Surgical Services New Item Weighted Impact Tool

Supply/Equipment Requested: ______Requestor: ______Date______

Rating Score and
Council Action / FDA Approval /

Patient Population and Proposed Benefits

/ Financial Analysis
≤5 points not acceptable
6 -12 points more info needed
³ 13 points approved / q  FDA Approval (type): 510K, PMA. IDE
______
Predicate Device(s):______/ Indications:
Proposed Benefits: / Product Cost: ______
Anticipated Volume: ______
Estimated Total Cost: ______
Current Cost: ______
Estimated Savings: ______
Estimated Overall Impact:
Quality of Clinical Evidence[1] / Clinical Benefits / Staff/Physician Safety/ Satisfaction / Supply Chain Goals & Strategic Plan / Financial Impact
Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.
£  6 points
Fair: Evidence is sufficient to determine effects on health outcomes, but the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes limits the strength of the evidence.
£  3 points
Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.
£  0 points / ↓ Length of Stay/Procedure
£  1 points
↓ Infections / complications
£  2 points
↓ Invasiveness
£  1 point
↑ Clinical Efficacy
£  1 point
£  2 points
£  0 pointsNeutral
↓Restarts/Redos/Follow up procedures
£  1 points
£  2 points
↑ Compliance with Patient Safety goals
£  2 points / ↓ Exposures
£  2 points
↓ Needle Sticks
£  2 points
↓ Workers comp (lifting/positioning)
£  2 point
↑ Staff accountability /Ease of Practice Compliance
£  1 point
£  2 points
↑Physician acceptance
o  2 points
Clinical Engineering Review
£  Positive: 1 point
£  Negative: -2 points / Promotes product standardization
£  Positive: + 2 points
£  Neutral: 0 points
£  Negative: - 2 points
Compliance with contract requirements
£  1 point local
£  2 points UHC/Novation
Replaces current product(s)
£  2 point
Complete portfolio of related products
£  1 point
Cost Saving Initiative
£  2 points
Inventory Reduction
o 1 point / Overall impact on Profit/Loss for Health System
(-6 ® +6 points)
Check box that corresponds to overall impact as noted in Financial Analysis:
£  > $50,000 (6 pts)
£  + $40,001 - 50,000 (5 pts)
£  + $30,001- 40,000 (4 pts)
£  + $20,001-30,000 (3 pts)
£  + $10,001 - 20,000 (2 pts)
£  + $ 1 - 10,000 (1 pt)
£  0
£  - $1 - 10,000 (-1 pt)
£  - $10,001 - 20,000 (-2 pts)
£  - $20,001 - 30,000 (-3 pts)
£  -$30,001- 40,000 (-4 pts)
£  - $40,001 - 50,000 (-5 pts)
£  > - $50,000 (-6 pts)

2009 Based on sample from The Ohio State University

[1] U.S. Preventive Services Task Force Ratings: Strength of Recommendations and Quality of Evidence. Guide to Clinical Preventive Services, Third Edition: Periodic Updates, 2000-2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/ratings.html