So we're going to talk about demystifying concepts in endoscopy unit efficiency. So we're changing gears a little bit here, moving into the more leadership and effectively section of our conference today. And this is going to be especially important for one of the questions that a previous audience member posed about increasing endoscopy unit efficiency. So we're going to talk all about that today. Now first, before we demystify, we're going to mystify a little bit. So one of the best ways, this is a take-home message, one of the best ways to really sound like you know what you're talking about, even if you don't, this is the whole fake it till you make it theory, that is to use lots and lots of buzzwords. So I'm sure all of you have seen emails or job postings or administrators or even physicians who really love to sound like they know what they're talking about, and they say something like this. At Phantom Healthcare, our endoscopy unit team delivers highly effective, cost-efficient patient care. We strive to optimize turnover time and operational bottlenecks in order to maximize patient throughput, case volumes and workflow efficiencies while following lean process improvement principles, thus yielding KPIs that allow our RCM to leverage supply chain analytics and produce high quality, bomb-dignity GI care. Oh, and we use AI too. Now show virtual hands here. How many of you understood anything in that and felt there was any substance to that? Probably not very many people, but we see things like this all the time. So what we're going to talk about today is what all of these terms mean that we come across on a daily basis and how to use them effectively, because this is one area, like many other areas in medicine, but this is one area where words really matter. So in our first section here, we're going to talk about key terminology as it relates to timing. I have some references here about figures that you'll see throughout the talk, but one of the first principles about timing is the idea of throughput. So throughput is the amount of information, people or materials that is put through a process during a specific period of time. When we think about an endoscopy unit, we think about a patient. We have a patient who is coming in for a procedure and then progressing throughout the day at various points in the care continuum and then being recovered and eventually being discharged home. So the way that we attach a time component to that to make it throughput time is generally speaking the time from patient arrival to discharge. Now a big caveat with a lot of these terms that we're defining here is that these are not set in stone. So your throughput time does not always, absolutely, certainly, 100% have to be the time from patient arrival to discharge. It can also be nuanced as to how you define it, as to how it pertains to your endoscopy unit in particular. So just keep that in mind as we progress through the talk here. The next key term is FCOTS. I'm sure many of you have heard FCOTS and had meetings about FCOTS and have reports about FCOTS and it's this big buzzword that both physicians and administrators alike really like to use. And that is basically the percentage of procedures that are starting on schedule. Now again, starting on schedule is up to you in your own individual unit of how you want to define that. Sometimes an 8 o'clock scheduled case means that the scope is in at 8 o'clock. Sometimes in another unit it may be that the patient is in the room at 8 o'clock. It could mean that the anesthesia and the propofol starts infusing at 8 o'clock. Or it could mean that you give your whole team perhaps a 5 or 10 minute grace period. So 8 o'clock scheduled time may be on the schedule, but an actual on-time start, again depending on how you define it, may be allowed up until let's say 8, 10. So again, it's up to you, but that's the general term. Turnover time is a big one. We could probably have an entire day course on turnover time, but I want to emphasize here that the turnover time is the time between endoscopy procedures. And again, this matters as to how you define it. So you can define it as wheels out. So the patient goes out of the room and then when does the next patient come into the room? That could be your turnover time. It could be scope out to scope in for your next case. It could be housekeeping time. It could be anesthesia time. Most of the time it is defined as some conclusion of a previous procedure and then some start of a next procedure. Now this is where a lot of blame game happens. Physicians love to blame anesthesia. Anesthesia loves to blame nursing staff. Nursing staff loves to blame the IV tubing. The IV tubing loves to blame the patient for being a heart stick. The patient loves to blame their ride for being late. The ride loves to blame the pharmacy because they didn't get the bowel prep and so on and so forth. Just keep in mind that turnover time is how you define it. And lastly, there is a metric that was proposed called true completion time. And this is defined as the scheduled procedure time to the time the patient exits the room post-procedure or wheels out. Now one of the benefits of this metric is that it can possibly capture the effect of a single delayed procedure early on in the day on patient experience delays throughout the day. So if you have a large or a high true completion time, then your next case, which was say scheduled at 830, your wheels in may actually be at 845, let's say, which is then going to push your wheels out depending on the procedure and then so on and so forth. That delay can get stacked throughout the day. So your true completion time could be an adequate reflector of that. Now let's talk about scheduling efficiency. So these terms are pretty straightforward. Case volume is the number of procedures performed in a specific timeframe. Again emphasis on the specific timeframe here. So this could be monthly, quarterly, yearly, however you define it. Cancellation rate is the percentage of scheduled procedures that do not proceed. Again this could be defined or subcategorized as a same day cancellation or cancellation within 24 hour or 48 hour period. It can also be measured from the physician's office. So say like you scheduled a patient for a procedure and then they call back and cancel a week later, totally up to you how you define it. But it is generally a percentage of scheduled procedures that do not proceed. No show rate is usually defined as the percentage of patients who fail to arrive for their procedure. And then we have this general term of scheduling optimization. So this is very commonly used in meetings and in quarterly reviews by staff and administration. But scheduling optimization generally incorporates these three metrics, the case volume, cancellation rate, and no show rate into one single categorical measure so that the team can then strategize in how to minimize these factors and minimize gaps between cases. Now let's talk about some procedure and workflow. So the first metric I want to talk about is the procedure time or case duration. Again, this could be scope insertion to scope removal. It could be wheels in to wheels out. It could be anesthesia time. But generally speaking, when we talk about actual case duration, we're talking about the actual endoscopy part. Cecal intubation time is the time to reach the cecum during a colonoscopy. This is especially useful in screening colonoscopies when designing colon cancer screening programs and is also often coupled with withdrawal time in order to provide mean metrics for physicians performing colonoscopy. And again, withdrawal time being the time from the cecum to withdrawal, average industry standard is approximately six minutes. This has been revised and is being constantly looked at. But a cecal intubation time coupled with a withdrawal time usually can give an idea of total procedure time per endoscopist. And then there is the recovery post-procedure. An important point here, this is often categorized into phase one and phase two recovery. Phase one recovery usually means immediate recovery when the patient is still under some form of deep sedation. So the propofol is just almost wearing off, but the patient is still asleep. And then phase two recovery indicates that the patient is more alert and arousable and can then proceed to the recovery room within a more minimal level of supervision and nursing vital signs, for example, every 15 to 30 minutes with spot pulse ox and blood pressure checks. And then finally, the probably most important term in procedure and workflow is the bottleneck. And again, we can have a full day course, we can have an entire month long course about bottlenecks. But generally, a bottleneck is defined as the key resource constraint or the point of maximum delay. So keep in mind that this is usually not necessarily a time component, but it is an actual care point in the care continuum of your patient going through an endoscopy procedure that is identified as the bottleneck. So that could be, for example, pre-op, intra-op, post-op, recovery, et cetera, et cetera. Now let's talk about staffing and resource management. This is a really big consideration nowadays, especially with national staffing being a huge concern across endoscopy units. So it's really important to have an endoscopy staffing matrix of some kind, which is some kind of algorithm that both physicians and managers and administrators can use in order to divide labor accordingly. So a staffing ratio, which is a common term you'll often hear, for example, in morning huddles as you go through your endoscopy day, is usually the number of staff per endoscopy room or procedure. Sometimes it's also defined as a staff per patient ratio, but usually the staffing ratio is defined per endoscopy room or procedure. Then there's a term called skill mix optimization, which means assigning staff based on competency and procedure type. So one example of this is that if you have nurses in your unit who have a higher level of certification or may have even been ICU trained in the past, one strategy may be to place those nurses in advanced endoscopy over therapeutic patients because these patients generally have longer sedation times and can have more involved procedures and advanced therapeutics as opposed to, say, a routine screening colonoscopy that is an elective outpatient case on a healthy individual. There's also a model called float staffing, which involves staff flexibility for coverage across multiple rooms. So one of the things that you may hear often as you go throughout your day or week is that you're short on your core staff, so we have to pull float staff from another pool. So this could be a useful trick or technique in order to still maintain optimal staffing ratios and not sacrifice patient volume or patient safety. And then there's the theme of cross-training. And this can be really important in order to maximize the potential and build on some of the team-based concepts that we were talking about in the last segment. But training staff to perform multiple roles for flexibility can be really, really helpful. One of the ways I have found this personally most useful is by training nurses to also be techs in the GI room, especially for minimally invasive cases or screening colonoscopies. That can be really helpful in a pinch if you are having staffing considerations, especially day of with sick calls and things like that. Task delegation is also really important, especially as a leadership tool, in order to assign non-clinical tasks to appropriate team members. Finally, the last term I want to discuss here is sedation turnaround efficiency, which is optimizing sedation administration and recovery so that we minimize time under sedation and then can get recovery and post-op flowing effectively. Now we'll talk a little bit about equipment and reprocessing. This has been a big theme for us over the past five to 10 years or so with infection control and prevention. So most institutions have some form of an automated endoscope reprocessing machine or reprocessing workflow. It's pretty rare nowadays to have all manual washing. One key term that has been incorporated in a lot of efficiency metrics is the endoscope reprocessing cycle time. This usually is a configuration based on whatever product or reprocessing machine is being used, but it can actually be quantified into an actual time component in order to assess how long your endoscopes are requiring in order to be turned around so that they can be prepared for the next use case. This can then be quantified into a metric called automated endoscope reprocessor efficiency, and this is a performance of automated cleaning systems as a percentage. So if you want to take a look at your entire endoscopy unit and say I have, let's say, 20 endoscopes and this is the reprocessing cycle time for each endoscope depending on the procedure it was used for, then you can come up with this AER metric so that you can then use that to prognosticate your future resource constraints. There's also scope to patient ratio. So this is the number of scopes available relative to procedure volume. Most of the time, many units have many more scopes, especially colonoscopes, generally in a two to one ratio based on average number of patient flow getting colonoscopies just so that there is minimal downtime with scope availability so that process flows can continue. There's also a metric called instrument turnover efficiency, which is the readiness of clean equipment for the next case. Now we'll move on to performance and quality terminology. KPIs or key performance indicators are metrics used to assess endoscopy unit efficiency. Really they can be metrics used to assess anything that you define, but KPIs are often included in quarterly reports and budget meetings and quality meetings of the sort. So really important term to be aware of in general. Also benchmarking is a very important term to be aware of. This is comparing efficiency metrics to industry standards. The ASGE is involved in benchmarking as well. But on the institutional level, it is really helpful to know your general metrics and we'll talk about that in the second segment as well and how they compare generally to possible industry standards if they are available to you. The procedure yield is the percentage of procedures successfully completed as planned. So if you have 20 colonoscopies scheduled on a day and you perform all 20 successfully, that's 100%. Or if you have aborted procedures due to poor prep, for example, that can affect your percentage of procedure yield and so on and so forth based on your no-shows, cancellations, etc. Complication rate is your incidence of adverse events per procedure. Usually that is zero for everyone. And adherence to guidelines can be compliance with ASGE or other best practices. This is often included in quality reports as well to assess endoscopy unit efficiency. Finally, continuous quality improvement is the ongoing effort to enhance unit performance. This is really where QI and PI projects come from and how they strive to enhance this metric overall. Next, we'll talk a little bit about cost and financial efficiency. Again, we can have a full week course on this if we wanted to, but I just wanted to define a few key terms here just for your unit's sake. The cost per procedure is the total cost associated with each procedure. Now this can seem like a really big bear of a term, and it often is, so it's very important to be very granular in how you define that. Are you defining it as your procedure cost, including sedation or without sedation, for example, and how are you measuring your device and equipment costs, whether you use things like biopsy forceps or snares or an Irby machine, etc.? It is really important to get with your finance team to see how you can adequately define this metric and keep it consistent as you use it to measure other areas of your endoscopy unit. RCM, or revenue cycle management, is the billing and reimbursement process side of things. So this is also hugely important for billing and collections so that we can be compensated on the unit and individual level appropriately for the work that we do. And the utilization rate is the percentage of available resources being used effectively. So the CPP and the RCM often go together to analyze costs and reimbursements. So then that can be used to determine a utilization rate, which can then be used to project volumes and costs for the next quarter, for example, and a lot of other different metrics. Overtime is a big cost driver in many endoscopy units. This is staff overtime based on an anticipated amount of labor versus the actual amount of labor. And supply chain efficiency, which Dr. Apollonini is going to be talking about later on, is also really important to manage inventory in order to avoid shortages or excess or having a large number of expired supply, for example. And that's all I have today. I just wanted to provide a general overview of endoscopy unit terminology. And we'll be talking more about specifically optimizing endoscopy unit efficiency a little bit later in the day.

endoscopy efficiency

medical administration

scheduling metrics

revenue cycle management

operational efficiency