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November 2017

Managing a Non-Compliant Patient in an ASC

Managing a Non-Compliant Patient in an ASC

By ASC Management, Uncategorized No Comments

ASCs fortunate to remain in business long enough are likely to have the unfortunate experience of a non-compliant patient. When non-compliance occurs, patient and staff safety may be jeopardized.

Patient non-compliance in an ASC can take many forms. These include not taking medications, personal removal of an oxygen mask, and getting out of a wheelchair or bed without caregiver approval. A non-compliant patient can disrupt the delivery of care and an ASC’s workflow. They can also injure themselves as well as individuals around them, including staff. In most cases, that harm is unintentional, such as a patient fall due to a failure to follow instructions. However, an aggressively resistant patient may intentionally hurt caregivers.

To help prepare your ASC to respond effectively and appropriately to a non-compliance scenario, follow these steps.

1. Simulate non-compliant patient events.

If you don’t practice your response to an incident, you can’t emulate what you want to achieve. That’s why it is critical to practice non-compliant events. You can do so through drills or use of “mock patients” where an employee acts like a difficult patient. Consider scripting the experiences to more accurately represent what may happen. Emphasize the importance of remaining calm. Evaluate the response to each simulation and determine opportunities for improvement.

When brainstorming scenarios to simulate, consider possible situations specific to your ASC. For example, if you have a convalescent center, patients staying with you for an extended period can present unique risks. An extended care patient on bed watch may determine it’s safe to ambulate independently without first alerting a nurse. This non-compliance could lead to a devastating fall.

2. Secure the situation.

Regardless of whether patient or staff safety is threatened, make sure to “secure” the situation. Securing the situation can range from calling in security to deal with a threat of violence to informing people around the non-compliance incident what is occurring. If staff members do not feel comfortable responding to a situation on their own, bring in a manager or physician to assist with the situation.

3. Empower staff.

ASC staff, particularly nurses, often have a patient-first mentality. As employees of the ASC, their work focuses on providing the best possible experience for patients. But sometimes the customer isn’t always right. Leadership should emphasize it is not only acceptable but encouraged for staff to speak up when faced with a non-compliant patient.

Empower staff to make decisions they feel are in the best interest of patient and staff safety. This may include transferring a patient to the hospital – a decision not to be made lightly, but one that staff should know is an option if the situation warrants it.

4. Engage family and friends.

Once you encounter a non-compliant patient, you’re no longer just dealing with the patient. The situation also indirectly involves those individuals accompanying the patient. It is important to be upfront about what is occurring with family and/or friends. When you are honest and respectful, conversations about the issue are typically easier. These individuals may have recommendations for how to help diffuse a situation and obtain compliance.

5. Determine level of seriousness.

After you address the non-compliant patient incident, asses its severity. If the incident was minor, including a note in the patient’s chart may suffice as documentation of the experience. However, if the incident led to a more significant patient and/or staff safety issue, consider involving your medical advisory committee and governing board. Also consider whether to involve your risk management and legal team.

If the incident resulted in serious patient harm, patient unconsciousness, or patient transfer, it may require reporting to your state. Understand your state specific reportable event policy and process.

6. Analyze the non-compliant patient incident.

Regardless of the incident’s severity, set aside time to analyze what occurred. Perform a root cause analysis if the incident is significant. Even a minor non-compliant patient incident is worth formally discussing with staff. The key is obtaining feedback on the response and determining if there are opportunities for future improvement.

7. Don’t overlook possible effect on staff.

Dealing with a non-compliant patient is typically not easy. The experience, particularly one which jeopardized safety, may cause distress for your staff and physicians. It is important to evaluate how these “second victims” respond to the incident. If anyone appears traumatized, offer professional support. One-on-one conversations with team members may bring trauma to light.

The More You Know

A non-compliant patient situation can escalate very quickly, going from a seemingly minor incident to one that risks patient and staff safety. By allocating time for education on non-compliance, you will put staff members in a better position to act responsibly when an incident occurs. Following an incident, take advantage of the negative development and turn it into a positive by evaluating the situation. Hopefully what staff members learn will improve their response during the next experience.

Jebby Mathew, Regional Director, Operations

Introduction to ASC Data Analytics

Introduction to ASC Data Analytics

By ASC Management, Uncategorized No Comments

Part 1: Introduction to ASC Data Analytics

In this three-part series, I will explore the topic of ASC data analytics. Part 1 introduces the topic of data analytics as it applies to ASCs. Part 2 provides examples of how analytics can benefit ASCs. Part 3 walks through the evaluation process to determine if data analytics is a good fit for your surgery center. Let’s dive in!

To succeed in today’s competitive business environment, every organization requires knowledge and understanding of its performance. This fact is especially true in the rapidly evolving world of healthcare, perhaps even more so for ambulatory surgery centers (ASCs). For some, a simple informal review of monthly financial statements may present a sufficient picture of the overall health of the organization. A review of standard accounting reports can provide the information necessary to guide general decision making. However, basic reporting and analysis may not provide sufficient insight to maintain pace with the constantly changing, fast-paced ASC market.

To gain a competitive market advantage, a deeper understanding of an ASC’s performance may be required. The emerging field of ASC data analytics focuses on providing nuanced introspections that surgery center leaders can rely upon as critical tools for decision making.

If you’re not familiar with ASC data analytics, don’t worry. You are not alone. While utilized extensively in financial and retail sectors, ASC data analytics has only recently gained traction. While many factors play into this rapid growth, they all essentially boil down to rising costs, tightening reimbursement, and the influx of integrated health networks. ASC data analytics is increasingly utilized to identify actionable areas of improvement and model the impact of potential changes before they are implemented. As the ASC arena continues to become more competitive internally, along with growing outside pressure – an aging population, payment model shifts, and fluctuating legislation, for example – the ability to identify core problems and predict the success of proposed solutions is an essential tool for organizations looking to gain a competitive edge.

Utilizing data analytics may sound like a panacea for struggling ASCs looking to get back on track or for successful ASCs seeking to further strengthen their position. However, before jumping on the ASC data analytics bandwagon, it’s important to fully understand what analytics entails in the ASC world. Once a basic comprehension is achieved, only then can one ascertain whether implementing an ASC data analytics program is likely to produce a suitable return on investment.

Stay tuned to gain additional understanding of ASC data analytics! My next post in this series will provide examples of how data analytics can be leveraged by ASCs. I will wrap-up the series in my third post by delving into how to determine if an ASC data analytics program is a good fit for your organization.

Cody Carlin, Director, Data Analytics

Patient Billing – Enhancing Patient Satisfaction & Your ASC’s Revenue Cycle Process

Patient Billing – Enhancing Patient Satisfaction & Your ASC’s Revenue Cycle Process

By ASC Management, Revenue Cycle Management No Comments

You may think service to your ASC patients ends upon completion of their surgical visit. The reality is, patient satisfaction extends far beyond their date of service. An effective patient billing and collections process can impact patient satisfaction both prior to and after their visit.

How can your surgery center create a positive revenue cycle experience and improve your patient billing process?

1. Proactively address financial concerns prior to each patient’s surgery by obtaining and providing thorough information on their behalf.

  • Contact patients prior to their date of service to verify registration information.
  • Perform insurance eligibility and verification to obtain prior authorization, if required.
  • Create a patient financial responsibility estimate for services to be performed.

2. Avoid potential billing misunderstandings by clearly relaying payment expectations upfront.

  • Discuss patients’ financial estimates with them prior to their scheduled appointment.
  • Secure payment from patients or explore payment plan options.
  • Clarify any remaining billing questions patients might have concerning the billing and collections process.
  • Record details regarding any prior arrangements made with patients in your ASC’s patient accounting system. This will assist with future collections efforts, if needed.

3. Improve upfront collections and/or adherence to agreed-upon terms for financing by reviewing patient estimates with them on the date of service.

  • Review financial responsibility estimates and payment options with patients again, answering any remaining questions they may have.
  • Secure signed financial agreements outlining payment plan details.
  • Collect payments that are due at time of service. Your patients are more likely to pay their bill when you review financial expectations and proactively involve them in the estimation and payment process.

4. Make it easy for your patients to remit payments.

  • Offer an online payment portal accepting ACH debits from bank accounts, a variety of credit cards, and payment plan options.
  • Provide patient friendly statements.

An efficient insurance verification process allows claims to move through the third-party payer system. The result? Timely reimbursement. Conversations with your patients regarding their anticipated financial responsibility ensure they are informed ahead of time. If you’re communicating well, they are able to understand and follow the ASC revenue cycle process.

The goal is a positive patient billing experience from referral all the way through to a zero balance on their account. Patient satisfaction, timely revenue collection, and recommendations of your facility to other patients seeking quality care and a smooth process is a win-win for all!

Carol Ciluffo, VP of Revenue Cycle Management

Overcoming ASC Management Nightmares: Keeping Up with Regulatory Changes

Overcoming ASC Management Nightmares: Keeping Up with Regulatory Changes

By ASC Management, Leadership No Comments

Second installment in the “Overcoming ASC Management Nightmares” blog series. Click here for Part 1 and Part 3.

ASC Management Nightmare #2: Keeping Up with Regulatory Changes

Rarely a week goes by where there are no new regulatory changes approved or existing regulations revised. This should come as no surprise when you think about how many regulations ASC’s must meet to remain in compliance. There’s Medicare’s interpretative guidelines. There’s HIPAA and the HITECH Act. There are coding rules, billing rules, human resources rules. The list goes on. On top of federal regulations, ASC management must understand their state-specific rules, some of which can trump federal rules.

Staying abreast of all the ongoing regulatory changes is a daunting, but crucial, task. If I fail to do so, I risk our ASCs falling out of compliance. Just the thought of that happening puts a knot in my stomach.


Fortunately, I’ve found comfort by using resources that help me stay abreast of regulatory changes and their effects on ASCs.

The national Ambulatory Surgery Center Association (ASCA) is a tremendous source of information. ASCA offers valuable education and networking opportunities through its annual meeting, monthly webinars, and periodic multi-day seminars. Members receive regular emails highlighting changes to federal regulations as well as those under consideration. ASCA has assigned staff members to monitor and research rules and regulations. You can be confident that if there are regulatory changes, they will know about it.

In addition, ASCA members can take advantage of ASCA Connect, an online discussion group. Active ASC professionals post a wide variety of questions and requests every day. Most of them receive helpful responses. Members of the ASC community are eager to help one another and willing to share their knowledge and tools. ASCA Connect provides a great opportunity to network with other members of ASC management outside of in-person meetings.

Many states also have their own ASC associations. If you’re not currently involved with your state’s association, consider joining. The active state associations monitor important regulatory developments and share this information with their members. They also typically host networking meetings and/or educational conferences.

Finally, there are other ASC trade conferences you may want to consider attending. Professional societies, law firms, and industry publications, for example, host their own meetings.

Information is your biggest tool in keeping up with regulatory changes. Organizations that provide timely, accurate information on regulatory changes are your most important allies. In this ever-changing regulatory environment, there’s no such thing as too much education.

Lisa Austin, VP, Facility Development

What’s Your ASC’s Leverage Point in Payer Negotiations?

What’s Your ASC’s Leverage Point in Payer Negotiations?

By Leadership, Payor Contracting No Comments

When it comes to payer negotiations, your ASC leverage point is the weight you bring to the game. What do you lean on to produce results? What card(s) do you play to change the game?

What we’re talking about here is simple physics – matter, motion, energy, and force. Or put more simply, influence. Influence equals change. And no influence equals no change. If what you’re leveraging weighs on you as much as it does your opponent, it’s not leverage. Think of a teeter-totter on a playground with two evenly weighted people on it. It doesn’t move much! You need force applied to one side to create influence and shift the situation.

Your ASC leverage point is achieving the most gain while exercising the least amount of loss. It is important to know what you can concede and what you must gain before your walk into any negotiation. Apply this to all parts of your ASC business operations, especially negotiation with payers.

Optimal leverage enables you to impact change that multiplies your efforts and preserves the utilization of your resources.

Let’s look at an ASC leverage point example.

Is achieving a slight increase in your ASC’s procedure reimbursement at the cost of surrendering payment for implants a leverage point? No, because it costs your ASC as much as it gains. Again, think of the teeter-totter example with two evenly weighted parties attempting to move it. You must work to concede less while still achieving positive results. If your ASC can gain a decent increase without giving up anything other than perhaps the time and energy necessary to make its case, then a true leverage point is exercised.

For a leverage point to work in your favor, it must be sensible, perceived as credible by the payer, and not merely a perceived threat. If perceived as a threat, it will not have the power to influence the other side to move closer to a negotiating position. In either case, an ASC leverage point has potential to bestow gains or impose losses on the other side. However, a genuine leverage point is not overstated or punitive; it’s consequential and practical. It’s the prime force you exert to get what you need and goes beyond strong negotiating skills. Negotiation skills cannot replace a genuine leverage point.

Consider another ASC leverage point example.

Say a payer bundles implant payment and is not offering adequate reimbursement to cover your ASC’s costs plus a reasonable profit. Does your ASC threaten to terminate its contract with the payer because the procedure pays poorly? (This is probably a threat some payers hear often but providers rarely follow-through on.) This tactic would likely amount to a lose-lose proposition for both parties.

An alternate option is to inform the payer your ASC can no longer accept these cases on their members and must divert the cases to a higher paid (facility perspective) and higher cost (payer perspective) center to make your case. The former is not a perceived leverage point unless your ASC truly intends to carry out the termination. But the latter is not only grounded, it will demonstrate to the payer how much they will lose by not administering a reasonable procedure reimbursement that covers your costs and nets a reasonable profit.

Let’s face it, your facility needs the payer to pay more, but the payer has little incentive to pay your facility more. Payers hold significant leverage. To make your case, your ASC must find and exercise its leverage point and change the equation.

A change in the equation can be a payer gaining more information and an increased understanding and willingness to adapt to your ASC’s thinking. Your ASC is offering a cost-containment solution to the payer. Rather than simply asking for greater reimbursement, your ASC must negotiate rates that allow you and your payers to stay in business in a competitive health care market.

Dan Connolly, VP of Payer Relations & Contracting

Overcoming ASC Management Nightmares: Finding OR Nurses

Overcoming ASC Management Nightmares: Finding OR Nurses

By ASC Development, ASC Management No Comments

First installment in the “Overcoming ASC Management Nightmares” blog series. Click here for Part 2 and Part 3.

One thing I’ve learned over the years is that if you hold an ASC management position, there’s always something that will keep you up at night. Whether your ASC has been open one day or 10 years, dealing with challenges is the norm. How you address those issues is what really matters.

This is the first installment in my “Overcoming ASC Management Nightmares” blog series which will explore the challenges robbing me of precious sleep. Fortunately, I’ve been successful in taking steps to keep these nightmares at bay. I suspect other ASC managers are experiencing these nightmares too. Hopefully my solutions can help put your mind at ease.

ASC Management Nightmare #1: Finding OR Nurses

The motto “If you build it, they will come” may have served Kevin Costner’s character in Field of Dreams well, but it typically doesn’t help ASCs when it comes to attracting staff. I recently helped build a new ASC. The first question each of the prospective administrators asked was, “How are you going to find staff?”

Nearly everyone I encounter is trying to figure out the answer to this question, particularly when it comes to hiring OR nurses. You can be in an area oversaturated or under-saturated with ASCs. In either case, you likely won’t find a large pool of good quality OR nurses to choose from.

How did we get here? Formalized educational forums for non-OR nurses to receive OR training is lacking. New nurses coming out of nursing school often feel they have received enough clinical education to justify a management position. The OR setting is heavy on mature nurses who are likely to retire in the coming years.

If you want to recruit high-quality OR nurses away from existing employment, prepare to pay them more than you pay your current pre-op and PACU nurses. You may need to offer OR nurses a different tier of benefits to entice them to join your ASC. Successful recruitment may even require you provide a substantial hiring bonus and cover relocation costs.

Adding OR nurses can affect many different layers of your business and operations, including physician/owner satisfaction, financials, and morale. Unfortunately, there is a lack of resources to help address this nightmare without breaking the bank.


Rather than look outside of our ASCs for OR nurses, we are looking within. We are implementing training programs that afford non-OR nurses the opportunity to become OR nurses. The Association of Registered Nurses (AORN) develops and sells the program’s infrastructure. It is comprised of a syllabus and criteria for staff to meet.

If a staff member expresses an interest in becoming an OR nurse, ASC management assesses the individual’s qualifications. When the nurse is in good standing and possesses the appropriate skill level, we purchase the AORN program on their behalf.

Once in the program, nurses in training work and are paid for their regular shifts. However, they do not perform their normal pre-op or post-op functions. Instead, they shadow a current OR nurse who serves as their mentor and helps provide on-the-job training. The trainees must complete homework and take tests on their own time. When they successfully complete the program, they transition into the OR.

We make a substantial investment in these nurses. Not only do we cover the cost of the program, we also pay another nurse to cover their responsibilities during their training. To enter the program, nurses sign an agreement with the ASC. They must remain with the ASC for an agreed-upon length of time that allows the facility to recoup its investment. If the nurses fail to complete the program, a payback mechanism in place.

Our use of the program is in its infancy, but the results are encouraging. Knowing we have a mechanism to help us groom our own OR nurses provides great comfort.

Putting Your ASC Management Nightmares to Bed

As long as you are in an ASC management position, don’t expect many anxiety-free evenings. That’s not unusual when you directly impact the success of a business and safety of people.

But try not to feel like you need to come up with all the answers to the challenges your ASC faces on your own. Brainstorm with people inside and outside of your organization. If you’re experiencing a challenging situation, chances are that others in ASC management are as well. When you connect with likeminded people working in the same industry, you can problem solve together.

And try not to be afraid to talk about the issues that are keeping you up at night for fear that it makes you appear vulnerable. I believe it does just the opposite: When you identify an issue and attack it head-on, you appear stronger. After all, no one has all the answers. Simply acknowledging there is a problem oftentimes makes it easier to develop a solution.

Lisa Austin, VP, Facility Development

Improving Clinical Staff Efficiency with ASC Business Education

By ASC Management, Leadership No Comments

Gradually moving up the ASC job ladder provided me with opportunities to learn a great many things. One of the most significant lessons arose not long after I moved into a management position.

As a nurse, my focus was on delivering the best care possible to every patient that crossed my path. When we delivered great outcomes, I felt successful. Because there were always patients for me to care for, I assumed the ASCs I worked in were also successful businesses.

My outlook changed when I became a manager. My effectiveness as a manager requires focusing on the bigger picture. A significant part of that picture still includes the delivery of safe, compliant care. However, another sizable part involves the financial side of running an ASC. I felt very comfortable with the former and completely unprepared for the latter.

In a clinical position with no management duties, I didn’t stop to consider the ASC business. I didn’t know the reimbursement we receive for a case covers everything we do for patients, from the moment they walk in the door until they go home. It also covers the ASC’s expenses, including our surgical supplies, utilities, rent, and, of course, salaries. I did not receive any relevant ASC business education until I assumed a management position.

Receiving an ASC business education changed my perspective on the delivery of care. Now, every time I see an unused towel or suture in the trash, I equate it to money – money that could go toward better equipment, new technology, and pay raises. I quickly surmised conveying some ASC business education basics to my clinical staff would likely go a long way toward cutting our costs.

Here are some of the ways I approach providing ASC business education to clinical staff.

Allocate time. During our monthly staff meetings, I commit time to discuss our business. I gauge what staff members do and do not understand. I provide clarification when they have specific questions. Once a quarter, I dedicate most of a meeting to ASC business education. This allows me to dive more deeply into specific topics. Since much of what I cover is new, I spread out education to avoid overwhelming staff. I want to teach, not scare them.

Keep it simple. Clinical staff don’t need to know every little detail about the ASC business. When I explain concepts like reimbursement, inventory management, just-in-time ordering, and case costing, I take a “101” rather than a “301” approach. I define concepts using basic terms and outline how they affect the ASC’s bottom line. I focus on how improvements in our ASC business performance benefit patients, staff, and facility.

Break down costs. Sometimes providing a little data can help drive a point home. Our ASC uses Project C.U.R.E. bins to gather medical supplies and equipment for donation. Staff discard unused items from surgical packs into these bins. After these bins fill up, I take pictures of the items inside and put a cost to them. I show these pictures and share the financial breakdown with staff. I also share data comparing the cost of “red” medical waste versus regular waste and disposable versus reusable supplies. Talk about eye-opening experiences!

Challenge staff. Once staff gain a better appreciation of waste costs, we attack our surgical packs. I ask staff to look at the packs to determine what is actually needed in them. At times, staff indicate rarely used items are included in the pack per physician request. In these instances, I speak with the physician. We typically remove the item from the pack but make sure it is available in the room during surgery. That’s a win-win!

New isn’t always necessary. On one occasion, an influx of non-ambulatory nurses joined our ASC. The facility they previously worked in purchased everything new. I educated them about refurbished equipment. I emphasized our use of this equipment did not jeopardize the delivery of high-quality care they were used to providing but did save us money.

Focus on safety. When speaking about cutting costs with your clinical staff, expect some looks of concern. Staff may translate “cutting costs” to mean “cutting resources” and, therefore, “cutting corners” on safety. Convey to staff the ASC will not authorize cuts that could jeopardize safety.

For example, we were using a lot of sterile towels during non-sterile cases. When I addressed how the use of non-sterile towels during these cases would benefit the ASC business, I also explained why doing so wouldn’t increase risk.

Engage Staff, Grow the ASC Business

As my clinical staff gained a better understanding of our ASC business model, they embraced the challenge of finding and implementing cost-cutting changes. With this mindset, we achieved significant savings in a short amount of time.

I know we can always do better. That’s why I try to ensure our clinical staff always have the business education of our ASC operations in the back of their minds. It’s easy, even for leadership, to become complacent when things seem to be going well. But in a health care environment where every dollar really does matter, there’s no room for complacency, and no reason not to empower all staff to make a difference in the bottom line.

Tara Demuth-Fenton, Director of Operations