We're going to turn back to Dr. Shrivastava, who's going to talk about improving efficiency in the endoscopy unit, which I think obviously is very important to all of us. So welcome back. Great. Thank you so much. So I think improving efficiency in the endoscopy unit, it's a very important topic and I think it's something that is applicable to all of us, regardless of what type of setting we're practicing in. Again, I have no financial disclosures. So to kind of start off with, it's important for us to actually define what is efficiency. So efficiency is defined as the use of available resources in such a way to maximize the production of goods and services. And for us, this would be maximizing or improving the overall health care for our patients in our community. So what does the data actually tell us about efficiency? So unfortunately, there's not a lot of literature on efficiency within endoscopy, and most of the available research has a number of limitations. Most of the studies are qualitative or descriptive in nature. Most studies only focus on one endoscopic procedure, and the majority of studies just look at improving physician efficiency. There are a few important pearls, however, that we can take away from the current research. One of the takeaways that I would really like to highlight is reducing procedure time does not enhance efficiency. If anything, this comes at more of a cost to quality and safety. The more important thing to look at is improving your operation flow and staffing, and we will talk about this in the next couple of slides. So this is a framework of how we're going to think about efficiency in our endoscopy units. At the top of the pyramid is the goal or the who. We want to improve the efficiency so that we can ultimately improve the care of our patients and our community. Below that is the what. What are the key elements or pillars necessary to achieve this goal of efficiency? There are four essential elements that include facility, staff, IT, and metrics. And at the bottom of the pyramid is the how. How are we going to sustain these changes over time? And this really is our workflow processes and the cultural beliefs of our own individual organizations. So now I'm really going to focus on each of these different categories, and to start off with, let's talk about facilities. So facility is a space you already have, and the goal is to optimize that space for the most efficient patient flow possible. There are three key areas that we should think about, pre-procedure, procedure, and a recovery room. So in the pre-procedure, it really discusses, you know, or it really talks about the positioning of your patients. Your patients mostly are they in private bays, are they grouped together, are they sitting in chairs, or are they lying in gurneys? There isn't a right or wrong way to position your patients, but you should ask yourself whether the patients are set up for optimal flow in and out of the room based on your physical space. If the setup is not optimal, then make changes to make sure that it is better. Ideally, you want your pre-procedure rooms close to your procedure rooms. This of course helps to cut down on the time it takes to transport patients back and forth between these areas. If possible, you also want to have a shared space between your pre-procedure and your recovery rooms. This makes it much easier to flex staff in beds throughout the day based on patient volume. Although there isn't any outcomes data, most experts agree that you should have about two procedure rooms for every one procedure room. This ratio may need to be lowered depending on the complexity of the procedures you are doing in your units. Now let's focus on procedure rooms. All your procedure rooms should be standardized. Stock all the equipment and drawers in the same way so that your staff doesn't waste time looking for things. This will also allow all of your staff to work in each of the rooms because they will be familiar with the layout. You also want to keep rooms stocked with commonly used supplies, typically enough for about one to two days so that your nurses or techs are not running in and out of the room during the procedure. We, in our endoscopy unit, actually assign someone the task of stocking the rooms at the end of each day to ensure that we don't run out of supplies and that all of our equipment is put in the correct place. Another thing you can utilize is mobile equipment and that can really help with improving the flow within the endoscopy unit. For example, some of our EUS machines are actually on wheels and so it can be transported from one room to the other. And then finally, the recovery room. You may want to think about optimizing patient positioning based on your physical space. If you can have a centralized open nursing station, this will help you flex staff between the pre-procedure room on the volume and flow. The recovery room actually tends to be the bottleneck for most units and therefore the recommended ratio of recovery rooms to procedure rooms is a bit higher at about 2.5 to 1. So now let's talk about staffing. So staffing is critical to efficiency. Too much staff is costly and too few can actually hurt your efficiency. Staffing is impacted by multiple factors. You need to know your state or local regulations to know what staffing is required. You also need to know what anesthesia and types of procedures you are doing so that you can decide how to distribute your staff. There are some guidelines around staffing ratios from the ASGE, the SG&A, as well as the AORN that you can take a look at and that can be really helpful. There are some similarities and some differences between these different organizations. Another thing to keep in mind is the type of sedation you're using. When using moderate sedation, it is recommended that you have at least one RN per room to administer the sedation. Most experts and many of the guidelines suggest that you should have another staff member in that room regardless of whether it's moderate sedation or anesthesia to assist the physician with interventions. The endoscope technicians can be embedded into the workflow in your unit as well. You can have them help with room turnover times by helping out with setting up the equipment and taking it out. Also, it can be really helpful to have a floater or circulator. So the next thing we'll talk about is IT. So IT can be stressful and expensive, but it can really be leveraged to make us more successful and efficient. Ideally, you want to have a single integrated EMR with easy access to it. You don't want different EMRs within your unit where you have to go to different programs or locations to get different information. Workstations on wheels can also be helpful during the check-in and recovery process and can make staff more flexible. Many EMRs have the ability to monitor and track patient flow from the time a patient checks in to the time a patient checks out. And finally, we should all strive towards a paperless interconnected system. Things to consider are leveraging the EMR to pre-populate nursing and provider assessments. Consider electronic consents so you don't have to print these out or be looking for them. There are also many systems that can download the vitals before, during, and after the procedure automatically into the EMR so that they don't have to be manually entered. And lastly, electronic endoscopy reports helps you to standardize what's entered and allows you to search these reports more easily in the future. And the last thing in this category is metrics. So when we think about metrics, we can think about this in three buckets, structure, process, and outcome. So let's start with structure. These are things that you probably already know. They include your unit layout, including how many rooms you have and the types of rooms. It also includes how many staff members you have, what type of sedation you are giving, and what IT infrastructure you have. Because these things don't change that much over time, they can be measured less frequently, about every 6 to 12 months. Now let's focus on process. Process measures tell us how well our systems perform. They include things like preparation time, first case start time, or first case on start time, sedation time, procedure time, room turnover time, and recovery time. This list can be quite overwhelming since there are so many different aspects to consider. So for that reason, I've starred two of the main things, first case start time as well as room turnover time. For each of your individual units, I recommend that you pick one or both of these to start and define them for your own individual organization. Devise how you're going to track them, and decide how you're going to share that data back with your team, and decide how you are going to make improvements based on those findings. I want to highlight that most units and experts are defining room turnover time as wheels out to wheels in, which means the last patient out of the room to the time the next patient enters the room. However, some places are also doing scope out to scope in. I bring this up to stress how important it is that you clearly define for your unit what these times actually mean. In high-performing ASCs, the room turnover time ranges from anywhere 10 to 12 minutes, but can actually range anywhere from about 5 to 25 minutes. This time is typically quite a bit higher for centers that are performing more advanced procedures where general anesthesia is used. I just want to mention again that interventions that are focused on reducing the actual procedure time have not been shown to improve efficiency, and can lead to reduced quality and safety. So the punchline is that you can measure it, but trying to improve that is not going to lead to efficiency within your unit. And last but not least, outcomes. Outcomes are the desired results of the system, and include patient waiting time. How long the patient waits to be brought back to the pre-op area, how long they wait to go back into the procedure room, et cetera, flow time, throughput time or volume, resource utilization over time and cost. Measuring waiting time can be a good place to start for these outcome measures, since it's typically a bit easier to calculate than some of the other outcomes, and because longer wait times also leads to poorer satisfaction, as I mentioned in the previous talk. Now we'll talk about themes that are the house, so the workflow processes. So understanding patient flow through the endoscopy unit is critical to understanding the associated workflow processes. Let's first talk about patient flow. I think it's useful to map out and understand the patient flow in your endoscopy unit. Typically you start with patients being registered, then they move into the waiting room to the pre-procedure room, the procedure room, the recovery room, and then discharged. We all know this is beautifully organized, a linear movement is probably not the way things in reality work within each of our own endoscopy units. So Dr. Day published this great paper in GIE back in 2014, and I suggest that you take a look at the maps in a flow diagram of his unit. What we see is that things are much more involved than the linear process on the previous slide. You can tell that there are different ways patients can move within each endoscopy unit. I encourage all of you to spend some time observing and recording the flow within your own endoscopy unit. This diagram took many years for him to complete and maps out all the processes within his unit, so I recommend that each of you start with only a single process at your unit. I suggest starting with room turnover time. Write down the steps, the times, and then go back to your team to discuss how you can improve this process. One of the ways to improve workflow processes is to understand what causes procedural delays. It's been shown that if you can reduce three procedure delays per day, this can actually lead to a cost saving of one full-time employee per year. This figure is from a study done in Canada at a tertiary hospital. They found that procedural delays were quite common, and most of the time were physician-related. In fact, 71% were physician-related, 19% were patient-related, and 4% were equipment-related. Nurses account for less than 0.5% in this study. So let's look at the factors that really cause the delay. This can be broken down into patient factors and physician factors. So starting with patient factors, you want to make sure that your patients are receiving clear instructions and expectations. Think about how long or how many pages your instructions are. Are they clear? What languages do you give them in? Is the language simple, and can it be easily understood by patients with different backgrounds and from different socioeconomic statuses? Confirmation calls where you actually speak to the patient are quite valuable. They can reduce your no-show rates and even improve your bowel preps. At our institution, they are actually done by endoscopy nurses at the end of their shift. The late nurse of the day does this, and we find that they can reach most patients when they actually call them after work, so about after 5 p.m. We call one week before the appointment so that we can put someone in their slot if the patients need to cancel or reschedule their appointments. The nurses go through a standard script with every patient, and these calls typically take them about two to three minutes. Some institutions are also using apps or text messaging services that can provide instructions and reminders about appointments, and these have been shown in studies to reduce no-show rates and improve patient satisfaction. You should also provide clear directions to the facility and endoscopy unit, and also let patients know where they should park. Anticipate and account for language barriers. Have translator phones or videos or in-person translator services for those patients that need it. Make sure you have wheelchair for patients that have mobility issues. And, of course, you want an efficient check-in process, whether that is the physical staff that's checking in a patient or whether it's done electronically via a kiosk or an app. Now let's focus our attention on physician factors. Interestingly, physicians are the source of the majority of delays, and that is probably for two main reasons. The first is because physicians tend to multitask, performing many other tasks that are not essential to endoscopy, such as charting from the clinic from the prior day, returning phone calls, etc. Another reason can be physicians who exceed their scheduled procedure time. So how do you deal with this? You need to track this data to understand what's going on. Share this data with the physician. Expectations should be clear and explained to all of your providers. When you say a first case is at 730, what is your expectation? Does the physician show up then? Does the scope go in at 730? Is the patient consented by 730, etc.? And of course, if delays are due to bad behavior, then there needs to be consequences. So let's look at some opportunities for improving efficiency through streamlining endoscopy workflow processes. In the pre-procedure area, are you spending too much time on obtaining informed consent? Could this be obtained in the clinic? Could other staff help with obtaining informed consent? Dedicated staff performing IV access can also greatly help reduce pre-procedure time. When it comes to sedation, propofol is very efficient. And for concerted sedation, fentanyl and Verset is much more efficient than Demerol. Room turnover time is critical and can greatly improve efficiency. Reducing procedural delays is important and can be done using some of the interventions we talked about on the previous slides. Parallel processing is critical. One staff member should not be doing everything, moving from step A to B to C. Having one staff member do step A while another does step B and C. Communication is extremely important so that everyone knows who is doing what, and there is no redundancy to work. It is also helpful for the provider to give everyone a heads up five minutes before the procedure is likely to finish so that anesthesia can wind down the sedation or that nurses in the room can start to clean up. Getting patients out of the room into the recovery area can also be a major source of bottleneck as we had discussed before. So in terms of some other ideas for workflow processes, one thing that you can consider doing is you can consider doing simpler cases that run on time earlier and save the more complex cases for the end of the day. Also, you can identify your most efficient individuals or teams and try to figure out what makes them tick can be very beneficial. What's different about the way that they're running their team or what are they doing that's more efficient? Experienced nurses or techs will see a poll up on the screen and anticipate the devices needed so that they are ready when the endoscopist asks for them. Once you've identified the efficient people in your practice, have less efficient members on the team observe them and disseminate best practices or even consider having the efficient folks train the new members in your departments. So how do we maximize procedure volume? If we can increase our procedure volumes without impacting quality in a negative manner, we are improving the value of the services we are providing. To maximize our procedure volume, there are a couple things to consider. If you have more endoscopy rooms than providers, using a one endoscopist for two room model can increase procedure volume and can increase efficiency. Similarly, having someone other than the endoscopist doing sedation can also improve efficiency. If you are doing conscious sedations and using fentanyl instead of Demerol, as we mentioned before, and reducing room turnover time has been clearly correlated with increasing volume of procedures and try to eliminate or reduce post-procedure paperwork. Cultural beliefs. This can be one of the most difficult things to change within your organization, but the culture among your staff is invaluable at identifying inefficiencies, implementing new ideas, and sustaining them. The cultural beliefs that are core to an efficient endoscopy unit are a strong emphasis on teamwork, organizational adaptability so that you can recognize inefficiencies and change them, flexibility among staff members. This is important because you want team members who can work through the endoscopy unit. Having staff members who only work in pre-op or only work in the endoscopy room leads to less flexibility and adaptability. As a corollary, you also want to encourage and promote everyone working at the top of their licenses or capabilities. And finally, clear and frequent communication to staff about expectations is critical to achieving an efficient and happy unit. Daily team huddles are successful in many units, are one way to ensure frequent feedback, can serve as a time to anticipate challenges of the day, discuss changes that are being made, as well as help with problem solving. You want the organization also to be adaptable so that you can implement change. You want flexibility among staff members. You don't want members of your team who only work in the recovery area or only give sedation. You want all members of your team to work at the top of their license and to be able to do everything. And most importantly, you want clear and daily communication to your staff, which can be done in a daily team huddle as well. And last, efficient endoscopy units will have a strong leadership. Growth leaders will create new system or change in the existing system. We need to examine our current system, recognize what needs to be improved, articulate the vision, where we want to go as an institution, and create alignment for our staff. Title does not define leadership. Leaders within your division do not need to be the head of the division. They can be anyone who has an interest and dedication to this process. So some of the take home points from my talk. You want to have clear and measurable definitions of what efficiency is within your unit. You should focus on issues beyond the length of the procedure itself when looking for targets, areas for improvement. We need to streamline and optimize workflow processes. And of course, it takes strong and innovative leaders who support a culture that emphasizes teamwork and supports change. Thank you.

efficiency

endoscopy unit

operational flow

staffing

facility optimization

IT systems