This is a common question that will be asked more frequently as trusts try to achieve more
productivity from endoscopy. This FAQ discusses the issues and provides some guidance to
managers and endoscopy teams.
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. Many units 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.
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 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.
- So 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 BCSP that performance declines (and cancers are
more likely to be missed) towards the end of a list.
- Thus lists in excess of 210 minutes should be avoided and if an endoscopist is scoping
all day, there should be time for a break between lists.
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
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
- 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?
In order 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 better still, measure 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.