the goals we want to achieve. In this particular talk, I'm going to talk about things that echo what's been talked about so far. And I'm going to jump into the definitions of benchmarking, because that is the basis of establishing quality metrics. We will have a benchmark about what benchmarking means. Say that 10 times fast. So you can see on this slide what most people agree represents benchmarking, and benchmarking's goal is to improve performance. Benchmarking includes all of these things, right? All of you are engaged in these activities, whether you realize it or not. It is a strategic and business imperative, particularly because healthcare is moving to a value-based payment system. All of these play a role in how healthcare is delivered, and the cost and value of these services you provide will impact on your success of your unit. So we're going to come to our first audience participation response. It's going to be, what challenges does your endoscopy unit face the most? Here's what people are thinking, Dr. Eisenberg. Very interesting. So I think this is tracking with what we've asked in the past, where staffing seems to be the most significant challenge. I think this goes back to what Neil talked about in terms of travel nurses, but I think it probably applies to the shortage of gastroenterologists in some regions. So endoscopy units everywhere face challenges, and I've listed many of them here. Many of you are acutely aware of some of these challenges. Some of you are experiencing these particular challenges. I've listed some additional ones here, and as you can see, sometimes these demands can seem counterintuitive. For example, outlays for technological advances can have significant upfront costs, which can impact your bottom line. How do you design or decide from a business plan perspective if a particular technology such as artificial intelligence will have enough return on investment to justify its upfront and or ongoing costs? Fortunately, healthcare costs, although rising, are decelerating in their percent rise year to year. If you recall the triple aim from my first talk, one of the aims is to reduce healthcare costs. In this figure, you can see that 2021 had a slight dip in costs, although as you know, this was because a significant number of our population avoided their usual healthcare during the pandemic. But you can see that with Medicare alone, a projected $1.8 trillion in healthcare costs is expected by 2031. So what do we mean by value? It's really in the eye of the beholder. The healthcare team looks at value equaling quality plus service over cost. However, employers look at value equaling employee productivity plus employment satisfaction over cost. For patients, the value equation looks like the healthcare team, but from quality from a patient perspective, not necessarily the same thing from the nurse or physician perspective. For example, the patient may look at more time spent with them as a quality metric, whereas the nurse may look at efficient throughput with less pre-op time waste as a quality metric. Whereas physicians and nurses look at quality and safety as being of utmost importance, patients may actually look at cost as being the greatest factor. So you can see here from this slide that value equations are not the same. Now, many of you are aware of the Centers for Medicare and Medicaid Services moving from traditional merit-based incentive payment plans to merit-based incentive payment value pathways, which started in 2022. These are based on benchmark measures and activities that CMS will require to be reported for payment. The MVP pillars are familiar to those who've been involved with meeting MIPS with population health pillar added. You'll need to pay attention to those measures as you establish your own benchmarking and quality metrics in your unit. Many of us think about quality as meeting a benchmark for procedures such as adenoma detection rate, but there are actually multiple definitions of quality as it pertains to the operations for endoscopy units. And these are shown here. Measurable quality can apply to ADRs, but also to turnover times and disinfection protocols. Appreciative quality can apply to competency in procedures and procedure skills. And perceptive quality can apply to patient and employee satisfaction. So here are quality indicators for colonoscopy screening. I chose colonoscopy because that's the most common endoscopic procedure being done in the United States. And you will see several goals listed here, but you will note that there are not any goals for perspective quality. And so, for example, from a patient perspective, their satisfaction with their prep or their procedure is not yet a goal. This figure shows several ways to improve colonoscopy quality based on those goals. You can see that every team member can assist in meeting the benchmarks and quality metrics for colonoscopy from pre-procedure calls from schedulers and nurses to go over prep instructions to techs and nurses assisting in polyp detection and adequate removal to biomedical engineers in ensuring equipment and video monitors are working properly for high definition endoscopy to IT people developing code in the electronic health record for pathology specimens and appropriate screening and surveillance intervals. Data from meta-analyses of randomized controlled trials show that the impact of these interventions on adenoma detection rates and advanced adenoma detection rates. Audit and feedback are important. Gathering data for every endoscopist performing screening colonoscopy and providing that information back to the endoscopist is an important first step. And there are several procedural techniques that can improve ADR. One example is a dual observer. So, how many of you encourage techs and nurses to assist the endoscopist in identifying a polyp? Does your team actually allow the psychological safety to do that? We talked about that in my first talk. If a nurse or a tech points out a possible polyp, will the endoscopist get angry or will he or she encourage it? There are several assistive devices. I don't know how many units actually use them. Then there's AI, which many units have incorporated as the latest kid on the block. AI will increasingly enter the realm of endoscopy to include Barrett's esophagus screening and surveillance and capsule endoscopy interpretation. But it's not just adenoma detection rate, right? I'm sure many of you out there have asked yourself, do you want this doctor to do their colonoscopy or their loved one's colonoscopy? There are other intangible factors in the perceptive quality that matter as well, and are not measured. How does your team meet that challenge? How are you and your team achieving your unit's benchmarks and quality metrics? What if you, as an endoscopist, has an ADR of 38%, but your colleagues are lower? What about a 10% cancellation or no-show rate? Can you say that you're delivering high care quality to your population? And you remember, population health is the other pillar in the GI care MVP. What about all these other things? Inadequate preps, patient experience course, employee engagement, high tech turnover, high nurse turnover, specimen errors, medication or infection control issues. So again, you can see it's not just the ADR. Supply chain costs are up 23%, sometimes in various institutions because physicians use different accessories. We talked about that in the supply chain analytics talk. So, as you saw from this slide from my first talk, endoscopy teams that are patient-centered with an emphasis on team-centered achievements get better benchmarks and quality metrics. And it takes a robust and thriving team culture to be high-performing. So, you've seen this slide So, you've seen this slide as well. I asked you, did you pick out any of these things on this chart that you might bring back to your team to make it better? Here's another take-home slide that I would recommend showing you the strategies that need to be adopted and the core competencies that need to be developed for a high-performing endoscopy unit. And having a vibrant team culture enables sound strategic execution of your team mission and goals. Every team is unique and different in many ways. So, I'm going to give you four strategies to consider in getting the most from your team to achieve success. The first utilizes recommendations from my first talk on team-based care. It takes time, patience, and hard work to establish a vibrant team culture, and it requires constant nurturing. Know and share your benchmarks. Utilize the ASGE in reviewing them. Understand how you compare with other similarly situated endoscopy units. I'm going to go to our next audience response question. Which of the following benchmarks are you aware of and share? Zero, one, two, or three or more. These selections include adenoma detection rates, turnover times, patient satisfaction scores, labor costs as a percentage of overall expense, and average device cost per encounter. Here's what you see generally, Dr. Reiss. Wow, that's amazing. This is impressive because I think that most endoscopy units, maybe five, 10 years ago, would have maybe one or two of these benchmarks. So, terrific job, guys. So, here's an example of a practice in New York City in which they were comparing their hospital and ASCE endoscopy units. Looking at a variety of measures listed here, you can see there's variability in pre-procedure HMP documentation, handoff documentation from nurse in room to nurse in recovery, and handwashing. So, knowing the data really allows you to make plans to improve. Here's an example of benchmarks and quality metrics for physicians that includes not only CECL intubation rates and other typical colonoscopy metrics, but also patient satisfaction scores. Another example of a New York practice showing adverse events and cancellations compared to local, regional, and national averages. The benchmarks included cancellations both within 24 hours and after they are in the pre-procedure area, and you find out, for example, they didn't prep correctly or they don't have a ride. Here's an example of benchmarking time efficiency with on-start times, procedure times, and visit duration. You can see that there are outliers in some positions with regards to colonoscopy and endoscopic ultrasound, and you can use these data to identify processes to improve efficiency. You can dive down into labor costs and scope repair expenses to compare your unit with other similarly situated endoscopy units to identify areas that need improvement. Here's an example of practice operations benchmarking, and as you can see, benchmarking is unlimited in its scope. No pun intended. You can see from this figure that often quality interfaces with efficiency and cost in many ways. You need to take into account how these interplay when using quality metrics to drive improved improvement. You don't want to drive improvement to a point where costs become unburdenable. So, the third strategy is to target those benchmarks and quality metrics that are crucial for your team's strategic plan and mission, and look at those that don't just focus on clinical ones but financial, operational, and satisfaction benchmarks. Develop a process improvement plan. I'm not going to spend much time on this other than, say, using a PDSA framework or SMARTI, which stands for Specific, Achievable, Measurable, Time-bound, Inclusive, and Equitable framework. These are templates for process improvement, and you'll hear more about QI projects soon. Just remember the acronym for TEAM. Having a vibrant team culture leads to success in using quality metrics to drive improvement. Thanks for listening.

benchmarking

endoscopy

value-based payment

quality metrics

healthcare challenges