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Leadership Archives - Page 2 of 2 - Pinnacle III

Jun 29
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Taking Care of Your “Second Victims” After an ASC Adverse Event

Taking Care of Your “Second Victims” After an ASC Adverse Event

By ASC Management, Leadership No Comments

Life is full of unexpected events. Despite our best efforts, bad things happen. If you work in clinical settings like ASCs long enough, it is likely you will encounter an unexpected event where the outcome is not optimal. Hopefully the resultant harm is minimal, but sometimes it’s not. Adverse events can lead to painful infections, injuries that require surgery, permanent damage, and death. Research shows medical errors are the number three cause of death in the United States.

When an adverse event occurs in a surgery center, the primary concern is the well-being of the patient and their family. With patient needs tended to, leadership works to prevent the mistake from occurring again.

While all of this is happening, potentially overlooked or underappreciated are the needs of your staff. Most ASC physicians and clinical staff pursue a career in medicine because they enjoy taking care of people. Many will establish emotional connections to patients. Surgery center caregivers often use possessive phrases – “these are my patients.” With such strong connections formed, caregivers may suffer significant distress if an adverse event results in patient harm. Given the nature of care provided in ASCs, staff rarely deal with emergencies or surprises. This can magnify the shocking effects of an adverse event.

The term “second victims” describes health care providers involved in an adverse event and traumatized by the incident. They often feel responsible for the outcome. The weight of the experience can have short- and long-term effects. These can include:

  • feelings of guilt, sadness, and shame,
  • distraction, both at and outside of work,
  • second-guessing of knowledge and skills, and
  • personal harm, even suicide.

Here are some recommendations that may help provide support to caregiver “second victims” following an adverse event.

1. Determine affected staff and evaluate.

Identify who served on the clinical team caring for the harmed patient. Clinical ASC supervisors and the administrator should then work to evaluate the impact of the event on involved staff. The administrator and medical director should evaluate the impact on physicians. These evaluations can include one-on-one conversations with team members about their response to the incident. They can help determine if staff are experiencing any emotional trauma.

Do your best to make staff feel comfortable about sharing their thoughts and feelings. While some team members may not open up to you, simply reaching out can help. Doing so conveys you are genuinely concerned about staff well-being and not just determining the cause of the incident.

2. Address patient ratios.

It is difficult to predict how team members will cope with an adverse event, even one that inflicts minimal harm. From a staffing perspective, it may behoove you to assume the worst. Expect involved caregivers to require time to process the situation — time that may keep them out of the ASC or lead to reduced shifts. Immediately address patient ratios and redistribute patient loads to allow for coping and account for reduced staff. You do not want someone treating patients not emotionally or physically prepared to deliver quality care.

3. Provide support.

Offer your support to those team members who indicate some form of trauma. Discuss how they are feeling. Ask if there is anything the surgery center can do for them. This may include providing longer breaks or shorter shifts (if possible). Let them know they can speak to leadership at any time if they find themselves distracted or struggling with emotions.

Note: Not everyone on your team will feel comfortable sharing their emotions or requesting assistance. Keep an eye on team members for signs of struggling. If your gut tells you someone is having a difficult time or you notice changes in behavior (e.g., crying), speak with this team member. Work to obtain an honest answer on their state of mind; it can impact your risk management.

4. Offer professional counseling.

As helpful as it can be for ASC leadership to provide support, some caregivers may require or want outside professional counseling. Have the ability to offer such counseling, even if no one takes advantage of it. Some caregivers may initially dismiss the offer only to take advantage of it later. What’s important is to have counseling available and for caregivers to know how to secure an appointment.

Preparation is Critical

An adverse event can occur at any time. When it does, what matters most is how you respond. Ensure your response plan takes into consideration potential second victims. When caregivers do not receive the necessary attention and support following an adverse event, the likelihood of another incident occurring increases. While you can’t undo a mistake, you can work diligently to prevent another one from happening.

Jebby Mathew – Regional Director of Operations

Jun 07
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asc political landscape

Preparing Your ASC for Political Battle

By ASC Governance, Leadership No Comments

There’s an old saying, “Laws are like sausages, no one wants to see them being made.”  When I was younger, I was fully on board with that analogy.  The last thing I wanted to do was participate in the political process.  Then, about 15 years ago, I was thrust into a position that forced me to get directly involved.

Within the same year, pieces of legislation were introduced in Colorado and Minnesota that would have severely negatively impacted the ambulatory surgery center (ASC) industries in those states.  Neither state had an active or robust state association.

Consequently, neither state was prepared to deal with the threat.  Through a herculean effort, disaster was averted in both instances.   Those of us involved in those fights learned a valuable lesson – the best time to prepare for a disaster is before it occurs.

Fast forward to 2017.  The landscape has changed in many ways.   After a five-year battle, the Wisconsin state association, WISCA, under the leadership of Eric Osterman and the association’s board, narrowly missed getting the state’s gross receipts ASC tax rescinded.  In Oregon, the state association recently pushed forward House Bill 2664, allowing 16 ASCs to introduce an “extended stay” license to committee.  In Colorado, CASCA is fervently addressing yet another attempt to negatively impact our state’s convalescent center license for ASCs.

At the federal level, the Ambulatory Surgery Center Association (ASCA) supported the Ambulatory Surgical Center Quality and Access Act of 2017. This act addresses a flaw in current law that allows the Centers for Medicare & Medicaid Services (CMS) to use different measures of inflation for ASCs and hospital outpatient departments (HOPDs) when setting reimbursement rates.

As demonstrated by that short list of activities in 2017, the ASC industry, both on the state and federal level, is far more equipped to deal with threats.  It is also more proactive than ever before.  That by no measure means every state or individual center should sit back and consider the battle won.  Rather, continual preparation and reform is necessary to avert the next crisis.

Some problems that still exist and are keeping ASCs from being formidable political players include:

  • Lack of organized state response to business threats
  • Embryonic, unsophisticated, or paralyzed state organizations
  • Unaware, unable, unwilling, or disinterested physicians
  • Insufficient funding
  • Nonexistent, minimal, or inconsistent education of key elected officials
  • Failure to engage ASCA on a state level
  • Lack of experience, robust understanding, or discomfort with politics, government, and public policy on the part of surgeons, administrators, and staff
  • Ineffective recruitment of hospital support by ASCs and physicians in joint venture arrangements

To set up your ASC for political survival:

  • Join or work to revitalize your state association.
  • Contribute to political fundraising at the state level.
  • Solicit contributions from facility investors for political fundraising.
  • Encourage key stakeholders in your ASC to join a committee in your state association.
  • Involve your physician investors, leadership team, and staff members in state association activities.
  • Engage ASC hospital partners as an ally with your state association.
  • Utilize the ASC’s staff or investors’ political connections.
  • Access key political players on federal and state levels.
  • Engage ASCA on a state level.
  • Contribute, and secure contributions from key stakeholders, to ASCAPAC.
  • Have key ASC personnel and physicians participate in the ASCA Washington DC Fly In.

The above suggestions are some ways every ASC can improve their own political standing along with the political standing of the industry.

To summarize, let me leave you with three quotes to consider when preparing for your ASC’s political survival.

“All politics is local.” – Tip O’Neil

“Never let a third party define your issues or your identity.” – Steven Covey

“It’s not the size of the dog in the fight that counts, it’s the size of the fight in the dog.” – Dwight D. Eisenhower

Robert Carrera – President/CEO

May 30
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How Marginal Gains are Crucial for Surgery Center Growth

By ASC Governance, ASC Management, Leadership No Comments

Over the course of many years, Pinnacle III has been tasked with the evaluation and turnaround of numerous failing or drastically underperforming surgery centers.  In each situation, it was relatively easy to identify the pain points and devise solutions to create marked improvement in the ASC’s performance.  

There are many centers, however, that already operate at an elevated level.  Their investors often ask us if it is possible for these facilities to improve.  

To answer this question, I am reminded of a story from the 2012 Tour de France and London Olympics. In 2010, Sir Dave Brailsford was tasked with improving the performance of the professional cycling team, Team Sky.  Eventually, he was asked to do the same for the British National Cycling Team.  At that time, Britain hadn’t had a Tour de France champion nor had they performed well in Olympic Cycling. Brailsford realized major gains in the realm of world class athletics were difficult to achieve.  Therefore, he focused on the concept of marginal gains aggregation.  He explained this concept as a one percent margin for improvement in everything.  He believed if you improved every area related to cycling by just one percent, those small gains would add up to remarkable improvement overall.

Initially, Brailsford and his team focused on the obvious – tire weight, seat ergonomics, and athlete nutrition.  Then they turned their focus on the far less obvious.  This included pillow choice and its impact on sleep quality, personal grooming habits and their impact on propensity to develop saddle sores, and hand hygiene to avoid illness.  Essentially, they searched for a one percent improvement in every area where they could create impact.  The results, despite some recent controversies, speak for themselves.  Britain’s Team Sky was victorious in the Tour de France in 2012, 2013, 2015, and 2016.  The British National Cycling Team also won 70% of the gold medals at the 2012 games.

I realize Team Sky is not the first or only organization to espouse the benefits of such an approach.  However, as a cyclist and a geek for human performance improvement, I gravitated to this example to illustrate my point.  Other examples that have paid dividends to the concept of marginal gain include David Cameron’s Behavioral Insight Team which improved the wording of tax demands to increase responsiveness.  Or Google testing 41 shades of blue for its advertising hyperlinks, which they claimed netted an extra $200 million in annual revenue.  The examples are endless.

So, how does a successful ASC ensure continuous growth?  We believe the best get better by consistently reassessing where there are opportunities to aggregate marginal gains.  I have written a great deal about culture.  This is another cultural characteristic which we work to ingrain in our partnered centers.

Every member of an ASC’s team can look for ways to identify marginal gains in their day-to-day activities.  Materials management can move more items to consignment.  Nursing staff can suggest the removal of unneeded items from custom packs.  The revenue cycle management (RCM) team can suggest changes to a dictation template to reduce the need for payors to request additional medical records.  Or, they may suggest implementing online bill pay to create an easier medium for patients to submit payments thereby expediting the receipt of receivables.  These are just a few examples of marginal gains that can be achieved through diligent management.  

It’s also important to keep in mind the reverse can be true as well.  A one percent decline in aggregated overtime can have significant impact on a facility’s operation.  The diagram below, adapted from James Clear, as referenced in “The Slight Edge” by Jeff Olson, effectively illustrates this point.

In closing, it’s easy to get caught up chasing the “large whales” – implementing bundled payments, a total joint program, or a re-syndication – to enhance facility prosperity.  But don’t forget to attend to the “small fish” by creating a culture around aggregating marginal gains.  The valleys in an ASC’s growth can be filled by marginal gains.  Doing so ensures the declines aren’t as sharp which leads to a steadier upward slope.  Overall, marginal gains are crucial to an ASC’s continuous growth.

Robert Carrera – President/CEO

Apr 25
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Management page header image

A Clinical Approach to Healthcare Business Management & Problem Solving

By ASC Governance, ASC Management, Leadership No Comments

I am a physical therapist (PT) by education and training.  I graduated from Wayne State University in Detroit, Michigan with a Bachelor of Science in PT. Go Warriors!

For over ten years, I practiced in a variety of settings, including my time spent as a clinical faculty member at the University.  After that, I moved full time into the world of management.  I like to think I could still earn an honest living as a clinician if I needed to.

As my career moved away from clinical practice, I retained my clinical approach when dealing with issues related to business practices.

The American Physical Therapy Association uses the following statement to describe what a physical therapist does:

“PTs examine each individual and develop a plan, using treatment techniques to promote the ability to move, reduce pain, restore function, and prevent disability.  In addition, PTs work with individuals to prevent the loss of mobility before it occurs by developing fitness and wellness-oriented programs for healthier and more active lifestyles.”[1]

Essentially, PTs evaluate the situation and assess findings to develop a treatment plan.  Our goal is to return patients to their previous or higher level of function.  In some cases, we develop a plan to prevent or forestall further disability.  Sound familiar?

As is the case with many healthcare disciplines, we learned to evaluate someone and then document our findings in a format called the SOAP note.

Here is what the SOAP note entails:

Subjective – Detailed notes regarding what the patient relays about their status in terms of function, disability, symptoms, and history.

Objective – This is derived from the clinician’s objective observations.  It can include visual observations such as posture and swelling, actual measurements such as range of motion or strength, and hands-on techniques such as palpation.

Assessment – The clinician’s analysis of the various subjective and objective findings yields an assessment.  It explains the reasoning behind the decisions made and clarifies the analytical thinking behind the problem-solving process.

Plan – Conveys how the clinician develops treatment to reach goals or objectives.

As a business leader, I use the clinical approach I learned and practiced to solve management problems.  Here is how:

Subjective – Years ago I read the difference between clinicians heralded at the top of their profession and those considered more average was based on the quality and thoroughness of the clinician’s ability to subjectively capture a patient’s history.  I believe the same is true in business problem solving.

In business, it is important to seek information directly from the source when issues arise.  For instance, I prefer to meet stakeholders in person to obtain the history of the situation and gain an understanding of how it developed.  What areas have been impacted?  What actions have been taken to resolve the issue?  What, if any, impact have those efforts had?  Lastly, I like to ask the stakeholders for their suggestions on resolving the situation.

Objective – When appropriate, I begin the objective portion of my evaluation visually, just like when I treated patients.  This can entail simply walking through the facility or office.  Many times, it involves taking subjective “histories” from stakeholders.  The measurement and hands-on review, in many cases, involves evaluating existing data and reports.  When necessary, and possible, it includes asking for additional information.  This provides me with a complete view of the situation.

Assessment – Again, the assessment is where the expertise and experience of the “clinician” shines through.  Taking all information gleaned from the subjective and objective portions of my evaluation, I can generate a list of problems.  Next, I can prioritize the items on my list.

Plan – Lastly, just as in a clinical setting, I develop a “treatment” plan for the problems in my facility.  The plan addresses not only the symptoms but also their underlying causes.

The business side of healthcare is made up of many clinicians who have transcended their clinical roles into business management and leadership.  I am one of those individuals.  The skills we learned as clinicians allow us to be effective problem solvers in the operational management side of the business as well.

Robert Carrera – President/CEO

[1] http://www.apta.org/PTCareers/RoleofaPT/

Feb 28
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ASC Front Office

Creating Financial Accountability with Your ASC Front Office Personnel

By ASC Management No Comments

One of the most challenging aspects of running a surgery center is eliminating claims processing errors and denials.  These issues lead to delays in reimbursement and decreased revenue.  When it comes to claims processing errors and denials, there are several items your front office can control.  ASC administrators can prevent many of these errors by establishing financial benchmarks that track front office performance.  Implementing these benchmarks will demonstrate to your staff how these controllable factors go a long way toward maintaining healthy reimbursement for your ASC.

To accomplish this, ask yourself the following questions:

Are you tracking registration data entry errors that cause claim denials?

An incorrect insurance address, inaccurate insurance provider, forgetting to include the subscriber date of birth (if subscriber is not the patient), and entering the wrong patient ID number create claim denials.

Review data entry errors with personnel responsible for patient registration.  Most patient accounting systems contain audit mechanisms that allow you to track field updates by user. Encouraging staff to methodically enter data, then double-check their work typically improves accuracy.

Are you tracking denials based on no pre-authorization?

Many payers have pre-authorization requirements for various procedures.  If pre-authorizations are completed prior to the date of service, payers will deny the claims.  

Review denials that occur for this reason with your front office staff.  Ask them to determine why pre-authorizations were not obtained to identify process issues.  Most insurance providers outline pre-authorization requirements on their websites.  Ask your staff to access these websites to review pre-authorization requirements.  They can print this information and place it in a resource binder for future reference.  Consider having your team develop a flow sheet identifying your facility’s top CPT codes, top insurance providers, and corresponding pre-authorization requirements.  These tools will be an invaluable resource.

Are you tracking time of service collection of co-pays and deductibles? Have you outlined expected time of service collection goals?

It is now standard practice for ASC front office personnel to collect co-pays and deductibles at the time of service. 

Set goals for upfront collections and track progress towards those goals.  Share monthly reports with your front office to review any co-pays or deductibles that were not collected.  Determine what types of actions, if any, can be implemented to increase time of service collections.  

Are you tracking whether supporting documents needed for claims processing are provided in a timely manner?

Set benchmark due dates on documents such as operative notes, implant invoices (when applicable), and pathology reports.  Track monthly documents that are not available on the due date. 

Work with your staff to determine why set goals are not met and identify how they can reduce the frequency of late documents.

Is your front office routinely receiving updates on insurance changes such as new contracts and sample cards?

When evaluating trends, you may discover failure to achieve established benchmarks ties back to outdated information.

Many payers have comprehensive information on their websites regarding benefits.  They often display sample insurance cards to assist providers with proper identification of patient plans.  Best practice is for your front office to maintain up-to-date payer information in a resource binder (paper or electronic, whichever works best).  If you maintain sample insurance cards on patients you’ve treated in your ASC, be sure to redact patient-specific information to remain HIPAA compliant. 

Set benchmark goals to track the above-mentioned items, then meet monthly with your front office staff to review these measures.  Identify trends. Encourage open discussion regarding benchmarks, errors, and denials, to help your staff understand how their role affects the health of your ASC.  Provide additional training when warranted to create a work environment where your staff can succeed.  Keep them engaged by asking for suggestions on best practices to optimize their efforts.  Celebrate their successes and enjoy watching your ASC thrive!

Kelli McMahan – Vice President of Operations

Feb 14
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surgeon recruiting

Become A Surgeon Recruiting Master for Your ASC with these Sales Tips

By ASC Management, Leadership No Comments

The recruitment of new physicians to an existing ASC is an essential component of surgery center management. Most ASC administrators are not trained sales/marketing professionals, nor are they supported by a sales force. Here are some tips I have found helpful as I’ve become self-trained in this area over the years.

Identifying potential new surgeons

  • Determine if they meet the criteria your board of managers has established for physicians in your center. Please see my previous blog post for a list of criteria to consider in vetting new surgeons.
  • Be aware of new surgeons moving to your area. Ask your current physicians and the manufacturer representatives who frequently visit your facility to alert you when new doctors enter your market.  Periodically review the list of newly licensed physicians who have recently moved to your area.
  • If your ASC is in a joint venture relationship with a hospital or health care system, work closely with their business development, marketing, or physician liaison team to identify prospects.
  • Target physicians who are unhappy at their current center. Disgruntled physicians oftentimes express their dissatisfaction in their current center’s ORs, hospital ORs, or hospital locker rooms.  You can often garner this information from the representatives mentioned previously, your existing surgeons, or your anesthesiologists who encounter them in these environments.

Setting yourself up for success

Once you have identified a single physician or a group of physicians as prospects, it’s time for the sale. Don’t be afraid of that word.   We’ve all engaged in sales.  At the very least, you sold yourself to your employer to secure your job.  Selling your facility is not that different.  Forge ahead – call the physician’s office and arrange a time to meet with them.

  • Determine what your objective is for the meeting. Is it getting the physician to the ASC for a tour?  Or securing the physician’s agreement to complete a credentialing packet?
  • Research your prospect to learn anything you can about them. Where did they go to school? Where did they train?  What procedures do they perform?  Do they have any dislikes?  If so, what are they?
  • Identify your needs and anticipate their wants. For example, you know you want them at your center, but can you accommodate their preferred day and time.  Determine how to deal with these kinds of scenarios ahead of time and be prepared to present options.
  • Determine what information you need to bring to the meeting. If you have specific information regarding a program you offer, bring that with you to present if afforded the opportunity.  When you have someone on your team who knows a lot about the surgeon’s specialty and will assist in closing the deal, bring them with you.
  • Know your competition. What will other centers be able to offer them?  What were they unhappy about elsewhere?  Prepare to address these topics in a subtle way.
  • Be aware of any previous history between this physician and your facility, or any stakeholders in your facility. Prepare to address these issues.
  • Think win-win. You must bring value to your facility, the physician, and the physician’s scheduler(s).  A one-sided relationship will never work.

Delivering what you promised

Let’s say you’ve identified your prospective surgeon(s) and had a successful meeting with them.  You were so successful, in fact, they are now scheduling cases at your center.  Now you need to ensure your team delivers what you promised.

  • Educate and empower your staff. Brief your staff on the physician’s expectations and what you promised.  Perform a dry run of the surgeon’s cases if you think it will assist the staff provide outstanding customer service.
  • Ensure the physician’s preference cards are correct and everything needed is present, including properly sized scrubs and gloves.
  • Make sure you are in the facility as the physician arrives for their first day. Welcome them, thank them for being there, and follow up with them at the end of the day. These are best practices to maintain for all your doctors every single day.
  • Attempt to schedule them with a consistent team.
  • Communicate, communicate, communicate!

Winning over the schedulers

Lastly, when recruiting new surgeons to your ASC, avoid underestimating the power of their scheduler(s).  I’ve been in many surgeon’s offices where the scheduler determines where their surgeon will perform a case.  I’ve spoken with numerous surgeons who’ve told me they go where their scheduler tells them to go. You must win their schedulers over!

What do schedulers want?

  • The path of least resistance. A full offering of managed care plans allows them to readily determine what procedures and/or surgeries can be performed at the center. And, if the physician has a set block time available, it’s easier for the scheduler to offer specific days to their patients.
  • We all want to do business with people we trust and like. Schedulers are no different.  They like people with “can do” attitudes.
  • They want to schedule at the time they call. Oftentimes the patient is standing there when they are making appointments.
  • They do not want to be put on hold. If this is unavoidable, ensure the hold time is short.
  • Little to no paperwork. We need information from the physician’s office but the process for exchanging information should be streamlined.

The best advice in recruiting new surgeons is to maintain open lines of communication among all parties.  This allows you to capture wants, needs, and dislikes.  Once you have this information, you can work toward creating a situation that satisfies everyone’s needs.  Your surgery center will be the preferred place of choice and you’ll be happy you created this environment from day one.

Robert Carrera – President/CEO

Aug 31
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Picking a Line: Leadership Lessons I Learned from Mountain Biking

By Leadership No Comments

Recently I was mountain biking and thinking about near/far vision. Near/far vision, or focus flexibility, is the ability to change focus from a faraway object to a nearby one, or vice versa. It is vital in a variety of sports.

That same skill is also vital for managers. Not, of course, in the sense of being able to assess a rock or root in front of your wheel as you are setting yourself up for a turn in the trail. But in the sense that your ability to clearly assess what is in front of you, and adjust accordingly, impacts your longer term goals and results.

For example, a physician showing up late for cases is similar to a rock dislodged by another trail rider careening directly into your path. You weren’t expecting it but you suddenly have to deal with it. Not only do you need to relay that information to those who are immediately affected, you have to determine how to minimize its impact on the schedule for the remainder of the day.

Another example – you are reviewing month end accounts receivable data and notice a marked increase in Medicare cases for the month. Ideally, you will use that information to predict the impact the change in payor mix will have on the facility’s available cash in the future.

Perhaps you are budgeting for the new total joint surgeon who “does everything like everyone else.” However, when they arrive and start performing cases, you learn their medication costs are significantly higher than your other physicians. There goes your budget! Now you are scrambling to minimize the impact going forward.

On second thought, maybe it is exactly like avoiding the rocks in your path or sending yourself headlong into a tree!

In the past I worked with young mountain bike racers helping them assess their near/far vision. I taught them exercises to improve their focus flexibility. As managers we can teach ourselves to look for the changes in our business that can knock us off course. We may have to chart an alternate route, but we don’t have to allow the bumps in the road to interfere with accomplishment of our goals. Furthermore, as leaders we can work with our teams to help them understand the importance of constant attention to what is happening now and teach them how doing so can positively impact their results.

By Robert J. Carrera – President and CEO