Next, it's my absolute pleasure to introduce Dr. Sameer Islam, who will talk on improving the efficiency in the endoscopy unit. Dr. Islam is a practicing gastroenterologist and hepatologist in Lubbock, Texas. He serves as a division chief of gastroenterology and the GI fellowship program director at Texas Tech University Health Sciences in Lubbock. Dr. Islam is also a very prolific digestive health video content creator, and as you can see, he's got the most professional Zoom background, so he really means business. I think one of the interesting things about him is how he deconstructs really complex GI issues that patients and the general public can understand. Dr. Islam, we look forward to hearing about how you improve efficiency in the endoscopy unit. Dr. Pinal, thank you so much. I think the thing about having a YouTube video means that you have really no life, and so I really do appreciate you highlighting that in my talk today. Well, today I'll be talking about improving efficiency in the endoscopy unit. I have no disclosures when it comes to this talk. Let's start with a question. Do you feel like your endoscopy center actually is efficient? Go to the polls, yes, no, or do you even know what efficiency means? I'm curious to see what you guys have to say. Well, wow. So 65% of you think your endoscopy center is efficient. I think I'm done with my talk. I'll go ahead and leave, and we'll call it an early day. No, I'm kidding. But I think it's important, even though you may think your endoscopy center is efficient, what can we do to make it more efficient? So let's talk about that. So what exactly is efficiency? It's important for us to find what this actually means. So efficiency helps to kind of frame the talk that we're doing today. So it's defined as the available resources in such a way to produce maximum production of goods and services. So specifically in the GI field, what we want to focus on is what we can do to make it more efficient to improve the overall care of our patients, but also what can we do to improve the overall health care of our communities as well. So what does the data actually talk about when it comes to efficiency and endoscopy? So unfortunately, there are very few studies that we have on this, and there's not a lot of literature that we have when it comes to that. And the current studies that we do have this have a lot of limitations in terms of what they talk about. They focus mainly on qualitative or descriptive information in nature. They focus typically only on endoscopic procedures and not as a unit as a whole. And they typically focus only on physician efficiency and not in terms of actual endoscopy efficiency as well. However, there are some important pearls I want to make sure we understand when we're looking at the literature that we can take away. And one of these is that reducing procedure time does not enhance efficiency. And so what that means is that doing a quick procedure in the efforts of being more efficient actually does not make you more efficient. This is a point I want to highlight in today's talk. Doing a quicker examination and a quicker procedure does not make you more efficient. So let's go to question number two. What do you feel like are some of the biggest barriers to efficiency in your endoscopy unit? Good. All right. Perfect. So staffing facility. Staffing seems to be a big one. So we're going to talk about each of these in the next couple of slides. So I'm glad people are responding to this. So this is kind of the main slide about exactly what are the themes that help to drive efficiency. This is the framework I want to talk about in the rest of the talk. So at the very top of the pyramid, we have the reason why we want to improve efficiency. So like I said before, we want to improve the care of our patients, but also to improve the care of our community. This is the whole goal of us to have more efficiency in our endoscopy unit. So what exactly are the ways that we can do this? And so these four things, the facility, the staff, IT, and metrics, these are the key elements or the pillars that allow us to achieve this goal of efficiency. And at the very bottom of the pyramid is how. How do we sustain these changes over time? And this is basically dependent on our workflow processes, but also the beliefs that we have within the center that we are running and that we're a part of as well. So let's focus right now on facility first. So when it comes down to facility, there are four ways that we can realize help drive efficiency. One is the overall layout of the facility. Number two is the pre-procedure area when you bring your patients in. Number three is the procedure area itself. We actually do the procedure. Number four is the recovery area. Then lastly, we also have the equipment and supplies that are available for us as well. So let's talk about the overall layout. How is the layout with the facility that we have? And how does this affect the efficiency of our endoscopy unit? What's important is that you need to have the waiting area steps from the procedure room. Number two is that you have the pre- and post-op bay steps from the procedure room as well. And then lastly, you need the scope room that are steps from the procedure room itself. And so the important thing is you want to minimize the travel time from patient to their area and from the staff to the area as well. Now, I know this can be hard because for a lot of us, this is already built in. But if you can find ways to minimize this to decrease the number of steps, those steps over time will help decrease the amount of time that it takes for patients to move and for your staff to move, which in turn will help efficiency as well. So let's talk about the pre-procedure room. So it's very important to assess how your patients are positioned. Are they in private bays? Are they grouped together? Are they in chairs? Are they laying in gurneys? Now, there's no right or wrong way to position your patients, but you should always ask yourself, are the patients set up for the most optimal flow in and out of the room based on your physical space? Because if it's not optimal, this is an easy way to make changes to make it better. And ideally, like I mentioned before, you want your pre-procedure area rooms close to your procedure rooms. You want them to be in steps from where they could be because this will help to cut down the time it takes to transfer patients back and forth between these areas. The shared space is also important because you want to make sure that you can have a shared space. It makes it much easier to flex staff and beds throughout the day based on your patient volume as well. Now, when it comes to the pre-procedure room, we don't have any outcomes data on what is the most optimal way to position your rooms or what the ratio should be. But most experts agree that you should have at least two pre-procedure rooms for every one procedure room that's available. Now, this ratio may change depending on the complexity of the procedure that you're doing and the volume that you have as well. So when it comes to the actual procedure room, what's very important is that you want to really standardize the room that's there. You want to reduce as much variability as you can in the procedure room. Stock all the equipment and drawers in the exact same way so your staff doesn't waste time looking for things. I cannot tell you how many times I've been in my own endoscopy center where there are things that are just not in the right place or they're in different areas per room. So you want to standardize that to make sure you have everything in the same place. This will allow your staff to work in multiple different rooms because they know where the equipment is. You also want to make sure that your rooms are stocked with most commonly used items and supplies for at least one to two days. So that's important so that you actually know where things are and you can make sure things are not running out in time. And it's important that you check this every single day and to assign someone to make sure they're on top of this as well. And then lastly, you may want to consider having mobile equipment that can help improve the flow. So for example, in our center, our EOS machine is mobile so it can be wheeled into different rooms depending if it's needed or not. And if the equipment is stationary or you need a certain room for special procedures, make sure you have that room standardized for that particular procedure as well. And lastly, the recovery room. So you also want to think about the optimization of patient's positioning based on your physical space in the recovery room as well. If you can, you want to have a standard centralized open nursing station, which will help you deflect staff between the pre-procedure area and the room based on volume and flow as well. And then finally, a recovery room tends to be the bottleneck where most units are having the issues when it comes to efficiency. And so the recommended ratio of recovery rooms to procedure rooms is a little bit higher, roughly around 2.5 to one. But once again, there are no outcomes data to suggest this is the standard. So just do it based on what your facility has, but also what's available for the layout that you are in as well. So equipment and supplies. So in order to provide a safe and efficient facility for patients, new and updated equipment honestly is a must. This is a must. This will help cut down on having a troubleshoot in the mid case and increase in delays due to equipment failures. So we recently had an upgrade of our equipment where we had old equipment before and that upgrade has been a game changer for the efficiency, but also making sure that we don't have a breakdown in the equipment either in the middle of the day or even worse in the middle of a procedure as well. You want to keep the supplies in a general area that is accessible to all areas of the practice. This would help improve the efficiency. If the supplies are organized like at home, which there is a place for everything and everything belongs in the same space, this will help minimize the amount of time it takes to find equipment and find supplies as well. And then lastly, something as simple as labeling and education of supplies is imperative. If you know where things are at and it's clearly labeled for your staff, for your techs, for your nurses, it makes it easier for your staff to find those things, but also makes it easier for your new staff makes it easier for your new staff, your onboarding to remember where things could be and remember where they should be as well. And lastly, like I mentioned before, you want to have commonly used supplies maintained in the facility, in the rooms, in the area where you have your supplies for at least a couple of days to make sure you can have enough of them available. And lastly, we talked about it before, mobile equipment may be an option for those centers that actually have other procedures that can be done besides the routine upper endoscopies and colonoscopies as well. So staff, big thing. This is a big reason why people have problems with efficiency. So let's move on to our next question. All right, one to five. That is a really efficient center. That's pretty impressive. And the next one is six to 10, so that's good. So let's talk about exactly what models we can use when it comes to staffing. So staffing probably is the most critical aspect when it comes to efficiency because too much staff is costly. However, too few can hurt the efficiency of your endoscopy unit as well. So it's influenced by so many factors, whether you have certain state or local regulations. So make sure you understand what they are. You also have to, it has to be dependent on the type of anesthesia that you use and also the type of sedation that you use as well. And so we're going to talk a little bit and also the type of sedation that you use as well. Now there are certain guidelines that are out there depending on what society you want to go into, whether it's the ASGE, SGNA, AORN. So take a look at those because they can be helpful as well. And also too, if you use moderate sedation, you do have to have at least one RN per room to administer the sedation. And most experts, many of the guidelines suggest you should have another staff member in that room, regardless of whether it's moderate sedation that's administrated by a CRNA or anesthesiologist to help assist the patients in case, or a physician in case there is any issues that may occur as well. Staff volume can also be important as well. Having the appropriate staff can help out with turnover when it comes to turnover in the rooms, also turnover in the recovery base as well. But also having enough staff can also minimize the burnout that employees can have as well. And that burnout, it's a real factor, especially when it comes to having too little staff or having a high volume center as well. In regards to how much staffing you have, it's important, it can be dependent for our facility. We have two nurses in prep and recovery for four patients along with a turnover tech as well. And this allows the nurses to focus on strict patient care and safety while the turnover tech can help grab supplies, turnover rooms, and hopefully maximize the time in between each cases as well. And lastly, you also may wanna consider having a dedicated endoscopic tech to help improve room turnover. We've implemented this in our practice, which has helped it with efficiency, but also has allowed the nurses to focus on patient care alone. And also too, you can also have a free floater or a free agent to help out with circulation in which they can be trained in different positions to allow the techs to help out with other things, complete things, and hopefully allow to improve the turnover time and the room recovery whenever you're doing your endoscopies or at least in between the procedures as well. So let's look at IT. So IT can be such a beast to manage because there's so much information that's out there. It can be stressful, it can be expensive, but it can really be leveraged to make us more efficient and to improve what we can see what the bottlenecks are. So it's important to measure some of the metrics that we're trying to talk about in terms of improving efficiency as well. And what you wanna do is you wanna make sure you have a single integrated EMR with prompt access for everyone. And sometimes we have found that having workstations on wheels can be helpful for during the check-in process and also the recovery process and make staff more flexible as well. You wanna see if you can also maintain a single database to help track patient flow, as many EMRs allow you to do this with one simple EMR system as well. And you really want to strive for a paperless interconnected system as well, in which you can have pre-populated templates for both nursing and for doctors as well. You can have pre-populated or at least electronically populated patient consent, sedation, and also pre-populated vitals, which can easily transfer from one node to another within one EMR as well. And then lastly, I know most of us use EMRs in which we can integrate some of the information and use that to help measure how we are doing and find out what those bottlenecks are to improve the efficiency in our center. So let's talk about metrics. What exactly should we measure? And so when I think about metrics, I want to think about three main buckets, structure, processes, and outcomes. This is what we can measure using our IT models to see what we can do to improve the efficiency of our endoscopy center. So let's start off with structure. So these are things that you probably already know, and they include your unit layout, how many rooms you have. It also includes how much staff members you have, what type of sedation you have, and what IT infrastructure that you have as well. Because these things don't typically change over time, they can typically be measured less frequently, usually every six to 12 months, just to see if there's anything you can change or improve upon as well. And when we think about processes, these are measures that tells us how our system is performing. And they include things like preparation time, first case start time, or the first time you start the case, procedure time, sedation time, room turnover time, and recovery time. The ones that are starred are probably the ones that you can make the best bang for your buck and improve quickly, which has the best evidence for improving your endoscopy time and improving your endoscopy center. This includes when your first case start time is and your room turnover time as well. And what I recommend is using these two ones as your first data points to see what you can improve upon and what you can change and how you can make your endoscopy center more efficient as well. Now, when it comes to room turnover time, I want to highlight that most endoscopy units and experts define this as room turnover time as wheels out to wheels in, meaning the last patient out of the room, the time to the next patient into the room. And so this is typically what we use in terms of measurement. Some people say it may be scope in or scope out, but what I want to stress is that you need to really clearly define what these terms are so we all know what you are measuring and can all know exactly what you can try and do to improve. And in very high performing ASCs, a turnover time in between room can be between 10 to 12 minutes, but it can also range between five minutes and 25 minutes as well. And it really depends on what type of procedures, the rooms, and exactly how efficient your unit is as well. But I wanted to stress one more time that interventions that focus on reducing procedure time have not been shown to improve efficiency and can actually lead to reduce quality and safety. So the punchline is, is that you can measure it, but trying to improve it is not going to lead to more efficiency in your endoscopy unit. Don't do a bad or quicker procedure in the efforts of becoming more efficient with your time. And then outcomes are the desired results of the measure, and they include patient waiting time, how long a patient waits before being brought back into the pre-procedure area, and how long they have to wait until they go back into the procedure room, the flow time, the throughput or volume, resource utilization, overtime, and costs. And what I would suggest is actually measuring the waiting time because this is a good indicator for not only how long it takes for you to actually get the patients back, but also patient satisfaction. Patients don't want to wait any longer. They've already prepped, they're already angry, they're already tired, and really making a measurement on waiting time can probably be one of the most effective things that you can do to not only improve patient satisfaction, but also can improve the outcome and the efficiency of your endoscopy center as well. So lastly, we'll talk about the workflow in the bottom. How do we implement this and how do we sustain these changes over time to make sure we have an efficient endoscopy center? So let's understand the patient workflow. So this is the ideal workflow that we all think everything is going on because we all think our endoscopy unit is the best. You know, the patient comes in, they wait for a couple of minutes, they go in the pre-procedure room, they wait a few minutes, they chit-chat, they go into the procedure room, you do your procedure, the recovery, and they get discharged. This is a very simple diagram that we all hope and we all think may be occurring in our endoscopy unit. And we know this is probably not the case because in reality, we know is that there are so many ways and so many different flows that patients can have. And this can be very messy, but this is the reality of what's going on. And what we can see here is that things are much more involved in the linear, easy process that we had on the previous slide. And there are different ways in which your patients can move throughout the endoscopy unit. What I would encourage everyone to do is just observe and record how your flow is in within your own endoscopy unit. Because this diagram can take years or months just to see exactly how your patients can go through. And you can understand the process of the patient experience from the very beginning up until they actually leave your endoscopy unit. And I would recommend to write down these steps, the times, and go back with your team to discuss how you can improve the process as well. Now, one of the ways you can improve the process is to understand what actually causes procedure delays. And it has been shown that if you can reduce three procedure delays per day, this can lead to a cost saving of at least one full-time employee per year. Now, if you look at the study from Canada, they found that procedure delays were quite common. And most of the time, I know we can guess this, it's due to physician-related. The vast majority, 70%, are related to physician-related delays for any number of different reasons we'll talk to you right now. So when we talk about reducing delays, there are two main ways I wanna think about this. Number one is patient factors. So you wanna make sure that your patients are receiving clear instructions and expectations of what to expect. Think about how long or how many pages your instructions are. Are they clear? What language do you give it to them? Is the language simple enough and can be easily understood by patients with different background levels and from different socioeconomic statuses? Keep in mind, you really wanna have it at least at a third or fourth or fifth grade level when it comes to education. You also wanna make sure that you can have confirmation calls or calls in which you actually speak to the patient because these are helpful and valuable and they can reduce your no-show rate. At our institution, they're done by our endoscopy nurses, typically at the end of their shifts or the late nurses at the end of the day, because we have found that we can reach most of our patients at five o'clock or at least after five o'clock when they're home from work. We typically call one week before the appointment so we can put in someone else in their slot if the patient needs to reschedule. And we go through a standard script with every single patient. And these telecalls typically take between two and three minutes. And some institutions, though, may also give apps or text messaging services that can provide instructions and reminders for patients to when to come in and when to take their prep as well. You need to make sure you have clear directions to the facility and endoscopy unit, and also make sure you understand, or patients understand where exactly to park as well. And you want to anticipate and account for language barriers. Have a translator phone, have videos, have apps, have people who can help out with translation to cut down some of those barriers as well. And then lastly, you want to make sure you have an efficient check-in process, whether that's a physical staff checking patients in or having a kiosk or it done electronically as well. Then there are physician factors. Keep in mind, we are the most common reason for delays. And the most common reason that we delay things is that we do things that are not essential to endoscopy, we multitask. We do other things that are going on, whether it's charting from the clinic from the day before, maybe it's having 10 new patients, or maybe we're doing other things like returning phone calls or other non-essential tasks. This is one of the reasons why we may be not efficient. Number two is that we actually may exceed our block time as well. We may have too many patients or not, or maybe we have an endoscopist who may not be as efficient with their time, or they may have more complex procedures. So you need to look at that to make sure you have efficiency when it comes to block time as well. And sometimes you have to have mechanisms to deal with physician behavior. And so you should provide these physicians with information on delays. You should recommend and share best practices, but also you want to be clear in terms of what the expectations are. So when you say the first case starts at 7.30 a.m., what is that expectation? Does the physician show up then, and the scope goes in at 7.30 a.m., or is the patient can send to 7.30 a.m., and then you actually start at 7.45 or 8 a.m.? It should be very clear on what these expectations are whenever you have them so that everyone's on the same page as well. And so there are other things that you can do in terms of the pre-procedure time. You want to see if you can maybe get consent in the pre-procedure area. Are you spending too much time on that? Or should this be done in the clinic or before that? Do you have enough IV access? Do you have a dedicated team to help out with that? Do you have equipment to help out with that as well? Are you doing the right sedation? Obviously, if you're doing propofol, it's very efficient. If you're doing fentanyl and Versed, a little bit more time will take when it comes to using that as well. Room turnover time. This is very critical when it comes to efficiency as well. Are you returning, are you recovering the room appropriately? Do you have enough staff for that? Should you consider having maybe more than one staff or different members or flexing members as well? Is your team communicating properly to understand what exactly are the delays? Are people getting the heads up? Are you letting the anesthesiologist know you're almost done so we can start to wean down sedation? These are things that are very important to help minimize recovery room turnover time as well. And then lastly, the recovery time. What type of sedation are you using? If you're using fentanyl and Versed, it may take a little bit longer. If you have longer procedures, that may take a little bit more sedation. These things are important when it comes to helpfully minimizing recovery time as well. Other ideas you may want to consider, consider scheduling complex procedures at the end of the day. And also it's important to identify who exactly are your most efficient individuals or teams? What makes them different? What makes them better? Use those best practices to helpfully educate other members of your team to see if you can come to an agreement about what the best things could be for your endoscopy unit. And also you want to have that culture of a hustle factor where you have very few wasted moments, you anticipate the needs, you anticipate what's going to happen, and you can disseminate those best practices to make sure that you can do the best thing for your patient and also be as efficient as possible. Then lastly, you may want to consider changing the procedure volume as well. Sometimes one endoscopist may need two rooms and that may be the most efficient way to improve your endoscopy center. You may want to consider making sure that you don't have your endoscopist do the sedation and get outside people to help out with that. If you do have to use conscious sedation, consider using fentanyl instead of miparidine for that as well. You want to find a way to reduce room recovery time and also you want to try to minimize or reduce post-procedure paperwork as well. Then lastly, let's talk about culture beliefs. This is one of the most difficult things that we can do to change our organization because culture is important and this culture can really change or affect how your staff will implement the changes that you want to do and maintain these changes you want to have as well. So there needs to be a strong emphasis on teamwork throughout the organization. A strong teamwork culture can really change and introduce new ideas and also make sure those new ideas don't have a lot of barriers to them as well. You want to have a teamwork that's adaptable and understands that you want to recognize those inefficiencies and be able to have the confidence to implement those changes to make your endoscopy unit efficient and effective as well. You really want to have flexibility among your staff members as well. Have people trained in different roles and understand that if somebody comes in sick, you may have to step in or maybe somebody needs some help, you can step in to help out with that as well. And then also having clear communication among staff members is critical. Having a daily huddle, at least for us, has been imperative to making sure we can catch these inefficiencies and do what we can to improve our endoscopy unit over and over and over again. And then leadership. Leaders change things. And this is what's important is that you need to have a leader both within the staff but also within the physicians to lead your endoscopy unit to have these changes that you need to do because you need to create these new systems or at least change the existing systems that you have. You need to examine exactly what is going on, what needs to be improved. You need to articulate the vision of how you want to improve it and then create alignment from all the shareholders within your unit to make sure we're all on the same page. And keep in mind, and I always stress this to my staff, title does not define leadership. And so anyone can see the efficiencies that are occurring and should be encouraged to make those changes from all the way down, from any staff member, any physician leader or nursing or anybody else, anything that's seen to be efficient, they should be encouraged to make the change as well. And I've always stressed this and I've seen this that leaders are defined by who can take the initiative and make the change that are needed to hopefully make your endoscopy unit safe and efficient. So some of the take-homes, you really want to have clear measurable definition of efficiency that are agreed upon from the very beginning so that we're all on the same page. Operational systems outside of the endoscopy procedures are self-critical, but procedure time, once again, is not the rate-limiting steps. So don't make your procedure time less than what it should be in the hopes of becoming more efficient. You want to streamline, optimize the workflow processes and see this over and over and over again. And you want to identify strong, innovative leaders within your endoscopy unit. And you want to develop a culture that emphasizes teamwork and change. I want to thank you guys for listening. I want to thank the ASG for allowing me to speak on today's talk.

efficiency

endoscopy unit

facility layout

staffing

electronic medical records

continuous improvement