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Preparing for Your AAAHC Deemed Status Survey  

By ASC Development, ASC Management, Leadership

Why Accreditation?

Undergoing a AAAHC “deemed” status survey, where compliance to both Accreditation Standards and CMS Conditions for Coverage (CfCs) are assessed, is demanding for an ASC. However, there are many reasons why this is beneficial. In general, accreditation may help with consumer confidence, providing a competitive edge for your center in your market. Some states require accreditation in order to maintain licensure, and many insurers and third parties require accreditation as a prerequisite to eligibility for insurance reimbursement and for participation in managed care plans or contract bidding. In addition, being accredited may reduce liability costs.

Deemed status provides these benefits plus it qualifies as a state agency review for Medicare certification for new and existing centers. In most cases, the state will not review an ASC that has been accredited through the Medicare or AAAHC deemed status survey, but it does not preclude the state from conducting validation or complaint inspections.  State licensure inspections are separate from Medicare surveys and are conducted according to state requirements.

Public Notice of AAAHC Deemed Status Survey

Prior to the start of the on-site survey, a packet of information about the upcoming, unannounced site visit is sent to the applicant ASC’s primary contact person.  The packet includes a general outline of the survey event, a listing of documents surveyors may request for review, a copy of the Notice of Accreditation Survey for posting, and other survey information.

It is important that the center post the Notice of Accreditation Survey for at least 30 days prior to AAAHC’s arrival for survey.  If not, the survey will still be conducted, but an accreditation decision cannot be rendered until the Notice has been posted for a period of 30 calendar days.

The Accreditation Process: The AAAHC Deemed Status Survey Team

Although an accreditation survey is, of necessity, evaluative, AAAHC emphasizes the educational and consultative benefits of accreditation. Thus, AAAHC uses health care professionals and administrators who are actively involved in ambulatory health care settings to conduct surveys. 

The Accreditation Process: Surveyor Conduct

Surveyors are representatives of AAAHC. Their priority when conducting surveys is to serve as ambassadors of AAAHC, by being objective fact finders, and educators when appropriate. It is AAAHC policy and practice that surveyors do not participate in surveys of organizations that may be in direct competition with the surveyor’s business interests, or that bear any significant beneficial interest to the surveyor or the surveyor’s immediate family. AAAHC policy also states that, while serving as representatives of AAAHC, surveyors may not solicit personal business or take part in any activities that appear to be in furtherance of their personal, entrepreneurial endeavors.

The Accreditation Process: The On-Site Survey

Each survey is tailored to the type, size, and range of services offered by the ASC seeking accreditation. The length of the on-site visit and the number of surveyors sent by AAAHC are based on a careful review of the information provided in the Application for Survey and supporting documents submitted by the ASC. Questions regarding the scope of a survey should be directed to the AAAHC office prior to the survey.

At the start of the survey, the survey team conducts an orientation conference for the organization. The members of the survey team will introduce themselves, review the survey format, confirm written documentation for which they anticipate a need, and ask the organization to identify the key personnel who will provide the information and access necessary to complete the survey. This is also a time for the organization to ask questions.

The Survey Process: Preparing for Surveyors

ASCs are notified in advance to have specific documents and other information available for surveyors during the on-site visit. This allows surveyors to gather and review information with minimal disruption to the daily activities of the ASC being surveyed. Surveyors may, however, ask to see additional documents or request additional information during the on-site survey.

ASCs are asked to make a work-space available for surveyor use. This private or semi-private area is used to review polices, conduct interviews, and hold survey team meetings to discuss findings.

The Survey Process: The Tour

Survey teams conduct their tours differently; however, most will conduct the tour within one to two hours of being on site. Generally, the tour will closely follow the patient flow throughout the building.

During the tour, the surveyors will be escorted to the areas of observation, including patient check-in. During this time, surveyors will observe posted signs and evidence of quality of care.

Information intake will be next. Limited questions are asked.  Surveyors may ask staff to clarify a process or a policy (i.e., ”How often do you check the refrigerator?” or “What kinds of snacks do you give to patients?”).

Watch for breaches in infection control during the times surveyors are observing staff.  Stethoscopes around the neck, missed opportunities for hand hygiene, multiple bags of IV fluid pre-spiked are some examples of infection control breaches.

Generally, surveyors will look into an operating room through the windows or doors. Remember to be firm on protocol at this point. The clinical surveyor will determine when to observe a procedure. The surveyor may ask for a daily schedule to review to facilitate selection of a case or the surveyor may want to spend time with staff for casual observation.

The surveyors will then be shown recovery, post-op/PACU, and discharge.  At this point, the surveyors will return to the designated survey work-space.

The Survey Process: After the Tour

After the tour is completed, the surveyors will most likely conduct a confidential discussion between themselves before they proceed with the remainder of the survey.  If conducting a Medicare survey, the clinical/administrative surveyor will break off from the life safety surveyor. If you have a maintenance employee or employ a building maintenance company, it is best to have them present to assist in providing information to the surveyors, who may have questions related to facility management and maintenance. The life-safety surveyor is generally at the facility for one day; therefore, all information gathering is performed in a brief period of time.

At the conclusion of the on-site survey, the surveyors hold a formal summation conference where they present their findings to representatives of the organization for discussion and clarification. Surveyors are fact finders for AAAHC; they do not render the final accreditation decision. No information regarding the organization’s compliance with the standards or the accreditation decision is provided during the summation conference. Members of the organization’s governing body, medical staff, and administration are encouraged to take this opportunity to comment on, or rebut, the findings, as well as to express their perceptions of the survey.

After the AAAHC Deemed Status Survey

Accreditation decisions are made by the AAAHC Accreditation Committee following a thorough review of the information gathered during the survey and documented in the surveyor’s report, any other applicable supporting documents, and recommendations of surveyors and staff. All documents reflecting the opinions or deliberations of any AAAHC surveyor, staff member, committee member, or its officers or directors constitute peer review materials and are not disclosed to the organization seeking accreditation and Medicare deemed status, or to any third party.

AAAHC expects substantial compliance with the applicable AAAHC Standards requirements. Accreditation is awarded to ASCs that demonstrate compliance with the AAAHC Standards and adherence to AAAHC accreditation policies.  

Compliance with each requirement is assessed through at least one of the following means:

  • Documented evidence.
  • Answers to detailed questions concerning implementation.
  • On-site observations and interviews by surveyors.

The ASC will receive a written, comprehensive copy of the findings after the on-site survey.

AAAHC works with a third-party calling center (customer satisfaction Survey Company) to conduct an evaluation of our survey process and our surveyors.  A representative from the calling center will phone the organization’s designated primary contact approximately one week after the survey to discuss the recent survey experience.  Obtaining this input by telephone provides the surveyed organization and AAAHC with a streamlined, efficient means of providing and receiving feedback about the survey process.  An organization’s feedback has no bearing on the accreditation decision. 

Approximately ten business days after the last day of survey, the ASC will receive a formal request and instructions for completing the required Plan of Correction if deficiencies have been cited. AAAHC will provide the ASC with directions and a timeline for submission for the required Plan of Correction.

The letter of accreditation is typically received approximately 30 days after the completion of the survey.

source: Accreditation Association for Ambulatory Health Care, 2019,

additional resource: Preparing for an ASC Accreditation Survey, 2018,

Jovanna Grissom, Regional Vice President of Operations

Running an Effective, Efficient ASC Daily Huddle

Running an Effective, Efficient ASC Daily Huddle

By ASC Management, Leadership

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

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

Daily Huddle Best Practices

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

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

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

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

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

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

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

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

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

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

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

Daily Huddle Topics of Discussion

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

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

Business office:

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


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


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


  • Challenging instrument turnovers that could delay cases


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

ASC Daily Huddle Success: Final Key Takeaways

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

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

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

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

Jebby Mathew, Regional Director of Operations

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

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

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

Quick Tips for Managing a Rural ASC

Quick Tips for Managing a Rural ASC

By ASC Management, Leadership No Comments

Managing a rural ambulatory surgery center (ASC) presents unique challenges. In a limited demographic region, staffing, physician recruitment, and patient access can be problematic, especially if a well-formed strategy isn’t in place.

Here are several tips to help manage a rural ASC.


In a remote (non-urban) region, there are typically a limited number of skilled professionals available to staff your rural ASC. While professionals in the area may possess the necessary medical credentials, they may not be equipped with firsthand ASC experience. If you require ASC experience as a minimum qualification, you will further limit your applicant pool. Therefore, it’s best to shift your focus to hiring qualified, motivated individuals who are willing to put in the time and effort necessary to achieve competency in the surgery center arena. Be prepared to spend adequate time onboarding and introducing new employees to the ASC model. It differs significantly from the hospital model where available staff may have gained much of their previous experience. A challenge faced by employees new to the ASC model is learning to perform multiple duties they were not likely required to complete in the hospital setting. Patience, consistent check-ins, and open communication with the preceptor are key in getting them up to speed.

Physician Recruitment

Physician recruitment can also be challenging for a rural ASC. Typically, there is only one hospital which employs physicians in the area. The ASC will either need to have a transfer agreement with that hospital or the physicians providing surgical and procedural services will need to have privileges at the local hospital.

If the hospital is not inclined to provide a transfer agreement to the ASC, physicians who only perform outreach medical services in the area may find obtaining medical staff privileges at the hospital burdensome. Because these physicians are not providing services to the rural community daily, they may be unable to meet the hospital’s case threshold requirements.

Take time to understand physicians’ relationships with the hospital prior to onboarding them to your ASC. In turn, ensure physicians you are recruiting to the ASC understand the steps they may have to take to secure the necessary relationship with the local hospital.


Patient access is limited in a rural area. Some patients may travel for an hour or more to receive medical services. Robust patient scheduling, admission, and discharge criteria are necessary to ensure optimal patient experience. Train your staff to ask your patients the right questions. Nursing staff need to supply patients with detailed post-operative instructions, as well as travel instructions to make sure patients are comfortable on their trip home.

Some patients may require longer recovery times to adequately prepare them for their extended post-op travel. Understanding these needs up front, will save your staff, physicians, and patients valuable time post-surgery. Provide patient satisfaction surveys, monitor the responses, and implement operational changes to enhance customer service.

The challenges encountered in running a rural ASC are different than those you may face in a surgery center located in a metropolitan area. Devise a strategy that considers staff, patients, and physicians. Focus on building and maintaining a high functioning ASC team. Create relationships that extend beyond the rural community. Focusing on these efforts will help you run a more successful rural ASC with the limited market and resources available.

Kelli McMahan, Regional VP of Operations