Ambulatory Endoscopy in the U.S. Robert L. Barclay, MD, MSc, FRCP(C) Clinical Assistant Professor of...
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Transcript of Ambulatory Endoscopy in the U.S. Robert L. Barclay, MD, MSc, FRCP(C) Clinical Assistant Professor of...
![Page 1: Ambulatory Endoscopy in the U.S. Robert L. Barclay, MD, MSc, FRCP(C) Clinical Assistant Professor of Medicine University of Illinois College of Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022061305/55141870550346e2488b53fe/html5/thumbnails/1.jpg)
Ambulatory Endoscopy
in the U.S.
Robert L. Barclay, MD, MSc, FRCP(C)Clinical Assistant Professor of MedicineUniversity of Illinois College of Medicine at Rockfordand Rockford Gastroenterology Associates, Ltd.Rockford, Illinois
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DAMNED if you don’t
DAMNED if you do
“C’mon, c’mon-it’s either one or the other.”
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Ambulatory GI Endoscopy: USA vs. Canada
Efficiency/productivity Standard time slots: colon 30 min, EGD 20 min Direct to AEC procedures: screen colon, Barrett’s Prep class Triage nurses & schedulers Fewer empty slots Electronic records, automated lab callback
Endoscopy days limited only by # days in week Procedural volume driven by standard of care in
community (e.g. CRC screening)
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Ambulatory Endoscopy Centers
I. Rationale for AEC’s
II. Setting up an AEC
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GI Practice Focus
0
10
20
30
40
50
60
'83 '92 '01
over 50% endoscopy
Source: ASGE survey 2001
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GI Endoscopy:Mostly An Outpatient Procedure
Cost Patient preference Physician preference Rapid assimilation of advances in
technology
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Service Locations For GI Endoscopy(Rockford GE Associates, Ltd., 1975-2007)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1970s 1980s 1990s 2002 2007
Inpatient
HOP
Office
EASC
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Sites of Service for Gastrointestinal Endoscopy
Hospital endoscopy unit Ambulatory surgery
center (ASC) Office endoscopy suite
“AECs”
“Facilities”
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Verispan, LLC, 2005.
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AECs: Advantages for Patients
Convenient
Efficient
Economical
Pleasant
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AECs: Advantages for Payers
Quality
Access
Cost
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2005 FASA Medicare Study
Mean payment per claim in ASC ~64% of HOPD
Mean savings ~$320 in ASC vs HOPD
Already $1.1 billion savings Potential savings $1.6 billion more
Federated Ambulatory Surgery Association, 2005.
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AECs: Advantages for Endoscopists
Reimbursement, cost and profit Control, efficiency and
convenience Marketing and competitiveness Quality Clinical research
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Economics of Endoscopyfor the Endoscopist
Reimbursement Cost Profit
Hospital $ $ $
Office $$ $$ - $$$ $$
ASC $$ - $$$ $$ - $$$$ $$ - $$$$
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First pants
THENyour shoes
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Ambulatory Endoscopy Centers
II. Setting up an Ambulatory Endoscopy Center
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Setting Up an Ambulatory Endoscopy Center
Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary
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Setting Up an Ambulatory Endoscopy Center
Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary
![Page 21: Ambulatory Endoscopy in the U.S. Robert L. Barclay, MD, MSc, FRCP(C) Clinical Assistant Professor of Medicine University of Illinois College of Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022061305/55141870550346e2488b53fe/html5/thumbnails/21.jpg)
Exploring the Possibilities
Type of endoscopy unit Business plan Regulations and certification
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Exploring the Possibilities
Type of endoscopy unit Hospital-based* Ambulatory endoscopy center (AEC)
Office endoscopy suite Ambulatory surgery center (ASC)*
Business plan Regulations and certification
*”Facility”
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Exploring the Possibilities(cont.)
Type of endoscopy unit Business plan
Market analysis Financial pro forma Implementation time line
Regulations and certification
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Exploring the Possibilities(cont.)
Type of endoscopy unit Business plan Regulations and certification
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Regulations and Certification
Federal laws, regulations and rules Facility state licensure Medicare certification Third-party accreditation Physician credentialing Private-payer requirements
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Setting Up an Ambulatory Endoscopy Center
Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary
![Page 28: Ambulatory Endoscopy in the U.S. Robert L. Barclay, MD, MSc, FRCP(C) Clinical Assistant Professor of Medicine University of Illinois College of Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022061305/55141870550346e2488b53fe/html5/thumbnails/28.jpg)
Setting Up an Ambulatory Endoscopy Center
Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary
![Page 29: Ambulatory Endoscopy in the U.S. Robert L. Barclay, MD, MSc, FRCP(C) Clinical Assistant Professor of Medicine University of Illinois College of Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022061305/55141870550346e2488b53fe/html5/thumbnails/29.jpg)
Facility Planning and Design
General points Planning and design team Planning the facility Designing the facility Summary
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Facility Planning and Design
General points Planning and design team Planning the facility Designing the facility Summary
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General Points on Planning & Design
Allow adequate time Set aside regular time Choose experienced design
professionals Involve staff Prepare statement of needs and goals
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General Points on Planning & Design(cont.)
Prepare inventory of equipment Visit other facilities Use flow studies Review prelim drawings carefully If questions, lay it out
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Facility Planning and Design
General points Planning and design team Planning the facility Designing the facility Summary
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Planning and Design Team
Physician Nurse responsible for patient care activities Administrator Architect Contractor Specialists (IT, phones, attorney, lay
person?) Consultants
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Suddenly, a heated exchange took place between the king and the moat contractor.
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Facility Planning and Design
General points Planning and design team Planning the facility Designing the facility Summary
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Planning the Facility
Scope of activities Equipment Physical environment Flow
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Planning the Facility
Scope of activities Equipment Physical environment Flow
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Scope of Activities
“Routine” high volume procedures Predictable turn-around times Minimal recovery times Standard equipment Less expensive accessories Medicare approved list Multi- vs single- specialty
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Procedures: AEC vs. Hospital
AEC Hospital
Routine EGD, colon Acute bleeds
Flex sig Immobile, infirm
Esophageal dilation Psychiatric disease
Hemorrhoid tx (IRC,RBL) Equipment needs (APC)
ERCP
Long cases (EMR,DBE)
Liver biopsy*
EUS*
Deep sedation (MAC)*
* Feasible in AEC
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Planning the Facility
Scope of activities Equipment Physical environment Flow
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Equipment – Misc. Points
Numbers of endoscopes Esophageal dilators Rolling stretcher carts
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AEC Devices & Medications Upper endoscopes, colonoscopes Biopsy forceps Snares Dilators (American > balloon) Clips Electrocautery unit Heater probe Injection needles (epi, India ink, saline) Rxx: midazolam, fentanyl, ondansotron
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Planning the Facility
Scope of activities Equipment Physical environment Flow
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Physical Environment – System Speed
Preparation and recovery Reprocessing endoscopes Physician work habits
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Planning the Facility
Scope of activities Equipment Physical environment Flow
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Simple Flow Diagram
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More Complicated Flow Diagram
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Functional Relationship Diagram
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1
Rockford Gastroenterology Associates Floor Plan
Procedures
RecoveryPrep
Wash
Docs desks (“bullpen”)
Waiting
Clinic Rooms
Covered EntryASC Egress
Quiet Room
Reception/scheduling
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Space Program Worksheet
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Facility Planning and Design
General points Planning and design team Planning the facility Designing the facility Summary
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Designing the Facility
Waiting module Business-reception module Preparation-recovery module Procedure room module Utility module Staff dressing module
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Building Exterior
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Waiting Module
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Waiting Module
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The Bullpen
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Designing the Facility
Waiting module Business-reception module Preparation-recovery module Procedure room module Utility module Staff dressing module
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Designing the Facility
Waiting module Business-reception module Preparation-recovery module Procedure room module Utility module Staff dressing module
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Preparation – Recovery Module
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Preparation – Recovery Module
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Prep Module
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Designing the Facility
Waiting module Business-reception module Preparation-recovery module Procedure room module Utility module Staff dressing module
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Utilization Chart
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Procedure Room Module
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Procedure Room Module
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Designing the Facility
Waiting module Business-reception module Preparation-recovery module Procedure room module Utility module Staff dressing module
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Utility Module
-Automatic washers
-5 bays
-GI-Zyme cleanse, rinse, 2.6% glutaraldehyde soak, rinse (40 min cycle)
-End of day: 70% EtOH rinse before hanging scopes
-Most devices disposable
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Utility Module
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Utility Module
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Designing the Facility
Waiting module Business-reception module Preparation-recovery module Procedure room module Utility module Staff dressing module
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Facility Planning and Design
General points Planning and design team Planning the facility Designing the facility Summary
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Setting Up an Ambulatory Endoscopy Center
Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary
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Staffing and Scheduling
Staffing General requirements Full-time equivalents
Scheduling
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Staffing and Scheduling
Staffing General requirements Full-time equivalents
Scheduling
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Setting Up an Ambulatory Endoscopy Center
Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary
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Setting Up an Ambulatory Endoscopy Center
Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary
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Setting Up an Ambulatory Endoscopy Center
Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary
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“Ha ha ha, Biff. Guess what? After we go to thedrugstore and the post office, I’m going to the
vet’s to get tutored.”
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April 2010 ?