I'm eager and anxious to dive into our cases for this segment, and then we'll also tackle any questions we have from the audience. Guys, we welcome your thoughts, your participation, so please don't hold back. Okay, so this is case number one. The hospital endoscopy unit director and nurse manager noticed that their colonoscopy prep scores, Boston bowel prep score average 6.2, and the number of colonoscopies that need to be repeated due to inadequate preparation, 8.7%, are worse compared to their affiliated ambulatory surgery center, and you can see those averages there. Score of 8.1, and repeat colonoscopy rate of 2.4%. What do we do? Where do we start? Gerard, I'm going to throw that back to you and let you tackle it. Okay. In a lot of instances, if you're going to try to create a successful QI project, you really need to take into account all factors. I think one consideration that you might want to entertain is that the hospital unit delivers care to a significantly higher proportion of care to patients who have worse social determinants of health scores. They have health scores that are lower in education, income, access to computers, transportation, ability to care for themselves compared to, say, for an example, an AESC patient population. How does one really overcome those aspects? That's just one example of trying to figure this out. I think it might behoove the hospital endoscopy unit director and nurse manager to look at the AESC or visit the AESC, talk to the endoscopy director and nurse manager there, find out what they're doing right, what they feel like they're doing wrong, compare it to what is being done at the hospital unit, looking at some of the metrics that I mentioned, and then involving the whole team. You want to go from the schedulers who are talking to the patients to the office staff who are interacting with the patients to the nurses who are doing the pre-calls to the physicians who are actually ordering these procedures. You want everybody's input before deciding on an action plan to start taking place for the quality improvement. That's what I mean by having the team culture. If you have that vibrant team culture, it's essential to get everybody's input into what can be done and what the barriers are to overcoming some of these factors. That's fantastic. I completely agree. I would piggyback on that and say, when you look at a problem like this, it feels daunting at the outset to tackle this massive issue, but I think exactly as you said, you're breaking this down into each one of the elements that may be contributing, I think is key and also makes it a bit more palatable to embark on that sort of project. John, Debbie, any other comments? Yeah, I would agree with Dr. Isenberg. There's multiple things that you can consider. I'm obviously outpatient in an ASC. Are the patients getting a pre-call or do they have the ability to speak to a clinical person if they call in and have questions about a prep? Sometimes we have found that diabetic patients, they can't use that standard prep, that they need maybe an extended prep to help them get cleaned out a little better. What preps are we actually sending patients? Is it based by physician or is it based by the practice all in one? I know we have doctors that prefer one prep over another. We try to use a standard prep, but inevitably somebody will give their own prep. Where did they get their prep? Were they prepped in the office? Did the office MA or the scheduler talk through the prep? Were they scheduled through the scheduling department and it got mailed to them? Maybe somebody had a set of old preps that was in their drawer that they handed to a patient. We're not really using that prep any longer. I agree that it takes a team approach. I think you need to bring people together, talk through your process, and see where we can improve education for patients and give that opportunity to improve on getting that solved. Debbie, you echoed exactly what was said in our question and answer box. Someone had commented, Talisa had commented that maybe more of an education piece is critical and needs to be done for the staff providing the information to the patients. Eden, I see you had your hand up and now your hand is gone. You're so good. I wanted to point out Talisa's comment. Thank you so much. Okay. John, any comments? If not, we can tackle. Maybe just a remark about the inpatient perspective. We all know that when it comes to hospital endoscopy units, it's the inpatient prepping population that can be particularly challenging, right, because of medical comorbidities, capabilities, et cetera. And there, you leverage your strong team relationship with the inpatient teams, the nurses, the house staff, the physicians, et cetera. Our charge nurse automatically maintains open lines of communication to make sure that graphics and so forth that are used to grade the level of prep that has been achieved has been documented and verified before the patient's ever sent down to the endoscopy unit. And so active repeated communication until that outcome has been achieved prior to the patient being transported to endoscopy can make a big difference in many ways, right? The patient doesn't want to be transported multiple times either, nor do they want to wait in the pre-post area for an hour all for nothing. So it helps everyone if communication supplants multiple errors of process. Completely agree, John. I would comment that at our institution, we have actually on the inpatient side started including a picture of what a clean prep looks like, what an appropriate prep looks like in the medical record. So when we write a consult note, it is part of our consult note and the nurses in our units know to reference that picture prior to sending the patients down. And as you said, seamless communication with the GI endoscopy charge nurse and the nurses on the floor really, really does make a difference. Okay. Eden, do you want us to tackle some questions or would you like us to move on to case number two? You know what, let's grab a couple of questions. There's been some really nice dialogue that you've been having one-on-one with some people who ask questions. And I don't know if everybody in the audience has checked out the Q&A box. So one of the questions here is how do you practically engage the team to achieve buy-in with QI projects when everyone seems so strapped for time? So if we could just kind of some review, some best practices there about how do you get past resistance? John, you had a fantastic response to that question, to Denise's question. I'll let you tackle that one. Yeah, give me that question specifically again, because I'd really like to tackle that part by part. Read that one more time. Okay, I think we're talking about two different questions, but they're related for sure. So Denise had asked, how do you communicate what QI projects you're working on to staff members and how do you ask them for input? So that really does kind of embrace getting over resistance and how do you engage the team? Yeah, and I think that, you know, the importance there is, and this actually ties into the second question, because everybody is short of time, right? And expectations of time management are very different from hourly nursing staff compared to salaried nursing staff, physicians and other providers, because, you know, hourly staff are there and paid for the time that they're there. And so necessarily expecting them to take on additional duties during unpaid time is very different for that professional population compared to those of us who are salaried, for example, where, you know what that means. So without getting into that detail further, I think, number one, there are many ways to engage where people can use what time they have available to them. So if you have projects that can be put together as research abstracts or presentations, make a poster, line your hallway with posters. You know, everybody's got some downtime between patients or while they're eating lunch in the staff lounge or whatever, wallpaper your staff lounge with these projects. We're all professional people. And, you know, while you're eating your sandwich, you can actually read that poster and go, wow, they saved a million bucks doing that. Hey, Bill, did you really save a million bucks doing this? What the heck? You know, and there you go. There's your discussion during a paid break. You just have to be smart about things the way that advertisers are smart. You also make use of your staff meetings. You know, does every staff meeting have to be the same or can you dedicate one per quarter to what's going on with QA and QI in your department? You know, make one of those quarterly meetings a journal club. I guarantee you some people are going to be interested, you know, and if you offer it virtually as well as with live participation, somebody who asked to commute an hour might be able to at least listen in. They don't have to actively engage with every part of it. They might get a lot out of it by listening. So I think it's this trite expression of thinking out of the box and leveraging all this wonderful technology that we've been leveraging much more quickly and adopting a lot faster by necessity because of COVID. Don't forget about those lessons because you've ditched your mask. Those lessons have great value going forward. Let's do the most with what time that we have, whether you're an hourly employee who's paid for every minute that you're there or if you're salaried and perhaps have a little bit more freedom with your time. Gerard, you had alluded to working with administration and leadership to actually make time for the team or finding ways to get the team paid for the time spent on QI projects. How do you embark on those conversations? Yeah, I think it's absolutely critical that administration and leadership make the time available to have these quality improvement projects because you can't do them during the usual workdays. Everybody has got different responsibilities and it's impossible to get the entire team together during the development of a QI project if everyone's being pulled in five different directions. So administration and leadership needs to have buy-in in order for this to occur. You need to have a separate venue and you need to pay people who are getting paid outside of a salary for accomplishing this. You need everybody on the team, whether it's not just the physicians and nurses, it's the techs, the office staff, the nurse practitioners, the PAs, the biomedical engineers, the IT people, all those people that I mentioned as part of the team. They need to be part of this process or venue and in our institution, we have the ability to actually, we have a hotel across the street from us, so we'll just go spend a Wednesday evening or Saturday morning having the ability to eat food, enjoy each other's company, and we'll have an agenda specifically looking at what specific projects that we're interested in. We're looking for the biggest bang in the buck and the ability to get the most for the least amount of time that we need to spend in order to get those QI projects going. And we'll hand out the agenda beforehand, we'll allow, we'll divide it up into teams where the teams involve physicians, nurses, techs, et cetera, and they'll bring to the group as a whole, four or five different ideas, and then the whole group can then chime in with their thoughts, their concerns, their issues regarding barriers for that particular QI project so that, again, everybody's voice is included in that particular QI project, but you're also developing team culture. Again, that all goes back to focusing on the kinds of things that make a team great and high-performing, and because it's critical that you have that team culture in order to get good QI projects accomplished. Debbie, John, Gerard, and I have really talked a lot about the hospital side of things. How do you do this successfully in the ASC world? So, you know, I'm sitting here listening to all of these, you know, different perspectives on how you actually tackle this with having a multidisciplinary team. You know, you've got your techs, you've got, you know, even maybe receptionists, scheduling, whatever that may be, and we're currently building a culture at our practice where we're, you know, getting people to come into these ideas of having, being part of these groups and setting up meetings, and yes, how do you find the time for this, right? I think one of the things that you can do is offer contingent or casual staff, maybe part-time staff who aren't there every day, time to either participate in those events, or maybe they cover for a team member who's full-time and lets them have that morning to have a meeting with the quality team, the managers, and maybe the physicians, or do it over lunch, you know, a couple times a month and feed them and, you know, give them the opportunity. You know, give them the opportunity to talk and work through problems and work through your process during the lunchtime. I tend to find if you feed them, they'll come, right? But, you know, I think that this will also go back to that team building where you're investing in those employees, right? They have a good purpose. They feel like they're contributing. They take ownership of your center, so they feel like they're helping with the improvement. And I think once you get them into that role and they really realize they're making a difference, you're not going to have so much pushback. Fantastic. Thank you. Eden, would you like us to continue tackling some questions? Do you have more to read to us? You know, as a great reminder to the whole audience, you all can always look at the open questions and the answered questions. Why don't we tackle another case here that actually, I think, will touch on one of the questions. So I'm just going to throw out this question before you read case two on the screen. And it's where can we find sources for hospital endoscopy benchmarks? And I think that'll probably get answered in this case. Okay, let me move on with case two then and then we'll come back. So the endoscopy unit director notes on the ADR score sheet that a physician consistently has an ADR of 16% over the past year. What should be done? What are our next steps? Gerard, I'm going to send that one over to you. Okay, so this could be somewhat of a challenging process. And it goes back to, you know, how is the team structured? You know, I think you have to back up to decide, you know, should the report cards be shared with everyone, which I think, you know, should be the case. Many endoscopy units do not share data within the group because they're concerned that they're going to start triggering bias amongst the various physicians and there's some unintended consequences of being judged in that way. So I think, you know, first you have to decide whether you're going to share it publicly and what are the exceptions to sharing. So, you know, for example, does this physician only perform 10 screening colonoscopies per year? And so does it really matter that their ADR rate is 16%? Does that, you know, should that be a quality metric to actually look at? I think you could argue that, you know, that it shouldn't. And then, you know, what are the cutoffs for disclosure? What are the solutions that you have available to tackle this situation? What's the process and determination of expected improvement? Is this a shared decision? Are there nuances to addressing this shared decision? And then, you know, you got to think down the road, what are the consequences if the desired outcome is not achieved? So it goes back to all of those things that, you know, we mentioned in our talks. I think, first of all, you know, setting down with the physician and trying to figure out what her or his expectations are for adenoma detection radar. Do they, you know, have questions or issues that they're coming up with during their procedure that impair their ability to detect an adenoma? And then I shared with you on one of the slides about some of the tactics that could be used, you know, from having a second observer in the room and saying, you know, one of the ways that you can improve your adenoma detection rate are these things. The following things. Do you incorporate artificial intelligence into their endoscopy processor? All of those things can occur. And then you also have to think about, you know, is there a problem with PrEP? Do they have, you know, issues that their bowel PrEP scores are consistently fiberless, which is actually an impact on their ADR? So again, you kind of have to take a global perspective of what's going on and accounting for as many factors as you can, implementing a process that will work for that particular physician, that that physician agrees should be done. And then re-evaluate, re-evaluate your process, look to see if there has been improvement in the ADR over time. Go ahead. I was just going to comment that to your point, it's certainly not a one size fits all. What plagues one physician and drives the 16% ADR may be very different than what his or her colleague is battling. Eden, I see your hand is up. Yeah, you know, I just wanted to mention that, you know, years ago, this is before the pandemic, a unit was applying to the endoscopy unit recognition program. And I had a very similar conversation with them. And they wrote into their policy, kind of the contours of a remediation plan, like how they would remediate. So I thought it was really clever of them because when they applied, actually all their providers were, you know, were above the performance targets. So they didn't need to, but they were thinking through these issues and they were ready to pivot and, you know, they would have agreed with you that obviously it's an individual conversation. But they thought through kind of these contours so that they were ready to pivot kind of quickly and I just thought that that was really smart and I actually have the policies and procedures up on the EURP webpage. So if people are interested, you can see sample policies there. And this unit was kind enough to let us share those out with everybody. So you can always download those from the ASGE website, the endoscopy unit recognition program page, and I'll hand it over to Dr. Martin. Richard I wanted to ask you a question about your point, a very interesting one at that regarding, you know, divulging individual ADRs of the operators because this is a discussion that came up in my group recently and as you were suggesting there are reasons to do that and reasons to shy away from it and the middle of the road approach would be to have that data available and visible but with every name redacted but the person looking at it. Do you think that there's value beyond the redacted data to have everybody's name and social security numbers slapped up there. Yeah, I think that that could be a little bit dangerous, especially in this world. But, you know, it, it, you know, the one of the slides that I showed you, like from the New York City multi ASE groups, you know, had their names redacted in that particular benchmark quality metrics and I think it, it really depends on, you know, the within which you're sharing those benchmarks. I, I personally think that, you know, the middle of the road probably will work best because then there isn't this bias and judgment but sometimes people can figure it out right. So you know that, for example, Physician A may have done only 10 to 20 screening colonoscopy because most of their cases are advanced endoscopy. Sometimes, just having that data up there you can quickly figure out who is who. If you have your general endoscopist who may, you know, there's there's a handful that are doing, you know, 1000 screening colonoscopies in a year you can kind of figure out who those people are. So, you know, I think that, you know, there's also some danger and even just having the identified data. If there's enough data in there to kind of potentially identify which position is, is which. So, I, you know, goes back to having those, those agreements up front, you know, after you've had your team mission it's team agreements and figuring out, you know, what the group as a whole thinks would be a way to share the benchmarking. It's a slippery slope for sure I do think it's worth making the comment that obviously if you are looking at a. Essentially an anonymous list of ADRs and you know where you fall on that list and you see the, that you are an outlier you see how your colleagues are performing relative to you. I would hope that that would be enough internal motivation to pick up the pace or figure out, you know, internally, where the issues may lie. They asked where, where do you get benchmarking. And we have another raised hand after that so Dr. Okay, Dr. Eisenberg but yeah so hospital benchmarking where can they find that. Yeah, so in that one of the slides. You know, when you get a chance to go back. There are some resources there but you know you can also look through ASGE and ASGE has some, I think, older benchmarking on operations and efficiencies and of course GI quick has benchmarking for endoscopic and procedural quality metrics so those are some resources that people can use. Wonderful, and we're gonna we're going to try this again with Denise Denise, I think you just have to unmute from your end, we see your hand raised. Okay, can you hear me, we sure can go for it. So I was just going to comment, we were talking about before about the ADR adenoma detection rates and posting that for everybody to see I was just going to give a little bit of my personal experience. I previously before working at Ohio gastro. I was a quality assistant nurse manager of quality at Taylor station Surgery Center. And so I did a lot of this. What we what I will do is I personally would email. Every three months I would email the doctors their personal statistics with the benchmark that we're trying to achieve, as well as the average of everybody in their group, so that it wasn't like the individual person's numbers, but as a group, this is what we're achieving. How are you comparing to everybody in this group. And then the, the people who are the lowest, we would, I would take that and say, give them like ASG. We required everybody to be a member of ASG because we were a center of excellence. And so I would give them like information from the ASG websites as things that you can do to help improve your adenoma detection rates, things like that. I just wanted to put that in there. Sorry. I love that strategy so you're not actually listing every individual's ADR you're aggregating it into an average and then showing the individual endoscopist how they compare to that average which I think that's great. In theory, should move the needle in the right direction should motivate the physician to improve. Great. Thank you for sharing that. So Denise Can I ask you, did you run into a situation where you know you share this data but the needle didn't move. What did you do. So, when you approach doctors, they usually give a little bit of give back because they don't want to be wrong nobody wants to be wrong. Nobody wants to be doing something incorrectly. But once they want you continuously once I continuously gave them that data, it wasn't just a one time thing. I can back up everything that I was doing everything I was saying evidence based practice that type of stuff, just consistency and keep them. This is, these are the things they were more receptive to that. And then they, the, they got better. They're like hey Denise you know, is there anything new on ASG that you saw, or, you know, is there anything like they would come to me and ask me for. If there was any more resources or anything new that I had heard of. So, it did change it just takes time, and you have to build a trust and relationship, it goes back to the whole team building and being part of a team and trusting and building a trust relationship with the people you work with. Fantastic.

quality improvement

hospital endoscopy units

colonoscopy prep scores

repeated colonoscopies

physician

teamwork

communication