The Hidden Burden of Equipment Failure in Endoscopy: Uncovered and Improved With Digital Technology

Objective A growing and ageing population combined with severe disruptions across endoscopy services throughout the United Kingdom (UK) during the recent pandemic has accelerated the backlog of patients awaiting endoscopic procedures. This places increased pressure to improve service efficiencies in an attempt to reduce this growing burden. Moreover, beyond repair costs, the full impact of faulty endoscopes on services is not well documented. This study aimed to outline tasks performed to traditionally report a broken endoscope; measure the impact on staff time, efficiency costs and staff morale; and report outcomes of staff experience and productivity when replacing traditional reporting with a digital reporting tool. Methods This study was conducted over six months at three endoscopy units. Cognitive-task analysis (CTA) and a time-motion study (TMS) were performed to process map all traditional tasks when an endoscope breaks, and again after a digital reporting tool was implemented. Two staff surveys were conducted. Data was aggregated to determine the overall impact and model efficiency costs. Results With traditional processes, on average one faulty endoscope generated 54 tasks, consuming 8 hours 53 minutes of staff time or £325 in efficiency costs, with 60% of staff reporting a negative effect on morale. In comparison, digital reporting generated 41 tasks, consuming 4 hours 31 minutes of time or £147 in efficiency costs, resulting in £45,468 saved annually. Furthermore, 95% of staff said their morale improved, and environmentally all paper-based processes were removed. Conclusion This study demonstrated the immense hidden burden of faulty endoscopes. Given the current challenges to endoscopy recovery, digital reporting tools may present an attractive means to minimise disruption to endoscopy services driven through improved equipment maintenance.


Backlog of care
Demand for endoscopic services in the UK has doubled over the last five years, due to an ageing population, increasing burden of gastrointestinal disease and uptake of national bowel cancer screening [1,2]. In May 2020 the joint advisory group (JAG)/British Society of Gastroenterology (BSG) national survey reported that the impact of the COVID-19 pandemic had resulted in significant delays unanimously across NHS endoscopy service providers [3]. At the height of the pandemic, the weekly average number of endoscopy procedures across the UK had reduced by 95% when compared to the pre-pandemic period. Several factors including reduced capacity and public reluctance to undergo endoscopy may have accounted for this significant drop [4]. Consequently, by January 2021, the estimated backlog of NHS endoscopy cases was over 476,000 [5]. Several strategies have been proposed to help eliminate this backlog including increasing capacity to 130% or delaying cases based on higher haemoglobin levels, but despite these interventions, any recovery is likely to be protracted [6].
Many units have implemented an endoscopy recovery plan to tackle this ominous backlog. The 'Getting It Right First Time' (GIRFT) report advocates that endoscopy units increase capacity and improve efficiencies [1]. This will be challenging as service delivery can be complex, requiring specially trained clinicians, patient preparation, administrative tasks, pathology, plus supply and maintenance of endoscopy equipment. Endoscopes, in particular, are intricate devices used in high-volume, thus are susceptible to damage.
The cost and impact of endoscope maintenance are therefore a key consideration. The majority of NHS Trusts will enter into a maintenance agreement with an endoscope service provider, as individual ad hoc repairs or replacement of endoscopes out of warranty can add a significant financial burden. Technical failure can reduce the number of endoscopes in circulation within a unit. A recent time-motion analysis revealed that the timely availability of endoscopes has been implicated as a direct contributor to daily service delays [7]. Thus, minimising the time an endoscope is out of action may improve efficiency within an endoscopy department.
Despite the potential value of optimised endoscope maintenance in aiding the COVID-19 recovery plan, to the best of our knowledge, no literature has been published to itemise the true, wider implications of broken endoscopes on hospital services, including factors such as the impact on staff time, efficiency costs and staff morale. It can be difficult to reliably measure this wider impact as traditional processes for reporting faulty endoscopes can be labour-intensive, unit-specific and paper-based. Studies have shown replacing such traditional processes with digital tools can lead to better data collection and benefits such as "efficiencies in workflow and improvement in communication" [8].
In this study, we aim to (i) define the standard processes traditionally followed when a broken endoscope gets reported (ii) measure the hidden burden of endoscope failure on services, including staff time, efficiency costs and staff morale (iii) create a model to estimate the total cost of endoscope failures and (iv) report outcomes of staff experiences using a digital reporting tool for equipment failure.

Clinical setting
This study was conducted over six months at the endoscopy and decontamination units of three NHS hospitals; Basildon and Thurrock University Hospital, Broomfield Hospital, and Southend University Hospital. Whilst these hospitals are all part of Mid and South Essex NHS Foundation Trust, the endoscopy units largely function independently of each other on an operational level. Faulty endoscopes were reported to the hospitals' Medical Equipment Management Services (MEMS) team and Olympus Medical UK & Ireland (Olympus), with whom the hospitals each had an endoscope maintenance contract. The study was performed during 9 am to 5 pm day shifts, when most endoscopic procedures occur. Nurses, healthcare assistants, doctors, porters and medical engineering staff were recruited if they were full-time staff and had over six months' experience in their unit. Staff were observed in all areas including endoscopy rooms, decontamination rooms, corridors and administrative rooms. Observers were recruited if they had a healthcare background, either as a clinician or hospital service manager, to ensure they understood different tasks.

Traditional Reporting: Cognitive Task Analysis and Time-Motion Study
The first two months of the study focused on defining the standard processes that were traditionally followed when a broken endoscope gets reported to MEMS and Olympus. This was achieved via cognitivetask analysis (CTA) and a time-motion study (TMS).
CTA was performed with staff at all three sites to process-map the entire sequence of tasks that occur when an endoscope breaks. Staff were led through two cycles of CTA. The first CTA included a walk-around of the units to note every step of the process. During the second CTA, staff were shown the process performed at other departments and they confirmed the accuracy of their initial answers ( Figure 1). The CTA identified "routine tasks" that occurred every time an endoscope breaks, such as decontamination, as well as "extra tasks" which occurred ad hoc, such as requesting a loan endoscope.

FIGURE 1: The stepwise process undertaken during Cognitive Task Analysis
A TMS was then conducted to measure how long it took staff to complete each of the tasks identified during the CTA. Three observers used a stopwatch to measure the time taken to complete a task on three occurrences, per site. They reported the average time in minutes taken per step, plus the job role of each staff member. "Routine tasks" were measured during clinical practice, whilst "extra tasks" were measured through roleplay due to their ad hoc nature.

Digital Reporting: Cognitive Task Analysis and Time-Motion Study
In the latter four months of the study a digital reporting tool, the MediShout app (MediShout Ltd, London, UK), was used to replace the traditional reporting processes. This digital tool enabled staff to report broken endoscopes directly to MEMS and Olympus, replacing all paper processes and phone calls. Each time staff reported a fault, the app asked them questions to gather prospective, real-time data on the nature of the fault, clinical impact, need for a loan endoscope and impact on morale. Olympus responded to hospital staff via the app to arrange repairs and provide updates. Hospital staff had full visibility of every issue reported and status updates via an online dashboard. CTA and TMS were repeated with the digital process to compare to traditional reporting.

Measuring Staff Satisfaction
Two staff surveys were conducted -one before the implementation of the digital reporting tool and one after the study ended -to further understand the impact on services when an endoscope breaks. Both surveys were undertaken by twenty staff members. The first survey asked about the traditional methods of reporting, and the second about the impact of digital intervention.

Resource Impact Analysis
After all data was gathered from the CTA, TMS, MediShout app, and staff surveys, a resource impact analysis was conducted to estimate the total resource requirement when an endoscope breaks. A model was created first to outline each potential task and assign how much staff time would averagely be consumed per task (see Appendices: Tables 4-6). Next, we calculated the probability of each task occurring based on how frequently the event occurred during the study, except for loan scopes where an average was taken based on the previous twelve months' activity. Finally, we input which staff were involved with each task, which enabled us to calculate staff time consumed when an endoscope breaks.
To understand the corresponding cost implication of this, each staff member was assigned a cost-per-hour value [9,10]. These costs were applied to the model, based on the staff member's job role, which enabled us to produce a total expected cost per endoscope failure. The process was completed for both traditional and digital reporting pathways.

The traditional processes of reporting a broken endoscope
Two of the hospitals had identical reporting processes, where faults were reported directly to Olympus. In the third hospital, faulty endoscopes were sent to MEMS, who then reported to Olympus. These differences impacted staff time consumed, such as the time taken to walk from Endoscopy to MEMS. Tasks performed could be grouped into ten main stages ( Figure 2). Across these ten stages, reporting directly to Olympus required up to 52 tasks, whereas reporting via MEMS required up to 58 tasks. The combined average across all three sites was 54 tasks ( Table 1).   It is important to note that not all the steps in Table 1 and Table 2 occurred every time an endoscope broke.
To view all individual tasks that occurred with traditional reporting compared to digital reporting via the MediShout app, in addition to the "probability" of each task occurring, (see Appendices: Tables 7-9).

Staff experience with digital reporting
During the four-month implementation period, the digital reporting tool was used by staff to report 56 faulty endoscopes. Of the users that identified the faulty endoscope, 30/56 (54%) were decontamination staff and 17/56 (30%) were Consultant-level doctors. Of the Consultant-level doctors who identified the fault, 1/17 occurred pre-procedure, 12/17 occurred during procedure and 4/17 occurred post-procedure. Whereas traditional reporting required 54 tasks on average, digital reporting required 41 tasks ( In the post-implementation survey, staff didn't answer some questions if they weren't involved in that step of the process. As per Table 3, 19/19 (100%) staff members stated communication improved with their endoscope maintenance provider, with 19/20 (95%) experiencing an improved reporting experience, 18/18 (100%) stating they now received feedback and 20/20 (100%) stating they were now more likely to recommend their services to colleagues. 15/19 (79%) wouldn't want to return to paper-based, non-digital reporting. 19/20 (95%) of staff believed their morale improved due to the new processes.

Discussion
COVID-19 has resulted in NHS endoscopy waiting lists rising to almost half a million procedures, making it imperative that endoscopy units perform efficiently and fully utilise existing capacity to clear the backlog. This study provides a revealing insight into the hidden and wide-ranging impact of faulty endoscopes on hospital services, in particular, the impact on staff time, efficiency costs, and staff morale.
On average, one faulty endoscope generates 54 tasks and consumes 8 hours 53 minutes of staff time, equating to £325 in efficiency costs. This can be as high as 12 hours 55 minutes if all potential tasks are required. Meanwhile, 60% of staff said faulty endoscopes can impact their morale. Contributory factors included the fact that traditional reporting was mainly paper based, with process variation between endoscopy units, and communication between stakeholders often fragmented. For example, whilst 35% of staff reported they didn't receive feedback from their maintenance provider, it is likely this occurred as staff couldn't easily communicate updates between themselves or didn't have full data oversight.
Staff often underestimated the true burden of tasks generated, despite them being appreciable. For example, 35% of staff perceived only 0-15 minutes of time was wasted when an endoscope breaks whereas our TMS showed reporting alone took 44 minutes. This significant time disparity indicates that staff aren't aware of all administrative tasks required when an endoscope breaks.
Kramolowsky and colleagues advocated that equipment repair costs alone meant "efforts should be made to minimize instrument breakage" [11]. Considering the additional impact of hidden costs we uncovered, hospitals should seek to proactively prevent the number of endoscope repairs. According to one study, this may be achieved by having endoscopists, nurses and assistants undertake more training in endoscope handling and care to avoid the "nuisance of unwanted and broken endoscopes" [12]. When repair requirements cannot be avoided, then digital technology can minimise the impact by standardising pathways, removing paper-heavy processes, and connecting hospital staff with maintenance providers.
The MediShout app reduced staff time consumed by 4 hours 22 minutes, saving £178 in efficiency costs each time an endoscope broke. This could result in an efficiency saving of £45,468 annually for the NHS Trust. Feedback to staff improved, rising from 35% to 100%, whilst 95% of staff said their morale and reporting experience improved, which aligns with a study that showed "digital technologies also contribute to improving healthcare performance and staff morale if skillfully designed and implemented" [13]. Improving satisfaction with suppliers and departments can bring long-term benefits, with studies showing that better autonomy and communication can help staff retention leading to a better quality of patient care [14].
A further motive to incorporate a change in the approach to endoscope maintenance is the potential environmental benefit. Indeed, the spotlight has been recently shone on the high carbon footprint of endoscopy units and has cultivated interest in a more sustainable future endoscopy model. It is conceivable that additional 'green' benefits of adopting a technological solution to reduce endoscope faults may reduce paper use, unnecessary decontamination and water use and transit of scopes to and from maintenance providers, all of which are listed as major contributors to endoscopy-related carbon dioxide production in a recent Lancet commentary [15]. Similarly, there has been discussion on the negative environmental impact of disposable endoscopes, with one study estimating that "if all endoscopic procedures were performed with single-use endoscopes and accounting for reprocessing, the net waste mass would increase by 40%" [16]. This further enhances the rationale for improving efficiency within processes that use reusable endoscopes.

Limitations
Despite providing useful information on current practices in endoscopy maintenance and potential improvements in efficiency, we recognise some limitations to this study. First, there were limitations in the data collection. Endoscopes usually break sporadically and unpredictably, several times per week on average, meaning some tasks had to be role-played and others measured via TMS. Thus, we had to assume that staff enacted role-play accurately. As we couldn't account for the time taken to switch between tasks or possible distractions to staff during their working day, staff time consumed could be underestimated. In the resource impact analysis, we used the cost of staff time saved, which is a resource efficiency, and not cash-releasing saving. It would be further prudent to understand the basic cost of endoscope repairs for instruments under a maintenance contract.
Second, although we reported the number of scope failures and tasks required for this reporting, data on the cause of the fault was not recorded. For example, whilst there is a possibility that less experienced clinicians performing endoscopy procedures may contribute to a higher frequency of endoscopy failures, our study did not capture such data. Further focus on these aspects may yield important information that may result in local changes to practice. In addition, although we have clearly documented the economic and efficiency benefits of improving endoscope reporting, we have not recorded the impact of endoscope failure and the potential benefits of integrating a technological solution on procedure numbers performed. This complete information may help to inform a health economic model to measure the true impact of such an intervention.
Finally, though there may be clear buy-in from staff and corresponding improved morale, more quantitative analysis is required to gain a more detailed understanding of staff motivations and perspectives on introducing and sustaining engagement in an electronic reporting platform in this setting.

Conclusions
This study demonstrated the immense hidden burden of faulty endoscopes. Each broken endoscope significantly impacts staff time, efficiency, and morale. Given that the backlog of endoscopy care has been compounded by the COVID-19 pandemic, it is imperative that hospitals aim to prevent faulty equipment from becoming a bottleneck in services. The introduction of digital reporting solutions could improve the efficiency in service through a reduction in endoscope maintenance downtime, in addition to having a positive environmental and staff morale impact.