We propose a conceptual framework for GI endoscopy efficiency measures that meets the AHRQ recommendations by adapting Donabedian's framework for assessing the quality of medical care through an analysis of structure, process, and outcomes.12
Structure involves the settings of a unit, including resources, organization, and staffing, which influence how well the unit operates. For gastrointestinal efficiency, examples of structural measures include unit layout; number of on-duty nurses, technicians, and endoscopists; and sedation type. Organizational attributes, such as organizational culture, information management and incentives, are also important structural components of efficiency.13 The strength of structural measures is that they are actionable. Limitations include the fact that changes in structural measures do not necessarily have a clear link to outcomes. For example, adding additional nurses may or may not improve efficiency in a unit depending on whether nurses are a constraining resource in the process flow. Similarly, the number of procedure rooms is a key input toward productivity but says nothing of efficiency unless the use of that room is known.
Processes include measures that capture how well a system performs using intermediate indicators that are either proven or assumed to be linked with desired outcomes. For example, data on preparation time, sedation time, procedure time, percentage of procedures that begin on time, and room turnover time could be used to identify the aspects of a GI unit that must receive attention to improve efficiency. Process measures are advantageous because they identify the enabling mechanisms by which structure mediates outcome. For example, the sedation type is an important structural feature of the unit and mediates throughput by affecting sedation time and recovery time. The limitations of process measures are that they are less conclusive than outcome measures and provide no information on the effectiveness of a process. In other words, sedation time may be long or short, but it says nothing about whether it was effective at sedating a patient so that the procedure could be completed in a timely and safe manner.
Dr. Cole P. Thompson
Finally, outcomes are intended to accurately describe the desired results of the system. Efficiency outcome measures may include patient waiting times, flow time, resource use, throughput (procedures per room per day or cases per room per day), and cost (expenses per case or procedure). Outcome measures are very useful because they reflect the product of importance to stakeholders and are reproducible enough that they can be used for benchmarking with peer institutions. In regard to limitations, outcome measures provide no information into the cause of a deficiency or strength. In addition, outcome measures require risk adjustment; for example, the throughput and costs in a unit performing advanced therapeutic procedures will be very different from one performing predominantly screening and diagnostic procedures.
Efficiency metrics for gastrointestinal endoscopy
In the absence of measures that have been evaluated rigorously in the context of the AHRQ criteria of scientific soundness as discussed earlier, there are a number of important, feasible, and actionable measures that endoscopy unit managers and staff should consider using when analyzing the efficiency of their own unit. In Table 1, we describe these metrics in additional detail.
We recommend that practices start efficiency measurement by focusing on outcomes and comparing their results with peer practices. Data-driven benchmarks for these measures then can be developed by identifying best practices among peer groups. Areas of suboptimal performance should lead to identification of opportunities for intervention, either through changes in the process components to improve efficiencies and/or investments in the structural components to remove bottlenecks. Systems engineering methodologies such as discrete event simulation can be used to identify opportunities for efficiency improvement and experiment with operational changes without disrupting the clinical care of patients.14 Developing workflow tools that collect necessary data in a clinically seamless fashion also will be a key step toward successful implementation.
Strategies to improve efficiency
A systematic review of strategies to improve efficiency in the endoscopy unit is beyond the scope of this article. Nonetheless, many opportunities exist to become more efficient in a number of areas including the following: staffing, patient flow, sedation, scheduling, and management of unit uncertainties (eg, no-shows, cancellations, and poor preparation). The existing literature is limited and is hampered by a lack of consistency in efficiency measures and failure to recognize the importance of risk stratification in comparing outcome measures. For example, recommendations on staffing and unit structure for ambulatory surgical centers will not be applicable to academic health centers or large hospital systems where more complex procedures are performed and with more variability in the patient population.
