This Week in Surgery Centers: Dawn Pfeiffer – Ask the Expert: Best Practices for Opening a New Surgery Center

Here’s what to expect on this week’s episode. 🎙️

This is a special LIVE edition of This Week in Surgery Centers!

Dawn Pfeiffer is the Director of Integration at Regent Surgical Health and a tenured ASC consultant. She has had a hand in opening many successful surgery centers, so we spent an hour with her covering as many best practices as we could and exploring effective strategies for a smooth process and successful opening. Together, we addressed common challenges, shared proven solutions to avoid missteps, and answered questions on the fly from those who attended live.

We covered the following and more:

• Feasibility Assessment: key components, CONs, red flags

• Facility Construction: planning, finding an architect, inspections

• Regulatory/Certification Process: state licensing, accreditation, life safety issues

• Payer Contracting: timing, negotiations, terms

• Quality/Clinical Preparation: reporting, initial clinical hires, staff recruitment

• Business Preparation: capital equipment, vendor contracts, software selection

• Opening & Marketing Ideas: community education, media coverage

• Continuous Improvement: QAPI, benchmarking, new technology

 

Interesting in learning more about opening a new surgery center? Check out our two previous episodes:

• Michael McClain – Opening an ASC: Navigating Payer Contracts

• Wil Schlaff – Opening an ASC: Conducting a Comprehensive Feasibility Assessment

 

Find the full episode on Apple Podcasts, Spotify, or YouTube to hear all the details.

0:00
welcome to this week in surgery centers if you’re in the ASC industry then
0:05
you’re in the right place every week we’ll start the episode off by sharing an interesting conversation we had with
0:11
our featured guests and then we’ll close the episode by recapping the latest news impacting surgery centers we’re excited
0:18
to share with you what we have so let’s get started and see what the industry’s been up to [Music]
Welcome
0:27
hi everyone here’s what you can expect on today’s episode so last week we held
0:33
a live online event with Don Pfeiffer Dawn is the director of integration at
0:38
Regent surgical health and an ASC consultant and we spent an hour with her covering best practices for opening a
0:45
new Surgery Center having done this herself many times Don shared effective
0:51
strategies for a smooth process and practical advice based on her own first-hand experience
0:57
Don also has 25 plus years as a nurse under her belt so her clinical background mixed with her business
1:03
background really makes her the perfect guest speaker to cover this topic and as you may have noticed we have been
1:10
focusing our most recent episodes on tips and tricks to successfully open a
1:15
new Surgery Center so we will continue this series into October covering topics
1:21
such as the Regulatory and certification process how to find your dream team clinical preparation what to do when
1:28
you’re 30 days out and a lot more so if you know anyone who is daydreaming about
1:33
starting a surgery center or is in the process of doing so make sure to share these episodes with them as there’s so
1:40
much to learn together hope everyone enjoys the episode and here’s what’s going on this week in
1:46
surgery centers before we jump into the poll and some
Meet Dawn Pfeiffer
1:53
other things do you mind just sharing a little bit more about yourself in the experience you bring to the table today
2:00
sure thank you everybody from joining I know you’re taking time out of your schedule to listen to the conversation
2:05
so thank you very much and thank you Erica for for having me so my name is Don Pfeiffer and I am a registered nurse
2:13
um I’ve been in the nursing field for 25 plus years I’ll just say that to not age myself for everybody to know I’ve been
2:20
specifically in the ASC market for the last 20 years um I do currently work at Regent surgical health and I’m director for
2:26
their integration process so I helped take the projects from syndication
2:31
um and maybe a step or two before syndication but syndication all the way through accreditation with one of the accreditation bodies so we’re going to
2:38
kind of cover that scope today um to be able to answer some of your questions again it will be high level
2:43
but we’ll have a lot of fun and we’ll see what we can get shared knowledge
2:48
thank you Don and I just wanted to share this side with you as well I always think data is
2:56
interesting um but again as you remember during that registration process we had asked um is
3:02
there one specific area that you wanted to focus on and learn more about and the
3:07
other day I went in to pull the data and see where which direction we should take the conversation
3:13
um and as you can see it was pretty evenly split um so Regulatory and certification
3:20
process did win out a little bit um but you know I was really hoping we’d
3:25
be like okay we’ll just focus in in one area but nope so we’re gonna cover them all today
3:32
and then last request here so I’m going to issue a poll if you don’t mind just
3:38
taking a second um give everyone about 30 seconds to fill it out I’m just curious with the
3:44
people we have on the call today um where you are at in your journey
3:49
um and see if we can even continue to tailor the conversation even further that way
3:55
okay just give everybody about 10 more seconds we have about 70 participation
4:01
so let’s see we can get to a hundred
4:07
all right I’m going to end the poll and share the results with all of you just
4:12
so you can see them um so it looks like a lot of people are here just to kind of learn more but we
4:18
do have a bunch of people that are within two years of opening one year three months which is very exciting
4:26
awesome all right thank you to everybody for sharing okay let’s get into it let’s
Feasibility Assessment
4:33
start with the feasibility assessment and also Don in your experience what are
4:39
some common drivers that you see why somebody wants to open up a Surgery Center
Why Feasibility Matters
4:45
sure so um the way the market is today we we find that a lot of Physicians are
4:50
looking at surgery centers on as another source of income for their um portfolio
4:57
um selfish reasons are not Physicians are usually business people are looking to visit and you know invest into
5:03
surgery centers so one of the big um common denominators that we have is
5:09
physician ownership on because the surgery center is not like a CVS on the corner if you build it they’re not going
5:16
to come unless there’s physician involvement and or Hospital involvement if you’re doing like a joint venture
5:21
with a large Health Care system so that feasibility is important when you’re doing the assessment
5:28
um because it’s like I said it’s it’s not like consumer’s just going to walk in and go oh this looks like a new
5:33
Surgery Center I want to have my surgery here it’s usually always directed by a referral from that position gotcha that makes sense and with the
5:42
feasibility assessment again I know this is kind of a beast in and of itself but what are the key components of the of
5:50
every feasibility assessment sure if you want to know that the Physicians who are interested in the
Key Components of Feasibility Assessment
5:55
project um have the volume and the cases that are qualified to be done first off in an
6:00
outpatient surgery center and the patient selection and criteria that’s being done in an outpatient surgery
6:05
center it’s very different for a physician to say I can bring 100 I want to invest in a surgery center and I can
6:11
bring 100 cases a month well the hunt you have to dig into it a little bit deeper you know are the hundred cases a
6:16
month that you’re going to bring me a are they are they on the Medicare fee schedule for an ambulatory Outpatient
6:22
Center and then then you have to drill down a little bit further what is your patient criteria like you know so we do
6:29
have stipulations of types of patients that can be done all of that has to be put into your feasibility to make sure
6:36
that the volume that the Physicians say they can bring is truly the volume that you can expect I always try to tell everybody try to
Red Flags
6:43
remain as conservative as possible um when you’re looking at those numbers it’s better to have a physician tell you
6:51
they want to bring 100 cases and then by the time you drill down and do your homework it may be 50 then they surprise
6:56
you and they have 75. so it’s always a win if there’s more it could be very detrimental to the business if they say
7:02
a hundred and then truth be told it’s maybe 20. because you’ve projected budgets and numbers and operating
7:08
Capital off of their numbers one of the the red flags are the thing that we want
7:13
to look for right when we’re building and looking at these feasibility assessments is the physician owner
7:19
interest and other surgery centers in the market um and also whether they are in any non-competes with larger Hospital
7:26
systems or other entities in the area um so you know Physicians have the one
7:32
through third rule they have to participate by um and so if they have ownerships in six centers around
7:39
um so there’s no way they’re able to adhere to that one-third rule so it’s things like that that you want to be
7:44
careful of and also Physicians who just maybe want to buy in
7:50
um for the distributions that will come later to that surgery center um that are just interested in buying in
7:56
that maybe don’t have the volume to support being a true partner um and so those are the things that
8:02
really take full effect when you’re looking at that feasibility of do we have a project is it really capable of
8:09
fruition and becoming a profitable set Center within 18 months of opening
8:14
gotcha and it so it sounds like when you’re when they’re working on their feasibility assessment The Physician
8:20
piece of it is really the the core of it and then that’s how you determine rev
8:25
potential Revenue expenses relationships Etc yeah absolutely Erica that is very
8:31
very important um is to have engaged positions um who who want to participate not only
8:37
in the surgery center but bring the volume and bring the right patient criteria there so that they’re not
8:42
putting a liability on their other partners um or any other management companies that are involved by bringing in the
8:48
wrong patients or over inflating what they’re capable of contributing to the partnership
8:54
gotcha that makes sense and for someone who has never done one of these assessments before how long should it
9:00
take them to do it should it be something that holds net not holds them up but like is
9:07
how can you over complicate it can you under complicate you can do both
9:13
so it really depends on how fast the position wants to turn the data around and how engaged they are right we’ll
9:19
have some Physicians that we’ll talk to you yesterday and today when I wake up in the morning I already have their numbers in my mailbox right
9:25
um I have other Physicians that I have to Hound down after we’ve met with them and said hey you promised me these numbers haven’t seen it yet so it just
9:32
kind of depends you know in all reality it’s usually a four or six week process if they’re willing to give you the data
9:38
they have the data to come out of their practice management software right to get the data to know what their CPT
9:44
codes are and then you run it against you know the Medicare fee schedule and then again to see how further down you
9:50
can drill then you have to add the layers inside of there what is their ownership do they have any other ownership in other centers is there any
9:57
non-competes in place and then all of that has to be taken in account or you can truly come up with a solid performer
10:03
and projections of what their investment and potential could be into the service center gotcha
10:10
um so one theme I saw a bunch in the questions that we received was around the certificate of need process
10:18
um any recommendations for streamlining that process um or making sure that you have enough information to get your application
10:26
right the first time so yeah it is really a so there’s only so many states that have this
Certificate of Need
10:31
certificate of need um some states do some states don’t so it’s very important to know that if you
10:37
are in a certificate of need state to know what those rules are um one of the things we do here at
10:43
Regent surgical um is we use a con consultant I’m in that state
10:48
um we have found that it’s worth the extra spin they know the state regulations they know the process they
10:54
know the timeline that’s involved in those processes and all the legal Hoops that you have to go
11:00
um so that’s one of the recommendations that we make is that if if you are in a strict to end State
11:06
um it may be worth talking to a con consultant in that state that you’re risk that you’re going to open the
11:12
Service Center to make sure that you can meet all the timelines and the requirements it can be very extensive
11:18
right so we have a project ongoing right now in New York um and that co1 process is extremely
11:24
extensive we just passed the co-n process in Illinois that one was less
11:30
intense and less restrictive so again but in both States we’ve had a con
11:35
consultant one in New York and one in Illinois um and we’re a management company right
11:40
but we still do rely on strong Consultants that specialize in their area to help us through that process
11:47
it’s interesting too that you mentioned just consultants in general do you recommend at this point bringing on so
11:55
obviously consultants for the certificate of need process but just consultants in general at this point
12:01
whether it’s um an independent consultant or more of a company or whoever like getting help
12:07
at this point is this really where you should start evaluating your weaknesses and lack of knowledge and where you
12:12
might need support um I do um you know take a grain of salt I do work for a management company and I have
12:19
a consulting firm so however what’s important to remember is that um it depends on the experience of the
12:27
Physicians and possibly your practice administrator or whoever’s coming to the table with you to build the surgery
12:32
center is what experience do they have that you can leverage right and if you have a bunch of great Physicians that
12:39
maybe have not opened multiple surgery centers or have not opened one in the last five or ten years
12:45
um or just don’t have to bandwidth to it then it may be in your best interest to
12:51
hire either a consultant or look at talking to a couple management companies to figure out what is the best options
12:57
and and you know opportunities that you have out there I know there’s a variety of different management companies out
13:04
there so I think some offer like a full service some you can do like a la carte so I think you just have to see where
13:10
your weaknesses are as a Physician Group that’s going to open this surgery center
13:15
um and then just kind of wrap around the services that you need to fulfill those gaps and knowledge that you have to open
13:21
a service center sure that makes sense one question that that came in you covered this a little
Choosing Services
13:28
bit but how do you decide on what surgical services to focus your opening
13:33
efforts on so it really depends on the type of Physicians that you’re bringing in that are Partners right so if you’re opening
13:40
a multi-specialty surgery center um then then everything from your blueprints to your design to the what
13:46
your performance all set up is based off of those case volumes and those Specialties that you’re bringing in right so if you’re doing eyes or ENT or
13:54
GI those are very high volume type of lines of Specialties um and so that but the revenue and
14:03
reimbursement on it may be a smaller so at that point you you’re looking at volume right so you have to have a
14:09
significant volume to make up a profit margin if you’re doing total joints and so forth then you have to look at that
14:14
so um all of that has to be considered early on in that feasibility study and
14:20
the group of Physicians that you’re surrounding yourself with when you’re going to build this surgery center um to know what kind of Specialties
14:26
you’re in there all of that will affect like the blueprints behind them these are examples of different types of surgery centers on Specialties and
14:33
non-specialties and multi-specialties and cardiovascular so all of it kind of depends on what what you’re going into
14:40
what type of cases you’re going to do there and what the future is for that I always believe in building futuristic
14:47
surgery centers and never get yourself pigeon holds that if you only build a GI Center that’s all you can ever do there
14:54
um because what if your Market changes in two or three years and you want to look at bringing in or expanding your
15:00
ability to offer services at that surgery center just something to think about when you look at design and so
15:05
forth of your Center got it that’s great advice uh one final question here and then we will keep
15:11
moving just for the sake of time um financing any tips or recommendations
15:17
or gotchas when it comes to financing the surgery center sure start early that’s all I can say is
Tips for Financing
15:24
start early shop around the rates um don’t just go with One Bank look at
15:30
your National Banks look at some of your local banks um you you need to have that conversation with the doctors early on
15:36
if they’re going to be holding personal guarantees with money coming into the project but most of them will have
15:43
um and so start that financing piece often and make sure you shop around for
15:49
the best options out there for loans whether it’s a construction loan and a
15:54
equipment loan whether you’re going to tie those two together but then also one thing and one of the biggest mistakes I
16:00
see on in surgery centers is people don’t put enough into a capture the current cost of construction that we’re
16:07
facing in today’s world um but also the operating costs and we’re going to talk about it a little
16:12
bit more in a couple slides from now but that operating cost once you go through your accreditation but before you’re
16:18
getting Revenue in you have a gap of time there where you have staff hired your buildings open operational you’re
16:25
paying your electric and your light bill and your HVAC bill right but you don’t have Revenue coming in so you need to
16:30
make sure that you have enough operational cash and we call it a cash burn analysis so know what you’re going
16:36
to spend and then some you will find them probably a little bit more conservative than most people in the
16:42
market but again I would rather have a conversation with my Physicians to give them back money because we’ve got
16:48
revenue in sooner that I would have to go back and go I am so sorry but I need to do a cash call because we weren’t
16:54
prepared for this that’s just a conversation no one likes to have especially very early in a project so
Construction Planning
17:01
take it out a little bit longer and give your doctors back the money perfect great advice all right so
17:08
feasibility assessment goes great we are ready to start construction and planning
17:14
we are ready to start tell us about this process love construction and planning who would
17:20
have thought all those years ago in nursing school that I would love construction but I’ve learned all kinds of things about construction so you’re
17:27
right we’ve we’ve done the feasibility so let’s just pick on we’re going to do a multi-specialty ASC the rest of the
17:33
presentation so we’ll kind of focus that way right so we’re going to build a multi-specialty surgery center we’ve
17:38
decided based on the feasibility of the numbers that it’s going to be like four ORS and one procedure so now that we
17:45
kind of have an idea we’ve got to find the right real estate we have to know if we’re going to rent space or if we’re
17:51
going to remodel a place or whether we’re going to go into something called a green space we’re going to build from ground up right found a lot we’re going
17:58
to build right so the Physician Group should have decided during that feasibility whether they’re going to own
18:04
the real estate or rent the real estate most rented but there are some out there
18:09
that own it and that’s wonderful keep the two separate things the ownership separate right so have a
18:15
business license if you’re going to own the building that operates the building the ASC physician owners should have
18:22
just a tenant lease inside of the building okay it’s important to keep those two things separate so then the
18:28
biggest plan that you have is finding the right Architects and finding the right engineering firms you want an
18:35
architect you’re going to want to do the interviews I know everybody says do you really still do interviews today Don I
18:41
absolutely do do the interviews talk to The Architects ask the tough questions
18:46
and don’t be afraid to ask the tough questions even if you’re a nurse and your doctors have tasked you with doing
18:52
this because you’re running their Surgery Center and you want to build a new Surgery Center ask the tough questions how long have you been doing
18:59
this how many surgery centers and I don’t want to know about hospitals or hopds or mobs or dialysis center that’s
19:07
great how many independent surgery centers have you built in the last three years
19:12
um asked to see where those are asked to talk to the administrator of those centers you want an architect and you
19:19
want an engineering firm that does ASCS all the time there’s a difference those
19:24
who do it some and then those who do it all the time and you want to go with the ones that do it all the time makes your
19:31
job a lot easier and you’ll have a lot less stressful sleepless nights if you if you uh decide to
19:38
Physicians are wonderful I love positions but they always have a brother cousin somebody who went to architect
19:43
school who can design it on the cheap those are the conversations you want to avoid
19:49
smile be nice entertain it thank you I’ll call him meanwhile you stay focused
19:54
on the correct ones that are in your Marketplace and do this for a living yeah that that makes sense yes um one
20:01
question that did come in uh what recommendations do you have to expedite the design and construction phase it
20:09
sounds like going with an expert would help but dealing with an expert helps um having friends in the industry
20:15
emailing me um having connections through aska and things like that is really saying Hey
20:22
listen we’re looking at a 16 000 square foot four or does anybody have a four
20:28
point that you love right you can just put that in your ask a membership thing and just there’ll be people who’ll say
20:33
oh my God I love my surgery center or oh don’t do this I don’t want to ever do that again right and so just kind of
20:38
asking around and then once you engage with that architect it’s totally okay to say listen I asked a couple friends they
20:45
love their Surgery Center this is what it looks like um and sometimes that can help now I
20:51
will tell you not all the times usually when we start a project um it can be three months by the time we
20:58
sign the contract with the architectural firm and we get final drawings what they call issued out on CDs it takes that
21:05
length of time in there the only way to shorten that time is if you go with a templated design that the architectural
21:11
Farm already has that they’re just charting out these ASCS and they might be able to cut some of that down doesn’t
21:17
cut it all down but it could cut off a couple weeks here and there that’s that’s good to know someone had
21:24
just asked how many um bids do you recommend getting for
21:29
construction for construction I usually interview again I know I’m old school remember that 25 plus year so I’ll just
21:36
leave that there again um I usually entertain um two to three gc’s construction firms
21:42
again I’m very particular if they’ve built a Kohl’s love to shop there but I don’t want you building my surgery
21:48
center right so um I will specifically interview two or
21:53
three General Contractors that all they do is health care and they do ASCS also
22:00
um and they’ve done ASCS again four to five in the last two years if they’ve not done four to five in the last two
22:06
years I don’t even entertain them so again interview talk to them figure it
22:11
out make sure they’re in the market one thing I’ve learned about doing ASCS ASCS
22:17
is just a really tight compact Hospital right so we can’t share or HVAC we can’t
22:23
share electrical there we have to be solely contained and on a complexity
22:28
level an ASC on a scale of one to ten on complexity and ASC design and
22:35
Engineering is about an eight in a hospital that does Open Hearts and all that it’s about a ten right and so you
22:42
have to remember you want to interview and select your best candidate because your complexity level of an ASD is
22:49
really up there um and it is a complex build and so you only want the right Partners in there
22:55
interview ask the questions you don’t know what to ask send me an email I can tell you what to ask so I sometimes I do
23:02
have a couple little cheat sheet questions as a nurse that I’ve come up with and it kind of lets me know right
23:07
away if that GC knows what I’m talking about and if they don’t I’m out thank you very much for the conversation but I
23:13
end it right there I love it that’s perfect I imagine with your background it just leads right into this and being
23:20
able to really ask those right questions and we doubt to people who know what they’re what they’re talking about yeah
23:27
perfect anything else about construction before we we move on no Enjoy wearing a hard hat get you some
23:35
steel-toed shoes they have them now in tennis shoes and they’re so much better than the boots so oh that’s actually
23:40
very demanding they’re like 50 on Amazon they’re worth it versus those nasty boots gone you got to get um an Amazon
23:47
affiliate link and we’ll send it okay so this we got a lot of questions
Regulatory Certification
23:55
um about the Regulatory and certification process mostly just about how to make make it go faster but
24:01
um starting at the top here or wherever you would like to start um what are the best things to know
24:07
about going through this process you know we’re kind of re-looking at this process internally at Regent just
State Licensing
24:13
lessons learned throughout the years one of the very first things that I recommend is you’ve syndicated you have
24:20
a group of doctors who want to build a surgery center we’ll just pick on 10 well we won’t pick on Tennessee because
24:25
we’re a coin state so we’ll pick on Texas they’re not a CO in state so you
24:30
have a group of doctors know right away even maybe before you Syndicate definitely after you Syndicate
24:37
get in touch with your State Licensing first figure out what your State Licensing rules are to open an
24:44
independent Ambulatory Surgery Center again whether you’re joint venture or not but to know what your state
24:50
regulations are from there you can kind of make yourself a Tracker
24:55
um to say okay I have to submit this license 90 days before opening so then
25:00
you kind of pull back and say okay this is the date I’ve got to submit my state license right then
25:08
you have to know if what accreditation body you’re going to go to right because most ASCS
25:14
um I’ve never heard of one none of them are going to wait that year to 18 months for the state to come in and accreditate
25:20
you and some states don’t even offer that anymore but no one’s going to wait that 12 to 18 months that it takes the
25:25
state so most people are going to go with either join commission or AAA or quad a or somebody so then know what
25:31
that application time is right so then again put that on your calendar just know okay when do I need to submit that
25:38
application for my accreditation okay and then you’ve got to do your 855 B for
25:45
your Medicare number right so that’s good for six months but it takes about 45 to 60 days to get it approved so you
25:52
have to kind of build yourself a chart right I call it a pull chart because we
25:58
use that term a lot in construction you kind of have to build yourself a full chart and say okay based off of what the
26:04
state says this license is due here this accreditation once due here the CMS
26:10
is done here now while you’re figuring out the timeline for all your Regulatory
26:15
and license and stuff like that you’ve got to get ready to say what the state of so remember we’re picking on Texas
26:21
right now you’ve got to know what Texas state regulations are and when the department of health comes out to
26:27
inspect and what they expect to see that day every State’s a little different some want you to be fully fully ready to
26:35
see patients the very next day that’s the state of Texas right that means your crash card’s stocked your staff is hired
26:42
you have your DEA license all of that stuff um other states not so much so that’s
26:48
why that call to the state early is so vital to know what their expectations are throughout the inspection process
26:57
um Joint Commission AAA quad a they’re all about the same on understanding what
27:02
that guideline is if you once you determine what accreditation body you’re
27:07
going to go with by their handbook go ahead and tell your doctors you need to buy the two or three hundred dollar book
27:13
do it I’m old school I want the book I don’t want the PDF I want the book I
27:18
want to color highlight Circle bark um buy the book just expense it the
27:23
doctors will appreciate it later there’s great worksheets and tools in there that will really highlight what their process
27:30
and what they’re looking for when the accreditation process comes in
27:36
um that kind of covers the CMS certification process because they kind of go hand in hand just remember that
27:43
855 application is only good for six months so that’s where understanding
27:49
your construction timeline like we talked about on that other slide and understanding a good GC that timeline
27:57
and when you submit that 855b application are vital because it will expire after six months so you don’t
28:03
want to submit it too soon but they usually won’t get to it for 45 days so
28:08
there’s just that window there so you have to kind of time when you expect to see your first patients and that’s your
28:14
first 10 free patients for accreditation right so understand the difference there
28:21
um with medical staff and accreditation you’re going to start that before you even open and a lot of times we’re
28:28
chasing doctors nothing personal if there’s any doctors listening I do love you guys but sometimes they’re not the
28:34
best at turning in their paperwork some have to ask their wife or their ex-wife or whoever where their social security
28:40
card is and where their notable diploma is some of them realistically think oh
28:45
just call the hospital Dawn they’ll give you my full credentialing packet doesn’t work that way right so I recommend
28:52
starting that medical credentialing process early um because you’re chasing the doctors a
28:58
lot for paperwork um so I I would start that six months
29:03
before you open myself just because it’s going to take you a couple months I’ve never had one doctor give me an entire
29:10
thing I need on time um the certificate of occupancy is a very very important date to know again
29:17
you will work with that GC to figure out when your certificate of occupancy is and that’s a fancy word some people you
29:23
hear some people call it the CEO or the certificate but occupancy or when you can take possession of the center that
29:29
date’s important because legally you can’t have any staff working in this space until you pass that certificate of
29:36
occupancy some states there’s a little bit of give room there but you’re really not supposed to because that’s when the
29:43
state and the fire marshal are coming in to say hey this space is safe for truly occupancy is exactly what it says so
29:49
just know what you’re State and your city requirements are before you just
29:55
automatically assume they’re almost done with my office there’s still a little construction going I can move in that
30:00
may not be true so know what your state and your study says and life safety
30:06
the best thing I can tell people is you just gotta get in there and learn it don’t be intimidated I was for years
30:13
don’t let that I’m a nurse I don’t know the electrical box is or I don’t want to touch that big gray box because I think
30:19
I’m going to get electrocuted the best thing you can do is when you start your very first de novo and you
30:25
start your very first remodel or whatever you’re doing is step outside of
30:30
your comfort zone and start asking the questions hey what is that box can I
30:36
touch it how do I open it what’s inside of here and so forth the more you expose yourself to the life safety regulations
30:44
the more you’re able to keep your building safe your employees safe and
30:49
your patients safe and at the end of the goal that’s that’s what matters so we have to get outside of our comfort zone
30:56
um to know what we need to be looking for I have a couple cheat sheets I’ve
31:01
made that translate Life Safety codes to nursing codes that we understand
31:07
to say okay what so again if you want to email me I’m happy to send that to you but I kind of translated like this an
31:14
electrical term means this and over here that way when I talk to a life safety inspector he says where’s
31:20
this whatever whatever I can go oh it’s right on here in L2 and life safety panel this and then they’re like okay
31:27
usually once they figure out that you know a little bit more than your average then that it breaks the rest your
31:33
inspection go a little bit easier yeah it’s interesting because we got a lot a couple questions about life safety
31:40
issues and kind of what to know there specifically and I don’t have a clinical
31:46
background and I had to look it up myself I’m like what are all these life safety questions coming in um but it
31:52
makes sense I was reading through it I’m like oh my gosh there’s so much there it is yeah and I’ve had surveyors in my
31:59
past tell me that you have to open the battery thing to test the battery acid no you don’t so you do not and you don’t
32:05
want to do that and that’s a huge OSHA violation there is a different type of battery that you have to have in your
32:11
generator but when the generator guy or girl comes out next time to do your check just take a timeout say I kind of
32:18
go outside to learn about this generator don’t be afraid to learn about it know how to open it know where the emergency
32:23
switch is know what the battery that they’re talking about is ask the right questions the more you ask the more
32:30
knowledgeable you’ll be the easier your life safety inspection will be perfect thank you Don I wish we could actually
32:37
ask about 20 more questions here but Let’s uh keep it moving here so payer
32:43
Contracting was another um Hot Topic here um when when should we really begin
32:49
these conversations with with payers so you can notify the payers early that
32:56
you uh syndicated about six months before you open you can just notify the payers in your Marketplace hey we are
33:03
opening a new Surgery Center here’s our name here’s our doing business as this is our location
33:08
um so you can do that introduction to your payers early um most the time you’re not going to get
33:15
really far down the negotiating role until you get through your accreditation
33:20
right and where you can start negotiating rates some payers will negotiate with you a little bit earlier
33:25
some will not so it’s really driven by the market so know your Marketplace on
33:30
what your payers will and will not do um and if you don’t have a great person
33:36
to negotiate contract rates this may be where you pull in a resource hire a
33:42
consultant to a management company something right because those negotiated rates are so vital to get right the
33:50
first time to go back and renegotiate those after afterwards it’s it’s painful
33:55
at best because it sometimes there’s a clause in there that says you can’t renegotiate for a certain period of time
34:02
and so you want to be very cautious of that so just know the rates um and know the process and if again if you don’t
34:09
have that skill set it is a very different skill set I would never negotiate a peer contract because I’m
34:15
not just not my wheelhouse I would reach out to another consultant or someone else in my management company that would
34:22
say hey this is how we’re going to do it because this is the gist of you know what the rates are in this marketplace
34:28
right so um and then just learn to speak the
34:34
language of what is a network out of sometimes I look at my insurance my
34:39
personal insurance and my internet work I don’t know I call I’m a typical patient I call and go do you take my
34:45
insurance right so and understand that language because that’s going to be important very early on so after you
34:53
open your surgery center and you get the little famous letter from accreditation accreditation body says we’ll
34:59
recommending you for accreditation right that’s your date you can start sometimes you can’t you won’t be able to
35:05
drop the claims until you have a Medicare number so sometimes you’re holding that date right you’re holding
35:11
claims for so long until you get your CCN number you can start dropping claims now some payers will allow you to build
35:18
out of network and in network understand the difference of what your regulations in your state and your payers say teach
35:27
your front desk staff that to the patient so when the patients call in and they go listen my doctor wants me to
35:33
come to your new Surgery Center but I know you’re out of network and it’s going to cost me a whole lot more and
35:39
the hospitals in network so what am I supposed to do because he’s saying you’re going to honor this how how can
35:44
you do that you want to have a solid answer so work with your front desk
35:50
staff have a scripted legal answer right from either a consultant or somebody or
35:56
team who knows how to do these contracts of explaining to the patients what it means to be in network or out of network
36:02
and what it means when you’re going to honor in-network or added Network benefits and then be very clear on the
36:10
costs associated with the patient nobody likes that surprise that morning when they show up and they’ve been NPO
36:17
or they’ve prepped for their surgery and then all of a sudden you’re telling them that morning you’re you’re going to have
36:23
to pay three thousand dollars cash so please update that to your patients have that conversation before the morning of
36:29
your surgery absolutely we did have one question um how much leverage do you have for
36:35
negotiations you know as you have some leverage but I
36:41
will tell you most payers the rates are Market based in Regional based right
36:47
most have a general idea of what they’re already paying other ASCS in your
36:52
Marketplace so to think that you’re going to go in and demand 300 of
36:58
Medicare because you have these phenomenal surgeons I would say good luck and if you get it I would say call
37:04
me because I’d be interested in hiring um so just know that you do have some
37:11
leverage but never set yourself never go in with your bar set low right don’t
37:16
ever go we’re happy with 110 times Medicare no you’re not right so set the
37:23
rate much higher and allow them to back down right it’s kind of the opposite of when you’re buying a car right you’re
37:29
not going to go in and go geez you’re only asking twenty seven thousand dollars there’s Honda how about I pay 30. that doesn’t happen right so you see
37:37
on a car right if you’re picking if you’re going to pick a Honda Accord you’re asking 27 I’m going to pay you
37:42
23s right so you go lowball right you’re buying a car and then you know you guys
37:48
meet in the middle it’s the same thing with the insurance you’re going to want to start high so let’s just let the
37:53
right shirt High they’re going to go low try to negotiate right and use public
37:58
data right so don’t go call your friend at the friend and try to get confidential information because that’s
38:05
bad and it’s illegal so don’t do that um but do some marketing research know
38:12
what the hopd rate which is another reason to be a member of ASCA know what the hopd rate is know that Blue Cross in
38:20
your area is paying for a knee replacement at an hopd x amount of dollars so know that you could and you
38:28
want to negotiate your ASC at this amount so know what the rate is don’t be afraid to go high let them back you down
38:35
never go in super low because they’ll accept that then then it’s a long time
38:40
before you can renegotiate out of that rate yep great advice all right quality and
Quality Clinical Preparation
38:47
clinical preparation so I just put a couple bullets in here things we saw
38:52
during registration we have some other questions as well um what is the process like preparing
38:58
for the clinical side of the house sure we start about four months out from
39:03
opening um with the clinical side of the house right with onboarding and administrator on policies and procedure
39:10
that are specific to not only that surgery center but to those state regulations you have to take all of that
39:15
in consideration um making sure that you’re following the correct um organization guidelines whether it’s
39:22
Arn or APAC or so forth right so all of that starts early on right
39:28
um and then know what as we’re coming into um scores and mandatory reporting in
39:35
2025 you’re going to you want to know which Quality Reporting software that you’re going to go with
39:41
um and so there’s multiple different softwares out there we use press gaining doesn’t mean you have to that’s just who
39:47
we’ve moved to um so know that you’ve got to get those softwares in place I would not wait to
39:53
the deadline to get them in place um I would try them out of several
39:58
months before the deadline is coming so that you you know how to use the software you know how to rearrange your
40:03
questions so that your patients use the software so just know that that regulation is coming down in 2025 so get
40:10
ahead of it early if you’re not there yet you might want to do that after that we get off this podcast
40:15
um so and then know what positions when you go to higher are going to fulfill
40:22
that quality need also right so staff hiring is important like I said we bring
40:27
the administrator in about four months before opening um if they’re not in RN you do have to
40:33
have an RN on staff to open and run the surgery center right so just know that if you’re hiring a business
40:39
administrator you can’t cut corners and hire you know an LPN or something like
40:46
that you have to have an RN who’s going to oversee the clinical side A lot of times we’ll initially open a center with
40:52
that dual role and then as the center grows we’ll split it on where we’ll have a strong administrator and then a strong
40:58
director of nursing right so either what you want to do it is fine um but that those key staff members are
41:06
very important when it comes to your quality program your coffee stuff your infection control life safety and all of
41:13
those different subcommittees that are inside of there perfect one question that came in um in
41:19
terms of organizational structure any tips for what it might look like for a
41:24
small Surgery Center that has limited staff yep so
41:29
um go to go first thing do is go look at your state regulation and be creative on your Staffing based off of your state
41:36
regulation so if you’re a small single specialty pain center GI Center whatever
41:43
the case is try to utilize and use your nurses to the top of their license or
41:48
the text to the top of their license so it’s important to know what your staff your state regulations are as you’re
41:54
building your Staffing and because you might be able to use um LPNs or even scrub Techs in certain
42:01
positions where you’ve traditionally had to use an RN or we thought you had to use an RN
42:06
um so that is important again ask us a huge um member base put a question in there
42:13
about your state regulation there’s already someone who’s done this so don’t recreate the will start getting on there
42:18
asking the questions right um but then work your staff to the top of their license
42:24
um and then look at ways that you can mix up your Staffing while ensuring
42:30
excellent patient care I’m a huge fan of Team nursing again a member of that 25
42:36
plus year nursing thing we had team nursing back then I loved it I still love it
42:41
um so know that you can have RNs LPNs and techs working utilize them everybody
42:48
has a place in healthcare because our common goal is to give great patient care so don’t overlook staff that are in
42:57
your area that have the potential to help your surgery center or cross-train cross-train your staff as
43:03
much as possible right so I’ve taken some of the meanest or nurses in the
43:09
country and I could pick on one of them right now and Houston Texas and I love her to death but she’s like I’ve not
43:15
taken care of a bedside nurse since I got out of nursing school I’m an or nurse and I’m not doing that I go absolutely you are we’re going to work
43:21
through this right so cross-trade your staff as much as possible there’s probably some art or orange right now
43:27
that are going to put down boost signs and that’s okay because I still love you guys but cross-train your steps right
43:32
because if a patient goes bad if you need an extra set of hands we’re in a
43:38
small Center together remember that independent you have to be totally isolated it’s the same when it comes to
43:44
patient care you’re independent you’re small you don’t have a huge Hospital resources to pull from cross-training is
43:50
going to be vital um for your Center and it’s going to help your camaraderie there to build a
43:56
successful Center also perfect we’ve got a lot of questions around around finding
44:02
the right anesthesia partner um I actually put this on the next slide as well but it feels appropriate to talk
44:08
about here too any tips for finding the right anesthesia partner and just making
44:15
sure you always have ever you know resources the resources that you need
44:20
yeah again if you find a great one out there that’s not charging you stipends can you have them call me I’d be
44:26
interested in this danger right now is a
44:31
painful subject Across the Nation we’re seeing it in the hospital space we’re seeing an Ambulatory Surgery space it’s
44:38
hard to find anesthesia providers it’s hard to find an anesthesia group that’s not going to come on and charge you a
44:44
stipend so you’re a new Surgery Center you’re trying to get your feet wet you’re trying to build cases you know
44:51
you’re not going to make revenue and get out of the red for maybe 18 months and
44:57
then to have to pay a stipend anesthesia partner it’s very painful and it’s A
45:02
Hard Sell to your doctors right and you’re born um look at your smaller providers look
45:07
at your smaller anesthesia in the community ask around interview anesthesia groups just like you do in
45:13
architecture GC and it’s okay to do that talk to different ones and find out
45:19
um figure out you want them to have skin in the game in your surgery center so you may have an anesthesiology group
45:25
that’s local to your area that maybe just wants a small position of ownership in the surgery center right you have to
45:32
remember they’re not bringing you volume right so you have to remember take that in consideration if they’re wanting to
45:37
join as an owner way back in the feasibility but there’s some give and take to that
45:43
because yes they’re not bringing you Revenue but they’re going to be engaged to keep that Center making money and
45:49
give you the coverage you need because they have a little bit of ownership right I wouldn’t give them a ton of ownership but that might be something to
45:55
think about right because that um and maybe reduce the amount of
46:02
stipend that you’re having not saying they’re not going to charge you still but maybe they wouldn’t charge you as much because they know they’re paying
46:08
for it ultimately in the end um right now it’s just it’s a shortage that we’re dealing with
46:15
um and I think we just have to be we have to be desperate and look around to see what’s available in the marketplace
46:21
and look at National level organizations too yeah definitely I have I have two in
46:28
mind and I’m going to ask them if they charge stipends now do you do that if
Business Preparation
46:34
they don’t will you send them to me Erica I’d be very interested to walk into them I absolutely will
46:41
um okay so clinical prep business prep um got a lot of questions here as well
46:47
uh where do you start preparing for the the business early on early on you want
46:53
to make sure you have solid policies and procedures for your business office know how you’re going to handle cash if you
46:59
have a little safe in there today is the world’s a little crazy you know we’re doing a lot of outpatient surgery
47:05
centers now that do bariatric patients that do plastic surgery so it would not
47:11
be uncommon to have a patient come in and just give you ten thousand dollars cash seeing it happen right so take some
47:17
of that in consideration early in your design process your surgery center do you have a little say if not maybe see
47:24
about putting one inside of there right um but you’re going to want to start your business preparation early right it
47:30
comes with selecting the right software um that’s going to manage it we use HST
47:36
we always have HST has been a big partner and big process in our life we
47:41
can use any software we just use HST there’s other ones on the market but to
47:47
track your spend to track your Capital to know what your case costing is to load in your equipment to be able to
47:54
inventory where that CRM is or how many implants that you have or so forth
47:59
understanding the software that you used is going to be vital to controlling the
48:05
spend of your surgery center one I think I read a statistic don’t quote me on it
48:10
a couple months ago that the number one loss of Revenue in a surgery center is
48:16
from supply chain and not understanding what money is going out the door with
48:21
supplies and case costing so having a having a solid business department and
48:27
revenue cycle department is Paramount in top of inventory control and knowing
48:33
what you’re buying what your contracts look at right because all of this gets
48:38
tied together right so we know the doctors that are coming in based off of the specialty right so we know now what
48:45
our payer contracts are going to pay us for that specialty so now we’ve got to married up with the supplies and then we
48:51
know the staff right so all of that has to start balancing just like you balance
48:56
your personal checkbook at home right you know how much your mortgage is you know how much car insurance is you how much car payment is what the bottom of
49:03
your personal budget you don’t want to see red right so it’s the same on your case so if you’re doing a colonoscopy by
49:10
the time time you know what Blue Cross is going to pay know what the anesthesia is going to take out know what it costs
49:16
to process the scope both material wise and human wise for your staff know what the supplies are needed and know what
49:23
your pre-op and pack you cost is you don’t want that bottom number to be read you want it to be black right so
49:29
ensuring that your business side of the house is solid will help your bottom
49:34
line if it’s messy you’re going to have a messy business and you don’t want to do that so you want to focus as much
49:41
attention on the business side of the house than you do the clinical side of the house because they really do work
49:48
parallel because what happens if a business is starting to hurt financially where do they they start cutting costs
49:55
on supplies they’re going to go to cheaper implants cheaper disposable cheaper Scopes cheaper this that’s going
50:02
to affect your clinical side of the house right clinical quality is going to start going down you could see your
50:08
infection control rates go up and so forth so it’s important to have a strong house both clinically and on the
50:15
financial side so I see this is probably one of the number one things I see on
50:21
Independent surgery centers is not focusing enough on the strength of their
50:26
business yeah and and it makes sense because having
50:32
clinical backgrounds and that’s their experience has been their exposure this might be the side of the house that you
50:38
might need to lean more heavily on some consultants and people have more experience that’s exactly right that’s
50:44
exactly right one of the things I recommend that independent surgery Centers do specifically is if you don’t
50:52
have a revenue cycle audit done on your business once a year you should so if
50:58
you’re using revenue cycle XYZ have higher revenue cycle ABC to audit
51:06
XYZ right once a year to make sure they’re not leaving any money on the
51:12
table right make sure that every penny that could be collected is collected
51:18
um and just have them audit a percentage like 10 or something to see which see what they’re doing it gives you the
51:25
ability to know that the revenue cycle company that you’re working with and the process that you have at your surgery
51:31
center is strong if not then it gives you an opportunity to go back and fix it
51:36
or go back and say eh maybe I want to look in another Direction because they
51:41
don’t really seem right you do have some Revenue company out there that will only collect based off of what the contract
51:48
has with their payer and so you want to be very cautious of that there there’s more that they can do but do they are
51:55
they doing that for you and so just like you’re interviewing your architects in your GC interview those revenue cycle
52:02
companies and find out and if you have one that you think is doing a great job they shouldn’t be they shouldn’t worry
52:09
about an audit if they’re doing a great job and they’re going to audit you they shouldn’t welcome the audit if they push
52:15
back pretty hard that should tell you the exact reason why you need to do that audit yes now we did just get a question
52:22
do you have any examples of revenue cycle companies that will perform an audit yeah so um I use one based in
52:30
Chicago and their name is accurate revenue cycle I always get it wrong
52:36
um it’s accurate um Mike orsino is the CEO but I think it’s um accurate revenue cycle and they
52:43
do an audit and um I’ve always been extremely happy with the audits perfect
52:48
thank you all right coming down to the wire here
Connecting with the Community
52:53
um this is when the sleepless night starts if you’re opening times [Laughter]
52:59
there’s so much more to actually open um but this also could have just been
53:05
you know maybe titled a marketing slide but we find that a lot of surgery
53:11
centers don’t think about this part of it and actually connecting with their community so any quick tips here yeah
53:17
you know what it’s a great time to highlight what a wonderful job that your architect has done that your Physicians
53:24
are doing to the community to the jobs that you’re bringing to the community um what your general contractor has done
53:32
um so it is a absolutely great time they want to show off their work just as much
53:37
as you want to show off your surgery center for great surgeries excellent patient care no infection control rates
53:43
right so we all want to show up our surgery centers like that but your Architects and your GCS they want to
53:48
show off the surgery center that they’ve built too team up with them to have an open house to hold something in your
53:55
community obviously you’ll have to terminally plan again and we know that because I have people go I don’t want
54:00
people stomping around you want to show you’re off your Center and it’s okay to show off your operating rooms you
54:07
terminally clean you do all the safety stuff that you have you do an icra before you do an open house and you do
54:13
all that but you you want to show it off so team up with your architecture and your GC and publicize it
54:19
um you also absolutely want the Physicians who are investors to bring
54:25
their office staff to that surgery center that scheduler at that Physician’s office is the key to your
54:31
success at that surgery center you want him or her in that surgery center as soon as possible to see it you know what
54:38
it looks like so when she starts scheduling when he or she starts scheduling surgeries they’re moving them
54:44
from maybe out of a hospital over to your new Surgery Center or out of an competitive Surgery Center into this new
54:50
one this doctor owns you want them to be excited about that surgery center because they’ve seen it they know what
54:56
it’s like and so that is those are the people that you want to get into that open house right away also and maybe do
55:03
a private open house for the Physicians and their friends and family and their schedulers right and so
55:10
um it’s worth the money that you spend for open houses I know aska does a great job at offering open houses they have
55:17
marketing abilities and all that stuff so tap into your resources connect with your vendors whether you’re using
55:24
Striker for equipment or arthrex or HST tap into your vendors also they may want
55:31
to highlight their services so know that it does cost money to oh to have an open house but sometimes if you partner up
55:38
with some of your vendors or contractors sometimes you can share that cost
55:43
um and get to share the rewards of people highlighting and seeing your new center
55:48
yeah that’s perfect I love the tip about the scheduler I have not heard that one yet but I can imagine if they’re on the
55:55
phone with the patient and the patient is stressed they can assure them it’s beautiful I’ve been there you know and
56:00
have that that dialogue with them very much so all right come down to the wire here
56:07
um so you’re open you have patience how do we continue to improve
56:12
we it’s constant right so every day you treat it like it’s a new Surgery Center you do physician recruitment you keep
56:19
your positions that investors happy um you know you make sure that there’s
56:25
they’re starting on time and so forth right investors doesn’t mean that you
56:30
want to lose them so keep that position recruitment going follow your quality improvement programs know where you are
56:37
on those um follow a guideline that you have do your benchmarking um whether you use ask
56:44
or any other company make sure that you’re doing your quality studies for those who don’t have ideal quality
56:51
studies this send me an email I’m happy right you can make a quality study out of almost everything but keep a little
56:58
tracker in your office of something that says you know are our discharge is too slow or how many IV starts you were
57:04
doing there’s always an opportunity for improvement people look at benchmarking and quality studies kind of sometimes
57:10
negatively they just give us a highlight to say hey we need to improve in this area and this is what’s going to give us
57:16
that option for improvement so kind of turn the table on that your physician and patient satisfaction are a
57:23
requirement that you’re going to need to do anyways so make them engaging for the positions you want that feedback
57:29
positive or negative turn it into something that you can say we learn from this the patients are telling us this
57:35
what can we do to correct it or change it right so take the feedback good or bad and do well with it that’s going to
57:43
be important cross-training your staff we talked about that early and it’s going to be Paramount and new technology
57:50
get your staff over their fear of change and we’ve always done it this way for 20
57:55
years John and we’re going to continue to do it this way absolutely no we’re not we’re going to change
58:00
um and so don’t be afraid of new technology in the Staffing shortage that we’re in right now we’re going to be
58:06
short one million nurses in this country by 2025. the only way that sometimes
58:12
you’re going to be able to get through a problem is to use the new technology that’s out there to fulfill a position
58:18
that maybe you were having a nurse do your pre-op calls some of the other stuff encouraging your patient to use
58:25
the pair the portals right embrace the new technology we’re going to have to use it so so go go forward look forward
58:34
to the new technology and don’t be afraid to try to use it perfect
58:46
[Music]