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

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

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

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

Scalpel please

2016 Medicare Physician Fee

Gastro Budgeted Overtime

Overtime Budgeted0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

201320142015

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)

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

Referrals

ERCP

ERCP

EUS

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

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

Good Morning

H.H. Chao Comprehensive Digestive Disease Center

Report of the World Endoscopy Organization

C.J.J Mulder et al 2013

C.J.J Mulder et al 2013

Optimal Room Layout

C.J.J Mulder et al 2013

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)

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)

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

Collecting DataChou Comprehensive Digestive Disease Center (H.H Choa 2014)

Why this assessment tool?

• Simple and comprehensive• Easily modified to meet your needs• Ability to track multiple factors in one form

The Data

Outpatients Inpatients0

500

1000

1500

2000

2500

3000

3500

Column1

Hurry up and Wait

0

50

100

150

200

250

Wait Time in Minutes

Wait Time

Average Scope Times

25

26

27

28

29

30

31

Dr.FunkenstienDr.DreDr.LoveDr. DetroitDr. Zhivago

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)

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

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

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.

Questions??