Ramp up the volume. That was my task when I came to the Michigan Endoscopy Center (MEC), six months after it had opened in 2003. That year, MEC performed 5,600 upper- and lower-GI procedures - with a 75-25 breakdown of colonoscopies to EGDs. In 2004, we performed nearly 13,500 in our five rooms, and this year we're on pace for more than 15,000 - about 65 procedures a day. Here's a look at how we've kicked our endoscopy service up a notch and how we're looking to improve this year.

Tight scheduling
We inform our patients that they'll spend an hour-and-a-half in our center once they've been admitted; the worst-case scenario is two-and-a-half hours from the time they walk in the door until they're on their way home. EGDs are normally quicker than colonoscopies.

Patients present an hour before their procedure times so we can adequately process all the intake paperwork and get their IVs and anesthesia started in pre-op. The last group of patients checks in at 2:30 p.m. each day; our last procedures take place at 3:30 p.m.

Our automated scheduling/ registration process interfaces with our clinical information system, which means we only have to enter information once. We also have a card scanner for insurance cards. We run them through like a credit card, and that information goes directly into the same database. Then it's just a matter of verifying information with the patients and running through the checklist of pre-op questions and consent forms.

Adequate staffing
In 2003, we were working out of four rooms, and when we decided to open the fifth to increase our volumes, we found we didn't have a full complement of staff. We went from about nine FTE nurses to 12, from five FTE endo techs to seven and from three office staff to four. We also have two MAs who help by decontaminating scopes, escorting discharged patients and generally helping out - wherever they're needed. So we now have a total of 25 FTEs in our Center.

Aggressively hiring an additional office staffer (patient service rep) was key. Every half-hour, five patients present at our center. As soon as they're done being registered, another five hit the door, and we need to be ready for that. Having enough people out in our reception area keeps us from bottlenecking the process on the front end.

Clinically, we run with one RN who circulates between two operating/procedure rooms (three for the five rooms), and one endo tech for every room. There's a CRNA in every room, and two MD anesthesiologists who supervise; they are independent contractors. Four or five RNs and an MA work 12 recovery room bays. Two or three RNs staff pre-op/admitting.

We also have a charge nurse who is responsible for the clinical staffing and relieving the RNs when necessary.

We have a dedicated reprocessing tech, which both standardizes our disinfection process and helps make it more efficient because that tech is focused on and specialized for the task. We rotate the rest of the endo techs in, so there's always a second set of hands helping out in reprocessing.

Our staff really is an experienced, all-star team, handpicked by the 17 physician-owners. But it doesn't hurt to incentivize them to maintain their high standards. We set aside a pool of money each year and dole it out to coincide with the physicians' quarterly distributions. Last year, the first year we used this program, I based the bonuses on general productivity and value to the team; nurses got the same amount, and techs got the same amount.

I've given them more direction with their goals this year: For the first quarter, we're looking to enhance chart completeness and compliance with documentation policy and procedures. At the end of the day, the charge nurse goes through all the patient records, and I can tell you we're seeing more diligence in completing records now. Next quarter, we'll add a new goal, and everyone will be expected to maintain the current goals.

Employees end up making about an extra 2 percent in bonus money on top of the cost-of-living increases they receive with their evaluations each year, which makes for a satisfied staff that's willing to work hard.

And it shows in the patient satisfaction surveys, which often mention staff by name; I always make sure the good comments find their way into the employees' personnel files.

Mandatory block scheduling
When I started here, I instituted a block-scheduling program to maximize our efficiency. Here's how it works:

• There are five morning blocks (about nine cases each) and five afternoon blocks (about seven cases each) per day. That's 50 blocks a week - and potentially 225 morning cases and 125 afternoon cases per week.
• The first case starts at 7:15 a.m., the last case at 3:30 p.m. The morning block runs from 7:15 a.m. to noon; the afternoon group starts at 12:15 p.m.
• I made a grid to make the schedule easy to visualize, and each of our 17 physicians is required to take at least one morning and one afternoon block per week. That fills 34 blocks, so after that, it's a matter of who wants more time. Most take at least one more block.
• Physicians must give us their vacation schedules three months in advance because, with 17 docs, someone is always out of the rotation for one reason or another. That way, I know when I'll have openings, and I can offer them to the physicians who'll be in town. If the dates and times work for them, they'll choose us over the hospital.

With this system, some physicians are here pretty much every day - I still can't find enough time for the big producers. With the schedule standardized, I can monitor utilization rates and have set the benchmark score at 134 cases. This score is based on the sum of the number equal to 80 percent of the minimum block volume per week plus 80 (percent of block utilization). For example, let's say a physician has the minimum weekly block time, for 17 procedures each week. Multiply that 17 by the number of weeks in a month (we'll use four here) and you get 68. Eighty percent of block capacity is 54. We add that to 80 percent utilization for the benchmark figure 134.

The benchmark comp score is a way to level the playing field when comparing our diverse group of physicians. For example, a physician might be taking four blocks but only operating at 50 percent or 60 percent of utilization. If that's the case, we might ask him to take only three blocks in favor of a physician who's operating at 80 percent of utilization and who wants more block time.

Anesthesia with a purpose
Propofol is the agent of choice here for one big reason: it's efficient. Yes, we need CRNAs to push it and MDAs to supervise, but we couldn't handle our case volumes without it.

For one thing, propofol cuts recovery times in half. Patients only spend about a half-hour to 40 minutes in recovery; if we were to use versed and fentanyl, that time would be more than an hour. Recovery nurses need only to collect three sets of vitals, and the patients need to have some liquids and pass some of the air we've inflated their colons with, before they're ready to be escorted out. The fast recovery times with low incidence of PONV are big contributors to our 98 percent patient satisfaction rate.

Propofol also speeds room turnover because it helps procedures go faster. Physicians can concentrate on the procedures and leave the anesthesia/sedation and airway management components to the CRNAs.

Interfaced coding, outsourced billing
Our corporate partner, Physicians Endoscopy, does all our billing. We've streamlined the coding process on our end by using an electronic dictation system (see "Coding for Colonoscopy: The Ins and Outs" on page 22). After each case, the physician pulls up the patient's name on the system, which interfaces with the scheduling system used when patients are admitted. They don't have to re-enter any information; they simply do their dictation online, using drop-down menu boxes for the CPT and ICD-9 codes.

We have a three-day window between the procedure date and when the reports are due to corporate headquarters, so each report is audited by one of the techs. The tech will know what was done in the room as well as what the codes should be, or be able to spot what's missing from the narrative and ask the physician to add it before the batch is sent off.

Room for improvement
My next challenge: Get us running at 80 percent capacity. We were at 72 percent last year. We can do 80 cases a day, and I'd like to get there.

How can we do that? For starters, we can credential some physicians who aren't owners here. If I have a Tuesday no one wants or can take because of vacation or hospital rounds, I would have a call list of physicians, and try to backfill open slots that way. It's not as easy a sell as it sounds, because lots of physicians want a block-time commitment. But it's something we're working on.

We're already pushing the envelope on afternoon procedure start times, because we require that patients be NPO, but starting cases at 4 p.m. is a possibility. We've also kicked around the idea of Saturday morning procedures, but there's not enough interest on the physician side for that yet.

Another option is a sixth room that's not being used. We have a license for six, but it's a $250,000 investment to open another room. We also need time to work out the process. For example, how would it affect the recovery/admitting bays? One idea is to open the sixth room for EGDs two days a week at first, and to stagger the procedure start times so they don't conflict with the other rooms.

The final aspect of our success is the medical director position, co-chaired by Greg Karris, MD, and Jay Levinson, MD. Four days a week, at least one of our two medical directors is on site. They're incredibly accessible to respond to medical or clinical issues; they were key in backing the block-time schedule; and they're involved in QA issues.