Teamwork and Talent Drive the ASC of Union County

Teamwork is a way of life for the 21 staff members and 50 physicians at the ASC of Union County, a two-OR, multi-specialty, physician-owned ambulatory surgery center in Union, N.J. At the heart of that teamwork lies a commitment to patient care that exceeds expectations and a family spirit that pervades everything at the center, which opened in 2000. And helping to drive that commitment are two individuals who work as the facility’s dynamic duo — Marcy Sasso, director of operations, and Debbi Holley, RN, BSN, director of nursing.

Nominating the duo for this year’s Who’s Who in Ambulatory Surgery is Glenn Davison, DPM, FACFAS, a board-certified podiatrist who is one of the owners of the center. He credits Sasso and Holley with leading the team to a number of notable achievements, including growing the physician pool and the center’s staff while cutting costs and increasing collections, as well as driving down the infection rate and causing patient satisfaction scores to skyrocket.

“Recruiting physicians is always challenging for any ASC,” Sasso acknowledges. “In New Jersey there are 300-plus ASCs so that translates into most doctors having their own place. We were fortunate in retrospect that our area hospital closed; we hired an outside marketing person to assist with recruitment. In 2008 we were at 80 percent capacity of our 7 a.m. to 3 p.m. block time so that marketing ended. Since then I found that word of mouth to other doctors was really our best means of recruitment. We have had several requests for credentialing packets every month for the past two years. I have a nice marketing packet put together that includes a brochure with our owners’ information, a physicians guide, all of our specific booking forms and criteria, information on our center from transportation to patient instructions, not to mention the give-aways such as letter openers, rolodex cards, sticky notes and pens. We also market all of our credentialed physicians on our Web site, and we place their business cards in our waiting room. When they come to tour the center we promote cross referrals and they meet with one of our financial coordinators to assist in educating their patients about our billing procedures.”

Building relationships is also key to working well with a diverse group of patients, physicians, colleagues, payors and vendors, and Sasso says the secret is “letting each person bring their unique talent and personality to work everyday. Really believing in their talents and bringing out their strengths that may have been dormant.” She adds, “The clinical staff here by far makes a lasting impression on our patients. The patients are greeted with a warm smile and often leave with a great cup of coffee and a hug. Our three administrative staff members multi-task as if they were a team of five and always with a smile and a kind word. They always look for ways to improve patient care and outside office communications.”

Sasso says that what she and her colleagues enjoy about the ambulatory care environment in part is the autonomy allowed by the center’s owners. “It allows Debbi and me to use our creativity, common sense and charitable side to run the ASC of UC so efficiently,” Sasso explains. “Being a smaller facility, we are able to cross-train and be a part of every day-to-day occurrence here. We have the opportunity to get to know our patients and they get to know us. Debbi and I don’t have to micro-manage in any way because when you come to an ASC setting you know you become part of a team and most days we consider our team our second family. It’s a positive and enthusiastic environment that one won’t find in the hospital setting.”

The ASC made a true believer out of Holley, who says, “My background was always in a hospital setting and the fear of joining an ASC was quite scary. I always believed that ASCs took away business from the hospital. When the local hospital closed, I had no choice but to jump in feet first to an ASC. I now see that the ASC has a warm and relaxing atmosphere. Nurses have enough time to spend with their patients to make them feel comfortable. They can have that idle chit-chat and not feel rushed to get onto the next patient.” Holley continues, “ASCs make it easier for the patient from arrival to discharge. Since our OR scheduling is close to or on time, patient scheduling is more convenient for patients and their family members. The patient has a specific OR scheduled time and they come in, their family member can sit with them in pre-op while waiting to go into the OR. After their procedure, the patient is offered coffee or juice cookies or muffins, then they go home. The patients feel more relaxed and comfortable before going in for their procedure and leave in a positive state of mind for a successful recovery.”

Sasso says the center’s team spirit and reliable retention rate are attributable to a number of factors, including treating everyone with fairness, equality and honesty, promoting a true open-door policy, as well as mentoring, coaching and supporting each other.

“A center can only work as well as their team,” Holley says. “To me, I am only one piece of the pie. Without the other pieces, there would be no pie. I feel that I would not be able to run a smooth and efficient center when one piece is missing. Our consistent reputation and positive work environment is cause for employee retention and terrific patient satisfaction. Positive feedback to the staff for all that they do on a daily basis is essential. No one wants to hear only the negative things that happen during the day.

“We also have pride and ownership, and we celebrate our successes,” Sasso says. Those celebrations of success range from an annual holiday party and bonus to a family picnic, staff birthday celebrations and a staff appreciation day, plus employment perks such as a retirement plan, paid health coverage and continuing education for all staff members.

The center had much to celebrate when they achieved accreditation with the Accreditation Association for Ambulatory Health Care (AAAHC). “Due to Marcy’s and Debbi’s leadership, we have received the highest accreditation from the AAAHC for a three-year term,” Davison says.

“Accreditation was something we had been putting off for several years for fear of the unknown,” Sasso explains. “When our medical director, Dr. Thomas Ragukonis told us we were ready and deserved to be in this prestigious category we took his suggestion and plunged in. During the pre-accreditation process we were able to review and improve many of our ‘stale policies.’ We split into sub groups to tackle the process; empowering all staff to take ownership along the way. We repaired some cracks in our foundation and Debbi wrote 65 new policies and re-vamped more than 100. Our staff philosophy has been treating each day as if the inspection were to happen and there is no need to worry when it does. Our two-day survey was intense and thorough, as they ought to be, and during our exit interview they told us that ‘we should be very proud of what we do here’ and we were rewarded with a three-year accreditation. Going through the process was an outstanding learning experience for all staff. Now we routinely review the assessment manual to be sure we keep this prestigious accreditation.”

Davison says that Sasso and Holley “believe in and promote continuing education, and every staff member has attended at least one or more courses last year. All staff members take the BLS course and all of our nurses take the ACLS course which we sponsor right here in the center.”

It is this focus on patient safety that has propelled the ASC of Union County in everything it does, including making ambulatory care the best option for healthcare professionals and patients.

“It is proven by all of the benchmarking statistics that ASC’s provide a cost-effective, top-notch setting for patients as opposed to the standard hospitals,” Sasso says. “The physicians feel that the latest technology is more available here and we are more patient-friendly. The doctors are able to perform more cases in one day here than they would be able to in the hospital. ASCs don’t have the ‘I am a number’ mentality, and patients are referred to by name and are remembered when they return for an additional visit. The infection control rate of most centers is 1 percent or less, and hospitals cannot offer that same optimistic statistic. (Ours, over the past eight years, is less than 1 percent). ASCs typically have better control of the flow over their patients, less red tape than a hospital from the registration process to the patient discharge much faster and fewer mistakes!”

Holley concurs, adding that ASCS must be prepared to face unique clinical challenges such as patient safety practices, especially proper identification. “What we do here is at registration, the patient is asked for the last four numbers of their Social Security number, birth date and a picture ID,” she explains. “In the pre-op area, the patient again is asked for their last four digits of their Social Security number, their birth date, what procedure they are having and where will be the incision site will be. The last four numbers of their social security number is on their identification band. This same list of questions is asked again during the consent period. Another challenge is having the patient bring in a list of medications that they are currently taking in order to complete the medication reconciliation at their time of discharge. Both the nurse and physician must sign the completed form at discharge. ASCs may find identifying the correct patient and information a little more difficult than in a hospital setting but with our process in place, we have not encountered any problems. We feel confident that we have the right patient here for the right procedure.”

Holley says that the ASC enhances patient satisfaction through positive encouragement and communication. “During our pre-op admission we instruct the patient that their discharge instructions and survey is in their envelope and hope that they will help us serve our community better by their comments. When patients are discharged we know something about them and we make a mention about this to let them know we heard them. We wheel or walk out every patient and wish them well. By the time they are leaving at least four people have said goodbye to them. We encourage patients to send back the survey when we make our next day post-op calls. We treat every patient as if they were a family member from start to finish.”

Holley adds that the ASC’s low infection rate is another accomplishment. “The most important part of keeping infections down is hand hygiene,” she says. Nurses must wash their hands immediately before and after touching a patient to prevent cross-contamination. We have constant monitoring; we have a full-time RN trained in infection control who runs in-services and is routinely changing signs in the patient/visitor areas. We also book 15-minute intervals between cases to clean and sterilize the ORs between cases.” Holley adds that in order to prepare for impending inspections, the ASC has a staff member do spot checks to ensure handwashing is done properly, and they also conduct mock surveys frequently to observe and educate staff on potential problems.

Contributing to the ASC’s clinical success is staff’s investment in the center and in their work. “I think ‘team’ and ‘ownership’ are the two words that describe our staff,” Holley says. “Each staff nurse has a specific job that they take ownership of. One nurse will be in charge of all the contracts for the center; it is her responsibility to update expired contracts on a monthly basis. Another nurse is responsible for the QA projects; she does monthly audits and chart reviews. Another staff nurse is responsible for keeping abreast of any OSHA problems and updates. This nurse will give monthly reports on any OSHA criteria. The nurses feel a sense of pride and accomplishment in their specific area. We also have two OR techs in nursing school and the other RNs take time to mentor them.”

Bringing staff together is the ASC’s quality assurance program, which also serves to audit physicians and their time in the OR. “Many book a case for a specific amount of time, and we are detecting some run-over in their allotted time and push other physicians back in their start time,” Holley explains. “This leads to physician and patients becoming frustrated with wait time. To improve patient satisfaction, we need to determine which physicians need extra allotted time for certain procedures. Dialogue between physicians and staff has improved by having an open communication policy. Physicians are asked on a monthly basis if anything needs to be improved or if they need a specific piece of equipment. The physicians educate the staff on procedures that are new or unfamiliar, and physicians allow any staff nurse to observe their cases. And during monthly staff meetings, they are encouraged to think of new ideas to make the center run smoothly.”

“Our staff enjoys coming to work and seeing the patients get well and leave happy,” Davison confirms.

The ASC staff echo this sentiment. Clinical coordinator Kathy Melnick, RN, BA, CCRN, emphasizes, “I have been a nurse for more than 40 years and I have never worked anywhere where the patient satisfaction surveys have come back with such glowing accolades; from the admitting process to the discharge, every staff member tries to make the patient stay as pleasant as possible. The staff prides themselves on a professional, compassionate and friendly demeanor which is demonstrated on a daily basis with every patient. A great percentage of our patients are repeat customers and we hear over and over again how they only want to come here for their procedures! It is an honor for me to be associated with a surgery center that provides exceptional patient care for the surgical patient.”

Jan Marsh, RN, says she appreciates the center’s dynamic environment. “Having worked in a hospital setting for most of my professional career, transferring to the ambulatory setting was a new experience for me. I truly enjoy the atmosphere at the ASC, which is professional yet patient friendly. The doctors and nurses work together as a team to deliver the best possible patient care for every individual.”

One of the center’s orthopedic surgeons, Clifford A. Botwin, DO, observes, “I don’t ever remember any institution receiving the accolades and satisfaction from patients, families and staff that have been attributed the ASC of Union County. Led by an outstanding administrator, Marcy Sasso, and staff this facility although relatively small has been in the forefront of community health and relations in our area.”

The center believes that participating in philanthropic efforts is a worthy way to give back to the community.

“Marcy organized and brought in more than 3,000 brand new toys for the local police holiday drive, and had more than 10 pallets of medical and child care items sent to Louisiana for Hurricane Katrina-related needs,” says Davison.

The local community in central New Jersey also benefited from the center’s generosity through its free health fair held last year.

“Our physicians came out in full support of this endeavor, with more than 15 doctors representing various specialties were available for the over 350 attendees,” says Mary E. Koch, RN, BSN, CNOR, the center’s OR supervisor. “In light of our current healthcare situation, there are many people who have no access to healthcare. This provided a unique opportunity for the public to speak with a physician. This is one of the many wonderful ways we care for our community, from Toys for Tots, Katrina relief supplies, Walk for Autism, and breast cancer awareness. I am proud to work in a surgery center that gives so much to the community in addition to the exemplary care we provide for our patients.”

“At our community health fair we saved and changed more lives in that one day than any of us ever expected,” Sasso says. “I believe you get what you give, so giving back was our motive for the health fair. The local hospital used to put on a health fair and since they closed several years ago the community was no longer afforded that special day. It seemed like the perfect opportunity to market our ASC and give back at the same time. It took just two days to get a commitment from our 15 owners, and we had six weeks to organize the fair. I called every one of our vendors, every local non-profit group, the blood bank, physical therapy, imaging centers, and the local chamber of commerce. The ‘give back’ message took hold with them and we had an overwhelming response. We had our 15 doctors on site talking to the public about their specialties — orthopedics, GI, general surgery, bariatric, pain management, podiatry, gynecology and chiropractic — as well as body fat screenings and all the give-aways a visitor would hope to find at a fair. We had 350-plus guests, gave away four glucomoters, took 185 blood pressure readings, and had 11 blood donors. Giving is so contagious, you can’t help it sometimes. That fair was one of the greatest achievements in my career.”

To read more about the ASC of Union County’s involvement in ASC advocacy and politics, don’t miss the January 2010 issue of SurgiStrategies.

Q&A with Marcy Sasso

What can other ASCs do to emulate the success of your center?

If ASCs strive to continually evaluate their actions and decisions in light of patients’ best care and treatment, they will automatically discover the path to success. Make safety your No. 1 priority, and put it on the agenda for every committee meeting. Monitor your patient surveys closely, as they will be valuable assessment tool; share them with all of your staff and physicians. Our surveys have been outstanding with some wonderful comments regarding our exceptional staff and comfort of our ASC, and 100 percent of our patients have indicated that they would return should the need arise. When we saw a comment about discharge instructions, we immediately held a brainstorming meeting and made a change as to when and to whom instructions were given. If an employee has drive and ambition, take a look at how they can bring additional value to the center. For example, Lauren, our OR tech, mentioned that it would be great to be an OR nurse and really admired our RNs. Mary is now her mentor while she is going to nursing school in the evenings. Our staff attends conferences and we encourage them to share their knowledge. Look inside your team, as you may find the next surgeon just waiting to be mentored!

How do you stay current in the industry?

I read at least nine trade publications weekly, and I have signed up for every “alert” there is. I attend the annual ASC conference and send many of my staff to specialty courses. I forward at least three or four “FYI” e-mails to my center’s owners on a weekly basis to be sure that they are kept up to date in the ASC world.

Making Cataracts More Profitable

Improving profitability in an already efficient operation has its challenges. However as the saying goes, when one stops improving, one stops growing.  The key to improving is to continually evaluating your efficiencies when it comes to patient & staff scheduling, doctors block time, labor mix and related costs, disposable costs and anesthesia expenditures.

Scheduling patients at the right time to make certain you have the right amount of patients in the queue for your staff and surgeon is crucial. Avoiding lateness (whether it’s the patient, surgeon or staff) is the key, along with making sure your surgeon and/or staff do not take breaks between cases.

Efficient staffing of your pre-op, operating room(s) and post op often times involves hiring part-time staff who can pick up the extra load whether it be prepping the patient, scrubbing or circulating in the OR, cleaning instruments, etc…  Staffing your center with more part time staff can reduce your benefit costs and staff overhead. Each function in the center should be done by someone with the proper skills and appropriate pay scale.  It has proven to be very economical to utilize outsourcing services, such as Vantage Outsourcing. They not only provide staff, but also all the equipment, micro instruments and disposables used in a cataract procedures.

Disposable costs are a major cost of doing cataract procedures. Every six months to a year, asking your surgeon/owner to evaluate his/her surgical preferences and consider alternative disposables and/or suppliers can prove to be very profitable. When surgeon asks for a more expensive supply, provide the surgeon with a cost/benefit analysis of adding this supply and the impact of profitability on each of their cases. WIth the expertise of companies such as Vantage Outsourcing, they too can help you reduce our case costs by sharing with you what other facilities and/or doctors are doing and by recommending quality disposable items to use as an alternative to your current costly disposables.

2 OR set up may be good for some, but not for all.  Many surgeons like working in an environment where they go back and forth between two ORs. Vantage Outsourcing generally recommends to their clients that unless the surgeon is doing five or more cases an hour and at least 20 cases a day, we have found that the 2 OR set up to be inefficient. Keep in mind with 2 ORs, the center needs to equip each room with a phacoemulsification equipment and microscope, as well as staff. Unless a surgeon is fast and doing significant volumes, your paid staff and anesthesia person may be waiting on the surgeon to complete cases, which becomes very inefficient and costly to a center.

The easiest way to improving profitability is to increase case volume. This may mean taking time out of your busy day to visit with the area optometric businesses to find out to which surgeon they are referring their patients. Let them know what your center and surgeon have to offer their patients. As part of the outsourcing service, Vantage Outsourcing is able to share with you the referral patterns of ODs in a particular market, in relations to the various MDs. This information is extremely valuable and helpful in determining where a facility and/or doctor needs to put forth their efforts in terms of OD relationships.

In summary, you need to know, evaluate & improve your efficiencies and identify the sources of your surgeon’s referral base, in order to improve your cataract service profitability.