I'm going to give a talk on improving efficiency in the endoscopy unit. These are my disclosures. This is a common definition of efficiency in endoscopy, or just a common definition of efficiency. Essentially, you know, the use of available resources as a way of maximizing productivity, you know, it doesn't have my little adaptations here, but essentially what I had written here that within endoscopy, you know, the way I think about efficiency is being able to provide high quality procedures to our communities. So unfortunately, there's not a lot of evidence with respect to improving efficiency. A lot of it's qualitative and, you know, it's predominantly focused on physician efficiency, you know, but I suspect it's not in here. Oh, it is. Perfect. One pearl, I sort of, when I was reviewing my slides, I realized that, but, you know, it's important to realize that, you know, reducing procedure time doesn't automatically equal enhanced efficiency. And dare I say, I think reducing procedure time can be antagonistic to quality, you know, for instance, like withdrawal time or the time you spent evaluating during an operant endoscopy. Whereas, you know, the real two big features that potentially can enhance efficiency are operational flow and staffing. So, you know, this is a table by Dr. Day, who's really pioneered a lot of this efficiency literature. You know, at the top of the pyramid, we're really looking at the goal, which again is improving efficiency or providing those high quality procedures to our patients. You know, some of the variables that go into controlling efficiency or have factors of efficiency are things like facility staff, IT and metrics. And then how do we go about actually improving efficiency? You know, this goes into workflow and, you know, cultural breaks within the endoscopy unit. So, we're going to focus on facility variable first. You know, I think layout is a challenging one. We're actually in the process of creating a new hospital. So, it's sort of exciting to sort of think about this, you know, but, you know, things that you want to think about, especially if you have the ability to maneuver and manipulate the layout of your endoscopy unit, is the proximity between certain areas, essentially trying to mitigate, you know, long transit times. So, for instance, you know, are your period procedural bays close to your endoscopy suite? On top of that, you know, for when you're thinking about the number of bays that you need for pre-procedure, you know, that's important as well, because you want to make sure that you have good flow into your endoscopy suite. And you may need to tailor that depending on the complexity of procedures that you're doing, potentially needing more if you're doing more advanced endoscopy procedures. I think this is critical, you know, room standardization. I'm sure everyone has been, whether, you know, you're a nurse tech, endoscopist, been in that situation where you want to find a tool and you just can't find it. And then you search around the room and then, you know, you maybe grab another nurse and you leave the room and you try to find it. And then you've got to modify your procedure, maybe because you've got to use a different type of tool. And that is for surely minutes of time that you could have had back, you know, with maybe standardization of the room design, making sure every room in the hospital unit as best as possible has the same layout and ensuring there's appropriate stocking. On top of that, you know, mobile equipment can be valuable, specifically, like for instance, if you're going into the OR or endoscopic ultrasound is a great example. If you're manipulating EOS through therapeutic and like an ERCP suite versus alternatively more diagnostic procedures, you know, similar to pre-procedure recovery is critical. You know, having enough space to recover patients, because this is commonly the bottleneck, you know, for instance, in my own endoscopy unit, because in Canada, we have these large provinces with a lot of dispersed populations, getting people to fly down for their procedure is not uncommon. And so recovery can be a challenge when these patients are remaining, waiting for this sort of air ambulance to take them back. And so having that sort of design in place can really improve efficiency. And then again, along the same lines, you know, being organized with respect to stock and having appropriate equipment for the appropriate procedures. So you know, next up, staffing. Now a lot of this, I think, has some state and local regulations. The ASG does have guidelines on this, and this is somewhat affected by, for instance, the type of anesthesia that you're going to be using, whether that be, you know, conscious sedation with midazolam and fentanyl, balanced sedations where you're incorporating propofol or potentially general anesthesia. And then also, again, the type of procedures that you're doing, but not uncommonly, you know, one to two or more nurses are needed per room. You know, staff volume clearly has an effect on efficient turnaround, but it's also important to mitigate burnout. You know, if people are not able to come to work, that's naturally going to affect flow through the unit. You know, having dedicated endoscopic technicians can really affect things as well. And I think having a floater can be great. You know, for instance, let's say someone's feeling unwell and there's a gap in the room, or let's say a room specifically delayed, you know, having that floatel out that room in any aspect of patient flow can hopefully get them back up to speed. So going into the IT aspects of efficiency, you know, although I'd be, I'd be curious to know, and people can just put it in the chat, if there are units that have different EHR or EMRs used by different physicians within the hospital setting, but, you know, but ideally you have everyone on the same electronic medical record, because again, that can just facilitate flow through the workday. And also on top of that, it allows you to actually appraise things. So for instance, to tracking efficiency, so you can look at ways of improving it. You know, Sonali is probably our sustainability champion here, but, you know, moving towards paperless endoscopy can also be really effective as well. The only caveat I say to that is because I have been in a situation where the electronic medical record has sort of gone down. It's good to make sure that you have a backup in that situation if you're moving to paperless. So now going into metrics, you know, there's multiple different things that we can look at when it comes to measuring aspects of efficiency within the endoscopy unit. Some things that are readily available and aren't really going to be sort of changing day after day are things like the unit layout, you know, number of staff members, the type of sedation you're providing in the procedures. When you get into the procedural aspects, there are many variables, and some of these can actually be a little bit challenging, especially if you're not, you know, currently evaluating these things. But things that you may be able to start with are things like first case start time, and on top of that, room turnover time. But now when looking at room turnover time, it can be important to sort of define that, especially from an academic perspective. So for instance, is it scope out, scope in, or is it bed out, bed in? Just so that's comparable, I personally like to try to capture as many variables as I can. So for me, I'd like to look at sort of, you know, when the scope is taken out of the patient and when this next scope is ready, because it just gives you more steps within that sort of efficiency process or turnover time. And then sort of the end game variables would be things like, you know, volume throughput, resource utilization, and overall cost of the endoscopy unit. So getting into workflow. Oh, I think this is an old slide version, but that's okay. Essentially, this is a, you know, this is a good example of patient flow. So, you know, patient is registered, you know, patient goes into the waiting room, goes into the pre-procedural room, procedural room recovery, and then ultimately the patient is discharged. And, you know, this is a very detailed example done by Dr. Day, but I think it highlights the fact that this is complex. You know, there's so many things that go into, and Kelly sort of highlighted the patient experience and also obviously staff experience in the workflow or efficiency process. And being mindful of all these steps allows you to sort of target these things. While going back though to maybe more of a simplistic model, you can see that these are some opportunities that we can actually really improve efficiency. So for instance, having informed consent prior to the patient coming into the endoscopy unit can definitely be an opportunity to facilitate efficiency. I work in like a downtown hospital, and so we have a large marginalized population, specifically the homeless. And so, you know, having a dedicated team to work on IV access is like critical in our endoscopy units. So again, you know, like for instance, the type of sedation that you're providing can definitely facilitate efficiency. In my own unit, we commonly use conscious sedation for the majority of our, you know, diagnostic procedures. But as we're getting into more complex procedures, we use balanced sedation. And then for high-risk procedures, normally we have anesthesia involved, like upper GI tract, EST, GJs, that sort of stuff. You know, with respect to room turnover, you know, it's really important to delineate the different roles that are needed when you're turning the room over, just so it's very clear about what people are doing for each sort of aspect of the turnover process. And then for recovery, again, speaking back to this, it's an old slide, but sort of thinking about, especially if you have a lot of people flying into your unit, or ultimately transfers from different hospitals, how are you going to manage that transfer process? Is that going to eat a lot up about your post-recovery phase? So lastly, you know, when you're getting into cultural beliefs, and again, Kelly, I think it's spoken to this lovely, is that, you know, endoscopy is a team thing. You know, I mean, I think it's probably the thing I enjoy the most about endoscopy is it's very much like this unique family environment. And I don't know if there's a lot of other specialties that have that sort of experience. And so having a team-based approach on improving efficiency is critical. For example, as an endoscopist, you know, between cases, I love to sit there and work on my computer, but it's important for me to help out in this process as well, whether that means, you know, taking the patient out into recovery, willing to pay in, you know, putting on ECG leads or helping, you know, set up their O2 sats, these can all be ways in which means the endoscopist can help efficiency as well. You know, I think it is important for people to be adaptable, you know, for instance, you know, from a nursing perspective, having people having different skill sets so they can slot into different positions, I think is imperative. However, on the flip side, I think it's also great to also have sort of champions in certain area who sort of become references for content knowledge expertise. For instance, in my unit, I sort of strive to have people who are experts in pancreatobiliary endoscopy, you know, third space, bariatrics, general endoscopy, IBD, and, you know, for instance, chromoendoscopy, just so that you have that reference point within your endoscopy unit. And then lastly, you know, having very clear communication. And so from an overall standpoint, we essentially have, you know, our our management, nurse leader, overall manager, but we also have representation from a physician's perspective and a nursing perspective. And it just gives an opportunity to sort of reflect on things, things that are going well, things that are not going well, and so we can hopefully address them. And so that is my talk on efficiency.

endoscopy efficiency

resource optimization

workflow optimization

IT integration

team-based approach