Linda Phillips, RN, administrator of Southgate (Mich.) Surgery Center, discusses how her surgery center successfully moved from a single-specialty ophthalmology center to a multi-specialty ASC with GI and pain.
Q: How did you decide to add your first specialty after ophthalmology?
Linda Phillips: When I started with the center, we had one room, and we expanded to two for ophthalmology. What initiated the process of adding another specialty was that a couple of GI doctors called me and were interested in doing cases here. We had to apply for CONs for two more rooms, and we originally had a medical ophthalmic clinic in here, which we had to relocate to convert the entire building to an ASC.
GI was the first specialty we added, and one of the things that made it attractive to me was that it's similar to ophthalmology in its procedure times. They're not long, drawn-out procedures; you can do multiple procedures in one morning, unlike something like ortho, where it may take 3-4 hours to do one case. Another reason was that one of the doctors who did the GI procedures was a general surgeon so I thought we could expand off that and bring in minor general surgery procedures as well.
Q: Could you walk me through the process of adding GI to your single-specialty ophthalmology center?
LP: I had to shop around for equipment because we were starting from scratch, so we needed everything you would need to do GI cases. Those are the basic things, and then you have to put in policies for GI including quality assurance, infection control and anesthesia. The anesthesia that's provided for GI is different than what we administer for eyes because we provide topical anesthesia for our eye cases rather than conscious sedation.
All of that was different than what we were doing here. We moved to scope washers instead of sterilizing instruments with ophthalmic procedures and implemented high-level disinfection for the GI cases.
I also hired new staff, and obviously we had to come up with all the pre-op and post-op instructions. There were a lot of forms for the medical records that had to be created.
Q: Did you bring several physicians on at once to guarantee case volume, or did you phase several into the center more gradually?
LP: To be honest, there were originally four physicians who were going to come on board, but as the process progressed, two of them backed out. We were concerned, but we did some calculations and figured that we'd be okay because the other two doctors' volume was pretty high. At the same time, we decided to bring in podiatry, so I felt like we were going to be okay. Since that time, I have recruited other GI doctors.
Q: Do you think it's common for physicians to approach a single-specialty ASC and ask the center to expand its specialties?
LP: I think it's uncommon. One of the reasons it happened for us was that one of our ophthalmologists, who is a shareholder, networked personally and talked to doctors within the hospital about how much she liked it here. That just sparked some interest. We were also able to offer shares to new surgeons, so it was enticing for them to come on board.
Q: What was the process for bringing podiatry into the surgery center?
LP: We brought in one physician. I tried to recruit several, but podiatry is a more difficult specialty. We no longer have it here, and it's more difficult for an ASC that's not affiliated with the hospital, because many times hospitals have podiatric interns and residents. It can be an obstacle for programs that don't have intern and resident program in place already.
In our experience, podiatrists in this area don't do a lot of surgery. We ended up dropping the surgery because there really wasn't enough volume — we may have been doing one case a month. I think podiatry is a good specialty to have if you already have a busy surgery center, but to count on podiatry as one of your only specialties didn't work for us.
Q: How easy do you find it to recruit new physicians to your center?
LP: There's not a steady stream, and I can tell you if you're trying to recruit physicians, be patient. On average, it probably took me about 18-24 months from the time I approached a physician to the time they joined the staff. They don't make decisions quickly.
Q: How do you keep in touch during that time period without becoming a pest?
LP: I send letters or emails, depending on what they prefer. I just try to update them when we add something new or have a nurse joining from a certain facility. I update them on things that are current to their specialty, or I let them know when we have shares available. Sometimes I'll visit their office, but I don't do it too often because you don't want to be a pest.
Q: Could you discuss a few things that make each of your specialties profitable and successful?
LP: For GI, it's definitely making sure that your cost-per-case is as low as you can get it without compromising quality. That's one of things that's trying with GI — you're definitely getting reimbursed a lot less. So you need to get cost-per-case as low as possible. I recruited GI RNs when we added the specialty because they are well versed in that specialty, and it definitely makes things more efficient. I also give the doctors two rooms, so they bounce back and forth and there's no turnover time.
For GI, we originally ordered [a lot of individual supplies] that all came separately. We met with another company and came up with a pack where everything is included. Not only do you save, but everything is on time, and you save on shipping and handling.
For our cataracts, we use a lot of lenses, so we made sure that we did consignment with all the lens companies to save money on shipping and handling. If you're going to use a company's lenses twice a year, they won't want to put a consignment in, but we've been lucky. We have one ophthalmologist who uses one type of lens, and another ophthalmologist who uses another type, and the rest all use the same brand. That's a significant amount of volume, so we're justified to do consignments. We don't have to call and order all these lenses; we can just pull them a few days beforehand and then fax in the bill and replace. We've been successful in getting doctors to standardize what they use for their packs as well, which helps to decrease costs.
Q: How is running a multi-specialty ASC different from running a single-specialty ASC? What considerations do you have to make that you wouldn't need to think about in a single-specialty ASC?
LP: I thought when we added those specialties that we would have to hire staff and buy equipment. But I didn't really think about all the paperwork that would have to be done, because everything is different. We had to change infection control policies and procedures, as well as all of our quality assurance and sterilization policies. Anesthesia is different, so recovery times are different. It forces you to wear a lot more hats.
I hired a team leader that would be in charge of an area and put a little group together to implement those changes. Our team leader came from the GI department at a local hospital, so she had many years of GI experience that really helped facilitate everything. I actually brought her in prior to opening so she could help with the set-up and come up with things you wouldn't think of. It's been invaluable. You may think you can do it on your own if you don't have GI experience — you may have been an administrator, but unless you worked back in the trenches, there are things you're not going to know that need to be done. Fortunately, I hired two very experienced endo nurses, one of whom also had some pain experience which was invaluable when we added pain management to our ASC.
Q: Of the specialties you have added to your ASC, which has been the most challenging?
LP: I think GI was the most challenging because it sounds like you're just going to do a colonoscopy, but you need specially-trained people who know what they're doing. It's not the case that you can bring in any nurse that's worked in the OR who states they can do GI but has never done it before. It's difficult because there aren't a lot of GI-specialized people who want to leave the hospital to come to an ASC. Since your reimbursement is much less, you have to be able to contain costs.
Q: How did you manage to recruit GI staff with that kind of shortage?
LP: The nice thing about being an RN is that I came from the hospital and knew people, so I put my feelers out that way. Those people know people, so it's basically networking within my peer group from the past. Then of course I put ads in papers and on different websites as well.
Q: Are there certain specialties that complement each other in an ASC — or, conversely, specialties that don't work well together in the same facility?
LP: I know ophthalmology and GI work together because they're similar in the amount of time the cases take. But in our ASC, they're done in separate places. GI cases are done in separate ORs. So while they work well together, we don't do them in the same spot.
I can only speak for myself, but with our existing facility, one specialty that wouldn’t' work for us is ENT. It treats a lot of kids, and we don't have a separate waiting room for them. Our pre- and post-op areas are not set up to provide noise reduction, and ENT does a lot of tubes in the ears or tonsils on children who can wake up a little agitated. If you have elderly seniors having cataracts while kids are screaming, that might not work.
Plastic surgery cases may take 4-6 hours, so it might not be something you want to add to your surgery center.
Q: Do you have any advice for surgery center leaders seeking to add new procedures?
LP: I think the biggest thing is due diligence. If you're going to add a specialty, you must understand what your capital investment and reimbursement will be. If you're going to do 10 cases a month and you're investing $100,000, you need to make sure you're getting return on your investment. Do a pro forma to make sure adding the specialty makes sense for your facility.
Also be patient because physicians take a long time to recruit. Remember that you don't always need to buy brand-new equipment. For instance, in GI, maybe you buy the best new scopes and towers for endo, but maybe the OR lights you buy are used or refurbished. The critical things for the procedure should be new, but other things may be bought refurbished or used.
Related Articles on ASC Operations:
6 Advantages to Developing a Hospital-Owned Surgery Center
10 ASC Must-Reads From the Week of Aug. 22
ASC Industry Leader to Know: Lori Ramirez of Elite Surgical Affiliates
Q: How did you decide to add your first specialty after ophthalmology?
Linda Phillips: When I started with the center, we had one room, and we expanded to two for ophthalmology. What initiated the process of adding another specialty was that a couple of GI doctors called me and were interested in doing cases here. We had to apply for CONs for two more rooms, and we originally had a medical ophthalmic clinic in here, which we had to relocate to convert the entire building to an ASC.
GI was the first specialty we added, and one of the things that made it attractive to me was that it's similar to ophthalmology in its procedure times. They're not long, drawn-out procedures; you can do multiple procedures in one morning, unlike something like ortho, where it may take 3-4 hours to do one case. Another reason was that one of the doctors who did the GI procedures was a general surgeon so I thought we could expand off that and bring in minor general surgery procedures as well.
Q: Could you walk me through the process of adding GI to your single-specialty ophthalmology center?
LP: I had to shop around for equipment because we were starting from scratch, so we needed everything you would need to do GI cases. Those are the basic things, and then you have to put in policies for GI including quality assurance, infection control and anesthesia. The anesthesia that's provided for GI is different than what we administer for eyes because we provide topical anesthesia for our eye cases rather than conscious sedation.
All of that was different than what we were doing here. We moved to scope washers instead of sterilizing instruments with ophthalmic procedures and implemented high-level disinfection for the GI cases.
I also hired new staff, and obviously we had to come up with all the pre-op and post-op instructions. There were a lot of forms for the medical records that had to be created.
Q: Did you bring several physicians on at once to guarantee case volume, or did you phase several into the center more gradually?
LP: To be honest, there were originally four physicians who were going to come on board, but as the process progressed, two of them backed out. We were concerned, but we did some calculations and figured that we'd be okay because the other two doctors' volume was pretty high. At the same time, we decided to bring in podiatry, so I felt like we were going to be okay. Since that time, I have recruited other GI doctors.
Q: Do you think it's common for physicians to approach a single-specialty ASC and ask the center to expand its specialties?
LP: I think it's uncommon. One of the reasons it happened for us was that one of our ophthalmologists, who is a shareholder, networked personally and talked to doctors within the hospital about how much she liked it here. That just sparked some interest. We were also able to offer shares to new surgeons, so it was enticing for them to come on board.
Q: What was the process for bringing podiatry into the surgery center?
LP: We brought in one physician. I tried to recruit several, but podiatry is a more difficult specialty. We no longer have it here, and it's more difficult for an ASC that's not affiliated with the hospital, because many times hospitals have podiatric interns and residents. It can be an obstacle for programs that don't have intern and resident program in place already.
In our experience, podiatrists in this area don't do a lot of surgery. We ended up dropping the surgery because there really wasn't enough volume — we may have been doing one case a month. I think podiatry is a good specialty to have if you already have a busy surgery center, but to count on podiatry as one of your only specialties didn't work for us.
Q: How easy do you find it to recruit new physicians to your center?
LP: There's not a steady stream, and I can tell you if you're trying to recruit physicians, be patient. On average, it probably took me about 18-24 months from the time I approached a physician to the time they joined the staff. They don't make decisions quickly.
Q: How do you keep in touch during that time period without becoming a pest?
LP: I send letters or emails, depending on what they prefer. I just try to update them when we add something new or have a nurse joining from a certain facility. I update them on things that are current to their specialty, or I let them know when we have shares available. Sometimes I'll visit their office, but I don't do it too often because you don't want to be a pest.
Q: Could you discuss a few things that make each of your specialties profitable and successful?
LP: For GI, it's definitely making sure that your cost-per-case is as low as you can get it without compromising quality. That's one of things that's trying with GI — you're definitely getting reimbursed a lot less. So you need to get cost-per-case as low as possible. I recruited GI RNs when we added the specialty because they are well versed in that specialty, and it definitely makes things more efficient. I also give the doctors two rooms, so they bounce back and forth and there's no turnover time.
For GI, we originally ordered [a lot of individual supplies] that all came separately. We met with another company and came up with a pack where everything is included. Not only do you save, but everything is on time, and you save on shipping and handling.
For our cataracts, we use a lot of lenses, so we made sure that we did consignment with all the lens companies to save money on shipping and handling. If you're going to use a company's lenses twice a year, they won't want to put a consignment in, but we've been lucky. We have one ophthalmologist who uses one type of lens, and another ophthalmologist who uses another type, and the rest all use the same brand. That's a significant amount of volume, so we're justified to do consignments. We don't have to call and order all these lenses; we can just pull them a few days beforehand and then fax in the bill and replace. We've been successful in getting doctors to standardize what they use for their packs as well, which helps to decrease costs.
Q: How is running a multi-specialty ASC different from running a single-specialty ASC? What considerations do you have to make that you wouldn't need to think about in a single-specialty ASC?
LP: I thought when we added those specialties that we would have to hire staff and buy equipment. But I didn't really think about all the paperwork that would have to be done, because everything is different. We had to change infection control policies and procedures, as well as all of our quality assurance and sterilization policies. Anesthesia is different, so recovery times are different. It forces you to wear a lot more hats.
I hired a team leader that would be in charge of an area and put a little group together to implement those changes. Our team leader came from the GI department at a local hospital, so she had many years of GI experience that really helped facilitate everything. I actually brought her in prior to opening so she could help with the set-up and come up with things you wouldn't think of. It's been invaluable. You may think you can do it on your own if you don't have GI experience — you may have been an administrator, but unless you worked back in the trenches, there are things you're not going to know that need to be done. Fortunately, I hired two very experienced endo nurses, one of whom also had some pain experience which was invaluable when we added pain management to our ASC.
Q: Of the specialties you have added to your ASC, which has been the most challenging?
LP: I think GI was the most challenging because it sounds like you're just going to do a colonoscopy, but you need specially-trained people who know what they're doing. It's not the case that you can bring in any nurse that's worked in the OR who states they can do GI but has never done it before. It's difficult because there aren't a lot of GI-specialized people who want to leave the hospital to come to an ASC. Since your reimbursement is much less, you have to be able to contain costs.
Q: How did you manage to recruit GI staff with that kind of shortage?
LP: The nice thing about being an RN is that I came from the hospital and knew people, so I put my feelers out that way. Those people know people, so it's basically networking within my peer group from the past. Then of course I put ads in papers and on different websites as well.
Q: Are there certain specialties that complement each other in an ASC — or, conversely, specialties that don't work well together in the same facility?
LP: I know ophthalmology and GI work together because they're similar in the amount of time the cases take. But in our ASC, they're done in separate places. GI cases are done in separate ORs. So while they work well together, we don't do them in the same spot.
I can only speak for myself, but with our existing facility, one specialty that wouldn’t' work for us is ENT. It treats a lot of kids, and we don't have a separate waiting room for them. Our pre- and post-op areas are not set up to provide noise reduction, and ENT does a lot of tubes in the ears or tonsils on children who can wake up a little agitated. If you have elderly seniors having cataracts while kids are screaming, that might not work.
Plastic surgery cases may take 4-6 hours, so it might not be something you want to add to your surgery center.
Q: Do you have any advice for surgery center leaders seeking to add new procedures?
LP: I think the biggest thing is due diligence. If you're going to add a specialty, you must understand what your capital investment and reimbursement will be. If you're going to do 10 cases a month and you're investing $100,000, you need to make sure you're getting return on your investment. Do a pro forma to make sure adding the specialty makes sense for your facility.
Also be patient because physicians take a long time to recruit. Remember that you don't always need to buy brand-new equipment. For instance, in GI, maybe you buy the best new scopes and towers for endo, but maybe the OR lights you buy are used or refurbished. The critical things for the procedure should be new, but other things may be bought refurbished or used.
Related Articles on ASC Operations:
6 Advantages to Developing a Hospital-Owned Surgery Center
10 ASC Must-Reads From the Week of Aug. 22
ASC Industry Leader to Know: Lori Ramirez of Elite Surgical Affiliates