WHO’S WHO
THE FACILITIES

By Kathy Dix

When Today’s Surgicenter asked members of the ambulatory surgery center (ASC) community to nominate the best ASCs they’ve encountered, some balked at the challenge. One state association’s president expressed regret after declining to name the best facility; “The quickest way for me to land in ‘hot water’ would be to favor one center over another!” he said. However, accusations of favoritism are moot when we consider the 10 facilities below — noted for their superiority in patient care, satisfied staff, revenue or commitment to the community.

“Benchmarks are the foundation by which we manage our center,” says Sue Majewski, CASC, the CEO at Bedford. “We monitor a number of operational and financial benchmarks on a monthly basis and compare these with national benchmarks every chance we get. We meet and most often exceed FASA and MGMA national benchmarks.”

The benchmarks by which Bedford ASC operates include:

• Supply and salary cost per case
• Labor hours per case
• Salary as a percentage of net revenue
• Total expense per case
• Days in accounts receivable (A/R)
• Net collections ratio
• Operating costs
• Bad debt percentage
• Average charge per case
• Average revenue per case
• Net profit/month
• Clinical benchmarks (including but not limited to infection rate, OR late start, return to OR, medication error, hospital transfer, peer review)

“As the largest freestanding ASC in our state, we have taken the lead legislatively on all ASC issues, including

• Successfully changing the law to allow for overnight accommodations for surgical centers in New Hampshire
• Founding and organizing the New Hampshire Ambulatory Surgical Association (NHASA)
• Changing the law to add a seat to the Certificate of Need board for an ASC member, nominated by the NHASA.”

“We also rotate/educate nursing and physicians’ assistant students in affiliation with local programs and participate in musculoskeletal research in conjunction with the New Hampshire Musculoskeletal Institute,” adds Majewski.

“Any financial or operational potential problems/trends are identified and addressed immediately,” she says. “We have shared these benchmarks with other centers to assist them in management of their facilities. We are pleased to assist groups that are contemplating construction of an ASC, as we initially received such outstanding help from other facilities.”

Although the facility is multi-specialty, it performs a great deal of orthopedic surgery, which drives a higher revenue per case than other specialties. It also accounts for a higher cost per case in medical supplies. “Despite the nature of orthopedic surgery, we continue to maintain a turnover rate of approximately 15 minutes,” she says.

The Bedford ASC has made a concerted effort to educate state legislators about ASCs, and the results have been dramatic. “We are fortunate that in New Hampshire our legislators are very accessible, even though the New Hampshire House of Representatives is the third-largest parliamentary body in the English-speaking world,” notes Majewski. “We have addressed issues revolving around state rules and regulations, ASC overnight stay, certificate of need and uncompensated care. As with other ASCs, the road has been rocky in that the hospital association has such a strong lobby.”

The facility prides itself on its low staff turnover rate. “Generally, turnover occurs as staff pursue higher education, family needs or physical relocation,” explains Majewski. “We try very hard to accommodate staff family needs and education needs by flexible scheduling, and we provide an excellent benefits package to encourage longevity. We recently had a nurse in the Reserves called to duty. The entire organization from the top down was greatly supportive, offering to supplement her military pay to ease the burden on her family, and keeping in touch by e-mail for the months she was away. In another instance, we had a staff person diagnosed with a serious illness that required time away from work. The staff proceeded to donate accrued vacation time so that the family income would not suffer. So the bottom line as to why the staff are happy is that this organization truly cares.”

The Northern Ohio Surgical Center is located in a community of 36,000, between Cleveland and Toledo on the shores of Lake Erie. The closest free-standing ASC is approximately one hour away.

“The mission of the surgical center is to provide the highest-quality patient care services using state-of-the-art technology in an environment that focuses on warmth and compassion while remaining cost-effective,” says Lauralee Krabill, RN, C, CNOR, MBA, administrator of the facility.

The surgery center is only three years old, but performed 899 cases in its first year. The case volume has increased steadily, and the ASC expects to perform 4,410 cases in 2003. The facility currently employs 26 full-time nurses and office staff, one part-time employee and seven PRNs, and 40 physicians have been credentialed.

The staff quality is exceptional; all RNs who qualify for the certified operating room nurse certificate (CNOR) hold the credential, and two-thirds of the circulating nurses are registered nurse first assist (RNFA). “There is an average of 25 years of experience for the fourteen nurses who work at NOSC,” says Krabill. “There has been almost no turnover.”

Patients consistently affirm the quality of the staff, and the ASC’s return rate of evaluations is 45 percent, with feedback such as “You are what healthcare should be,” and “Made me feel I was their only patient. There’s nothing you could do to improve.”

Krabill recounts, “JCAHO has recently performed its unannounced inspection. During the two-day survey, no area was identified as having a discrepancy. The surveyor gave us the score of 100 percent and added that he had never given a perfect score before.”

Benchmarking for the facility is done at the state and national levels, and returns to surgery, transfer and infection rates are always below those levels. “We did send a patient’s family member to the local hospital to be evaluated,” remembers Krabill. “He was rubbing his chest and complaining of tightness. Soon after, he had a heart catheterization with follow-up procedures. Had we not acted on his non-verbal behavior, he could have had permanent cardiac damage.”

Northern Ohio Surgical Center has been successful financially nearly from its inception; after three months of opening, the ASC was operating in the black. The facility exceeds benchmarks set by the MGMA, including cost per case, days in A/R and comparing revenue and expenses.

What sets the Northern Ohio Surgical Center apart from other facilities? “Not only do we provide excellent patient care using state-of-the-art technology, but also we have given back to the community,” Krabill verifies. “Each year, the six area high schools receive a scholarship to award to a graduate who will be attending college and entering a healthcare field.”

In 2002, the center-sponsored COPE Sandusky, a support group for women with cancers of all types. The ASC even recycles its pop cans and tabs for charity, and offers its lobby for blood drives.

The center also promotes continuing education for nurses, providing credit for nurses and radiological technicians to maintain their licenses and certifications. “This is a free service for the staff at the center and is offered to the office staff of our physicians,” says Krabill. “Evening programs are designed for the public. Physicians and nurses provide topics from breast cancer to asthma. During the event, people in attendance can participate in a hypertension screening.”

The last continuing education seminar for nurses included a bus trip to Toronto, with videos on the six-hour bus trip, and tickets to a play and a baseball game, covered by the surgical center.

The Urology Group in Cincinnati, Ohio, was formed in 1996. The group’s original members consisted of 24 urologists. Today, 36 urologists serve the greater Cincinnati and northern Kentucky patient population.

Early in the group’s formation, the physicians knew they wanted a freestanding surgery center, and in August of 1998 The Urology Center was opened. It is entirely owned by the urologists. The facility celebrated its fifth anniversary in August 2003, and over 30,000 patients have received treatment there since its opening.

“Excellence in patient care is The Urology Center’s top priority,” says Deborah L. Bray, RN, clinical director. “Each patient receives a survey asking questions regarding staff performance before and after their procedure, pain control, instructions and overall satisfaction with their care. The facility has always been in the ninety-five percentile for satisfaction.”

Performance improvement activities at the center include monthly reviews of pain assessment, OR start time, facility utilization, length of stay, cancellations, medical record reviews and audits, occurrence reports, post-operative complications, and ESWL complications/ admit. The Performance Improvement committee meets quarterly to review performance and make recommendations for improvement.

“The Urology Center benchmarks our performance improvement with FASA Outcomes Monitoring Project and The Ohio Association of Ambulatory Surgery Centers (OAASC),” says Bray. The staff includes 17 RNs with a combined 25 years of urological experience, an RNFA, a CST, and six administrative employees. Average daily volume is 40 to 50 cases.

The center has six pre-op pre cubicles, two cysto suites, three general operating rooms, one lithotripter and eight PACU beds.

“The Urology Center has contracted with all the major insurance carriers and almost all of the smaller carriers servicing the Cincinnati area,” Bray notes. “Several of the procedures not normally allowed in an ASC have been contracted with these carriers on a carve-out basis.”

The most common procedures at the facility include cystourethroscopy, prostate biopsy, lithotripsy and ureteroscopy. There are no overnight facilities.

The center utilizes the AdvantX management system. Management reports and costing reports are prepared monthly and distributed to the facility’s management and physician owners.

Adjacent to The Urology Center, The Urology Group has an eight-room physician’s office, a bladder control center and urodynamics. Clinical research trials are conducted in the physician office area. The clinical research team has participated in over 45 research projects, including erectile dysfunction, prostate cancer, bladder cancer and chemotherapy prevention.

In 2002 The Urology Group added a CT scanner and ultrasound machine to their services. In September 2003, they added their own pathology laboratory equipped with state-of-the- art analytical equipment. The Urology Center plans to begin brachy therapy in the late fall or early winter of 2003-2004.

Park Ventura Endoscopy Center in Plano, Texas, is staffed by physicians from the Digestive Health Associates of Texas. “They have combined their talent, expertise and resources to create an outpatient endoscopy center with quality patient care unsurpassed in this area,” says Lauren Jensen, administrator of the center.

“From the doctors, nurses and technicians, to administrative staff, every aspect of care provided at Park Ventura Endoscopy Center has been designed with patient satisfaction in mind,” Jensen affirms. “Providing high-quality cost-effective patient care is the primary goal of our center. Staff physicians share experience, talent and technology to ensure the patient’s comfort. Excellent nursing staff and other health care professionals support our physicians. In addition, our center maintains a Quality Assurance committee that strives to continually improve services and care for our patients.”

The physician group is one of the largest gastroenterology groups in the country, with 60 physicians. Serving the Dallas/Fort Worth metroplex, the group provides digestive care at over 28 locations, covering a 100-mile radius.

“I feel like my patients will experience the best digestive healthcare in the area,” says Jensen. “Many years of personal experience as an endoscopic nurse have allowed me to assist the architects, builders and physicians in putting into place a truly patient-oriented digestive endoscopic center. Our patient satisfaction is high and the staff has said it is a ‘GI nurse’s heaven.’”

The atmosphere at Park Ventura is a “GI nurse’s heaven” because “we all come from hospital settings where we work long hours, take call and are always getting called in on the weekends and in the middle of the night,” Jensen points out. “Once you get into GI, you stay. I have nurses who have been in GI for 15 years.”

Park Ventura makes a point of recognizing superior staff members and participating in their continuing education. Turnover is very low and morale high, Jensen adds. “We have employees of the quarter, and at the end of the year, we pick one of those employees to be rewarded monetarily, with a plaque and days off.”

Fairway Medical Center in Covington, La., is a 14,040 square foot multi-specialty surgery center that opened in October 2000. Its most common procedures include gastroenterology, ear, nose and throat procedures, pain management, plastic surgery, podiatry and urology.

Although the facility is just celebrating its third anniversary, it has experienced rapid growth — nearly doubling its number of cases in its second year, and growing by 23 percent in its third year to 5,224 cases.

The center is owned and operated by 33 physicians, and over 70 area physicians are credentialed. Located 30 miles north of New Orleans in one of the fastest-growing parishes in the state, Fairway is currently expanding its size and services to become a surgical hospital by the end of 2004.

Patient satisfaction is a trademark of the ASC industry, notes David Guzan, Jr., MBA, CASC, and CEO of the center. The center’s desire to offer overnight stays to its patients is a driving force behind the conversion to a surgical hospital. The expansion will add 27,000 square feet and will include 21 private suites and four additional operating rooms.

“From the time of arrival to discharge, you are treated as if you are the only patient here,” says one employee. “At other facilities, patients are herded through and made to feel like a number, but here, the staff strives to make the patient feel as though they are an individual of importance.”

“It makes me feel good to know that in a time of need, the one thing I don’t have to worry about is being taken care of before, during and after a procedure,” says the mother of one patient.

“I wish they would have built this facility sooner!” says a patient responding to the facility’s post-procedure survey.

“This was a very pleasant experience, considering that surgery was involved,” says another.

“I have used Fairway Medical Center three times within the last year and I am very impressed with it. I have recommended it to all of my friends (and enemies). You’re doing an excellent job!” says a third.

The staff responds quickly to any patient suggestions. One patient mentioned that the walls in the preoperative area were not soundproof; in response, the physicians owners quickly approved the addition of soundproofing barriers. Patients awaiting procedures were also provided with small under-counter televisions to make waiting time more pleasant.

“It’s not always the bottom dollar,” says Guzan. “It’s about customer service and happy employees. Happy employees mean happy patients.”

Texas Orthopedics Texas Orthopedics, Sports and Rehabilitation Associates was established in July 1986 by two orthopedic surgeons and a physiatrist (a physical medicine and rehabilitation physician). “Surgery is only half of it, you can’t get better without rehabilitation,” says Frosty Moore, MD, founding partner.

Over the years, sub-specialties and enhanced imaging technologies including hifield MRI and bone densitometry have been added, and the practice has grown to nine orthopedic surgeons and two physiatrists with sub-specialties in hand surgery, spine surgery, sports medicine, adult hip and knee reconstruction and electrodiagnostic medicine.

In August 2001, Texas Orthopedics Surgery Center came to fruition, and Norma White, RN, was selected as director. White was one of the first board members of FASA, and she opened the first ambulatory surgery center in Texas and the largest in the United States. She also assisted in constructing the Medicare reimbursement schedule for ambulatory surgery centers.

Strong financial management and excellent cost controls have propelled the center through a very short ramp-up period that has resulted in a very profitable center by the end of its first year of operation. “Everyone on the team participates in our standard of cost control and efficiency. Further, this translates into excellent patient care which is the sole purpose of being for a surgery center,” says Thomas Wolfe, CPA, FACMPE, CASC, administrator of the center. “Patients have a positive experience when coming to our center, which is evidenced by the 97 percent average patient satisfaction rate.”

“Acquiring staff members that have had previous ambulatory surgery center experience is key to low staff turnover”, says White. “The physician’s involvement in the surgery center and how they adhere to high standards makes for a very enjoyable work environment”, she continues.

The philosophy of Texas Orthopedics Surgery Center is that each patient is an individual, a member of a family, and a member of the community. Therefore, each patient requires varied amounts of physical, emotional, psychological, social and spiritual support.

“There have been many occasions on which patients have come in with flowers, cards, lunch, cookies, cakes or hot sauce they’ve made themselves, thanking the staff for the excellent care they received during their stay at our facility. I find it very rewarding to see a patient who is just ‘stopping by’ after attending their post-operative appointment upstairs with the surgeon to tell their nurse hello and how well they were doing. This goes to show that our nurses really do treat the patients like they are one of their own family members,” says Sara Pokluda, office manager at the facility.

“Having a director who adheres to the highest standards in patient care allows me to go home with a sense of accomplishment because of the good processes in place and the idea of ‘safety first’. Also, a good patient-to-nurse ratio — no higher than 2:1 — allows us to be thorough with our patients, not missing one minute detail when instructing them. All of these things allow me to go home thrilled that I work at Texas Orthopedics Surgery Center,” says Maxine Hernandez, RN, a patient care nurse.

The New Horizons Surgery Center opened in November 2000. The ASC offers orthopedic, urology, gynecological, podiatric, ENT, GI endoscopy, general surgery, dental and pain management services. The facility has 16 credentialed physicians and 22 full time staff members.

“Patient satisfaction survey trending reveals greater than 95 percent excellent responses. During its last AAAHC survey, the facility was awarded a three-year accreditation, the maximum available,” says Jo Ellen Braden RN, director of nursing at the center.

The center is known as the community employer of choice, with 100 percent retention of charter staff.

Many patients and families have said walking into the center is like being in someone’s home. Each staff member treats patients like guests in their own home. The result is evidenced by the center’s reputation and excellent survey scores.

New Horizons is committed to continuing education for the healthcare community, its staff and physicians, offering semi-annual ACLS classes conducted by resident RN instructors.

Robyn J. White, RN, and an employee of New Horizons, recently became a patient there as well. “Why would I choose the same place that I work to have surgery? How can I encourage others to have surgery here if I didn’t?” she asks.

In June 2003, White underwent an outpatient laparoscopic gallbladder procedure. “I have had previous surgeries at our local hospital and always with high anxieties. Not that anything is wrong with the hospital — just the usual nervousness of surgery,” she recalls. “With this surgery, I felt relaxed and confident. I had confidence in my surgeon, my anesthesiologist and the nurses.”

“As employees, we let the patient have as much control as possible. The feeling of loss of power can be overwhelming to some people,” White explains. “We strive to make the patient a person, not a number. I know.”

Amy Garwood, RN, reiterates the center’s focus on a friendly environment. “Patients are greeted by a friendly receptionist, escorted to a private dressing room and offered a bathrobe and a warmed blanket to cover up with in a leather recliner,” she says. “The pre-op nurse is able to devote attention to each patient and family, preparing them physically and emotionally for the procedure. The anesthesiologist and doctor visit them in pre-op and thoroughly review and explain information. The circulator nurse introduces herself to the patient and family, providing reassurance, and escorts the patient to the procedure. The patient is then greeted by their specialized team in the surgery/procedure room and comforted with another warmed blanket or bear hugger blanket. The PACU nurse awaits her patient after the procedure, providing individualized attention, care and pampering.”

“We have never received better, more attentive care at any other facility,” says state Senator Larry A. Mumper (R). “The center is known in the Marion community as the place to go for outpatient surgery and procedures. The pursuit of excellence in this surgical facility sets the bar for standards of customer service, excellent care and clean, striking surroundings.”

The Aultman Center for One Day Surgery opened in October of 1984. It was the first and still is the largest freestanding one-day surgery facility in the five-county market area it serves.

The Aultman Center moved to a new location in 1998. The new facility also houses a stat care center, extensive therapy services, and sophisticated diagnostic services including MRI, CT, and ultrasound. Patients can complete pre-admission testing and postoperative rehabilitation on an outpatient basis.

“Patient satisfaction consistently rates in the 99th percentile of excellent care. Aultman has been the Healthcare Market Guide Consumer Choice for 8 years in a row,” says David Thiel, senior vice president, Aultman Health Foundation. Of note, the facility has a 10-minute OR room turnover rate.

Patients are greeted at the door by a concierge service and are discharged directly to their cars by a nurse. An evening follow-up phone call recognizes patients for choosing the facility and reinforces the personal touch.

The center views and treats physicians as customers as well by surveys and participation in equipment and supply choices. Medical direction is provided by a board-certified anesthesiologist. The center is overseen by a medical review committee composed of a member from each specialty.

Aultman North Center is part of the Aultman Health Foundation, a non-profit, locally owned healthcare system. Aultman has the largest hospital-based PPO joint venture with physicians in northeast Ohio. “This allows us to provide high-quality care with significant reduction in cost that is passed on to businesses and the community,” Thiel emphasizes.

The center’s employee turnover has been less than 1 percent for five years. Salaries and benefits are very competitive and include longevity compensation. Each employee is empowered to resolve patient problems for up to $150 without management approval. The facility consistently has a waiting list of providers who wish to work there.

The Center grosses over $5.2 million with an EBIDA margin of 18 percent. “This is in the 95th percentile of benchmark ASCs,” points out Thiel.

With over 5,000 procedures, the Center’s primary focus has been ophthalmology, orthopedics, plastics, general, gynecology and podiatry.

“The center is fully committed to JCAHO standards as an outpatient center and has been since its opening 19 years ago,” Thiel states.

The Aultman Center also promotes the advancement of medicine through research; patients participate in research protocols in cancer, orthopedics, and ophthalmology.

Educational needs are assessed annually. Continuing education programs are presented an average of three times weekly, providing the community and staff with pertinent educational programs.

The Shreveport Surgery Center serves more than just the local community — patients come from as far away as Arkansas and Texas. “The center pulls from a 200-mile radius around the city of Shreveport, including Dallas, Monroe, Lafayette and New Orleans,” says Mary B. Jones, RN, administrator of the facility.

The facility opened in December, 1982, and it is owned by the physicians who use it. “Since the onset, the motivation of the center has been its superb patient care, excellent treatment to its doctors, competent nursing and office staff,” says Jones. “The center caters to the schedule of the doctors by being willing to start as early as 6:30 a.m. We have 10-minute turnover times and efficient readiness in the operating room.”

The center works closely with the physicians’ office staffs to ensure each detail of the patient’s surgical experience is smooth and efficient.

“The center’s fee schedule is extremely competitive with the local market, oftentimes half the cost of the hospitals,” Jones notes. “The staff works with the patient prior to their surgery day to ensure a complete understanding of their financial liability.”

The ASC is a multi-specialty center but is known mostly as “The Plastic Surgery Center” of Shreveport. Although the largest percentage of cases are cosmetic surgery, a rapidly growing percentage of cases include ear, nose and throat procedures, oral surgery, gynecology, podiatry and hand surgery .The center has state-of-the-art equipment covering each of these fields, as well as the largest stock of breast implants in the area.

“I know that what we offer to our patients is the best around,” Jones affirms. “Many of my employees and their families have chosen the center for their surgical needs.”

Jones functions as the center’s administrator, business office manager, OR manager, purchasing agent and partnerships liaison. “My major philosophy in taking over the administration of the center was to achieve the fine balance between efficiency and the personal touch of warm patient care,” she says. “I was involved in the charter membership of the Louisiana Ambulatory Surgery Center Association and serve currently as the vice president. My strategy for involvement in this organization is to keep the center and its owners informed of the ever-changing legislative mandates related to healthcare and particularly related to ambulatory surgery centers. This allows us quickly and without interruption to make changes in policy and procedure that fit with my overall philosophy. Our state licensing has been met with no deficiencies for the past three years.”

“The Holzer Clinic has long prided itself on the fact that the patient is the center of all that we do,” says administrator Todd M. Fowler. “I am confident you could contact any of the thousands of patients we have tended to and receive highly positive feedback on how we attended to their needs, medically and personally.”

The clinic performs ongoing surveys, which indicate high levels of patient satisfaction — 95 percent or better. “The care and attention the patient receives the day of surgery is only part of our satisfaction efforts. We also make post-operative telephone calls on over 50 percent of our patients. Anesthesia satisfaction surveys also conducted and we consistently receive an average of 3.8 to 3.9 out of a 4.0 scale system,” Fowler adds.

Case costs are tracked regularly for every case performed. In 2003, the facility set a departmental objective to increase revenue per case by 5 percent. “We are more than achieving this, primarily through cost-containment efforts,” affirms Fowler. “These efforts include proper staff allocation, high awareness of supply usage, improved case mix, and increased case volumes. Manager Carol Fairchild, RNC, has done an excellent job of sharing cost issues with staff and getting their understanding and buy-in into the importance of aggressive cost management. The staff also realizes that cost containment cannot have a negative impact on our ability to provide quality care. If a decision needs to be made that requires a sacrificing either quality or expense, we always sacrifice the expense to maintain quality.”

No team is stronger than its weakest link, Fowler quips, noting that Holzer Clinic has a skilled and talented staff who pride themselves on good service. “The staff realize that the quality of care we give a patient, or the level of service and support we give our surgeons, is a direct reflection on them as individuals and as a team. There is also a level of competitiveness between our staff and the local hospital. We want our surgery center to be the location of choice when someone needs elective surgery. Furthermore, we want the surgical staff to prefer our services to those the hospital offers. The way to do that is to ensure a smooth operation that makes working here enjoyable and efficient for our surgeons. When that is achieved, quality care and patient satisfaction fall right in behind. Turnover in the ASC has been 0 percent in 2003, a testament to the staff satisfaction.”

Superior service is normal; “Our daily efforts to improve services, increase volumes or cut costs seem to us routine and just part of what we are supposed to do,” Fowler says. “I don’t feel we see ourselves as innovative or trend-setting in what we do. But we have been aggressive in how we approach continuous quality improvement, from schedule management to patient and staff satisfaction to clinical outcomes.”

Holzer Clinic is a multi-specialty group practice; the ASC is but one component of the organization. “We are fortunate in one sense that we have multiple surgical disciplines in our center, but at the same time that creates challenges to scheduling,” Fowler points out. The center’s services include gastroenterology, general surgery, orthopedics, gynecology, cosmetics, pain management, ophthalmology, mammotome breast biopsy and urology.

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