Five Keys to a Successful ASC
These policies benefit patients, surgeons and staff, while enhancing profitability.
BY JAMES D. SHULER, M.D., F.A.C.S.

To operate a successful ambulatory surgery center (ASC), all patients must receive excellent care and service, the staff must have a high level of job satisfaction, and the surgeons must enjoy the surgical experience. It is also desirable that the business of running the ASC is profitable for the owners.

As the original owner of our ASC, and now an equal partner with an orthopedic surgery group and currently the medical director of the facility, I have found five factors that have been key in keeping our ASC successful over the last 5 years: simplicity, excellence, efficiency, staff retention and cost reduction.

In this article, I will explain why and how these factors are integral to the success of any ASC operation.

Our Facility

To briefly summarize our ASC, it is a one-room center specializing in ophthalmology — primarily cataracts, LASIK and ophthalmic plastics — and orthopedic surgery. The center, which is open 8 to 10 hours per day 5 days a week, performs approximately 2,700 major cases per year plus YAG lasers and some pain management. Our total operating overhead is approximately 40% of revenues. We have one board-certified anesthesiologist who is highly skilled and efficient, and who plays an active role in reducing our turnover time. We have two front-desk employees, one nurse administrator, one full-time nurse, four part-time nurses and two surgical technicians. A full orthopedic day consists of about 10 arthroscopies and a full eye day encompasses 30 or more cataract surgeries. The center is small, less than 1,300 square feet, is certified by Medicare for general anesthesia and is California State certified.

Simplicity is crucial to the success of our ASC. The simpler it is for the patient, from admission to discharge, the better the patient's perception of his or her experience. The simpler the process is, the less likely that mistakes will be made. The fewer instruments used, the less likely they will be damaged and need to be replaced.

We try to minimize the number of steps in the process to only those actions that have a purpose in providing quality care to our patients. Reducing a highly technically advanced phacoemulsification surgery to a few simple questions at check in, a few drops to dilate the pupil and numb the eye, some painless moves by the surgeon during surgery, a couple of drops afterwards and a pair of sunglasses to wear on the way home helps the patient and staff to have an enjoyable experience in the ASC.

Striving for Excellence

Surgical excellence is the foundation of a successful ASC. Each step, from greeting the patient on arrival to walking the patient out to the car upon discharge, must be done without error. Keeping everything as simple as possible helps. But in addition, we ask each patient what type of surgery they are having done, and to which eye. We confirm this with the order and consent form, and then mark the operative eye with a marking pen. This is checked a second time, without the mark, by the preoperative nurse, and a third time by the operative surgeon in the room. The prep is performed by either the surgeon or a registered nurse. The intraoperative complication rate at our center (posterior capsule tear, cornea burn, vitrectomy, zonular dehiscence) is less than 1 in 500 cases. We have no cases of endophthalmitis in more than 5,000 cataract surgeries in our center. A successful ASC must have exceptional staff and excellent surgeons and not tolerate mistakes.

Supporting Efficiency

The beauty of the ASC model is its ability for surgical efficiency. In our center, one surgeon can perform three to four cataract surgeries per hour out of one room, with the help of one scrub tech and one circulating nurse. The patient's drops are started in the waiting room and continued in the pre-op area.

We use the Sovereign Compact with WhiteStar technology (AMO, Santa Ana, Calif.) and reusable tubing for phaco cases. This machine sets up quickly and is user friendly both to the staff and surgeon. The Compact is extremely efficient inside the eye and has power and fluidics every bit as good as the full-size Sovereign, which I also own as my back-up machine. We use 4% topical lidocaine for anesthesia, and sedation is typically 2 mg midazolam hydrochloride (Versed, Roche) and 1 mg fentanyl (Duragesic, Janssen) given by the anesthesiologist at the time the drape is placed over the eye.

We have two cataract surgeons in our center, and both perform the surgery in almost exactly the same way to keep things simple for the staff. Our belief is that the fewer the steps and the less time spent inside the eye, the less likely anything bad will happen.

We perform standard phaco in the following steps:

• diamond blade keratome

• diamond blade second instrument site

• viscoelastic

• capsulorrhexis

• hydrodissection

• phacoemulsification

• irrigation/aspiration

• viscoelastic

• implantation of a one-piece Acrysof IOL injected directly into the bag

• irrigation/aspiration of viscoelastic

• balanced salt solution to reform anterior chamber

• 1 mg intracameral vancomycin

• discharge to recovery for eye drops and vitals.

We use no shield or patch, but the patient is given a pair of protective sunglasses to wear on the way home. The patient walks in, and the patient walks out. It is simple, efficient and successful.

Retaining Skilled Staff

The cost in dollars, time and energy to train staff properly is great, making staff retention another important factor in operating a successful ASC. When the staff can perform demanding jobs while making it look effortless to the patient and surgeon, it reduces the stress within the operating room for both the patient and the surgeon.

Well-trained staff with experience make the fewest mistakes and know how and when to help cover other staff when it is necessary. As one watches the staff during a busy cataract day, it looks like a dance, with each employee performing his or her duties without getting in the way of each other. They have practiced and perfected what they do.

The staff of the ASC is critical to the success of the center. They should feel valued and have a high level of job satisfaction. We pay our staff slightly above the median for our area. We provide lunch to all of our staff members and surgeons. I also give them complimentary Botox, photofacials, hair and vein laser and LASIK, which helps the staff feel better about themselves and translates into better job performance and referrals as patients ask the staff why they all look so young. We also take the staff on a yearly retreat to eliminate any residual stress. The value of such trips goes beyond the trip itself; we experience increased staff productivity due to the 4 months of excitement prior to the trip and the 4 months of talking about the trip to each other afterwards. When staff feel valued and appreciated, it is amazing how hard they will work for you, and how much they will enjoy doing it. But great employees are hard to find, so keep them as part of your team for as long as you can.

Controlling Costs

Although profitability is not as important as quality patient care or the job satisfaction of the staff, it is a major factor in making an ASC successful from an owner's point of view. Remember the basic business rule: assuming that overhead costs approximate 50% of revenue, to obtain each additional dollar of net income one can either earn two dollars or save one dollar.

As surgeons, we can only work so hard, and it often does not take much effort to reduce costs. But never reduce costs at the expense of excellence. Don't take money from your employees, from the quality of instruments and machines or from the service being provided to your patients.

Eliminate the disposables that are not necessary. Each company we deal with has a competitor who would love our business and all companies will negotiate costs. My goal is to always get the best product for the same price as a lesser product, and often we are able to obtain the best product at the lowest cost. Have all the surgeons agree to use one best IOL, and then obtain significant rebates based on high-volume usage. Additionally, using as few vendors as possible makes ordering easier and can help you receive larger discounts based on dollars spent with that company. Obtaining consignments is also useful, so that no money is spent until the product is used. Finally, whenever possible use reusable products, such as phaco tubing, diamond blades and cannulas. With these steps, it should take very little effort to reduce a successful ASC's overhead to 50% or less.

Common-Sense Policies

It is an honor and a privilege to work in our ASC. The patients love the convenience and the quality of care and service the staff provide, and they tell me that daily. Patients enjoy their experience because of the simplicity, excellence, efficiency that our ASC offers, and the consistently friendly qualified staff who will be there the next time the patient returns. The way we operate our ASC is based on nothing more than common sense. The key is putting this common sense into practice so that an ASC can be as successful as possible.

James D. Shuler, M.D., F.A.C.S., is a partner in Empire Surgery Center Partners, Bakersfield, Calif., and an associate clinical professor of ophthalmology, Jules Stein Eye Institute, UCLA School of Medicine.