Much of what is in this talk kind of echoes what Debbie has spoken about, including some of the specifics. And I'm going to get started by going through some of the definitions of benchmarking, because it's good to have a benchmark for the definition of benchmarking. Benchmarking is a method for identifying and importing best practices in order to improve performance. It involves the process of learning, adapting, and measuring outstanding practices and processes from any organization to improve performance. But I remind you that the benchmark can be from your own institution. It can be granular to a point of, you know, things that aren't actually published or done by anybody else. So benchmarking includes all of these things, from processes to analysis, comparing metrics, looking at indicators, looking at costs, looking at the actual business of performing some of the things that an endoscopy unit does. It's a strategic and business imperative because we are moving towards value-based payments. And many of you know that this is soon to come to a head in the next few years. Risk contracting and bundle payments, alternative payment models, all of these play a role in how health care is delivered, and you really need to understand the costs associated with every single thing that is done in the endoscopy unit. So endoscopy units all face these challenges. There's shifting demographics. There's this drive towards cost efficiency. The access to capital equipment may not be as robust as we would want. There's the pay-for-performance issues that come up. Population health management approaches are starting to come to a head. Insurances are demanding that the population that you take care of be treated in a way that improves the overall population health itself. And then there's the issue with data transparency and, you know, putting up benchmarks and quality metrics that your own endoscopy unit has. Do you put them on your website? Do you put them on a poster in your waiting room? Those are some extreme examples. There are advances in technology, including things like artificial intelligence that people are starting to integrate into their units in terms of trying to detect precancerous colon polyps. There's this increasing focus on leadership, not just for physicians, but also for nurses and technicians and how these leadership teams aligned and engaged. There's a lot of variation in care. If you look at the cost of care between, say, for example, California versus Ohio versus Minnesota versus Texas, there is actually a lot of variation in what we do. And does it matter? Yes, it matters because some of those variations may actually increase the cost without improving outcome. There's a need for clinical integration and care coordination. There are a number of institutions and endoscopy units that are undergoing tremendous changes in terms of mergers and acquisitions. Private equity is becoming a big player in outpatient endoscopy units. There are hospital chains that are looking to develop systems, ways of leveling the quality of care throughout, not just the mothership, but also all of the community and various outpatient facilities under one roof. There's growing demand for patient and family engagement. This includes things like these surveys that we're often subjected to, but many people feel are somewhat unfair in that the surveys sometimes are answered in small numbers, and those small numbers can sometimes result in inappropriate or inconsistent strategy decisions. So the cost of curve is bending a bit. The triple aim that I showed you at the beginning of my first talk was talking, how do we reduce healthcare costs? Well, it's a problem, and it's going to continue to be a problem. Here you can see in 2021, the costs seem to dip a bit, but I would argue that that was because of the COVID pandemic and the number of people who actually put their healthcare at risk by not showing up to the doctor, not showing up to the physician's offices, not going to the hospital for their various levels of care. And 2022, we don't exactly have that data back yet, but it is projected to be a little bit higher than this particular bar. So what do we mean by value? And it's all in the eye of the beholder, right? So physicians and employees kind of look at value equaling to this particular formula of quality plus service divided by cost, whereas the employers typically will look at value as what is the productivity of their employees? What's the satisfaction of their employees over the cost of paying the wages for these employees? And so you can see that when patients or physicians and employers look at value, there's marked differences in what they think is the major factor regarding what they consider value. Patients and physicians often look at value as mostly related to quality, although patients consider cost a big significant problem in some instances compared to physicians, whereas the cost for employers are also significantly higher. But that's a different type of cost, right? So it's the cost of hiring nurses, physicians, and technicians, whereas the patients are looking at cost from their outlays. So patients are a little bit different than employers who look at things a little bit different than physicians. Now many of you are aware that there's going to be this transition from the traditional merit-based incentive payment system to something that's called MVPs, which is the merit-based incentive payment system value pathway. And this is going to take into effect this year. There's voluntary MVPs that are being installed. There aren't any specific for gastroenterology or endoscopy in particular, but those are coming. And this is supposed to change the way that measures are going to take place. So measures that include measures of quality and activities of quality and the quality of care that is delivered by providers. So the MIPS value pathway pillars include some very familiar pillars to MIPS. MIPS includes quality measures, improvement activities, cost, interoperability, but the value portion of it is also focused on population health. The MIPS value pathway for advancing care for appropriate colon health. So you can imagine that this is actually focused on colonoscopy, colon cancer screening. This is not yet available for public review, but it soon will be. And this is what you will need to pay attention to if you're trying to establish benchmarking and quality metrics for your unit. So what is quality? I mean, quality can mean different things, and this is from a handbook from 2016 where measurable quality, the things that Debbie talked about in terms of compliance or adherence to standards, practice guidelines, protocols, things like hand washing that she described versus appreciative quality where you're actually trying to raise the bar a little bit above the minimum standards and criteria versus perceptive quality, right? So that's what kind of like, what is the patient perceived as good quality care may actually not be good quality care at all. It may be down to this, you know, whether the physician dressed appropriately or not, whether the tech looked her part or his part. Those may not play a role in the outcomes of their care or their healthcare problems, but it's the perceived quality that is in the eye of the beholder of the patient. So here's just an example of some quality indicators for colonoscopy. I chose colonoscopy because that's obviously the most commonly performed procedure, both from a hospital outpatient center and an ambulatory surgery center. And you can see that there's a number of goals here that are listed, but you'll notice that there isn't really any metrics for perceptive quality. There's a number of ways that people can try to improve colonoscopy quality indicators by things like longer withdrawal time to improve somebody's adenoma detection rate, procedural techniques, the way that we've constructed the electronic medical record to include the support for deciding when a patient needs to come back for surveillance, to things that we can do during endoscopy, the audit and feedback, second observer, things like that, which I'm going to show you here. This is data from several meta-analysis from randomized controlled trials. This is an extensive chart showing how do we improve adenoma detection rate? We've got the audit and feedback. We can tell the doctor who's got a low adenoma detection rate what we can do to improve their techniques. There's a number of things here that are listed, different assistive devices. And then of course, artificial intelligence is the latest kid on the block. But it's not just adenoma detection rate, right? Many of you, I'm sure, have asked yourself, do they want this doctor to be performing their colonoscopy, right? But if your adenoma detection rate is 38%, and meanwhile, your colleagues, their adenoma detection rate falls below the considered standard, 19 to 24%. What happens if there's a 10% cancellation or no-show rate? Can you say that you're delivering a good, high-quality care to your population? What about 15% of the preps are inadequate? Your patient experience scores are declining. Your employment engagement is declining. You have high nurse to tech turnover. Specimen errors, infection control issues, these are all things that you need to consider. And you have to sometimes think outside the box. What about supply chain costs? Because now physicians are using all kinds of different accessories and toys during their procedures. And you've got several people who are, for example, closing polyp defects with five hemo clips. Is that a problem? It should be. So endoscopy teams that are patient-centered and team-centered achieve better benchmarks and quality metrics. You've seen this slide before. And it takes a village to do better, right? So you've seen this slide as well. This is one of the take-home slides that I suggested that you bring to your endoscopy unit as a way to structure your teams and have that culture that matters. And there's a number of, quote, must-do strategies. And how do you develop these core competencies? You really need to integrate the team, have an accountable governance leadership plan, communication plan, strategic planning. You need to collaborate not just within your own group, but sometimes you actually need to collaborate with people outside of the endoscopy unit, including those IT people, the people down in your core who are supplying the equipment and figuring out what the costs are associated for something, say, for example, snares that are used for polypectomies. You really need to have a kind of stewardship of both not just the way the processes are working from a patient care perspective, but from a business perspective. And utilizing all of this data includes things from supply chain analytics to the electronic medical record for patient care. So really, having a vibrant team culture really enables this sound strategic execution to getting these strategies in place and developing these core competencies. So these are five strategies that I would recommend. Again, bearing in mind, not all teams are created equal and everyone has different pressures. Things that you want to do, establish the vibrant team culture. And that goes back to that first talk that I gave about team-based care. It takes time to build culture. Know and share your benchmarks. There are a number of areas where you can actually accumulate data to understand not just what your benchmarks are, but maybe what the benchmarks are compared to similarly situated endoscopy units. So here's, say, for an example, this is in New York City. This is an example of different various endoscopy units. And you can see that there is some variability in terms of the documentation of pre-procedure H&P. Some fall way below the norm. Here's another example of handoff to recovery room nurse communication. And, you know, hand-washing was illustrated before the personal protective equipment and things like that. And so knowing these benchmarks, you can also use them for physicians. And so physicians look at, for example, how many of them get to the CECOM, how many are prepped adequately, what their adenoma detection rate, which is also important. And then you have patient satisfaction scores listed there. And you can see between the various physicians what their scorecard looks like. And you really need to know and be able to share those benchmarks with everyone. Here's an example of the number of procedures that are being performed, how many of them had complications. And then in the bottom here is how many cancellations occurred. You know, does it occur within 24 hours or do they occur after the patient is in the pre-op area and you find out that they didn't do their prep work correctly? They ate at a buffet the night before. Here's some other benchmarks in terms of time, right? So here are three different physicians who are doing basic procedures versus advanced procedures. And you can see that, you know, there's some outliers here with colonoscopy or endoscopic ultrasound, and you can use those to identify ways or processes to improve the ability for your unit to work efficiently. You can go dive down into labor costs, scope repair costs. This is unlimited. Benchmarking is really unlimited. You can look at anything you want. Here's accounts receivable, how much money you're actually spending on devices and scope costs between different units. So you really need to target the specific benchmarks and quality metrics that really make an impact on how you work as an endoscopy unit. And I've categorized them here as financial, operational, clinical, and satisfaction type information that you can evaluate. And then this is the process of developing a PI plan, right? So this is kind of going back to what Debbie showed earlier in developing a process improvement plan. I'm not going to go over that in detail, but this is another reference that you can use for your particular project. And you really want to work on the priorities in terms of best bang for the buck, small easy wins, worth the effort versus saving the best for last. Because it depends on the type of project that you're working on is how disruptive it's going to be for your team to even implement it, right? So the more energy that it takes to implement a PI project, the less likely that it's going to work. So focus on the small easy wins if you can, besides getting the best bang for the buck. And then just repeat the process, okay? So sometimes you'll find that the problems associated with your process improvement plan include problems with team culture. You'll actually find out that it's related to how behaviors are occurring in the endoscopy unit that are an impediment in the delivery of quality of care in your unit. So just beware of pitfalls with this process. These are a number of pitfalls, lack of leadership attention, poor work planning, poor implementation, rocky rollouts, and insufficient follow-up. We all have these plans, we work on these plans, and then boom, we fall to the ground because we didn't get them implemented in a way that gave us adequate information about whether we actually made an improvement or not. So again, focusing on team, right? Together, everyone achieves more. Thank you.

benchmarking

performance improvement

endoscopy units

cost efficiency

quality metrics

patient engagement