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March 2018

Simple, Effective Ways to Boost ASC Staff Satisfaction

Simple, Effective Ways to Boost ASC Staff Satisfaction

By ASC Management, Leadership No Comments

There is no denying the importance of staff satisfaction in an ASC. When staff are content with their jobs, the positivity permeates throughout the facility. Patients and their families notice. Physicians enjoy coming to the center more and overall care improves.

In a busy ASC, managers may find it challenging to plan activities intended to help boost staff satisfaction. Although it is often difficult to make the time, such activities are critical. And, once you commit to them, they should occur regularly. If you employ good staff, you can be sure other organizations would love to hire them away from you. The moment staff morale starts to dip, the door begins to open for your competition.

ASC administrators and managers who want to boost staff morale have many employee engagement options. Two staff-focused activities commonly implemented at ASCs and other health care facilities designed to improve staff satisfaction and retention are outlined below. They are fun, inexpensive, and easy to administer.

Staff Satisfaction Booster #1: Monthly Birthday Celebrations

Most people enjoy celebrating their birthday with others. That’s why birthday celebrations are an excellent opportunity to show appreciation for staff members. They present an opportunity for ASC staff to gather during work hours, have some fun, and receive a treat.

In a very small ASC, it might be possible to celebrate everyone’s birthday individually. As an ASC grows, that becomes more difficult. For a staff of 50, a birthday celebration could occur every week. This adds up to a lot of time . . . and a lot of cake! Additionally, the celebrations may quickly lose their luster if conducted too frequently. One solution is monthly birthday celebrations.

Once a month, around the same time each month, celebrate the birthday of everyone born that month. Buy a large enough birthday cake to provide all team members with a piece. During the lunch hour, available staff come together in the break room. Anyone with a birthday that month is recognized.

By taking this approach, no birthdays are missed. It doesn’t matter if someone’s birthday falls on a weekend or holiday. During monthly celebrations, everyone is acknowledged equally. With a month between celebrations, excitement builds over the get-together and, of course, free cake.

Staff Satisfaction Booster #2: High-Five Appreciation Program

High-fives between people are a way of acknowledging a job well done. That’s the objective of the high-five appreciation program. Rather than staff giving each other physical high-fives (which they can still do), these high-fives are written and recorded.

The materials needed to launch this program are a bulletin board, thumbtacks, paper, pencil, and scissors. Trace hand figures on paper and cut them out. I recommend streamlining the process by cutting multiple sheets at a time. Repeat this process until you have a large stack of paper hands.

When staff members see another team member doing something they feel is worthy of a high-five, they make a note of the outstanding action on a paper hand and then tack the hand to the bulletin board. Items written on the hand include:

  • recognized staff member’s name;
  • date of the observed activity; and
  • description of the staff member’s action.

Recognized actions should be specific – notable behaviors or achievements that go beyond a person’s job responsibilities or something someone does well consistently.

If staff are actively participating in the program, a good number of hands will be posted to your bulletin board after about a month. Each month, take the hands down, review them, and pick out a few that stand out as exceptional. Bring staff together to acknowledge the great work recognized during the previous month. When is a good time to do this? How about during the monthly birthday celebration?

After singing happy birthday and handing out cake, read the high-fives that you selected. If your budget permits, providing a small gift to these “winners” can be a nice bonus. Take time to hand out all the high-fives to the staff members acknowledged on them. The simple recognition of a job well done – with or without a gift – is sure to bring smiles to the faces of your team.

Note: There may be value in including high-fives in your staff evaluation process. Before distributing the high-fives, note the acknowledged action(s) in staff personnel files.

Keys to Success

While these activities are easy to implement and sustain, they have a profound effect on staff morale – particularly the high-five program.

To ensure your high-five program is successful, take these steps:

  • Educate staff. At an all-staff meeting, explain how the program works and why you are doing it. Build some excitement.
  • Task your managers with ensuring their departments fill out at least a few hands during the first several months. Regular encouragement by managers to team members during department meetings should help do the trick.
  • Actively promote the program. If your high-five celebration happens on a Thursday, send an email to staff on Monday or Tuesday. Remind staff that the celebration is in a few days and encourage them to submit their high-fives. This will help nudge anyone thinking about completing a high-five to get it done before the celebration.
  • Review the high-fives. If you find people are submitting high-fives that are not representative of the types of actions you want to acknowledge, remind staff about the “rules” and objectives.
  • Seek feedback. Not every staff member will want to be recognized in the same fashion. Take time to seek feedback from staff or your managers on how people feel about the program and being recognized. For example, some individuals would rather you send them a personal note than to be publicly recognized. Tailoring your recognitions will go a long way with your staff.

For the monthly birthday celebrations, the most important step is to ensure the events happen every month, without fail. Once you announce the monthly celebrations, most of your team will look forward to their celebration month. If you stop the celebrations before completing 12 months, you are likely to disappoint staff members who were never in the spotlight.

Consistency is critical for the high-five celebrations as well. By putting in the time and effort, and maintaining the excitement surrounding these activities, your ASC will establish valuable ways to boost staff satisfaction.

Jebby Mathew, Regional Director of Operations

Running a Successful ASC Convalescent Center

Running a Successful ASC Convalescent Center

By ASC Development, ASC Management No Comments

When our ASC opened in late 2014, we had more to celebrate than a new surgery center. We also toasted the opening of our new ASC convalescent center.

Located in the same building, the ASC convalescent center (also referred to as our “recovery center”) allows our surgeons to perform more complex procedures in the ASC that require an overnight stay. These include total knee, hip, and shoulder replacements as well as spine procedures such as anterior cervical fusions and posterior fusions. Upon completion of these procedures in our ASC, we move these patients to the convalescent center. There they recover up to 72 hours under the supervision of at least two medical professionals. A registered nurse, always present, is joined by either a certified nurse aide or medical assistant. Together, they provide personalized care and attention. Meals are served and visitors are welcomed most of the day.

Without the ASC convalescent center, our surgeons would have to perform these procedures in a hospital. Thanks to the recovery center, more patients can take advantage of our high-quality, low-cost surgical care. Our ASC benefits by capturing more surgical volume. In 2017, more than 400 patients stayed in our convalescent center. In the fourth quarter of 2017 alone, more than 130 patients remained in the recovery center overnight.

While the growth is exciting, what’s even more gratifying is the feedback we receive from our recovery center patients. They rave about it on our patient satisfaction survey. One of the questions we ask is: “Would you recommend this facility to friends and family?” Not only will they circle yes, they usually add a comment along the lines of “I would absolutely recommend the Orthopaedic and Spine Center.” That tells me we’re doing something right.

Recommendations for Developing a Convalescent Center

Here are some of the key factors that contribute to ongoing success with an ASC convalescent center.

  1. Careful patient selection. The ability to send patients to the recovery center does not lower our ASC’s standards for patient selection criteria. Patients must be in generally good health. Those with an American Society of Anesthesiologists physical status classification of III or IV are better suited for the hospital. We do not risk patient safety solely to increase volume. Surgeons inform the ASC when they want a patient kept overnight and how long they anticipate the patient staying.
  2. Involved anesthesiologists. Our anesthesiologists are critical to selection and management of convalescent center patients. One of the reasons patients stay is because their procedures are more extensive. This usually brings a greater level of pain following the surgery, which must be managed appropriately. Anesthesiologists are always part of the surgery planning process, ensuring these patients are appropriate for admission and their pain levels addressed throughout their stay. They discuss the different options for anesthesia with patients. They play a vital role in our efforts to use pain pumps to help reduce patient reliance on narcotics.
  3. Appropriate reimbursement. Reimbursement for procedures requiring an overnight stay can be tricky. Not all insurance companies pay for services provided in a convalescent center. When this is the case, the reimbursement for the procedure itself must cover the ASC’s expenses and those associated with the recovery center as well as a reasonable profit margin. By taking the time to conduct a thorough cost-benefit analysis and understanding fully the expenses associated with running the convalescent center, we armed ourselves with data that has assisted with payor contract negotiations.
  4. Focus on compliance. A convalescent center receives regulatory scrutiny just like an ASC. Compliance shortcomings can jeopardize the ability to keep a recovery center open. Make sure you understand and follow state rules for operating an ASC convalescent center. For us, that includes a license, entrance, waiting room, and medical records system separate from the ASC. Although a hallway connects our ASC to our convalescent center, patients are still discharged from the ASC before they are admitted to the recovery center. Following these processes helps keep both facilities in compliance.
  5. Supportive physicians. We are fortunate our physicians embrace the recovery center model. They are able to bring more high acuity cases to the ASC, explaining to patients beforehand the value of staying in our convalescent center. We return the favor by working to provide our physicians and their patients with a great surgical recovery experience. Maintaining the support of our physicians is essential to our growth.

Quick Tips for Getting Started with a Convalescent Center

While it’s great to have the option of providing extended care for patients, running a convalescent center isn’t for every ASC. Here are a few quick tips to follow before you move ahead with opening your own recovery facility:

  • Know your state’s rules. Only some states allow an ASC to operate a convalescent center.
  • If your state has an active ASC association, reach out. They may be able to answer questions about state rules for recovery centers. Lean on your local health department for information as well.
  • Make sure you have commitment from physicians to bring enough overnight cases to justify the convalescent center. Without this commitment, you run the risk of opening a recovery center that will cost your ASC and its owners money rather than help generate revenue.
  • Speak with your payors about your plans. Gauge their willingness to cover the more complex procedures requiring overnight stays at a fair rate.

Opening an ASC convalescent center does not guarantee its success. You will need to encourage your surgeons to schedule these complex cases, when appropriate, at the ASC. Marketing the convalescent center can help attract new physicians. It can also motivate patients to speak with their surgeons about undergoing a procedure at the ASC and staying at the recovery center. When word spreads, you may even attract patients from outside of your market. As we have experienced, the hard work that goes into building and growing a recovery program is truly rewarding.

Jennifer Arellano, Director of Operations

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

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.


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.


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?


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