I just wanted to bring up that there was actually one question on sustainable practices within the endoscopy unit. I believe this refers to green endoscopy and how we can reduce endoscopic waste. So in the chat, I've actually provided the ASGE resources page link for this. One of the things that I think is very valuable on this particular web page are practical steps to green your endoscopy unit and how to get started. And so there are a couple of articles from gastrointestinal endoscopy that are included on this web page as one of the audience participants wanted more information about this. So I don't know if we have any more questions for our panelists. We do have a question from the first segment, which I think nicely builds up, and it looks like we just got another question in. So this came from the first segment, so it builds on the two. How to run an endoscopy unit on time where most cases are done in a timely manner. If you have frequent delay in starting cases on time and long turnaround times in between cases, what can be done? And then they specifically add, as a leader, how do you handle this situation? Yeah, this is a common theme, right? I think all endoscopy units face this challenge. And so I think just from a perspective of as a leader, you want to, first of all, identify that this is an issue, and then you're going to ask your team what potential solutions there are, because they're the ones that are in the trenches, right? So Neil, do you want to comment on what sort of things that you think about when facing this situation? Yes, absolutely. And we'll talk a little bit more about this in my next talk about optimizing endoscopy unit operations. But I think there are two main things to understand. From the leadership standpoint, I think it's really important as a leader in the endoscopy unit to show everyone that you care about this, and to understand, just like Dr. Eisenberg was saying, that understand that this is an issue that is affecting not only your whole care team, but patient care as well. So once you establish that you are someone who wants to take this on head-on, then the next part of that is I think it's really important to get as granular as possible as you can in order to find out where potential delays may be occurring. So it's very easy to think about things like room turnover time as the sort of go-to point for trying to optimize endoscopy unit efficiency. But as we'll see a little bit later on, there are many, many steps in order to successfully get a patient to the endoscopy unit, perform that procedure, and get that patient safely discharged. So the more granular you can get at every step in the way of that process, the better your yield will be in trying to figure out exactly where delays are occurring. And then, as Gerard was saying, it's really important to engage your team members in how to provide solutions to try to combat those problems. I worked in one endoscopy unit where we did this process, and it actually came down to the number of transport gurneys that were available to transport a patient from the procedure room to recovery. So then we were able to put together a business plan, take it to the hospital administration to buy us a whole bunch of more gurneys, and that significantly improved our throughput for the day. So it can be something as simple as that, but the hard part is figuring out a system and a process in order to figure that out, and then implementing the solutions. And we'll talk a little bit more about that in the next half. Those are great comments. Allie, are you on as well? I am, yeah. I think I totally echo everything that Neil said. I think one thing that he said in his talk, which really struck me, and I think we've all felt this before, is that everyone is anxious to blame everyone else. So as the endoscopist, you're blaming anesthesia. As anesthesia, you're blaming the IVs or the difficult veins. As the difficult veins, you're blaming the tubing. I think that just completely resonates with me. And I think the challenge is trying to identify which step of the process is causing the most delay, which is most intervenable, and really where to start. And some of that has to do with how you can obtain and get the data that you need to be able to make sound decisions. Because oftentimes, we know that at certain endoscopy units, you have very sick patients coming through, and maybe the efficiency or inefficiency is because some of those patients really require additional care before they can be brought back to the unit, and that additional care takes time. And so the leniency or understanding that certain components of it may be prolonged for a reason, but the data to reflect what that reason is, is what's so challenging. So I think this is a multi-step process that I know Gretchen and I are working on at University of Michigan. And I am excited to hear your talk during the second half to try to really understand and drill in on some of those really important components for efficiency. Yeah, and I look forward to hearing Praveena's talk as well, because this obviously would be a perfect setup for a QI project, right? So we'll get some of the nuts and bolts associated with how this can be evaluated and turned into success. Eden, do we have other questions that we want to address? We do. So our next one is, how do you manage inventory when you have multiple endoscopists? For example, different endoscopists have preference for different snare, and so you end up with four different cold snares, and that takes up inventory. Oh, that's the first, I will take that question, Gerard. It's so important that we standardize in our practice, which is the hardest part to do, including the prep solutions that we use for our patients. I mean, it's hard to get 10 different people to use the same. That's what helps. But in our particular unit, we have only one cold snare, one type of hot snare that we use. I mean, let me take it back. One type of a small snare, one type of a big snare, and one type of a barb snare. It's not like multiple companies that we use. So that's important, trying to standardize what works, because you're looking at cost efficiency. Just because you love a platinum snare doesn't mean the endoscopy unit is going to get it. It's important that we need to learn and be part of it, be accountable. If somebody is giving you trouble, just bring them on the leadership team, make them part of the team so that they're part of the solution rather than being complaining. That's what I would think. I would love to see any other people have any other ideas. So I can chime in, too. You have great potential for economies of scale when you're able to consolidate, as Dr. Apollonini just said, when you can get group consensus. And consensus doesn't mean everybody agrees. It means most agree. Then you actually are able to purchase better because you're purchasing at a higher volume. You're able to offer potentially some different resources then because you have more space within your area to store. You don't have four different areas. You've got one box, one place. You're also able to then leverage that further with the vendor. So if you're using Company X for your snares and you're able to consolidate to one cold snare of your preference, then you actually have the ability to do that at a much broader spectrum and say, we're going to use Company X for four different devices. And because we're standardizing, we get an even greater economy of scale purchasing. And I saw the question in there about a GPO, and that's essentially when you look at a GPO and you look at these group purchasing options, they're going to encourage you to do the same thing. They are already going to have bargained with a lot of these vendors to negotiate prices based on your economies of scale and your standardization for an even greater purchasing power because you're then looking at being able to purchase with three or four or 10 or 20 organizations. And whether you're a large faculty group practice or whether you're a freestanding facility, private provider owned facility, there are different groups out there for you. And so you can find them and then through that, you find who their best vendor pricing really does look like. And oftentimes, that's how you can drive your standardization also. And I've also found that in many cases, the real low hanging fruit in order to get the most traction on this is your general GI endoscopist. As a general endoscopist myself, I really don't care that that much what biopsy forceps I use and what snare I use. I just want to open and close, you know, and do 15 colons in a day. And I'm happy with that. And many, many general GI endoscopists are in that same boat. It usually is your therapeutic and advanced endoscopist who have such a nuanced understanding of the equipment that they want to use and are so particular about it, which is what makes them great endoscopists. So leaning on what Gretchen was saying, building consensus among your general GI endoscopist can help you source vendor contracts that can build economies of scale. So then you can go to your whole team and you can do a little give and take. You can say that we have consensus here, so we're going to achieve a lot of cost savings on our run-of-the-mill biopsy forceps, snares, etc. But we can use that cost savings and then cater a little bit more toward the individual preferences of the advanced and therapeutic endoscopist. So you can get more than one biliary snare and different stents and things like that. So a little give and take there and understanding that economies of scale principle, especially amongst the general GI endoscopists, can go a long way in elevating your practice. To add to what Neil and Gretchen has mentioned, one quick comment. When we are trying a new product, for example, we constantly want to be looking into, is this the right product that we are using? Or is this the right pricing at this time? Yeah, it was right pricing three months ago or six months ago. So constantly the procurement team is looking into it. But when we are trying a new product, when Gretchen said you don't have to get consensus from everybody, we give everybody a chance to try the new snare or biopsy forceps, but it's the majority that has to like it. If majority liked it and the cost makes sense and it's a safe product, we want to run it through the endoscopy unit. And the other 20%, 30% that didn't like it will end up using it. I mean, that's how it works. Yeah. And I see that many of our participants are providing their perspectives as well. As you can see in the chat, there's been some participants who use a value analysis committee, which I think is a good suggestion. I think the difficulty is trying to find time for the value analysis committee to meet given time restraints that we often have in clinical practice. I put in a reference to an article by my colleagues here in Cleveland regarding how they approach which talks a bit about some of these things. So I encourage you to look at that as well. We have any other questions coming up, Eden, or do we want to jump into our case? What we do have another question that's been sitting here is, what is the ROI different technologies for inventory management? Is RFID tracking worth it on a PAR system that requires manual inputs enough? It depends on the volume, I would think. This is where it's important trying to understand the cost of each procedure or cost for each patient. That's where if somebody asked me a few years ago, like, what's the cost of your colonoscopy? I have no clue. But we need to go deep, delve into it, sit with our teams, trying to learn. As Neil mentioned, are you adding sedation costs? Are you adding device costs, which are important. If you're opening one room versus three rooms, you're still putting on all the electricity. You are opening the doors. You are having the crew cleaning, you know, cleaning crew come. So there are definitely some fixed costs that go with. Once we know what these are, and then you are trying to find this new technology that's going to help. That's why I said it's important to learn what is the cost of this new technology and what am I going to gain from that? That's how I would say, you know, I'm trying to understand, is it cost efficient or not? Or should I just live in the old technology because it's not worth it for my particular practice? Yeah, you have to determine whether the squeeze is worth the juice, right? So, you know, oftentimes we have, we get down to such granular details that we become lost in the forest. And so, you know, for example, you might look at how costs change from hour to hour, right? So sometimes the cost in the morning is a little bit different than the cost in the afternoon versus when you do on-call cases versus when you do cases, for example, on a Saturday, which are a little bit different than cases done on the weekdays. So sometimes, you know, the amount of money that you might actually save is just so minimal and that the time that you actually spent on doing the analysis just isn't worth it. So keep that in mind too. I think the RFID can be a little bit painful to set up in the beginning, just to do a full inventory management of all your supplies and again, how granular you want to get with it. But that technology is becoming incrementally more cheaper and scalable as you use it more. So I think that is a good way forward in order to think about growth, especially in your endoscopy unit, because it does get incrementally much cheaper as you do it more, which then gets you more net ROI for that. I think there's probably somebody on this webinar who's getting their wheels turned in their head about, hey, can I develop an AI company that looks at this? Because I think this is a perfect example of where AI can help in all of these analytics. We have a request to poll the faculty. So I will read the requested poll. How many of you work in an endoscopy facility that has a dedicated purchasing agreement with one device provider that is contracted to percent of use? So they say 90% compliance with the device provider. You want to start us off, Dr. Isakson? So that's a little bit of a tricky question. I guess, to my knowledge, the answer is yes, there is one of our facilities that has a dedicated purchasing agreement. Any other panelists want to chime in on that? We can. So we do. And actually, it's an interesting divide, and you see it in multiple areas across the organization, and you do see it in GPOs. And you can usually set and negotiate what that percentage is. It can be an 85% with one vendor and 15% open vendor, 80-20, 75-25, based on where you recognize your utilization is. But back to that whole GPO conversation, you can really impact your cost and then your cost per procedure by how you leverage that. But when you set those, you appreciate that economies of scale that you can get while still leaving the door open for bringing in some new technology and new products. Coming to me, we have single purchase agreement for the biggest expense, which is our machine products, scopes. And we do endoscopic ultrasound as an outpatient, too. So we have a different vendor for that. As for the general GI, we have a different vendor. And 90% or more utilization in those two categories, but we come to devices and other stuff, we have multiple vendors in those areas. Neil, do you have an answer to that? Yeah, I think I was going to echo what Gretchen was saying, that you can have actually multiple vendors and varying levels of compliance. And the level of compliance is negotiable. So you can definitely work with your procurement team to find a level of compliance that's reasonable for you and gets you appropriate economies of scale. Of course, the vendors will come in high, and they want you to use all their products all the time. And we'll claim a lot of cost savings, and we'll show you a lot of numbers. But it's important to stay grounded with what's realistic for your endoscopists. And not everything that they show is rosy and green, so going to the details of it, definitely. Yeah. Check the fine print. They will all say that if you do everything with us, we will save you hundreds of thousands of dollars. Every single one of them will say the same thing. I agree. I don't know what Dr. Armandewicz says. Dr. Eisenberg, we have a question about how can you join a GPO. And I'm wondering if, while somebody might take that, we could actually bring up case number nine, if our AV team could help us with that. Might be interesting, just as we're talking about this topic, to think about the cautions when you're participating in a GPO, as well. Yeah, I think this probably goes up Gretchen's alley, right? Yeah, so depending on what your facility is, if you are a smaller, well, say, physician-owned practice, there are various groups out there that are dedicated to that. And actually, just a quick Google search, I was able to find some various ones that are there. And I'm sure from a professional organization standpoint, there would be an opportunity to leverage some of that. Your larger practices, your larger health care systems, are probably already members of GPOs. They've been in place for 15, 20 years in various levels, and certainly get bigger every year. And so if the question is, are we? Maybe I don't know, and are we? That would be a question for your organization. But if you are a smaller, grounded practice, I would actually encourage you to query your peers, even through ASGE, and see if there isn't one that is already established that you could partner with. And then, Dr. Eisenberg, would you just mind reading it for the audience as well? Sure. So this is the hospital endoscopy department's been experiencing budget deficits over the years. What a surprise. Accounting for nearly half of all expenditure was the costs associated with supplies and consumables. And a preliminary review of the operations shows that record expenditure probably through different equipment categories. And so, for example, there's misappropriation with the category of enteral feedings in the GPO organization's online catalog. So, for example, a EUS fine needle aspiration needle, metal esophageal stents, and some of the ERCP guide wires are under the enteral feedings consumable catalog indexing. And so, how does one approach or ensure expenditure is recorded appropriately as the hospital continues to use this particular GPO? This has happened. You will find that in almost all GPOs, there are misappropriations with endoscopic equipment and accessories that occur all the time. I can take that question. But reviewing this, you know, I just see the major problem that happened was putting the product in a wrong category. The first thing we want to do is review and reclassify the products. Are they in the current category? For example, enteral feedings should be what are related to the enteral. You know, could it be nutritional formulas, tubes, pumps, et cetera? And EUS needles, metal stents, and ERCP wires shouldn't be in that. Obviously, it's completely wrongly categorized. You know, as Neil said, everybody tries to play more different. You know, here, some committee or whoever is this procurement team need to be looking into this GPO catalog, collaborate with the GPO to ensure that the current catalog reflects proper categorization. Some are business people, and I think a clinical mind having partnership with a physician or a nurse, you know, whoever has some clinical experience would help trying to put these products in the right category. And if they don't align with that particular category, change it. And define the purchasing criteria and the internal purchasing protocols. Monitor, track the expenditure in that subcategory. For example, even if it is a advanced endoscopy procedure, there could be some subcategories in it where different expenditures can be recorded in the different categories. And software can usually track it. You know, as we talked, Excel, even simple technologies like that can help. And performing regular audits. Are we in the right area? Are we doing the right thing? Is it rightly coded or rightly categorized? And training the staff and the stakeholders. I'm sure others may have some other thoughts to add. I would agree with you. And that partnership early on with the GPO group is really essential. And I would encourage any organization, whether again, small or large, as you're reviewing those things that are coming on through the GPO to make sure they're appropriately categorized. And you can use that opportunity then to share that product line availability with your providers also. So you're checking off all the boxes as you go through. Here's the product, the service line. It's going to look like this when we bill it out. Because on the back end, as your administrators or your medical directors are reviewing your SOAs or your statement of accounts at the end, you're going to then be able to evaluate, you know, what did we spend? How much did we use on it? And is it categorized appropriately? And it's going to trail back to, did we spend within our category appropriately also? And so it really is, it's a comprehensive continuous evaluation because things do slip, things get fat fingered in all the time. One number off can really derail someone. Another thing that can really help is that, especially if you're part of a larger institution, your GI procurement and even VAC process is usually part of a much larger one in your institution. So your institutional supply chain, they're going through this with orthopedic surgery, neurosurgery, ENT, and all of their different specialties. So if you can somehow have GI representation on your VAC committee through someone on your team, that is so huge in trying to streamline your operations and really trying to have a foot in the door of your institution's procurement processes that will be to your benefit a lot. Because a lot of times we are stuck kind of on the outside looking in, feeling that we kind of work for supply chain management and trying to explain GI things and disease processes to people who don't have a great understanding and then trying to make a case for essential equipment that we feel that we need. It can really, really be an uphill battle. So if you do have some standing GI representation on those committees, that can be really, really helpful. Yes, that is so key. And I totally agree with Neil that having some sort of representation, whether it's through the hospital or practices is extremely important. Any comments from our participants? I haven't seen anything come in. Why don't we move to case 10? All right, so this is actually a pretty interesting one. The endoscopy unit director and nurse manager received a complaint from a VIP about the care he received. He states that the pre-procedure nurse was rude. The anesthetist didn't provide enough sedation. He was in pain during the entire time of his procedure. The endoscopist didn't talk to him about his results afterwards. He didn't remember anything. When he got home, he indicates to the endoscopy unit director and nurse manager that he wants to talk to the CEO about his dissatisfaction and threatens to post his complaints on social media. So what should be done? So this began in the front line and went all the way to the back line. Al, you've never had any of this, right? Of course not, yeah. So this just resonates because you work so hard as a unit to make sure that the care for every patient who comes to the unit, whether they be a VIP or not, is really seamless and that the people who are working in the unit day-to-day are valued and work as a group and feel like a valued member of the team and you just hope that when someone comes through who may or may not be a VIP, that their experience is what you expect their experience to be and it sometimes is not. And so I think this gets into really what Gretchen had said in her talk, which is that you can't recreate a first impression and so you just have to assume that everyone who you meet, that this is their first impression of you, this is their first impression of the unit, their first impression of the team, their first impression of maybe your entire hospital and you really have to be conscientious about the care of everyone who comes through. And so I think this can be used as really a kind of a case to review with your team as a whole and to figure out where the failure points came through. We did this on a much smaller scale in my bariatric endoscopy program, which is a self-pay concierge type medicine program where a couple, a nurse and her husband, came through, paid $25,000 out of pocket that day and then basically conveyed to us after that moment, they had wonderful care in the office, they felt excited to move forward and then they conveyed to us all of the failure points they experienced in the system that basically led to a different impression of the program. And it had nothing to do with the single provider who was in the office who saw them, who explained to the procedure that they were excited about or the staff that checked them in that day, but they tried to figure out who was the person to call to prescribe the meds we had discussed, who was the next person to call to figure out when they should be setting up their next nutrition visit. And we realized as a team, we came together and said, this is not appropriate care for anyone, let alone people who have just paid out of pocket for a procedure and we need to identify the failure points. And as a group and team about six or seven years ago, we did this and it strengthened our group so much. So we identified the need for a care coordinator, someone to kind of tie everything together, a single point person. So I would use an experience like this, obviously an apology, but recognition that you can do better and your team can do better and pulling the team together to really discuss the failure points and to try to figure out and strategize as a team, what do you need so that no patient, whether VIP or not, can come through the unit and have this experience? So I would just add also to include the patient in the development of that process, because having patients who are going through those failure points, be part of the solution, goes a long way in developing a program that becomes successful. I can't echo that enough. And that's exactly what we did in this specific experience that I spoke about several years ago. One of our behavioral psychologists basically reached out during her visit with them and said, can you walk me through everything you experienced so that we can fix this? And as a team, we did fix it. So thank you for that added information. I think one really important point to, I'm sorry, go ahead. No, I just, let me quickly just add, Tatiana wrote in the chat, from the nursing perspective, patient complaints specific about nursing care, I specifically have the nurse involved, contact the patient to start with, as well as the other members of the multidisciplinary team. This provides ownership and accountability and an opportunity for the patient to be heard. Sorry, Dr. Cashel. No problem. I just wanted to emphasize that one, I think really important point is to always remember to not cut corners, especially when it comes to these so-called VIP patients. A lot of times somebody is a somebody at your institution or in the community. They'll make a phone call. This person will send a text. Someone will get an email after hours. Then all of a sudden this really important person will just kind of appear in the endoscopy unit. You do the procedure and they're texting the physician four hours later at home. Did my path come back yet on my one hyperplastic polyp that I had? And when is my next one should be? And it's like this fly by the seat of your pants thing that happens a lot of times because many people are well-intentioned that we want to streamline and get them in and get them out and everything. But I think it's really important to just slow down and be formal about your processes. Like when I read this case, the first thing I would do is schedule an office visit. Now I might go above and beyond to do that, very next day, after hours, before hours, double book, whatever. But it's really important to, first of all, convey that you understand who this person is. Thank you for your service to our community, our university, what have you. But I also want to give you the same quality care at our institution that I do with everybody else. And then that gives you an opportunity to document your happenings. Most of the time, these people know too much or have too much insight for their own good. So you can document appropriately, you can follow your protocols and follow your processes so that in case something like this does arise, then you can show this person, hey, we did everything to a T. And especially in your case, yes, I was more attentive and things like that, but I can be transparent with all of the procedures that I followed. Now, I'm happy to partner with you to figure out how we can do that better. But I think it's just really important not to cut corners, especially with these so-called VIP patients. Well, much of this too has an opportunity with de-escalation of the patient. Just as we saw in the comments, I would echo everything everyone said, but it can start with whomever, whomever is the first to receive the complaint, if it's your nursing leader, if it's your medical director in partnership, sit and take that five minutes to call that patient. Very humble, right? Humble apologetically. Sorry that that was your experience, right? We're not, in acknowledging that that was their experience, we're not apologizing for wrongdoings because we don't necessarily know that anything was done wrong, but we're apologizing for your perception about your experience. And so you can start really there and you can hear them, right, what was your experience? Can you share with me what happened that day and how it deviated from what your expectation was? Because sometimes, to Neil's point, we did everything the way we do it for everyone, you were expecting something different. And that gives us a chance to meet in the middle and understand it. I will often invite people to have a conversation with staff, if the staff are willing to, but if it is a provider, I see the comment about asking the endoscopist and the anesthesia provider to meet with them, that can be great. But oftentimes, having someone in leadership have that humble, apologetic conversation can deescalate the entire situation because chances are we didn't meet their expectation somewhere along the lines. And often, it's not an intentional, egregious issue. Yeah, I agree with everyone. I would like to add, as soon as you read this, everything went wrong. The reception was rude, sedation was not good, and the endoscopist did not talk. So just as soon as we read this, it's biased that maybe the patient has unrealistic expectations or a different level of expectation. Completely agree with Neil and Gretchen, trying to talk and apologize for the perception of the experience. That's how I would start, rather than apologizing for what has happened. For some people, we will never be able to satisfy them. I mean, I don't wanna start the notation there, but I'm trying to, or our team is trying to do their best. As a physician, many times I see, I am the leader of this unit, and wherever the patient hears from, they may not be happy. Sometimes patients react differently to your nurses or the front desk person, but when it comes to you, they're acting completely different. Oh, is it the same person that spoke badly to the front desk? So getting involved as a physician, as the leader, sometimes alleviates the problem faster.

sustainable endoscopy

ASGE guidelines

operational challenges

inventory management

economies of scale

patient care complaints

process efficiency