Here are our keys for cranking close to 4,000 GI procedures through our 3 procedure rooms each year.

1. Focus on the start. Have patients arrive 45 minutes before the scheduled procedure, which should be more than enough time to complete registration paperwork, ask the necessary pre-procedure questions, have patients change out of their street clothes and get IVs started. Our pre-op nurse is expected to have 2 patients readied for procedures every 30 minutes. Doing so demands a carefully choreographed routine. Also, don't ignore the time-saving importance of training your staff on efficient IV starts. Nurses who can get IV fluids flowing on the first try will have patients' journeys off on the right foot from both efficiency and patient satisfaction perspectives.

2. Share the load. We have 6 RNs working each day (plus myself) and 2.5 FTEs manning the front office and handling our billing. That's it. How does such a small staff maintain a high-volume center? By working as a team and being willing to do whatever it takes to keep the day's schedule on track. When case volume slows, RNs jump up front to help file. When the recovery staff senses a lull in the schedule, they'll lend a hand in the pre-op area, even if it's only to grab warmed blankets for patients. As clinical director, I cover for breaks. We sometimes work through lunch. Potential hires are told of my staff philosophy during the interview process: Come in focused on patient care, work fast and work as a team. When you're done with your work, that doesn't mean the work is done.

3. Follow the "rule of 30." Set your schedule based on 30-minute procedures and 30-minute discharges. We have 2 physicians working each day. The faster of the 2 is assigned 2 of our 3 rooms, so while he's finishing with one case, another patient is prepped and ready for him in the third room. One nurse helps out the physicians during each procedure. She gives sedation, keeps track of biopsies and performs whatever tasks the physician needs to keep cases flowing smoothly. We also use a circulating nurse who helps turn over rooms and transport patients, and jumps into the pre-procedure fray when necessary. We give patients a preemptive dose of ondansetron (Zofran) to head off PONV. We sedate with fentanyl and Versed, a combination that combines short-term memory loss with low incidence of nausea and vomiting.

In recovery, patients receive only water — no juice or snacks, which we've found actually increase PONV. Our physicians are also skilled at removing scopes in a way that limits post-procedure cramping and discomfort. Patients are given 15 minutes to sleep upon arriving in recovery. After that rest, their escorts join them in the recovery bay (as long as patients had given them permission to do so beforehand). We've found that friends and family don't want to spend too much time sitting and waiting, so they'll gently encourage faster recoveries.

4. Rely on AERs and EMRs. We have only 7 colonoscopes and 3 scopes for upper endoscopy, so like most GI centers, efficient scope turnover is essential. Our pair of automatic endoscope reprocessors each holds 2 scopes and are key to getting the instruments back into the hands of our physicians in about 45 minutes. To help trim reprocessing times even more, we've recently made the switch to a high-level disinfectant that boasts shorter scope soak times.

Our physicians' offices have made the switch to EMRs, and we know we'll have to make a full transition in the near future. In the meantime, all of our billing is handled electronically, which has lessened our biller's workload, improved the accuracy of our charges and, in turn, upped our collection rate. We're seeing more checks than explanations of benefits in the mail and our accounts receivable rate has been reduced to just 3%.

5. Limit staff turnover. Keep the atmosphere light and do what you can to accommodate the demands of your employees' personal lives. Happy and satisfied employees are more fun to work with and work more efficiently. Employee turnover is rare within my facility, which means my staff is able to build rapport and familiarity with the procedures and processes that work best. We developed into a well-oiled machine because we've worked together for so long.