Many surgery centers are considering the addition of spine surgery, a specialty that can boost profitability due to its high per-case revenue. This specialty is particularly appropriate for surgery centers already performing orthopedics because much of the necessary equipment may already be in-house.
But beware: A surgery center that implements spine without careful planning can end up with dissatisfied surgeons, worried staff and high equipment costs. Here, Lisa Austin, vice president of operations for Pinnacle III, discusses nine pitfalls to avoid when adding spine surgery to an ambulatory surgery center.
1. Neglecting to create a unified and educated core team. In her experience, Ms. Austin indicates surgery center administrators often forget to speak with the surgeon and staff about their fears and concerns when adding new types of cases. She recalled a spine surgeon came to one of her ASCs in the middle of the year. She relayed to the ASC staff they would be performing spine procedures with this new physician but didn't realize the staff were verbalizing concerns to the surgeon that they were uncomfortable carrying out spine cases in an outpatient setting. While staff members had experience with these types of cases in the hospital, undertaking these cases in the surgery center would be a new experience for them which contributed to their fearfulness.
She says if she could do things differently, she would have sat down with staff members at large and said, "We're considering adding spine surgeries in our ASC. We would like to develop a team of spine specialists to become proficient in performing these cases with our spine surgeon. Who would like the opportunity to join this team?" That small team of specialists would have mastered the new specialty then acted as mentors to other staff members as case volume grew. She would have also included the surgeon in team meetings which would allow him to obtain a greater level of comfort in the new facility.
2. Starting with complex spine cases right away. It may be tempting to ramp up your new specialty right away, but Ms. Austin recommends starting with less-complex spine cases and moving to more complex cases once your staff obtains the necessary comfort level. "We typically start with disc replacement cases, fusions and anterior cervical discectomies," she says. "There tends to be a stronger comfort level with these types of cases and we work with the surgeon to identify appropriate patients for the ASC."
Ms. Austin recommends identifying a few cases that will be performed in the first month. Over a six-week period, scrutinize any issues encountered and figure out how best to address them. "Before we started adding high volume, we did case studies on every patient having these procedures," she says. "We had our top-notch spine team evaluate what the pre-op process was like, what the education aspect was like, and what needed to be addressed." She says the surgery center also examined case outcomes and determined where processes could be improved.
3. Neglecting to include your surgeon in equipment selection. Your surgeon may be coming from a hospital with access to equipment and instrumentation more suited to higher levels of care than what would be performed in the ASC, so make sure to discuss equipment needs required to provide quality care without exceeding the budget. First, look at the surgeon's preference cards and determine which supplies and equipment you will have to purchase. Then develop your shopping list with the surgeon. In some cases, you may be able to utilize existing equipment. "If the surgeon is used to using a particular type of spine-specific OR table, it may be possible to buy attachments for general, multi-functional OR tables to make them compatible with spine," Ms. Austin says. She notes her ASC was able to use their pre-existing microscopes and simply purchase a few attachments, rather than buying a spine-specific microscope.
4. Forgetting to market a new surgeon's services to the community. If you're recruiting a surgeon from outside your community, he may not have a pre-existing patient base in your town or city. Ms. Austin states it's important to have a marketing plan before you add spine to your ASC; you don't want to invest in the equipment and then find you have no case volume.
She suggests marketing include patient education about spine surgery in the outpatient setting, since it may be a relatively new development in your market. "Provide patients with a comfort level for receiving care in an ASC with a shorter length of stay than that typically experienced in a hospital setting," she says. Ask the physician to hold educational seminars at your surgery center to help the public understand the safety of these procedures.
5. Not giving thoughtful consideration to appropriate patient selection and education. "Patient selection is huge" in spine surgery, Ms. Austin asserts. Spine surgery in the outpatient setting is still relatively new in some areas, and surgeries should only be performed on patients who can recover without an extended stay or transfer to the hospital. Discuss with your surgeon the parameters he feels are pertinent in his selection criteria for his ASC patients. Set pre-admission guidelines with input from your anesthesia and spine specialty team that includes weight, co-morbidities and age that you can share with scheduling staff.
Ms. Austin says it's also important to educate patients about what to expect during their surgical experience. "This is a procedure that will be performed early in the day, so you should let them know what their afternoon and evening are going to be like," she says. "Let them know what to expect regarding their pain level, discomfort and activity level during their stay. When you help them manage their expectations, that advance understanding assists them in their recovery process."
6. Failing to discuss with the anesthesiologists the team expectations for spine surgery. Spine surgery may require different types of anesthetic blocks than are used for other cases, as well as more intensive airway management. "You have to ensure your anesthesiologists are comfortable with techniques the surgeon might request," she says. If your anesthesiologists are not comfortable with certain techniques for spine surgery, consider bringing in other providers for those specific cases or providing existing anesthesiologists with additional training.
7. Failing to perform a "dry run" before you start. Ms. Austin says she would recommend doing a "dry run" of your spine cases before you bring actual patients into the facility. This means going through every single step, from the time the patient checks in at the front desk to the time the patient is discharged. Everyone should be involved in the "dry run" and review the process as they go through each step.
8. Failing to get approval for new procedures. Ms. Austin says ASCs tend to forget that facilities have an approved procedure list that must be amended when new procedures are added. This means the administrator must, on behalf of the spine team, recommend to the medical advisory committee and governing board that these procedures be added to the procedure list and obtain approval for the change. This approval assures compliance with accrediting bodies and CMS.
9. Failure to negotiate managed care contracts. Ms. Austin states that often facilities get caught up in the clinical performance requirements and overlook the important task of ensuring reimbursement for these cases is secured prior to performing them in their centers. Meet early and often with your insurance carriers. You likely will need to collect case data and provide education in order to effectively negotiate optimum case rates, particularly in markets where these cases are relatively new.
Learn more about Pinnacle III.
Related Articles on ASC Turnarounds:
4 Items to Boost ASC Strategic Planning
5 Action Steps for In-Debt Surgery Centers
Ideas to Achieve Positive Cash Flow at ASCs: Q&A With Andrew Schrage
1. Neglecting to create a unified and educated core team. In her experience, Ms. Austin indicates surgery center administrators often forget to speak with the surgeon and staff about their fears and concerns when adding new types of cases. She recalled a spine surgeon came to one of her ASCs in the middle of the year. She relayed to the ASC staff they would be performing spine procedures with this new physician but didn't realize the staff were verbalizing concerns to the surgeon that they were uncomfortable carrying out spine cases in an outpatient setting. While staff members had experience with these types of cases in the hospital, undertaking these cases in the surgery center would be a new experience for them which contributed to their fearfulness.
She says if she could do things differently, she would have sat down with staff members at large and said, "We're considering adding spine surgeries in our ASC. We would like to develop a team of spine specialists to become proficient in performing these cases with our spine surgeon. Who would like the opportunity to join this team?" That small team of specialists would have mastered the new specialty then acted as mentors to other staff members as case volume grew. She would have also included the surgeon in team meetings which would allow him to obtain a greater level of comfort in the new facility.
2. Starting with complex spine cases right away. It may be tempting to ramp up your new specialty right away, but Ms. Austin recommends starting with less-complex spine cases and moving to more complex cases once your staff obtains the necessary comfort level. "We typically start with disc replacement cases, fusions and anterior cervical discectomies," she says. "There tends to be a stronger comfort level with these types of cases and we work with the surgeon to identify appropriate patients for the ASC."
Ms. Austin recommends identifying a few cases that will be performed in the first month. Over a six-week period, scrutinize any issues encountered and figure out how best to address them. "Before we started adding high volume, we did case studies on every patient having these procedures," she says. "We had our top-notch spine team evaluate what the pre-op process was like, what the education aspect was like, and what needed to be addressed." She says the surgery center also examined case outcomes and determined where processes could be improved.
3. Neglecting to include your surgeon in equipment selection. Your surgeon may be coming from a hospital with access to equipment and instrumentation more suited to higher levels of care than what would be performed in the ASC, so make sure to discuss equipment needs required to provide quality care without exceeding the budget. First, look at the surgeon's preference cards and determine which supplies and equipment you will have to purchase. Then develop your shopping list with the surgeon. In some cases, you may be able to utilize existing equipment. "If the surgeon is used to using a particular type of spine-specific OR table, it may be possible to buy attachments for general, multi-functional OR tables to make them compatible with spine," Ms. Austin says. She notes her ASC was able to use their pre-existing microscopes and simply purchase a few attachments, rather than buying a spine-specific microscope.
4. Forgetting to market a new surgeon's services to the community. If you're recruiting a surgeon from outside your community, he may not have a pre-existing patient base in your town or city. Ms. Austin states it's important to have a marketing plan before you add spine to your ASC; you don't want to invest in the equipment and then find you have no case volume.
She suggests marketing include patient education about spine surgery in the outpatient setting, since it may be a relatively new development in your market. "Provide patients with a comfort level for receiving care in an ASC with a shorter length of stay than that typically experienced in a hospital setting," she says. Ask the physician to hold educational seminars at your surgery center to help the public understand the safety of these procedures.
5. Not giving thoughtful consideration to appropriate patient selection and education. "Patient selection is huge" in spine surgery, Ms. Austin asserts. Spine surgery in the outpatient setting is still relatively new in some areas, and surgeries should only be performed on patients who can recover without an extended stay or transfer to the hospital. Discuss with your surgeon the parameters he feels are pertinent in his selection criteria for his ASC patients. Set pre-admission guidelines with input from your anesthesia and spine specialty team that includes weight, co-morbidities and age that you can share with scheduling staff.
Ms. Austin says it's also important to educate patients about what to expect during their surgical experience. "This is a procedure that will be performed early in the day, so you should let them know what their afternoon and evening are going to be like," she says. "Let them know what to expect regarding their pain level, discomfort and activity level during their stay. When you help them manage their expectations, that advance understanding assists them in their recovery process."
6. Failing to discuss with the anesthesiologists the team expectations for spine surgery. Spine surgery may require different types of anesthetic blocks than are used for other cases, as well as more intensive airway management. "You have to ensure your anesthesiologists are comfortable with techniques the surgeon might request," she says. If your anesthesiologists are not comfortable with certain techniques for spine surgery, consider bringing in other providers for those specific cases or providing existing anesthesiologists with additional training.
7. Failing to perform a "dry run" before you start. Ms. Austin says she would recommend doing a "dry run" of your spine cases before you bring actual patients into the facility. This means going through every single step, from the time the patient checks in at the front desk to the time the patient is discharged. Everyone should be involved in the "dry run" and review the process as they go through each step.
8. Failing to get approval for new procedures. Ms. Austin says ASCs tend to forget that facilities have an approved procedure list that must be amended when new procedures are added. This means the administrator must, on behalf of the spine team, recommend to the medical advisory committee and governing board that these procedures be added to the procedure list and obtain approval for the change. This approval assures compliance with accrediting bodies and CMS.
9. Failure to negotiate managed care contracts. Ms. Austin states that often facilities get caught up in the clinical performance requirements and overlook the important task of ensuring reimbursement for these cases is secured prior to performing them in their centers. Meet early and often with your insurance carriers. You likely will need to collect case data and provide education in order to effectively negotiate optimum case rates, particularly in markets where these cases are relatively new.
Learn more about Pinnacle III.
Related Articles on ASC Turnarounds:
4 Items to Boost ASC Strategic Planning
5 Action Steps for In-Debt Surgery Centers
Ideas to Achieve Positive Cash Flow at ASCs: Q&A With Andrew Schrage