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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, and there is confusion, even among surveyors, on the use of some multi-dose medications, such as eye drops.

Centers for Medicare and Medicaid Services (CMS) clarifies with CfC 416.48 that we must provide drugs and biologicals in a safe and effective manner, in accordance with accepted professional practice and under the direction of an individual that we have designated responsible for our pharmaceutical services.  In addition, CMS adds in the same CfC that drugs must be prepared and administered according to established policies and acceptable standards of practice. Below is a list of safe medication practice guidelines to prepare ASC Clinical Directors to meet the standard set forth in CfC 416.48.

Safe Medication Standards of Practice:

  1. Designate a licensed staff member to oversee your pharmacy program, and make sure this individual is routinely present in your facility. You must also follow your state regulations as it relates to the need for a registered pharmacist, as regulations vary from state to state. Some states do not require a registered pharmacist and some, like Texas, require a weekly consult.
  2. Keep the appropriate records for the ordering, receipt of, 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. For multiple-dose medications/vials (MDV) – date upon opening with the beyond use date and do not take a MDV into an immediate patient care area; if this occurs, that MDV becomes a SDV for that particular patient.
  5. Make sure that 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 and conduct staff training on this process.
  7. Review and be knowledgeable of the questions on the CMS infection control surveyor worksheet. Exhibit 351.

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

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

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

The area where CSP 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).  Make sure the entry ports are disinfected and calculations are verified so that accurate mixing takes place.  Proper labeling must also be done prior to taking the CSP for administration.

ASC clinical leaders may refer to the lists above to ensure safe medication practices and compound sterile preparations are compliant with CMS regulations.  For further information on CMS guidelines, visit the CMS infection control surveyor worksheet referenced above or the CMS website.

Part two of this blog series will focus on compounding pharmacies – problems and understanding the differences between the types of compounding pharmacies.

Jovanna Grissom, Regional Director of Operations

ASC billing office process improvement

ASC Billing Office Process Improvement – Conducting a Quarterly Review

By ASC Management, Leadership, Revenue Cycle Management No Comments

The saying goes, “Old habits die hard.” But in the ASC billing office, repeating the same mistakes costs time, money, and resources. Hence, the process of identifying process inefficiencies and areas of improvement is a constant responsibility for an effective ASC billing office. It is generally good practice to conduct a complete billing office process improvement evaluation and plan implementation at the end of each financial quarter. At the close of a quarter, there is enough data to review, identify, and correct negative trends. The start of a new quarter provides a clean slate for tracking the impact of the changes three months from now.

Where to begin?

Start by identifying your weaknesses by analyzing available data. This data can come from your patient accounting system and/or clearinghouse. Error tracking allows you to quantify mistakes that prevent clean claims. Reviewing clearinghouse rejection reports may identify trends. If you regularly find the same rejections, log the incidence as well as the resolution changes you make to help you identify and correct the issue. It may also be beneficial to review adjustment journal codes and ensure they meet your tracking needs in case you need to analyze payment or adjustment trends. These metrics can help you identify training opportunities for your staff at all stages of your billing cycle.


In an efficient billing office, a system of checks and balances establishes itself when billing tasks are departmentalized. The schedulers provide the patient and billing information, verification confirms the feasibility of the case under the provided circumstances, coders translate the visit for delivery to the insurance carrier, data entry qualifies the billing information, and accounts receivable ensures maximum reimbursement for the team’s efforts. Each subsequent person that handles the information relies on the previous person’s understanding of healthcare billing. Every individual’s work is verified, but not repeated, in the next step in the process. When each of these groups of people are housed in the same location, collaboration is as simple as looking over the cubicle wall. If your ASC billing office is off-site, the frequency and timeliness in which front office errors are communicated may impact the ASC billing office revenue cycle. It is important to have timely and frequent communication in this scenario.


Requests should not be put on hold when someone is out sick! Besides needing backup to cover absences, cross-training allows employees to understand how people in other roles manage their time and contribute to the success of the team. Transparency among departments and roles invites accountability. The quarterly billing office process improvement review is a perfect time to identify areas where cross-training is needed to fill gaps and/or back up a role.


A billing office’s process improvement plan success is dependent on the team’s commitment to the improvements. Encourage staff to participate and take charge of change. They perform the tasks that bring the money in the door. Policies and procedures sound good on paper, but execution can reveal unexpected roadblocks. Your team has ideas of how to prevent issues and improve the process. Implement the solutions that will work best for your team and your center.


CMS guidelines, fee schedules, CPT/ICD-10/HCPCS codes, pre-certification lists, and coverage policies – this information changes monthly, quarterly, annually. Subscribe to insurance company newsletters and follow medical societies, revenue cycle resources, and vendors. Assign someone to distribute beneficial information to affected groups of people. This may include surgeons, their billing office, facility administrators, and insurance verification specialists, in addition to your own revenue cycle team. The information released may force you to take yet another look at your revenue cycle needs and adjust as necessary!

Summary of Tips for ASC Billing Office Process Improvement

Make it regular. ASC billing office process improvement review should take place on a regular basis, whether conducted monthly, quarterly, or on another schedule.

Review the data. Reviewing rejected claims logs and other data allows you to identify trends and billing office inefficiencies.

Promote team collaboration. Billing office roles will naturally back each other up when operating in sync with collaboration.

Incorporate occasional cross-training. A fresh set of eyes can provide valuable insight into simple changes that can increase efficiency or reduce errors.

Don’t leave out clinical roles. They have valuable insights that can affect coding and thus reimbursement. Evaluate the use of expensive implants and supplies to ensure you are billing and collecting as your contracts allow.

Re-evaluate and update regulatory information. It is crucial to the essential function of the ASC billing office to maintain accurate and up-to-date records when it comes to CMS guidelines, fee schedules, CPT/ICD-10/HCPCS codes, pre-certification lists, and coverage policies. This should also be a part of the regular ASC billing office process improvement review.

The only constant in the healthcare industry is change. When so many professionals rely on your office for the financial deliverables of their organization, as in the ASC billing office, it is imperative to stay up-to-date with industry changes. Regular review of your internal processes is the best way to keep up.

Bethany Bueno, Director of Billing Operations

Advancing ASC Technology: The Industry's Next Big Move

Advancing ASC Technology: The Industry’s Next Big Move

By ASC Management, Leadership, Uncategorized No Comments

Healthcare is a field that is heavily vested in advancing technology. Physicians and their practice locations, including ASCs, are under great pressure to invest in new technology. Patients are expecting their healthcare facilities not only look modern but deliver an experience that also feels modern. A recent Black Book survey found, for their next healthcare purchase, 83% of consumers will seek providers offering the following four technologies: digital scheduling, online payment options, online portal and engagement capabilities, and results reporting tools.[1]

It’s not just patients who desire healthcare facilities using electronic solutions. Prospective physicians and staff may also find the prospect of using non-electronic solutions unappealing. This is most likely to be true for “digital natives” – those raised during the age of digital technology. Telling them they must use non-electronic solutions or outdated technology may be all it takes to lose physicians and/or job candidates.

Guidance on How to Effectively Add ASC Technology

Despite the growing pressure to add new ASC technology, surgery centers will want to be careful not to try to do too much, too fast. Here is some advice to help you make smart decisions.

Understand your options. As the demand for ASC technology has grown, so have the types of technology available. Our ASC recently implemented two new technologies. One was a texting program managed through an online patient portal vendor (read more about this program in my previous blog). The other was a surgery scheduling application. It allows any authorized personnel logging into the application – whether it be physicians, schedulers, staff or vendor reps – to see our current schedule. The application provides real-time updates when scheduling information changes.

These are just two of the many new technology options to hit the ASC market in recent years. There are also many vendors offering similar technologies. This makes it vital for ASCs to carefully research their technology choices. One way to find out about new solutions is by attending ASC conferences and visiting the booths of exhibiting vendors. Afterwards, you may find it advantageous to schedule demos and speak with other users of the technology. Remember, you should get all questions answered before moving ahead with an investment.

Resist hype. Refrain from implementing technology just because it is the latest trend. You may choose a solution that fails to fill a need as effectively as another option. Rather, consider developing a technology strategy with target initiatives that support specific organizational goals. Benefits of aligning with goals include stronger process efficiencies, cost savings, added functionality, and increased safety.

Involve end users. To help ensure successful adoption, I involve end users from the beginning of the research process. Users are typically more accepting of a new system when they understand how it will positively impact their jobs.

At our ASC, we focus on providing the appropriate amount of training for the appropriate length of time. We get staff feeling comfortable using the new system and avoid overwhelming them with unnecessary details about functionality. You can always provide additional training once staff grasp basic functions of the system.

Anticipate pushback. Resistance to a change of any sort is almost inevitable. That is true with the addition of new ASC technology, even if the technology has the potential to improve existing processes. Reasons for pushback can vary. Some staff may question changing a process if that process seems to still work well. Others may express concern about their comfort with using technology. Some physician owners may wonder whether the financial investment is worthwhile. Factor in resistance in your technology planning and be prepared to address it (see the tips at the end of this article).

Learn from experiences. Every new ASC technology implementation presents opportunities for learning that can be applied to future implementations. Following an implementation and initial use of a new solution, it can be helpful to assess the experience. What obstacles encountered – internally or with the vendor – could have been avoided? If strong resistance remained even after implementation, what can be done to better address it? If staff struggle to use the technology, where can training be improved? The lessons you learn can help make the addition of your next ASC technology a little easier.

Tips for Overcoming ASC Technology Resistance

As noted, you should expect resistance from at least some staff to the addition of a new ASC technology. I already highlighted the value of involving end users, which can play a critical role in overcoming resistance. Here are some other quick tips:

  • Be clear. Even before you select a solution, it is helpful to inform staff about your plans for the new technology. You may consider explaining your plan’s purpose and the benefits you anticipate achieving and letting staff know the decision has board support. As you move forward with the selection process, keep staff in the loop. This will help secure buy-in and build excitement.
  • Lean on your champions. When encountering resistance, identify team members most excited about the new technology and ask them to be your champions and cheerleaders for the project. Think about encouraging your champions to speak with peers about why they are excited and why everyone should share this feeling. Peer pressure can be a valuable tool.
  • Adjust training. Your staff will likely need different levels of training to become comfortable with a new solution. Be prepared to adjust training accordingly. Let staff know that training will be individualized, where necessary. You will likely need to spend more time with those less tech-savvy individuals on your staff. Their training should focus on building a basic understanding of and comfort with the solution. This can help alleviate fears of transitioning to the new ASC technology.
  • Lean on the vendor. You may want to invite vendor representatives to your ASC if they weren’t planning to visit already and ask them to present on the benefits of their technology. The vendors should allow staff time to ask questions. Some staff may be less hesitant to ask questions and express concerns to vendor representatives than to ASC leadership.
  • Celebrate milestones. The more positive energy you can associate with the adding of a new technology, the better. Celebrate significant milestones achieved during the project. These can include choosing a solution, beginning implementation, and go-live. Ways to celebrate include email announcements, posters, snacks, and catered lunches. By building enthusiasm, you may even bring your most rigid naysayers on board.

The addition of technology can transform ASC operations and bring about improvements throughout the organization. But if decisions are rushed, new technology can create significant problems with processes and personnel. Approach potential ASC technology additions with care and purpose. Doing so will better help ensure the solution you choose delivers on its promise.

Michaela Halcomb, Director of Operations


ASC Case-Costing: Improving the Data Collection Process

ASC Case-Costing: Improving the Data Collection Process

By ASC Management, Leadership No Comments

For an ASC leader, understanding the financial impact of each surgery performed in an ASC is critical to the facility’s success. To achieve this, you must have detailed, accurate data on surgical costs and reimbursements.

Most facilities have software that produces reports which assist with gathering and modeling data. Depending on the resources available at your facility, the difficulty in gathering and using case-costing data will vary.

Avoiding ‘bad’ data

Some management companies, like Pinnacle III, employ a data analyst to provide tools to analyze the cost and reimbursement of cases. However, even with the help of a data analyst, the analysis will only be helpful if the data collection process is accurate and thorough. A common saying among data scientists is, “Garbage in equals garbage out.” For ASCs, if the person pulling the data does not have accurate data to work with, case-costing will be inaccurate.

Here are a few ways to avoid producing bad data.

  • Ensure staff are entering valid data into your software and paying attention to details. Educating staff about the impact of their role in this process is key. Staff mistakes, such as entering equipment cost as supply, can falsely inflate the cost of the case in your analysis. These mistakes are easily avoided by focused staff members who have received adequate training on their function and impact.
  • Update staff compensation. If pay rates aren’t current in your software, the labor costs associated with a case will be incorrect.
  • Engage your materials personnel. The material personnel are vital to keeping information current and accurate. Supply pricing changes must be up-to-date in your software.
  • Keep preference cards current. Make sure hold items are not listed as open. Ensure standard items used on every surgery are correct. This will avoid waste and reduce errors when accounting for what was used during each surgery.
  • Don’t forget supplies used outside of the OR. The supplies used in pre-op and PACU for a patient can seem insignificant. However, accounting for them with the surgery ensures general supply expenses spread among all cases is reduced. Create a pre/post bundle price for each type of surgery that gets added to the supply used. And don’t forget to include anesthesia supplies and drugs, which are often overlooked.
  • Include everything with a fee. Often there will be a charge for something, such as rental for a laser or a tray drop-off, that can be easily left out. If certain items are always used and the fee is known, add them to the preference card and include the fee in your software. Educate staff to facilitate understanding about which items carry a fee to ensure those costs are added to the case.
  • Accurately capture implants and instrumentation. Avoid including reprocessed items as an expense. Ensure fees are not attached to reprocessed instruments or they could be charged to the case as a supply used. Ensure implants used are reflected in your software with the appropriate price.

Final tips for case-costing analysis

There are obvious costs to capture, however, some items may be overlooked, particularly if you are not utilizing a data analyst. Some things to remember when gathering case-costing data are:

  • Include total visit time as well as OR time. The length of time the patient spends in the facility from admission to discharge is an important factor in the overall cost of a case.
  • Use your P&L to tie-in general expenses to be allocated among all cases as an indirect expense.
  • Include the payor mix. This is very important as the payor mix can be a contributing factor to variances among surgeons.
  • There is never too much detail. The process is tedious, but the result will benefit the ASC in many ways. The more ways the data can be sorted, the easier it will be to identify inefficiencies, waste, spending variances, long recoveries, and a variety of trends.
  • Separate supplies and implants. This will allow you to compare surgeons by case and identify opportunities for savings and standardization.

Once the data is gathered, configure it in a way that will allow you to study it from multiple angles (e.g., via a spreadsheet program). Begin with a broad view – by specialty, physician, CPT, or payor, for example. Then examine the subsets – perhaps by specialty/by physician or by physician/by CPT. If you notice significant variances, dig deeper to determine the cause. As you study the data you may find errors. Rather than being frustrated by inaccuracies, use errors as an opportunity to refine your processes and/or systems. Avoid sharing data with your surgeons until you are confident it is accurate. Seek their insights when sharing the information; they may be able to point to additional areas to investigate prior to making operational decisions based on the data.

As you refine your processes and systems, keep your staff and surgeons in the feedback loop. Addressing errors as they arise will create a more seamless process that allows you to focus on other improvement opportunities.

Stay tuned for the second-part of my case-costing blog series. In my follow-up blog, I will further discuss best-practices for analyzing case-costing data. I will also delve into ways to utilize case-costing data, and the benefit of engaging surgeons in the process.

Lori Tamburo, Director of Operations

Curbing Healthcare Spending: What Health Plans Are Doing to Work Against Out-Of-Network Providers

Curbing Healthcare Spending: What Health Plans Are Doing to Work Against Out-Of-Network Providers

By ASC Development, ASC Management, Payor Contracting No Comments

As healthcare spending in the United States continues to rise at a seemingly unstoppable pace, healthcare entities are making attempts to curb healthcare spending. This has led to changes in the healthcare marketplace and delivery of care to consumers. For example, health insurers are attempting to rein-in spending by decreasing the use of out-of-network providers. Recently, when asked what health insurers are doing to make it more difficult for out-of-network providers to secure patients and collect payment, I responded with “A variety of things depending on what the health plan is trying to prevent.”

While health plans are using a variety of measures to thwart out-of-network activity, this blog will focus on three prevention techniques that have perhaps become more prevalent recently:

  1. Educating members on the costs of using an out-of-network provider,
  2. Imposing penalties on in-network providers for use and/or referral to out-of-network providers.
  3. Making it difficult for out-of-network providers to collect payment.

Educating Members on the Costs of Using an Out-of-Network Provider

Health plans offering their members out-of-network benefits/coverage are going to greater lengths to steer their members away from out-of-network providers and to in-network providers through education.

As a first line of defense, health plans are taking steps to re-direct members to in-network providers via posts on their website and/or calls from pre-authorization staff, where the member is being educated on the increased cost associated with care rendered by the out-of-network provider. Some health plans provide an online hypothetical cost comparison tool. The tool helps members better understand the cost differences among doctors, facilities, and laboratories that do not participate in their networks.

Some health plans inform their members the out-of-network provider has no limit on what they can charge for their services, and those provider’s fees will not be discounted because they do not participate in the health plan’s provider network. Additionally, insurers may inform their members when an out-of-network provider is used, that they will likely end up paying a higher deductible and co-insurance.

Finally, health plans are alerting their members if they use an out-of-network provider, only a portion of the out-of-network charges will get paid by insurance and, absent a state-specific law or regulation, the member will be responsible for paying the remainder of the charges.

Penalizing In-Network Providers for Use of Out-of-Network Providers

When an in-network provider such as a surgical facility or surgeon uses the services of another provider who is not contracted with and participating in the plan’s network, the in-network provider may now be putting itself at risk for repercussions from the health plan.

Contracts between health plans and providers may require contracted providers to restrict their use of or referral to other contracted providers within the network. When these contracts are breached, consequences may arise including being served a contract termination notice or experiencing financial penalties. These types of restrictions have recently been extended to anesthesiologists, radiologists, pathologists, and surgical assistants.

These out-of-network referral situations have garnered significant attention because they can create unexpected “surprise bills” and substantial financial burdens for patients. As a result, health plans have started terminating contracts with in-network surgeons that use out-of-network surgical assistants and/or out-of-network facilities.

Some health plans are requiring new facilities seeking in-network status to accept contract provisions that allow the health plans to impose financial penalties on the facility for the use of out-of-network anesthesia, radiology, lab, and pathology providers. Penalties have ranged from a small amount to over half of the negotiated surgical fees. In addition, health plans have begun pressing providers to hold harmless provisions that protect both the payer and member from the added costs of out-of-network providers, including limits or prohibitions on balance billing.

Not Making It Easy to Collect Payment

Rather than reimbursing the out-of-network provider for services rendered, some health plans issue payment directly to the patient. This may occur even if the out-of-network provider has had the patient sign an assignment of benefits form, whereby the patient requests his or her health plan issue payment directly to the provider. And once the payment they’ve been waiting for has been sent directly to the patient, it may become more difficult for the out-of-network provider to collect payment. If patients have cashed and already spent the insurance reimbursement check, it may be difficult for the out-of-network provider to secure remuneration.

The practice of sending the payment to the patient will continue to be a deterrent to out-of-network providers. While a handful of states have enacted legislation which requires insurers to honor the assignment of benefits, chasing patients for payment will likely remain a labor-intensive administrative burden associated with managing out-of-network claims well into the future.

Making an Informed Decision on Going Out-of-Network

For some providers, the out-of-network strategy may appear to be the best fit for their business. But, facilities and physicians who either currently accept patients on an out-of-network basis or are contemplating doing so should also be aware of the potential obstacles and limitations of this strategy. Obstacles for out-of-network providers include persuasive education for plan members on the financial consequences of securing care from an out-of-network provider, the possibility of having penalties imposed on in-network providers, and the risk of chasing patient payments. If surgery centers do not understand the impact this will have on their business in the long-run, the vitality and long-term success of the center could suffer. It is in each practice’s best interest to understand the pros and cons of being an out-of-network provider prior to making an informed decision for the organization.

Dan Connolly, VP, Payer Relations & Contracting

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

Understanding the Administrator's Role in ASC Quality Improvement

Understanding the Administrator’s Role in ASC Quality Improvement

By ASC Management, Leadership No Comments

A quality assurance performance improvement (QAPI) program has long been the foundation for the delivery of quality care in an ASC. That’s because an effective QAPI program helps improve all aspects of an ASC’s operations. Despite its longstanding importance, ASC quality improvement has taken on greater significance in recent years.

There are a few reasons why. Physicians, staff, regulatory bodies, payors and even patients are demanding increased transparency concerning quality and quality improvement data. Accreditation organizations are requiring a high-level QAPI process to meet standards. Reimbursement is increasingly tied to quality measures and outcomes. Reports of poor quality tend to make the news and spread like wildfire.

This makes it vital that a QAPI program be an organizational commitment for ASCs. It is the administrator’s responsibility to secure such a commitment from employees, management, physicians and the governing board. To do so, an administrator must be an active participant in ASC quality improvement and embrace the steps necessary for success.

10 Steps for Administrator Involvement in ASC Quality Improvement

Here are 10 steps administrators can follow to help ensure effective involvement in their ASC’s QAPI program.

  1. Understand your program. Allocate the time necessary to learn about your QAPI program, plan, and processes. Without a strong understanding, administrators cannot provide effective oversight and participation.
  2. Learn requirements. If your ASC delivers care to Medicare and/or Medicaid patients, you are required to meet the Centers for Medicare & Medicaid Services’ (CMS) QAPI requirements. As noted earlier, if your ASC is accredited, your QAPI program must comply with accreditation standards. While there is likely overlap between the requirements, there may be some differences. Understand what surveyors expect to see when they visit your ASC.
  3. Focus on what matters. ASC quality improvement can feel overwhelming when you’re unsure what areas of operation to focus on for improvement. Study performance data and identify those measures and benchmarks critical to your success. This will help ensure you measure, track, trend, report on, and improve what is most important to your ASC.
  4. Carefully select a program manager. While administrators should be active participants in ASC quality improvement, they do not normally serve as the QAPI program manager. Rather, they select and appoint a responsible individual. This person, who is often a nurse, must have interest, knowledge, and experience in quality improvement. Passion for improving care is vital to your QAPI program manager’s success. Also critical: administrative and organizational skills, including using spreadsheets and databases, and developing meaningful presentations for QAPI committee meetings. Note: Maintain a current, clear QAPI program manager job description for guidance and accountability.
  5. Establish oversight. Develop a process to ensure effective oversight of the QAPI program. Follow your organizational chart to maintain accountability of the employee responsible for the QAPI program. Include yourself on that chart as you will likely work directly with the QAPI program manager on specific projects.
  6. Support the program. A surefire way for a QAPI program to fall short of its potential is lack of support. Provide resources critical to a successful program. These can include time for the manager to work on ASC quality improvement, training, education (e.g., industry conferences, webinars, publications) and software. It also includes authority for the QAPI program manager to hold stakeholders accountable.
  7. Be active on committees. Take an active role on your QAPI committee. This will help you provide a comprehensive summary about QAPI activities to your medical advisory committee (MAC) and governing board.
  8. Serve as interface. As administrator, you are the interface between staff, physicians, MAC, and the governing board. You are responsible for maintaining an efficient flow of information regarding QAPI activities that help achieve objectives. Work closely with the MAC and governing board to ensure implementation of their directives.
  9. Stay involved. QAPI programs are most successful when administrators are continually involved, even when the program is delivering strong results. Such involvement demonstrates commitment and support. It also provides the opportunity to share input on benchmarking and studies appropriate and important to QAPI priorities.
  10. Keep current. Healthcare is a dynamic sector, undergoing frequent changes. This extends to ASCs. Administrators must keep abreast of industry changes that impact ASC quality improvement efforts. When changes arise, incorporate revisions to your QAPI process to meet new needs and requirements.

ASC Quality Improvement Quick Tips

The steps outlined above should help define your role in your QAPI program. Here are a few tips that can further boost your ASC quality improvement efforts:

  • Rely on your data. Using data helps administration make evidence-based decisions, allocate resources more effectively, and engage in targeted corrective actions.
  • Involve many staff in your QAPI program. This will help create a learning organization where ASC quality improvement processes are understood and improvements are sustained and built on.
  • Promote your program. Keep QAPI as a top-line item for MAC and governing board meetings. Share program results and explain how they improve your ASC. Provide this information to payors to further demonstrate your ASC’s commitment to quality.
  • Leverage partner support. If your ASC has a management company and/or hospital partner, its QAPI expertise can be an asset to the manager and program.

The importance of QAPI and ASC quality improvement efforts are likely to magnify as the demand for quality information and data grows. Quality improvement must be an ongoing effort if ASCs want to achieve meaningful results and maintain compliance. By carefully balancing their participation with QAPI program oversight, administrators can play a crucial role in achieving these objectives.

Ross Alexander, Director of Operations

ASC Business Strategy: Peering Through a Looking Glass into Your Organization

ASC Business Strategy: Peering Through a Looking Glass into Your Organization

By ASC Management, Leadership No Comments

I have often told groups who are interested in developing a surgery center, or who already have one, that seeking “professional help” to assist them with ASC business strategy is a smart move. Outside consultation can provide an organization with a fresh, yet experienced, point of view. This year I decided to practice what I preach.

Over the last year, Pinnacle III has been diving deep internally to refine our systems, processes, and strategy. After several months of self-assessment, we decided to seek outside professional help to realize the true benefits of our strategic planning process. We selected a consultation firm that specializes in small businesses experiencing growth. Their task? Provide us with operational, organizational, and cultural input and guidance throughout that growth process. The process of internal review and change has been challenging and rewarding.

I now double down on my original stance – organizations, especially developing or growing businesses such as ASCs, should seek outside professional consultation to assist in building and implementing business strategy.

Taking the Steps

To help you visualize how this process might work in your organization, I’ve listed the steps I took when seeking outside professional consultation.

  • First, we made an initial determination of the strategic initiatives we wanted to accomplish. This gave us an idea of the organizational goals we might need outside help to accomplish.
  • Next, we chose a strategic consulting firm. To obtain a list of the consultants serving businesses like our own, I reached out to people I respected in the business community for recommendations. I discussed with my contacts what I was trying to accomplish. After combining input from trusted colleagues and business associates with my own research, I narrowed my scope to three potential consultants.
  • Third, I interviewed each firm. The first firm operated under proven, academic-based structure, with a great deal of experience working with institutional organizations. The second firm was experienced in strategy, but typically worked with companies larger than Pinnacle III. And the third firm, the one I ultimately chose, was a group run by an individual who had started and run several companies and whose experience was geared more towards mid-sized companies. I felt this was the best fit for us.

What I Learned

Since making the decision to go down this road and choosing someone to work with, I have learned several things.

  • You must be ready for transparency. Unless you are willing to pull back the curtain on how your business is run and managed, don’t take this step. We opened our books and gave our consultant access to our management team, as well as other key members of our organization. We made it clear to our entire team no topic was off the table and all comments would be confidential.
  • You must be ready to put your ego aside. If you can’t “handle the truth” (remember Jack Nicholson in “A Few Good Men”), don’t embark on this journey. Each management team member – especially my partner, Rick DeHart and I – were provided feedback that resulted in small to moderate ego bruising. We were reminded the feedback received, both from the consultant and the team, was meant to improve our organization and meet our established goals.
  • Getting a diagnosis is worthless unless your organization is committed to the treatment plan. We went into this exercise committed to addressing the problem areas and taking the time to make changes to ensure our continued success. If you, as the leader, or members of your team are not committed to doing what is necessary to achieve the goals initially identified when the process began, you will only end up wasting valuable time and money.
  • Keep the fire burning. We are experiencing what we expected to experience. None of the initiatives are a quick fix – if they were, we would probably already have implemented them. Instead, as an organization, we have had to stay committed to our original goals and the long-term benefits we will receive from this initiative. It is up to each leader in our organization to keep us moving forward to reach our goal.

Regardless of how your business measures success, strategic initiatives need to be in place to accomplish your organization’s goals. Evaluating your organization’s current business strategy and environment relative to where you want to be is the first step toward creating those strategic initiatives. Then, when appropriate, business leaders should have the courage to seek outside consultation to structure the implementation and execution of plans designed to achieve the desired goals. Building a team capable of accomplishing the initiatives and recommendations to move the company forward is an equally important step. Working with an outside consultant can also bring clarity on how to strategically build and refine your team at a rate on pace with your company’s growth.

As established leaders, it may be difficult to admit things could be better managed, or that you may not have all the answers. A business that overcomes the ego of its leaders, incorporates input from trusted resources including outside consultants, and grows through internal process review and refinement, is a sign of a truly strong and humble leader.

Robert Carrera, President & CEO

When a Screening Colonoscopy Becomes Diagnostic: Educating Patients on Financial Responsibility

When a Screening Colonoscopy Becomes Diagnostic: Educating Patients on Financial Responsibility

By ASC Management, Uncategorized No Comments

A patient comes into your ASC and undergoes a screening colonoscopy. Polyps are found during the procedure and are removed. Considering the circumstances, this sounds like good news. The screening served its purpose. You detected and removed cancer precursor lesions, hopefully helping to prevent the disease.

There’s just one problem: The patient is angry. Not about the successful removal of the polyps, but about how a change in type of procedure also changed the patient’s financial responsibility. A scheduled screening colonoscopy has become a diagnostic colonoscopy. Rather than being a preventative service provided at no cost to the patient after their insurance has processed the claim, the patient now owes a payment – possibly one considered quite significant.

Guidance for Screening Colonoscopy Education

By taking a proactive approach to colonoscopy education, your ASC can help reduce its number of upset patients. You may even improve their satisfaction in the process. Here are some recommendations on how to help patients understand their potential financial responsibilities before undergoing a colonoscopy.

Develop Documentation

Alleviate some of the confusion about colonoscopies by providing patients with documentation explaining possible outcomes of their screening colonoscopy. Share background on preventative services, noting limitations on this provision. Explain how the definition of a preventative service is adjusted due to changing (and strict) insurance guidelines. Elaborate on how this may affect patients scheduled for a screening colonoscopy and their financial responsibility. Define the categories of colonoscopies: screening/preventative, diagnostic/therapeutic, and surveillance/high-risk.

This background information will hopefully help patients gain a better understanding of colonoscopies. Then summarize what can happen when patients receive a screening colonoscopy referral. Describe how categorization can change based on information captured during the scheduling and pre-procedure processes. Consider addressing some frequently asked questions, such as whether physicians can change a diagnosis so a procedure can qualify as screening and why insurance companies may seem to indicate that your ASC can alter a CPT or diagnosis code.

Share Benefits Information

Along with this documentation, provide patients with information about their colonoscopy benefits. Give your benefits coordinator a form to fill out when they review coverage information online and/or contact patients’ insurance carriers. This form would include details on patients’ covered benefits concerning screening and diagnostic colonoscopies. It would also state patients’ financial responsibilities (or potential responsibilities), broken down by co-pay and deductible.

You may want to include details about payment plans your ASC offers on this form. This can help patients start planning how they will pay for their care if the colonoscopy categorization changes. Include this form with the background documentation.

Speak Directly With Patients

While these documents should better prepare patients for their colonoscopy and possible financial outcomes, calls to patients are also worthwhile. Use this opportunity to review the information in the documentation and form. Ensure individuals at your ASC who speak with patients can explain the difference between screening and diagnostic colonoscopies. Staff should receive training to help them effectively communicate with patients and accurately answer questions.

Quick Tips for Dealing With Upset Patients

Despite your best educational efforts, you may still receive phone calls from upset patients following their colonoscopy. Consider following these steps to help address their concerns:

  • Let them vent. If patients sound animated, give them time to share their thoughts and feelings. Avoid interrupting and try to respond only when asked a question. Giving patients this opportunity to vent can help them calm down and become more focused on the discussion to follow.
  • Remain polite. Throughout your conversation, strive to remain polite, listen carefully and remain calm. If patients believe you are becoming frustrated, not listening closely, or failing to take their concerns seriously, they are likely to become angry.
  • Review case history. Help patients feel like you take their concerns seriously by discussing the details of their situation. Pull up their chart and bill. Talk through the procedure: what was scheduled and found, and how that affected information submitted to their insurance carrier. Verify that your ASC properly coded and billed the procedure.
  • Explain insurance rules. After discussing the case history, patients may still question what they owe. Describe health insurance rules and how they dictate changes in colonoscopy categorization. Provide education on diagnosis codes and your ASC’s requirements to code based on the procedures performed, not scheduled. Discuss the claims submission process and how that triggers the health insurance reimbursement process. Note: If patients spoke with their insurance before you, they may have been told that had you coded the procedure as a screening colonoscopy, it would have been covered. Be prepared to explain the potential fraud implications of improper coding and billing.

Going through these steps can provide comfort to patients and help them better appreciate your ASC’s responsibilities. Once you address any outstanding questions, move to the discussion about how patients will cover what they owe. Be cognizant that patients may be in a delicate state as they come to accept their financial responsibility. Help relieve some stress by informing them of payment options that can spread their financial responsibility over time. While patients may express displeasure with what they’re hearing, patience and compassion can move the situation toward a positive resolution.

Catherine Sayers, Director of Operations

Launching an ASC Staff Certification Program

Launching an ASC Staff Certification Program

By ASC Management, Leadership No Comments

When members of your staff indicate they want to get better at their jobs, your response is probably enthusiastic support. After all, a more competent, skilled staff is better prepared to achieve improved clinical and financial results and higher patient and surgeon satisfaction. These are some of the reasons ASCs allocate time and resources to staff training and in-service education. They are also compelling reasons for developing a program that supports ASC staff certification.

ASC Staff Certification Program Components

Here are some of the essential components to address when developing your ASC staff certification program guidelines.


Determine certification program eligibility. Is the program limited to full-time employees or are part-time employees also eligible to participate? Are staff required to work at your ASC for a specific amount of time (e.g., one year) before they are eligible for the program? Will you restrict participation to employees in good-standing?

Acceptable Certifications

Specify which certifications your program will cover – preferably, those that are essential to your facility’s success. Examples of certifications you may want to include:

  • Certified Perioperative Nurse (CNOR)
  • Certified Post Anesthesia Nurse (CPAN)
  • Certified Ambulatory PeriAnesthesia Nurse (CAPA)
  • Certified Surgical Tech (CST)
  • Certified Gastroenterology Registered Nurse (CGRN)

It’s important to permit staff to propose certifications not included in your program. You can weigh the merits and applicability of each proposal. While you may add to your original program list, consider including only those certifications awarded by nationally recognized professional organizations.

Covered Expenses

Identify which expenses are eligible for reimbursement upon successful completion of the ASC staff certification. You will likely want to cover the certification exam fee. You may want to reimburse certification renewal fees. Other expenses to consider:

  • Educational resources to support exam preparation (e.g., books, webinars, conferences)
  • Practice exams
  • Transportation to and from an exam center
  • Continuing education required to maintain the certification

Include a qualifier noting that reimbursement only applies to the portion of eligible expenses not already covered by other payment sources, such as scholarships. Put a cap on the amount of reimbursement available for a single certification and/or timeframe (e.g., annually).


Require documentation at the beginning and end of the program. Employees seeking certification assistance should submit their application/request in writing. Following certification program completion, ensure employees provide documentation demonstrating they earned the certification. If you are covering other expenses, request itemized receipts.

Secure a Return on Your Investment

An ASC staff certification program is one way for your ASC to invest in staff. Help protect your investment by including a reimbursement qualifier in your guidelines. State how long employees are expected to remain with your surgery center following completion of, and reimbursement for, the certification program. Clearly outline the financial penalty for failing to reach this mark.

For example, you might require employees to repay 70% of their assistance if they do not stay with your ASC for one year after achieving certification. While you cannot require employees to remain at your center, financial penalties encourage them to thoughtfully consider the impact leaving prior to completion of the qualifying term will have on them and your ASC. Financial qualifiers also deter individuals not fully committed to staying with your ASC from applying to the program.

ASC Staff Certification Program Expansion

If you launch a program that is successful, consider additional ways to encourage staff members to participate. One way is to add certifications to your list. Ask staff for their recommendations. Monitor the development of new certifications, such as the recently launched Certified Ambulatory Infection Preventionist (CAIP).

Another way to expand the program is to go beyond certifications. Include courses provided through an accredited educational institution of higher learning (e.g. college, university, trade or vocational school). These offerings may attract individuals already holding certification(s) or those not interested in certification.

Here are some additional considerations if you are going to offer reimbursement for course tuition:

  • Require the primary business of the institution attended is education. Academic or college credit hours should be earned upon successful completion of the class.
  • Ensure course work is applicable to the employee’s current position or tied to a degree related to an employee’s career path with your ASC.
  • Require proof of completion, such as a transcript or grade report.
  • Determine whether to reimburse for books and other supplies mandated for course participation.

Offering reimbursement for certifications and courses is a potentially low-cost, high-reward method to improve staff performance and productivity. This investment can encourage greater staff loyalty and appreciation of leadership support. An ASC staff certification and educational course program promotes an ASC’s mission of providing compassionate, high-quality care. That’s a proposition easy to endorse!

Michaela Halcomb, Director of Operations