ENDOSCOPY SUITES ARE BEING REMODELED OR NEWLY BUILT AS THE SPECIALTY BECOMES MORE AND MORE IN DEMAND. ENDONURSE TALKED WITH SUITE DEVELOPERS AND USERS TO DISCOVER WHAT’S NEW, WHAT’S RECOMMENDED, AND WHAT’S DISCOURAGED.
Endoscopy centers are being built to achieve certain goals,” says Marc Shapiro, software and integration systems director at Olympus America Inc. “One of their goals may be to develop the best learning environment; others may look to manage efficiency and flow. They are looking for the best environment not only for taking care of patients, but also being able to provide a learning environment and have an environment that is state-of-the-art. The other questions are, what are the objectives, and how does the technology have a return on investment?”
Shapiro points out that hospitals differ from one another in terms of the levels of technology integration they are willing to adapt — some prefer video routing or video conferencing, or, with respect to room turnover, being able to send observation camera images to a central nurses’ station, so they know when the procedure is done and can bring the next patient back. “It’s not a surprise that we’re seeing some of this enter into endoscopy, where you’re not only looking for ways to maximize efficiency but also to be able to deliver it at a reasonable price point, given cost constraints within healthcare today,” Shapiro observes.
As technology becomes more complex, more information needs to be managed. “Information management needs to be done seamlessly, and it can’t be a burden that’s going to detract from patient care,” Shapiro adds. “We’re seeing more information management, and we put it in three categories: communication, collaboration and connectivity. The important thing is to do it right from Day One. Just like building a house, it’s going to cost you twice as much to do it later than doing it up front.”
Healthcare centers must determine at the very beginning what their objectives and requirements are, in order to “layer in” the correct size, space and footprint, as well as the right technology to maximize productivity. “We are moving more toward an electronic age for electronic medical records, capturing endoscopy images, and also being able to manage patient information,” Shapiro observes. “Ultimately, that must have a proven return on investment. That allows them to get real-time patient information, the ability to maximize patient care, and being able to reduce costs.”
Shapiro points out that there must be a balance between technology and efficiency, but not to overwhelm staff by biting off too much technology at once and causing disruption. “Define what’s critical, the ‘must-haves,’ and the ‘nice to haves,’ so that it’s scalable, and has the ability to grow, so when you’re ready, we have a system that doesn’t require people to make major technology changes,” he advises. “Building it up front will reduce the need to make massive technology infrastructure changes later on.” A center that will eventually need three rooms but currently will only use two should at least build the shell for the third space. “Put the technology under the hood. Put all the wiring and conduit and technology cabling in place, so when you are ready to move and expand and grow over time, you don’t have to make major changes and have a lot of cost impact for your facility,” he adds.
Some items that may rate as ‘bells and whistles’ include LCD monitors, ceiling-mount systems, booms or ceiling mount monitors, even observation cameras or video routing to a physician office, a conference room or nurses’ station. There are also video switches and routers, DVD recording and video streaming and video management, audio video conferencing.
“As for the nurse’s perspective, we need to make their lives easier,” Shapiro continues. “The fewer wires and cables they have to deal with to take the focus off patient care, the better; the less equipment they have to move, the better. Driving efficiency and maximizing patient care is clearly the endpoint here. There is a better way.”
When planning an endoscopy suite, it is essential to find a true advocate for the physician(s) or hospital so there is someone on the team looking out for their best interests, say Joe Oberle, business development director at Olympus America, and Nancy Vacante, business development manager for Olympus Strategic Resource Solutions. The other essential is developing an accurate financial proforma and a five-year strategic plan. “Both are needed, not just one or the other,” they say. “There are lots of bad business plans out there that force you to make critically important strategic business decisions based on limited information contained in a single business model representation that cannot possibly reflect the myriad of variables that affect a successful business outcome and return on investment.”
Other key components to consider during the planning stage include an experienced architect and general contractor, good site selection, and successful payor contract negotiations. Oberle and Vacante also recommend connecting with resources and experts on these topics in advance — before problems arise.
Funding can have many sources — banks, other lenders, equipment manufacturers; and equipment can be split between purchasing outright and leasing. Determining a procedure volume is helpful to determine if cash flow will be cyclical or seasonal.
When it comes time to start construction, it is critical to enlist an experienced medical contractor, and to carefully review the medical contract, incorporating an advocate. Also ensure compliance with all regulations — federal, state, county and local.
Olympus also recommends against over-equipping the suite; Oberle and Vacante suggest an equipment planner, and a look at the five-year plan rather than just the immediate future. “While high-tech is not as expensive as it once was, and bells and whistles are nice, if they don’t contribute to a quantifiable benefit, i.e., efficiency, safety, increased throughput, patient/staff satisfaction, increased procedure volume/productivity, lower costs, etc., you may want to reassess that expenditure,” they add.
B. Todd Heniford, MD, chief of minimal access surgery at Carolinas Medical Center in Charlotte, N.C., has a history of involvement in developing laparoscopy suites. “Perhaps the most important thing is having well-trained nurses, anesthetists, surgeons and scrub technicians,” he says. “Second would be the equipment. There has been a huge marriage between industry and surgery or patient care over the last dozen years, where there has been tremendous technological advancement.”
Asked if funding was hard to obtain to upgrade the suite, Heniford says, “Our hospital has seen that minimally invasive surgery is the wave of the future. They believe and are showing they believe by making investments in upgrading equipment as we need it. We will spend a couple of million dollars over the next year to upgrade our equipment, which we upgraded just a few years ago.”
“Typically when a customer starts their thought process around a digital operating room (OR), it’s usually when they’re in the construction phase,” says Sal Chiovari, vice president of digital operating rooms at Smith & Nephew Endoscopy. “In fact, it lends itself to the construction phase, because the digital OR involves the pulling of cables, the placing of infrastructure to support booms and lights. At the time you’re starting to think through the architecture, you need to think about capabilities now or in the future. You’re limiting your ability if you decide at a later point you now want to put in a digital OR, and you haven’t put in the additional beams necessary for support to hold a boom, or the necessary cable to conduit — what is necessary to network all the rooms together. If you’re not sure you want a digital OR yet, at least set up your infrastructure, so you can come back and do it at a later point.”
He points out that most ORs have a typical lifetime of 10 to 20 years; if you will want a digital OR before then, it is wise to at least install the infrastructure when constructing the OR. “If you decide to do it later, you are going to have to tear up the ceiling and roof, put in additional infrastructure, place conduit back and forth, so it’s very disruptive,” he observes.
Smith & Nephew offers the technology necessary to integrate the digital aspects of an OR, as well as project management. “We’re not the ones who are going to put in the additional high beam support in the ceiling; we certainly work with the architect and the construction people on the elements you need to put in, what power has to be where, what structures need to be built in place to support and/or house the digital components of the OR,” he says. “When you’re running a network environment, where’s your cable going to go, your network closet going to be? We actually start off the process by creating an architecture design that lays out how ORs are going to be structured, how we would network them together, how we’d get communications in and out, where we would place all our equipment, where cameras and microphones go, or video playback, monitors — all of these are elements we would design right up front.
“It actually happens in the bid process,” he adds. “You cannot bid unless you understand what you’re bidding against. You need to understand what your vendor is going to provide for you, and it should be very clear in writing.”
Smith & Nephew stays involved throughout the project; they stage all the equipment and mimic the OR in their own environment, test all the cables, then deliver it themselves to the facility, set up the equipment, and test it again. “We work with them every step of the way, because we want to keep them informed, not just pop up now and then,” Chiovari says. And customers are given choices; even if they change their minds later in the process, it is generally possible to accommodate alterations in the placement of cameras, for example.
“Smith & Nephew offers a customized implementation. We don’t say, ‘here’s your prepackaged solution.’ We also are very open from an architecture standpoint, in that we don’t restrict them to certain vendors. We haven’t partnered up with a particular light vendor and said we’d only work with them; we will work with all of them. In a lot of cases, hospitals have set up who they want to partner with, worked with someone for a long time, have a comfort with them, and we don’t want them to change,” he adds.
One unique aspect of Smith & Nephew is that components for the digital OR can be purchased separately or as a package; customers can choose just the items that they need. The equipment is designed to be modular, so an image capture device bought today can later be incorporated into a full digital OR.
“The main thing that changed from the old endoscopy is we put all our video monitors on Skytron, on a boom; it’s a tower suspended by the ceiling, and it keeps everything organized,” says Mary Wiener, BSN, NPA, assistant vice president for perioperative services at South Nassau Communities Hospital, which now provides endoscopy services in an expanded and redesigned endoscopy suite.
The new design “keeps wires off the floors; the air, oxygen and suction are on the opposing boom. It helps the procedure, whether it’s upper or lower endoscopy because they rotate from 180 degrees to almost 360 degrees,” she says.
That was not the only element that changed. Turnover time is excellent, says Wiener. “In the new unit, we put in two scope washers and two high-level disinfectant machines. That keeps the turnover of the scopes going throughout the day. We also went to a cost-per-procedure contract with Olympus, so we have an increased inventory of scopes.
“We developed with Olympus and the endoscopists what types of scopes they wanted, upper and lower, pediatric and EUS, and we’ve got all the newest equipment, so we didn’t have a big outlay of money, and it comes out to a cost per procedure, so you pay on a monthly basis,”
Wiener explains. “At the end of the lease, you can roll the lease over or buy the equipment. You have lots of options, so that enabled us at that time to increase our inventory of scopes, and we didn’t have to use loaners or rent any scopes.”
An upgraded design was another change — there are three individual procedure rooms, with the admission function separated from the recovery function. “When patients are admitted, they go to a four-bedded admitting room, with individual cubicles, telephones and TVs. Then they go into the procedure room, then back to a separate recovery room on the other side of the hall,” Wiener says.
“The patients do very well, because it minimizes the anxiety level, so we can focus on their needs, and teach them to understand what they’re about to go through,” explains Robin Holzmann, RN, BSN, nurse manager of the endoscopy unit. “The nurses are focused on patient education, diminishing anxiety levels, building trust in the intake area before going into the procedure room.”
Patient satisfaction is excellent; volume is up, and patients return to the facility for repeat procedures. “Patients remember our old unit and comment that they like the improvement, the efficiency and the unit’s cleanliness,” says Holzmann.
A new endoscopy suite has been open for a year and a half now at Mount Sinai Hospital in Chicago, says David Hoekstra, vice president of clinical services. “It’s not too new, but it’s still new compared to the rest of our building, which are over 100 years old,” he laughs. “Previous to endoscopy being in its own specific area, we just had it as part of surgery, in two of our 10 surgical suites.”
Before moving to operations, Hoekstra was on the finance side. It took some time to have the project approved, as there were delays due to negative air pressure, exiting, and basic architectural drawings being accepted by the state, he says.
“One of the most important lessons we learned is usually these projects are spurred on by a combination of need in the community and usually by a physician champion,” Hoekstra continues. “It’s very important that the physician champion not only be locked into ownership of the process, but after it’s built, having the amount of volume they thought they would have,” he adds.
Volume has increased, but only about 60 percent of what was predicted. “Changes in technology are causing changes in referral patterns,” he explains. “We’re in an era when some procedures are going to multi-slice CT, instead of being endoscopic.”
There is a caution when upgrading, however; when asked if the improved endoscopy suite has increased productivity or financial gain, Hoekstra replies, “We’re a case study in urban culture — we’re on the near west side of Chicago, and we’re nearly 60 percent public aid; we’re the largest provider or public aid in the state of Illinois, more than Cook County Stroeger hospital. The Illinois department of public aid as well as other states that follow similar reimbursement patterns aren’t known for reimbursing at the level of, say, Medicare, so you have to be extremely efficient in what you do or you can’t break even.”