Enhancing Efficiency in the Endo Suite

Multiple factors have intensified the demand for gastrointestinal endoscopy services. Two factors acknowledged are the importance of colonoscopy as a colorectal cancer avoidance and screening tool and an ongoing decline in reimbursement for services.^1,2 This leads to a compelling need for enhancing the efficiency for the maximal delivery of endoscopic services in existing and new endoscopy units.

There are some excellent studies demonstrating for us opportunities to improve efficiency; creating time in our schedules for performing additional procedures. Young, Zenkova, et al. have shown us as Walk Kelly, writer of Pogo, originally wrote, “we have met the enemy and he is us (sic).” In their prospective study of delays in an endoscopy unit, the most common reason for a delay of fifteen minutes or more was physician related (70.5%). Patient-related issues were responsible for 24.4% of delays. Equipment issues were responsible for 8% of delays, and nursing-related delays only accounted for 0.5% of the delays. Approximately 22% of the procedures in this teaching hospital GI endoscopy unit were prolonged. The most common cause of prolonged duration of an EGD was teaching, and for colonoscopy, the most common cause of a prolonged procedure was technical difficulty (difficulty negotiating the colon to the cecum, poor prep and therapeutic intervention).³

Performing some simple math reveals the importance of avoiding delays and improving efficiency in the endoscopy unit. In an endoscoy unit with 14 procedure slots in the schedule for each room, and five-minute delay per case translates into over an hour delay each day. Avoiding delays would allow for one or two more cases a day; an additional 200-400 procedures per room per year.

In our quest for efficiency, we must remain focused on the quality of our work. Overholt makes note of this with the term Efficient Quality Care.⁴ Cohen, in an excellent editorial, cautions us against concentrating on quantity without remaining focused on quality.⁵

Making use of some established benchmarks for financial measures and quality indicators can provide us with the guidance to establish the best balance of efficiency and quality. There are several commercial resources for financial and volume benchmarks, as well as the American Society for Gastrointestinal Endoscopy’s Endoscopic Operations Survey.⁶

Some current targets for each GI endoscopy room include a procedures-per-room-per-day mean of 10.4 to a maximum of 31.1 according to the Endoscopic Operations Survey. Of course, this depends on other factors, including hours of operation. In our practice’s experience, having 14 thirty-minute procedure slots per day, an office-based endoscopy unite can achieve 3,500 cases per room per year.

Expense and revenue vary significantly among hospitals, ambulatory endoscopy centers and office-based endoscopy centers. The Endoscopic Operations Survey, based predominantly on ambulatory endoscopy centers, shows a mean expense per procedure of $325.00 and a mean revenue per procedure of $583.00.

The ACG and ASGE have formed an Internet-based registry organization, the Gastroenterology Quality Improvement Consortium, to assist GI endoscopists in improving and benchmarking endoscopy quality with no more effort than they already expend in preparing the patient’s endoscopy report. In addition to helping us achieve our goal of providing the patient with the highest quality and safest procedures, it seems more and more apparent that the level of our reimbursement will be tied to our ability to demonstrate the quality of our work.^7,8

To address the issue of physician-related delay, the most common delay in GI endoscopic units, physicians need to arrive on time. After arrival, the physician focus must be on the schedule only. I have learned the hard way that receiving phone calls and managing other activities cannot take place during the day’s endoscopy schedule. As noted above, five minutes of non-endoscopy-related time per procedure turns into a major delay by the end of the day .Practices have used various tactics to manage physician compliance with delays. One practice has reported that monetary fines after counseling failed to make a difference, as did the loss of a scheduling block. Ultimately, the imposition of a loss of vacation time made a difference for offending physicians. Following the philosophy that not everyone is able to work at the same pace and perform quality endoscopy, being flexible within each scheduling block is important. In my situation, our endoscopy unit typically schedules all patients slots at 30-minute intervals including patients who undergo both a colonsocopy and EGD. I find that scheduling one less procedure each day and placing a fifteen-minute catch-up slot in the morning and afternoon block allows me to be more relaxed during the day and able to focus on the quality, as well as the completion of each procedure.

It is important to make use of as many blocks as possible. A policy in our unit has been developed to not leave a block unused when one or our six physicians is on vacation. We will leave an office block open and fill the endoscopy unit block with a covering physician. The revenue-per-expense ratio in the unit versus the clinical visit mandates this.

To avoid delays for equipment, an adequate supply of equipment is important. Current suggestions generally recommend two upper endoscopes and two or three colonoscopies per room. In addition to this recommendation, our unit keeps a backup gatsroscope and colonoscope on premises in the event of a cope being taken out of service for repair in the course of a day. Units will want to have adequate disinfectant and washing space and equipment to keep the scopes in use during the day.

Staffing requirements vary according to state and accrediting body requirements. In our AAAHC-accredited office endoscopy unit, we have one LPN or RN and one endoscopy technician per endoscopy room. There is one RN per room to prep and recover for that room. This works very well for flow through our unit.

Current recommendations suggest 3-4 prep-recovery rooms per endoscopy room. We use only moderate sedation in our unit and find that three prep-recovery rooms per procedure room works quite well. I don’t remember a delay due to the non-availability of a room for patient preparation.

Some units find themselves locked in by their space. These are typically older unites designed at a time when fewer procedures were being performed. They may have only two or less prep-recovery rooms per endoscopy room. These units may find that despite the fact that the multi-society position is against the routine use of propofol sedation by anesthesiologists for standard endoscopy, doing so may allow for the necessary volume in their unit due to the shorter recovery time with this form of sedation.⁹

Activity that occurs before the patient checks in for endoscopy is also important in terms of achieving an efficient and high-quality endoscopic procedure. At the time of an office visit or the scheduling of an open-access procedure, it is important to be thorough and clear with patients to ensure the greatest likelihood of the patient arriving for their procedure and doing so on time, and in the case of a colonoscopy, the best possible prep.

In summary, it is important that gastroenterologists must work efficiently in the face of reduction in professional fees, as well as for those with physician-owned or partnered AECs, declining CMS facilities payment. It must be kept in mind while seeking the greatest efficiency that there will be a delicate balancing act to do this while maintaining the highest level of quality.

Source: American College of Gastroenterology 2010 Annual Scientific Meeting Breakfast Sessions handout.

Refernces

1. Yong E, Zenkoma O, Saibil F, et al. Efficiency of an Endoscopy Suite in a Teaching hospital: Delays, Prolonged Procedures, and Hospital Waiting Times. Gastrointest Endosc 2006;64,No.5,760-4.
2. Cohen LB. Production Pressure in Endoscopy: Balancing Quantity and Quality. Gastroenterology 2008;1842-1844.
3. Yong E, Zenkoma O, Saibil F, et al. Efficiency of an Endoscopy Suite in a Teaching hospital: Delays, Prolonged Procedures, and Hospital Waiting Times. Gastrointest Endosc 2006;64,No.5,760-4.
4. Overholt BF. Ambulatory Endoscopy Centers: Efficiencies and Additional Revenue Streams. The Ambulatory Endoscopy Primer. ASGE. 3^rd editon. Chapter 21:121-7.
5. Cohen LB. Production Pressure in Endoscopy: Balancing Quantity and Quality. Gastroenterology 2008;1842-1844.
6. Chapman F. American Society for Gastrointestinal Endoscopy 2009 Endoscopic Operations Survey Data Book. Participant Edition.
7. Pike I, Vicari J. Incorporating Quality Measuresement and Improvement into a Gastroenterology Practice. Am J Gastroenterol 2010;105:252-4.
8. Hewett GH, Rex DK. Improving Quality through Health-care Reform. Am J Gastroenterol 2010;Jun 15 (Epub ahead of print).
9. Sipe BW, Rex DK, Dolk A. Propofol Versus Midazolam/Meperidine for Outpatient Colonoscopy: Administration by Nurses Supervised by Endoscopists. Gastrointest Endosc 2002;56:815-25.