Advanced Clinical Engineering Workshop, Moscow, RussiaThey came from Duvna and Kazan, from St Petersburg and Novgorod, from Samara and Stavropol, even as far away as Vladivostok. Top-level health care professionals joined their peers from Moscow at the Advanced Clinical Engineering Workshop in Svenigorod, a 200-acre estate just outside of the Russian capital. Established in the 18th century by a Russian prince, the estate named Snigiri (Snowbird) is now a retreat centre. The cool clean air invigorated all. Some 40 participants learned from and exchanged experiences with top-level clinical engineers and health care technology managers. The ACEW was organized by the American College of Clinical Engineering, Association of Medical Physicists of Russia, Ministry of Health of the Russian Federation, Russian Academy of Medical Sciences and the World Health Organization, in association with the International Federation for Medical and Biological Engineering and International Federation of Hospital Engineering and co-sponsored by the American International Health Alliance, Oregon Health Sciences University, Swiss Tropic Institute, and the World Bank. The theme of the ACEW was Effective Planning, Acquisition and Utilization of Healthcare Technology. The ACCE faculty, lead by Yadin David, ACEW Program Chairman, comprised Bob Morris, Al Jakniunas, Jim Wear, Frank Painter, and Joe Dyro. Andrei Issakov, an ACCE member and Team Coordinator, Department of Health Services Delivery World Health Organization (WHO), was instrumental in arranging the Workshop. Other faculty members included Peter Heimann, Cape Town, South Africa, Director of Technology and Business Development Group Medical Research Council and President of the International Federation of Medical and Biological Engineering Clinical Engineering Division, Martin Raab of the Swiss Tropical Institute. Russian faculty members included Valery A. Kostylev, President of the Association of Medical Physicists of Russian (AMPR), Oleg Shereshevskiy, AMPR Director of International Projects, Nikolai N. Blinov (AMPR), Alexander N. Varin (AMPR), and Vladimir Klimanov. Kostylev and Shereshevskiy were Workshop co-coordinators. Special thanks go to Ludmila Alexeeva, Sergei Varzar, Natalia, Olga, Galina, and Irina, who handled all the local details, photocopying, taxi service, tourism and administration. Irina Dubovskaya and Victoria Droganova admirably translated the formal lectures and the often-spirited discussion. Opening the Workshop, Dr Andrei Issakov reminded all that this day was the national day of mourning for those killed and injured in the recent bomb blasts in Moscow and asked for a moment of silence to reflect on this tragedy. Opening and welcoming remarks continued with Bob Morris (ACCE), Valery Kostylev (AMPR), Peter Heimann (IFMBE), and Prof. Martinoff of the Ministry of Health of the Russian Federation. Yadin David gave an overview of the Workshop, highlighting the presentations that were to follow, and introduced all of the faculty members, who each said a few words of introduction. He then made the first presentation: Healthcare Technology and Healthcare Technical Services. This was followed by Heimann and Issakov presenting WHO Guidelines on Formulating National Healthcare Technology Policy. The first web-based streaming audio biomedical engineering lecture on the management of medical technology was offered by Yadin David. David also introduced the English and Russian versions of the manual he authored on Y2K Issues and Medical Equipment. A Y2K Issues panel discussion with David, Painter, Morris and Dyro concluded the day. The next day began with Blinov and Equipping Clinics with Modern Means of Medical Imaging: Problems of Organization and Management of Diagnostic Centers. Varin continued with The Prospects of Equipping Medical Institutions with Domestically produced Equipment. Raab related Clinical Engineering Experiences in Nizhny Novgorod, Perm and Samara. David and Heimann presented Macro Technology Assessment and Strategic Planning and Technology Assessment in the Local Healthcare Facility. Bob Morris discussed Planning, Selection and Procure-ment Strategies. Heimann and Issakov delivered the WHO Essential Healthcare Technology Package. Valery Kostylev closed the second day with two papers: The Medical Physicist and His Role in the Management of High-end Medical Technologies in Radiation Therapy and Construction and Equipping of Facilities for Radiation Therapy and Radiology Departments: Organization of Their Effective Functioning and Quality Control. On the third day Painter dealt with Ongoing Relationships with Manufacturers and Morris, with Maintenance and Service Management. Morris finished with Budgeting and Financial Reporting. Painter led the fourth day with Determining Workloads and Service Marketing. From Vladivostok, where he is Deputy Chief of Physics, Vladimir Klimanov described his experiences with imported equipment and highlighted the need to allocate special funds for maintenance and spare parts. Fortunately through a partnership with the Medical College of Virginia new diagnostic radiographic equipment has been installed. Wear and Dyro tackled Human Resource Development. Dyro concluded with Safety and Risk Management and Accident/Incident Investigation. On the final day, Painter addressed Quality Assurance. Joined by Morris and Wear, he followed with a panel discussion on Utility Systems. Dyro presented the ACCE Guidelines on Donated Medical Equipment. Painter returned to the dais to speak on Certification of Clinical Engineers and Biomedical Engineering Technicians in the US and Internationally. An open discussion followed with comments from the ACEW faculty and participants. The following is a compilation of many sound bites from that open discussion. Over the last decade, importation of medical devices has skyrocketed while production of domestic devices has plummeted. With the closing of military factories, many military engineers are available for work in medicine. A system of medical device standards has been difficult to implement. Some participants felt that the government could take more initiative in fostering the development of the domestic medical device industry. Some despaired at the prospect of not ever being able to compete with Western companies in the healthcare technology arena. One participant felt that government involvement with centralized purchasing is a necessity but that organization should begin today without waiting for government and Ministry of Health (MoH) initiative. A common lament expressed was the ability to acquire high-quality Western diagnostic imaging devices but the inability to financially support the operating costs. While medical physicists are regulated, enforcement of these regulations leaves something to be desired. The chief physician of a medical diagnostic centre urged the improvement of the quality of medical engineering personnel and stressed the importance of certification programs. He went on to state, ‘MDs, clinical engineers and financial managers must work together closely.’ He noted the widening gap between technological developments worldwide and the credentialling of physicians in Russia. Physicians desire more modern equipment to improve their credentials. Often equipment is underutilized or improperly utilized for a lack of physician training. Counterproductive competition among medical specialties in Russian hospitals exists but some hospitals enjoy a high level of teamwork and cooperation. Utility problems are severe in several places. Problems include poor quality of electrical power and electromagnetic interference. A debate ensued over whether hospitals closer to Moscow received more financial assistance from the central government. Another participant after hearing the presentations declared that his hospital needed clinical engineers. He realized the value of forming consortiums to share resources, which would include clinical engineering. A Director of Finance remarked, ‘We need to ask why high-tech is needed to the exclusion of mid-and low-tech and perhaps more appropriate technology.’ The consensus was that the ACEW would enable the formulation of objectives that should be presented at the governmental level to the MoH. Some noted that on more than one occasion initiatives presented to the MoH did not materialize, in part, from lack of follow-up and support. One participant said his hospital cannot afford to hire a clinical engineer while another described how organizing a shared service made this possible. Another participant recognized the need to train specialists in management and observed that administrators and directors of hospitals do not know what management is. He even proposed that the government mandate management programs for administrators and directors. From another part of Russia came the statement; ‘We have no idea about industry and business. We don't have a medical device industry and must import.’ And yet another participant voiced her desire to see established educational programs in quality improvement topics. It was suggested that participation in future workshops by MoH representatives would engender substantive dialogue concerning financial and management issues. Martin Raab saw three steps that must be taken. First, centres of excellence needed in Russia at different levels with reference materials in the Russian language adapted to the Russian environment. Second, increased interest at the federal level is needed. He perceived a vacuum existing where nobody knows where to attach the knowledge imparted during such events as the ACEW. And third, concrete solutions and models need to be developed. After the lively, substantive, and illuminating open discussion, David provided a Summary of Workshop Goals, Objectives and Conclusions. The ACEW closed with the presentation of Certificates of Recognition and Achievement to ACEW faculty and participants. The Workshop strategy was first to present the most theoretical approach to technology management and then as the week progressed to present concrete examples of methodology and practice. Rather than ‘preaching to the choir,’ the clinical engineering faculty held economists, finance directors, medical directors, and hospital directors in rapt attention throughout their presentations. All in attendance recognized the enormous financial impact clinical engineering principles have on health care delivery systems. A great deal of information was transferred both in the spoken and written word. Contacts and networking were established. Reprints, slides, overheads, outlines were left behind for reproduction and dissemination in Russia. The Journal of Clinical Engineering sent copies of the Journal for each participant as well as copies of The Guide to Biomedical Standards. Thanks go to the Journal's Jack Bruggeman, Tim Baker and Joyce Meals who approved and facilitated the shipment of these workshop materials. Commitments to develop papers based on the Russian experience were obtained. Membership applications to ACCE were distributed to those who requested them. ACCE looks forward to adding colleagues in Russia to the ACCE membership roll. The co-coordinators of the Workshop, Oleg Shereshevskiy and Valery Kostylev will examine the articles of incorporation and organizational history of ACCE as an aid in the formation of a similar organization in Russia. Similar consultations have facilitated the establishment of national clinical engineering organizations in other countries such as Italy, Mexico, Brazil and Saudi Arabia. Andrei Issakov, thanking the ACCE faculty for their considerable effort in enduring the rigors of foreign travel with its many vicissitudes, remarked that it was all worthwhile. The feedback he has received confirmed that the faculty did an admirable job to plant and water the seed of clinical engineering and technology management in Russia through state-of-the-art lectures, stimulating discussions, formal and informal exchanges which opened the eyes of many participants on many issues. Now, technology management and clinical engineering will be put on the agenda of health authorities and health professionals in Russia. He urged that the momentum created be maintained, particularly through the implementation of recommendations and action points drafted by the ACCE team and Workshop Co-coordinators, Kostylev and Shereshevskiy. ACCE Workshop Chairman Yadin David, wholeheartedly agreeing with Issakov, summarized in the following statement the challenges and opportunities arising from the ACEW in Moscow:
The following points were formulated:
The above proposal will not differ significantly when applied to other countries in the world that are in need of establishing and developing the principles promulgated by way of the ACEW. All work and no play make Jack a dull boy. Receptions at both the opening and closing ceremonies afforded the opportunity to sample fine Russian food and drink. The staff of the conference centre prepared delicious meals each day. This author was particularly fond of the many dishes prepared with mushrooms gathered from the surrounding woods. During the week, after the formal presentations and dinner, discussions would carry late into the evening in the fireplace room. One special evening, we left the warmth of the blazing hearth to enter the 230°F heat blast of a nearby sauna. Birch branches and leaves produce not only tactile stimulation but delight the olfactory senses with their sweet fragrance. Snow had not yet come to Snigiri, so we had to settle for dips in the pool to bring our body temperature to normal. Side trips to downtown Moscow and a nearby monastery provided a glimpse of that great country's splendours. The icy wind whipping over the Moscow River and through Red Square chilled the body to the bone and greatly increased the sales of fur caps proffered by peddlers swarming about the crowd. We delighted in the beauty of the Cathedral of the Protecting Veil of the Mother of God, St Basil's Cathedral, the Resurrection Gates, and the Cathedral of the Kazan Icon of the Mother of God. That evening at an ancient hunting lodge, bedecked with the usual animal skins, Cossacks keep close watch to keep the vodka and kvas glasses filled to the top. A sumptuous buffet preceded entrees, which included grouse, bear, rabbit, venison and a variety of local freshwater fish. Later in the week several faculty members visited St Sergius Lavra, the monastery and residence of the Patriarch of the Russian Orthodox Church. Much evidence was seen of the reconstruction of the significant architectural treasures of Russia. The usual matroishkas (nested hand-painted wooden dolls), lacquered boxes, postcards and fur caps were purchased before boarding the van for the ride back to Snigiri through pastoral beauty and dark, pine forests highlighted by white birches brilliant against the setting sun. While most of the faculty arrived at Moscow's Sheremetyevo Airport without incident, Bob Morris managed to find himself in the airport jail, booked on the next flight back to Mongolia. His entry visa to Russia was to have been handed to him upon his arrival since it was issued in the Washington, DC, Russian Embassy too late for it to reach Bob in Mongolia. Al Jakniunas with visa in hand waited patiently for Bob's arrival at Terminal 1. It wasn't until he realized that flights from the east arrived at Terminal 2 that Al and Sergei Varzar scampered over and serendipitously found a bemused Bob in the lockup. Eventually Bob was sprung and on his way to Svenigorod. After the ACEW the faculty scattered to all points of the compass: Switzerland, Bulgaria, Estonia, France, South Africa and the USA. Painter and Dyro's way to Airport was interrupted as traffic police stopped and searched the van. At that time throughout Moscow, no van escaped the scrutiny of the police ever vigilant in the face of terrorist activity. ‘Let there be no doubt as to the high quality of medical care available in Russia’, remarked Al Jakniunas. A bad champignon, perhaps, on an Air France flight disagreed with Al. Discomfort rapidly worsened. Were it not for the timely intervention of Dr Sergei Barsukov, who was a Workshop participant, this would have been Al's last Workshop. Dr Barsukov is Deputy-Chief of the A. Vishnevsky Central Clinical Hospital, Ministry of Defense of the Russian Federation (MoD RF). Six hours of emergency abdominal surgery and a two-week stay in the Intensive Care Unit did the trick. Al, recuperating in a VIP suite, reported that doctors, nurses and technicians who provided the best quality of care imaginable, treated him like a five-star general. He especially thanks his surgeon, Dr Valery K. Zuyev, Deputy Chief Surgeon, MoD RF, and Chief Surgeon of the Hospital for saving his life. Valery, Natalia and Ludmila visited with flowers, chocolates and smiles to buoy General Al's spirits. Dr V.K. Belyakov, General Director of the International Telemedicine Center in Russia, played a substantive role in keeping Al's spirits up. Dr Belyakov's Telemedicine Center has evolved with the help of consultation from Yadin David. He brought magazines (in English), water and fresh fruits to Al while he was hospitalized and maintained communication among Al, his family, and Dr David. It was truly good fortune to have Dr Belyakov and his interpreter Alexander Zabolotsky present at such a critical time. Representatives of the U.S. State Department at the behest of Yadin David visited with more flowers and chocolates and facilitated the necessary arrangements for an extended stay and expedient transfer to a homebound flight. Al, fit as a fiddle, is now back to work at Howard University Hospital. Joseph F. Dyro, PhD, CCE 21 Bob's Lane, Setauket, NY 11733 | ||