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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 at Rockford and Rockford Gastroenterology Associates, Ltd. Rockford, Illinois
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“C’mon, c’mon-it’s either one or the other.”
DAMNED if you do DAMNED if you don’t “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
Rationale for AEC’s Setting up an AEC
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GI Practice Focus 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
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Sites of Service for Gastrointestinal Endoscopy
Hospital endoscopy unit Ambulatory surgery center (ASC) Office endoscopy suite “Facilities” “AECs”
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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 Endoscopy for the Endoscopist
Reimbursement Cost Profit Hospital $ Office $$ $$ - $$$ ASC $$ - $$$$
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First pants THEN your shoes
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Ambulatory Endoscopy Centers
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
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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
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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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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
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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Rockford Gastroenterology Associates Floor Plan
1 Docs desks (“bullpen”) Procedures Clinic Rooms Wash Recovery Prep Reception/scheduling Waiting ASC Egress Covered Entry Quiet Room
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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
General requirements Full-time equivalents Scheduling
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Staffing and Scheduling
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 the
drugstore and the post office, I’m going to the vet’s to get tutored.”
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April 2010 ?
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