The prospect of integrating new office-based procedures into an already busy outpatient practice may seem daunting. Yet the success of an OBGYN practice depends on its ability to adapt to changing business models.1 New financial pressures—as well as financial incentives—are motivating us to perform outpatient obstetrical and gynecologic procedures in our offices.1,2,3 At the same time, our patients are becoming more discriminating healthcare consumers and expect more services and greater convenience in outpatient care. Patients are asking more often to take an active role in their care, especially in situations where they can exert some control over scheduling, treatment, or procedures in a way that minimizes the impact on their life.
A deliberate, step-wise consideration of the factors involved in this transition can make the process less intimidating and help us to better serve patients in an increasingly value-based care system. This article outlines steps you can take to keep your practice operating smoothly as you incorporate minimally invasive procedures into your workflow.
Considerations for integrating procedures into the practice workflow4
Choose the right in-office procedures. Carefully review everyone’s patient panel to identify the most common outpatient procedures. Recent surveys indicate that OBGYNs treat an average of 55 patients with abnormal bleeding per month.5 There are several procedures to treat abnormal uterine bleeding that can be performed in the office. In my experience, for example, most gynecologists are either performing or are interested in offering office-based endometrial ablations.5You need not transition from the OR to an office that offers the full range of outpatient procedures all at once. Even if you are comfortable with all types of procedures in the OR setting, your office staff may not be, so a tiered introduction may lead to greater acceptance and successful adoption.You may choose to implement this practice change gradually. Consider starting with diagnostic hysteroscopy, simple operative procedures like polypectomy, then ablation, and finally more advanced procedures like adhesiolysis, septoplasty, and myomectomy. For optimal efficiency, it makes sense to limit the expansion of office-based services to common procedures while avoiding those that are complex and rarely performed. This limits the possibility of disruption caused when office staff are asked to participate in unfamiliar procedures.6
Staff capacity and capabilities. Confirm that your staff have the interest, skill, capacity, and training to support in-office procedures.7 Reinforce that your motivation is not solely financial reward but hinges on your practice’s desire to provide higher quality, patient-centric care. Ensure that you have your staff’s buy-in and support for the integration.Plan ahead by reallocating routine tasks, such as inbox management, prescription refills, pre-visit planning, and other duties. This can free up your staff’s time, enabling them to take on new responsibilities. The appointment of a “point person,” assigned to manage the procedure room and procedural protocols, can help with logistical oversight of office-based procedures.6Consider the skill sets of each member of your staff and the role each team member will play in procedural support. Ensure that any new responsibilities are within the team member’s scope of practice.6 For procedures that require a greater level of sedation, a certified registered nurse anesthetist or an anesthesiologist may be required. When offering such services, your practice will need to determine whether additional staff is needed on a full- or part-time basis.6 CLICK HERE for tools and resources for your staff.
Office layout and exam room space. You don’t need to replicate the surgical theater to perform in-office procedures. In fact, you should consider doing just the opposite. Instead of a sterile, unwelcoming environment, create a comfortable and safe space for patients with artwork and music in your procedure room.Some practices can dedicate a room to procedures. Others have exam rooms spacious enough to accommodate additional equipment, allowing those rooms to be used for routine examinations as well as procedures.3,8,9 A basic planning rule is that the space should easily accommodate all members of your support staff during the procedure. In addition, space will be needed in or near the procedure room for patient preparation and recovery, and this can be a small room, enough to fit a chair.6 If possible, dedicate a room in a low-traffic area of your office to procedures. Patients will appreciate the peace and comfort that offers.
Proper equipment and supplies. The necessary diagnostic and surgical equipment will depend on the procedure(s) being performed. Most practices already stock basic supplies required for invasive procedures, such as gloves, cotton swabs, pads or fluid drapes, and speculums.6Adequate lighting is essential. Therefore, in addition to procedure-specific instruments and equipment, lighting upgrades may be necessary.6 Your practice should determine if an automated exam bed and ergonomically designed and/or space-saving equipment profiles would make movement in the room easier or procedures more efficient.6 Think about adding carpeting to your procedure room to manage fluid spills.Consider the example of office-based hysteroscopy. When offering this outpatient service, six basic types of equipment are needed:9
- Diagnostic or operative hysteroscope
- Light source
- System for uterine distention and fluid management
Once you have identified which procedures you plan to incorporate in your office, perform an internal audit of your equipment to ensure you have all the instruments needed to be successful.
Certification, credentialing, and accreditation. Regulatory oversight of in-office procedures is limited. As a result, your practice bears responsibility to monitor quality, uphold standards, and comply with guidelines.3,6The position of the American College of Obstetricians and Gynecologists (ACOG) is that “any physician planning to transition procedures to in-office should first demonstrate competency in that procedure in an accredited operating room setting.”6,10 After obtaining credentials to perform in-office procedures, you and your colleagues may opt to periodically review each other’s competency and evaluate patient outcomes.6 Suggested metrics to track include hospital admissions, patient satisfaction, and performance on safety drills etc. You can also ask patients to rate their pain during the procedure to help refine your analgesia protocol.Depending on the procedure being performed and the level of patient sedation involved, you and your team may need to be certified in basic life support or advanced cardiovascular support.6 Familiarize yourself with guidelines for use and maintenance of resuscitation equipment, including oxygen, suction, and defibrillation.Procedures and documentation required regarding equipment use, sterilization, and cleaning may vary by state or province. Ensure that best practice, not just minimum protocols are met
Policies and protocols. Developing policies and protocols in advance will help maintain quality, safety, and consistency for your office practice. These written policy documents should encompass staffing, equipment, standards for each aspect of the procedure, patient flow, and integration into the broader workflow of your practice.6Procedure-related documentation should include:6
Patient consent forms
Checklists for team members
Pre- and postprocedural care instructions, such as preprinted orders to reduce complications and areas of omission
Policies, documents, and standards from state and local agencies
National recommendations from ACOG, the American College of Surgeons, the Joint Commission, or the American Medical Association, as applicable3
There are numerous companies that provide protocols and consulting services for procedural policies but ACOG’s 2010 Report of the Presidential Task Force on Patient Safety in the Office Setting is a great place to start. It contains example privileging forms and checklists that your practice can include in the documentation binders.10
Scheduling. Scheduling can make or break the efficiency of you practice, day in and day out. It’s essential that the schedule be well-thought-out for an office practice to be both efficient and profitable. The care team must be trained in preparation, procedural steps, patient monitoring, equipment handling, and cleaning to rapidly turn over the room.9 Organized planning can allow a medical assistant to set up or clean the procedure room while you perform an annual exam or see an established patient. This type of approach can maximize the efficiency of the practice. For example, one practice reported being able to schedule a hysteroscopy in the same room every 30 minutes, an efficiency they attribute to staff training.9Companies such as Hologic can put you in touch with other practices and clinicians that have arranged their schedule in an efficient way that works well for the clinicians, staff, and patients.
While it may seem like a considerable effort, your practice may have already applied many of these planning and execution steps when adding new physicians to a group practice, or when implementing new methods of team-based care. A phased approach to integration can help your practice avoid feeling overwhelmed or like you have taken on an insurmountable task. Phased approaches also help stagger the costs so you can start to see early returns from simple procedures as you and your staff become more comfortable with complex procedures. Preparing now to integrate in-office procedures into existing workflows can position a practice for future success from a profitability perspective but most importantly, for improved patient outcomes and satisfaction.
1. Wieand E, Lagrew Jr, DC. Value-based payment: what does it mean, and how can ObGyns get out ahead? OBG Management. 2018;30(1):17-26. 2. Witt M. In-office hysteroscopy procedures: reimbursement jumps 237%. OBG Management. 2017;29(7):26-29. 3. Cholkeri-Singh A. The benefits of integrating in-office hysteroscopy. MDedge web site. Accessed February 19, 2019. 4. Data on file. Hologic, Inc. 2018. 5. Data on file. Hologic, Inc. 2015. 6. Emery JD, Paraiso MFR, eds. Office-Based Gynecologic Surgical Procedures. New York, NY: Springer Science+Business Media; 2015. 7. Data on file. Hologic, Inc. 2016. 8. Cholkeri-Singh A. Payment changes drive hysteroscopy to the office. MDedge web site. Accessed February 19, 2019. 9. Wong M, Miller V. Why you should be performing office hysteroscopy...now. Contemporary OBGYN web site. Accessed February 19, 2019. 10. The American College of Obstetricians and Gynecologists. Report of the Presidential Task Force on Patient Safety in the Office Setting. Washington, DC: The American College of Obstetricians and Gynecologists; 2010.
Dr. Thiel is a paid consultant of Hologic. Hologic provided editorial support for this article.