Update following the COVID-19 pandemic
The number of points possible on a standard endoscopy list has changed as endoscopy practice has evolved and improved. For example, where common practice was to schedule 12 points for a morning list, recent JAG assessments show that many services only schedule 10 or 11 points with perhaps 9 points delivered.
There are many reasons for this which reflect developments in both diagnostic and therapeutic practice. Many of the changes which improve quality have also lengthened procedure times. Changes include increased photo-documentation, better visualisation and yield of pathology, longer withdrawal time for colonoscopy and increased inspection time for Barretts oesophagus. Because of this, report writing has become more detailed and longer, increasing the cognitive workload and demand on endoscopists.
Additional challenges now face endoscopy services following the COVID-19 pandemic. Infection control measures require the use of either standard or enhanced personal protection equipment (PPE) and increase downtime to allow room cleaning. There are also multiple human factors that challenge the efficiency and capacity of endoscopy. The May 2020 JAG/BSG survey shows that during the early recovery phase capacity of lists across the UK was significantly reduced. The number of points per list varies and will reflect local infection control and the ease of environmental adaption (such as donning and doffing processes). The median number reported in the survey is 6 points per list (with an interquartile range of 5-8). This is likely to change as services adapt and new working practices evolve further and become embedded.
Productivity and efficiency
Productivity refers to the relationship between inputs and outputs. Efficiency is a much narrower concept, usually referring to the throughput (numbers) in a given time for a given resource allocation. Output in healthcare is a product of numbers of episodes and outcome of patient care in terms of quality, safety and their experience. Better and patient‐centred healthcare also impacts positively on the wider economy.
This FAQ focuses on efficiency but clinicians and managers need to be aware that a highly efficient service may not be productive if patient outcomes are poor. Moreover an efficient service designed around the needs of its staff, may impact negatively on the wider economy. Fortunately, there are good markers for quality and safety in endoscopy, and the service is routinely capturing and acting on the patient experience.
What is a point?
A point is a unit of time. For example some units assign 15 minutes to one point and allocate 1 point for an OGD, 2 for colonoscopy etc. Increasingly, this crude allocation is being adjusted for case mix and training. A unit may allocate 12 points to a morning list and 10 to an afternoon list on the basis that a morning list lasts 3.5 hours (210 minutes) and an afternoon list 3 hours (180 minutes). If the time of each list is divided by the points then for this allocation a point = 17.5/18.0 minutes for morning and afternoon lists respectively. Thus a point allows for 2.5‐3 minutes of room turnaround. This is insufficient, so some of the time in the ‘point’ is actually required for room turnaround if the list is to finish on time.
JAG is not prescriptive about the number of points that should be on a list, and this should be agreed locally depending on local practice.
How long is a list?
Before agreeing to the number of points on a list, the list time must be agreed. Ultimately, this is for local negotiation but it is worth considering these points:
- If a list is scheduled to start at a particular time then it is expected that this is the time the first patient is in the room and ready to scope, not the time the endoscopist arrives in the department. If scoping is to start when the list is scheduled to start, an endoscopist will have to arrive at least 10‐15 minutes beforehand.
- An endoscopist will not usually be able to leave the department immediately after the last patient leaves the endoscopy room: there is invariably some paperwork required and the endoscopist would be expected to check with the nursing team that all was well before he/she leaves the department. For a four hour PA it is reasonable to allow 30 minutes for starting and finishing, and it is recommended therefore that a list should last a maximum of 210 minutes.
- There is no compelling reason why morning and afternoon lists should be different.
- It should be appreciated that endoscopy is physically and mentally demanding and that there is very good evidence from the English bowel cancer screening programme that performance declines (and cancers are more likely to be missed) towards the end of a list. Lists in excess of 210 minutes should therefore be avoided and if an endoscopist is scoping all day, there should be time for a break between lists.
- Services should ensure that the number of points delivered on a list is maximised through safe patient preparation, pre-assessment and patient centred booking to minimise did not attends (DNAs) and cancellations.
Endoscopists work at different speeds
Endoscopists undoubtedly work at different speeds. There is expected variation between individuals of different experience: for example recently qualified endoscopists will scope more slowly. Training, experience and annual workload will determine performance but there is also variation between endoscopists of a similar level. This variation should not exceed +/‐ 10%: for example a slow endoscopist might do 11 points while a fast one might do 13.
For variation beyond this the following possibilities need to be considered:
- Does the points allocation truly reflect case mix? Does the ‘slow’ endoscopist have more complicated procedures or higher risk patients?
- Are there process factors that explain the difference? Are this endoscopist’s patients consented and cannulated before they enter the room? Is this endoscopist slower completing the report? Does this endoscopist speak to all the patients after their procedure?
- Does this endoscopist scope either very slowly or very quickly? Is the actual scoping time longer or shorter? Too fast may be inappropriate because cancers can be missed, therapy can be rushed and complications might be higher.
The solutions to these possibilities will be different but if all case mix and process factors are accounted for then very slow and very quick endoscopists should have their performance and technique reviewed.
How should points be adjusted for designated training lists?
To satisfy the measures laid down in the training domain of the GRS and to achieve eligibility for JAG accreditation, units which offer training need to provide designated training lists with workload adjusted to accommodate the specific needs of trainees. The adjustment made will clearly differ according to the skill level of a particular trainee, but as a guide, an increase of 50% in the points allocated for a procedure in early training seems appropriate (eg. colonoscopy becomes 3 rather than 2 units).
Are points the best measure of performance?
While endoscopy teams hone their efficiency the points system is a very good proxy for efficiency. However, ultimately the key marker of efficiency is how well the room is utilised. Endoscopy teams should be measuring the time the patients are in the room as a percentage of the total list time, or the time a patient is actually being scoped. There are no benchmarks but if everything is operating smoothly it should be possible after an uncomplicated procedure to turn a room round in 6 minutes. For a list with 12 endoscopies and 11 ‘turnarounds’ the patients would be in the room (210‐66)/210, or 68% of the time. For six colons with five turnarounds room utilisation could be 86%.
Endoscopists might view achieving these levels of efficiency in two ways: having undue pressure to scope or having more time to scope properly without the pressure of time because, through efficiency, there is more time to scope. In time points allocation should be refined by measuring how long a procedure takes and allocating points accordingly.
Attention to efficiency is a very important requirement of a highly performing service but high efficiency does not always mean greater productivity. It is important to be clear on the length of lists and what is expected of a given start time. The points allocation system is a universally known and accepted method of scheduling patients but there needs to be better adjustment for case mix and training. Accurate timing of procedures will aid this adjustment. The speed at which endoscopists work varies, but the impact of training, experience and process factors need to be taken into account before concerns about performance and technique are raised. Ultimately endoscopy teams should be measuring utilisation of rooms to monitor efficiency, and make adjustments to scheduling on the basis of this. Finally, it must be appreciated that the real world is not straightforward, that there are patients being subjected to invasive and potentially uncomfortable procedures and that there are, as a consequence, inevitably unforeseen interruptions that will affect efficiency.