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Nov 13
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What’s Your ASC’s Leverage Point in Payer Negotiations?

What’s Your ASC’s Leverage Point in Payer Negotiations?

By Leadership, Payor Contracting No Comments

When it comes to payer negotiations, your ASC leverage point is the weight you bring to the game. What do you lean on to produce results? What card(s) do you play to change the game?

What we’re talking about here is simple physics – matter, motion, energy, and force. Or put more simply, influence. Influence equals change. And no influence equals no change. If what you’re leveraging weighs on you as much as it does your opponent, it’s not leverage. Think of a teeter-totter on a playground with two evenly weighted people on it. It doesn’t move much! You need force applied to one side to create influence and shift the situation.

Your ASC leverage point is achieving the most gain while exercising the least amount of loss. It is important to know what you can concede and what you must gain before your walk into any negotiation. Apply this to all parts of your ASC business operations, especially negotiation with payers.

Optimal leverage enables you to impact change that multiplies your efforts and preserves the utilization of your resources.

Let’s look at an ASC leverage point example.

Is achieving a slight increase in your ASC’s procedure reimbursement at the cost of surrendering payment for implants a leverage point? No, because it costs your ASC as much as it gains. Again, think of the teeter-totter example with two evenly weighted parties attempting to move it. You must work to concede less while still achieving positive results. If your ASC can gain a decent increase without giving up anything other than perhaps the time and energy necessary to make its case, then a true leverage point is exercised.

For a leverage point to work in your favor, it must be sensible, perceived as credible by the payer, and not merely a perceived threat. If perceived as a threat, it will not have the power to influence the other side to move closer to a negotiating position. In either case, an ASC leverage point has potential to bestow gains or impose losses on the other side. However, a genuine leverage point is not overstated or punitive; it’s consequential and practical. It’s the prime force you exert to get what you need and goes beyond strong negotiating skills. Negotiation skills cannot replace a genuine leverage point.

Consider another ASC leverage point example.

Say a payer bundles implant payment and is not offering adequate reimbursement to cover your ASC’s costs plus a reasonable profit. Does your ASC threaten to terminate its contract with the payer because the procedure pays poorly? (This is probably a threat some payers hear often but providers rarely follow-through on.) This tactic would likely amount to a lose-lose proposition for both parties.

An alternate option is to inform the payer your ASC can no longer accept these cases on their members and must divert the cases to a higher paid (facility perspective) and higher cost (payer perspective) center to make your case. The former is not a perceived leverage point unless your ASC truly intends to carry out the termination. But the latter is not only grounded, it will demonstrate to the payer how much they will lose by not administering a reasonable procedure reimbursement that covers your costs and nets a reasonable profit.

Let’s face it, your facility needs the payer to pay more, but the payer has little incentive to pay your facility more. Payers hold significant leverage. To make your case, your ASC must find and exercise its leverage point and change the equation.

A change in the equation can be a payer gaining more information and an increased understanding and willingness to adapt to your ASC’s thinking. Your ASC is offering a cost-containment solution to the payer. Rather than simply asking for greater reimbursement, your ASC must negotiate rates that allow you and your payers to stay in business in a competitive health care market.

Dan Connolly, VP of Payer Relations & Contracting

Nov 06
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Overcoming ASC Management Nightmares: Finding OR Nurses

Overcoming ASC Management Nightmares: Finding OR Nurses

By ASC Development, ASC Management No Comments

First installment in the “Overcoming ASC Management Nightmares” blog series. Click here for Part 2 and Part 3.

One thing I’ve learned over the years is that if you hold an ASC management position, there’s always something that will keep you up at night. Whether your ASC has been open one day or 10 years, dealing with challenges is the norm. How you address those issues is what really matters.

This is the first installment in my “Overcoming ASC Management Nightmares” blog series which will explore the challenges robbing me of precious sleep. Fortunately, I’ve been successful in taking steps to keep these nightmares at bay. I suspect other ASC managers are experiencing these nightmares too. Hopefully my solutions can help put your mind at ease.

ASC Management Nightmare #1: Finding OR Nurses

The motto “If you build it, they will come” may have served Kevin Costner’s character in Field of Dreams well, but it typically doesn’t help ASCs when it comes to attracting staff. I recently helped build a new ASC. The first question each of the prospective administrators asked was, “How are you going to find staff?”

Nearly everyone I encounter is trying to figure out the answer to this question, particularly when it comes to hiring OR nurses. You can be in an area oversaturated or under-saturated with ASCs. In either case, you likely won’t find a large pool of good quality OR nurses to choose from.

How did we get here? Formalized educational forums for non-OR nurses to receive OR training is lacking. New nurses coming out of nursing school often feel they have received enough clinical education to justify a management position. The OR setting is heavy on mature nurses who are likely to retire in the coming years.

If you want to recruit high-quality OR nurses away from existing employment, prepare to pay them more than you pay your current pre-op and PACU nurses. You may need to offer OR nurses a different tier of benefits to entice them to join your ASC. Successful recruitment may even require you provide a substantial hiring bonus and cover relocation costs.

Adding OR nurses can affect many different layers of your business and operations, including physician/owner satisfaction, financials, and morale. Unfortunately, there is a lack of resources to help address this nightmare without breaking the bank.

Solution

Rather than look outside of our ASCs for OR nurses, we are looking within. We are implementing training programs that afford non-OR nurses the opportunity to become OR nurses. The Association of Registered Nurses (AORN) develops and sells the program’s infrastructure. It is comprised of a syllabus and criteria for staff to meet.

If a staff member expresses an interest in becoming an OR nurse, ASC management assesses the individual’s qualifications. When the nurse is in good standing and possesses the appropriate skill level, we purchase the AORN program on their behalf.

Once in the program, nurses in training work and are paid for their regular shifts. However, they do not perform their normal pre-op or post-op functions. Instead, they shadow a current OR nurse who serves as their mentor and helps provide on-the-job training. The trainees must complete homework and take tests on their own time. When they successfully complete the program, they transition into the OR.

We make a substantial investment in these nurses. Not only do we cover the cost of the program, we also pay another nurse to cover their responsibilities during their training. To enter the program, nurses sign an agreement with the ASC. They must remain with the ASC for an agreed-upon length of time that allows the facility to recoup its investment. If the nurses fail to complete the program, a payback mechanism in place.

Our use of the program is in its infancy, but the results are encouraging. Knowing we have a mechanism to help us groom our own OR nurses provides great comfort.

Putting Your ASC Management Nightmares to Bed

As long as you are in an ASC management position, don’t expect many anxiety-free evenings. That’s not unusual when you directly impact the success of a business and safety of people.

But try not to feel like you need to come up with all the answers to the challenges your ASC faces on your own. Brainstorm with people inside and outside of your organization. If you’re experiencing a challenging situation, chances are that others in ASC management are as well. When you connect with likeminded people working in the same industry, you can problem solve together.

And try not to be afraid to talk about the issues that are keeping you up at night for fear that it makes you appear vulnerable. I believe it does just the opposite: When you identify an issue and attack it head-on, you appear stronger. After all, no one has all the answers. Simply acknowledging there is a problem oftentimes makes it easier to develop a solution.

Lisa Austin, VP, Facility Development

Nov 02
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Improving Clinical Staff Efficiency with ASC Business Education

By ASC Management, Leadership No Comments

Gradually moving up the ASC job ladder provided me with opportunities to learn a great many things. One of the most significant lessons arose not long after I moved into a management position.

As a nurse, my focus was on delivering the best care possible to every patient that crossed my path. When we delivered great outcomes, I felt successful. Because there were always patients for me to care for, I assumed the ASCs I worked in were also successful businesses.

My outlook changed when I became a manager. My effectiveness as a manager requires focusing on the bigger picture. A significant part of that picture still includes the delivery of safe, compliant care. However, another sizable part involves the financial side of running an ASC. I felt very comfortable with the former and completely unprepared for the latter.

In a clinical position with no management duties, I didn’t stop to consider the ASC business. I didn’t know the reimbursement we receive for a case covers everything we do for patients, from the moment they walk in the door until they go home. It also covers the ASC’s expenses, including our surgical supplies, utilities, rent, and, of course, salaries. I did not receive any relevant ASC business education until I assumed a management position.

Receiving an ASC business education changed my perspective on the delivery of care. Now, every time I see an unused towel or suture in the trash, I equate it to money – money that could go toward better equipment, new technology, and pay raises. I quickly surmised conveying some ASC business education basics to my clinical staff would likely go a long way toward cutting our costs.

Here are some of the ways I approach providing ASC business education to clinical staff.

Allocate time. During our monthly staff meetings, I commit time to discuss our business. I gauge what staff members do and do not understand. I provide clarification when they have specific questions. Once a quarter, I dedicate most of a meeting to ASC business education. This allows me to dive more deeply into specific topics. Since much of what I cover is new, I spread out education to avoid overwhelming staff. I want to teach, not scare them.

Keep it simple. Clinical staff don’t need to know every little detail about the ASC business. When I explain concepts like reimbursement, inventory management, just-in-time ordering, and case costing, I take a “101” rather than a “301” approach. I define concepts using basic terms and outline how they affect the ASC’s bottom line. I focus on how improvements in our ASC business performance benefit patients, staff, and facility.

Break down costs. Sometimes providing a little data can help drive a point home. Our ASC uses Project C.U.R.E. bins to gather medical supplies and equipment for donation. Staff discard unused items from surgical packs into these bins. After these bins fill up, I take pictures of the items inside and put a cost to them. I show these pictures and share the financial breakdown with staff. I also share data comparing the cost of “red” medical waste versus regular waste and disposable versus reusable supplies. Talk about eye-opening experiences!

Challenge staff. Once staff gain a better appreciation of waste costs, we attack our surgical packs. I ask staff to look at the packs to determine what is actually needed in them. At times, staff indicate rarely used items are included in the pack per physician request. In these instances, I speak with the physician. We typically remove the item from the pack but make sure it is available in the room during surgery. That’s a win-win!

New isn’t always necessary. On one occasion, an influx of non-ambulatory nurses joined our ASC. The facility they previously worked in purchased everything new. I educated them about refurbished equipment. I emphasized our use of this equipment did not jeopardize the delivery of high-quality care they were used to providing but did save us money.

Focus on safety. When speaking about cutting costs with your clinical staff, expect some looks of concern. Staff may translate “cutting costs” to mean “cutting resources” and, therefore, “cutting corners” on safety. Convey to staff the ASC will not authorize cuts that could jeopardize safety.

For example, we were using a lot of sterile towels during non-sterile cases. When I addressed how the use of non-sterile towels during these cases would benefit the ASC business, I also explained why doing so wouldn’t increase risk.

Engage Staff, Grow the ASC Business

As my clinical staff gained a better understanding of our ASC business model, they embraced the challenge of finding and implementing cost-cutting changes. With this mindset, we achieved significant savings in a short amount of time.

I know we can always do better. That’s why I try to ensure our clinical staff always have the business education of our ASC operations in the back of their minds. It’s easy, even for leadership, to become complacent when things seem to be going well. But in a health care environment where every dollar really does matter, there’s no room for complacency, and no reason not to empower all staff to make a difference in the bottom line.

Tara Demuth-Fenton, Director of Operations

Oct 26
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ASC Vendor Contracts – How to Track Service and Save Time!

ASC Vendor Contracts – How to Track Service and Save Time!

By ASC Management No Comments

Surgery center stakeholders expect administrators to proactively evaluate ASC vendor contracts and continually assess vendor performance to ensure their ASC is receiving high-quality services. These tasks not only ensure ASC operations run smoothly and cost effectively but maintain compliance with expected quality metrics.

ASC vendor contracts are defined as services obtained from an agency or vendor external to the facility. Examples of vendor contracts your surgery center may hold include laundry, environmental services, transcription, medical waste disposal, lab/pathology, etc. Your medical supply distributors also fall under the vendor classification.

While this task may seem time-consuming and onerous, here are some ideas on how to streamline the process of regularly assessing if your vendors are meeting your needs.

First, get organized. A best practice is keeping all your ASC vendor contracts in one location where they can easily be accessed. A hard copy contract binder or an electronic folder with multi-user access may meet this need. Establish a master list or spreadsheet of all the service contracts held by your facility. Include information for each vendor – contact information, expiration dates, billing cycles, and service(s) provided. File the master list at the front of your contract binder or on your computer desktop for frequent reference. This list will come in handy for monthly OIG verifications and periodic quality reviews.

Your facility’s quality plan should include an annual review of your ASC vendor contracts. Tracking the quality of the services provided by external vendors is essential. This is because the facility holds ultimate responsibility for the provision of quality services regardless of who is supplying them.

To assess ASC vendor quality, set up one or two measurable, mutually-agreed upon benchmarks or goals. For example, you might establish a benchmark with your laundry service to send no more than ten pieces of torn or unusable linen items to your facility per quarter. Or, you may want to track the return rate of your pathology reports to determine if they are received within the contracted terms. You could track your medical supply distributor’s fill rates to determine if they are meeting your expectations. Tracking controlled variables may prompt you to establish other benchmarks and formalize them in your service contracts. Schedule periodic meetings with your vendors to share measurable results and any new expectations.

Once quality measures are established, add them to your master list. Leave extra space to record the status of each quality measure and a section for comments regarding quality or service. Make sure any poor or unsatisfactory ratings are backed up with specific comments. Explain any non-compliance issues by comparing them to your set standards. Remember to document positive comments for excellent service.

Review poor ratings to determine if there are any trends in declining service. The service review process and subsequent actions taken may lend itself to a quality improvement study. You can use these trends to decide if you need to meet with vendors for corrective action or if it’s time to vet out other vendors for a possible change in service. Be careful not to jump to conclusions. Give vendors a reasonable amount of time to address identified issues.

Combining quality indicators and service assessment into an ASC vendor spreadsheet makes annual presentations to your governing body organized, concise, and relative. This tool also serves as a tremendous time saver because you can proactively address ASC vendor contract expirations, quality assessments, and service expectations. Last, but certainly not least, this system allows you to identify problems early and establish improvement plans with your vendors. If efforts to improve fall short, recommendations to the governing board to change vendors are more likely to be met with support and buy-in due to your continuous documentation, due diligence, and assessment.

Implementing this process will earn you a pat on the back for saving time, while simultaneously addressing quality, due to your strong planning and organizational skills. That’s a win-win for everybody!

Kelli McMahan, VP of Operations

Oct 19
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Outpatient Care: The New Business Model for Hospitals

Outpatient Care: The New Business Model for Hospitals

By ASC Development No Comments

The September 25th addition of the Wall Street Journal published a thought-provoking article about large hospital corporations developing outpatient facilities. The article, “Warding off Decline, Hospitals Invest in Outpatient Clinics” by Melanie Evans, indicates this outpatient migration includes ambulatory surgery centers (ASCs), urgent care clinics, and freestanding emergency rooms (ERs).

There are several interesting points raised in the article for hospital executives, physicians, and current operators of ASCs to consider.

The increase in patient responsibility

The patient’s role in controlling health care costs is increasing. It can be seen in the proliferation of high deductible insurance plans and the push to make consumers more aware of the cost of their care. The article cites RBC Capital Markets’ managing director, Frank Morgan, and the California Employees’ Retirement System (Calpers) as sources touting the responsive move by hospital operators toward providing more care in the outpatient setting. This trend has presented both challenges and opportunities for Pinnacle III’s clients. Several years ago, as patients quickly became the second most prevalent health care payer behind the federal government, we focused our partnered ASCs on the need to effectively collect patient deductibles and copays. Doing so preserved the cash flow necessary to sustain ASC operations. We also worked with our clients to improve their outbound messaging to educate the public about the cost-effective options offered by ambulatory surgery centers.

ASCs fill the need for additional options for access

While ASC development dipped a few years ago, as noted in our previous blog publications and identified in Ms. Evans’ article, this sector is growing again. The increase in patient responsibility has led many patients to actively seek out lower cost options for care. Ambulatory surgery centers address that need. Additionally, payers are encouraging patients to utilize ASCs and other outpatient venues to reduce their costs. Hospital systems and physicians witnessing this transition are identifying needs in underserved area as opportunities to grow their market share. As Ms. Evans states, this is all done, “In an effort to strengthen their hold on their market and prevent rivals from siphoning off patients.” For these reasons, we continue to experience robust de novo growth of ASCs throughout the country.

Improved technology

The article briefly acknowledges that technological improvements are driving some of this change. This point is not taken lightly by Pinnacle III. The migration of high acuity cases from the inpatient setting to the outpatient arena is a significant driver in both the growth of ASC volume and the increase in de novo activity. To move high acuity cases safely to the outpatient setting, advancements in medical technology are a necessity. Technological improvements also increase time effectiveness for physicians and provide enhanced convenience and comfort for patients. The types of care offered in outpatient settings will continue to grow as more states evaluate the efficacy of convalescent care or recovery centers as optional add-ons for ASCs. Finally, significant growth will occur once CMS begins to encourage the transition of total joints to the ambulatory setting.

While several factors are at play, one thing is clear – the health care industry is experiencing rapid growth in outpatient care, driven by hospitals, physicians, patients, and payers alike. Ms. Evans’ article provides a wakeup call to some, and validation to others, of the need to clearly define the outpatient strategy for their practice or system.

Robert Carrera, President/CEO

1Wall Street Journal article March 29, 2017 Warding Off Decline, Hospitals Invest in Outpatient Clinics; https://www.wsj.com/articles/warding-off-decline-hospitals-invest-in-outpatient-clinics-1506331804

Oct 11
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ASC Real Estate Ownership v. Leasing – What’s Best for Your Business?

ASC Real Estate Ownership v. Leasing – What’s Best for Your Business?

By ASC Development, ASC Governance No Comments

Surgery center investors, like other business owners, must weigh the pros and cons of leasing or buying the space in which an ambulatory surgery center (ASC) resides. How does one decide which option is best? Investors who understand the financial impact ASC real estate ownership or leasing is likely to have on the short- and long-term development of their business project are better equipped to make sound decisions. Only then can investors thoughtfully examine other reasons for either leasing or owning their ASC space. Let’s explore the considerations of both options.

Leased ASC Space

Leasing space for an ASC from an unrelated third party is typically the most straightforward option. It avoids many of the additional steps required in the ASC real estate ownership model described below. Best practice allows the prospective owners to determine a geographic location that ensures the greatest potential for physician partner participation. The ownership partnership then locates a space that will meet its needs – no more, no less. The ASC partnership evaluates the lease rate of the space as well as the construction costs required to convert it to an operating ASC. Costs are then evaluated against the project pro forma to determine if the space best meets the identified needs and desired financial outcome.

Owned ASC Space

The second option is an ASC real estate ownership model in which the ASC LLC, or some portion of its members, own the space where the facility will be located. This model, while providing equity, presents a few challenges and considerations for the ASC investor group.

  1. Fair market value: Regardless of who owns the space, the terms of the lease must represent fair market value for like-space in the area to ensure the entity does not run afoul of federal Anti-Kickback laws. The health system partner cannot subsidize the ASC partnership with artificially low rent; nor can the ASC partnership pay an inflated rental rate in space owned by some, or all, of its physician investors or a potential referral source.
  2. Location, Location, Location: The old real estate adage holds true in our business as well. The location of the facility is the most important factor when considering ASC real estate ownership. I have seen some centers struggle, and others fail, because fifteen minutes is too far for the partners to drive. I have also worked with partnerships who are convinced a location twenty minutes away is the better option because the ASC real estate ownership deal makes more sense for those physicians. The bottom-line? The best location is the one that will be consistently utilized.
  3. The ASC is the primary business: A business owner once told me he would have been more successful if he had made fewer of his business decisions based on the fact that he owned the building. While real estate ownership may be attractive, if the ASC meets the expectations of a well-vetted pro forma, its returns should far outpace that of the real estate investment. Thus, the primary concern for the ASC LLC partnership should be the location and lease terms that make the most financial and operational sense for the ASC.
  4. Ownership structure: Many times, ASCs include the ASC real estate ownership in the ASC LLC partnership. In every one of these instances, problems arise down the road. Our advice, while not always accepted, is to have a separate LLC own the real estate. The real estate partnership can then lease space to the ASC LLC at fair market value. The real estate entity can be structured in a number of ways – owned by the ASC LLC partners, a subgroup of partners, an individual partner, or another similar arrangement. The benefit is this structure will allow the real estate to be dealt with separately from the ASC.

Owning versus leasing the real estate in which your business operates is never an easy decision. ASC owners must consider a variety of factors, including which option makes most financial sense and what will best serve its customers, physician partners, and patients. Carefully weighing all options will yield the best outcome when deciding if you should lease or buy space for your surgery center.

Robert Carrera, President/CEO

Oct 04
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Safe Medication Practices: Understanding CMS' Standard for ASCs

Safe Medication Practices: Understanding CMS’ Standard for ASCs

By ASC Management No Comments

Highly publicized instances of patient complications associated with compounded sterile preparations (CSPs) have increased scrutiny of safe medication practices in ambulatory surgery centers. Citations are being issued related to safe medication preparation and administration. There is confusion, even among surveyors, on the use of some multi-dose medications, such as eye drops.

In CfC 416.48, Centers for Medicare and Medicaid Services (CMS) clarifies that ASCs must provide drugs and biologicals in a safe and effective manner, in accordance with accepted professional practice, and under the direction of an individual the ASC has designated responsible for provision of the ASC’s pharmaceutical services. In the same CfC, CMS indicates drugs must be prepared and administered according to established policies and acceptable standards of practice. To meet the standard set forth in CfC 416.48, ASC Clinical Directors will want to consider this list of safe medication practice guidelines.

Safe Medication Standards of Practice

  1. Designate a licensed staff member to oversee your pharmacy program. Make sure this individual is routinely present in your facility. Follow your state regulations as they relate to the need for a registered pharmacist. Regulations vary from state to state. Some states do not require a registered pharmacist and some, like Texas, require a weekly consult.
  2. Maintain appropriate records for the ordering, receipt, and disposition of scheduled II, III, IV, and V drugs.
  3. Understand that single-dose medications/vials (SDV) are to be used immediately upon opening, on one patient only, and then discarded. Once opened, they cannot be stored for any period of time.
  4. Date multiple-dose medications/vials (MDV) upon opening with the beyond use date. Do not take a MDV into an immediate patient care area. If this occurs, that MDV becomes a SDV for that particular patient.
  5. Ensure staff are aware of the definition of a MDV – “A vial of liquid medication intended for parenteral administration that contains more than one dose of medication.”This does not apply to eye drops. Adherence to this guideline will prevent confusion in a survey.
  6. Create a policy and procedure for the administration of eye drops. Conduct staff training on the process.
  7. Review and be knowledgeable of the questions on the CMS infection control surveyor worksheet found in Exhibit 351.

United States Pharmacopeia Chapter 797 (USP 797) provides guidelines on compounding sterile preparations in ASCs. It is acceptable for a center to compound for immediate use, but the following rules apply:

  1. The compound sterile product (CSP) must be intended for immediate use or an emergency.
  2. The CSP cannot be stored for the purpose of anticipated need or batch compounding.
  3. No more than three (3) commercially available sterile products in original container and no more than two (2) entries into any container/package/device can occur.
  4. Continuous process must be completed within one (1) hour.
  5. Adhere to aseptic technique.
  6. Administer within one (1) hour, or discard CSP.

Examples of immediate use CSPs are antibiotic solutions, blocks, and irrigating solutions. Dilating solutions may also fall into this category. The development of best practices for immediate use CSPs is important and should be included in training and competencies for licensed staff involved in the preparation, transportation, and/or administration of CSPs.

The area where CSP preparation takes place should be quiet and free from distractions. The designated staff member should disinfect the area, complete proper hand hygiene, and wear appropriate personal protective equipment (PPE). The entry ports must be disinfected. Calculations should be verified to ensure accurate mixing takes place. Proper labeling must occur prior to removing the CSP from the preparation area and administering it to the patient.

To ensure safe medication practices and compound sterile preparations are compliant with CMS regulations, ASC clinical leaders may find it helpful to refer to the lists above. Additional information on CMS guidelines is available via the CMS infection control surveyor worksheet and the CMS website.

Jovanna Grissom, Vice President of Operations

Sep 27
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ASC Disaster Response: A Case Study

ASC Disaster Response: A Case Study

By ASC Management, Leadership No Comments

This is the second part of a two-part blog series on ASC disaster response by Diane Lampron, Director of Operations. Click here for part one.

In the blink of an eye, a completely normal day in your ASC, can be upended by a natural or man-made disaster. And it can take days, weeks, or months to return to your pre-disaster routine.

Emergency preparation is not only critical for an effective ASC disaster response, but, as we previously discussed, it’s a Medicare requirement for ASCs. Part of proper preparation is revising your emergency plan based on your response to drills, tabletop exercises, and emergency events. Every revision should improve the helpfulness of your plan. Understanding what it’s like for another ASC to respond to a disaster can further your ASC disaster response preparation.

Below are some of the critical steps taken during a Colorado ASC’s response to a ruptured pipe. The subsequent flooding caused substantial damage throughout the ASC. Areas flooded with the equivalent of sewer water included the waiting room, front hallway, registration desk, pre-op, and recovery room. The sub-sterile area also suffered significant damage. Thanks to a strong, tested emergency plan, hard work by staff, and outside support, the ASC re-opened to full capacity in three months.

Immediate ASC Disaster Response

Steps taken upon discovery of the flood and damage included the following:

  • Called the disaster code
  • Activated the emergency management plan (EMP)
  • Contacted fire department (which turned off water)
  • Ensured there were no patients, visitors, or personnel requiring evacuation.
  • Closed front entrance
  • Notified ASC leadership
  • Assessed affected areas
  • Took pictures of damage
  • Set aside damaged items/equipment (for insurance purposes, this included items that caused the damage, such as a broken sprinkler pipe)
  • Moved unaffected equipment away from damaged areas
  • Notified property insurance carrier
  • Rerouted deliveries

Activating the EMP

Activation of the ASC’s EMP triggered the following actions:

  • Established incident command team
  • Identified who would fill the roles identified in the EMP – Role assignments are critical. Each role guides the activities required to address all aspects of the disaster, from suspension of business operations to the response and through recovery.

Roles assigned included incident commander and staff (e.g., safety officer, infection preventionist, public information officer) as well as sections for operations, planning and logistics, and finance/administration. If you are not familiar with the responsibilities of these positions, the Federal Emergency Management Agency provides helpful resources here. Note: Some of the activities that took place under these sections are discussed below.

  • Developed incident action plan which established objectives throughout response to the incident and underwent regular updates as recovery progressed
  • Notified the facility’s governing board

Communication

The following steps were taken to disperse information regarding the incident and closure:

  • Changed telephone greeting
  • Posted notice on center’s website
  • Notified physicians’ offices
  • Notified the state’s Department of Public Health
  • Issued press release
  • Notified the state’s Department of Fire and Life Safety
  • Notified the facility’s accreditation organization

Disaster Recovery Work

The project was separated into five phases to be completed prior to a re-opening phase:

  1. Mitigation/ restoration
  2. Safety
  3. Demolition
  4. Rebuilding/construction
  5. Risk reduction

Mitigation/Restoration

Steps taken included the following:

  • Restoration company commenced water cleanup and mitigation activities working 24/7 to mitigate further damage
  • Industrial hygienist conducted assessment and took samples
  • Infection control risk assessment (ICRA) performed

Safety

Steps taken included the following:

  • With fire sprinklers offline, fire watch implemented
  • Conducted and documented fire watch walkthrough every 30 minutes during recovery period
  • Created signage for emergency fire exits

Demolition

Steps taken included the following:

  • Brought in contractor for demolition and construction phases of the work
  • Obtained permits needed for demolition and renovation/construction

Rebuilding/Construction

Renovation plans previously scheduled for a future date were incorporated into the disaster recovery work to save on construction costs.

Risk Reduction

Planning included efforts to help reduce the risk of a reoccurrence. For example, additional insulation was installed and a new checklist was created for facility personnel to follow when investigating leaks.

Incident Command Officers and Sections

The incident command officers and sections oversaw the ASC disaster response work described above. Additional responsibilities are described below.

Safety Officer

The safety officer performed the following tasks:

  • Daily walkthroughs for interim Life Safety measures, ICRA, and hazard control risk assessment ensuring corrections were made as needed
  • Daily count of narcotics and medication storage security checks

Infection Prevention Officer

The infection prevention officer performed the following tasks:

  • Daily ICRA assessment walkthroughs
  • Ongoing communication with industrial hygienist regarding assessment and safety tests

Public Information Officer

The public information officer performed the following tasks:

  • Issued regular press releases providing updates on repairs
  • Kept website notices and telephone greeting current
  • Developed wayfinding signage and maps
  • Provided weekly briefings with facility employees

Planning and Logistics Section

The planning and logistics section performed the following tasks:

  • Determined staff availability and work assignments
  • Determined staff pay structure during recovery
  • Worked with local hospital to accommodate ASC patients and coordinate ASC staff support
  • Provided hospital with necessary supplies, equipment, and instrument sets to accommodate procedures rescheduled from the ASC
  • Identified replacement items to be ordered immediately due to lag time in ordering and delivery (e.g., cabinets, counters, doors, carpeting)
  • Maintained communication/phone system and information technology (IT)
  • Coordinated re-establishment of services (e.g., housekeeping, waste removal, linen)
  • Maintained “disaster book” of all response activities

Operations Section

The operations section performed the following tasks:

  • Obtained temporary storage for unaffected equipment that required relocation
  • Identified need for replacement equipment and IT
  • Ensured the hard drives of damaged computers were stripped/wiped before disposal
  • Developed risk reduction plans

Finance/Administration Section

The finance/administration section performed the following tasks:

  • Conducted walkthrough with insurance adjustor
  • Compiled all invoices to be paid
  • Tracked lost revenue
  • Provided cost analysis and cash flow data to governing board
  • Provided insurance carrier with all requested information (e.g., projection of business loss amount, list of damages, photos)

Reopening

The following steps were taken to ensure a successful reopening:

  • Conducted mock patient walkthrough of new space
  • Posted required documentation previously removed (e.g., ASC license, patient rights and responsibilities, HIPAA, accreditation certificate)
  • Reinstated facility logs (e.g., refrigerator temperature, malignant hyperthermia cart check, defibrillator test and cart check)
  • Changed telephone greeting and website notice
  • Issued press release
  • Planned, publicized, and hosted open house
  • Celebrated re-opening and facility’s return to normal operations!

You Can Never Be Too Prepared

As I write this, Hurricane Harvey has wreaked havoc on Texas. Fires are consuming hundreds of thousands of acres across multiple western states. Hurricane Irma has Florida in its crosshairs. There is no shortage of news about the extensive damage that occurs in the wake of these disasters.

On a positive note, there are reports highlighting the improved preparation and response effort thanks to lessons learned from disasters like Hurricane Katrina and Rita. There will undoubtedly be lessons learned from Harvey and Irma that will help with future disaster planning.

Hopefully the Colorado ASC disaster response outlined above helps your surgery center identify opportunities for its own preparation improvement. If your ASC experiences a disaster, I encourage you to share your own response efforts. Relaying your story to an industry publication or presenting on it at a state or national meeting could ensure other ASCs benefit by learning from your experience.

I will leave you with this key takeaway. You cannot plan for everything. However, the more you prepare, the better off you should be when faced with the unexpected.

Diane Lampron, Director of Operations

Sep 19
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2017 OAS CAHPS: Should Your ASC Implement CMS’ Survey in 2017?

2017 OAS CAHPS: Should Your ASC Implement CMS’ Survey in 2017?

By ASC Management, Payor Contracting No Comments

The Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Provider and Systems (OAS CAHPS) collects information about patients’ experiences of care in ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs). The survey gathers patient perceptions related to communication and care provided by surgery staff, expectations prior to surgery, and planning related to discharge and recovery. Enforced implementation of the survey has been delayed until 2018, with the specific date being released this November. Surgery centers across the country are deciding if they should implement the survey as planned, or wait until the Centers for Medicare and Medicaid Services (CMS) begins enforcing survey implementation.

To assist in decision making, it’s helpful to review information regarding the OAS CAHPS Survey.

Why is CMS developing this survey?

  1. The number of ASCs has increased considerably in recent years as has the surgical case volume at both ASCs and HOPDs.
  2. Medicare expenditures from outpatient surgical sites for ASCs and HOPDs also continues to rise.
  3. Implementation of OAS CAHPS will provide CMS with statistically valid data on the patient experience to inform quality improvement and comparative consumer information about outpatient surgery facilities.

The results of the OAS CAHPS will be used to:

  1. Provide CMS with information for monitoring and public reporting purposes,
  2. Provide a source of information enabling prospective patients to make informed decisions in outpatient surgery facility selection, and
  3. Aid facilities with their internal quality improvement efforts and external benchmarking comparatively with other facilities.

What modes are available to administer the OAS CAHPS?

  1. Mail only
  2. Telephone only
  3. Mixed mode (mail survey with telephone follow-up of non-respondents)
  4. An electronic mode of surveying is currently under review.

How often is the OAS CAHPS administered?

  1. Surveys are administered on an ongoing basis.
  2. An annual minimum of 300 surveys must be completed for each facility.
  3. Participating facilities will provide a monthly sample of patients who received at least one surgery or procedure during the sample month to their survey vendor.
  4. Vendors will initiate surveys within three weeks after the sample month closes.
  5. Once a survey has been initiated it must be completed within six weeks.

The OAS CAHPS may be administered in conjunction with other surveys but sampling methods need to be followed to ensure patients are not overburdened by multiple surveys.

  1. For each sample month, the survey vendor must select the OAS CAHPS sample prior to selecting the samples for any other ASC survey.
  2. The ASCs cannot select the sample for any other facility survey they may choose to implement.
  3. The vendor must select the sample because the sample selection for OAS CAHPS cannot be disclosed to the facility.

OAS CAHPS Survey Implementation

  1. National voluntary implementation began in January 2016 with required participation scheduled to begin January 2018. CMS has proposed delaying implementation of the mandated 2018 date. The decision will be released in Medicare’s final 2018 ASC payment rule this November.
  2. It is unlikely the delay will be permanent because CAHPS surveys are already mandated in hospitals, home health, hospice, and dialysis centers.
  3. ASCs that have voluntarily participated in OAS CAHPS have received valuable information about the quality of outpatient care provided at their facility.

There are pros and cons to implementing the survey now versus waiting until CMS mandates the survey next year. It is often better to prepare early. What should administrators consider in determining what is best for their center?

Reasons to delay the OAS CAHPS Survey until 2018:

  1. Financial and administrative burden of submitting the data.
  2. Decision on the electronic survey mode option.

Reasons to implement the OAS CAHPS Survey now:

  1. You will know where your surgery center stands before mandatory reporting begins.
  2. You will have an opportunity to address identified issues for improved survey results.
  3. You can learn and understand your patients’ perceptions and make changes to increase overall satisfaction.
  4. Post-discharge surveying allows for a better assessment of the entire surgery process.

Peak One Surgery Center located in Frisco, Colorado has chosen to move forward with implementation of the OAS CAHPS survey now. It was an easy decision for us because it will allow us to get ahead of the competition. We can build out processes with our vendor and adjust our internal reporting systems. There will also be time for staff, physicians, and administration to learn the program. When my fellow administrators ask, I advise them to begin work with a vendor on voluntary implementation of the OAS CAHPS survey to avoid being at a disadvantage when the survey becomes mandatory.

Michaela Halcomb, Director of Operations

Sep 13
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ASC Emergency Preparedness: Checklist for Compliance

ASC Emergency Preparedness: Checklist for Compliance

By ASC Governance, ASC Management, Leadership No Comments

Disasters come in many forms. They can be natural – a hurricane, tornado, flood, earthquake – or man-made – a chemical spill or cyberattack. While the impact of disasters varies greatly, what ultimately matters is how your ASC responds. An effective response, outlined in an ASC emergency preparedness plan, can protect and save lives, reduce facility damage, and make recovery easier.

Critical to such a response is the development of an ASC emergency preparedness program. I witnessed its value firsthand at a Colorado ASC that suffered a significant disaster in 2015. The ASC’s plan was instrumental in containing the damage, ensuring patients received the care they needed, and expediting repairs.

If your ASC is certified by Medicare, meeting emergency preparedness regulations is a requirement. Centers for Medicare & Medicaid Services (CMS) outlined these regulations in their final rule posted in September 2016. While the regulations went into effect in November 2016, providers and suppliers have until November 15, 2017 to comply with and implement them.

Earlier this year, Pinnacle III published a blog on “What the CMS Emergency Preparedness Rule Means for ASCs.” With the implementation deadline fast approaching, I thought it would be helpful to publish the ASC emergency preparedness program requirements below. They are organized for your convenience with the intent of helping you achieve and maintain compliance.

Your program must include, but is not limited to, the following four elements:

1. ASC Emergency Preparedness Plan

Develop and maintain an ASC emergency preparedness plan. The plan must:

  • Include a risk assessment. The plan should be based on a facility- and community-based risk assessment that employs an all-hazards approach. This approach focuses on capacities and capabilities critical to preparedness for a full spectrum of emergencies or disasters specific to the location of your ASC.
  • Factor in the types of hazards most likely to occur in your area. Take into consideration facility damage, care-related emergencies; equipment and power failures, and communication interruptions, including cyberattacks.
  • Include strategies for addressing emergency events identified in your risk assessment.
  • Address the needs of the patient population, including services your ASC can provide in an emergency.
  • Address continuity of operations, including delegation of authority and succession plans.
  • Include a process for cooperation and collaboration with emergency preparedness officials (e.g., local, regional, state, federal) in their efforts to maintain an integrated emergency response.
  • Include documentation of your ASC’s efforts to contact emergency preparedness officials and participate in collaborative, cooperative planning efforts.
  • Undergo a review and update at least annually.

2. Policies and Procedures

Develop and implement ASC emergency preparedness policies and procedures. Base them on the emergency plan and risk assessment discussed above and communication plan discussed below. Review and update policies and procedures at least annually. At a minimum, policies and procedures must address the following:

  • A system to track the location of on-duty staff and sheltered patients in your care during an emergency. Note: If you relocate on-duty staff or sheltered patients during an emergency, document the name and location of the receiving facility/location.
  • Safe evacuation from your ASC, including consideration of care and treatment needs of evacuees, staff responsibilities, transportation, identification of evacuation location(s), and primary and alternate means of communication with external sources of assistance.
  • Means to shelter in place patients, staff, and volunteers who remain in your ASC.
  • A system of medical documentation that preserves patient information, protects information confidentiality, and secures and maintains records availability.
  • Use of volunteers in an emergency and other staffing strategies, including the process and role for integration of state and federally designated health care professionals, to address surge needs.
  • Your ASC’s role in the provision of care and treatment as an alternate care site identified by emergency management officials, in the event of a waiver declared by the U.S. Health and Human Services Secretary.

3. Communication

Develop and maintain an ASC emergency preparedness communication plan. Review and update the communication plan at least annually. The plan must include the following seven components:

  • Names and contact information for staff, organizations providing services under arrangement, physicians, and volunteers.
  • Contact information for emergency preparedness staff (e.g., federal, state, regional, local) and other sources of assistance.
  • Primary and alternate means for communicating with your staff and emergency management agencies.
  • A method for sharing information and medical documentation for your patients with other providers to maintain continuity of care.
  • An appropriate means to release patient information in the event of an evacuation.
  • An appropriate means of providing information about the general condition and location of patients under your care.
  • A means of providing information about your ASC’s needs and its ability to provide assistance to the appropriate authority.

4. Training and Testing

Develop and maintain an ASC emergency preparedness training and testing program based on the emergency plan, risk assessment, policies and procedures, and the communication plan discussed above. Review and update the training and testing program at least annually.

With regard to training, your ASC must:

  • Provide initial training in emergency preparedness policies and procedures to all staff, individuals providing on-site services, and volunteers (consistent with their expected roles).
  • Provide emergency preparedness training at least annually.
  • Maintain documentation of all training.
  • Demonstrate staff knowledge of emergency procedures.

To meet the testing requirements, your ASC must conduct at least two exercises annually to test its emergency plan. You must:

  • Participate in a full-scale community-based exercise. If a community-based exercise is not accessible, participate in an individual, facility-based exercise. Note: If your ASC experiences a natural or man-made emergency requiring activation of your emergency plan, you are exempt from engaging in an exercise for one year following the onset of the event.
  • Conduct an additional facility-based exercise. This can be another individual, full-scale exercise or a tabletop exercise that includes a group discussion.
  • Analyze your response to and maintain documentation of all drills, tabletop exercises, and emergency events.
  • Identify and implement improvement opportunities, revising the emergency plan as needed.

Note: If your ASC is part of an integrated health care system with a unified and integrated emergency preparedness program, you may choose to participate in the system’s coordinated program. If you do so, there are additional requirements your ASC must meet. Review the CMS final rule to identify those requirements.

Quick Tips

To achieve compliance, follow the steps provided above. Some tips that will further assist you in your emergency preparation efforts are:

  • Designate an incident commander. This individual is responsible for the overall management of the emergency response.
  • Pre-assign other incident command roles. This could include a deputy incident commander whose responsibilities include filling the incident commander role in the event the incident commander is not on-site during the emergency. It could also include command staff (e.g., public information officer, safety officer, liaison officer) and general staff (e.g., operations, planning, logistics, finance/administration).
  • Make sure your ASC has the appropriate insurance and coverage for the emergencies and disasters you are likely to face.
  • If financial, patient, and other data is stored on-site, plan for how you will protect servers and other critical information technology.
  • Consider any “what ifs.” If there is something you think could happen during an emergency, plan for it.

Improving Your Emergency Preparedness Program

Development of an ASC emergency preparedness program can help a center achieve a more successful response to a disaster. But disasters are unpredictable. An ASC emergency preparedness program can only account for so much. That’s why it is critical to take advantage of every exercise to identify areas of your plan to revise and improve.

It’s also valuable to study how other health care providers responded to actual disasters. Doing so provides an opportunity to incorporate tried-and-tested processes and practices into your plan. In an upcoming blog, I will share many of the steps the Colorado ASC I mentioned took in response to its disaster. By doing so, I hope to help your ASC prepare for what you may face one day.

Diane Lampron, Director of Operations