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Recruiting Surgeons

Questions to Consider when Recruiting Surgeons to Your ASC

By ASC Management, Leadership No Comments

There will come a time when your ASC will need to recruit new surgeons.  Whether it’s for a new, thriving, or struggling ASC, recruiting new surgeons is a continual priority.  The selection process for adding physician members to your ASC is critical to becoming and remaining a prosperous center.

Ask yourself the following questions when recruiting surgeons.

  1. What is the surgeon’s character/competence?

If the surgeon has been problematic in the health care community and has established a reputation as being difficult to work with, consider the impact they may have at your center.  If you would not send a family member to them for surgery, would you associate yourself professionally with them?  Choose your partners wisely.

  1. What is the return on investment (ROI)?

Not all cases, or case mixes, are created equal.  Sometimes an ASC is not the best place for certain procedures or specialties.  To obtain an understanding of the ROI, evaluate the surgeon’s CPT codes and case mix.  Compare these to your facility’s existing contracts (or the proposed contract rates if you are evaluating a startup situation).  Avoid assuming all cases and surgeons are alike when it comes to supplies, staffing, and implant usage.  Perform due diligence on what a surgeon utilizes or what a case requires.  Additionally, payor mix will play a significant role in determining how appropriate a surgeon is for your ASC.  If you do not want to contract with a particular payor, and that payor represents a significant portion of a surgeon’s cases, recruiting that surgeon may not be the best move for you.

  1. Is there exclusivity or conflicting interests?

In the late 1990s, there were very few ASCs and they performed very well. In the early 2000s, word got out ASCs were a viable means of augmenting a physician’s income and improving their quality of life.  Thus, in many parts of the country, ASCs proliferated.  This proliferation contributed to physicians diluting their cases across many ASCs.  This was not a problem when the ASCs serviced distinct geographic areas and did not jeopardize the physician’s ability to meet federal Safe Harbor requirements.  However, that is not reflective of the current environment.  When considering surgeons for membership in your center, vet any other ASC investments they may have. Determine how those investments might impact their commitment to your center, as well as their ability to meet federal and ASC specific requirements.

  1. Are you clearly defining expectations?

We all do better when clear expectations are established ahead of time. This is no different for ASC physician members.  You can accomplish this via the center’s operating agreement and bylaws.  I like to consider these documents the ASC’s prenuptial agreement.  Allow boards and steering committees to clearly define responses to issues they may encounter down the road by addressing them proactively in these documents.  These can include, but are not limited to, behavioral expectations, dictation expectations, non-compete provisions, Safe Harbor compliance, buy/sell agreements, and enforcement.  All potential members need to thoroughly read and acknowledge their agreement with these documents before you consider them for membership.  Lastly, if you are evaluating membership for new surgeons in an existing ASC, consider implementing a trial period of three to six months.  This allows all parties to ensure the center is a good fit.

Use these questions to assist you with your recruitment initiatives.   Remind ASC leadership when seeking new members, it’s typically easier to obtain a divorce than it is to remove an undesirable surgery center partner.  This fact makes the vetting of new partners that much more important. Remember, it is never as simple as “s/he has a lot of cases.”


Robert Carrera – President and CEO

ASC Experience

The ASC Experience: A Patient’s Perspective

By ASC Management No Comments

Those of us who work in ASCs can easily forget that many health care consumers are not familiar with the services we provide.  If a patient hasn’t been directed to an ambulatory setting for surgical care, they are often unaware that freestanding ASCs exist.  If they’ve had surgery in a hospital’s outpatient department (HOPD), they may not be aware alternative outpatient settings are available.

While we know the benefits of choosing an ASC over a hospital setting, our patients experience the care we provide from a completely different point of view.  While it is uncommon for patients to have the same procedure performed both in a hospital and at an ASC, one of our billing service employees was able to offer this unique perspective.  

We hope her story resonates with you.  It may even help you identify what makes your ASC a facility of choice for your physicians and patients.  

Here’s her story:

“The day we had been dreading for years finally arrived.  My husband could no longer walk without significant pain. He needed a left knee replacement.  He had his right knee replaced 10 years earlier in a hospital setting.  The process went about as badly as any could go.  But now, he could no longer hold out.   We made an appointment with a surgeon. 

Our surgeon, Dr. Ian Weber, described a newer process for the procedure including a post-operative pain block.  He suggested my husband was a good candidate for having the procedure in an ambulatory surgery center instead of a hospital.  We chose The Surgery Center at Lutheran. 

We arrived at 6:00 on a Monday morning.  Within 10 minutes a nurse took us back to pre-op and explained the procedure my husband would undergo.  During each step of the process, the nurses made sure we both understood what was occurring and why.  Within an hour, my husband was prepped for surgery and off he went.   Approximately two hours later a nurse came to let me know he was in recovery and led me back to stay with him.  My husband recognized and spoke to me immediately. 

From that point forward, the recovery nurse never left our line of sight.  She checked on my husband frequently to see if he needed anything and assessed how the pain block was wearing off.  She explained the goals he needed to achieve to be released and then helped him accomplish them.  By noon he was sitting up, eating lunch, and ready for physical therapy.  Around 1:00 p.m., with the aid of crutches, he walked around the surgery center.  The physical therapist was on one side and the recovery nurse on the other side to ensure his safety. By 2:00 p.m., the surgery center released my husband to go home with me. 

What a difference!  Ten years earlier, my husband spent four days in the hospital with various nurses assigned to his care.  Unfortunately, shift changes represented a step backwards as each new nurse needed to be brought current with my husband’s condition.  This year he spent eight hours at an ASC with one recovery nurse who knew exactly what was going on with my husband every step of the way.  The ability for my husband to sleep in his own bed that night and recover at home was amazing.   The difference between the two experiences could not have been greater. 

We are grateful to The Surgery Center at Lutheran and their amazing staff.  If we ever need surgery again, we will choose an ASC over a hospital stay.”


-The Pinnacle III Team

CMS Survey

An ASC Administrator’s Guide to Responding to a CMS Survey & Plan of Correction

By ASC Management No Comments

At some point, most facilities undergo a Centers for Medicare and Medicaid (CMS) Survey. These unannounced surveys can occur on any given day; hopefully your ASC is ready!

Prepare for Your Survey – Know the Conditions of Coverage

CMS establishes minimum health and safety standards, called Conditions for Coverage (CfCs), that ASCs must meet to obtain and maintain certification. The standards cover all aspects of an ASC from operational organization – including patient care and safety – to facility design. CfCs must be met for all patients seen in your facility, not just those covered by Medicare and Medicaid. You can find these standards in Appendix I: Survey Procedures and Interpretive Guidelines for Life Safety Code Surveys[1] and Appendix L: Interpretive Guidelines for ASCs[2] of the CMS State Operations Manual.

It is imperative for all members of your facility to be familiar with and understand these standards prior to a survey. To ensure sufficient preparation for an unannounced survey, put together binders of all the documentation the surveyors will want to review – policies, contracts, and other agreements – that address each CfC. Include an index that references back to each standard. These binders can then serve as survey preparation for your staff. As staff review each standard and locate the documentation supporting the standard, they are also educating themselves. Remember, the more educated and prepared your facility is, the higher the likelihood that you will achieve a satisfactory survey outcome.

What to Expect When Your Surveyor Arrives

Surveyors usually arrive early in the morning for unannounced surveys. You can plan on them conducting their on-site review for one and a half days to two full days depending on the size of your facility. They will review all aspects of your clinical and business operations. The surveyors will ask to review a multitude of items and one of them will follow a patient through the entire treatment process. The Life Safety surveyor will focus on the building and Life Safety Codes.

Although aiming for a perfect score, even the most highly functioning ASCs are typically cited for something. That’s the nature of the beast. Surveyors, intent on ensuring safety and quality of care for patients and staff alike, seek strict adherence to their certification standards. Deficiencies cited, no matter how minor, prompt a Plan of Correction. 

Upon completion of your survey, you will receive a report via certified mail. The report, which usually arrives within a few weeks of your survey, will include a request for a Plan of Correction (POC). The POC outlines any deficiencies cited during the survey. The deficiencies are reported on CMS-2567.[3] You must respond to each deficiency with specific details pertaining to the corrective actions you plan to take to fully resolve the citation. Your responses are recorded on the right side of the form.

Components of Your Plan of Correction (POC)

Five main components need to be included in your POC:

  1. The first component is the deficiency standard number and a detailed statement of what needs to be corrected. This should be a concise sentence related to the shortcoming.

If you are cited for expired medications in your inventory, for example, your response could be: Q181. The entire medication supply will be monitored monthly for expiration dates.

  1. Next, specify how the deficiency will be corrected. Note detailed information about the corrective action taken and who was involved. List all the items you completed to correct the inadequacy and maintain documentation regarding how you addressed the issue.

For example: Performed staff training on 12/12/2016. All clinical personnel were in attendance. Reviewed policy on expiration of medications and solutions. Revised policy to clarify preference for single dose vials and ampules. Responded to questions from staff regarding who retains responsibility for monitoring medication expiration dates.

  1. The third component notes how you will ensure ongoing compliance with the corrected deficiency – via random audits, for example. If you do audit, retain documentation of audit results. Be specific about how you will monitor the corrections made. Ensure monitoring is consistent and timely. Clearly state how you will maintain compliance.

For example: Updated emergency cart medication lists. Began actively monitoring the expiration dates of all medications throughout the facility. Implemented random audits of the medication supply to ensure compliance. Initial audit was conducted on 12/16/2016 in various locations around the facility. No expired medications were found. Compliance expectation is 100% removal of expired medications from floor stock as evidenced by monthly inspections.

  1. Name the responsible party for completion of each task and ensure ongoing compliance. You are permitted to use a person’s name but noting someone’s title (e.g., Clinical Director or Business Office Manager) ensures responsibility is linked to a defined role rather than a specific individual.
  1. The final component is provision of a completion date for the deficiency. Ensure the deficiency is corrected by the date you set.

Next Steps

Upon completion of the plan, sign and date the form. Return the document to the person and address noted on the Plan of Correction. You typically have 10 days after receipt of the POC letter to return your response.

Make sure you retain a copy of the POC on file at the center with all your corrective action documentation. As you work through the POC and collect supporting documentation, keep everything together in one binder. This is very helpful in the event of a re-survey.

The CMS regional office will review your POC. You can then expect a response letter from them regarding acceptance or denial of your plan of correction. If your POC was accepted, the letter will also inform you whether a re-survey will occur. A rejected POC will contain information regarding any changes that need to be made and a new deadline for completion. Update the POC and return per the letter’s instructions by the specified due date.

Conclusion

Although preparing, undergoing, and responding to a survey is a daunting task, surveys provide us with opportunities to view our ASC operations from the outside in. They allow us to implement best practices that ultimately lead to a center of excellence, a goal we are all trying to achieve. Don’t let the prospect of an unannounced survey worry you. Preparation and organization is key to successfully completing your survey, even if you are required to submit a plan of correction.


Kelli McMahan – Vice President of Operations

[1] https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_i_lsc.pdf

[2] https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_l_ambulatory.pdf

[3] https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS2567.pdf

CMS Survey

An ASC Administrator’s Guide to Responding to a CMS Survey & Plan of Correction

By ASC Management No Comments

At some point, most facilities undergo a Centers for Medicare and Medicaid (CMS) Survey. These unannounced surveys can occur on any given day; hopefully your ASC is ready!

Prepare for Your Survey – Know the Conditions of Coverage

CMS establishes minimum health and safety standards, called Conditions for Coverage (CfCs), that ASCs must meet to obtain and maintain certification.  The standards cover all aspects of an ASC from operational organization – including patient care and safety – to facility design.  CfCs must be met for all patients seen in your facility,  not just those covered by Medicare and Medicaid.   You can find these standards in Appendix I:  Survey Procedures and Interpretive Guidelines for Life Safety Code Surveys[1] and Appendix L:  Interpretive Guidelines for ASCs[2] of the CMS State Operations Manual.

It is imperative for all members of your facility to be familiar with and understand these standards prior to a survey.  To ensure sufficient preparation for an unannounced survey, put together binders of all the documentation the surveyors will want to review – policies, contracts, and other agreements – that address each CfC.  Include an index that references back to each standard.  These binders can then serve as survey preparation for your staff.   As staff review each standard and locate the documentation supporting the standard, they are also educating themselves.  Remember, the more educated and prepared your facility is, the higher the likelihood that you will achieve a satisfactory survey outcome. 

What to Expect When Your Surveyor Arrives

Surveyors usually arrive early in the morning for unannounced surveys. You can plan on them conducting their on-site review for one and a half days to two full days depending on the size of your facility. They will review all aspects of your clinical and business operations. The surveyors will ask to review a multitude of items and one of them will follow a patient through the entire treatment process. The Life Safety surveyor will focus on the building and Life Safety Codes. 

Although aiming for a perfect score, even the most highly functioning ASCs are typically cited for something.  That’s the nature of the beast.   Surveyors, intent on ensuring safety and quality of care for patients and staff alike, seek strict adherence to their certification standards.  Deficiencies cited, no matter how “minor,” prompt a Plan of Correction.  

Upon completion of your survey, you will receive a report via certified mail.  The report, which usually arrives within a few weeks of your survey, will include a request for a Plan of Correction (POC).  The POC outlines any deficiencies cited during the survey.  The deficiencies are reported on CMS-2567.[3]  You must respond to each deficiency with specific details pertaining to the corrective actions you plan to take to fully resolve the citation.  Your responses are recorded on the right side of the form. 

Components of Your Plan of Correction (POC)

Five main components need to be included in your POC:

  1. The first component is the deficiency standard number and a detailed statement of what needs to be corrected. This should be a concise sentence related to the shortcoming. 

If you are cited for expired medications in your inventory, for example, your response could be:  Q181. The entire medication supply will be monitored monthly for expiration dates.

  1. Next, specify how the deficiency will be corrected. Note detailed information about the corrective action taken and who was involved.  List all the items you completed to correct the inadequacy and maintain documentation regarding how you addressed the issue. 

For example:  Performed staff training on 12/12/2016.  All clinical personnel were in attendance.  Reviewed policy on expiration of medications and solutions.  Revised policy to clarify preference for single dose vials and ampules.  Responded to questions from staff regarding who retains responsibility for monitoring medication expiration dates.

  1. The third component notes how you will ensure ongoing compliance with the corrected deficiency – via random audits, for example. If you do audit, retain documentation of audit results.  Be specific about how you will monitor the corrections made.  Ensure monitoring is consistent and timely.  Clearly state how you will maintain compliance.

For example:  Updated emergency cart medication lists.  Began actively monitoring the expiration dates of all medications throughout the facility. Implemented random audits of the medication supply to ensure compliance. Initial audit was conducted on 12/16/2016 in various locations around the facility.  No expired medications were found. Compliance expectation is 100% removal of expired medications from floor stock as evidenced by monthly inspections.

  1. Name the responsible party for completion of each task and ensure ongoing compliance. You are permitted to use a person’s name but noting someone’s title (e.g., Clinical Director or Business Office Manager) ensures responsibility is linked to a defined role rather than a specific individual. 
  1. The final component is provision of a completion date for the deficiency. Ensure the deficiency is corrected by the date you set.

Next Steps

Upon completion of the plan, sign and date the form.  Return the document to the person and address noted on the Plan of Correction.  You typically have 10 days after receipt of the POC letter to return your response.

Make sure you retain a copy of the POC on file at the center with all your corrective action documentation.  As you work through the POC and collect supporting documentation, keep everything together in one binder.  This is very helpful in the event of a re-survey.

The CMS regional office will review your POC.  You can then expect a response letter from them regarding acceptance or denial of your plan of correction.  If your POC was accepted, the letter will also inform you whether a re-survey will occur.  A rejected POC will contain information regarding any changes that need to be made and a new deadline for completion.  Update the POC and return per the letter’s instructions by the specified due date.

Conclusion

Although preparing, undergoing, and responding to a survey is a daunting task, surveys provide us with opportunities to view our ASC operations from the outside in.  They allow us to implement best practices that ultimately lead to a center of excellence, a goal we are all trying to achieve.  Don’t let the prospect of an unannounced survey worry you.  Preparation and organization is key to successfully completing your survey, even if you are required to submit a plan of correction.


Kelli McMahan – Vice President of Operations

[1] https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_i_lsc.pdf

[2] https://www.cms.gov/Regulationsand-Guidance/Guidance/Manuals/downloads/som107ap_l_ambulatory.pdf

[3] https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS2567.pdf

Front Office Personnel

Best Practices for Hiring Some of the Most Important Roles in Your ASC – Your Front Office Personnel

By ASC Management No Comments

Some of the most difficult positions to fill in a surgery center are in the front office.  If you focus on hiring someone with a positive attitude who enjoys greeting patients and talking with family members, they may spend their entire day happily conversing but fail to attend to the mounting pile of paperwork.  Conversely, if you focus on hiring someone who accurately processes all that paperwork and is detail oriented, they may have a difficult time acknowledging the presence of others.  What’s an administrator to do?

Perhaps one of the best places to begin is with task delineation.  If you can afford to hire several employees, segregate front office duties by aligning them with specific personality traits.  Prepare job descriptions that support those traits.  Employees who enjoy interacting with others are best suited for greeting patients, securing pre-authorization of services, obtaining physicians’ signatures on medical records, working with physicians’ schedulers, and ensuring vital information is communicated to colleagues and family members.  Those who have an eye for details and are inclined to double-check their work can be tasked with verifying benefits, registering patients, entering data into the patient accounting system, securing patient payments, overseeing petty cash transactions, and obtaining implant invoices from vendor reps before they leave the facility. 

Developing comprehensive job descriptions with personality traits in mind should then lead to interview questions designed to elicit the attitudes, values, and skill sets that are important to you, your team, and your business.  If you are seeking someone who possesses a high level of integrity, asking an applicant to tell you about a time it was necessary for them to admit to others they made a mistake may reveal their capacity for being honest and humble.  Or posing a question about how they react when they are asked to do something beyond their capabilities could provide you with insight into their initiative, determination, and capacity for growth. 

If you intuitively sense the prospective employee is a good cultural fit, move on to technical skill assessment.  Attention to detail, for example, can be assessed in a variety of ways.  Start with the applicant’s resume and/or employment application.  Are there typographical, spelling, or grammatical errors?  If so, they may not be someone who takes the time to double-check their work (or the work of others if their resume was prepared by a professional).  Next, replicate the working conditions by administering a time-based screening tool to assess the applicant’s ability to quickly and accurately identify transposed numbers and letters under pressure. Finally, pay attention to the prospective employee’s responses to instructions you provide and/or interview questions you ask.  While it is easy to misunderstand someone else’s intent during these types of exchanges, applicants who possess attention to detail will typically request clarification to ensure they are responding appropriately.

When you sense you’ve identified a solid candidate, ensure you check references.  Checking references can be tricky – many former employers have policies in place preventing them from extemporaneously responding to questions, choosing instead to only confirm employment dates, position held and, if you’re luck, eligibility for rehire.  However, for those who are willing to discuss the skill sets, personality traits, and work performance of your potential hire, ensure you use their time wisely.  Carefully craft your questions to address items essential for effective performance in your work environment.  And be sure to tap into resources that will provide an honest assessment – former (or current) direct supervisors who are listed on the candidate’s job application, for example.  Recognize the list of references provided by an applicant with his or her resume may contain names of friends or co-workers who may not be familiar with how well the candidate performed on the job but are more than happy to provide a glowing recommendation.

Finally, when you make your job offer, if there are contingencies – successful completion of a background check or drug screen, for example – note how the applicant responds.  If they drag their feet on completing authorization paperwork or physical tests, they are waving a red flag regarding their willingness or ability to follow-through. 

Your assessment of the applicant should continue throughout the onboarding process.  The first couple of weeks your new employee is on the job will provide you with a better idea of what you’ve gotten yourself into.  If you believe the individual oversold themselves and is under-delivering, dig below the surface to determine the root cause.  Has the onboarding process (or lack thereof) contributed to confusion regarding expectations?  Are there tools that need to be provided and/or reviewed to assist the employee attain success in task accomplishment?  While it’s important to work on finding what’s leading to your new hire’s underperformance, sometimes it’s just not the fit you initially envisioned.  It’s okay to recognize that and part ways with the individual rather than allocating additional resources to a situation that isn’t working for either of you. 

Performing due diligence throughout each step of the process provides you with the best chance of finding someone who is the perfect fit.   That’s as satisfying as finding the puzzle piece that has baffled your entire extended family for the better part of a week during your annual holiday ski vacation! 


Kim Woodruff – Vice President of Corporate Finance & Compliance 

Attract Surgeons

How to Retain & Attract Surgeons to Your ASC

By ASC Management, Leadership No Comments

Do you have a favorite store where you enjoy shopping? It may be convenient to your home or office. They always seem to have what you need.  And, when you can’t find something, friendly staff members are readily available to assist you. It may not be the least expensive place, but the service and atmosphere make the extra dollars spent worthwhile.

Think about your favorite restaurant – perhaps the excellent food was the original draw.  But you keep going back because the service and overall feeling you have while you are there adds to your overall enjoyment.  It wins out often despite the multitude of dining options available to you.

Then there’s that shop you use to service your car or bike.  When you call, they always remember you.  When you walk in the door, the owner and staff greet you as if they genuinely care about your business.  They provide you with service options that may not always be the most profitable for them, but may make the most financial sense to you.

When we consider how to retain and attract surgeons to our surgery centers, it is helpful to keep these types of experiences in mind.  I purposely mentioned retain first.   It is much easier and less expensive to keep current business than it is to attract new business.  This is especially true for surgeons in an ASC. Emulate the owners and staff members at your favorite businesses who provide you with the quality customer service you appreciate.  Ensure the actions and attitudes of everyone at your center convey to your physicians their business is valued.

Surgeons use ASCs for a variety of reasons.  Here are six ways you may be able to attract them to your center:

  1. Consistently provide outstanding customer service. One size doesn’t fit all.  Surgeons value different aspects of their customer experience.  They may be drawn to measurable factors – low infection and transfer rates or high patient and physician satisfaction, for example.  Or, it may be as simple as the reliable availability of competent staff, the proper equipment, and necessary supplies.
  2. Save them time. When you save surgeons time, you improve their quality of life.  This can be as simple as your center being near their home or office which reduces time in the car.   On time starts and rapid room turnover times strongly impact surgeon time.  And, if the scheduling process is convenient for physicians and their staff, they are more inclined to use your ASC.
  3. Ensure quality. In today’s healthcare environment, quality should be a given.  When we are asked to revitalize struggling centers, we rarely encounter ASCs providing poor quality of care. Surgeons look for measurable factors when assessing quality – make this information available to them.   They also want to see the high nurse to patient ratios they have come to expect in an ASC.  Lastly, quality usually comes down to perception – is your staff knowledgeable, skilled, and experienced?
  4. Offer extensive managed care participation. Provided you are not an out-of-network center, physicians and their offices do not want to have to choose their site of service based on remembering which center participates with which third party payor. Being able to offer surgeons the full spectrum of managed care plans in your market makes your center a more desirable place to work.
  5. Provide return on investment. Most investors subscribe to a simple formula.  If they are receiving distributions – tangible ROI – they are much more likely to participate.  If distributions are far and few between, investor participation decreases and your ASC has minimal opportunities to recruit new surgeons.  Managing your center in a fiscally responsible way with financial stewardship in mind affords you opportunities to both retain and attract new physicians. 
  6. Add value. Be able to answer the question, “What have you done for me lately?”  Constantly look for ways to add value to the lives and practices of the surgeons who use your ASC.  Focus on the items I’ve outlined above and never rest on your laurels.

Rob Carrera – President and CEO

Onboarding New Physicians

ASC Management Tip: Successfully Onboarding New Physicians

By ASC Management No Comments

Bringing new physicians onboard can be one of the most exciting and challenging parts of ASC management.  New physicians create opportunities to enhance your center’s initiatives and fuel growth.  Onboarding, however, can present challenges as you orient new physicians while simultaneously managing daily operations.  Despite busy schedules maintaining focus on first impressions is important.  Starting off on the right foot with new physicians is instrumental to establishing lasting relationships for your ASC and physicians alike.  

What can you do to ensure smooth transitions that successfully engage new physicians?  We sat down with Kelli McMahan, VP of Operations for Pinnacle III, for some advice.  Here are her top five tips for successfully onboarding new physicians.

  1. Schedule an introduction & tour: Meet with new physicians before they begin performing procedures at your facility.  Schedule time for them to tour your space.  Introduce physicians to as many staff members, anesthesiologists, and physician partners as possible.  This will help new physicians feel welcome and provide them with friendly faces to turn to or contact should they encounter any issues when they begin work at your ASC.  New physicians may also wish to review available instrumentation and equipment.  Make sure your clinical nurse manager, instrument technologist, and other staff members who are familiar with the potential needs of your new physicians, are available to answer questions during the tour.  Navigation to the locker room, the Pre-Op/PACU area, or ORs can be challenging for new physicians.  Make sure your new physicians leave the tour feeling comfortable finding their way around your facility.
  1. Provide a physician welcome guide: Provide a welcome packet to new physicians when they initially arrive at your facility.  The packet should contain helpful information to successfully orient physicians to your ASC.  Examples include, but are not limited to, your mission statement and core values, directions to your facility, important contact information, leadership bios, and relevant resources for new medical staff members.  Include medical staff expectations from your medical staff bylaws, as well as information on how to start scheduling cases, access transcription services, obtain pre-op and post-op guidelines, and find resources for their patients.  List your facility’s H&P requirements, block time guidelines, dictation instructions, approved procedures, and managed care relationships.
  1. Collect preference cards: Discuss with new physicians the importance of supplying preference cards that are applicable for all the services they intend to offer at your facility.   Useful preference cards provide detailed information on physician preferences for supplies needed, OR set-up, and block time/clinic time.  Preference cards can typically be obtained from any of the other facilities at which physicians worked prior to your ASC.  Obtaining preference cards early will allow you and your staff ample time to prepare for the new cases and ensure the appropriate supplies are available. 
  1. Arrange a meeting between physician scheduling staff & ASC scheduling staff: Your scheduling staff should plan on meeting with your new physicians’ scheduling teams to review scheduling processes.  Your staff should take contact information, instructions, forms, and patient information packets to these meetings.   They need to engage the new physicians’ staff and ask how they currently process scheduling information to other entities.   Doing so will set the stage for both entities to work together to establish a mutually beneficial process for sharing appropriate information efficiently and securely.
  1. Follow-up with your new recruits: When new physicians arrive for their first day at your surgery center, be available to greet them and answer any questions.  If you are not personally able to meet them on their first day, ensure you appoint a qualified designee to fill in on your behalf.  Speaking with new physicians at the end of their first day will help you address issues that arose and instill confidence in your facility.

By following these tips, you can provide smooth transitions for new physicians joining your ASC.  If physicians are satisfied with their initial interactions with your center, they are more likely to perform cases at your center for many years to come.   Your success with new physicians will create a positive reputation and opportunities for more physicians to join your facility.  Simply put, successfully engaging new physicians helps turn your facility into the center of choice.  Wouldn’t having too many physicians to onboard due to your ASC’s growth be a nice “problem” to have?


Kelli McMahan – Vice President of Operations

ASC Turnaround Case Study Key Takeaways

ASC Turnaround Case Study – Key Takeaways

By ASC Management No Comments

Adopting Best Practices to Optimize Performance

One of the best ways to analyze your center’s performance is to re-evaluate your facility’s strategy.  Is that strategy meeting the goals of the center – financially, operationally, and through reimbursements of its negotiated payor contracts?  If not, it may be time to rethink it and create a new plan fit for profitable, successful outcomes.

Best Practices

The most effective and successful ASCs do three things exceedingly well – evaluate case volume, rethink cost structures, and align operational performance and revenue cycle management.

1. Evaluate case volume. A profitable ASC researches and understands the cases that best fit the facility. There are several variables to consider.

Scheduling efficiency – What are the optimal number of procedures to schedule each day?  Which procedures reap the highest profits? Are there procedures that make sense to schedule back-to-back to facilitate flow? For instance, you may want to place a longer procedure between shorter cases to allow staff adequate time to flip rooms and clean the equipment effectively.

Payors – Payors may have an influence on the cases scheduled at the facility.  Do your current contracts contain appropriate carve-outs for specific procedures being performed? Which payors offer the highest reimbursements and are the most proficient to work with?

Physicians – Are your physicians informed on cases that are appropriate to bring to your center? Are you providing your physicians and their staff with adequate information on reimbursement relative to case costing? How do you maintain physician satisfaction?

By evaluating and considering all case volume variables, and by sharing that information with key stakeholders, the ASC becomes more effective in operational performance.

2. Rethink cost structures. Analyze financials on an ongoing basis to identify areas of opportunity and improvement. Reviewing staffing overhead, vendor costs, and supply expenses on a cost per case basis and assessing performance against your established budget are vital to the sustainability and growth of your center. Additionally, you will need to keep a close watch on inventory and purchasing practices to make sure you’re not only getting the best products at the lowest prices but preventing costly product shortages. Be strategic in your financial approach and look for ways to enhance the profitability of your center.

3. Align operational performance and revenue cycle management. Revenue cycle management is a multifunctional process that requires cooperative efforts from administrative, clinical, and billing personnel.  Each of these components is vital to moving the patient account from creation, to point of service, to coding, and finally to payment.  A skilled ASC will integrate all these components into a holistic solution that leads to profitable results.


For more information about the Lutheran Campus ASC Turnaround Case Study or if you are looking for a partner to discuss best practices at achieving optimal performance at your center, please contact Trista Sandoval, Director of Business Development and Physician Relations at tsandoval@pinnacleiii.com or call 970.492.6059.

ASC Turnaround Case Study

ASC Turnaround Case Study

By ASC Management No Comments

When the Lutheran Campus Ambulatory Surgery Center (LCASC) opened in Wheat Ridge, Colorado in late 2005, it appeared poised for success.  Having interviewed several management companies, the joint-venture ASC selected the one it believed would maximize returns for the facility’s investors.  It didn’t take long for visions of a successful ASC to fade.  “We opened the ASC and the management was horrible,” recalls orthopedic surgeon Thomas Fry, M.D.  LCASC experienced losses of more than $1 million in 2006 and more than $1.4 million in 2007.

What Went Wrong                                                                                                                                                            

With LCASC heading toward bankruptcy, Pinnacle III was brought in to conduct an operational audit.  “The center never realized the volume they projected in their pro forma.  Their staffing didn’t meet the needs of their physicians.  They had a difficult time collecting revenue on the cases that were being performed.  They were paying way too much for supplies.  With all of these problems, they dug themselves into a hole and were unable to pay their bills,” says Pinnacle III President & CEO, Robert Carrera.

After reviewing Pinnacle III’s recommendations for change, the leaders of LCASC elected to remove the existing management company and enter into a six-month agreement with Pinnacle III.  When Pinnacle III assumed management in 2008, the center projected a loss of nearly $2 million.

Pinnacle III Quickly Got to Work                                                                                                                                  

“We went out and heavily marketed to physicians,” Carrera says.  “We evaluated existing staff and worked on growing the physicians’ confidence in their team while simultaneously building the staff’s confidence in the ASC’s leadership.  We focused on improvements in a number of other areas as well, including customer service, policies and procedures, materials management, and the facility’s overall culture.”

To address its revenue cycle problems, LCASC contracted with Pinnacle III’s centralized billing office, Specialty Billing Solutions (SBS).  SBS trained LCASC’s staff to adhere to defined collection parameters on new accounts.  Their trained ASC coding and billing staff performed “forensic collections” on existing accounts including re-evaluating all write-offs and reprocessing claims that had not been properly processed to ensure as much money was collected as quickly as possible.

Building on Success                                                                                                                                                            

Due to the renewed focus on facility operations and revenue cycle management, the center ended up cutting its projected 2008 loss by 75 percent.  “We still had some problems to overcome, but the hemorrhaging had stopped,” Dr. Fry noted.  After six months had passed, LCASC extended their management agreement with Pinnacle III who continued to implement improvement measures.

Achieving Profitability                                                                                                                                        

Turnaround efforts continued with LCASC undergoing refinancing and re-syndication in the years that followed.  In 2012, more than $1 million was distributed to the investors.  Similar distributions have continued through the present day.*

“We went from a cash call to paying dividends for four straight quarters and showing a profit,” stated Dr. Fry.  “I relate that totally to the changes that Pinnacle III identified and put into practice.  Specialty Billing Solutions has made a tremendous difference as well.  Their expertise and hard work really turned things around for us. It’s hard not to be happy with the difference between a cash call and a dividend payment.”


*From 2012-2016, distributions to investors have topped $1 million each year.

Pinnacle III has managed The Lutheran Campus Ambulatory Surgery Center for 8 years. For the full white paper, “ASC Turnaround:  Lutheran Campus Case Study,” visit www.pinnacleiii.com/white-paper.

8 Things ASC Board Members Need to Know About Materials Management

By ASC Management No Comments

As an ASC board member, you are tasked with monitoring your ASC’s total operation. This is no simple feat! It can be difficult to know what questions you should be asking to ascertain whether or not your facility is operating as well as it could be. In an effort to help out, we sat down with our VP of Facility Operations, Kelli McMahan, who provided us with some insight into ASC materials management.

  1. What is your ASC’s medical supplies expense as a percent of its net revenue? Ideally, this figure should come in under 20%. If it does not, determine what’s causing it to be so high and act accordingly.
  1. Are all your physicians using the same supplies or are there any outliers? Sometimes one particular physician routinely uses a specific supply that no one else is using. When supplies can be standardized among all physicians, inventory can be reduced. Because many supplies have to be ordered in bulk, only having to stock one type of gloves in four sizes, for example, creates a more streamlined ordering process, minimizes inventory costs, and frees up valuable storage space.
  1. Does your facility use custom packs and review their contents routinely? A custom pack is a procedural pack that incorporates a majority of supplies used 90% of the time for specific types of procedures. Although most ASCs use custom packs, they tend to overlook the importance of reviewing the contents of those packs on a regular basis. When new procedures are implemented and/or supply preferences change, items that were once used frequently from the packs may now be routinely thrown away. Conversely, an item may be opened for every case that isn’t currently included in the pack. Instead of ordering, stocking, and opening this particular item every time, your ASC may be able to save money by adding it to the custom pack. At a minimum, custom packs should be reviewed annually to ensure they address the facility’s current needs.
  1. Does your ASC contract with a GPO (group purchasing organization) to provide the majority of your basic medical supplies? GPOs are able to extend discounted pricing based on their contracts with suppliers. Make sure your distributor knows you are hooked up with a GPO and loads your discounted pricing into their system. Periodically check the invoice pricing against the contract price to ensure your ASC is receiving the benefit of those discounted arrangements.
  1. Are you ordering inventory using the just-in-time methodology? Items that are used routinely should be ordered according to your case volume to avoid overstocking. Standard orders and delivery dates should be set up with your distributor. Knowing your delivery dates helps you manage supplies on hand. It may be better to place smaller orders two to three times a week rather than placing larger bulk orders which can naturally lead to overstocking.
  1. Have preference cards been updated to reflect supplies actually being used? Reviewing preference cards routinely prevents staff, especially those new to your facility, from opening everything that’s reflected on the card without first checking if the supplies being used have changed. In some cases, the physician no longer uses what’s on the card resulting in opened supplies going to waste.
  1. Have deleted items been moved out of inventory? When items need to be removed from inventory, try to recoup some of the expense. Ask your materials manager to see if your vendor will buy those items back from your ASC or trade in unused items for commodities that continue to be stocked. If your vendor isn’t willing to work with you, determine if other ASCs in the area are interested in purchasing your unused inventory. When all else fails, donate the goods to charity as a tax-deductible contribution.
  1. Are you capturing all the current month’s expenses on your financials? Have materials management personnel look at their purchase order accrual log. If they have not received an invoice for an item that has been ordered and received, the expense can be accrued on the current month’s financial statements. Matching your expenses with your income allows you to more accurately identify financial trends and make sound business decisions.

Knowing what questions to ask about your ASC’s materials management practices not only helps determine where money is being spent but provides insight into the total operation. It can serve as a springboard for discussion with your physician investors about supply use and how best to achieve medical supply standardization. It can create efficiencies that optimize your facility’s operations. Having a thorough understanding of best practices is a great first step toward achieving your goal of a prosperous ASC.


Kelli McMahan – Vice President of Operations