Ambulatory Endoscopy in the U.S. Robert L. Barclay, MD, MSc, FRCP(C) Clinical Assistant Professor of Medicine University of Illinois College of Medicine at Rockford and Rockford Gastroenterology Associates, Ltd. Rockford, Illinois
Ambulatory Endoscopy in the U.S. Robert L. Barclay, MD, MSc, FRCP(C) Clinical Assistant Professor of Medicine University of Illinois College of Medicine.
Mar 26, 2015
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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
DAMNED if you don’t
DAMNED if you do
“C’mon, c’mon-it’s either one or the other.”
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)
Ambulatory Endoscopy Centers
I. Rationale for AEC’s
II. Setting up an AEC
GI Practice Focus
0
10
20
30
40
50
60
'83 '92 '01
over 50% endoscopy
Source: ASGE survey 2001
GI Endoscopy:Mostly An Outpatient Procedure
Cost Patient preference Physician preference Rapid assimilation of advances in
technology
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
Sites of Service for Gastrointestinal Endoscopy
Hospital endoscopy unit Ambulatory surgery
center (ASC) Office endoscopy suite
“AECs”
“Facilities”
Verispan, LLC, 2005.
AECs: Advantages for Patients
Convenient
Efficient
Economical
Pleasant
AECs: Advantages for Payers
Quality
Access
Cost
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.
AECs: Advantages for Endoscopists
Reimbursement, cost and profit Control, efficiency and
convenience Marketing and competitiveness Quality Clinical research
Economics of Endoscopyfor the Endoscopist
Reimbursement Cost Profit
Hospital $ $ $
Office $$ $$ - $$$ $$
ASC $$ - $$$ $$ - $$$$ $$ - $$$$
First pants
THENyour shoes
Ambulatory Endoscopy Centers
II. Setting up an Ambulatory Endoscopy Center
Setting Up an Ambulatory Endoscopy Center
Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary
Setting Up an Ambulatory Endoscopy Center
Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary
Exploring the Possibilities
Type of endoscopy unit Business plan Regulations and certification
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”
Exploring the Possibilities(cont.)
Type of endoscopy unit Business plan
Market analysis Financial pro forma Implementation time line
Regulations and certification
Exploring the Possibilities(cont.)
Type of endoscopy unit Business plan Regulations and certification
Regulations and Certification
Federal laws, regulations and rules Facility state licensure Medicare certification Third-party accreditation Physician credentialing Private-payer requirements
Setting Up an Ambulatory Endoscopy Center
Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary
Setting Up an Ambulatory Endoscopy Center
Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary
Facility Planning and Design
General points Planning and design team Planning the facility Designing the facility Summary
Facility Planning and Design
General points Planning and design team Planning the facility Designing the facility Summary
General Points on Planning & Design
Allow adequate time Set aside regular time Choose experienced design
professionals Involve staff Prepare statement of needs and goals
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
Facility Planning and Design
General points Planning and design team Planning the facility Designing the facility Summary
Planning and Design Team
Physician Nurse responsible for patient care activities Administrator Architect Contractor Specialists (IT, phones, attorney, lay
person?) Consultants
Suddenly, a heated exchange took place between the king and the moat contractor.
Facility Planning and Design
General points Planning and design team Planning the facility Designing the facility Summary
Planning the Facility
Scope of activities Equipment Physical environment Flow
Planning the Facility
Scope of activities Equipment Physical environment Flow
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
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
Planning the Facility
Scope of activities Equipment Physical environment Flow
Equipment – Misc. Points
Numbers of endoscopes Esophageal dilators Rolling stretcher carts
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
Planning the Facility
Scope of activities Equipment Physical environment Flow
Physical Environment – System Speed
Preparation and recovery Reprocessing endoscopes Physician work habits
Planning the Facility
Scope of activities Equipment Physical environment Flow
Simple Flow Diagram
More Complicated Flow Diagram
Functional Relationship Diagram
1
Rockford Gastroenterology Associates Floor Plan
Procedures
RecoveryPrep
Wash
Docs desks (“bullpen”)
Waiting
Clinic Rooms
Covered EntryASC Egress
Quiet Room
Reception/scheduling
Space Program Worksheet
Facility Planning and Design
General points Planning and design team Planning the facility Designing the facility Summary
Designing the Facility
Waiting module Business-reception module Preparation-recovery module Procedure room module Utility module Staff dressing module
Building Exterior
Waiting Module
Waiting Module
The Bullpen
Designing the Facility
Waiting module Business-reception module Preparation-recovery module Procedure room module Utility module Staff dressing module
Designing the Facility
Waiting module Business-reception module Preparation-recovery module Procedure room module Utility module Staff dressing module
Preparation – Recovery Module
Preparation – Recovery Module
Prep Module
Designing the Facility
Waiting module Business-reception module Preparation-recovery module Procedure room module Utility module Staff dressing module
Utilization Chart
Procedure Room Module
Procedure Room Module
Designing the Facility
Waiting module Business-reception module Preparation-recovery module Procedure room module Utility module Staff dressing module
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
Utility Module
Utility Module
Designing the Facility
Waiting module Business-reception module Preparation-recovery module Procedure room module Utility module Staff dressing module
Facility Planning and Design
General points Planning and design team Planning the facility Designing the facility Summary
Setting Up an Ambulatory Endoscopy Center
Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary
Staffing and Scheduling
Staffing General requirements Full-time equivalents
Scheduling
Staffing and Scheduling
Staffing General requirements Full-time equivalents
Scheduling
Setting Up an Ambulatory Endoscopy Center
Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary
Setting Up an Ambulatory Endoscopy Center
Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary
Setting Up an Ambulatory Endoscopy Center
Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary
“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.”
April 2010 ?
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