Optimizing Endoscopy Center Efficiency Within the Safety-Net Hospital. Lukejohn W. Day MD

Transcription

1 Optimizing Endoscopy Center Efficiency Within the Safety-Net Hospital Lukejohn W. Day MD

2 Webinar Goals Introduction and rationale California Healthcare Foundation (CHCF) planning grant Comprehensive literature review Survey of California public hospital endoscopy centers Site visits of high performing endoscopy centers Future directions: Recommendations for improving efficiency in the safety-net

3 Background GI is in great demand at public hospitals Scant data on endoscopic services available

4 What is Efficiency? Efficiency is the use of resources in such a way as to maximize the production of goods and services Steps toward achieving efficiency Defining metrics Utilizing internal and external benchmarking Outlining workflow processes Objective assessment of an organization Desire to change and be innovative

5 Process for Improving Efficiency Identify area/issue for improvement Learn and study best practices Incorporate benchmarking data Study published literature Visit and partner with similar organizations Develop an improvement strategy and plan for implementation Assess effectiveness of improvement strategy

6 Efficiency in Healthcare Anesthesia is a leader in the study of healthcare efficiency Important lessons learned from the anesthesia literature Defined and accepted metrics are key Surgical procedure time is not a rate limiting step Steps preceding and following a procedure are more critical Central themes were identified for improving efficiency in anesthesia Identify process inefficiencies early and institute multidisciplinary education programs to address them Parallel processing of tasks among staff members

7 Little Known About Endoscopy Center Efficiency Few published studies to date Small, poor quality observational studies No clear consensus on methods for measuring efficiency Varying definitions of efficiency used Proposed metrics/benchmarks based on expert opinion Available benchmarking studies are limited and flawed Limited areas identified for improving efficiency Reducing procedure time does not enhance efficiency Operational flow and staffing are more important factors

8 California Public Hospital Endoscopy Center Survey

9 Survey of California Public Hospitals Assessed state of GI endoscopic services at California public hospitals Survey designed in partnership with CHCF and medical advisory board of safety-net endoscopy center directors Surveyed key aspects of endoscopy center operations Pre-procedure process Staff and facility Endoscopic services provided Quality and performance measurements Sedation Distribution of pathology results to patients

10 California Public Hospitals Surveyed Alameda County Medical Center Arrowhead Regional Medical Center Contra Costa Regional Medical Center Harbor/UCLA Medical Center Kern Medical Center LA County + USC Medical Center Natividad Medical Center Olive View/UCLA Medical Center Rancho Los Amigos National Medical Center Riverside County Regional Medical Center San Joaquin General Hospital San Mateo Medical Center San Francisco General Hospital Santa Clara Valley Medical Center UC Davis Medical Center UC Irvine Healthcare UCSD Medical Center Ventura County Medical Center Response rate of 41%

11 Pre-Procedure Endoscopy Process: Closed and Lengthy Closed access system commonly used for scheduling patients Variability in patient wait time for a procedure Ranged from days Mean days Open Access (14.3%) Closed Access (85.7%) Elevated no-show/ cancellation rates High as 33% in some centers Mean %

12 Staffing and Facility Nuts and Bolts Staffing structure varied 27% of centers employed either a LVN, NP or GI technician Mean FTE for physicians was 2.7 Mean FTE for nurses was 6.3 Physical layout Over half (57%) of endoscopy centers used a common, shared space for the pre-procedure and recovery room Mean number of patients occupying pre-procedure room = Mean number of patients occupying recovery room =

13 Common and Diverse Endoscopic Services Offered 100% Colonoscopy Upper endoscopy (EGD) Flexible sigmoidoscopy ERCP PEG tube placement 43% Video capsule endoscopy Motility/manometry ph monitoring/bravo Liver biopsy Paracentesis 14% Endoscopic ultrasound (EUS) Balloon enteroscopy

14 Who is Performing Endoscopy in the Safety-Net? Multiple providers perform endoscopy Medicine/Family practice/surgery resident = 33% Nurse practitioner = 33% Surgeon = 50% Gastroenterology fellow = 83% Education and training frequently incorporated into endoscopy

15 Broad Range of Endoscopic Volume 3 Annual number of procedures Number of endoscopy centers Colonoscopy Fleixible Sigmoidoscopy EGD ERCP Endoscopic Procedure >4000

16 Measuring Success Quality Measurements Adverse outcomes (100%) Cecal intubation (60%) Bowel preparation (40%) Withdrawal time (20%) Adenoma detection (0) Performance Measurements Procedure volume (100%) No show/cancellation (50%) Wait time for procedure (33%) Procedure duration (17%) Room turnover time (0) % of start-on time for procedures (0)

17 Sedation and Endoscopy Gastroenterologist primarily responsible for administering sedation 14.3% 71.4% 14.3% General anesthesia utilized in the vast majority of advanced endoscopic procedures (ERCP and EUS)

18 Array of Methods Used in Distributing Post-Endoscopy Results Several, simultaneous modalities used to communicate results 86% % of endoscopy centers 43%

19 Survey Limitations Small sample size with low response rate Largest public hospitals responded which represented over 50% of California s underserved patient population Our response rate is within published rates for surveys of this type (37-47%) Survey has not been validated Focused only on California public hospitals

20 Endoscopy Center Survey - Conclusions First to examine the operational systems and services of California public hospital endoscopy centers Multiple similarities shared among the largest California public hospitals Utilize closed access endoscopy for scheduling patients Involvement of trainees in performing endoscopy is common Specific endoscopic procedures such as colonoscopy, upper endoscopy, and ERCP are universally offered

21 Endoscopy Center Survey - Conclusions Advanced endoscopic procedures currently not available at most centers Heterogeneous practices in quality assurance and follow-up Assortment of quality and performance measurements documented Blend of methods used for communicating pathology results to patients

22 Endoscopy Center Site Visits: Discovered Best Practices

23 Site Visits to Endoscopy Centers Examine high volume endoscopy centers considered to be efficient and cost-effective Document best practices and policies Assess innovations and design changes that have improved efficiency at various centers Determine if there is a best model for efficiency in endoscopy Diverse group of endoscopy centers studied California public hospitals (6) High performing academic, tertiary hospitals (2) Large volume outpatient ambulatory endoscopy centers (2)

24 Common Themes Driving Efficiency Staff Facility Information Technology Internal Benchmarking Workflow Processes Cultural Beliefs

25 Staff: Defining Leaders and Continuous Education Identifiable and active leadership Identify a daily charge nurse who helps to manage flow of patients and staff as well as address ongoing issues Recognize a Physician-in-charge who works closely and collaborates with the charge nurse Identified leadership meets prior to the beginning of endoscopy each day Significant emphasis on training and education Cross-training of staff for multiple roles in the endoscopy center Providing and encouraging continuous educational opportunities

26 Staff: Responsibilities within Endoscopy Center Pre-procedure area Mix of LVN/GI assistants/nurses or nurses alone Ratio of nurse : patient ranged from 1:2 to 1:6 Procedure room Universally staffed by one physician and one nurse Ancillary staff used to assist with therapeutic aspects of standard endoscopic procedures in most cases Recovery room Less variability among staff All staffed with nurses Ratio of nurse : patient fairly consistent at 1:2 or 1:3 regardless of the size or volume of center

27 Pre-Procedure Area: Organized Set- Up and Close Proximity Pre-procedure area Positioning of patients Shared space and staff with recovery room was common Near procedure rooms Consistent ratio of procedure room : preprocedure space of 1: 2

28 Procedure Room: Standardized and Accessible Procedure room Reduce variability within it Mobile equipment Commonly used supplies maintained in room (stocked for 1-2 days) Central supply unit in hallway outside rooms Smaller endoscopy centers had PIXIS machines and endoscopes stored directly in each room

29 Functional Facility Layout Recovery room Open model used in higher volume centers whereas ambulatory centers provided individualized space Centralized nursing station was common Universal ratio of procedure room : recovery space of 1: 2 No optimum defined square footage for rooms Inversely related to the number of procedures and procedure rooms per center Seamless patient movement/flow throughout center

30 Integrated Information Technology Integrated electronic health record for each patient with prompt access to it Operate a single database to monitor and track patient flow Easily and visually accessible to the staff Strive toward a paperless, interconnected system Scheduling Endoscopy reports Patient consents Nursing and provider assessments Sedation record and vitals

31 Internal Benchmarking: Consistent and Publicized Performed consistently across all endoscopy centers Which individual metrics to measure varied extensively, but most agreed that two major areas are required Performance Quality Method of capturing information differed Electronic Paper Anecdotal systems Communicating metrics in a clear, transparent manner to staff was crucial

32 Endoscopy Center Workflow Processes: Rational and Clear Streamline referring process Debate of open vs. closed access system Utilize an electronic based system Triaging of referrals vital but heterogeneous methods used Trained schedulers at larger volume centers Empowering nursing staff to triage consultations

33 Endoscopy Center Workflow Processes: Rational and Clear Enhancing patient preparedness Nurses led this task Education and assessment key to perform before procedure day Varied from group education classes, individual one-on-one meetings or telephone call with patients Critical at improving patient adherence to multiple aspects of endoscopic procedure

34 Endoscopy Center Workflow Processes: Rational and Clear Flexibility and adaptability of endoscopists in performing procedures Assortment of endoscopist models utilized Reducing procedure room turnover Parallel processing approach with defined staff roles Communication of when the procedure was completed is necessary Standardized process for following up and communicating findings to patients and providers

35 Cultural Beliefs Core to an Efficient Endoscopy Center Strong emphasis on teamwork Adaptability of the organization to recognize inefficiencies and implement change Flexibility among staff members Clear and daily communication among all staff

36 Endoscopy Center Site Visits - Conclusions Tremendous diversity existed No single model emerged as the most efficient Several endoscopy center models exist that are successful and efficient Goals of the organization Organizational setting (academic vs. private vs. public) Endoscopic services provided (advanced vs. standard) Number of endoscopy centers (single vs. multiple) Patient population served

37 Endoscopy Center Site Visits - Conclusions Essential and consistent values discovered that enhance productivity and efficiency Identify daily leaders Continued broad staff education Reduce variability within the center Integrated electronic health record Measured and transparent benchmarking Clear and balanced workflow processes Strong emphasis on teamwork Ability to identify inefficiencies and implement change

38 Recommendations for Improving Efficiency in the Safety-Net

39 Key Elements to Improving Endoscopy Center Efficiency Clear and measurable definition of efficiency agreed upon from the beginning Identify strong and innovative leaders with a culture that emphasizes teamwork and change Operational systems outside of the endoscopic procedure itself are critical targets for improvement Procedure time is not a rate limiting step Steps immediately prior to and after procedure need to be areas of focus

40 Key Elements to Improving Endoscopy Center Efficiency Recognize that health IT is integral and leveraging it for success Streamline workflow processes Parallel processing of patients at various steps prior to and after endoscopy Flexibility of staff to perform multiple tasks Clear and accessible documentation of staff roles and responsibilities Apply lessons learned from similar organizations and be willing to share information

41 Thank you to.. California Healthcare Foundation (CHCF) David O Neill Endoscopy center efficiency project medical advisory board Hal Yee John Inadomi Taft Bhuket Loren Laine Thomas Savides Stan Rockman California Association of Public Hospitals (CAPH) California Healthcare Safety Net Institute (SNI) Medical directors and staff of endoscopy centers from site visits Participating hospitals in the California endoscopy center survey 41