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ASC Administrator Archives - Pinnacle III

Sep 04
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Running an Effective, Efficient ASC Daily Huddle

Running an Effective, Efficient ASC Daily Huddle

By ASC Management, Leadership

In the fast-paced, team-oriented environment of an ambulatory surgery center, a regular group meeting, also known as an ASC daily huddle, can serve as one of the most important times in an ASC’s day. A daily huddle can help staff get on the same page concerning potential challenges for the upcoming surgical day. Discussing foreseeable issues provides an opportunity to address them and helps ensure safe and productive operations.

In structuring an ASC daily huddle, clinical leaders must be sure to focus on engaging and relevant discussions. Otherwise, if huddles aren’t structured and executed meaningfully, they can quickly lose their value. Staff may start coming to huddles unprepared and disinterested. After a short while, huddles may be viewed as more of a social gathering or an optional meeting. Many may logically determine an unproductive huddle is a huddle not worth holding.

Daily Huddle Best Practices

Here are a few tips to make each ASC daily huddle more effective and productive.

Keep huddles short. A brief daily huddle helps keep people focused and engaged. Staff should come prepared to discuss only the issues and concerns that matter to the upcoming surgical day. A huddle is not an opportunity for staff to ramble or discuss insignificant topics. More serious issues requiring significant time and attention are also not appropriate for a huddle – these should be addressed as soon as they arise.

Consider using a timer to measure how long participants speak and track the huddle’s total time. Use this information to keep the discussion moving along in an efficient manner. A good time limit for an ASC daily huddle is seven minutes or less.

Choose an appropriate time for the huddle, then stick with it. Some ASCs hold their huddles in the morning. Some in the afternoon. But what other ASCs do shouldn’t matter to you. The time to hold your daily huddle should be what’s best for your ASC. If you seem to experience many issues in the morning (e.g., poor workflow, coordination, communication), a meeting every morning to plan out that day may be worthwhile.

If you tend to experience issues with appropriate staffing and instrument availability, for example, consider a mid-afternoon meeting. This can provide the time necessary to resolve such issues before the next day begins.

Once you determine the time that’s best for your ASC, do not deviate from it. This will help establish a routine for your daily huddle and better ensure participating staff do not miss a huddle.

Establish a consistent location. Holding the huddle in the same location can also support consistent participation. Choose a central location to make it as easy as possible for participating staff to attend. The location should be a private area that won’t interfere with operations.

Consider asking staff where they would prefer to hold the ASC daily huddle. This will help secure buy-in and ownership of the huddle.

Limit the number of participants. To maintain focus and avoid distractions, every daily huddle should only involve essential individuals. This typically means a single person from each department – business office, pre-op, operating room (OR), central sterile services department (CSPD) and post-anesthesia care unit (PACU).

Every department should be represented at every huddle. Establish this expectation during the first huddle and then hold staff accountable.

Run huddles in a consistent manner. To keep the ASC daily huddle functional and quick, follow the same direction every meeting. Establish the order for department representatives to speak and always proceed in that manner. Once participants become accustomed to that order, they will know when it’s their turn to speak, eliminating wasted time.

Daily Huddle Topics of Discussion

Representatives should come to each daily huddle prepared to speak about their departments’ specific concerns for the upcoming day. A concern one day may not be a concern the following day. If a matter is not a concern for the upcoming surgical day, it should not be raised during the huddle.

Here are examples of worthwhile topics staff may want to discuss, broken down by department.

Business office:

  • Appropriateness of check-in times
  • Patient comfort upon arrival
  • Staff comfort with patient flow
  • Ability for staff to handle unusual scheduling (e.g., add-on cases)
  • Patient financial issues that could delay the start of a case
  • Patients with similar names that could create safety issues

Pre-op:

  • Assessment concerns
  • Missing paperwork (e.g., history and physicals, consent forms)
  • Noteworthy patient health issues (e.g., fall risks, poor vision or hearing)

OR:

  • Challenging surgeries, surgical approaches, physicians or staff
  • Availability of instrument sets and supplies
  • Availability of required implants
  • Status of vendors expected to participate in procedures

CSPD:

  • Challenging instrument turnovers that could delay cases

PACU:

  • Discharge red flags
  • Appropriate staffing levels for patient flow/timing
  • Potential need for extended shifts

ASC Daily Huddle Success: Final Key Takeaways

When beginning with huddles, the first few might take longer than you desire. That’s to be expected as staff learn about and become comfortable with how you want to approach each daily huddle.

Provide guidance to participants on topics they should and should not discuss. Remind them about the importance of coming to the daily huddle prepared. Help them with timing. If someone starts to ramble, reel them in. While structure is important, strive to keep huddles loose and full of positive energy.

With each passing week, the amount of time a daily huddle takes should decline. After a little while, huddles should rarely – if ever – exceed your maximum time allotted.

Most importantly, every daily huddle must provide value. Participants should share their thoughts about what they believe is necessary to improve operations. Staff should come away from a huddle knowing what must happen to make the upcoming surgical day safe and productive.

Jebby Mathew, Regional Director of Operations

Dec 06
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Onboarding a New Department Manager

Onboarding a New Department Manager

By ASC Management, Leadership, Revenue Cycle Management No Comments

For those in ASC leadership, building the right management team is essential to success. This primary objective should not be taken lightly. Once you build an effective team culture with dynamic and engaged individuals, you can expect to make meaningful progress towards organizational goals. Thus, the process for finding and hiring management team members should be a selective one, based on your organizational needs. But what happens once you have selected and hired new management team members? How do you effectively integrate new department managers into your company and cultivate dynamic, engaged team members?

One key to the success of a new manager is a solid onboarding program. Anecdotal evidence shows, properly onboarding an employee can lead to higher job satisfaction, decreased occupational stress, enhanced company commitment, and improved employee retention.

A thoughtful onboarding program eases a new or existing employee’s transition into a new role, ensuring the individual has the tools needed to succeed. Without it, you will likely be performing another employment search soon.

Joining an existing team may be difficult for the new manager and existing team members who have already formed working relationships. So, how do you create an onboarding process that works for all members of your team?

Onboarding takes many shapes and forms, including, but not limited to, meetings, printed materials, one-on-one training, webinars, and corporate retreats. It’s not just training and education – there is also a social aspect to onboarding.

An example of how you may choose to approach employee onboarding for new department managers is outlined below. The process is outlined from a global perspective. As you read, consider how you might incorporate specific actions for your company.

Let’s get the onboarding process started! Day 1:

  • Make the new manager feel welcomed. Ensure their office, computer, phone, etc. are set up and ready for use.
  • Walk through the office and make personal introductions to colleagues.
  • Hand the new manager off to HR for completion of all the necessary employment forms and benefits enrollment.
  • Schedule meetings with other managers and key personnel. Share informative insights on the organizational culture and important team initiatives.
  • Set the tone, framework, and timing for learning. Be open to the process and willing to change timelines based on individual needs.

It is important to be patient during the initial onboarding process. Listen to the feedback and questions from the new manager. Not everyone is comfortable forging ahead or immediately creating relationships in a new company. Many might be hesitant to ask questions. Even new managers with industry experience have much to learn about this unfamiliar environment. It is our job to make sure they are given ample opportunity to absorb all the information and have the tools needed to succeed.

Onboarding checklist guide

It can be helpful to maintain a detailed onboarding checklist to guide you through the manager’s initial employment period. Some of the items you may want to include on your first 90-day checklist follow.

  • Set a 90-day expectation of objectives and performance.
  • Discuss the onboarding checklist in detail – and I mean detail!
  • Be available to mentor and coach daily. Make yourself available to discuss ideas and perceptions with the new manager and how to proceed.
  • Establish regular reporting with the new manager, perhaps weekly. Determine the reporting format and due dates. These reports may provide you with insight about the progress or struggles of the new manager as you move through the onboarding process.
  • Share a company organization chart and make introductions, demonstrating the bench strength and support of the company infrastructure.
  • Schedule regular one-on-one sessions to review the progress of onboarding and performance objectives. Identify tasks/initiatives which need further review and education. Identify initiatives from the orientation checklist which need to be added.
  • Schedule or incorporate the manager into existing management meetings and encourage collaboration from everyone present.
  • Observe, listen, and support. These activities will likely provide additional insight into the manager’s performance and how they are integrating into the company.
  • Complete a 90-day evaluation and thoroughly review the orientation checklist. Ensure any area that has not been adequately covered is addressed.

Following up

Once the new employee has successfully completed the initial employment period, don’t make the mistake of cutting the cord. Continue to offer relevant opportunities for education and development.

Figuratively speaking, it is common for companies to let the manager jump into the pool before they know if there is water in it. This tactic typically does not allow the new manager to get up to speed more quickly. Rather, it will likely delay the successful results you were hoping for from the beginning. Alternatively, giving your new manager adequate training and introduction to the company’s philosophy before overloading them with responsibilities sets them up for the best possibility of success.

Hiring is challenging enough, but once you have done your due diligence and recruited the person you want to your team, your job is not complete. An effective onboarding process requires putting in the time to foster training, provide support, and cultivate positive relationships. You want this to be a long-term win-win for the employee, the company, the clients, and you.

Carol Ciluffo, VP of Revenue Cycle Management

Jul 05
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Opening a New Surgery Center: A Roadmap for Success

Opening a New Surgery Center: A Roadmap for Success

By ASC Development, ASC Management No Comments

If you’re planning on opening a new surgery center, congratulations! If all goes well, you will soon provide your community with a high-quality, low-cost option for surgical care. But there’s a lot of work to do before you reach that exciting grand opening. It is said that “Rome wasn’t built in a day,” and neither is a successful ASC.

Before you proceed with plans to open a new surgery center, consider the following list of questions. Knowing the answers will help ensure the facility you picture today is what you end up presenting to your community tomorrow.

New Surgery Center Questions to Answer

Are your partners committed?

A new surgery center is destined to fail if you do not have committed partners. That commitment needs to be short and long-term. Commitment can be gauged in several ways – their financial investment, their case volume, and their participation in research and decision-making.

Once partner commitments are confirmed, you will need a well-structured operating agreement. This agreement should account for potential issues that may arise during the ASC’s development and as the business matures. Getting a group of physicians to verbally agree to partner on a project is one thing. It’s another to obtain their signatures on paper and make their vision reality.

Where will financing come from?

Building a new ASC isn’t an inexpensive undertaking. Expenses that will need to be covered before performing the first procedure include:

  • Construction, either of a new facility or remodeling an existing space
  • Medical equipment and supplies
  • Service providers (more on these in the next section)
  • Computers and software
  • Furniture and fixtures
  • Signage
  • Licenses
  • Staff salaries and benefits

You will also require working capital to cover expenses as you wait for reimbursement for procedures. Before you break ground, know how you will pay for all these expenses – and some unforeseen ones as well. You’ll probably need a mix of debt financing and cash capital contributions from the owners.

Who is on your team?

You’re going to need a lot of help to bring your plan for a new surgery center to fruition. Carefully consider the selection of individuals and teams with whom you contract to fill project needs. These service providers may include:

  • Architect
  • Management firm
  • Engineer
  • Attorney
  • Managed care contract negotiator
  • Recruiter
  • Marketer
  • Website developer

A poor choice of one or more of these service providers may result in serious ramifications. These could include project delays, failed surveys and inspections, poor contracts, and over-staffing.

What is your desired location?

This can be an easy or challenging question to answer, depending upon your circumstances. Do all the new surgery center’s owners practice out of the same building? If so, it may make sense to explore developing the ASC in, or attached to, that building. If that’s not an option, or you’re bringing together owners from multiple practices, you will need to decide whether to build a new facility or move into a remodeled space.

Both options have their pros and cons; weigh them carefully. Do you desire full control over construction of the building and its floor plan? Are you prepared to cover the additional costs (e.g., permits, foundation, connecting water, sewer, and electricity) associated with constructing a building from scratch? Is there an existing space you could remodel and open faster than building a ground-up facility? Will the potential savings of remodeling eventually be offset by building repairs and upgrades? While it may seem counter-intuitive, the cost of remodeling an existing space can surpass that of new construction.

What do you envision for the ASC?

The building of a new surgery center can take many months up to a few years. That’s why planning should consider not only physicians’ current case mix but their future volume projections.

For example, if your ASC will perform orthopedic procedures, are total joints on the horizon? If so, you will need larger operating rooms and additional storage space. If your physicians plan to eventually perform higher acuity cases, will you have the means to accommodate overnight stays (state permitting)? If you anticipate expanding to accommodate future growth, does the location you’re eyeing provide that option?

In the excitement of planning your ASC for today, don’t overlook the potential needs of your ASC for tomorrow. Be careful not to overbuild “just in case.” There’s a fine balance between building for what you need when you open and what you will need to grow.

New Surgery Center Pitfalls to Avoid

We’ve already touched on some of the issues to watch for when planning a new surgery center. Here are a few other pitfalls to avoid:

Don’t make rash decisions. It’s natural to want to break ground as soon as possible to move the project toward completion. But racing to build your new ASC could result in failure to provide appropriate attention to important matters. It’s better for a project to take longer if it means taking time to make educated decisions.

Don’t neglect project management. Building an ASC requires oversight and coordination of numerous moving parts. This adds up to a lot of time and energy. You and your partners may desire significant involvement in managing your new surgery center project. However, juggling it and a busy practice will likely prove quite difficult. Securing adequate, knowledgeable project support will help ensure nothing is overlooked or rushed.

Don’t underestimate the paperwork. You’re going to need to provide documentation to many organizations throughout the development of your ASC. This includes your state’s department of health, the Centers for Medicare and Medicaid Services, and an accreditation organization. The paperwork can be cumbersome and complex, and you will need to appropriately time its submission to keep your project on track.

Don’t wait to begin staff recruitment. Competition for suitable surgery center employees is high across the country. Recruiting and onboarding the staff needed for the first day your ASC is open will take time. Poor management in this area could leave you shorthanded, potentially forcing you to delay opening or slowing case migration.

Final Key Takeaway

One closing thought. I cannot overstate the importance of involving the right people in the building of your new surgery center. Individuals and organizations who are knowledgeable about what makes ASCs successful can help keep your project on schedule and on budget. Choose wisely!

Jebby Mathew, Regional Director of Operations

Mar 15
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Hiring an ASC Clinical Director

Hiring an ASC Clinical Director

By ASC Development, ASC Management, Leadership No Comments

Recently I took some time to reflect on what I’m grateful for. The long list I came up with included my ASC clinical director.

Our clinical director does a lot for our center. She certainly makes my job as administrator easier. Concerns have never been raised about her work ethic and performance. I wouldn’t think twice about leaving the ASC under her command for an extended period of time. I know that, if an issue arises, she can effectively address it or find the resources to do so. You can’t put a price tag on that peace of mind.

An ASC clinical director is a highly important function within the facility. Finding the right person for this role can be difficult. The clinical director must possess a variety of qualifications related to both clinical and business operations. To find the optimal clinical director for your ASC, I have listed characteristics to hone in on during your search.

Clinical Director Characteristics

Several characteristics clinical directors should possess to help them succeed in their role are outlined below.

Relevant clinical background. The clinical director should have a solid understanding of their center’s specialty(ies). For example, at an endoscopy center such as ours, our clinical director’s gastroenterology background is valuable. If you work in a multi-specialty center, the clinical director should possess a broad surgical and PACU background.

The appropriate clinical background allows the clinical director to:

  • Understand the roles and responsibilities of their staff;
  • Fill in for clinical staff members if someone calls in sick or needs to take a break;
  • Understand how to meet the needs and requirements of physicians in their respective specialties;
  • Earn respect from staff and physicians because of a demonstrated knowledge and experience with the specialty(ies);
  • Support the delivery of high-quality care; and
  • Help the center meet accreditation and regulatory requirements.

Eagerness to learn. ASC clinical directors typically work their way into the position by ascending the ranks of the clinical staff. Clinical directors often do not possess a strong business background as they move into this leadership position. To perform successfully as a clinical director, though, one must understand the business side of running an ASC. This includes budgeting, expense monitoring, and third-party payer contracting and reimbursement.

A clinical director must embrace learning. Your ASC will benefit as your clinical director learns the ASC business and incorporates new knowledge into his or her approach to clinical responsibilities. A clinical director who is motivated to go outside of his or her comfort zone in the learning process contributes to the ASC’s success and is worth his or her weight in gold.

Responsiveness. ASC clinical directors should be responsive to their physicians and staff. They must know how to recognize when issues are developing, such as a dissatisfied physician or poorly performing staff member. They must also know how to deal with these issues in a timely fashion to avoid them becoming more significant problems.

For example, a clinical director should recognize when a physician is becoming busier and adding cases. Such a development touches on many aspects of an ASC’s operations. It may require hiring more staff, allocating more block time, and/or purchasing more supplies. The clinical director is not expected to address these potential developments independently. Rather, they may research the development and speak with other members of the ASC team about actions to effectively accommodate the growth.

Proactiveness. Strong clinical directors can foresee future challenges and know how to act in advance. When a clinical director is new to the position, these challenges may primarily be clinical in nature. The longer the clinical director is in the position, the more he or she should consider business and operational issues as well.

Effective communicator. Clinical directors should be strong communicators, an important ability for effective leaders. They must know how to engage in clear communication with everyone in the center, including physicians, staff, vendors, patients and their families.

Remember, effective communication is a two-way street. A clinical director should feel comfortable approaching others and promote an environment where others feel comfortable approaching the clinical director.

Giving Thanks for My Clinical Director

Our center recently went through an unannounced CMS survey. We were understandably stressed when it occurred, but no one panicked. The staff performed their job duties and provided the high-quality care that they do every day of the year. The physicians expressed complete confidence in the performance of the staff and the leadership of the clinical director. We passed the survey with no deficiencies.

This experience demonstrates how well our clinical director performs. ASCs typically have a small group of physician owners. The physician owners are likely to be critical of the clinical director because it is a clinical role. A successful ASC needs its physician owners to be confident in the clinical director’s leadership and ability to help run the center. If staff members feel the same way, employee turnover rates tend to be low. When staff members like their leaders and work environment, they’re not going to leave.

Patients notice this dynamic. They often comment, “You all seem to like your jobs and have fun here.” That speaks to how the center is managed and how ASC staff members feel about their culture and work environment. Much of this hinges on the presence of a strong clinical director.

Catherine Sayers, Director of Operations

Mar 08
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ASC Lifecycle

The Lifecycles of an ASC

By ASC Development, ASC Management, Leadership No Comments

ASCs, like any other entity or organization, have lifecycles. I’ve found each stage in a typical ASC’s lifecycle lasts about ten years, give or take a year. As each stage of the ASC lifecycle draws to a close, a variety of issues generally begin to appear. Each of these issues need to be dealt with to prepare the ASC to enter into and thrive in its next lifecycle stage.

The Physical Plant

Diane Lampron, Director of Operations at Pinnacle III, recently posted a blog about the physical challenges of an aging ASC. The physical challenges include issues that arise with outdated and aging medical equipment, IT equipment and systems, facility design/aesthetics, etc. I won’t rehash the details; however, I encourage you to access her insights

The bottom line? ASC administrators and governing boards need to proactively consider how they will deal with looming physical plant issues, both logistically and financially, before they become insurmountable nightmares.

Space

Most new ASCs located in leased space begin with a ten-year lease with options to renew lease terms at a later date. As the ten-year mark approaches, it behooves the facility’s investors and board of managers to begin considering whether their existing space meets the partnership’s current and expected needs. Much may have changed over the ASC’s initial ten years of operations. An ASC re-examining its space and lease agreement might consider the following –

  • Is the current space too small or too large based on case volume and OR utilization?
  • Is the current geographic location still desirable?
  • Are there physical plant issues?
  • Are the physical plant issues such that moving (rather than repairing or renovating) is a better option?
  • What is the cost of relocation?

Any tenant improvement dollars provided by the landlord should be fully amortized – a fact that should be reflected in a new lease. For facilities located in space owned by the ASC’s members, the question is likely more focused on renovation or expansion. In some cases, the members may consider selling the building.

One size does not fit all. Different scenarios require different solutions. Here are three examples.

In 2016, the governing board of an ASC that was poorly designed, unattractive, and inefficient in its use of leased space, decided to move into a state of the art, investor-owned facility, despite the substantially higher cost. The new location was a new build, custom-designed for the ASC and one of its partnered physician practices. The reasons for the move included physical plant issues at the old site, improved efficiency at the new site, investment opportunities for partnered physicians, and aesthetic factors.

A facility owned by a physician partnership experienced considerable volume growth. In addition, its case mix significantly changed within a short period of time. The partnership anticipated these trends would continue. It elected to pursue a large expansion of its existing location to accommodate the ASC’s changing needs.

Finally, a leased facility used the option of relocating or downsizing its existing space as leverage to dramatically renegotiate its lease renewal.

Finances

There are numerous financial situations to consider as an ASC reaches the end of the first stage of its lifecycle. Generally, near the ten-year mark, the center’s original loans will be fully amortized and retired. Consideration now shifts to what to do with the additional cash that typically becomes available. Will extra revenue contribute to additional partnership distributions? Will funds be used to pay for some of the identified physical plant or space issues? Will future plans to address physical plant and space issues incur additional debt for the partners?

As was true with space considerations, a variety of situations can influence finance decisions at the end of an ASC lifecycle. A partnership may elect to take on the financial responsibility of a complete relocation at the time of their debt retirement. Or, the board, proceeding within its rights determined by their operating agreement, may opt to open a line of credit for the facility to handle larger unforeseen expenses so they can add the additional cash flow from the loan retirement to partnership distributions. Their plan may be to use the line of credit as a bridge if a need arises and address any draws on the line of credit with the additional cash flow.

Membership & Recruitment

ASC physician membership is one of the most serious issues a partnership may have to deal as it approaches the end of each lifecycle. At these junctures, many of the partnership’s original members may also be reaching a new stage in their personal lifecycle – considering retirement or moving, for example. The crisis level associated with physician membership is dependent on how successful the partnership has been with recruitment during the previous ten years. The manner in which an ASC and its board of managers deals with potential membership changes is critical to its longevity and its next lifecycle.

The most effective approach to the ASC lifecycle membership challenge is multi-faceted. It begins with continuous recruitment efforts throughout the entirety of the ASC’s business operations. It seeks physician and case volume recruitment targets from a variety of sources, including individual “free-agent” physicians, physician groups, and the introduction of new product lines.

Ideally, the physician retirement process begins with a review of, and familiarity with, the partnership’s operating agreement. Know the retirement requirements related to notice, investment buy out, etc. By staying well informed, the board will be prepared to act as it should. Conduct regular reviews of the ASC’s physician partnership roster. Begin communication with physician partners who may be indirectly mentioning retirement as well as those who appear close to retirement. Determine the impact their retirement will have on your ASC and develop an appropriate succession plan. Will their practice recruit an additional physician to make-up for the retiring physician’s case volumes? Is it possible for you to collaborate in that effort?

Governance

ASCs are governed by their operating agreements. And, like ASCs, the partnership’s operating agreement has its own lifecycle. A review of the agreement by the board of managers, the management company, and, in most cases, the ASC’s healthcare attorney is probably in order when a center begins to approach the end of one stage in its lifecycle and the beginning of another.

Questions to consider include: Are the provisions that made sense ten years ago when the ASC was newly launched still applicable now? Can the agreement be modified or re-written to better serve the ASC’s partners over the next ten years?

Examples of operating agreement and governance changes that occur during an ASC’s lifecycle are varied. Some centers adjust their non-compete radius to respond to growth in their community. Some facilities, with the assistance of legal counsel, adjust market value formulas to reflect changes in the market place. Partnerships who originally did not allow for entity physician investment may adopt investment concessions to accommodate the increased prevalence of physician group practices or LLCs. Partnerships may opt to allow management company membership by altering agreements that originally excluded these entities. Some ASCs that once had multiple classes of membership may alter their agreements in favor of greater equity recognizing that physicians have multiple ASC ownership options in their communities. Lastly, board of manager structures may need to change to allow for additional members or appropriate representation.

Be Proactive!

Change in life is inevitable. Change in business is expected. The end of a ten-year stage in an ASC’s lifecycle can signify a make or break moment. ASC lifecycle changes are best dealt with through anticipation and planning. The key to making it is to remain mindful of the many moving parts that require attention. Important areas to monitor include your ASC’s physical plant & space, finances, governance, and physician membership.

Plan ahead! In the ASC industry, it is better to be proactive than reactive. You will thank yourself in the long run if you are able to avoid and mitigate foreseeable issues at your aging ASC.

Robert Carrera, President/CEO

Feb 21
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Matchmaker, Matchmaker: Finding the "Perfect" Surgery Center Team

Matchmaker, Matchmaker: Finding the “Perfect” Surgery Center Team

By ASC Development, ASC Management, Leadership No Comments

In the classic “Fiddler on the Roof” song “Matchmaker, Matchmaker,” Tevye and Golde’s daughters sing about a matchmaker finding husbands for them. The lyrics include the following line: “Matchmaker, matchmaker, look through your book, and make me a perfect match.” When tasked with building a new surgery center team, I play the matchmaker role.

My “book” is comprised of information on job seekers – a collection of resumes/CVs, interview notes, and insight from the candidates’ references. With this information, the pressure is on me to accomplish what those daughters ask for – perfect matches. I cannot simply choose who I think is the best clinical director, administrator, materials coordinator, operating room nurse, recovery nurse, and business office person on paper. These selections cannot happen in a bubble. Instead, I must do my best to ensure this initial set of team members will work well together. They will jointly create the desired culture for the ASC. And they will instill this culture in the staff members hired and trained after them, helping attract more likeminded individuals.

There’s a lot of pressure to get these initial hires right. I hope they will remain with the ASC for years, forming the foundation for the facility. When building a surgery center team, I focus on the following to increase the likelihood that I make the correct selections.

Ownership Expectations

During meetings with the ASC’s owners, I seek first to understand their expectations of the new facility. What does their optimal surgery center team look like? How do they envision the facility’s culture? What type of employees are they looking for to support that culture?

When PINNACLE III is the manager of the facility, I factor in our culture expectations as well. Defining an ASC’s culture isn’t easy. In my experience, if I take the time to understand expectations, I’ll gain the insight required to create the anticipated culture. In an ASC, it will likely include expectations of delivering the highest quality care via a skilled, efficient team who perform their respective roles with integrity.

Surgery Center Team Interviews

A resume or CV tells me about a prospective employee’s background. That background information is important – I want to hire competent, qualified staff. However, resume review is not the most important step in the hiring process. Candidates can appear quite impressive on paper but fall short of expectations in person. The interview process is the best opportunity to assess whether candidates fit the mold for the new surgery center team.

My interview questions aim to accomplish several objectives. I dig deep to truly understand how an interviewee will work for the ASC. My focus isn’t just be on short-term performance but the candidate’s potential longevity and adaptability as the center grows. What are their values? Do they place importance on honesty and integrity? Are they lifelong learners? How do they envision positively impacting the business? I’m looking for positive signs as well as potential warning signs.

I inquire about their previous employer’s culture. Coming from an organization with a different culture than the new ASC isn’t necessarily problematic. Depending upon the situation, it’s important to recognize that I may need to do a little work to address the effects of that culture, particularly if the candidate was not valued in their previous work setting.

I like to ask interviewees how they would act when faced with difficult situations I’ve witnessed firsthand in ASCs. For example, what would they do if they encountered a disruptive physician? What if the narcotic count was off at day’s end? What if a daily deposit didn’t match the books? I want to obtain an understanding of how they are going to respond during stressful events.

These types of questions serve two purposes, First, I hope their responses give me confidence that they will act responsibly. Second, I learn if they will respond differently than I would in a similar situation. If they turn out to be the right fit for the surgery center team, I have identified an area where this person may require some guidance.

My Presentation

When interviewing job candidates, I am typically the first, personal representation of the ASC. I am the face of its culture or, in the case of a new or developing ASC, its desired culture. I am likely all the candidates know of the surgery center team. If I want the ability to hire the candidates I determine are right for the ASC, I need to ensure these candidates view the ASC as a good fit as well.

With the low unemployment rate, health care professionals typically have at least a few, if not many, job options. Hiring is a two-way street. I need to ensure the way I present during the interview process reflects the way I want the ASC to be perceived. I believe it’s best to be clear and concise when interviewing. If I adopt an overly laid-back approach, I risk alienating individuals looking for structure. More laid-back candidates will still appreciate the professional manner through which I conducted their interview.

Achieving Surgery Center Team “Perfection”

While finding “perfect” matches may prove difficult, I want to come as close as possible with my initial hires. I would rather hold off on filling a position than make a “bad” hire. With bad hires, I often spend extra time and effort bringing them on, only to lose them after a short period. In a worst-case scenario, a bad hire can create untoward results in the ASC’s culture – gossiping, not focusing on personalized service, or not treating physicians as customers, for example.

That’s why the key for me is never to hire out of desperation. There’s no better way to find an imperfect match. Remember: When playing matchmaker for an ASC, the task is finding matches for the owners, other staff, and patients. And like that of a matchmaker, this is a responsibility not to be taken lightly.

Lisa Austin, VP of Facility Development

Oct 04
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Safe Medication Practices: Understanding CMS' Standard for ASCs

Safe Medication Practices: Understanding CMS’ Standard for ASCs

By ASC Management No Comments

Highly publicized instances of patient complications associated with compounded sterile preparations (CSPs) have increased scrutiny of safe medication practices in ambulatory surgery centers. Citations are being issued related to safe medication preparation and administration. There is confusion, even among surveyors, on the use of some multi-dose medications, such as eye drops.

In CfC 416.48, Centers for Medicare and Medicaid Services (CMS) clarifies that ASCs must provide drugs and biologicals in a safe and effective manner, in accordance with accepted professional practice, and under the direction of an individual the ASC has designated responsible for provision of the ASC’s pharmaceutical services. In the same CfC, CMS indicates drugs must be prepared and administered according to established policies and acceptable standards of practice. To meet the standard set forth in CfC 416.48, ASC Clinical Directors will want to consider this list of safe medication practice guidelines.

Safe Medication Standards of Practice

  1. Designate a licensed staff member to oversee your pharmacy program. Make sure this individual is routinely present in your facility. Follow your state regulations as they relate to the need for a registered pharmacist. Regulations vary from state to state. Some states do not require a registered pharmacist and some, like Texas, require a weekly consult.
  2. Maintain appropriate records for the ordering, receipt, and disposition of scheduled II, III, IV, and V drugs.
  3. Understand that single-dose medications/vials (SDV) are to be used immediately upon opening, on one patient only, and then discarded. Once opened, they cannot be stored for any period of time.
  4. Date multiple-dose medications/vials (MDV) upon opening with the beyond use date. Do not take a MDV into an immediate patient care area. If this occurs, that MDV becomes a SDV for that particular patient.
  5. Ensure staff are aware of the definition of a MDV – “A vial of liquid medication intended for parenteral administration that contains more than one dose of medication.”This does not apply to eye drops. Adherence to this guideline will prevent confusion in a survey.
  6. Create a policy and procedure for the administration of eye drops. Conduct staff training on the process.
  7. Review and be knowledgeable of the questions on the CMS infection control surveyor worksheet found in Exhibit 351.

United States Pharmacopeia Chapter 797 (USP 797) provides guidelines on compounding sterile preparations in ASCs. It is acceptable for a center to compound for immediate use, but the following rules apply:

  1. The compound sterile product (CSP) must be intended for immediate use or an emergency.
  2. The CSP cannot be stored for the purpose of anticipated need or batch compounding.
  3. No more than three (3) commercially available sterile products in original container and no more than two (2) entries into any container/package/device can occur.
  4. Continuous process must be completed within one (1) hour.
  5. Adhere to aseptic technique.
  6. Administer within one (1) hour, or discard CSP.

Examples of immediate use CSPs are antibiotic solutions, blocks, and irrigating solutions. Dilating solutions may also fall into this category. The development of best practices for immediate use CSPs is important and should be included in training and competencies for licensed staff involved in the preparation, transportation, and/or administration of CSPs.

The area where CSP preparation takes place should be quiet and free from distractions. The designated staff member should disinfect the area, complete proper hand hygiene, and wear appropriate personal protective equipment (PPE). The entry ports must be disinfected. Calculations should be verified to ensure accurate mixing takes place. Proper labeling must occur prior to removing the CSP from the preparation area and administering it to the patient.

To ensure safe medication practices and compound sterile preparations are compliant with CMS regulations, ASC clinical leaders may find it helpful to refer to the lists above. Additional information on CMS guidelines is available via the CMS infection control surveyor worksheet and the CMS website.

Jovanna Grissom, Vice President of Operations

Sep 27
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ASC Disaster Response: A Case Study

ASC Disaster Response: A Case Study

By ASC Management, Leadership No Comments

This is the second part of a two-part blog series on ASC disaster response by Diane Lampron, Director of Operations. Click here for part one.

In the blink of an eye, a completely normal day in your ASC, can be upended by a natural or man-made disaster. And it can take days, weeks, or months to return to your pre-disaster routine.

Emergency preparation is not only critical for an effective ASC disaster response, but, as we previously discussed, it’s a Medicare requirement for ASCs. Part of proper preparation is revising your emergency plan based on your response to drills, tabletop exercises, and emergency events. Every revision should improve the helpfulness of your plan. Understanding what it’s like for another ASC to respond to a disaster can further your ASC disaster response preparation.

Below are some of the critical steps taken during a Colorado ASC’s response to a ruptured pipe. The subsequent flooding caused substantial damage throughout the ASC. Areas flooded with the equivalent of sewer water included the waiting room, front hallway, registration desk, pre-op, and recovery room. The sub-sterile area also suffered significant damage. Thanks to a strong, tested emergency plan, hard work by staff, and outside support, the ASC re-opened to full capacity in three months.

Immediate ASC Disaster Response

Steps taken upon discovery of the flood and damage included the following:

  • Called the disaster code
  • Activated the emergency management plan (EMP)
  • Contacted fire department (which turned off water)
  • Ensured there were no patients, visitors, or personnel requiring evacuation.
  • Closed front entrance
  • Notified ASC leadership
  • Assessed affected areas
  • Took pictures of damage
  • Set aside damaged items/equipment (for insurance purposes, this included items that caused the damage, such as a broken sprinkler pipe)
  • Moved unaffected equipment away from damaged areas
  • Notified property insurance carrier
  • Rerouted deliveries

Activating the EMP

Activation of the ASC’s EMP triggered the following actions:

  • Established incident command team
  • Identified who would fill the roles identified in the EMP – Role assignments are critical. Each role guides the activities required to address all aspects of the disaster, from suspension of business operations to the response and through recovery.

Roles assigned included incident commander and staff (e.g., safety officer, infection preventionist, public information officer) as well as sections for operations, planning and logistics, and finance/administration. If you are not familiar with the responsibilities of these positions, the Federal Emergency Management Agency provides helpful resources here. Note: Some of the activities that took place under these sections are discussed below.

  • Developed incident action plan which established objectives throughout response to the incident and underwent regular updates as recovery progressed
  • Notified the facility’s governing board

Communication

The following steps were taken to disperse information regarding the incident and closure:

  • Changed telephone greeting
  • Posted notice on center’s website
  • Notified physicians’ offices
  • Notified the state’s Department of Public Health
  • Issued press release
  • Notified the state’s Department of Fire and Life Safety
  • Notified the facility’s accreditation organization

Disaster Recovery Work

The project was separated into five phases to be completed prior to a re-opening phase:

  1. Mitigation/ restoration
  2. Safety
  3. Demolition
  4. Rebuilding/construction
  5. Risk reduction

Mitigation/Restoration

Steps taken included the following:

  • Restoration company commenced water cleanup and mitigation activities working 24/7 to mitigate further damage
  • Industrial hygienist conducted assessment and took samples
  • Infection control risk assessment (ICRA) performed

Safety

Steps taken included the following:

  • With fire sprinklers offline, fire watch implemented
  • Conducted and documented fire watch walkthrough every 30 minutes during recovery period
  • Created signage for emergency fire exits

Demolition

Steps taken included the following:

  • Brought in contractor for demolition and construction phases of the work
  • Obtained permits needed for demolition and renovation/construction

Rebuilding/Construction

Renovation plans previously scheduled for a future date were incorporated into the disaster recovery work to save on construction costs.

Risk Reduction

Planning included efforts to help reduce the risk of a reoccurrence. For example, additional insulation was installed and a new checklist was created for facility personnel to follow when investigating leaks.

Incident Command Officers and Sections

The incident command officers and sections oversaw the ASC disaster response work described above. Additional responsibilities are described below.

Safety Officer

The safety officer performed the following tasks:

  • Daily walkthroughs for interim Life Safety measures, ICRA, and hazard control risk assessment ensuring corrections were made as needed
  • Daily count of narcotics and medication storage security checks

Infection Prevention Officer

The infection prevention officer performed the following tasks:

  • Daily ICRA assessment walkthroughs
  • Ongoing communication with industrial hygienist regarding assessment and safety tests

Public Information Officer

The public information officer performed the following tasks:

  • Issued regular press releases providing updates on repairs
  • Kept website notices and telephone greeting current
  • Developed wayfinding signage and maps
  • Provided weekly briefings with facility employees

Planning and Logistics Section

The planning and logistics section performed the following tasks:

  • Determined staff availability and work assignments
  • Determined staff pay structure during recovery
  • Worked with local hospital to accommodate ASC patients and coordinate ASC staff support
  • Provided hospital with necessary supplies, equipment, and instrument sets to accommodate procedures rescheduled from the ASC
  • Identified replacement items to be ordered immediately due to lag time in ordering and delivery (e.g., cabinets, counters, doors, carpeting)
  • Maintained communication/phone system and information technology (IT)
  • Coordinated re-establishment of services (e.g., housekeeping, waste removal, linen)
  • Maintained “disaster book” of all response activities

Operations Section

The operations section performed the following tasks:

  • Obtained temporary storage for unaffected equipment that required relocation
  • Identified need for replacement equipment and IT
  • Ensured the hard drives of damaged computers were stripped/wiped before disposal
  • Developed risk reduction plans

Finance/Administration Section

The finance/administration section performed the following tasks:

  • Conducted walkthrough with insurance adjustor
  • Compiled all invoices to be paid
  • Tracked lost revenue
  • Provided cost analysis and cash flow data to governing board
  • Provided insurance carrier with all requested information (e.g., projection of business loss amount, list of damages, photos)

Reopening

The following steps were taken to ensure a successful reopening:

  • Conducted mock patient walkthrough of new space
  • Posted required documentation previously removed (e.g., ASC license, patient rights and responsibilities, HIPAA, accreditation certificate)
  • Reinstated facility logs (e.g., refrigerator temperature, malignant hyperthermia cart check, defibrillator test and cart check)
  • Changed telephone greeting and website notice
  • Issued press release
  • Planned, publicized, and hosted open house
  • Celebrated re-opening and facility’s return to normal operations!

You Can Never Be Too Prepared

As I write this, Hurricane Harvey has wreaked havoc on Texas. Fires are consuming hundreds of thousands of acres across multiple western states. Hurricane Irma has Florida in its crosshairs. There is no shortage of news about the extensive damage that occurs in the wake of these disasters.

On a positive note, there are reports highlighting the improved preparation and response effort thanks to lessons learned from disasters like Hurricane Katrina and Rita. There will undoubtedly be lessons learned from Harvey and Irma that will help with future disaster planning.

Hopefully the Colorado ASC disaster response outlined above helps your surgery center identify opportunities for its own preparation improvement. If your ASC experiences a disaster, I encourage you to share your own response efforts. Relaying your story to an industry publication or presenting on it at a state or national meeting could ensure other ASCs benefit by learning from your experience.

I will leave you with this key takeaway. You cannot plan for everything. However, the more you prepare, the better off you should be when faced with the unexpected.

Diane Lampron, Director of Operations

Sep 19
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2017 OAS CAHPS: Should Your ASC Implement CMS’ Survey in 2017?

2017 OAS CAHPS: Should Your ASC Implement CMS’ Survey in 2017?

By ASC Management, Payor Contracting No Comments

The Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Provider and Systems (OAS CAHPS) collects information about patients’ experiences of care in ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs). The survey gathers patient perceptions related to communication and care provided by surgery staff, expectations prior to surgery, and planning related to discharge and recovery. Enforced implementation of the survey has been delayed until 2018, with the specific date being released this November. Surgery centers across the country are deciding if they should implement the survey as planned, or wait until the Centers for Medicare and Medicaid Services (CMS) begins enforcing survey implementation.

To assist in decision making, it’s helpful to review information regarding the OAS CAHPS Survey.

Why is CMS developing this survey?

  1. The number of ASCs has increased considerably in recent years as has the surgical case volume at both ASCs and HOPDs.
  2. Medicare expenditures from outpatient surgical sites for ASCs and HOPDs also continues to rise.
  3. Implementation of OAS CAHPS will provide CMS with statistically valid data on the patient experience to inform quality improvement and comparative consumer information about outpatient surgery facilities.

The results of the OAS CAHPS will be used to:

  1. Provide CMS with information for monitoring and public reporting purposes,
  2. Provide a source of information enabling prospective patients to make informed decisions in outpatient surgery facility selection, and
  3. Aid facilities with their internal quality improvement efforts and external benchmarking comparatively with other facilities.

What modes are available to administer the OAS CAHPS?

  1. Mail only
  2. Telephone only
  3. Mixed mode (mail survey with telephone follow-up of non-respondents)
  4. An electronic mode of surveying is currently under review.

How often is the OAS CAHPS administered?

  1. Surveys are administered on an ongoing basis.
  2. An annual minimum of 300 surveys must be completed for each facility.
  3. Participating facilities will provide a monthly sample of patients who received at least one surgery or procedure during the sample month to their survey vendor.
  4. Vendors will initiate surveys within three weeks after the sample month closes.
  5. Once a survey has been initiated it must be completed within six weeks.

The OAS CAHPS may be administered in conjunction with other surveys but sampling methods need to be followed to ensure patients are not overburdened by multiple surveys.

  1. For each sample month, the survey vendor must select the OAS CAHPS sample prior to selecting the samples for any other ASC survey.
  2. The ASCs cannot select the sample for any other facility survey they may choose to implement.
  3. The vendor must select the sample because the sample selection for OAS CAHPS cannot be disclosed to the facility.

OAS CAHPS Survey Implementation

  1. National voluntary implementation began in January 2016 with required participation scheduled to begin January 2018. CMS has proposed delaying implementation of the mandated 2018 date. The decision will be released in Medicare’s final 2018 ASC payment rule this November.
  2. It is unlikely the delay will be permanent because CAHPS surveys are already mandated in hospitals, home health, hospice, and dialysis centers.
  3. ASCs that have voluntarily participated in OAS CAHPS have received valuable information about the quality of outpatient care provided at their facility.

There are pros and cons to implementing the survey now versus waiting until CMS mandates the survey next year. It is often better to prepare early. What should administrators consider in determining what is best for their center?

Reasons to delay the OAS CAHPS Survey until 2018:

  1. Financial and administrative burden of submitting the data.
  2. Decision on the electronic survey mode option.

Reasons to implement the OAS CAHPS Survey now:

  1. You will know where your surgery center stands before mandatory reporting begins.
  2. You will have an opportunity to address identified issues for improved survey results.
  3. You can learn and understand your patients’ perceptions and make changes to increase overall satisfaction.
  4. Post-discharge surveying allows for a better assessment of the entire surgery process.

Peak One Surgery Center located in Frisco, Colorado has chosen to move forward with implementation of the OAS CAHPS survey now. It was an easy decision for us because it will allow us to get ahead of the competition. We can build out processes with our vendor and adjust our internal reporting systems. There will also be time for staff, physicians, and administration to learn the program. When my fellow administrators ask, I advise them to begin work with a vendor on voluntary implementation of the OAS CAHPS survey to avoid being at a disadvantage when the survey becomes mandatory.

Michaela Halcomb, Director of Operations

May 03
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ASC Administrator

Successfully Transitioning into an ASC Administrator Role

By ASC Management No Comments

In the spring of 2016, I was approached by my management company supervisor about accepting an interim administrator position at our ambulatory surgical center.  Interested, yet hesitant, I agreed, as his confidence in me to take on the role was genuine and complimentary.  

With a new boss and role ahead of me, the necessity to decipher what was needed to succeed occupied my thoughts.  As clinical director of the surgery center for three years, I understood the importance of leadership and management.  However, I did not possess a complete understanding of the administrator role.  To gain this understanding and to succeed in my new role, I needed a plan.

Success Requires Knowing the Answers

Initially, I needed to understand the expectations.  Specifically, I wanted to gain knowledge about the following:

  • What was the vision of the ASC’s board of directors?
  • How will the management company assist with executing this vision?
  • What was required of me to meet this vision?

Success Requires Knowing Who Has the Answers

To determine who had the answers I was seeking, I needed to build relationships and identify what resources were available to me.  I found myself asking:

  • Who are the members of the management team and what are their roles?
  • How does each role impact the facility?
  • How is each role impacted by the facility?
  • Which members of the team have experience or expertise in which areas?
  • How can I tap into this experience or expertise to create success in my new role?
  • Who are the points of contact for the daily tasks of conducting business (accounting, banking, business insurance, credentialing, etc.)?

Success Requires Knowing the Deficiencies

As I began gathering responses to my questions and utilizing the educational resources available to me, I recognized the importance of assessing my needs.  I asked:

  • Where can knowledge and information assist me in successfully accomplishing the expectations of my new role?
  • Where can I obtain that knowledge and information?
  • What areas within the facility need immediate attention?
  • Are there resources available to address the areas requiring immediate attention?

In my twenty plus years in healthcare, I discovered relationships are an integral and necessary part of success.  This was true in my new position as well.  It was incumbent upon me to reach out for assistance, build relationships, and successfully integrate into the existing management team.  Within the healthcare industry, or any business for that matter, an open mind, patience, and willingness to visualize the big picture all propel an individual’s efforts forward.  An African Proverb states, “If you want to go fast, go alone.  If you want to go far, go with others.”

My integration into an ASC’s existing management team consisted of the following–

  • Knowing the vision of the stakeholders
  • Aligning the facility with that vision
  • Building relationships within the existing management group
  • Researching and obtaining useful resources
  • Identifying areas of improvement
  • Proactively addressing the identified needs

Later that year, having successfully navigated the interim role, I was offered the administrator position. 

In summary, I found Henry Ford’s statement to be true: “Coming together is a beginning.  Keeping together is progress. Working together is success.”

Tara Demuth Fenton – Facility Administrator, Children’s North Surgery Center