Ambulatory Endoscopy in the U.S.

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 do DAMNED if you don’t “C’mon, c’mon-it’s either one or the other.”

4. 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)

5. Ambulatory Endoscopy Centers • Rationale for AEC’s • 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 “Facilities” “AECs”

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 Endoscopyfor the Endoscopist

17. First pants THEN your shoes

18. Ambulatory Endoscopy Centers • 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

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.

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

42. Procedures: AEC vs. Hospital * 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

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