Getting Skin in the Game

Orthopedic surgery can be a demanding specialty, and with its rewards comes its challenges and opportunities. No one knows this better than J.F. James Davidson, MD, who specializes in sports medicine, shoulder and knee surgery and who is part of Canyon Orthopaedic Surgeons and also practices at Gateway Surgery Center, both in the metropolitan Phoenix area. He discusses life inside and outside of the OR.

Q: Why was the specialty of orthopedics right for you?

A: I greatly respect physicians in other fields such as family practice, oncology and trauma surgery, to name just a few. Good physicians can solve a complicated medical puzzle and potentially save a sick person’s life. These physicians carry the burden of a weighty responsibility. One reason I chose orthopedics and specifically the area of sports medicine is because our patients usually have treatable problems and the capacity for relatively rapid improvement. They usually do not have life threatening conditions and are highly motivated to improve in order to maximize their quality of life. I remember rotating through cardiology and nephrology in medical school and learning the serious consequences of chronic disease. On the first day of the orthopedic clinic we examined a man with a fractured patella. The patient jovially answered our questions regarding how he managed to be kicked in the knee by a goat. In spite of the discomfort of the fracture the patient laughed at his unusual predicament. I though, now I have found the right specialty.

Q: The practice of medicine is becoming more challenging in terms of medical malpractice, tighter reimbursement, etc., so how do you cope with these modern challenges?

A: I have had some very good teachers and role models. Bill Brainard, MD, one of the founders of our group, Canyon Orthopaedics, taught by example the benefit of finding enjoyment in working with patients and colleagues, and in performing surgery. Our practice has the innate rewards of helping people, solving problems, interacting with others. My partners and I feel fortunate to do what we do. The negatives certainly can be a drain on the system, but we try to focus on the positive reasons that we come to work each day.

Q: Most physicians are never trained in business, and when they become medical entrepreneurs, they can be unprepared for the rigors of business. What has been the most valuable lesson you have learned about being a medical entrepreneur?

A: As I mentioned, I have had some very good teachers. Dave Ott, MD, was the driving force developing our successful orthopedic ASC, Gateway Surgery Center. He proved that bringing traditional competitors together for a common business goal can lead to a win for all. Prior to Gateway’s development, Canyon Orthopedics consulted with a national firm regarding the viability of creating a small ASC as an extension of our six-man group. The consultant determined that the project would be worthwhile, but with lower volume than ideal. Instead we became part of the 30-physician Gateway ASC. This has proven to be far more efficient and successful than the project we could have done on our own. Currently under construction is the Southwest Orthopedic and Spine Hospital, an orthopedic specialty hospital in Phoenix. For this project 37 orthopedists and spine specialists have partnered with Catholic Healthcare West and USPI to build what we are determined to be the highest quality orthopedic facility in the region. Finally, a number of currently independent orthopedic groups in greater Phoenix are now working on the merger of our established practices to form a single large orthopedic group. We are hopeful that this of relationship will benefit from similar synergy as Gateway Surgery Center.

Q: What clinical lessons have you learned from sports medicine that you carry over into your other practice, and vice versa?

A: A high school athlete with the goal of a college scholarship is driven to return to the playing field as quickly as possible. A few extra days off the field may mean missing a game and a chance to help his team win and shine for a college scout. The athlete wants aggressive treatment to get him back in the game as quickly as possible. In worker’s compensation cases, an injured worker may or may not have similar motivation to get back to work quickly. However, fast-tracking treatment leads to more rapid return to the job, and less time on sick leave. Similarly, the injured worker (and his employer) benefit from avoiding unnecessary operations, but meanwhile not delaying the inevitable procedure. If a surgery ultimately will be required then spending time on additional therapy is not advantageous. Making this determination requires experience and judgment. The same is true in the treatment of the athlete. On the other hand, many middle-aged athletes as well as injured workers have degenerative changes seen on an MRI. It is important to make clinical decisions as to what changes seen on scan are degenerative and incidental versus acute and painful. An over-read of an MRI can lead to a potentially avoidable surgery in both the athlete and laborer.

Q: What are the technological/clinical advancements in orthopedic surgery that get you most excited?

A: I’m excited by a number of new devices and procedures. I’m always on the look-out for methods leading to better or more reproducible results; easier or less invasive ways of doing procedures; and faster or less painful recoveries. Throughout the year the Arthroscopy Association of North America (AANA), hosts cadaver training courses to teach new techniques and improved ways of performing standard techniques. I have been an assistant instructor at the AANA shoulder courses for years and always learn from the master faculty leading the discussion and training. Two areas of special interest are the use of preoperative MRI to determine the pattern of rotator cuff tears and method of repair; and the use of an MRI to preoperatively design cutting jigs to add to the precision of total knee replacement.

Q: What do you believe is the future for outpatient orthopedic surgery in terms of keeping up with the ever changing medical and economic environment?

A: Practicing-physician involvement in management and ownership is one key. No one has a greater interest in maintaining a top-flight center than the orthopedist taking care of the patients, doing the surgery, and watching the bottom line. As we discussed earlier, my partners and I are betting on “big is better.” We built Gateway without a corporate partner. Last year for a number of reasons we sold a portion of our center to AmSurg. We are hopeful that this association will lead to economies of scale in purchasing and a stronger position in contracting. Cooperation with our colleagues has led to success in business and has improved our practice of orthopedics as well. We consult one another, adopt best practices, and learn from each other’s successes and failures. Healthcare is changing rapidly and we will all need to stay nimble to adjust to these changes.

J.F. James Davidson, MD, graduated with honors from Yale University and received his MD degree from Columbia University. He then completed his orthopedic residency and sports medicine fellowship in Phoenix. He is board certified by the American Board of Orthopaedic Surgery and is a fellow of the American Academy of Orthopaedic Surgeons. He has also served as an officer in the American Orthopedic Society for Sports Medicine and the Arthroscopy Association of North America. Davidson has published scientific papers and spoken nationally on topics ranging from anterior cruciate ligament reconstruction to arthroscopic rotator cuff repair. He is the lead spring training physician for the Chicago White Sox as well as the team orthopedist for several local schools. His special interests include disorders of the shoulder and knee. Davidson has been with Canyon Orthopaedic Surgeons since 1994.

2010 Management Guide

Dealing with Survey Deficiencies

After receiving 23 pages of citations and a threat of losing its license, a Texas ASC (that had gone three years without a state/Medicare survey) recognized its desperate situation. While many of the citations concerned the new conditions for coverage and multiple notes for the same deficiency, the center still needed to respond with corrections within 10 days. Typical of smaller facilities, the employees responsible for compliance activities are the same individuals involved in routine care. While intending to comply with regulations, patient treatment takes priority and administrative paperwork falls behind.

In addition to their daily routine, management now needed to research, evaluate and interpret the regulations in order to rewrite/update their policies within the response time. The practitioners (both administrative and physician) realized that the task they faced required the resources and skills of an outside expert. The facility searched for a consultant that could help solve their problems. Separated by 1,500 miles, with the days ticking away, recognizing travel arrangement difficulties and skyrocketing travel expenses, they requested FWI Healthcare’s assistance.

Receiving and reviewing their citations, FWI presented a cost-effective proposal to the client that was accepted. The client faxed requested documents for our analysis. We discussed existing materials and the need for changes. FWI also developed some revisions to their policy manual and the plan of correction for submission. This information was provided to the client and after telephone clarification and minor adjustments; the transcripts were ready for use.

The plan of correction was accepted and upon the surveyor’s return for a follow-up visit (finding everything to be acceptable), she recommended the license and certification be renewed.

Many small ASCs do not have personnel with experience, knowledge or time necessary to rapidly respond to deficiencies cited by survey agencies. This is where relying on the resources of consultants (who provide assistance on a fee for service basis) is invaluable. All of FWI’s work was completed with minimal expense and without either party leaving their office.

By Roger Pence, president, FWI Healthcare www.fwihealthcare.com • 419.298.3700

Challenges Unique to De Novo Facilities

De novo projects can be a long and not always painless process, but like turnarounds, they have incentives as well. With a new development, we are able to construct the center from the ground up to ensure our high standards are met and so high-quality care can be administered efficiently from day one. We are also able to form a great group of physician partners with the right balance for a successful ASC. Now, just because we get to make initial decisions on the facility and the business with our partners, it is not always roses when developing a new center. We deal with doubting partners, setbacks, stumbles and roadblocks. In the case of our new de novo facility in Mt. Dora, Fla. we hit an unusual roadblock — gopher turtles. Yes, gopher turtles. This protected species was living on our construction site. We had to have the turtles moved, but that could only be done after three consecutive days of 50 degrees or warmer weather. The turtle relocation caused about a six-week delay in the building process, and while no one could have anticipated a gopher turtle infestation, we took care of the situation and did what we could to get the project back on track.

We found that the perspective of the partnering physicians in de novo projects is quite different from that of partners in turnarounds. While in turnarounds we are often thought of as better managers than we are, sometimes in new developments we are thought of as worse. Partners focused on financial returns view any stumble on the way to distributions as a failure, when in fact, stumbles are a part of the process and sometimes result in positive outcomes. The objective is to have the “wiggle room” to adjust, correct problems, and move forward.

No matter what we encounter along the path to developing a new center, we are committed to our partners and the success of the center and look forward to developing new, successful centers across the country.

By Tom Mallon, CEO, Regent Surgical Health

www.regentsurgicalhealth.com 708.492.0531

Ostrich Strategies for ASCs: Never A Good Idea

The phrase “burying your head in the sand” has become synonymous with hiding from the truth or hiding at the first sign of danger. Ostriches are alleged to do that, but they actually do not. However, owners of distressed outpatient centers sometimes really do.

Our firm gets involved in helping distressed outpatient centers, including surgery centers, and our experience has shown that it is the rare owner who does not “bury his (or her) head in the sand” hoping that something will occur that will cause the source of the distress to simply go away. Employing an “ostrich strategy” is a bad idea, as well as a waste of valuable time and resources because the sources of distress rarely go away simply and easily.

The “ostrich strategy” usually results in the center being behind in payments to lenders, landlords, the taxing authority, staff and most vendors by the time we get involved. The task of pulling your head out of the sand and developing workable strategies is complex and multi-dimensional, and involves lawyers and lots of different personalities. In addition, there are always varying degrees of trust among the owners and the managers (who are also often owners). Getting to the core problems requires information analysis, lots of conversation and a site visit or two. Once those core issues are made clear, then the people leading the charge put a simple strategy in place. It needs to be simple because additional and incremental complexity will only complicate matters and likely make things worse. Our firm often leads the charge, but many times we do it in tandem with the center’s lawyers. Depending upon how far behind the center is with various creditors and what legal actions have already been taken, the lawyers may well take the lead.

Follow your strategies, keep your head out of the sand, stay calm and focused, engage the right professionals for you and you may be able to yourself of the sources of distress that caused you the problems in the first place.

By Robert S. Goodman, managing partner, The Mansfield Group www.mansfield-group.com 609.267.0990

Adding Specialties to Increase Profitability

Foundation Surgery Affiliate of Huntingdon Valley, Pa. is an AAAHC-accredited, multi-specialty ASC that opened in 2003. With four operating rooms, two procedure rooms and 19 surgeon partners, this 18,000-square-foot facility was profitable; however, there was still a tremendous opportunity for growth through increasing OR utilization and case volume. “We continually strive to develop new tools and methods that will enhance the profitability of our centers while also adapting to the changing outpatient surgery environment,” says FSA chief operations officer Thomas A. Newman. He recalls the FSA specialty and case analysis:

1. Take inventory. FSA creates a checklist of all specialties that can be performed at an ASC.

2. Analyze and evaluate. Management performs an extensive cost/benefit analysis, weighing equipment and labor costs against typical revenues provided by the specialty.

3. Determine which specialty is most worth pursuing.

4. Recruit surgeons. Utilize data collected in steps 1-3 and tap existing surgery partners as a primary resource for new partner candidates.

In the case of Huntingdon Valley, a surgeon partner suggested that the center consider adding fertility as a specialty. Based on that recommendation, FSA performed steps 2-4. During the first month of adding fertility, case volume increased 12 percent and overall revenues increased by more than 25 percent. As a result of this exercise, FSA formalized the process and rolled it out to all of its centers.

“Our center was already doing quite well when FSA performed the specialty and case analysis and presented the impact of adding gynecology partners specializing in fertility,” says center administrator Robert Puglisi. “Now, return is even higher as a direct result of adding our reproductive medicine partners.”

Larry Barmat, MD, one of the center’s fertility partners, says, “Reproductive medicine is almost tailored to the ASC environment because the procedures are of short duration and low risk, thereby lending them to being done in an outpatient setting.”

Chairman of the board Robert Mannherz, MD, says, “The addition of reproductive medicine has been positive for the center on several levels. It has increased the utilization of the center and our cash flow, as well as diversified our services to patients.”

By Caleb Germany, Foundation Surgery Affiliates www.foundationsurgery.com800.783.0404

Reimbursement and Billing Compliance Issues

A full financial, business office and clinical evaluation was performed by Surgery Consultants of America (SCA) and Serbin Surgery Center Billing (SCB); however, this case study is reporting only reimbursement and billing compliance issues. The initial findings were determined during the evaluation. The current improvements are results obtained after twelve months of reimbursement management by SCB.

The Medicare-certified, multi-specialty center was open 18 months, has two ORs and performs an average of 100 cases per month; the physician-owned clinic shared the same site with the ASC. The challenges were as follows:

» Practice software not meeting all ASC needs

» Billing outsourced to clinic billing staff resulting in:

•overwhelming volume

•increase in errors due to lack of ASC billing knowledge

» Revenue stream reduced to trickle

» Days in A/R escalating – 97 at time of evaluation

» Claim backlog growing – minimum 7 to 10 days lag time between services rendered and subsequent posting and billing

» Denial rate climbing – 20 percent to 25 percent first time denial rate

» Cost of staffing and supplies as a percentage of revenue continuing to increase because of claim backlog

» Non-compliance concerns mounting

Our findings and recommendations were as follows:

Processes

» Using practice software

» Recommend acquiring ASC software

» No CMS list of ASC covered services or matrix of insurance contracts

» Recommend providing both to scheduler and insurance verifier

» No up-front collections

» Recommend notifying patient of financial responsibility before DOS

Reimbursement

» Billing not up-to-date

» Recommend hiring additional staff or outsourcing

» Coding inaccuracies identified

» Recommend coding audit by certified coder – rebill where necessary

» Not following up on submitted claims

» Recommend audit to determine timely filing, refunds, resubmission claims

Compliance

» Receptionist making patient contact calls

» Recommend moving these calls to back desk for HIPAA reasons

» No notification to payor of out-of-network status

» Recommend notifying payor at time of verification and again at billing

» No advance notification of financial policy to patient

» Recommend providing written policy prior to DOS via phone or brochure

Our evaluation resulted in the following changes:

» Appointed separate ASC administrator

» Changed to ASC software

» Revised fee schedule

» Acquired copies of payor contracts

» Initiated use of bank lockbox

» Created new insurance verification position

» Established process to collect co-pays

» Developed financial policies to handle self-pay patients, payment plans, financial hardship cases, etc.

» Made changes in business office task responsibilities

Improvements included:

» No billing backlog

» Decrease in days in A/R – 58 percent (97 days to 41 days)

» Increase in average net revenue per case – 14 percent

» Increase in average charge per case – 31 percent

» Meeting billing compliance guidelines

By Caryl A. Serbin, RN, SSN, LHRM SURGERY CONSULTANTS OF AMERICAwww.surgecon.com 888-453-1144

Florida ASC Increases Revenues

Acting as a strategic business partner, NovaMeda dedicates an experienced team of experts to help our ASCs grow and prosper, while assuring the best possible experience and outcomes for both patients and physicians.

We recently increased the revenue of our Florida ASCs by employing a comprehensive managed care strategy. Over the last two years, we have renegotiated contracts with major payors in Florida and increased the value of the contracts by as much as 20 percent. This has equated to an increase in revenue of 5 percent to 10 percent for each of our four ASCs in Florida.

Developing and executing an overall managed care strategy can lead to major revenue enhancement and overall improved financial performance of our ASCs. Our strategy is founded upon the principles of maximizing the revenue of all our managed care contracts, assuring that the ASC is getting paid what it should based on the contract, and monitoring the performance of managed-care contracts to ensure the ASC is realizing projected revenue.

Executing our managed-care strategy begins by reviewing our ASC’s total book of business and managed-care contracts. Using best-of-breed financial models, we assign a value to each contract based on payor case/mix and market dynamics, and then negotiate (or renegotiate) each contract to ensure maximum revenue generated for our ASC. An ongoing process, we employ a proactive stance on managed-care contract negotiations to ensure the profitability of our ASCs.

By Lisa Streit, director of managed care, NovaMed www.novamed.com 888-NOVAMED

Implementation, Cons & More

The Practice Partners in Healthcare (PPH) team met with the physicians and began to plan for the implementation of the single-specialty center. During the planning process PPH reviewed volumes, expenses and thresholds in the CON. It was determined that additional surgeons would be necessary to make the center successful. PPH began to recruit additional surgeons to the project. To recruit physicians it was necessary to modify the operating and partnership agreements to make the arrangement fair for all physicians and not have the initial group control the project. PPH negotiated with the groups for a successful operating agreement and partnership arrangement to allow the entry of new physicians.

The ability of a third party to develop an independent plan, negotiate and execute is necessary to assure the original group and joining physicians that the best plan for the total partnership is presented. During the negotiations it was clear that the groups combining were fierce competitors and the role of PPH was to make fair and strategic decisions that would demonstrate to both groups the combined strength in the ASC setting but allowing the market forces to continue in the practice setting. Furthermore, the individuals had to work together to develop block time schedules and utilization of the center that would present the most favorable results. In doing so PPH developed a block time schedule that interfaced with both practices clinic schedule and inpatient surgical schedules. PPH developed a strategy and schedule designed for each group’s physician to follow block time by that same group. In doing so the potential conflicts of another group adding on patients and extending the operative day would only affect that group and not the competitor.

When administrators are considering modifying of implementing block time considerations on the impact of running over to other physician block time may reduce issues by this practice. The physicians could then work within their individual groups to correct reoccurring situations. Additionally, when administrators are planning for block time the utilization of historical operative or procedure times should be utilized when evaluating the duration of the individual block to allow for the anticipated daily throughput for each surgeon.

By Larry Taylor, president and CEO, Practice Partners in Healthcare, Incwww.practicepartners.org 205.824.6250

Joint Venture Feasibility

In early 2005, Alegent Health engaged Health Inventures (HI) to perform a feasibility study for joint-venturing (JV) outpatient surgery services with physicians at their Lakeside and Bergan Mercy Medical Center campuses in Omaha, Neb. HI conducted extensive physician interviews to educate physicians about the JV process and gauge interest. Based on positive feedback from the interviews and HI’s financial forecasts, it was determined that a JV was feasible.

The degree of physician interest showed enough case volume to occupy two new facilities. However, HI determined the most immediate opportunity to establish a JV was to convert an existing two OR HOPD to a free-standing ASC in a medical office building (MOB) on the Lakeside Campus. The conversion process included obtaining licensure and certification to operate as an ASC. This facility would operate for 18 months while a new facility with four ORs and one procedure room was built in the same building.

Throughout 2005, a steering committee with representatives from HI, Alegent Health, interested physician groups and legal counsel met regularly to determine the terms of the operating agreement and the governance structure of the JV. Meanwhile, valuation firm performed a third-party valuation of the existing ASC. Based on financial projections and this valuation, HI and deal counsel developed a private placement memorandum (PPM) and subscription agreement and opened the “offering” for physician investment.

The offering closed in December 2005. Two major surgeon groups and 19 individual physicians invested in the facility for a total of 31 physician users/owners. Alegent maintains 51 percent ownership in the new LLC that leases operating space from Alegent in the MOB.

The owners appointed a management board (MB) and clinical operations committee (COC) as the principal decision making authorities. The MB has equal physician/Alegent representation and the COC is physician-controlled.

In September 2007, the physician owners moved their cases from the upstairs ASC to the newly constructed facility on the ground floor of the MOB. The high subscription rate of the offering and cash flow from the existing facility provided adequate funding for the construction without any term debt financing. Only a line of credit was needed when the facility opened.

By Catherine A. Martin, contract manager, Health Inventures, LLCwww.healthinventures.com 877.304.8940

Compiled by Jessica Barreras

ORs of Tomorrow Can Yield Pay-offs Today

The operating room (OR) of the future is closer than many facilities think. While the level of sophistication in equipment and technology depends upon a facility’s budget and ability to retrofit to accommodate exciting new developments in OR modalities, facilities should be aware of the changing dynamics of OR design and planning.

The challenges of efficient and effective surgical planning are numerous, according to Charles Martin, AIA, and Lynne Shira, RN, BSN, both principals with the Seattle architecture firm NBBJ, who were part of the Designing High-Performance ORs, a day-long symposium presented by STERIS Corporation last October. Martin and Shira explain that owners/operators of medical facilities must find a way to juggle their increasing equipment needs, technology demands and compatibility issues. They see an upward trend among healthcare facilities in the overall demand for additional space to grow their surgical service lines, including new ORs, procedure rooms and the requisite spaces needed to support these new rooms. Today’s facilities require much greater flexibility in the infrastructure and its operational capacity to accommodate more integrated systems both in and out of the OR. Not only can this flexibility create an environment to better foster staff recruitment and retention, Martin and Shira say, but it can improve the patient experience.

The size of ORs has been increasing over time, with the OR of yesterday being about 400 to 500 square feet, with a total department space of about 2,000 square feet. The OR of today and tomorrow is now an average of 600 to 800 square feet, with a total departmental space between 3,200 and 4,500 square feet. The reason for this expansion can differ greatly from facility to facility, but many institutions are creating hybrid ORs that encompass and integrate surgical and interventional services, imaging and clinical services. This kind of OR can accommodate multiple care-delivery models and new technologies, as well as support clinical and administrative uses.

Fred Bentley, practice manager for syndicated research at the Advisory Board Co., says that ORs have been invaded by numerous “space-eating” technologies, such as PACS, C-arms, endoscopic towers, robotics and inter-operative MRIs. The space around the operating table has become increasingly cramped; an OR of 300 cubic feet frequently must accommodate about 115 cubic feet of surgical and anesthesia personnel and about 150 cubic feet of equipment, leaving just about 35 cubic feet of free space. It can be a struggle for facilities to balance comfort and efficiency, Bentley adds, that an OR of less than 400 square feet is now considered to be an anachronism because of its cramped, inflexible space; the 500-square-foot OR is now a tight fit; and an OR with more than 800 square feet is probably an over-indulgence and has the potential for too much dead space. The sweet spot, Bentley says, is an OR of about 600 to 650 square feet, which has enough space to accommodate equipment, but facilitates enough unimpeded circulation throughout the room. To cope with smaller ORs that cannot be immediately retrofitted, some facilities are opting to move some bulkier pieces of equipment out of the OR, such as a mobile C-arm that can stored in a corridor alcove or an adjacent equipment closet, or using utility booms to get equipment lifted off of the floor. Other facilities are opting for more streamlined integrated interventional suites that come turn-key from manufacturers such as STERIS.

A hybrid OR is quickly becoming a favorite option for some facilities wishing to make better use of their OR space. Neurological surgeon Jeffrey Yablon, MD, of the Lake Norman Regional Medical Center in Mooresville, N.C., defines a hybrid OR as “an actual operating room located within the surgical suite that accommodates uncompromised interventional, open and minimally invasive surgery within a given specialty.” Yablon says that a number of trends are driving the hybrid OR craze, especially recent technological advancements and specialists’ desire to expand their sphere of expertise amidst competing services. Another driver is the limited space with which many facilities must contend; Yablon says a hybrid OR can be used for several services or procedures and will provide maximum utilization of space. Yablon also cites increased competition for procedural services, with cardiothoracic moving into interventional cardiology, interventional radiology moving into vascular surgery and interventional cardiology moving into interventional radiology. Another factor is tighter reimbursement; Yablon says a hybrid OR’s flexibility will allow for this space to be fully used with a continual stream of reimbursement dollars. He adds that increased readiness and flexibility results in fewer complications and better outcomes, which ultimately achieves lower costs and higher profit margins.

Hybrid ORs are a win-win situation for surgeons, Yablon says, because they allow for improved patient care because of integrated technologies, and because they provide room flexibility and improved workflow. Nursing staff members like these ORs because they improve staff productivity, workflow and ergonomics, as well as improve room utilization and reduce scheduling challenges. And administrators like them because they help to retain surgeons and nurses as well as optimize capital monies. Yablon adds that hybrid ORs are not without their challenges – including costs, simultaneous competition for the room’s unique resources among surgeons and the need for continual future upgrades – but says the advantages frequently outweigh the challenges.

One healthcare system that has moved boldly into the OR of the future by embracing cutting-edge technology is the Carondelet Health Network in Tucson, Ariz., whose hybrid ORs boast the BrainSUITE iCT, a dual-room intraoperative large-bore, multi-slice CT with sliding-gantry from BrainLAB. Neurosurgeon Eric Sipos, MD, FACS, medical director of the Carondelet Neurological Institute, says the advantages of a two-room CT scanner system include the minimized disruption of the familiar surgical workflow with a maximized CT scanning range providing the widest range of patient positioning. The surgical table position for scanning can be stored prior to draping to avoid collisions with scanner, and once positioned for surgery, the patient is not moved, especially outside of the sterile air field; the anesthesia is fixed and constant throughout the surgical and imaging procedures. With a sliding gantry moving between two ORs, there might be the opportunity for cross-contamination, but Sipos emphasizes that the preservation of the sterile environment is achieved and the patient in the adjacent OR is not compromised in any way. Carl Colombi, technical consultant with the Integrated OR Solutions (iORS) Division of BrainLAB, says the BrainSUITE fully integrated intraoperative CT surgical operating room can facilitate surgical planning and navigation, as well as achieve data management and coordinated equipment integration.

While this level of technology might be reserved for the larger health systems, ASCs shouldn’t count themselves out of the technology game nor assume they cannot replicate a hybrid OR set-up. “Over the years, we have seen more and more surgical cases migrate to the outpatient environment, primarily due to the advances in anesthetic agents and minimally invasive technologies,” Shira says. “Our previous thinking that an outpatient surgery is for ‘minor’ surgical procedures simply doesn’t hold true any longer. The equipment and technology required for minimally invasive work demands a surgical footprint and boom configurations that are not unlike the inpatient environment. ASCs that want to plan for this technology in the future need to remember this as they are planning.” Shira continues, “Recognizing that ASCs are held to a different building standard than hospitals, there should still be planning for proper air exchanges, good surgical traffic patterns with non-restricted, semi-restricted and restricted zones understood with the design. And of course, there can be no compromise on safety protocols and cleaning protocols regardless of the location of the surgical environment.”

Martin and Shira emphasize that the numerous rapid advances in imaging technology are dictating some OR planning and design elements, and note that many imaging interventions are transitioning from diagnostic to therapeutic, thus blurring the boundaries between imaging and surgery. The goal of many facilities is to integrate these departments into a single service with common support in terms of supplies, equipment and staff. If designed correctly, this concept also can eliminate the all-too-common duplication of pre- and post-operative functions, as well as eliminate the duplication of space, equipment and supply storage. Martin and Shira add that integration of staff with similar skill sets can greatly improve operational efficiencies. The integration concept also can apply to universal procedure rooms that specialists can share, as well as universal prep and recovery areas that can accommodate varying patient volumes throughout the day, as well as minimize patient transfers and reduce the number of supply-distribution points.

While we have seen how the physicality of the OR is evolving for the future, it’s important to note that healthcare professionals are following suit. Bentley points to the trend of surgeons and interventionalists becoming one and the same in the future; in the past, these two groups have performed distinct classes of procedures, while in the present, some surgeons are learning select interventional techniques. In the OR of the future, it may be no surprise to see surgeons familiar with nearly all major interventional procedures and perform them frequently; there may also be the rise of the multi-purpose proceduralist. Bentley says these proceduralists can be co-located on the same floor of a facility, or they can even be housed in the same suite, functioning in what Bentley calls a “multi-purpose sandbox” to accommodate all kinds of disciplines.

No next-generation OR can be planned and executed without buy-in from all stakeholders during the project planning and management process, including surgeons and clinical personnel, administration, the architect, the engineer, the IT department and key vendors, according to collaborators Chris Kantorak, technical consulting manager with BrainLAB, Inc., Brian Hartman, project design manager with STERIS Corporation, and Paul Niehaus, project manager with Philips Healthcare. They say that advanced OR suites require space for technology, personnel and ancillary equipment, and that design input from all user groups must be obtained to ensure an optimal environment for all. More specifically in terms of roles among stakeholders, the architect is responsible for evaluating trends such as fixed-based imaging versus mobile imaging, and OR integration; providing for the expansion to a larger OR footprint ; and understanding the changes in sterility needs when going from an imaging suite to a flexible hybrid OR suite, for example. They must also design into the OR future flexibility, such as empty conduits for information/video routing, blank structural plates and positions to accommodate new equipment in the future. To this end, the equipment manufacturer can help plan for the support of new technologies as they are added. In turn, the vendor plays a key role by helping to maximize functionality and the placement of multiple technologies, offering design expertise with proper sequencing of design needs, and planning for both existing and future technologies or evolving clinical procedures.

IOL Master 500

What is the fastest and easy way to find the right IOL?  Simply speaking, the IOL Master 500.  The all in one biometer created by Carl Zeiss Meditec (headquartered in Jena, Germany) is the world’s first non contact measuring device that offers the precision measurements surgeons require to give their patients the quality outcomes they deserve.  In 2006, the IOL Master was recognized by ASCRS as a leader in precision biometry.  A 2005 survey conducted by ASCRS showed that 47 percent of cataract surgeons in the United States were using the IOL Master for measuring axial length.  Since 06’, Carl Zeiss Meditec has continued to dominate the area of biometry and the IOL Master 500 is the latest technology leading them into the future.

Using the Zeiss principles of precision, simplicity and outcomes, the IOL Master 500 is again a complete comprehensive workstation designed to aid in the efficiency of a busy clinical atmosphere.  Equipped with a new Twin Technology mode, the IOL Master 500 will allow for multiple axial lengths and keratometry readings to automatically be captured.  The IOL Master 500 has also been integrated to handle any of the aspheric, multi-focal, or toric measurements and their necessary calculations as well.  IOL calculations are simply done and the reports are easily transmitted to the surgeons desired electronic storage locations or can be printed for paper copies.  Equipped with FORUM, Zeiss data management solution, the IOL Master 500 can provide diagnostic data wherever it is needed.  It also integrates with the CALLISTO eye, and electronic medical records as well.

The IOL Master 500 is fundamentally the “Gold Standard” for IOL calculations.  Carl Zeiss Medical has revolutionized the field of ophthalmic biometry and created a diagnostic tool that benefits all of the surgeons that choose to take advantage of this technology.  As IOLs evolve, the IOL Master will continue to provide the quality and reliable data that surgeons expect.  For further detailed online information, please visit www.meditec.zeiss.com/iolmaster and www.iolmaster-online.zeiss.com

OR Technology: A Glimpse Into The Future

As we move into 2010, a new wave of technology awaits us. Highly-developed health information technology (HIT)-driven systems and equipment are becoming the standard in many operating rooms (ORs), whether they are in a single-specialty ambulatory surgery centers (ASCs) or advanced surgical hospitals. It is important to stay up-to-date on these new technologies which not only reduce medical errors, but improve patient comfort and post discharge follow-up. The following case studies highlight this trend.

Enhancing Communication, Collaboration and Education: An Olympus Case Study

Three years after adopting integrated ENDOALPHA ORs, Penn State Hershey Medical Center is ready for more. As the only teaching hospital in central Pennsylvania, Penn State Milton S. Hershey Medical Center is one of the area’s largest healthcare providers. The hospital is equipped with 23 surgical suites and its department of surgery performs more than 19,000 procedures annually.

Staying Ahead of the Technology Curve

As industry trends move toward minimally invasive techniques, the hospital was quick to understand the benefits of integrated surgical suites as a way to stay competitive with the specialized technology demands of increasingly sophisticated procedures. “Several years ago, we realized we had a need for advanced, integrated technologies in our OR as we anticipated the convergence of laparoscopic and flexible endoscopic instrumentation,” says Randy Haluck, MD, professor of surgery and division chief for minimally invasive surgery and bariatrics. “We also recognized the need for a sophisticated system relative to data acquisition, storage, and transfer.”

Penn State Hershey began the process of integration in 2005, building three new Olympus ENDOALPHA surgical suites in 2006 and then converting two existing ORs to ENDOALPHAs the following year. The hospital anticipates completion of four more integrated ORs, for a total of 27 surgical rooms with one-third of them set up as state-of-the-art ENDOALPHAs this year.

Taking a Comprehensive Approach

True systems integration goes beyond the equipment and operating platform. It also takes into account the ergonomic design, workflow and technology optimization of each surgical suite. This means designing rooms with ceiling-mounted booms for holding imaging equipment and monitors off the floor, allowing for more efficient post-procedure clean-up and ergonomic positioning of monitors during the procedure. It means integrated equipment (scopes, imaging platforms, monitors, video and accessories) that work together and can be easily interchanged during a procedure. And it means a cohesive information management system for patient and procedural data, images, and audio that can be captured, stored, and retrieved from both inside and outside the sterile field. “We needed to have multiple surgical services using the same operating room, between general surgery, urology and minimally invasive GYN surgery,” says Gerald Harkins, MD, medical director for minimally invasive GYN surgery. “We’re all able to function in the ENDOALPHA laparoscopic suites, and it’s been a fantastic platform for that utilization.”

Experiencing the Installation Process

Olympus offers turnkey solutions, working with customers from start to finish on the design, construction and set-up of integrated operating and intervention rooms. “The flexibility of Olympus’ ENDOALPHA system means it can be easily customized to create a right-sized solution unique to each facility,” says David Alexander, Penn State Hershey’s Olympus integration consultant. “We were able to incorporate their legacy equipment along with their pre-existing video-conferencing system and streaming video package into their ENDOALPHA ORs to create one seamless solution. Hershey proved to be very knowledgeable, so it was a highly collaborative effort.”

Taking Centralized Control

The nerve center for each ENDOALPHA OR is a centralized control panel. With audio, video, data and images all controlled via a single touch screen, clinicians have the power to connect, communicate and collaborate with others outside the procedure room. Clinicians can also control surgical and room lighting, in-room observation cameras and all information and imaging systems without ever leaving the sterile field. To further enhance efficiency, the ENDOALPHA system provides preset capabilities so that monitors, lighting and all equipment can be custom-tailored to surgeon preferences and made available at the press of a button.

Communication, Collaboration, and Education

Penn State Hershey Medical Center’s custom-placed displays ensure all team members have the perfect view of live images. They regularly create video networks for sharing, collaboration and education from within and outside the hospital. “There’s no question that the Olympus system has dramatically changed how we teach in the OR,” says Peter Dillon, MD, chairman of Penn State Hershey’s surgery department and surgical director of perioperative services. “We’re now able to broadcast these procedures to first- and second-year medical students, exciting them about the wonders of surgery at a much earlier stage in their training. So it really has changed dramatically and in a very exciting fashion how we teach.” Haluck adds that it also gives the Penn State Hershey team a better way to collaborate with other physicians and share information with patients. “We can educate other physicians and record images for colleagues or bring them in when needed to confer and/or assist on a procedure. We are also able to show patients what their surgery was about and why they were having problems. That’s a great benefit to us, and certainly patients appreciate it as well.”

Interventional Radiology Breaks New Ground: A Skytron Case Study

Philips and Skytron have teamed up to help fully realize the promise of a hybrid angiography suite by implementing new cardiovascular solutions with the latest Allura Xper FD technology from Philips and state-of-the-art surgical lighting and boom technology from Skytron.

For more than a decade, Barry T. Katzen, MD, medical director of Baptist Cardiac and Vascular Institute (BCVI) in Miami, has pioneered the integration of surgical and interventional procedures. Katzen and his team continue to show that surgical procedures in an angiographic environment can be accomplished with the same degree of efficiency as in an OR.

“The specialties of interventional radiology and vascular surgery bring more to each other when we work together,” Katzen says. “Procedures that help drive this relationship include aneurysms of the thoracic aorta and abdominal aorta. Having an environment where we can use a surgical option allows us to think out of the box for individualized patient solutions.”

In 2008, Philips Healthcare and Skytron entered into a collaborative agreement to provide comprehensive, integrated solutions for the cardiovascular environment. Katzen seized the opportunity to refine the surroundings. Based on a well-coordinated plan from Philips and Skytron, a room at BCVI underwent a significant upgrade to enhance hybrid functionality.

“One of the great advantages of the new room design is it’s so spacious that we can all function effectively without being in each other’s way. Information can be transferred to the head of the bed — to the anesthesiologist — down to where we’re working very easily,” says James F. Benenati, MD, medical director of the peripheral vascular laboratory.

A Room That Works

BCVI’s surgical team appreciates the changes made. Katzen believes the upgrade has created a better environment for all involved. A recent experience demonstrated how the teams successfully combined surgical access with an interventional solution. A patient presented with critical narrowing of an artery to the brain and chest, and a narrowing of that same artery in the neck. “It was a very complex situation,” recalls Katzen, “but we combined our skills. The surgeons removed the plaque in the neck with an endarterectomy and we used that same access to go down and stent the chest.”

Installation With Minimal Impact

“We’re a busy lab and taking a room down for a period of time is always an inconvenience,” says Katzen. “The one thing everybody remarked upon was how fast this upgrade was accomplished.” In two and a half weeks, Philips and Skytron, working closely with the implementation team at BCVI, completed the staging and upgrade. The new room reflected the input of interventional radiologists, surgeons and anesthesiologists, with each group helping to define the clinical specifications to make it a multi-disciplinary environment.

OR Technology Update: A Steris Case Study

The epitome of surgical technology today is one OR in which surgeons can perform image-guided, catheter-based interventional procedures; minimally invasive endoscopic procedures; extremely precise robotic surgery; or full open surgery, depending on the case load or discoveries made in surgery. In this type of hybrid OR, integrated imaging, computerized patient information and live video routing technologies instantly display test results and critical real-time information on high-definition monitors in the sterile field. This allows surgeons and staff to ascertain the most timely and accurate diagnosis and treatment for the patient. It also helps them achieve the most flexible and effective uses of the room and optimize scheduling and utilization.

These are also the types of rooms in which medical leaders and pioneers train residents and other clinicians, develop new minimally invasive procedures, such as natural orifice trans-luminal endoscopic surgery (NOTES) and trans-catheter heart valve replacement and master new surgical devices.

These highly advanced rooms can incorporate advanced communications, connectivity, LED surgical lighting and high-definition visualization such as intra-operative fluoroscopy, intra-operative computerized tomography, magnetic resonance imaging, image-guided navigation, 3D software extrapolations of the imaging, robotics and many other technologies. Each of these tools are important in today’s hybrid OR, but when integrated correctly they form a seamless whole that is greater than the sum of its parts.

To accomplish this synergy, STERIS collaborates with leading manufacturers to design and install customized, integrated HD360°™ Hybrid ORs for healthcare facilities. STERIS project design managers configure STERIS’s open infrastructure Harmony® Lighting and Visualization systems, equipment management systems and advanced integration technologies with interoperative imaging, robotics, endoscopic and video technologies and more. The result is a suite that enables fully informed staff, highly efficient procedures, extremely flexible room use, successful surgeon recruitment, medical education, ongoing surgical innovation, leading edge robotic surgery, telemedicine, and new possibilities yet to be imagined.

OR Technology Update: A Berchtold Case Study

Problem

Before hybrid ORs existed, imaging and communications capabilities were not an option during cardiovascular and neurosurgery operations, resulting in patients getting diagnosed and treated in two different visits. Separate procedures and imaging consultation can be costlier for patients and surgeons, can result in additional stress, more down time and longer hospital stays for the patient, and are not conducive to emergencies that sometimes arise during surgery.

Solution

Combine minimally invasive and interventional surgical technologies with medical imaging and communications equipment in one operating room: the hybrid OR.

A growing trend involving endovascular procedures during cardiovascular and neurological surgeries requires equipment to accommodate open and closed procedures in the same room, even at the same time, although this is not necessarily planned from the start. The new hybrid OR model provides the surgeon flexibility in performing a variety of interventional, imaging and surgical services in one setting, eliminating the need to transfer the patient.

For example, two of the most popular hybrid ORs are for cardiovascular and neurosurgical procedures:

» Neurosurgical hybrid ORs can include magnetic resonance imaging (MRI); computed tomography (CT) and angiography equipment within a neurosurgical operating room.

»Cardiovascular hybrid ORs often features: Fixed ceiling- or floor-mounted C-arms, ultrasound and endoscopy equipment, coupled with cardiac catheter laboratories.

Because a hybrid OR is specifically designed for endovascular procedures, careful planning from the beginning can help to ensure all rooms are equipped with necessary tools. Some tips to consider while creating a specially designed hybrid OR include:

»Identify factors that are important to the hospital team, such as, should all equipment hanging from the ceiling (surgical arms, flat panel arms, etc.) be able to cover the whole patient in all orientations?

»Think as far ahead as you possibly can to “future proof” the room, reducing the need to renovate the OR moving forward. For example, what is the most extreme type of procedure the team might do in the OR? Then outfit the room in preparation for the procedure.

»Involve the end user at the very start of the project to give a real world perspective for offering scenarios, as well as discussing needs and concerns. This can include nurses, surgical technicians and staff, as well as anesthesiologists.

»Consult with the vendor providing lights, booms and imaging equipment to accommodate all of their needs. For example, many imaging companies have different requirements for ceiling heights.

Hybrid therapies enable hospitals and clinicians to provide less invasive care that is safe and cost-effective for the patient. Careful planning can lead to an effective hybrid operating room design that offers the following benefits:

» Cost-effective operations for patients and surgeons, with better outcomes.

» Reduced stress, faster recovery and reduced hospital stays for the patient.

»Safer procedures, especially in the case of an emergency.

New Bair Paws® Gown Brings “Flex Appeal” to Patient Warming: An Arizant Case Study

The recent Centers for Medicare and Medicaid Services (CMS) adoption of the SCIP-Infection-10 normothermia quality measure has made it more important than ever to simplify the process of warming every surgical patient. Arizant Healthcare’s latest innovation in forced-air warming, the Bair Paws Flex gown, does just that by incorporating a surgical warming product — Bair Hugger blankets — into a comfortable patient gown that warms before, during and after surgery.

While clinical versatility is a key benefit of the Bair Paws Flex gown, so is the practical economic approach of standardizing multiple warming capabilities into one gown that can accommodate most perioperative warming needs. While helping to improve outcomes and boosting patient satisfaction, the Bair Paws Flex gown may save facilities money by supplanting multiple OR warming blankets and the warmed cotton blankets and gowns often used to comfort patients.

Just One Gown Warms From Start to Finish

Before surgery, patients appreciate the Flex gown for its controllable warmth; they can simply dial the temperature of the air flowing through the gown to a level that’s comfortable. The surgical warming products built into the gown are unknown to the patient because they are deployed only by surgical staff.

In the operating room, the same Bair Paws Flex gown offers clinicians the ease and convenience of having multiple patient warming options available during surgery. Seamlessly integrated into the gown are: a head drape, adhesive tape to isolate the surgical field, and deployable arm extensions to transition into a Bair Hugger upper body blanket with tie strips. A second insert in the lower portion of the gown may be used to prewarm before surgery and then warm again as a lower body blanket once in the OR. The gown’s design allows upper or lower body warming for any surgical positioning — supine, prone or lateral.

After the procedure is over, the upper body blanket arm extensions, head drape and surgical tape strip perforate off, returning the garment to a standard warming gown for post-operative use through the lower warming blanket insert.

The Bair Paws Flex gown is comfortable for patients, convenient for clinicians and warms from pre-op to the OR to PACU. Best of all, it’s also economical. One gown handles almost all your warming needs, including contributing to quality goals like SCIP-10 and improved patient satisfaction. It incorporates a highly effective surgical warming device directly into a soft, comfortable hospital gown that does something positive for patients and hospital staff. It’s not just a gown. The Bair Paws Flex gown is a patient warming and patient satisfaction tool. It’s the future of patient warming, and it’s available today.

Practicing Arthroscopic Surgery on Computers, Not People: A Toltech/Sensable Case Study

Learning diagnostic knee arthroscopy is not unlike learning to play the violin — both art forms require a mixture of cognitive and proprioceptive skills that can only be developed through rigorous practice. And while both require intensive mentoring, surgical apprenticeship is unique in its resulting increase in operating room time and potentially patient risk. Just as with a violin that makes no sound, little can be learned from surrogate surgical environments having no objective feedback, including costly and labor-intensive cadaver training. And little transference of either skill can be expected from computer based training lacking the feel of the instrument(s).

In late 2009 the University of Michigan Medical Center’s Orthopaedic Surgery department, led by James Carpenter, MD, became an early adopter of the Knee Arthroscopy Surgery Trainer (KAST) from Touch of Life Technologies (ToLTech). This simulator was co-developed with the American Academy of Orthopaedic Surgeons (AAOS), Arthroscopy Association of North America (AANA), and the American Board of Orthopaedic Surgery (ABOS). It provides both cognitive and haptically-enabled skills training for the proper and efficient techniques required for diagnostic arthroscopy of the knee as done on an outpatient basis — including training to competency, and a modality for complete evaluation of residents’ skills.

In the KAST simulator, trainees hold a customized stylus in each hand — emulating the probe and camera used in actual surgery — that are attached to PHANTOM® force-feedback haptic devices, made by SensAble Technologies. The haptic devices allow trainees to navigate in true 3D space while interacting with high-resolution models that are viewed on-screen, as if through an actual arthroscope. The force feedback devices are programmed to push back on the user’s hand to deliver the “feeling” of the soft tissue, cartilage, and ligaments involved in knee arthroscopy.

The “Virtual Mentor” in KAST guides, critiques, and scores the resident on each part of the procedure. In one module, trainees must perform three steps for examining the medial meniscus with a probe. The Mentor requires the trainee to score 100 percent on each step before attempting subsequent tasks, and finally a time-trial. A special “cheater view,” only available at the novice level, shows the outside image of the knee (seen in the right hand portion of the Mentor screen), to help residents understand where the tools they are using are located with respect to the anatomy. KAST switches seamlessly between a right and a left knee, forcing the trainee to be ambidextrous with respect to the camera and probe.

Haptically-enabled surgical simulation provides cognitive and skills-based training — freeing up the outpatient facility’s attending physicians to teach higher-level skills, and giving residents unlimited autonomous practice opportunities. It allows residents’ skills to be objectively measured and validated before they undertake procedures on patients. The University of Michigan Health System’s Orthopaedic Surgery department plans trials comparing beginning residents who have trained on KAST, against a control group. Separate validation studies led by the AAOS using KAST are underway nationwide during 2010.

Ambulatory Surgery Center Outlook for 2010

With 2009 closed, the preparation for a successful 2010 is here. Most centers have considered the trends and utilization by surgeons and begun the budgeting process to establish goals and objectives for 2010. When setting those goals, the greatest factor for existing centers is capturing the appropriate cases from prior utilizers and recruiting new cases from surgeons seeking the efficiency of an ambulatory surgery center (ASC). Management team members need to assess their individual challenges at their center and work to contain cost, improve production and eliminate waste. Similarly, physician partners need to assess their role in the center in assisting the cost control, reviewing data on cost, preference items and consider case adoption when appropriate.

For centers under development or under consideration, team members should be recasting projections, timelines and fully understanding the progression from planning to operations making assurances that the plan reflects today’s environment. As the economy continues to remain slower than anticipated, the economic downturn results in the need for all members of the partnership to personally guarantee loans, there is additional scrutiny of the deal points, terms are aggressive and the process is slower than in past history.

In general, 2010 has many positive aspects to consider. From an operational aspect the decrease in professional fees result in surgeons seeking an ambulatory setting for partnership as well as the need for efficiencies to impact their total practice. The investment in an ASC is often a great stabilizer to a physician base attempting to control their surgical environment and production. An ASC could be formed easily around a smaller core group of physicians to assist in attaining their goals. As with any partnership, the greater affinity for the groups’ cohesiveness the greater focus on core principles and alignment.

As hospitals continue to have pressures and cuts in personnel, the ASC environment can recruit registered nurses and surgical techs more easily by bringing quality offerings with less pressure on elevated salaries. This will allow ASCs the ability to recruit and retain talented employees and bring value to those employees seeking part-time and PRN work schedule. The ASC setting can be of great value to registered nurses, as the flexibility of part-time and PRN work can fill current needs of local resources. Surgeons will continue to seek potential avenues for an ASC and hospitals may consider expanding the potential for joint-venture opportunities. A counter measure by hospitals may be to employ specialists and reducing the potential for surgical intervention outside the hospital catchment entities. This could reduce the availability of specialists needed to expand or develop existing or future ASCs.

Currently, building and labor costs are lower due to the economic pressures and the need for contractors to keep crews active, resulting in lower costs and rental rates. This is a critical point for existing center remodeling and expansion allowing for tired assets to be updated and keep pace in the local standard of care. Additionally, the start-up facility has the opportunity to increase margin by lower cost space and lower lease rates as the entire construction cost is decreased. This drives great value, as the fixed cost is often over a longer time frame and the savings great over the life of the lease. Additionally, the availability of new, used and refurbished equipment remains of value with the current pressures on companies to move existing equipment and reduce inventory in all categories. Equipment and surgical instrumentation companies are increasing the ability to provide valuable terms and payment methods to meet centers needs.

Reimbursement is always a challenge in any healthcare entity. In the ASC industry the negotiation of contracts and details that must be included in each negotiation is critical to the success of a center. Each year, a careful evaluation of the centers managed care contracts, covered codes, multiple procedures, carve-outs and implant reimbursement must be reviewed and negotiated. Beyond the contracting, the appropriate billing and collections- to-contract standards must be complied to receive each dollar on every case. As the consolidation of payors continues and contract language becomes more complex, it is essential that your team has the appropriate resources to grow net revenues. The collection of co-pay and deductibles must also be conducted in a proactive manner. Each patient must be notified of the expectations at time- of-service and associated costs of the surgical encounter. The evaluation of in and out-of-network must be weighed, justified and aligned with each state’s regulatory guidelines. As the co-pay and deductible becomes more burdensome on the population, the potential for the delay in elective cases being scheduled timely may occur.

As the healthcare debate continues, ASCs continue to be the lower-cost environment to assist in keeping healthcare costs from climbing into the future. Assuring the right case for the right environment is often an indicator that is overlooked in an ASC. Having partners understand the appropriate case type, acuity, co-morbidities and implant reimbursement is key to assisting in the profitability of cases. ASC management teams must communicate trends and encourage participation in the process allowing all employees become knowledgeable in the aggregate center costs. All team members must have the necessary attention to detail, high customer service and clinical excellence required of today’s successful ASC. The center’s management team must proactively manage the center to optimal levels to assure the clinical and financial performance of the center.

At Practice Partners in Healthcare we specialize in de novo and turn-around opportunities, providing a unique development process and management arrangements. Practice Partners is a minority equity holder, leaving the majority to physicians and hospital partners. We bring success-proven management expertise to the clinical, financial and regulatory performance of new and existing surgery centers. Experienced in both CON and non-CON states our team provides seasoned talent for developing and managing physician-owned and hospital-physician joint ventured surgery centers.

Larry Taylor is president and CEO of Practice Partners in Healthcare, Inc.

 

Are Physicians Political Animals at Heart?

Traditionally, medical schools do not instruct physicians on how to be a politician, nor do they adequately equip them with the tools they need to fend off attackers of their industry, especially if they are in ambulatory surgery. In a recent study, medical researchers asked, to what extent are physicians civic-minded, and do they have a responsibility to advocate for their community? The answer, according to physicians themselves, is yes.

This Commonwealth Fund-supported study found that nearly all of the 1,600-plus physician respondents believe they should play public roles, and two-thirds are actively involved in community activities, political work or advocacy.* More than 90 percent of respondents said that political involvement and advocacy were important roles for physicians. According to the researchers, anesthesiologists and surgeons were significantly more likely to rate political involvement as being very important than were other physicians. The study found that two-thirds of physicians had participated in some type of community, political or advocacy work in the past three years, with one-quarter taking political action and one-quarter encouraging a professional society to advocate for a particular issue. However, there is one important finding revealed by the study — 28 percent of physicians who identified themselves as civic-minded reported had not taken part in public activities in the previous three years. So you can never really tell how physicians see themselves as political animals and what kind of political activity resonates with them.

Trying to change all of that is a number of groups working diligently to cultivate greater participation in advocacy efforts by physicians in ambulatory surgery centers. Chief among them is the ASC Advocacy Committee, which debuted in August and strives to create a unified voice among ASCs in order to convey the compelling ASC story to lawmakers at state and federal levels. You’ll meet Andrew Hayek, chair of this committee, as well as the New Jersey Association of Ambulatory Surgery Centers and a few other champions of ASCs, as part of our annual legislative and regulatory section in this issue. They want to convince you that if you don’t get involved, your enemy certainly will.

* Reference: Gruen RL, Campbell EG and Blumenthal D. Public Roles of U.S. Physicians: Community Participation, Political Involvement and Collective Advocacy. JAMA. 296(20):2467-75.Nov. 22, 2006.

Get a Grip: An Overview of Trends in the World of Medical Gloves.

As the increasing concern over infection control continues to dominate discussion among healthcare professionals; many facilities find themselves looking for answers through stringent policy changes dealing with cleaning and sterilization of instrumentation.  A major component of infection control that is often overlooked is the type of gloves that are being used.   Healthcare facilities need to take the time to examine their glove inventory and determine what types of gloves addresses their particular needs and concerns.

When evaluating gloves, one of the most important factors to consider is barrier protection.  It is essential to have a glove that provides excellent barrier protection against blood borne pathogens and infectious diseases.  An inferior quality glove exposes both healthcare workers and the patients they care for to unnecessary risk of infection.  Natural rubber latex gloves have been shown to have the most effective barrier protection, however due to the increased awareness of latex sensitivity/allergies there are a number of other alternatives (such as synthetics and those with a low level of latex proteins) on the market that address those healthcare workers and patients that may have adverse reactions to latex.

According to data reported by the American Latex Allergy Association, somewhere between 3%-22% of healthcare workers are sensitive to natural rubber latex.  Healthcare workers increase their likelihood for latex sensitivity due to the fact that they are more prone to be exposed routinely to latex proteins in their work environment.  A concerning factor in latex sensitivity/allergy to not only healthcare workers but to patients as well is the use of powdered gloves.  The powder allows for the latex to become airborne and inhaled as well.  Latex sensitivity can result in mild skin irritation to as something as serious as anaphylaxis.

Manufacturers have introduced synthetic materials such as nitrile, neoprene, and polyisoprene into the medical glove marketplace that try to mimic the fit, tactile feel, and protection of the traditional latex glove.  Other manufacturers offer low protein latex alternatives as well.  It is estimated that by the year 2015 the global surgical glove market could exceed $1.38 billion in sales, and is also estimated the powder free alternatives will make up a significant portion of those sales.

Other factors that are important when deciding on a glove are tensile strength, durability, comfort, and ease of donning.   Strength of material must be able to stretch and conform to the hands appropriately.  They must have the durability that corresponds to the tasks the staff or surgeon will be completing, be comfortable to wear, and easy to put on as well.

Gloves are a fundamental component in controlling the spread of pathogens, critical in providing the necessary personal protective equipment for facility staff and surgeons, and key to patient safety.  It is important for any healthcare facility to “get a grip” on the glove needs of their staff, surgeons and patients.

Pleasing Your Surgeons

Pleasing the surgeons of your facility needs to be the number one priority for any staff member.  I say this is number one because they are the ones that bring the patient (who is in close competition for being in that number one position).

In our facility our surgeons don’t need a lot of the visible perks to make their day easier and their return quicker.  The belief around here is that they are our number one customer and should be treated as such.

Customers in the retail business expect to be treated in a certain manner.  In the retail business customers return when they are treated with respect, their purchases are treated with care, and their time is treated as being valuable.  This comparison can be seen as the surgeon’s “retail” experience.  Respect is seen when you make them feel welcome each day, let them know that you are here to help them get the job completed efficiently, and that the staff is knowledgeable.  The patient can be seen as the surgeon’s “purchase”.  The patient must be treated with care and concern.  Each patient must feel that they are safe during their visit.  A surgeon is very pleased and proud when his patient says that they would return to the facility if needed.  They know that the staff treated the patient with care.  Time is very valuable to any person.  To get in and out of a business with the items you came for and little time is spent “waiting in line” speaks wonders.  Quick room turnover time speaks wonders for your surgeon!  The surgeon sees this as efficiency and realizes that each staff member is doing their part in making sure that time is treated as valuable.

The surgeons at our facility are seen as our number one customer.  Customers in any business must be treated with respect and know that their time is valuable.  By making these the “perks” to their day they will continue to return.

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.

Next Page »