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Ambulatory Endoscopy in the U.S. Robert L. Barclay, MD, MSc, FRCP(C) Clinical Assistant Professor of Medicine University of Illinois College of Medicine.

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Presentation on theme: "Ambulatory Endoscopy in the U.S. Robert L. Barclay, MD, MSc, FRCP(C) Clinical Assistant Professor of Medicine University of Illinois College of Medicine."— Presentation transcript:

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 at Rockford and Rockford Gastroenterology Associates, Ltd. Rockford, Illinois

2 DAMNED if you dont DAMNED if you do Cmon, cmon-its either one or the other.

3

4 Ambulatory GI Endoscopy: USA vs. Canada Efficiency/productivity Standard time slots: colon 30 min, EGD 20 min Direct to AEC procedures: screen colon, Barretts 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)

5 Ambulatory Endoscopy Centers I.Rationale for AECs II.Setting up an AEC

6 GI Practice Focus Source: ASGE survey 2001

7 GI Endoscopy: Mostly An Outpatient Procedure Cost Patient preference Physician preference Rapid assimilation of advances in technology

8 Service Locations For GI Endoscopy (Rockford GE Associates, Ltd., 1975-2007)

9 Sites of Service for Gastrointestinal Endoscopy Hospital endoscopy unit Ambulatory surgery center (ASC) Office endoscopy suite AECs Facilities

10 Verispan, LLC, 2005.

11 AECs: Advantages for Patients Convenient Efficient Economical Pleasant

12 AECs: Advantages for Payers Quality Access Cost

13 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.

14 AECs: Advantages for Endoscopists Reimbursement, cost and profit Control, efficiency and convenience Marketing and competitiveness Quality Clinical research

15 Economics of Endoscopy for the Endoscopist ReimbursementCostProfit Hospital$$$ Office$$$$ - $$$$$ ASC$$ - $$$$$ - $$$$

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17 First pants THEN your shoes

18 Ambulatory Endoscopy Centers II.Setting up an Ambulatory Endoscopy Center

19 Setting Up an Ambulatory Endoscopy Center Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary

20 Setting Up an Ambulatory Endoscopy Center Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary

21 Exploring the Possibilities Type of endoscopy unit Business plan Regulations and certification

22 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

23 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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25 Exploring the Possibilities (cont.) Type of endoscopy unit Business plan Regulations and certification

26 Regulations and Certification Federal laws, regulations and rules Facility state licensure Medicare certification Third-party accreditation Physician credentialing Private-payer requirements

27 Setting Up an Ambulatory Endoscopy Center Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary

28 Setting Up an Ambulatory Endoscopy Center Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary

29 Facility Planning and Design General points Planning and design team Planning the facility Designing the facility Summary

30 Facility Planning and Design General points Planning and design team Planning the facility Designing the facility Summary

31 General Points on Planning & Design Allow adequate time Set aside regular time Choose experienced design professionals Involve staff Prepare statement of needs and goals

32 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

33 Facility Planning and Design General points Planning and design team Planning the facility Designing the facility Summary

34 Planning and Design Team Physician Nurse responsible for patient care activities Administrator Architect Contractor Specialists (IT, phones, attorney, lay person?) Consultants

35 Suddenly, a heated exchange took place between the king and the moat contractor.

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37 Facility Planning and Design General points Planning and design team Planning the facility Designing the facility Summary

38 Planning the Facility Scope of activities Equipment Physical environment Flow

39 Planning the Facility Scope of activities Equipment Physical environment Flow

40 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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42 Procedures: AEC vs. Hospital AECHospital Routine EGD, colonAcute bleeds Flex sigImmobile, infirm Esophageal dilationPsychiatric disease Hemorrhoid tx (IRC,RBL) Equipment needs (APC) ERCP Long cases (EMR,DBE) Liver biopsy* EUS* Deep sedation (MAC)* * Feasible in AEC

43 Planning the Facility Scope of activities Equipment Physical environment Flow

44 Equipment – Misc. Points Numbers of endoscopes Esophageal dilators Rolling stretcher carts

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46 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

47 Planning the Facility Scope of activities Equipment Physical environment Flow

48 Physical Environment – System Speed Preparation and recovery Reprocessing endoscopes Physician work habits

49 Planning the Facility Scope of activities Equipment Physical environment Flow

50 Simple Flow Diagram

51 More Complicated Flow Diagram

52 Functional Relationship Diagram

53 1 Rockford Gastroenterology Associates Floor Plan Procedures Recovery Prep Wash Docs desks (bullpen) Waiting Clinic Rooms Covered Entry ASC Egress Quiet Room Reception/scheduling

54 Space Program Worksheet

55 Facility Planning and Design General points Planning and design team Planning the facility Designing the facility Summary

56 Designing the Facility Waiting module Business-reception module Preparation-recovery module Procedure room module Utility module Staff dressing module

57 Building Exterior

58 Waiting Module

59

60 The Bullpen

61 Designing the Facility Waiting module Business-reception module Preparation-recovery module Procedure room module Utility module Staff dressing module

62 Designing the Facility Waiting module Business-reception module Preparation-recovery module Procedure room module Utility module Staff dressing module

63 Preparation – Recovery Module

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65 Prep Module

66 Designing the Facility Waiting module Business-reception module Preparation-recovery module Procedure room module Utility module Staff dressing module

67 Utilization Chart

68 Procedure Room Module

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70 Designing the Facility Waiting module Business-reception module Preparation-recovery module Procedure room module Utility module Staff dressing module

71 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

72 Utility Module

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74 Designing the Facility Waiting module Business-reception module Preparation-recovery module Procedure room module Utility module Staff dressing module

75 Facility Planning and Design General points Planning and design team Planning the facility Designing the facility Summary

76 Setting Up an Ambulatory Endoscopy Center Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary

77 Staffing and Scheduling Staffing General requirements Full-time equivalents Scheduling

78 Staffing and Scheduling Staffing General requirements Full-time equivalents Scheduling

79 Setting Up an Ambulatory Endoscopy Center Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary

80 Setting Up an Ambulatory Endoscopy Center Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary

81 Setting Up an Ambulatory Endoscopy Center Exploring the possibilities Choosing a site Facility planning and design Staffing and scheduling Documentation Quality improvement Summary

82 Ha ha ha, Biff. Guess what? After we go to the drugstore and the post office, Im going to the vets to get tutored.

83

84 April 2010 ?


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