When our endoscopy center moved into its new location in 2003, we had a chance to start from scratch and design an efficient, high-volume facility that would let our business evolve as gastroenterology's clinical, regulatory and financial landscape changed. A lot has happened in the last five years, including reduced Medicare reimbursement for ASCs, the arrival of EMRs and technical advances allowing for better viewing and imaging of the GI tract. Here's how we've addressed these changes with a creative mind and become more efficient along the way.

1. Use computers everywhere you can
When we developed our new center, we decided to install workstations wherever they'd be needed rather than rely on handheld units or mobile workstations. We have 50 computers in our center. In the PACU, each bedside has a workstation. Each of our three procedure rooms has two workstations. Having more than enough computers eliminates staff having to wait for access. (See "Automated GI" on page 78.)

2. Devote an anesthesia provider to pre-op and PACU
Our contract with our anesthesia group calls for an anesthesia provider to work in pre-op and PACU areas. The nurse in pre-op interviews for the overall history for all patients, while the anesthesia provider performs the anesthesia assessment.

This provider, either a CRNA or an anesthesiologist, starts IVs and cares for patients as needed after surgery. This assignment saves the busy nurses time because they don't have to start IVs and run back and forth. It also lets the anesthesia provider who works the procedure room focus on the patient in the room. The anesthesia provider assigned to the procedure room greets patients, works the procedure room and transports patients to the PACU.

3. Use limb clips for the ECG monitor
We've found that using electrodes on limb clips, rather than the adhesive electrodes, saves time. They're just as accurate and much easier to remove than the sticky electrodes that pull out body hair and can cause irritation. Using limb clips has resulted in great savings over the years. Using three ECG pads costs about 50 cents per procedure. The limb clips cost about $60 per set and last about three years. Based on the 9,000 cases we do per year, the limb clips cost less than a penny per patient.

4. Have patients return to the same bay
We have 14 patient bays that we use for pre-op and post-op care. After the procedure, the patient returns to same bay where he underwent assessment and changed out of his clothes. Returning to the same bay lets the patient leave his clothes and belongings in one spot, rather than putting them in a locker or a box that would have to be moved once a new patient entered the bay.

5. Groom a well-trained reprocessing staff
Having experienced, well-trained reprocessors is important to improving efficiency in a GI center. We've helped our reprocessors grow in their careers by encouraging them to receive as much continuing education as possible. Our reprocessors are GI tech specialists who receive on-the-job training as well as off-site training through the Society of Gastroenterology Nurses and Associates and equipment manufacturers. I rotate all the reprocessing techs into procedure room shifts once a week so that their clinical skills stay fresh. We have very little turnover in our reprocessing department because the techs have pride of ownership in their department. Since we have so many computers, there's never a bottleneck when staff members complete online training courses.

6. Automate faxing
Although we're primarily a paperless facility, we send a lot of faxes. At the end of a procedure, the physician who performed it faxes documentation to the referring physician's office. By clicking the print function at the end of a case, the document is sent directly to the fax server.

To better comply with Joint Commission requirements for medication reconciliation, we plan to begin faxing from the patient's bedside a list of medications that the patient received in our facility to the referring physician's office. Faxing this list to a physician should be more effective than sending the patient home with the list and hoping that he will give it to his physician.

7. Discharge patients directly from the PACU
Not all patients need to go back to the front desk to check out. Unless the physician asks for a follow-up visit, we discharge patients directly from the PACU, where they receive all the documents that they will take home with them. For cases in which the person responsible for accompanying the patient home has not arrived yet, we've created a discharged patient waiting room. Directing patients to this area opens up a bay for the next patient and helps shorten the line that can grow at the front desk. Patients who need a follow-up visit are directed to the front desk, where they can schedule their next appointment.

8. Listen to your patients and staff
The best ideas usually don't come from managers. They come from the people closest to the workflow: the hands-on staff and the patients. Listen to your patients. Find out what they don't understand. This is especially important with prep for GI procedures, since improper bowel prep can lead to the cancellation of a case. If you learn that a patient is confused about something, chances are that other patients are just as confused but haven't spoken up.

The same goes for employees. Often a staff member will have an idea but is reluctant to speak up. Make it as easy and non-threatening as possible for employees to share their ideas.

In the end, remember that health care is constantly changing and that you have to continuously critique and adjust the way that you do things, even when everything is running smoothly. If you keep looking, those good ideas will never stop coming.