The Growing Colonoscopy Boom: Secrets of Top-Performing GI Centers

Facilities are unlocking efficiencies to meet unprecedented demand.

It’s been a busy couple years for gastroenterology centers, providers and staff who perform colonoscopies. A backlog of patients who delayed these potentially lifesaving procedures due to the pandemic, a newly reduced recommended colorectal cancer screening age of 45, and a graying of the population have created high demand and, at the busiest centers, high patient volumes.

All three factors are in full force at Novant Health Wilmington (N.C.) Endoscopy Center, which hosts about 6,500 colonoscopies a year. “We’ve got the trifecta here,” confirms Jeannine Benoit, ASC administrator and clinic regional manager. Maximized efficiency is key to meeting this capacity challenge. GI centers want to see as many patients as possible — making sure to not only get them in and out quickly and profitably but also safely, while providing the high level of care patients of this crucial procedure expect and deserve.

Scope of practice

AMSURG, an independent ASC company that has partnered with physicians in a variety of specialties to acquire, develop, operate and provide care at more than 250 centers in 34 states and the District of Columbia, says its national network of gastroenterologists and colorectal surgeons performed more than one million colonoscopies at its facilities in 2022.

“We’re ensuring we’re able to keep up with the increasing demand at our centers, clinically and operationally. Obviously, efficiency is important,” says Alexis Roberts, director of operations for AMSURG’s nine ASCs in the greater Los Angeles area.

Here’s how AMSURG and Novant GI centers are prioritizing and enhancing the efficiency of their colonoscopy lines.

• Scheduling. AMSURG centers regularly examine their block scheduling to accommodate more colonoscopies, says Ms. Roberts. “We typically schedule about 30 minutes per procedure, and depending on the flow, each can be faster than that, so we may be able to squeeze in additional procedures,” adds Jackie McDougall, AMSURG’s senior director of clinical services, who covers AMSURG’s western region. Some AMSURG centers can perform three to four colonoscopies per hour. Some perform colonoscopies from 7 a.m. to 5 p.m., though many patients prefer scheduling their procedures in the morning.

Ms. Benoit says the Novant Wilmington center starts performing colonoscopies each day at 6:30 a.m. Over the next nine hours or so, each of its three procedure rooms hosts 16 to 18 patients, with the average colonoscopy lasting a half-hour.

TIME OPTIMIZATION Colonoscopy providers at the most efficient centers aim to spend just the right amount of intubation and withdrawal time on each patient to ensure thorough examinations while keeping the schedule humming.

Of course, keeping procedure rooms full and active for the entire day depends in large part on all scheduled patients properly preparing for their colonoscopies. “We definitely have been experiencing same-day cancelations and focusing on decreasing those,” says Ms. McDougall. She says pre-visit phone calls have been crucial. “During these calls, we do an initial screening to make sure the patient has received their prep, understands the instructions on how and when to take it, and confirm their time of appointment.” AMSURG is also using text messaging for these purposes. “The messages ask kind of the same questions, but it’s allowing us to have patients cancel earlier so we can fill those slots with other patients,” she says.

Ms. Benoit likewise emphasizes effective pre-visit communications as key to efficiency. “It starts with the patient’s initial phone call, getting them into the practice and having them scheduled,” she says. Staff designated as “colon cancer screenists” handle that initial contact with the patient. They perform a health assessment and review each patient’s health history to ensure they meet criteria for outpatient colonoscopy, with those who don’t scheduled at an inpatient facility. If criteria are met, the staff member schedules the patient at a time convenient for them, and then provides prep instructions.

Ms. Benoit notes that giving those instructions over the phone isn’t enough. “We try to keep the patient well-informed right out of the gate, so we communicate prep instructions in multiple ways,” she says. “We mail it to them. We get it on their MyChart. We have nurses available on triage to answer questions on prep instruction. We’re updating our website so patients have even more resources.”

Beyond ensuring that patients properly prep, Novant also focuses on making sure they arrive for their scheduled appointment. “Our automated system reminds patients days in advance of their appointments via text message or telephone,” says Ms. Benoit. “We have staff who reach out to the patient about two weeks ahead of time to make sure they are still planning to come to their appointment, and to ask if they have any concerns or questions. If we find out a patient is going to be out of town, that gives us the opportunity to bring in another patient.”

• Scope availability. Having enough colonoscopes available to keep a busy, full schedule on time throughout the day is crucial to efficiency. “Every minute counts,” says Ms. Roberts. This involves not only buying more scopes when needed, but also having loaners on hand and improving reprocessing times, she says.

While wear and tear is a necessary evil — colonoscopes at high-volume centers have roughly a five-year lifespan according to everyone quoted in this article — accidental damage can negatively impact patient flow on any given day. “We’re really focused on making sure that staff who are handling the scopes are properly trained and retrained constantly so they have the technique to prevent breakage and unnecessary damage over time,” says Ms. Roberts. “It’s important to make sure they know just how delicate the scopes are and how to handle them properly.” To further aid in this effort, scopes are transported to and from procedural, reprocessing and storage areas in lidded, rigid containers at both AMSURG’s and Novant’s centers.

We definitely have been experiencing same-day cancelations and focusing on decreasing those.
Jackie McDougall

Negotiating with scope vendors for loaners is vital. “If you have a good service contract in place, they’ll send you a loaner right away, so you’re only down for a day or a couple days while they repair the scope,” says Ms. Roberts. Adds Ms. Benoit, “When you purchase X amount of scopes, our vendor provides a couple loaners, so when you send a scope out to repair, you have a backup.” Novant has also purchased more scopes to meet demand.

Scope availability requires efficient and thorough reprocessing. A large component of that process is the automated endoscope reprocessor (AER) that disinfects the devices. AMSURG is evaluating upgrades, and the fastest AER cycle it has seen is 23 minutes; currently, AER cycles at most of its GI centers require 28 to 30 minutes. Improved speed is not the only consideration, however.

“With AERs, we’re really looking at the time it takes for the cycles to run as well as how many scopes we can run at one time,” says Ms. McDougall. “If we’re looking at two different AERs, and one can run two scopes in one basin for a total of four at a time, we definitely want to go that route versus running one at a time.”

“Some AERs process them at the same time, so you’re limited based on the number of cycles because you need to fill it up and then run the cycle,” notes Ms. Roberts. “Others have independent cycles.”

AER efficiency directly ties into room turnover efficiency. Currently, AERs at Novant’s Wilmington center are just over four years old with processing times of 27 minutes per scope, and the system is evaluating upgrade options. “We are aware that some newer AERs have reduced processing times and can handle more scopes — and probably in a smaller footprint, with the machines not quite as large,” says Ms. Benoit.

Another consideration is safe and accessible storage of clean scopes. Ms. Benoit says Novant uses scope-specific air-drying cabinets with HEPA filters, as do many AMSURG centers. At these high-volume centers, however, reprocessed scopes don’t have much time to “hang around” in storage. “We’re reusing those same scopes several times throughout the day, and then they’re stored overnight for the next day’s procedures,” says Ms. Roberts.

• Room turnover. High-volume GI centers closely track room turnover times to optimize patient flow. AMSURG has provided additional resources to safely drive those times down. “Previously, the teams that supported a procedure would be responsible for turning over the room, and that’s still fairly common, but at our very busy centers, we look for more support,” says Ms. Roberts. “We might have a runner or somebody else assist in the room to get ready for the next patient. We check in with the team to see how efficiency is moving and that’s really reflected in our scheduling. If we can turn over the room faster with that extra support, and have scopes ready for the next case right away, we can adjust how long we’re scheduling procedures.”

Of course, not every room turnover is the same. “We try to work pretty efficiently, but sometimes it depends on the situation and what’s gone on in that room,” says Ms. Benoit. “Some rooms may require a more advanced deep terminal cleaning.”

• New scopes, new technologies. Both AMSURG and Novant monitor the marketplace for new scopes with an eye on increased performance and new features that can enhance both clinical and operational efficiency. Ms. Benoit says performance improvements and new features of the processors that power some newer scopes are even more impressive than enhancements to the physical scopes themselves.

The use of artificial intelligence (AI) to improve adenoma detection rates (ADR) is intriguing but still in its relative infancy. Ms. McDougall says some AMSURG centers utilize it “a little bit, but not across the board,” and Novant is still investigating the technology. “We need to do good due diligence on the clinical research side regarding the use of the AI technology for the gastroenterologist — how they view it, the pros and cons, looking at each vendor,” says Ms. Benoit. “It’s certainly promising technology.”

At AMSURG, another digital platform, though much less high-tech, is helping providers improve ADR: GIQuIC, a registry developed in conjunction with the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy to collect, organize and display digestive healthcare data in the interest of improving patient outcomes by allowing users to benchmark quality, identify gaps in care and develop specific, targeted quality improvement initiatives. Data provided to and generated by the registry also contributes to further research that can assist the GI societies in developing patient care guidelines while providing quality measure data to third parties including CMS’ Merit-based Incentive Payment System (MIPS), private payers, accrediting bodies, referring providers and patients. Participating providers can use the data not only to demonstrate quality of care to patients and payers, but also to provide benchmarks that its endoscopists can strive to achieve.

“Our GI centers utilize GIQuIC and internal benchmarking to improve our patient outcomes,” says Ms. McDougall. AMSURG not only monitors and benchmarks ADR, but also metrics like times for cecal intubation and withdrawal. “Our providers need to meet certain benchmarks so they’re spending ample time to appropriately detect any polyps and balancing that with the detection rate, while making sure they are moving through at an appropriate pace,” she says. The goal is for providers to move quickly, but not too quickly. “The most important thing is spending ample time on each patient for their colonoscopy,” says Ms. Roberts.

Providers linked into GIQuIC and internal benchmarking tend to be enthusiastic about improving their metrics by competing with themselves and their colleagues. “We can see how many of our providers are hitting a metric or are below or above it, and we’re sharing the data,” says Ms. Roberts. “Providers get involved because they really want to make sure they are performing at their best. The data is a great motivator for them.”

• Expansion. Demand for colonoscopies is so high that some ASCs and endoscopy centers are proactively expanding both their volume and their physical facilities to increase efficiency. “I have a couple surgery centers that are seeing such an increase that we have undergone expansion to accommodate more volume with a second, third or fourth procedure room,” says Ms. Roberts. “Major health systems have been reaching out to us and our centers looking to collaborate to take on more GI cases because they are backlogged and don’t anticipate being able to catch up. They think it could maybe be six months to a year before they could get caught up even with us collaborating with them.”

Always adjusting

Keeping a colonoscopy line humming at peak efficiency ultimately is a matter of constant tracking and adjustment to help providers, nurses and techs perform together as a well-oiled machine. “We’re always monitoring,” says Ms. Benoit. “We keep a close eye on our room utilization rate, we look at patients’ scheduled throughput the day, we track our no-show and cancelation rates, and our scheduled-open rates to make sure we’re booking at 100% of our schedule.” OSM