Inpatient endoscopy workflow is complex due to the need for multidisciplinary care coordination and on-demand scheduling. At our facility, weekday inpatient procedures are performed in dedicated operating rooms (ORs) with anesthesia support, with staff resource changes after 17:00. Delays result in unpredictable schedules and extended work days, negatively impacting patient care and both patient and provider dissatisfaction. This initiative sought to find targetable opportunities to streamline endoscopy workflow and minimize time between cases by utilizing a time-series study, with the goal to decrease days with cases extending beyond 17:00. We conducted an IRB-approved QI (Quality Improvement) retrospective analysis of all weekday inpatient endoscopy cases from 7/2017 through 9/2018. Our primary outcomes were number of cases performed each day and the day’s finishing time, defined as the endoscope-out time for the day’s last case. For all weekday inpatient cases over a two-month period, we conducted a time series study of the processes involved in completing an endoscopic procedure to find the takt time and identify sources of variability. All OR cases are completed with anesthesia support in consecutive order, unless resources are provided to staff other ORs for simultaneous cases. We engaged stakeholders to build a detailed process map, known as a swim lane diagram, and identify barriers in care that lead to delay. The process map for inpatient endoscopy shows key areas of variability and delay (Figure 1). During 315 weekdays over a 15 months period, the total number of cases was 2220, with a mean of 7 per day (SD 2, range 2-17), finishing time of 17:46 (SD 2:23 hours, max 1 am). The time series study included 28 weekdays of OR consecutive cases (176 procedures, 45 of which were same-day add on cases mixed into the caseload). We calculated the mean times of each process step per procedure with total takt time, accounting for whether the patient goes to the peri-op holding (PRA) (Figure 2). The total amount of time for the patient from leaving the hospital room to leaving the OR was 2:38 and 1:53, with and without PRA respectively. The average total OR time per patient, defined as the time of a patient’s OR arrival to the next patient’s OR arrival, was 1:33 and 1:56 with and without PRA respectively, where the latter included transport time. The mean time spent on endoscopy per case was 26 minutes (IQR 12-36 min), which was 26% of the total OR time (from 7:30 to last case endoscope-out). The OR was unoccupied for 31% of total OR time, with an average time between cases of 34 minutes (SD 22 min). There was high variability in caseload and finishing time, and substantial amount of time between cases. The time-series study identified barriers in workflow, which will be targets for improvement with measurable process and outcome metrics. This study shows how quality improvement tools and methods may be used to improve efficiency of inpatient endoscopic procedures.View Large Image Figure ViewerDownload Hi-res image Download (PPT)
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