I'm really anxious now to try to dive into the cases for this segment and hear from our audience as well as our presenters for this segment, but first I do want to look at the Q&A in terms of the chat. We do have one question so far, Dr. Abdi, so it's in the short term, what is the financial incentive for starting a strong quality incentive program? Sure, so I'm going to pose that to our speakers. Gerard, would you like to comment on kind of the financial incentive in terms of a strong quality incentive program? Yeah, so I guess it would depend on the viewpoint of the questioner. I mean, is it an issue regarding trying to get enough resources financially to establish the QI project or is the QI project going to lead to a financial improvement in the bottom line of what the endoscopy unit is trying to reach from a strategic business plan standpoint? So I gave the example earlier on about how there may be physicians, different physicians in the endoscopy unit that are using equipment maybe more so than others and does it really lead to better clinical outcomes for patients? So for the example of a post polypectomy in which one physician is using multiple clips to close a polyp defect versus another physician who leaves it open without closing, is there a significant difference in clinical outcomes for those patients and can you save money by reducing those practice deviations or variations? Or could it be because a particular QI project is going to involve some additional resources maybe perhaps from the quality institute if there is one at that institution? Do we need data from our IT people, from our electronic health record support to try to accomplish the things that we need? Those have to be built into a business plan and an executive sponsor really needs to lead that charge to get approval for that financing. Amazing. If we have time, Eden, why don't we start our case-based interactive discussion with the audience? So let's talk about our case one. When reviewing your colonoscopy quality metrics, you're pleased to see that the group average ADR is 42%. However, you discover that your most productive physician has an ADR that is 26%. On further examination, you note that this same physician has an average withdrawal time of six minutes while other physicians tend to have an average withdrawal time of eight to 10 minutes. This physician's metrics meet the current benchmarks. What if anything should you do? Go ahead, Gerard. Okay. Well, yeah, obviously this person is meeting the benchmarks, but you want to improve their performance, right? And so you can point out to them, I think that's the first step, right, is to show them that their ADR is lower than the group's average and also point out to them, he or she, that they are spending less time on withdrawal and perhaps just pointing that out to them turns on the light that maybe this physician should be thinking about adding those two or four more minutes to their withdrawal time as an attempt to increase their ADR. Just showing them the data sometimes changes behavior, right? The other thing that I did mention before in my previous two talks is how to improve ADR overall. If they're open to having a nurse or a technician in their room as they're withdrawing, pointing out things or incorporating an artificial intelligence program that highlights polyps during withdrawal sometimes can slow people down enough that they're capturing more adenomas or advanced adenomas and then thereby leading to an improved ADR overall. If they're concerned about the possibility that their revenue value unit generation is being compromised by the fact that they're the most productive physician and they might be penalized because they already meet those metrics, you could actually show them that if, on the other hand, that their ADR rate is lower, that the chance that they're going to come back and offer a different surveillance interval than their colleagues and show that downstream revenue from improving surveillance intervals might be beneficial for them from a financial perspective, that also might be another way to approach that position. Obviously, it's trying to get to the bottom of how they're thinking and what viewpoints they have in order to convince them that it's not just meeting a benchmark, but also trying to improve quality overall. You want to be those 50% people. You want to be achieving for a higher goal than just meeting the benchmark metric. That's a great point. I know also one thing is that all of us as an endoscopist are continually learning. I think one of the things that we can do is offer our staff and faculty small mini lectures of education, such as a 15-minute presentation on how to improve your ADR. Talking to physicians as a whole can be very engaging. I know that Mary Rose and Shanshan were instrumental during our last faculty retreat, having dedicated time at the end of the day that was just literally an endoscopy primer. It was time for providers to just take a step back, learn how to use equipment that they may not be using well, get a refresher. But then also incorporated with that beforehand was a didactic lecture on how to actually improve your ADR so that physicians get high-yield 15 minutes to collectively talk as a group and understand the challenges. Then you may have a safety leader or a champion within your group or the physician lead that can have those individual conversations and say, every year or six months, we're going to review everyone's ADRs and give them resources for improvement. So great comments. We do have an ADR-related question, Dr. Addy. And this person says this question may be a bit more involved, but ADR has been a challenge to implement at our hospital due to a large system and lack of automation with pathology to GI-Quick, so into the GI-Quick registry. We have a bit more control at our ASC. Different branches of our department have hired an FTE to input data into the registry, but have you found any shortcuts through Epic that could make this process more streamlined? So I don't know if other people through there, if they are working with Epic, if they've been able to create a process for tracking ADR. So at our institution, fortunately or unfortunately, not sure how to put it politically correct, but we are in Epic Lumens. And one of the painful issues with Lumens is that the coding behind the scenes has not been great in terms of capturing adenoma detection rates. It also, as people understand with GI-Quick, there hasn't been an integration or open communication between Epic and GI-Quick. So there has to be a lot of workarounds associated with this, but I'd be interested to hear what people are doing at Johns Hopkins. I don't know if Shanshan has a comment about this. That has been a long frustration for our institution. We do have a safety lead that is actively trying to work with our endoscopy software in terms of the EndoPro to identify our ADRs. I am not that familiar with any projects that we have currently running with Epic as a tool to calculate ADRs, but Shanshan, please correct me if I'm wrong. No, Dr. Apley, you are absolutely spot on. It is actually a pinpoint for us as well. Luckily, we have been able to work with EndoPro for probation, who's our documentation platform vendor. And they put a business status tool, which is called ClickView, and provide a dashboard and help us to essentially mine information out of the documentation to essentially have a separate reporting system for abnormal detection rate. And no, we're not on Epic Lumen, so I don't think for now, unless we have a separate documentation requirements, which is going to be another pain, I don't think we have a Epic solution at this point yet, although we're in the process of trying to explore other options. Yeah, so stay tuned. Hopefully with Epic, for those of you that use Epic, as Epic seems to grow in number of hospital utilizations throughout the country, I'm sure this is not a local or regional problem, but a national problem with this electronic health record. But there is another question that talks about how they have both surgeons and GI providers who provide screen colonoscopies, presumably. And maybe the surgeons aren't as enamored about the metrics, and how do we inspire perhaps the surgeons to be more mindful of these metrics and aspire to be similar to our gas neurology colleagues? Again, I think just pointing out the data is one way to push surgeons a little bit. And then also having those suggestions that I mentioned before about how to improve ADRs overall. As we know, having a second observer in the room, if they're open to having the tech and or nurse in the room pointing out polyps as they're coming back and a slower withdrawal time are ways to just try to improve the process for them, if they're open for that. Again, it's going to be a discussion between the quality leaders, the nurse manager, the endoscopy unit leader, and each individual provider. There are physicians out there that are family practice trained endoscopists that also have some similar issues. And it's just raising the tide for all boats to get better, to get higher. Absolutely. Why don't we now switch gears and go to our case two? Okay. As the nurse manager checked on her staff in an endoscopy room, she saw that the biopsy specimens for the patient's EGT were still on the table, listing gastric biopsies at 38, 36, and 34 centimeters. She knew that the patient had a history of Barrett's esophagus. The patient was undergoing a subsequent colonoscopy and she realized that the specimens had not been verified before the next procedure was done. The unit has been short staffed for the past several months. And during this time period, multiple specimen collection errors have occurred. What should we do? I want to pose this question to Mary Rose, because I think this may be a frequent issue that may come up from time to time in endoscopy suites. And I'm just curious how you manage it. So just to be clear, the situation is that there's specimens left in a procedure room with the prior patient and it hasn't been taken. And so things that we would do here in our suite is number one, we would make sure that the specimens need to get to where they need to go, because that's what these patients are coming in, going on. And if they're here and they're a hospital required patient, so we don't do normal screenings and normal procedures. We're dealing with that ASA3 for classifications of patients coming in. We often treat patients, not just in our community, national, internationally. So this is a big thing to me. So first of all, we definitely want to verify that the biopsies are correct and it's the right patient, right specimens with the physician, the team. And once that is completed, we want to make sure they go where they're at, where they belong. We also have a process here that Rosa, who will be speaking with me later, is our CUSH champion, right? And she's pretty much our safety champion along with another physician. And those things we would document in our system and Rosa would review that. And then she would tag every folks in personnel that was involved in that situation. And then at our routine meeting, we would review this as a case study, having all parties involved and looking at this of how do we number one, make sure this never happens again. And what processes do we need to put in place and where was the link broken in that chain? So these types of meetings are not punitive. It's based around improving quality of patient care and discussing these issues because unfortunately, humans make error and this comes up. I would see if Rosa wanted to add anything to that because she is our CUSH champion for endoscopy. Hi, I think Dr. Eisenberg touched on this earlier with Michael Jordan, that we learn from our mistakes. When we train our staff in the room, we're very diligent about the workflow process. And I'm always telling, as I train, don't leave anything behind from a previous patient. Don't leave any labels, pathology forms, don't leave anything behind. And I think I learned that like a long time ago when I made a mistake. And as Mary Rose said, we have a hospital event report online system. So when these things happen and fortunately, I haven't gotten any heroes or safety reports related to biopsies. So I think we're doing well in this area, although yes, it's a potential problem, but I have not seen it. I know I did it. I just took over about a year and a half ago and all last year we had kind of other type events where we were tubing specimens. We don't do that anymore and we've improved. So there's always area work for improving, but I'm happy to report that we haven't had any type specimens regarding like GI specimens. We're doing pretty good with that. Yeah. I think in this instance, I think that the nurse should speak up, right? Call a time out and say, hey, before we proceed with this colonoscopy, can I just make sure I have the right idea about what you're putting in for the pathologist to evaluate? And I think that the endoscopist in the room is going to appreciate the fact that there are time pressures and sometimes making sure that the right thing is being done before moving on to the next procedure is important. And so in this particular instance, I would say if there's a vibrant team culture, that the nurse should be allowed to say, hey, time out. I need to get these things done before we move on. Yeah, we actually do a specimen time out and you can't verify in EPIC in procedure room unless you do your specimen time out. So this helps, excuse me. So usually when we're going out of room, then our workflow is to bring the specimens with us, give report in PACU and then return to the specimen room and then go back to your procedure room and get ready for the next case. So just to sum this up, we have safety nets in place in our EPIC system that you cannot proceed without doing the time out for the specimens. And you cannot start another case until you verify those things with the physician and the team in the room. But even with those safety nets and bumper guards, staff could still leave it behind when they left. So I do like the fact we have a cost review system to learn from our mistakes. Amazing. I wonder if Lisa may want to comment on the case as well, just from the perspective of the ASCs and how they might handle this situation or case. Yes. So we're actually a hospital outpatient department. And so what we developed in our area is a clinical practice guideline for specimen collection. And it's a very detailed workflow on how specimens are collected. It's a two person check in the room. There is a time out with the physician. And we also developed the electronic path requisition within EPIC that is now being used GI system wide. But we developed it, the workflow. And I'm going to tell you something. And I'm going to brag here. The team has had zero specimen errors. Or we also count discrepancies. An error is like a mislabel or something that doesn't match the physician electronic record. And a discrepancy is a leak, a leaking container, right? Or when things are left in the room. And that has consisted over the last year and a half because the team follows the workflow, the clinical practice guideline to the letter. So it's worked for us. Thank you so much, Lisa. And I'm just looking at the questions that have been posed. Someone did ask, what does CUSP stand for? It's our comprehensive unit based safety program. You know, acronyms are used at different institutions. So basically it's a safety program that engages the endoscopy unit in reviewing cases, identifying what happened and creating interventions for change. Another comment that was made from Angela Stewart Phillips was utilize an end of case summation while all team members are present. The idea at the end of the case that you go over all the specimens that we're taking is an amazing comment and suggestion. Another comment from Tanisha. To reduce specimen errors, our GI center has adopted a specimen verification process where the RN and the physician must sign off and verify specimens together. This in addition to the sign-off verification timeout in our EPIC documentation. And they've also seen great results with this additional step. Thank you guys so much for the engaging conversation and discussion.

quality improvement

endoscopy units

financial incentives

clinical outcomes

specimen collection errors

safety programs