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Formation of a multi-discipline advanced endoscopy inpatient team to decrease bottlenecks in patient flow in a limited
unit work space
Jason Sims BSN,RNHenry Ford Hospital
Detroit, MI
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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
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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
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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
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Scalpel please
2016 Medicare Physician Fee
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Gastro Budgeted Overtime
Overtime Budgeted0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
201320142015
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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)
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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
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Referrals
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ERCP
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ERCP
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EUS
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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
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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 11/30/2015www.aafp.org/fpm March/April 2015
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Good Morning
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H.H. Chao Comprehensive Digestive Disease Center
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Report of the World Endoscopy Organization
C.J.J Mulder et al 2013
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C.J.J Mulder et al 2013
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Optimal Room Layout
C.J.J Mulder et al 2013
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Process Improvement
What are the basic principles of process improvement?1. Most problems are process rather than
people issues2. The people closest to the process know it
best3. Decisions should be made based on
measurable data (SGNA Gastroenterology Nursing 5th edition pg 59)
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Where do we start?
A comprehensive plan starts with a working knowledge of the process and the tools necessary to achieve the goalFlowchart the processEstablish work teams with defined rolesCollect and interpret the data
(SGNA Gastroenterology Nursing 5th edition pg 59)
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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
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Collecting DataChou Comprehensive Digestive Disease Center (H.H Choa 2014)
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Why this assessment tool?
• Simple and comprehensive• Easily modified to meet your needs• Ability to track multiple factors in one form
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The Data
Outpatients Inpatients0
500
1000
1500
2000
2500
3000
3500
Column1
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Hurry up and Wait
0
50
100
150
200
250
Wait Time in Minutes
Wait Time
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Average Scope Times
25
26
27
28
29
30
31
Dr.FunkenstienDr.DreDr.LoveDr. DetroitDr. Zhivago
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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)
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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
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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
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Citations2016 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.
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Questions??