So, kicking off our next segment, we're going to further our discussions about GI unit leadership. We're talking about optimizing endoscopy unit operations. This is a very important topic for the whole care continuum, and I'd like to talk about some specific themes in optimizing endoscopic operations. So, as we were talking about in the previous segment, it's pretty simple, right? You have a patient, patient needs a procedure, patient comes to an endoscopy unit, patient gets procedure, patient goes home, everybody goes home happy, right? It's as easy as getting from A to B. Well, depends how you get there. Sometimes you can, if you get lucky, take a straight line from A to B, and you have a very easy journey. But sometimes you can encounter some curveballs along the way that can throw a wrench in your plans. So, you could get there in a straight line, but you could also go a whole different route. It's almost like when we tell the fellows, hey, all you have to do is take this thing, put it in there, and get to the C-Cover, ready, set, go. Easy, right? Not so much. Well, over the next 15 minutes, I promise that all your endoscopy unit problems will be solved, and you will be endoscopic unit efficiency experts. Just kidding, not really. We'll probably end this talk with more questions and answers, but that's a good thing because this is an evolving topic and will provide a lifetime of questions and answers that can be explored on a day-to-day basis. So let's talk about endoscopy unit efficiency. First of all, it's very important. There's this old moniker in medicine, see one, do one, teach one, right? We all learn that as physicians, when we're residents, when you're placing an IV or a central line, for example, or doing an endoscopy procedure, and same thing with nurses and staff, when you see something, you don't quite learn it, but when you do it yourself, you get a little bit further, and then when you're able to teach it, that's when you can truly say that you're getting closer to mastering that subject. Well, endoscopy unit efficiency is very similar, and I borrowed this moniker and came up with my own that says, see it, write it, and do it. Now, it's very important to follow all of these steps, because as you think of your endoscopy unit, and even as you walk through the front door when you're coming to work each day, your endoscopy unit is this living, breathing organism, and things are happening to it that are both internal, and it's also being subject to these external pressures, and it can be very, very difficult to make sense of all the things that are going on and all the things that you have to get done on a given day in order to provide quality endoscopy care. One of the biggest pitfalls that happens in many endoscopy units is that we end up operating in what I like to call dumpster fire mode, meaning you get to work, your inbox as a nurse manager or as a physician, a medical director, or whomever, your inbox is full of all these dumpster fires, and you're on a quest starting at 7 a.m. or 7.30 a.m. to put out all of these dumpster fires one by one, and by the end of the day, you have put out many of these dumpster fires, and you feel very, very accomplished, that wow, I was able to really deal with some tricky stuff today and avoid disaster in a few situations, so that was a good day. Yeah, it was in a sense, but on the other hand, there isn't a whole lot of growth or a whole lot of strategy in that approach, and that's why I call it dumpster fire mode, because it's very easy to get into this mode and continue operating in dumpster fire mode for weeks and quarters and months and maybe even years on end without really accomplishing a lot as an endoscopy unit as a whole, so it's very important to map out your process, meaning physically walk through your unit as if you were a patient, or if you can partner with your patients, have them also share a lot of feedback about their experiences and figure out exactly what journey your patient is going through. Again, it's very important to physically write this down, whether it's on a big whiteboard and you have a lot of people in the room, or you are taking notes on your own notepad, for example, it is really important to write down and capture what you see as you or the patient goes through their endoscopy journey from point A all the way to point B. The big stuff usually comes without even thinking about it. Sure, I'm a patient, I'm going to check in at some sort of front desk, I'm going to get an IV, I'm going to go through some kind of assessment, I'm going to get my procedure, and then I'm going to go home, but the devil is really in the details, so it's very important to classify and quantify every single part of the journey that you can imagine and that you can walk through and then act upon it, and we'll talk about some ways to do that. In order to understand endoscopy unit efficiency, it's very important to understand the phases of care that a patient goes through. Some of these figures you'll recognize from the previous talk, and the references are included, but I wanted to divide the journey of a patient into some main categories. First, there's scheduling and patient preparation. This is before the patient even gets to the endoscopy unit. Then there are equipment and instrument considerations, again, oftentimes before the patient even goes through a procedure. And then there's your procedure workflow. This can include pre-procedure workflow, intraoperative or intra-procedure items, and then post-procedure workflow such as recovery and discharge. Then there's documentation and reporting, both on the nurse and technician side and on the physician side, and we'll talk about some details. Then there's sedation and recovery management, staffing and team coordination, which we talked about a lot in the first segment, and we'll touch on some similar themes in this talk. And finally, quality, safety, and regulatory concerns. Scheduling and patient preparation. Every patient goes through some sort of pre-procedure assessment. It's very important to note the indication of the procedure that you're going to perform. One of the most common complaints from patients nationwide, there have been studies done on this and reported by the ASGE among other organizations, one of the most common patient complaints is a patient goes for a colonoscopy thinking that it's a screening colonoscopy when in fact it turns out to be a diagnostic colonoscopy. The result is that the patient ends up having to pay a portion of the cost of the procedure and then gets very upset because the patient was understanding that this is part of my preventative healthcare and covered 100% by my insurance, so why should I have to pay a portion because this is covered under my plan? The patient then calls the doctor's office, finds out that the procedure was coded in a way that was not favorable, and then engages in an animated discussion to have procedure codes changed and documentation audited and so on and so forth. So in your pre-procedure assessments, especially with colonoscopies, and I'm biased to this especially because a general GI endoscopist is very important to remember what the indication of your procedure is and to code that appropriately, especially when it comes to the point of a screening colonoscopy versus a diagnostic colonoscopy. Patient comorbidities are also very important to note because this can factor into certain things such as anesthesia considerations, airway considerations, anticipated recovery time, and possible unexpected events during and after the procedure. Informed consent is now also becoming a really, really hot topic in endoscopy. One of the main reasons for this is open access endoscopy programs have gotten very, very popular. These are very well-intentioned programs in which patients have a need to obtain screening or surveillance for colorectal cancer, and a very well-intentioned primary care physician will set this patient up for a colonoscopy, patient shows up to the unit prepped and gets their procedure, and then off he or she goes. But along this process, the informed consent process can be lost in the cracks a little bit, so it's very important to maintain informed consent throughout the journey, whether you are seeing your own patients or performing open access procedures. Bowel preparation protocols are also really, really important to try to standardize as much as possible. Dr. Appolini touched on this in the previous segment, that sometimes endoscopy units can have up to five, six, seven, eight different bowel preparation protocols, whether that's the actual formula type or the amount of clear liquids that the patient is supposed to take, whether the patient can have a soft diet the day before based on more recent studies that have shown outcomes based on that, whether the patient has to be strict NPO, morning medications with additional bowel preparation, et cetera, et cetera. So it's very, very important to not only have bowel preparation protocols, but be able to stick to them depending on your patient population. Insurance considerations are also very important in bowel preparation because many times a patient will come to a physician office and say, oh man, there's no way I can drink that whole gallon of stuff. Please give me the pills or give me something that's really small volume. And your well-intentioned gastroenterologist will say, oh, no problem. I'll prescribe you this really low volume preparation. It'll be much easier than the experience you had 15 years ago. And you're going to do a real, real good thing for your patient there. But maybe come to find out closer to your procedure when the patient goes to obtain the bowel preparation, it's not covered by insurance and maybe the patient cancels the procedure or doesn't follow through. And it comes back to kind of bite you. So knowing which bowel preparations are covered by which insurance plans is really important. And it's really important to hardwire that in your pre-procedure protocols. Medication management is also really important, especially with anticoagulations. And nowadays, GLP-1s have really been come to the forefront in endoscopy, especially with anesthesia guidelines. So very important to pay attention to those too. And in addition, sedation planning and assessments. Many centers use propofol regardless of whether monitored anesthesia care is sort of covered by insurance or not. But many freestanding centers also still have this as a limiting resource. So it's very important to note in your pre-procedure assessments what kind of sedation the patient will require based on comorbidities so that the sedation can proceed without difficulty. And instrumentation. Now, this is a really, really important topic that often flies under the radar. It is very important to know what types of endoscopes are needed in order to get through the day, the week, or the month in your endoscopy unit. I'm sure many endoscopists in this conference can attest to the fact that there's almost nothing worse than being in the middle of a procedure and needing an instrument or a device and being told by the staff that that's not available. For whatever reason, if a patient, if you need to change out the endoscope because of patient anatomy or a tortuous colon, for example, to be told and find out that that piece of equipment is not available to you to render the care that you need, that can be a very, very frustrating point. And it can also cause a lot of delays in your endoscopy unit. So having data on what procedures your endoscopist perform and what equipment they use is really, really important. RFID technology is something that can also help with that too, especially with ancillary devices. Make sure to take caution between who performs general GI procedures and who does interventional GI procedures. Also note outpatient elective cases versus inpatient add-ons. If you're a freestanding ASC, inpatients may not be much of a consideration. But if you do work in a hospital-based unit and you're adding on inpatients, they may need a whole separate set of devices and equipment that may be needed for more higher acuity cases. Technology, technology, technology. Everybody loves technology, right? Especially AI. All the rage these days across many industries, especially in GI. Well, there's also other considerations like what kind of light source are you using? What kind of imaging technology do you have? Insufflation? Are you using CO2? Do you have enough CO2 tanks? What's your process to make sure those CO2 tanks are always stocked so that you can keep your procedures moving? Who is physically reloading those CO2 tanks? Are you overburdening your technicians? All of these things come into play when you have to do GI procedures over and over again and perform them to a high degree of quality. Next is reimbursement considerations. We all love to use the latest technology. And as physicians, we kind of have the luxury of saying, hey, administration, I need this and I need that. And then complaining when administration doesn't give us a credit card with no limit on it so that we can go to whatever vendor of our choice and go buy things. But the important part of that is that reimbursement is a really important consideration. For every endoscopy unit, in order to incorporate a new piece of technology, it's really important to consider what's the reimbursement on that. Or if you're not getting reimbursed for that piece of technology itself, what is the total reimbursement or what we call contribution margin, meaning the aggregate total of revenue that you're going to capture based on usage of that piece of equipment or device that your endoscopy unit is going to benefit from, which then adds to your bottom line and improves your financial performance. Reprocessing and sterilization are also considerations. We talked a little bit about reprocessor efficiencies and machine automated reprocessing in the last talk. And then finally, storage and maintenance of scopes and especially capital equipment are a really important point to make sure to take note of whether your endoscopy unit buys capital equipment or leases it. These have different implications both for the lifetime and the usage rate of the equipment, as well as what it looks like on your pro forma. Procedure workflow. So this is an example of seeing it and then writing it. This is from a reference here in the journal. This is the level of detail that can be achieved if you really put your mind to it in order to map out the journey of your patient as he or she goes through your endoscopy unit. So for your pre-procedure workflow, very important to know your setup and pre-procedure safety checks and timeout procedures. Now, not just the week when joint commission is showing up for the inspection, but it is important to have these procedures hardwired into your processes so that if and unfortunately when adverse events do occur, you can go back to these and make sure that you are providing quality care even when things inevitably go wrong, especially in higher acuity patients. Patient positioning and setup is also really important in the workflow. Endoscopy ergonomics is now an emerging field which is getting more and more attention and rightfully so. And anesthesia and sedation protocols are also important to have hardwired into your procedure workflow, as well as real time monitoring like continuous pulse ox, etc. And also knowing what endoscopic techniques you're going to be using, whether this is diagnostic, therapeutic, combination of both, inpatient, outpatient, etc. And also along with this comes sample collection and processing, whether you're using in-room cytology, sending specimens out to pathology, very important to be able to take note and have a good process for that. And then also sedation and recovery management, which we talked a little bit about phase one and phase two recovery in the previous talk. For documentation reporting, I'm sure we've all seen figures like this. I won't mention any specific brands, but procedure documentation is an essential part of GI endoscopy. But it's also important to take into account how your documentation system and image capture management intertwines with your home EHR workflows and orders. This is one source of delays and sometimes frustration on behalf of physicians and endoscopy staff when you're having to do redundant workflows, when you're charting in one area, say in your procedure reporting software, and then having to take mostly the same information and sort of redo it in your EHR so that other physicians can see that information or you're having to put in orders in one and document in the other. So having a strong workflow and intertwined process in that workflow is very important as well in order to prevent delays in the functioning of your endoscopy unit. Similarly, specimen tracking and processing is also a really important source or could be a source of delay. Even something as simple as labels for specimens printing in another room or in another station could cause delays in processing those specimens and then could lead to gaps in tracking where those specimens go. And having appropriate pathology follow-up is also important for establishing strong surveillance and recall colonoscopy programs. And this can also lead to increased quality and performance tracking and reporting with resources like GI Quick and add to Medicare-based incentive programs. Staffing and team coordination is also a hugely important aspect of making your endoscopy unit successful. We talked a lot about this in the first segment, but culture, culture, culture is extremely important in having a highly efficient and high-functioning endoscopy unit team. Understanding the roles of the endoscopist, the nurses, technicians, support staff and everyone supporting each other, distributing workload in terms of scheduling and performing daily duties, also including cross-training can be very helpful, especially when staffing considerations put you in a pinch, whether that's sick calls or seasonal illnesses or even the ebbs and flows of nursing staff. Having appropriate task delegation is very important into ensuring that nurses are functioning at a high level, but not being overburdened. And finally, having a system to divide on-call schedules and work hours appropriately with your appropriate skill level can lead to increased satisfaction and higher retention rates of your nursing staff. One of the big challenges nowadays that a lot of our units are dealing with is travel nursing. Travel nursing is seen as a highly lucrative job, and these nurses just kind of parachute in and parachute out and make many, many more times what many staff or permanent staff make, and that can be a source of dissatisfaction. So also really important to manage in your team culture as you build and sustain your endoscopy units. For quality, safety, and regulatory considerations, borrowing a little bit from a previous talk but be sure to be mindful of what KPIs are being used to assess your unit's efficiency. How those benchmarks compare to industry standards when applicable. Having a strong system to know your complication rates and what your adherence to guidelines is is also very important when assessing your endoscopy unit performance from a quality perspective because if you are adhering to guidelines and still having complications, for example, that could be something in terms of formulating a QI project that could be investigated. And finally, having a continuous quality improvement program so that you can enhance unit performance on an ongoing basis is going to pay huge dividends in the long run. Endoscope reprocessing audits are also important for infection control perspectives, and that can also be important when a joint commission and similar agencies come to do their annual certifications of your endoscopy units. So that's a brief overview of endoscopy unit operations. Again, I'm sure there will be many more questions than answers, but I did want to give the group a little overview of some of the principles of running an effective endoscopy unit. And with that, I will turn it back over to the panel so that we can continue on. Thank you.

endoscopy operations

efficiency

patient journey

scheduling

equipment management

workflow documentation