The concept of a “tipping point” is very old; this rhyme, published in about 1390 and later popularized by Benjamin Franklin, shows at least a military appreciation of tipping points. In more recent days, tipping point theory has been applied in physics, urban sociology, epidemic epidemiology, and more recently in popular culture and management theory.2 Tipping point theory owes much to mathematical catastrophe theory, which studies the ability of small environmental changes to cause large behavioral changes. Catastrophe is not a place we want the ambulatory surgery center (ASC) to go. Tipping points are not synonymous with turning points, with turning points tending to be a single major event of immediate and obvious impact, as in the turning point of the battle or the turning point of the political campaign. Tipping points may be less sudden or less obvious; there may be no headline event, but a decision or moments of indecision that tips the organization one way or another. In some cases, many small changes sneak up and suddenly tip the organization. Most ASCs exist because of a tipping point. ASCs were a small niche segment until a tipping point about a dozen years ago, and now ASCs are in the mainstream of healthcare services. Start-ups and Tipping Points Launching a new facility presents a series of tipping points, scattered along a critical path³ of decisions. Each is an opportunity to tip the organization in a positive direction, but each also presents to possibility of tipping toward the negative, or at least to being less effective. From the initial concept through governance design through development and startup, there are any number of key decisions that will determine the positive or negative tipping of the organization. These inflection points can help to insure or sabotage the success of the new organization. 
Tipping points during startup sometimes offer an opportunity to catch and repair the problems, but at some point down the path, like the point at which an airplane is committed to take off, the path has few or no options. Hiring an architect inexperienced in ASC design could tip a project into a negative direction and leave the organization stranded with a less than optimal operating stance for many years. Hiring an architect well versed in ASC design can have a positive impact on operations for many years to come. Understanding Context Tipping points are context sensitive4 and so understanding the ASC context is important. Surgery is a complex business requiring high skill levels, huge demands on employee performance, and exacting equipment performance; it involves complex technology, requires superb management coordination and task supervision, and sometimes a little luck. Failure can be crippling or deadly. And if we want a profit at the end, we need excellent performance from all levels of support staff. How is that for pressure? The patients are always at a personal tipping point. The facility is always near a tipping point. Pressure is a constant companion in the ASC. This is not all bad, because there should never be complacency in an ASC. Pressure is a reason to sharpen focus. Governance Tipping Points I don’t think I will surprise anyone by mentioning that many physician-owned organizations have governance problems. From initial concept to ongoing operations, a clear and fully functional governance structure is critical to ASC success. If your ASC has a dozen physician board members, does your facility have a dozen bosses? Is the chain of command clear and fully functional? Ownership and management conflicts can cripple an ASC. Lackadaisical governance may be as harmful or even more harmful. Executives and nurse executives who are placed in the middle of governance squabbling lose effectiveness. Operational Tipping Points An existing facility will face various tipping points, ranging from sneaking up from a gradual series of changes and other times from a single major event. If I were to pick the single most important tipping point in ASCs, it would be the change of the director of nursing services (titles vary). In most facilities the chief nursing officer position has the most impact on the quality and profitability of the facility. A change in nursing directors may cause the facility to tip in a positive or negative direction, often depending upon who is leaving and who is being hired. The chief nurse has a major role in both leadership and management (and shame on those who do not appreciate the difference), and will set the tone for the performance of the staff. A blunder in hiring a director could tip the facility in a negative direction, while an inspired hire might tip the facility in a welcomed, new direction. Just as germs can create healthcare-related epidemics, management errors can cause epidemics of bad morale or turnover. Other changes can be critical as well; a new executive director, a new medical director, the admissions of new physicians, the retirement of physicians, a governance rift, new procedures and services, a new surgical supply vendor, or a new IT application could potentially tip the facility. Some tipping points can be positive for some constituencies and negative for others. The election of an orthopedist as president could be very positive for orthopedists and very negative for general surgeons. Whenever one constituency loses, it is likely the entire facility will feel negative impacts eventually; negativity tends to breed negative results. The Most Important Tipping Point of All Given the requirement of choosing one tipping point as the most crucial, I would pick any action that tips staff morale. Tipping morale to the better can make an amazing improvement in most healthcare organizations. Tipping morale downhill can truly be a catastrophe. Leadership sets the tone and an atmosphere, but has little value unless management and supervisors are doing a good job with the daily tasks – the horseshoe nails of everyday operations. Epidemiologists use tipping point theory to explain epidemics, and social scientists use epidemics as a metaphor to describe social phenomena. Epidemics can occur in your facility when bad morale spread likes a deadly virus through your staff. Governance discord comes in a close second. Anticipation Understanding tipping points provides us with a major management tool – anticipation. The ability and willingness to anticipate tipping points, to consider the potential benefits and risks, and to set up monitoring mechanisms, gives ASC executives a major head start on possible tipping points. Perhaps it is my background in risk management, but anticipating everything that can go wrong is second nature to me; anticipation allows planning and preparation. We can see many tipping points coming, and that should allow anticipation. Installing a new billing and electronic medical record (EMR) system is not something we do a few days in advance. We have time to anticipate the impacts of the installation. Tipping points should be thoroughly discussed with both the vendors and staff, and the transition should include as many preventive measures as possible. The installation of a new billing system can be a tipping point, so increased monitoring, focused supervision and increased compliance activity should be brought to bear. Some definitions of tipping point use speed as an indicator; when the tipping point is reached the positive or negative effects will accelerate. The acceleration of a benefit (improved morale) is much welcomed, the acceleration of a problem (declining morale) is very unwelcome. It is likely that problems accelerate faster than benefits. Some tipping points are external and out of the control of providers. The U.S. healthcare system may undergo a drastic overhaul in the next few years, and there may be little we can do at the ASC level.5 We can anticipate, but some events are too remote to be controlled or contained.  Tom Ealey, MAcc, CPA, is associate professor of business administration at Alma College in Alma, Mich. He has three decades of healthcare experience as a CPA, management consultant, practice administrator, litigation analyst, seminar leader and writer. He can be reached at ealey@alma.edu
References 1. John Gower. An epic love poem about 1390 AD, modern translation. 2. Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. Little, Brown & Company. 2002. 3. “Critical path method,” aka “CPM,” is a frequently used project management tool. 4. Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. Little, Brown & Company. 2002. Chapters 4-5. 5. Halverson GC. Healthcare tipping points.
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