres, seek out local preference data and maintain databases of patient outcomes and utilisation of services. The use of local evidence to support institutional decision-making can also reduce problems of external validity. In both case studies, important differences among the hospitals within health system were found. These differences affect the prioritisation of different attributes of a technology, and could result in different conclusions being drawn about how the technology should be used at each hospital, even within the same healthcare network; the experience and expertise of local clinicians should be respected when making decisions at the hospital or health network level (it helps decision makers understand possible differences in local patient populations or in processes of care that may affect the cost or effectiveness of the technology, and it promotes ‘buy-in’ from the clinicians who must implement the decision).	While analyses were done in retrospect (data have to have been collected and available for analysis), the research could not control variables such as changes in staffing or new infection control policies. In analysis of ICU outcomes, the study lacked APACHE scores for ICU patients before the introduction of telemedicine coverage, so the ability to control for patient acuity was limited. The available claims information did not include enough detail to ascertain whether possible lapses in care happened in the ICU or elsewhere. While there was no such problem with availability for the survey data used in cardiac imaging decision, gathering that data required considerable fieldwork.
Mosessian35	PhD thesis	N/A	2016	USA	Multiple hospitals (unspecified)	Orthopaedic implants	To examine the extent to which value-based purchasing is being used to purchase implanted orthopaedic medical devices, and the decision-making processes that are being implemented to support those acquisitions.	Description of process: a survey tool was developed (with input from a focus group with 10 professionals) and responses obtained from two groups of stakeholders, hospital executives (n=29) and orthopaedic surgeons (n=40).	Use of value-based committee: physicians and surgeons make decisions; hospital administrator makes decisions, and bundles corporate purchase agreements, request for proposals issued and group purchasing organisations. Intervention specifically studied: value-based purchasing and knowledge of procurement officers use (rather than HTAs).	Results include: (1) the two most important decision-making attributes for both groups were quality of care and cost containment; (2) most healthcare settings now use decision-making systems more amenable to value-based purchasing than previous ad hoc decisions driven by surgeons; (3) decisions are commonly, but not universally, made by committees with representation from surgeons, administrators and often others, who work together to choose implants; and that (4) their processes are still mostly based on information derived from the clinical experience of clinicians and local knowledge of procurement officers, with less influence from more formalised health technology assessments.	Data based on USA hospitals only; reimbursement entities, patients nor regulators’ views not included; general limitations of survey responses noted.
Nisbet and Ward33	Journal article	The British Journal of Radiology	2001	UK	1 hospital	Radiotherapy equipment	To describe financial factors affecting decision to purchase or lease radiotherapy equipment in one hospital and to describe technical consideration to be taken into account.	Description of process: case study. Financial analysis (over 10 years to correspond with the assumed economic lifetime of the equipment) and operating lease test.	Overview of the procurement process, including a summary of the advantages and disadvantages of leasing, with the figures from the financial analysis; a detailed description is given of the technical considerations to be taken into account in the financial analysis and negotiation of any lease contract. Comparison of leasing as defined in the Statement of Standard Accounting Practice 21 (SSAP21) and purchase.	It is essential that technical staff are involved in the discussion and detailed negotiations on the content of the lease, and ideally the financial aspects of these considerations should be taken into account during the financial analysis of purchase versus lease.	Larger centres with a rolling programme of replacement equipment would expect to keep up to date with technological advances, and the conclusion reached for this hospital may not apply.
Obremskey et al (Vanderbilt case)36	Journal article	Clinical Orthopaedics and Related Research	2012 (2008 start of intervention)	USA	1 academic medical centre	Vanderbilt case: surgical implants (physician preference items: surgical endomechanical stapling devices, orthopaedic joint arthroplasty, spine internal fixation, trauma internal fixation, cardiac rhythm management implants, drug-eluting stents and cardiac valve implants). In table: endomechanical, total joints, cardiac rhythm management, drug-eluting stents, spine implants, interventional cardiology, cardiac surgery, trauma, abdominal mesh. 2013 report: Closure devices, transcription, oral care and reference laboratory phase I.	To describe the challenges, implementation and outcomes of cost reduction and product stabilisation of a value-based process for purchasing medical devices at a major academic medical centre.	Description of process (with reported cost savings): case study.	Vanderbilt case: implementation (2008) of a physician-driven facility-based technology assessment committee (=Medical Economic Outcome Committee) that standardised and used evidence-based, clinically sound and financially responsible methods for introducing or consolidating new supplies, devices and technology for patient care. This committee worked with institutional finance and administrative leaders to accomplish its goals.	Using this physician-driven committee, we provided access to new products, standardised some products, decreased costs of physician preference items 11%–26% across service lines and achieved savings of greater than $8 million/year. The implementation of a facility-based technology assessment committee that critically evaluates new technology can decrease hospital costs on implants and standardise some product lines.	Vanderbilt: First, the study describes the experience of only one institution. Each institution has its own challenges in physician alignment, history and culture. Each institution’s process will be unique to its individual characteristics. Second, the institution is an academic setting with closely aligned faculty and hospital. Academic practices that are not directly affiliated with the hospital and community hospital with community-based surgeons will have to establish a mechanism to partner with each other for mutual benefit. Third, the institution established the committee a short time ago, and long-term effects of the process cannot be described. Finally, while other institutions could reproduce this process, it will not guarantee the reproducibility of the effects of this study. Each institution will need to develop and modify the described process to fit the culture, history and geography of their situation.
Olson et al (cases: Vanderbilt and Duke)37	Journal article	Clinical Orthopaedics and Related Research	2013 (intervention since 2008 and 2010)	USA	2 academic medical centres	Duke: endomechanical, total joints, cardiac rhythm management, drug-eluting stents, spine implants(hardware only), trauma, mesh, heart valve rings, nerve stimulation, kyphovertebral plasty, negative wound pressure, electrophysiology (EP) catheters and accessories, bare metal stents, Duke University Hospital system total. Vanderbilt: endomechanical, total joints, cardiac rhythm management, drug-eluting stents, spine implants, closure devices, interventional cardiology, cardiac surgery, transcription, trauma, mesh, oral care, reference laboratory phase I.	To describe physician-led processes for introduction of new surgical products and technologies; and to inform physicians of potential cost savings of physician-led product contract negotiations and approval of new technology.	Description of process (with reported cost savings): case studies (2).	Duke case: implementation (2010) of medical staff committee with a charge to evaluate equipment, devices and information technology (EDIT) to be brought into the operating room (OR).	A collaborative arrangement should address three objectives in which hospitals must find ways to meet three objectives: (1) collaborate with medical staff leadership to provide surgeons with feedback regarding the financial impact of their implant selection on the cost of an episode of care; (2) ensure that medical staff leadership has an effective means of communication with hospital administration regarding the medical evidence supporting the use of newer, more expensive technologies or implants to benefit patient care; and (3) both the hospital and physicians need a system that allows tracking of the impact of efforts to manage implant use. There are potential disadvantages in setting up a physician-led system as well. For physicians leading such efforts, a substantial amount of time may be required. The value for hospital systems from these programmes is centred around cost savings, whereas the value for surgeons is centred around access to technology and products required for cutting-edge medical care. Thoughtful communication to each of these key groups of stakeholders is necessary to ensure the successful work of the programme is shared to each group.	See Obremskey et al 36. First, there is very little peer-reviewed research and literature in this area. Second, the experiences in academic centres may not be applicable to other environments. Third, to achieve physician participation in these programmes, some higher form of alignment between physicians and hospital or the health system must be in place. Fourth, we have very little published peer-reviewed data on cost savings. Such data will need to be accumulated in the future in a form that can be subject to peer-reviewed publication.
Pandit et al38	Journal article	Anaesthesia	2011	UK	N/A	Airway management devices	To establish a process to create appropriate level of evidence to inform purchasing decisions within hospitals (in UK) with a working party (Airway Device Evaluation Project Team).	Description of process: case study of process developed to support adoption.	Difficult airway society working party advises on how to set up design of a trial appropriate specifically for airway devices and guides hospital in implementation of this trial together with company (who sponsors it); results published for other hospitals and results in final purchase.	N/A—does not report on implementation of proposed procurement process.	(‘Weaknesses of strategy’) Airway Device Evaluation Project Team's (ADEPT) decision to leave many judgements to individual discretion was a pragmatic one, and arguably, there is not enough dictated from the centre. Some trusts may continue to ignore anaesthetic opinion, prioritising instead the financial consideration. Some manufacturers may try to use a non-evidence-based approach to marketing their products.
Satta et al39	Book chapter	Clinical Engineering Handbook (Second Edition)	2019	Italy	1 hospital	Ophthalmic surgery femtosecond laser	To describe a tender of ophthalmic equipment.	Description of process: case study based on experience.	To test a procedure for regional public tender purchase (Ente di Supporto Tecnico-Amministrativo Regionale=ESTAR) including: accessories, consumables needed for sustained use, quantitative/financial evaluation (all included in the contract for true costing, which includes number of interfaces with technicians expressed in days, and limitations set in contract for locking prices over 5 years). User ‘trial’ performed for 10 months to test each option in real-life settings.	ESTAR tender procedure gave an excellent result in terms of quality of equipment and awarded prices but the total time to achieve the result is quite long (±4 years).	During the installation, emerged technical problems could probably be addressed during the tender design phase. Furthermore, the aspects related to the data flow would have the deserved deeper analysis already from the drafting of the specifications and then also during the assessment.
Verma and Peacock43	Journal article	Ultrasound	2014	UK	1 hospital	Ultrasound imaging	To describe the management structures concerning ultrasound equipment in hospital.	Description of process: case study based on experience.	Use of medical equipment management group.	Medical equipment management group created successes: (1) oversight of ultrasound equipment improves handing financial implications and plans yearly expenditure; (2) consolidating equipment from one manufacturer in a department improves procedures; (3) redistributing equipment within hospital prevents unnecessary buying; (4) buying with research funding; maintenance costs after grand period taken into account.	None listed.
Wong53	Master thesis	N/A	2007	UK	2 hospitals	Case 2 most relevant: X-ray equipment	To generate a detailed understanding of the relationship between the risks which the private sectors bear and the returns they actually earn, to highlight how risks are allocated appropriately with the stage of the procurement process and to identify how the current risk management model controls and manages public finance initiative (PFI) project risks.	Description of process: two case studies: interviews, questionnaire, document analysis.	Use of PFI procurement.	Risks in PFI contracts are appropriately transferred and mitigated under the current risk management system in technology and equipment management NHS projects. The transfer of technology and obsolescence risks to the private sector is fundamental to the delivery of value for money (VFM) in PFI procurement in health sector. PFI procurement in hospital projects results in a more structured approach to operating, maintaining and replacing medical equipment assets.	None listed.

APACHE, Acute Physiology and Chronic Health Evaluation; BME, Biomedical Engineer; HTA, health technology assessment; ICU, intensive care unit; NHS, National Health Service.