How to run a successful ASC: A cheat sheet by 55 industry leaders

The evolving healthcare landscape brings new challenges and opportunities to the industry each year. However, many leaders say there are certain aspects of ASC management that are pivotal to success.

 Fifty-five healthcare leaders connected with Becker's to share what they would add to their own "successful ASC management" cheat sheet.

Editor's note: Responses have been lightly edited for length and clarity.

Shireen Ahmad. System Director of Finance for GPO and Affiliate Business, CommonSpirit Health (Chicago): I think instituting financial controls and stewardship are a crucial part of a successful ASC.  Negotiating great prices and contracts with vendors helps keep costs down, but strong terms and conditions can also help reduce costs through delivery, maintenance, warranties and keeping high compliance. Often ASCs lose out significantly by paying higher prices or list price when they buy products or implants that are not on contract, which has a significant impact on profitability.

David Altchek, MD. Co-Chief Emeritus of Hospital for Special Surgery Sports Medicine Institute (New York City) and Founding Medical Director for HSS Florida (West Palm Beach): One thing outweighs all else: CULTURE. 

Laurie Antonik, MD. Medical Director of Perioperative Services for Johns Hopkins Medicine (Baltimore):

1. Appropriate contractual arrangements with insurers.
2. Realistic discussion with all stakeholders of what volumes are needed to make the venture successful.

Donald Arnold, MD. Chair of Anesthesiology, Mercy Hospital St. Louis: 

1. Relentless communication with facility staff, anesthesiology staff and surgeons to ensure that the anesthesiology and facility staff are aligned in work to support service line specific improvements in care.
2. Prospective work focused on same week and near-term scheduling needs to optimize scheduling, making maximize effective use of staff and facility in meeting procedural service needs. 

Christine Blackburn, BSN, RN. Administrator, South Kansas City Surgicenter (Overland Park, Kan.):

• Review payer contracts, vendor contracts, credentialing and familiarize yourself with the patient and payer operating agreement and bylaws.
• Get to know staff. What are their concerns? What makes them happy?
• Meet with each surgeon even for a few minutes. What are their needs, areas of concern, etc.?
• Become best friends with your medical director.
• Managers: What are their concerns or issues? What makes them happy?
• Understand your staff: Who attends and what is their job role?
• Who accredited the facility? Learn their bible.
• Quality and risk management: Learn the process for the facility and attend the meetings. Take an active role.

Galina Bondar, Business Analyst at Legacy Emanuel Medical Center (Portland, Ore.):

• Efficient room/block utilization and turnover
• Robust scheduling in sync with block releases and/or anesthesia involvement
• Patient- and provider-oriented billing with up-to-date information
• Patient- and provider-oriented up-to-date use of equipment, supplies and technology
• Quality and safety checkpoints
• Patient-, staff- and provider-oriented room and other areas design
• Effective discharge process
• Tracking costs, productivity, profitability, and maximizing efficiency
• On-going Lean processes implantation and improvement
• Effective IS and IT teams
• Patient/provider/staff satisfaction

Julie Breakey. Manager of the Department of Surgery, Bassett Healthcare Network (Cooperstown, N.Y.): I would consider 1) high block utilization and block management and 2) a cost accounting system as two keys for success.

Rebecca Bruce. Senior Director, UPMC Leader Surgery Center (York, Pa.): 

• Take excellent care of staff; they are the best resource to identify savings: time, cost and safety.
• Listen and respond to surgeon needs — and be prepared to recruit new surgeons.
• Identify, streamline and standardize processes as much as possible.
• Remember WHY we do this: patient care.
• Identify "fixed contributors" versus "growing contributors": Some staff are content to punch the clock and do a great job, others want to grow and be part of performance initiatives; water the growers. Thank both types — make it meaningful to their specific desires. Finally, prune the weeds.

Lee Ann Cain, DrPh., COO of Thomas Hospital (Fairhope, Ala.): I would suggest knowing your state laws, especially in medication procurement. So many laws differ from state to state, and it can cause delays if this is not a part of the implementation processes. 

Kimberly Cantees, MD. Clinical Director for Anesthesiology and Perioperative Medicine, UPMC Presbyterian Hospital (Pittsburgh): Successful ASC management cheat sheet:

Hospital administration and medical staff (surgeons and anesthesiologists) must be in agreement about the types of cases and the medical complexity of cases that can be performed in ambulatory surgery centers. With the CMS discontinuation of the “ inpatient procedure” identification for certain orthopedic and spine procedures, cases are identified as ambulatory surgical cases and moved out of the hospital surgical suite. We have found at our institution that our surgical colleagues are often reluctant to move from the hospital to the ambulatory surgical centers, and the request for movement to the ASC has had to be reinforced (as not optional) by our hospital administration.

There must be adequate incentive to move into the ambulatory center for staff members and physicians. This can be time and or financial incentives.

Education and continuing education is essential for all levels of staff, including members of the anesthesia care  team. The care of patients in ambulatory settings differs in many ways from the care of the patient in the hospital setting, with the main focus on patient safety and efficiency.

Patient satisfaction is paramount in the ambulatory setting; hospitable client facing staff, easy parking, efficiency and coffee and food for families during the wait and families and the patient post-op are key.

Armando Colon. CEO of DNA Medsolutions: Successful ASC management is committed to quality. ASC leadership needs to stay current with new and potential quality reporting rules. Compliance with these standards, while considered a necessary component of quality, spending time on effective studies can demonstrate opportunities for improvement and can shore up infection prevention practices and improve patient outcomes. These studies can often be done using data already available in the clinical record or within the center's practice management system, thus saving time and money. 

Another management factor for success is a financial accountability plan and cost savings plan;, financial discipline matters. We are all aware of metrics that make ASCs  equitable like, A/R days, net revenue per case, cash collections and the list goes on. Creating an accountability plan to help make time to follow through with the necessary activities by leveraging technology to automate or enforce tedious yet critical processes. Focus on financial discipline; you will see results. Remember, you can’t manage what you don’t measure.

An outstanding leader who is well-organized, reliable, and communicative can make all the difference. Successful ASC leaders empower staff to make their views heard, even if the decision reached isn't the employees' preferred choice. Leaders lead by example and show that they empathize with everyone on the team, and they expect the team to do the same towards one another. In an ASC's intensely collaborative environment, the organization won't function with brisk efficiency if leadership begins to view staff as resources or interchangeable assets; a workplace is healthier when everyone feels valued for their unique contribution.

Active case recruitment by speaking of new cases. Physician recruitment both internal and external is a critical ongoing effort that can pay dividends, literally. Physician involvement is one of the easiest ways to improve an ASC’s profitability. The champion can act as a bridge between the center and the board and can advocate for important initiatives that may face resistance from other physicians or board members. Ideally, a physician champion understands the business of running a surgery center, communicates well with staff and is a respected board member.

Benchmarking. The most successful centers consistently compare their supply and staffing costs, efficiency and volume to industry benchmarks. Outside your physician practice, there are the people you are dealing with most frequently who aren’t directly on your team. But these resources are an extension of your team and should be working with you to accomplish your goals. Maintaining good relations with your vendors can equate to better response times as well as better rates. Don't be afraid to ask them for help.

Technology should help you work smarter, not harder. Taking advantage of software to improve both your work flow and cash flow is crucial. In today’s post-pandemic digital world, you are at a disadvantage if you don't fully embrace your software.

Prepare for different payment models such as bundled payments or payments based on the [Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey] or value-based care, etc., and even more aggressive cost management.

George Dickstein, MD. Gastroenterologist at Boston Endoscopy Center and Chair of the Department of Medicine at MetroWest Medical Center (Natick, Mass.): 1) Staff appropriately now and for the future; the medical workforce changed seemingly overnight. Extended days and weekend shifts, even at time and a half, no longer appeal to many employees. Successful center HR management requires renewed attention to recruitment and retention of nurses and techs, understanding what keeps them happy at work (beyond competitive wages) and working collaboratively to achieve those goals. This may be one area where accepting a higher cost structure really pays dividends in the long term.

2) Assure fair facility fee compensation for the services provided. This will take a dynamic understanding by center leadership of the commercial and government payer base, including burgeoning Medicare Advantage plans. Getting accurate rate information to know what your competition is collecting can be challenging but will often be worth the investment. As dollars tighten and costs increase and insurers try to shift procedures to non-hospital licensed sights of care, there are inevitable conflicts and bumps in the road that will sometimes require difficult decisions to be made, including deciding what plans NOT to participate in. Resist the temptation to participate in poorly paying plans, especially when such participation will have little real impact on your success.

3) Secure sufficient anesthesia staffing--The anesthesia staffing shortages are not easily solved, particularly as reimbursement shrinks in many markets. Many ASCs are swallowing the bitter pill that they now have to supplement Anesthesia pay with stipends or guaranteed day rates to keep sufficient staff. Discord between scope of practice among CRNAs and MDs does not help the matter. However, there are major staff shortages even in states where the working relationship between MDs and CRNAs is very good.

4) Be on the constant lookout for opportunities for additional volume growth. Sometimes this makes for strange bedfellows, like learning to work with, not against, your local hospital, or learning to work with your competition to be better aligned as a community of providers dedicated to keeping independent physician providers and the center financially secure.

5) Manage costs aggressively. Look for group purchasing organizations and do not be shy about pitting one against the other. Do not accept someone's claim that their prices are best without actually confirming it. Critically look at your inventory and concentrate on using lower-cost supplies, especially when they have little impact on patient care or outcomes, even when the providers might prefer one peripheral or device over another.

Sharon Edwards Laskowski. Director of Safety and High Reliability at Advent Health (Altamonte Springs, Fla.): I view all healthcare services from the Safety II Lens, being proactive in identifying defects rather than reactive.

A cheat sheet from me, in safety and high reliability, would include the following:

• Is there a method for soliciting input from the front-line team members?
• Is there a feedback loop so team members know action is taken based on their input?
• Does the leader promote a culture of psychological safety?
• Do they have a robust time out?
• Do team members feel safe stopping the line if they have a concern?
• Do they share near misses and risk events openly?
• Do they promote a just culture looking at the process and not the person?
• Do they support the second victim when events happen?
• Do they openly debrief when events occur?
• Do they ask if everyone has the tools, resources and knowledge to provide safe and effective care to every patient?

Adeel Faruki, MD. Program Director for Advanced Perioperative Ultrasound and Clinical Training at the University of Colorado (Aurora): A leadership team that's developing or already has developed strong relationships with all physicians and nursing staff, not just the leadership teams. This ensures open communication in good times and in crisis situations.

Eva Fesi, MSN, RN. Senior Infection Preventionist at Carle Foundation Hospital (Urbana, Ill.): When you handle yourself, use your head. When you handle your staff, use your heart.

Gary Haynes, MD, PhD., Merryl and Sam Israel Chair in Anesthesiology, Tulane University School of Medicine (New Orleans): 

Some important points for anesthesia at an ASC: 

• Solid anesthesia professionals that are focused on excellent patient care
• Complete pre-anesthetic clearance and evaluation to last minute delays or cancellations.
• Reliable scheduling: must keep cases within planned hours of operation to avoid OT costs and patient complaints.
• Very capable anesthesiologists: ASC patients are increasingly complicated with comorbidities; need anesthesiologists that can manage.
• Always need a plan for patient disposition when there is a complication.

Jeron Jackson. Service Line Administrator for Musculoskeletal and Orthopedics, Marshfield (Wis.) Clinic Health System:

• Benchmarking tools for staffing
• Tools for standardizing purchasingTips for improved room turnover times Best practices for insurance screening/verification
• Summary of various ownership structures possible/legal with both employed and independent surgeons
• Innovations found across the country
• Opportunities areas for additional service specialties in ASC settings.

Scott James. Surgical Service Line Leader, Parkview Health (Fort Wayne, Ind.): A cheat sheet needs to be simple yet highlight what is important. I firmly believe when it comes to ASC management the following items should be included (in no particular order):

• Empower your team:  Surround yourself with a team that is smarter than you and give them the tools they need to be successful. Your job is to break down barriers and allow them to do what they do best.
• Patient experience: Provide your patients with the best experience, and go out of your way to make them and their families feel comfortable and over communicate.
• Physician experience: Regardless of how the entity is set up, physicians are your customer. Create an environment where they only want to do cases at your entity.
• Turn over time: Your goal is to be so efficient that the physician doesn't have time to take a break; by the time they are done meeting with the family, they should be heading to the next OR.
• Be available and be seen.

Your physicians and your team need your leadership and direction. Make time for them, be available and I always recommend that leaders shadow their physicians in the OR, you can't fully understand their concerns if you cannot picture or have seen what they are referring to.

Leslie Jebson. Executive Director of Texas A&M Health (College Station): My cheat sheet would include up-to-date internal and external operational-quality-financial data points/benchmarks. Like the dashboard of your car, having timely comparisons is paramount for efficient quality ambulatory care. Congruently, I would have a staffing "depth chart" from anesthesia to supply chain staffing to mitigate any potential disruption to scheduled procedures.  

Christopher Kane. Chief Strategy Officer, Phoebe Putney Health System (Albany, Ga.):

A few suggestions:

• Develop a monthly dashboard with metrics that are relevant for all constituents: physicians, board and staff.
• Establish a patient/family panel for qualitative feedback. Change the panel every quarter.
• If your ASC is part of a health system, use the ASC for pilot projects that can be adapted and implemented elsewhere, e.g., inpatient surgery, diagnostic testing, etc.
• Constantly scan the industry and competitors for ideas. Differentiation is critical and occasional paranoia about falling behind is OK.

Trishul Kapoor, MD. CSTAR fellow, University of Michigan Medicine (Ann Arbor): The management of an ASC can be challenging but can be successful with a few key strategic moves. First, it's important to establish a physician champion to observe for areas for improvement, lead initiatives, and communicate effectively with peers. Second, it's vital to create ownership of responsibility with incentives amongst staff to reach growth and quality targets. Third, ASCs must invest in digital transformation of operational practice and patient interaction. 

Dr. Omar Khokhar, President of Medical Staff at OSF HealthCare (Peoria, Ill.): Know your referral patterns and payer contracts inside and out. Staffing should be commensurate such that everyone is performing at their highest level of licensure. Maximize your throughput. Maintain quality metrics and use those in payer negotiations.

Choll Kim, MD, PhD. Director of the Excel Spine Center (San Diego): I see a lot of great management trends in the ASC world. What I think can be done better is to highlight, emphasize, and promote the special skill of surgeons who perform surgeries in the outpatient setting. This especially true in the field of spine where state of the art minimally invasive techniques not only offer the convenience of surgery in the ASC setting, but inherently provides care with less pain, less risk of infection, faster recovery and a host of other benefits inherent in MIS spine techniques. Most surgeons who perform spine surgery in the ASC have spent extra time and effort to adopt and optimize MIS techniques, which almost always occurs after they have undergone formal training in residency and fellowship. That effort and their consequent abilities should be acknowledged and highlighted. 

Walter Koltun, MD. Chief of Colorectal Surgery, Penn State Health (Hershey, Pa.): Listen to the physicians.

Susan Lee, DO. Chief Operating Officer of South Meadows Medical Center, Renown Health (Reno, Nev.): I would say that successful ASCs need to be fully aware of their contracted rates and schedule opportunities to review contractual negotiation calendars and procedure lists. As ASC procedure lists are changing with payer policies, it is always a good idea to proactively reach out to a payer to review the procedural lists and contracted rates. ASCs also need to be aware of their physician customers/consumers — ensure time utilization is consistent with their policies and work hard to create additional access for their top producing surgeons.

Shawn Lerch. Chief Executive Officer, Sauk Prairie Healthcare (Prairie du Sac, Wis.):

• Invest in your current team to retain the talent you have.
• Know your key performance indicators and report to stakeholders.
• Be transparent in communication with all team members.
• KPIs need to be both departmental and organization level.
• Empower everyone in the organization to participate and "be an owner" of their area.
• Encourage and reward innovation.
• Teach lean principles and continuous improvement.

Rick Mace. Healthcare consultant and Former Executive Vice President of Adventist Midwest Health (Hinsdale, Ill.): 

1. Understanding of physicians and how to work with them.
2. Business development skills.
3. Management of costs including labor.
4. Hiring a well-experienced manager who understands throughput.
5. Well-defined “rules of engagement” as to how the ASC operates on a daily basis.
6. Having a well-defined budget which the physician partners or providers assumed ownership of.
7. Excellent organizational skills.
8. Patient satisfaction surveys and follow up.

Javier Marull, MD. Medical Director at UT Southwestern Medical Center (Dallas): With the increased number of patients coming to ASCs, a successful ASC management cheat sheet would be one that is supportive of staff, consistent, efficient and good with time management. 

Mark Mattar, MD. Director, IBD Center, Quality Improvement Officer, MedStar Georgetown University Hospital, Department of Gastroenterology (Washington, D.C.): My secret to success stems from the framework of transformational servant leadership. Leading in a successful GI practice in a health system as we come out of a pandemic brings its own special challenges. At the end of the day, we focus on the people. We prioritize patient care without compromising associate wellness. We work as a team to evaluate each provider’s needs and how we can help them work towards our common mission. This isn't easy, but when you pay attention to the needs of the team and act on them, we all succeed.

Angela Mayer. Director of Radiation Oncology and Outpatient Therapy at Barnes-Jewish West County Hospital (Creve Coeur, Mo.): Some components that are critical to a patient-centric and financially viable ASC that is also attractive to surgeons are:

• Sufficient and timely access for patients.
• OR utilization for one room vs. two rooms, and criteria for when you assign two rooms vs. staggering rooms.
• Standard work to continuously improve turnaround times.
• Specialized staff — allowing staff to specialize in an area is a win for all parties involved: the team member, the physicians working with that individual, the formation and cohesion of the team itself and, most importantly, the patient.
• Scheduling of resources (such as critical equipment) so resources are not double booked, thereby prolonging procedures and reducing inefficiencies.
• Team building that includes physicians and administrators.

Michael McKevitt. Former Senior Vice President of Business Development of Regent Surgical Health (Franklin, Tenn.): Of all the items I would want on a successful ASC cheat sheet, it would be a measurement of contractual allowances between what was billed and what was collected compared to the actual cost associated with a specific procedure. Then extrapolate that information into a usable format that is transparent and able to be shared with all stakeholders.

Peter Newcomer, MD. Chief Clinical Officer of UW Health (Madison, Wis.): For us, managing an ASC is similar to our other clinical care. You have to focus on quality and safety. You have to ensure the ASC is integrated with the larger system, so the right clinical leaders, operational leaders and experts are appropriately engaged to align clinical and financial incentives and review operations. Patient experience is a big area of focus as well. Increased ambulatory surgical options are a patient satisfier, but the experience needs to be consistent and meet expectations.

Mary O'Connor, MD. Co-founder and Chief Medical Officer, Vori Health (Nashville, Tenn.): A structured program to drive medical, social and behavioral optimization prior to larger surgeries (THA, TKA, spine surgeries). PCP medical clearance may not involve potential targets for optimization, e.g., low albumin, vitamin D, risk of sleep apnea, hepatitis risk, etc. Good optimization prior to outpatient surgery will improve clinical outcomes and lower the risk of admission to hospital and postoperative complications. It is simply good doctoring.

John Olmstead, MSN. Senior Director of Surgical and Procedural Services, Ann & Robert H. Lurie Children’s Hospital (Chicago): Our focus lately since the resurgence of volume is to ensure we routinely check the list of logs that we are expected to keep up to date in the facility. It only takes a second to check them regularly for completion, such as cleaning duties, supplies used, etc.  You can really see how easy it would be to miss many of these, especially if staff are not in the habit of checking/completing them!

Justin Oppenheimer. Chief Operating Officer and Chief Strategy Officer for Hospital for Special Surgery (New York City):

• Surgeon-led structure: Successful ASCs have an engaged group of surgeon leaders who care about every aspect: the clinical outcome, the patient experience, the staff experience and the bottom line. Ensuring the right leadership structure and the engaged surgeons in each role is critical.
• Unified culture: Every member of the team from the scrub tech, to the PACU nurse, the surgeon, to the receptionist needs to feel connected to the mission and goals. Everyone is a leader and has an impact on quality, experience, efficiency and results. People matter.
• Data-driven operations: While a culture of improvement is critical, you cannot improve what you cannot measure. Having a set of metrics that everyone is keyed in on helps drive performance.

James Parsons. Administrative Director of Orthopedics and Sports Medicine, Neurosurgery, Pain Management at Indiana University Health Arnett Physicians (Lafayette): Know your operational metrics forward and backward. Build a scorecard and track the data as close to real time as possible. Additionally, build good relationships with your surgeons.  Their insights will help identify opportunities for improvement.

Bernadette Purser, BSN, RN. Associate Chief Nursing Officer of Ambulatory Surgery at Duke University Health System (Durham, N.C.)

1. Keep your eye on your true north of delivering the best patient care at the highest quality, in the safest way and at the lowest cost.
2. Engage front-line staff and those doing the work to help identify reasons for defects. Identify and prioritize problems to work on (safety concerns should be front and center) and work on items that provide the most bang for your buck if improved. Be persistent, committed and pull out any improvement tools you have in your pocket to facilitate improvement.
3. Communicate, communicate, communicate: Follow-up is critical and allows staff to see leadership is dedicated to improvement and has a side effect of improving the culture.
4. Staffing, hiring and recruitment. Reach out early to recruiter consultants for key positions.  Keep staff updated on where you are with hiring.
5. Engage physicians, talk to them, ask how things are going and keep them informed.  Follow up.

Robert Quickel, MD. Vice President of Medical Operations, Surgery, Procedural and Orthopedics at Allina Health (Minneapolis):

• Safety first, no matter what.
• Check in with your staff regularly and often to ensure that they are happy and engaged. 
• Keep a close eye on your metrics and share them with your staff and surgeons often.
• Set "SMART” goals (Specific, Measurable, Achievable, Relevant, Time-bound)
• Accountability is key: Hold yourself and others accountable for the center's outcomes.
• Have a low tolerance for poor behavior from surgeons. Nothing poisons culture more than turning a blind eye to misbehavior like failure to uphold standard processes or toxicity toward staff.
• Celebrate successes often and recognize those who drive good outcomes or go above and beyond.

Randall Rentschler, RN. Perioperative Services Director at Artesia (N.M.) General Hospital: It is all about relationships! Foster strong interpersonal relationships with both providers and staff to improve communication, patient satisfaction as well as provider and staff satisfaction. 

Michael Richards, MD, PhD. Graduate Program Director of Health Services Research at Baylor University (Waco, Texas):

ASCs will increasingly be seen as a key care delivery setting as more covered lives are included in value-based payment arrangements. Succeeding in these arrangements will crucially depend on sufficiently granular and timely data, but not just data for the sake of data. Innovative and relevant ways need to be crafted to best understand and act upon the data. An important ingredient for doing so is getting the clinical providers engaged in the process throughout (e.g., what data to collect, how to make it clear and transparent, and ultimately how to use it to make positive care delivery changes). Such an approach leverages “on-the-ground” clinical insights and encourages greater acceptance from the providers with respect to the process as well as the collective care delivery improvement goals tied to the endeavor. All of which can save precious time and make success more likely.  

Kimberly Scarborough. Business Manager for Financial Services at Wellspan: Be data driven — develop and rely on facts. 

Steven Schwaitzberg, MD. Surgery Chair at University at Buffalo (N.Y.) School of Medicine:

Here would be my top five:

• Owner and non-owner users are equally committed to financial efficiency and clinical outcomes
• Minimization of inventory through standardization
• Case selection, case selection, case selection
• Commitment to the optimal patient experience  including an after-care plan
• Engaging the staff through a transparent effort-to-reward program

Anthony Sclafani, MD. Director of Facial Plastic Surgery for Weill Cornell Medicine (New York City): Instead of a lot of particulars, I will offer one word: "Gemba,"  a lean concept indicating essentially "where stuff happens," and we all know it doesn't happen in the manager's office. The best manager is going to be present and evaluate the specific, day-to-day strengths, weaknesses and opportunities of every employee, every structure, every workflow and every square tile in the ASC. A nurse manager can see what the nurses are doing right, wrong or struggling with, but they can also see the same for the surgeons, anesthesiologists, housekeeping staff, etc. Same holds true for physician managers.  Get out of the office, get out of the silo, understand how and why the ASC functions as it does to understand how it can function better.

Cindy Segar-Miller, RN. Principal at Spectrum Health Partners, (Portland, Maine): One thing that every ASC should be doing for successful ASC management is deeply involving clinical and nonclinical line staff in their performance improvement program. The staff working closest to the patients have the most intimate knowledge of the problems, opportunities and usually know exactly how to fix them. By involving the staff in all aspects of the performance improvement program, staff are given the opportunity to own and improve their results.

David Sendrowski, OD. Chief of Ophthalmology Consultation and Ocular Disease Service, Ketchum Health/Marshall B. Ketchum University (Fullerton, Calif.):

I would put down on a successful ASC cheat sheet:

1. Group surgical procedures as close as possible.
2. Any surgical spots not filled by the administrator, look for other subspecialties in the area that might choose to utilize the facility for their procedures.

Michelle Shaban, BSN, RN. Nurse Manager of Outpatient Procedures, University of Chicago Medicine: I believe a successful ASC management cheat sheet should include the following:

• Adaptability in type of procedures and service lines offered.
• Able to quickly mobilize services at the ASC such as C-arm, anesthesia, sterile processing and  nursing to meet the needs of procedures.
• Ability to flex down when needed to meet productivity.
• Enlisting staff to help make decisions to meet the schedule’s needs on a daily basis.
• Ensuring that you have enough staff with the skill type to support procedures.
• Encourage and offer in-services to staff for education.
• Skills training and competencies on a bi-annual or at least annual basis.
• Give feedback on a quarterly basis with staff.
• Monthly unit meeting.
• Update preference cards with physicians on a yearly basis.
• Hold a high-level quarterly meeting with physicians and anesthesia complete with agenda and meeting minutes.
• Rotate stock and supplies and check for outdated items.
• Do not over/under buy supplies.
• Regular equipment checks.
• EOC rounding.
• QI projects.

Marietha Silvers, RN. Administrator of The Surgery Center of Cleveland (Tenn.): 

• Know your ASC.
• Know your staff (skills, physician preferences).
• Know your physicians ( habits, likes, dislikes, actual length of their cases, preferences).
• Know your payers.
• Know your budget.
• Know your days in accounts receivable.
• Know your days to bill.
• Know your personal strengths.
• Know your personal weaknesses.

Tammy Straps MSN, RN. Nurse Manager at Harris Health (Houston):

Some important items I would put on the cheat sheet:

1. JAC ( just accountable culture) tool for evaluating performance management issues.
2. Empowered employees = engaged employees.

Arun Swaminath, MD. Chief of Gastroenterology at Lenox Hill Hospital (New York City): As we've opened a wonderful new ASC/Endoscopy Center at Lenox Hill Greenwich Village, this question has been central to our mission.

Two guiding principles: (1) Prioritize patients [and] (2) prioritize physicians.

Operationally, for patients this meant we chose a central area convenient for travel,  quick appointments, efficient scheduling, excellent arrival/recovery space, and doctors who are specialists in their fields.

For the physicians, new top-line equipment (the latest endoscope models), a spacious suite in which our procedures can be performed (a true luxury in Manhattan) and a dedicated and well-trained team of anesthesiologists, nurses and techs that align in our mission.

Joset Taylor BSN, RN. Director of ASC at BlueRidge Medical Group (Raleigh, N.C.): Making your team/staff part of your strategic strategy. Clear communication: We are one team and no one’s part of the patient experience is more important than others, from check-in to discharge to billing. If you explain the whys of what is being asked of them, you will find engagement. When they excel, let them know it in real time. If there is deviation from the plan, let's discuss the why in real time. 

Staffing nationally is in crisis. ASCs can't compete with the constant competition of rising salaries. So my pearl of wisdom is to take care of your team. Make them a priority, involve them in decision-making whenever feasible. Most importantly, model the behaviors you expect from them. 

Robert Thomsen, MD. Senior Medical Director of Perioperative Services, Johns Hopkins Medicine (Baltimore): A robust regulatory affairs program is key to a successful ASC. An individual or group who fully understands the scope of performance element changes allows you to maximize potential efficiencies and mitigate operational barriers for the practice. A surveillance system is an essential element to identify compliance issues, provide education and reduce potential liabilities from new staff and contracted service providers. 

Merlin Wehling, MD. Anesthesiologist, Kearney (Neb.) Regional Medical Center: 

• Know your surgeons and communicate with them daily. Talk with each surgeon. Go to the OR and discuss in person your top three issues. (Make the rounds.)
• Know your supply manager and communicate with them daily. Discuss any potential backorders and unobtainable items. Discuss back-order items with these surgeons immediately and work on subs.
• Know your staff (techs, RNs and processing techs). Go to each department daily and follow up with problem solving.  
• Know your numbers. How many cataracts does it take to break even? How many knee scopes does it take to make money?
• Know your anesthesia team. In today's landscape, anesthesia providers are hard to come by. Make sure yours are happy.
• Be prepared for meetings.
• Be an advocate for your staff and be ready to help when outside problems become your problem.
• Be present.
• Be a listener.

Peter Whang, MD. Associate Professor in the, Department of Orthopaedics and Rehabilitation at Yale University School of Medicine (New Haven, Conn.): I think it is always important to remember that an ASC is more than just a physical location where procedures are performed and actually represents a system for us to provide quality surgical care to our patients. Thus, what is equally as important as securing the right equipment and keeping the lights on is making sure that there is an adequate investment in personnel as well — physicians, anesthesia specialists, nurses, administrators, and other staff — because without them there is little chance of long-term success. When you have the right people involved in your ASC, you will have the ability to create an environment in which patients can undergo a wide range of therapeutic interventions in a more efficient, safer and cost-effective manner.

Brian Young, MD. Physician Informaticist for the National Office of Clinical Data Science, CommonSpirit Health (Chicago): Vigorous cost control and choice limits at the level of vendor supply contracts for hips, knees, implants, etc.

Pre-determined workflows for cases with complications, or who subsequently require overnight in-hospital stays.

Ali Zadeh, MD. Corporate Director of Ambulatory Surgery, Prime Healthcare (Ontario, Calif.): There are many items that could likely fit within a successful ASC management cheat sheet, but if I had to pick seven, they would be:

• Fair payer contracts with the top three health plans most utilized in the service area that my ASC is in, with carve-outs for implants and a rate that provides a minimum contribution margin after accounting for all costs.
• Aggressive accounts receivable (A/R) management with days to bill, days to post, days in A/R tracked weekly.
• Methodical accounts payable (A/P) review to ensure no balance greater than 200 percent of cash on hand, effectively ensuring sufficient margin to operate the business without undue overhang from A/P.
• Strong physician relationships, including a mix of owners and non-owners who bring cases, and who have developed affinity and pride to the ASC for service, efficiency, quality, etc.
• Engaged physician owners held accountable for one-third test, of bringing one-third of revenue and cases, per applicable regulations.
• Appropriate triangulation between management service organization with oversight on Administrator and reporting to board, physician investors meeting the one-third rule, and hospital or third-party equity ownership providing both clinical services that need to be outsourced at fair market value and clinical cases.
• Effective governance with both healthy tension and agreement between members but resolute commitment by all equity holders to the sustainability and growth of the ASC.