Before we move into our next roundtable discussion, I'm going to present on improving efficiency in the endoscopy unit. Let's start with a few polling questions. First question is, is there someone in your endoscopy unit working on improving efficiency? Excellent, so about three quarters of you have someone in that role and about a quarter do not. Next question. Procedural delays are most commonly related to patient factors, physician factors, nurse factors, or equipment. And we'll find the answer to this in the upcoming lecture. So what do you guys think now? Okay, the majority of you think it's physician factors, a quarter patient factors, and then 4% nurse factors. All right, so look for that in the upcoming lecture. And then our final question, reducing which of the following has not been shown to improve efficiency in the endoscopy unit? Important turnover time, recovery time, or procedure time? Excellent, so we're sort of split here too. All right, perfect. Well, that's a good segue into our next lecture on efficiency. Thank you everyone for being here. So for this next 20 or so minutes, I'm going to talk about improving efficiency in the endoscopy unit. I think this is a great topic and something that's applicable to all of us, no matter what setting we practice in. So what is efficiency? It's really important that we define this. It helps us frame the conversation, and it's hard for people to work towards being more efficient if they don't know exactly what we're striving towards, what we want to achieve. So efficiency is a use of available resources in such a way as to maximize the production of goods and services. And when we say available resources, it means things we already have. We're not going out and buying new endoscopy centers, even though that would be nice. And here, we're trying to maximize or improve the overall health care of our patients and of our communities. So what does the data tell us about efficiency? Unfortunately, there's not a lot of literature on efficiency within endoscopy, and most of the available research has a number of limitations. The limitations include that most of the studies are qualitative or descriptive in nature. Most of the studies only focus on one endoscopic procedure, and the majority of studies just look at improving physician efficiency, even though we know there's a lot of elements that go into this. There are a few important pearls from the current research that I think we should all focus on. One of these is that reducing procedure time does not enhance efficiency. If anything, this comes at a cost to quality and to safety. And the more important thing is to look at improving your operational flow and staffing, and we'll talk about those in the next couple of slides. This is the framework for how we're going to think about improving efficiency within endoscopy units and the framework that we're going to use to sort of guide our conversation today. At the top of the pyramid is the goal or the who. We want to improve efficiency so that we can ultimately improve the care of our patients and of our community. Below this is the what. What are the elements or pillars necessary to achieve this goal of efficiency? And there are four essential elements we're going to cover today. These are facility, staff, information technology, and metrics. And then at the bottom of the pyramid is the how. How are we going to sustain these changes over time? And this is really our workflow processes and the cultural beliefs of our organizations. We're going to drill down into each of these four key pillars of efficiency, starting with facility. 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 you should focus on. Your pre-procedure rooms, your procedure rooms, and your recovery rooms. In the pre-procedure rooms, it's important to assess how your patients are positioned. Are they in private bays or grouped together? Are they in chairs or laying in gurneys? There really isn't a right or a 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 it 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 area and your recovery rooms. This makes it much easier to flex patients and staff and beds throughout the day based on patient volume. Although there isn't any outcomes data, most experts agree that you should have about two pre-procedure rooms for every one procedure room. This ratio may need to be lower depending on the complexity of the procedures you are doing in your unit. All your procedure rooms should be standardized. Stock all the equipment and drawers in the same way so that your staff don't waste time looking for things. This will also allow 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 aren't running out of the room to get things. We assign someone the task of stocking the rooms at the end of the day to ensure we don't run out of supplies and that all the equipment is put in the correct place. Mobile equipment can also help with improving flow within the endoscopy unit. For example, our EOS machines can be wheeled into any of the rooms for use. If equipment is stationary, then only certain rooms can be used for specific types of procedures. Finally, for the recovery room, you also want to think about optimizing patient positioning based on your physical space. If you could have a centralized open nursing station, this will help you flex staff between the pre-procedure rooms based on volume and flow. And finally, the recovery room tends to be the bottleneck for most units, and therefore the recommended ratio of recovery rooms to procedure rooms is a bit higher, at 2.5 to 1. Alright, we're now going to drill down into this second component of staffing. Staffing is really critical to efficiency. Too many staff is costly and too few can hurt your efficiency. So there are multiple factors that affect the staffing that you may choose. You need to know your state and local regulations. These will dictate what staffing is required. You also need to know the types of anesthesia services and types of endoscopic procedures you're doing at your unit. These will greatly impact how many staff you need and how you best want to distribute them. There are also some guidelines that I recommend you check out. There's some from the ASGE, the SG&A, the ARN. These can be very helpful. There's some similarities between them, also some differences. And there are some guidelines around how many staff members per room that you can take a look at. When moderate sedation is being used, you need at least one RN per procedure room. And a lot of the guidelines and most experts agree that having one additional dedicated staff room to help the physician with interventions is very helpful. You may also want to consider having endoscope technicians come in to help with room turnover. So for us, the endoscope technicians come in, they take out the dirty scope, they bring them back to get them cleaned, and they also deliver clean scopes. And this can really help with the flow in our rooms. And then finally, having a floater or free agent or what's called a circulator can also be extremely helpful. This is one person who's basically dedicated to keep things running smoothly for that day. They can work out any issues, any equipment that's not where it needs to be, any patient-related issues in the pre-opping area, et cetera, et cetera. But they're really responsible and a go-to person for making sure everything is running smoothly and efficiently on a day-to-day basis. Next, we're going to talk about information technology. So IT can be stressful and it can be expensive, but it really can be leveraged to make us more successful and more efficient. Ideally, and I know it's easier said than done, but 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 processes and 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 that can help us track some of the metrics we're going to talk about later. And finally, of course, we should all strive towards a paperless interconnected system. Things to consider are leveraging the EMR to pre-populate nursing and provider assessments. You should consider electronic consents so you don't have to print these out or go looking for them. And there are many systems that can download the vitals before, during, and after the procedure into the EMR so that they don't have to be manually entered. And then finally, electronic endoscopy reports help you standardize what's entered and allows you to search these reports more easily in the future if you're looking to do some quality assessments. All right, moving on to metrics. So if we want to improve quality, then we need to measure it, and that's really where these metrics come in. What should you measure? We can think about this in three buckets, structure, process, and outcome. Let's start with structural measures. These are things that you probably already know and can think of off the top of your head. 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 types of sedation you are given, and what IT infrastructure you have. Because these things don't change that much over time, they can be measured less frequently, about every six to 12 months. Process measures tell us how well our system performs. 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 pretty overwhelming since there are so many aspects to consider. So for that reason, I've started first case on time start and room turnover time. Improvements in both of these things have been shown to lead to enhanced efficiency. I recommend you pick one or both of these to start with. Define them for your organization, decide how you're going to track them, decide how you're going to share the data back with your team, and then decide how you're going to make improvements based on your findings. I really want to highlight that most units and experts are defining room turnover time as wheels out to wheels in, meaning the last patient out of the room to the time to the next patient is brought into the room. However, some places are also doing scope out to scope in. I really bring this up to stress how important it is that you clearly define for your unit what these times means. In high performing centers, room turnover time is about 10 to 12 minutes, but can range from 5 to 25 minutes. This time is typically quite a bit longer for centers performing advanced procedures where general anesthesia is used. And I also want to mention, again, that interventions focused on reducing procedure time have not been shown to improve efficiency and can even lead to reduced quality and safety. So basically, the punch line is that you can measure it, but trying to improve it is not going to lead to efficiency within your unit. And in terms of outcomes, these are our 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 to the procedure room, et cetera, flow time, throughput or volume, resource utilization, overtime, and cost. Measuring waiting time can be a good place to start for these outcome measures since it is typically a bit easier to calculate than some of the other outcomes and because long wait times also lead to poor patient satisfaction. Let's shift gears now and move to the bottom of the pyramid to discuss how we are going to sustain some of the changes we want to make within our units. Let's start with workflow processes. Understanding patient flow or movement through the endoscopy unit is critical to understanding the associated workflow processes. Ideally, patients get registered, they go to the waiting room, followed by the pre-procedure room, to the procedure room, to the recovery room, and get discharged in a linear and efficient manner. So this looks a little bit more realistic for all of us. This was published in 2014 by Dr. Day. It's a great paper in GIE I encourage all of you to take a look at. And this is a flow diagram of Dr. Day's unit. And what we see here is that things are much more involved in the linear process than the previous slide. You can tell there are different ways patients can move within the endoscopy unit. And really what I encourage all of you to do is spend some time simply observing and recording the flow within your own endoscopy unit. This diagram took many years to create and to map out all the processes. So I'd recommend, since this is very overwhelming, that each of you start with only a single process in your unit. Perhaps starting with room turnover time is a good place to start. You can write down the steps, the times, and then go back to your team and discuss how you can improve this single process. And then once you get a hang of that, you can start doing a more deep dive. One of the ways to improve workflow processes is to understand what causes procedural delays. And it's really been shown that if you can reduce three procedural delays per day, this can lead to a cost savings of one full-time employee per year. So that's huge and shows us that this is important. So this figure you see here is from a study done in Canada at a tertiary care hospital. They found procedural delays were quite common. And most of the time, around 71% of the time, they were physician-related, 90% of the time they were patient-related, 4% of the time they were due to equipment, and then nurses accounted for less than 0.5% in this study. Let's take a deeper look at patient and physician factors that we could change in order to reduce delays. So starting with patient factors, you want to make sure your patients are receiving clear instructions and expectations. Think about how long or how many pages your instructions are. Are they clear? What languages are you giving them in? Is the language simple? Can it be easily understood by patients with different backgrounds and from just 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 done by our endo-nurses at the end of their shift. So the late nurse every day does this, and we find that they can reach most patients when calling after 5 p.m. We call about one week before the appointment so that we can put someone else into the patient's slot if they need to reschedule. And then nurses go through a standard script with every patient, and these calls typically take about two to three minutes. Some institutions use 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. And our nurses really go over the things that you see listed below, the prep, when to stop eating, medications. A big one is anticoagulation. We were having a lot of issues where people would come and they hadn't stopped their anticoagulation despite receiving written instructions, and then they discuss that the patients need a ride home. It's also important that you make sure you give excellent directions to the facility. Where should patients park? This can help with making sure patients show up on time. And then anticipate and account for language barriers. Make sure you have translator phones or videos or in-person translator services for those patients that need it. Make sure that you have wheelchairs for patients that have mobility issues. And of course, you want an efficient check-in process, whether that is physical staff checking patients in or whether it's done electronically by a kiosk or an app. All right, so now we're going to move to physician factors. Like I mentioned, physicians are the source of the majority of delays, likely for two main reasons. This is because physicians tend to multitask, performing many other tasks that are not necessarily essential to endoscopy or what's being done that day. Oftentimes, we're charting from the clinic the day before, returning phone calls. This is not uncommon, and it's not because they're goofing off, but because there's a lot of other stuff going on. But this can definitely delay things. Another cause is that physicians can exceed scheduled procedure times. This is less common, but also a possibility. So how do you deal with this? It's very important that you track this data to understand what's going on. Share this data with the physician. It's really important to say, hey, you always run X minutes behind. That is much more concrete than saying, you know, we've noticed that you're running behind. You need to give objective data in order to ask for improvements. Expectations should be clear and explained to all of your providers. For example, when you say a first case is at 7.30, what is the expectation? Does the physician show up at 7.30? Does the scope in go at 7.30? Should the patient be consented by 7.30? All of this, of course, needs to be clear. Let's now look at some other opportunities for improving efficiency by streamlining this endoscopy workflow process that I had shown earlier. So in the pre-procedure area, some ways to sort of streamline these things is to obtain informed consent prior to the patient getting there. So, for example, if this patient was seen in clinic, the patient could be consented then. Can other staff members help if they have not been seen in clinic and they come to the endoscopy center? Can a nurse practitioner or PA help with obtaining the consent? In some centers, nurses obtain the consent, even though the physician comes out and sees the patient, but the nurses actually get the signatures. Consider having dedicated staff performing IV access. That means your experts who are more efficient, quicker at getting the IVs, get them in. And it frees up other staff members to ask the questions with the check-in process. In terms of sedation time, propofol is very efficient. And for conscious sedation, fentanyl and midazolam is much more efficient than miparidine. So your choice of drugs here makes a difference to the sedation time. In terms of room turnover time, this is critical, and this can greatly improve efficiency if you can make sure you're doing things well here. Reducing procedural delays is important and can be done using some of the interventions we talked about on the previous slide. Parallel processing is also critical. One staff member should not be doing everything, moving from step A to step B to step B. Have one staff member do step A while another staff member does B and C. So, for example, if your nurse takes out the patient, have another nurse or tech come into the room, clean up the room, set up the new scope, so that the nurse that initially left with your previous patient can be grabbing the next patient and bringing them in. The alternative is that you have one nurse who leaves with the first patient, then she has to come back to the room, clean up, hang a new scope, leave again, go get the next patient. So that is not parallel processing. You really want people and your staff members working in parallel. And there needs to be great communication. People should not be working on the same thing. Make sure your staff communicates well with each other so that you can maximize efficiency. I think another way that communication can be used is if your providers can give anesthesia and the nurses in the room a heads up that they're likely to finish the case in the next two, three, four minutes, that anesthesiologists can start cranking down on the anesthesia. Your nurses can start getting the room ready for turnover. And then finally, in terms of recovery time, again, the sedation has a huge effect on how long your patients are going to be recovering for. This is a major source of bottleneck endoscopy. It's typically, like I'm saying, due to the sedation you use. So propofol and fentanyl and midazolam typically get your patients out of the recovery room faster. Finally, a few other ideas for workflow processes include scheduling a complex case at the end of the day. If you get the simpler cases done, these typically run on schedule. You don't have to worry about a complex case putting everything behind. And then really identify your most efficient individuals or teams and trying to figure out what makes them tick. This can be super helpful. What's different about them? What hustle factor do they have? Typically, you'll find that these teams, nurses or techs have few wasted movements. They anticipate actions. So, for example, you're doing a colonoscopy. You see a small polyp. These experienced individuals generally will already be pulling out a snare and they can anticipate what you're going to ask for before you do. And this can greatly improve your efficiency. Once you've identified who these people are in your practice, have less efficient members of the team observe them. Have these great members of your team disseminate best practices or even consider having them train the new members in your department so that the new members can learn from the best. Ultimately, the goal of streamlining the workflow processes that we've talked about in the last couple of slides is in order to increase our procedure volumes without impacting quality in a negative manner. So a couple other things that I want to mention to improve procedure volume. Things that you might want to consider are one endoscopist per two procedure rooms. If you have the space, consider not having the endoscopist perform sedation. Like we mentioned, use fentanyl instead of parodine for moderate sedation. Reduce room turnover time. Like I keep mentioning, this has been shown time and time again to really improve efficiency. And then try and find ways to minimize post-procedure paperwork and leverage your EMR to fill out as much as you can automatically. Finally, let's talk about cultural beliefs. This can really be one of the most difficult things to change within your organization, but it is very, very important. The culture among your staff is invaluable at identifying inefficiencies, implementing new ideas, and sustaining them. So this is a very important thing to focus on. 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 particularly important because you want team members who can work throughout the endoscopy unit. Having staff members who only work in the pre-op area or only work in the endoscopy rooms leads to less flexibility and adaptability. And as a corollary, you also want to encourage and promote everyone working at the top of their license or capability. And finally, clear and frequent communication to staff about expectations is key to achieving an efficient unit. Daily team huddles are successful in many units and are one way to ensure frequent feedback, and they can serve as a time to anticipate challenges of the day, discuss changes that are being made, and work as problem-solving sessions. And lastly, efficient endoscopy units will have strong leadership. Good leaders will create new systems or change the existing systems. They will examine our current system. They will recognize what needs to be improved. They'll articulate a vision where we want to go as an institution and create alignment for our staff. Title does not define leadership. I really want to stress that. Within your division, you do not need to be the head of the division, the head of the department. Anyone who has an interest and dedication to this process can be a leader at efficiency and at making the changes that all of our organizations need. So let's go over some take-home points. You want to have clear and measurable definitions of what efficiency is within your unit so that everyone knows what you're striving towards. You should focus on issues beyond the length of the procedure itself when looking for targets for improvement. We need to streamline and optimize workflow processes. So, again, I encourage you to pick one or two things from the different slides we talked about and strive to work on those first so that this isn't overwhelming. And, of course, like we just talked about, it takes strong and innovative leaders who support a culture that emphasizes teamwork and supports change. So try to identify who those people are within your organizations. Thank you very much.

efficiency

endoscopy unit

procedural delays

physician factors

facility optimization

staffing considerations