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Is Your GI Service as Efficient as It Can Be?
Don't wait for 2008. Here?s how to move faster and increase profits.
Kent Steinriede
Publish Date: November 17, 2007   |  Tags:   Gastroenterology

There's no news in saying that Medicare reimbursement rates for GI procedures will drop 40 days after Thanksgiving. However, what is news is that dozens of GI centers across the country have already set out on a path to increase their efficiency. We talked with several GI center owners and administrators who aren't fretting what's to come because they've already improved how they manage their staff, schedule, equipment and materials.

1. Pay for productivity
At Houston's Medical Center Endoscopy, administrators, nurses, techs and assistants all receive a quarterly bonus based on their own performance and the overall performance of the center. Each fiscal quarter, employees share 2.5 percent of the center's net collections. This helps the staff focus on productivity. "They know that there's more money in the pot based on how hard they work," says Karen L. Woods, MD, one of 14 physician-owners.

The administrator gets 15 percent of the pot; the administrative head nurse gets 15 percent; and the administrative assistant gets 5 percent. The remaining 65 percent of the pot is distributed using a point system. Full-time employees earn points based on hours worked, patient or doctor compliments, punctuality and if they came up with new ideas to help things run smoothly. Employees can lose points for tardiness, unscheduled absences and complaints from doctors or patients.

The amount of money in the bonus pot goes up and down depending on the center's caseload. Dr. Woods says that sometimes this can cause some complaining among staff members who take the bonus for granted. With reimbursement rates for GI declining, "we've had to explain that everyone's bonus is going down," says Dr. Woods.

2. Dynamic scheduling
As soon as you get a cancellation, work on filling that spot. At Nueterra Healthcare's nine GI centers across the country, the person in charge of scheduling is always in touch with the physicians' offices, letting the staff there know about openings. "You have to be aggressive," says Rod Carbonell, RN, Nueterra's regional administrator for its single-specialty division. To make this work, it's important that your scheduler build a good rapport with the schedulers in the docs' offices. If possible, make an appointment for the scheduler to meet their counterparts in other offices. This will pay off, says Mr. Carbonell. "I've seen business go up by 20 percent as a result of having people meet."

Just as important, don't assume that the scheduler is doing all that's possible to fill up the calendar. Make more than one person accountable for filling empty time slots. Even though he's a regional administrator, Mr. Carbonell often sends group

E-mail blasts on behalf of his centers to physicians' offices, alerting them to available time slots. In the end, everyone benefits.

3. Turn the scopes over
Processing endoscopes, although not the most glamorous job, might be the most important one, says Mr. Carbonell. Nothing can bring patient flow to a grinding halt like a lack of ready endoscopes. To avoid backups, look at your system. Is the person in charge of this task both fast and thorough? But don't let this person get burned out. Make sure that you have a good backup for the job or you'll have a backup in your center.

Where the endoscopes are cleaned is just as important as who cleans them. If you're remodeling or building a new facility, consider the distance from the room where the scopes are cleaned to the procedure rooms. Saving steps adds up. Even 25 steps saved equals miles saved over the year.

4. Get outside help
Sometimes a stranger can see solutions to your problems more clearly than you can. At the Torrance Memorial Medical Center in Torrance, Calif., the endoscopy center was bogged down with delays and a lack of space, which decreased efficiency and deflated staff morale. "I had to do something," says Debbie Wells, RN, CGRN. So the hospital administration hired a team of consultants to help figure out how to turn things around. After collecting benchmarking data and other stats, the consultants came back with a handful of suggestions.

First, the endo department needed to hire more techs so that there'd be one for each scope room. The tech helps the physician so that the nurse can concentrate on sedating and monitoring the patient. With the tech dealing with the hands-on tasks, the nurse also can take care of the needed documentation, including labeling the biopsies. Freeing the nurse from the hands-on work with the physician has decreased the number of biopsy labeling errors and helped with room turnover time. "The paperwork for the biopsies is done by the time the patient is done," says Ms. Wells.

Space was another problem at Torrance Memorial, where sometimes patients had to be moved to another floor for recovery. One bottleneck was the holding area, where patients changed out of their clothes. Before, the patient's clothes stayed in a drawer in the holding area during the procedure. Now, the clothes are bagged and they travel on the gurney with the patient. To make this change, the hospital had to buy four more gurneys.

These and other changes, including block scheduling and having patients fill out the admitting paperwork in the waiting room, has decreased the time patients spend from admission through recovery by 38 percent, from 2 hours and 58 minutes to 2 hours, says Ms. Wells.

5. Contact your local business school
If you don't have the budget for a consulting firm, there are other ways to get help. Every city has at least one business school with dozens of students looking for case studies. Many business schools also work with local business development agencies and offer their services for free or just a few hundred dollars. In Atlanta, students at the Georgia Tech College of Management created an efficiency study for Atlanta Gastroenterology Associates, which operates six endoscopy centers in the Atlanta area. The students found a few glitches in how the centers scheduled procedures.

Atlanta Gastroenterology uses block time scheduling for the procedure rooms. However, many physician times went unused, especially in the afternoon. Management focused on keeping the rooms full, especially during the sought-after morning time slots. The students found that physician time off for vacations and meetings was a major cause of unfilled time slots because the other doctors didn't know that the time slots were available. "We had huge gaps," says Steven Morris, MD, JD, chief executive of Atlanta Gastroenterology.

To remedy this, now physicians give the centers the dates when they'll be away at least six weeks in advance so other physicians can take those blocks.

Management also addressed physician tardiness. "It sounds juvenile, but it's a fact of life," says Dr. Morris. Block scheduling helps with this because once the physician arrives for his first case, he's already in the building for the rest. And for the chronically late in the morning, their schedules have been changed so that their blocks begin at 10 a.m.

6. Buy billing software
At Rocky Mountain Gastroenterology Associates, a 21-physician practice with three endoscopy centers in the Denver area, Jeff McCaffery, chief financial officer, was looking for a way to automate his company's billing. After talking with administrators at other centers and logging onto the forums on the Medical Group Management Association's Web site, Rocky Mountain administration decided on a revenue cycle management software package.

The software, which the group has been using since June, lets the billing department submit claims daily and track them through Web links with several payors. "You can see the status of your claims in almost realtime," says Mr. McCaffery.

The software has a "scrubbing" function that verifies that the claims have proper coding and necessary information on the patient, physician and procedure. The software also compiles reports, including one on rejected claims. This helps the group identify recurring errors in the claims, says Mr. McCaffery. "We can do in-house training and fix the problems."

7. Go high tech
Using information technology shouldn't stop with billing software, says Philip Grossman, MD, FACP, FACG, a gastroenterologist and IT consultant in Miami. Practice management software can be used to generate reminders for follow-up visits and regular screening. If the patient doesn't show up, the software can remind the staff to call the patient.

When the software contains a database with patient information, including diagnoses, it becomes a powerful tool. "You can shuffle that deck for very important efficiencies," says Dr. Grossman. For example, if recommendations on the frequency of screening for colorectal cancer for patients over 50 years were to change, the software could create a list of all patients over 50 years old who haven't had colonoscopy in the recommended time period. Then the physician's office could contact the patients to schedule appointments.

Software specially designed for endoscopy centers can also help speed things along. Some packages automate nearly every step of the documentation process, including sending a report to the referring physician. It's almost immediate, says Dr. Grossman. "I haven't walked out of the room and he's already got the report on his desk."

8. Look for redundancy
If you find you have a log jam in recovery, take a good look at what goes on there, says Hortensia Dziedzic, endoscopy coordinator at the Northwest Michigan Surgery Center in Traverse City, Mich. Ms. Dziedzic and her staff found that patients were given discharge instructions twice during a visit, in pre-op and post-op. Now, after a bit of staff training, patients and the person accompanying them receive discharge instructions only during pre-op. This small tweak has made an impact of the amount of time that patients spend in the recovery area. "We decreased it to half an hour," says Ms. Dziedzic.

9. Treat them and street them
For physicians looking for efficiencies, drug choices can make a difference, says Dr. Morris. This is especially true when it comes to anesthesia. Using propofol can cut post-op recovery time by as much as 75 percent, he says. "It comes on quickly, and they come back soon."

Propofol use is becoming more common. In 2004, about 17 percent of GIs in the United States used propofol for endoscopy, according to a July 2005 article in Gastrointestinal Endoscopy. However, the article says, 43 percent planned to begin using propofol in 2006. Dr. Morris says that using propofol takes some of the burden off the recovery area because patients spend less time there.

There's no denying that GI as a specialty — and especially GI ASCs — will be hardest hit by the restructured ASC payment system that goes into effect in January. Putting these tips into practice should help offset that.

GI Products Engineered With Efficiency in Mind

Scope companies understand that GI centers must become more efficient and have responded with new technology in that direction. Here are a few products that were exhibited at last month's American College of Gastroenterology meeting.

Super-slim Scope Breaks the 5mm Barrier. The Olympus Evis Exera II GI is the first scope in the world to have distal end and insertion tube diameter of less than 5mm. Olympus says it achieved this size reduction while improving the image quality. Upper and lower GI scopes are available in HDTV as well as a super wide-angle version with a 170