Formation of a multi-discipline advanced endoscopy inpatient team
1. Formation of a multi-discipline
advanced endoscopy inpatient team
to decrease bottlenecks in patient
flow in a limited unit work space
Jason Sims BSN,RN
Henry Ford Hospital
Detroit, MI
2. Objectives
• Present tools and methods to identify
bottlenecks in patient flow in a hospital based
gastroenterology unit that performs
interventional endoscopy
• Identify common causes of bottlenecks and
the importance of increasing efficiency
• Ideas for process improvement
• Review currently recommended building
designs for optimal patient flow
3. Our Story Begins…
• Inpatient procedures performed in the same
center as ambulatory procedures can have
significant impact on resources and workflow
• CMS has gone from a 90% acceptance rate of
RCU fee schedule recommendations to 76% as
of 2014 which lead to significant additional
cuts to reimbursement
Kaushal, N et al 2014
Mehta,S and Brill,J 8/1/2014
4. Wait there is more!
In 2014, U.S. health care spending increased 5.3 percent
following growth of 2.9 percent in 2013 to reach $3.0
trillion, or $9,523 per person. The faster growth
experienced in 2014 was primarily due to the major
coverage expansions under the Affordable Care Act,
particularly for Medicaid and private health insurance.
The share of the economy devoted to health care
spending was 17.5 percent, up from 17.3 percent in 2013.
Centers for Medicare & Medicaid Services National Health Expenditure Sheet 2014
https://www.cms.gov/Research-Statistics-Data-and-
Systems/Statistics-Trends-and-Reports
7. What is a “bottleneck”?
• A phenomenon where the performance or
capacity of an entire system is limited by a
single or small number of components or
resources (Wikipedia)
8. Limiting Factors for Advanced
Interventional Services
• Increasing demand for services
• Complexity of services such as ERCP,EUS and
EMR
• Limitation of space to accommodate increased
need for services
• Poor utilization of staff resources
• Unpredictable procedure times related to the
complex nature of the cases
13. What is the hold up?
– Unstable co-morbidities
• Renal insufficiency
• Decreased cardiac output
• Impaired respiratory systems
– Altered anatomy
• Prior surgery
• J shaped stomachs
• Tumor growth
– Additional interventions needed:
• Biopsies
• Dilating
• Brushings
• FNA
• Tardiness
– Patients or staff
• Hospital wide transport for inpatients
• Too many cases and not enough
rooms
• Not enough time is allotted
– ERCP and EUS should be 75-80 min w/
turnover time
– What about time for intubation and
extubation?
Peterson,B and Ott,B 11/30/2015
14. Too Big to Fail
• Hospital environments historically used
existing patient care areas to move into once
growth increased
• Patients are forced to backtrack during all
phases of care in suboptimal layouts
Peterson,B and Ott,B 11/30/2015
www.aafp.org/fpm March/April 2015
28. Process Improvement
What are the basic principles of process
improvement?
1. Most problems are process rather than
people issues
2. The people closest to the process know it
best
3. Decisions should be made based on
measurable data
(SGNA Gastroenterology Nursing 5th edition pg 59)
29. Where do we start?
A comprehensive plan starts with a working
knowledge of the process and the tools
necessary to achieve the goal
Flowchart the process
Establish work teams with defined roles
Collect and interpret the data
(SGNA Gastroenterology Nursing 5th edition pg 59)
30. Overview of A6 Gastro
• Limited space and increased patient demand for
advanced interventional services
• No immediate space is available to move services
• $$$$$ of relocating or updating the unit and loss
of revenue during the transition to new unit
• No separate pre admission and recovery area
• HFH interventional doctors are also required to
perform luminal procedures with the limitation
that these cases are often EMR’s (endomucosal
resection) that increase procedure times
36. Intervention
• All members of the inpatient interventional team
assesses the inpatient before direct arrival to
endoscopy suite.
– EPIC (electronic medical record) completed (RN and CRNA)
– MDA has approved the inpatient
– Interpreters notified if needed
– Fellows consent patient at the time of boarding at bedside
– Fellows get the consent signed by family when they board
the patient if patient is unable to sign
– If not a same day add-on, anesthesia will assess the
patient the day before and clear patient for procedure or
write orders to be completed before transport
(Labs,EKG,etc)
37.
38. Considerations
• Staff engagement
– This does not allow staff to become satisfied with the status quo
– Empowering staff to make changes in how they do their work
(SGNA Gastroenterology Nursing 5th edition pg 59)
• Staffing
– Having team members available to assess inpatients
– Electronic charting allows interpretation of info away from the bedside before face to face assessment( i.e.
lab work, medication allergies, etc)
– Staff assigned to the room can be available to complete pre assessment off the unit
– While the room is vacant the second staff member can turn room over
– GI Fellows add Anesthesia Pre Procedure grid to assessment when boarding patients
• Unit Design
– Space projections should include 5-8 years of potential growth
– Cost of expansion, new build or relocation
• No dedicated transport team for inpatient GI
– This is very vital because a room can be left vacant because of delays in transport
– Consider using the team assigned to the room if needed
– Using in-hospital system staffing agency to provide assistance during project
39. Citations
Shivan J Mehta and Joel V Brill What Is the RUC and How
Does it Impact Gastroenterology?
Gastroenterology,2014-08-01 Volume 147:Issue 2:498-
501
Kaushal, N MD Chang,K MD et al Using efficiency analysis
and targeted intervention to improve operational
performance and achieve cost savings in the endoscopy
center. Gastroenterology Endoscopy Volume 79, No
4:2014
SGNA Gastroenterology Nursing A Core Curriculum 5th
Edition
40. Citations
2016 Medicare Physician Fee Schedule Payment Analysis -
Final Rule www.asge.org
C.J.J Mulder et al. Guidelines for designing a digestive disease
endoscopy unit: Report of the World Endoscopy Organization
Digestive Endoscopy 2013; 25: 365-375
Inefficiency in Primary Care: Common Causes and Potential
Solutions www.aafp.org/fpm March/April 2015
Peterson,B and Ott, B Design and management of
gastrointestinal endoscopy units www.gastrohep.com Nov 30
2015.
