Administrator: Linda Phillips, RN
Surgeries: Ophthalmology
Staff: 18 - 11 RNs, 2 scrub techs, 4 OR assistants and 1 surgical counselor (all OR staff are contingent except 1 RN, 1 OR assistant and the surgical counselor)
ORs: 2
Operating surgeons: 14
Monthly case volume: 150
Years in operation: 20
Ownership: Physician-owned

Linda Phillips, RN, the administrator for Castleman Surgery Center's one-OR ophthalmology practice, didn't realize that adding an insurance provider and an operating room would take so long (18 months) or be so hard (AAAHC accreditation and a certificate of need).

A condition of Blue Cross participation for single-specialty facilities in Michigan is accreditation by the Accreditation Association for Ambulatory Health Care (AAAHC). And because Castleman Surgery also wanted to add a second OR, it would need a certificate of need (CON), which can be a six-figure expense. "Depending on the consultant's work, I knew it could be $40,000 to $100,000 to do the CON," says Ms. Phillips. "So I thought I would do this myself."

With help from an RN completing her master's in health management, Ms. Phillips set to work.

In the beginning
Getting accredited by AAAHC, the first step, went smoothly and took three to four months.

"That entailed a 50-page application," says Ms. Phillips. "Then we had a site review by surveyors; they reviewed our clinical setting as well as policies and procedures. We received a three-year accreditation, which is quite an accomplishment for your first time."

The nine-month CON process was not as easy.
"That was very overwhelming," says Ms. Phillips. "The verbiage was very difficult, and the application is long, tedious and repetitious."

To obtain and maintain Blue Cross participation and the CON, Ms. Phillips had to prove Castleman Surgery could and would do 1,200 cases per room per year. "The biggest obstacle was proving to them I had those cases waiting to be done - and that I was not going to steal them from a hospital," says Ms. Phillips. "If I say, 'Doctor so-and-so is doing X cases at this hospital,' [the state] is going to say, 'You're jeopardizing that hospital's CON,' and you can't do that."

Wooing physicians
So she recruited four more physicians to use the facility.

"We have a medical ophthalmology practice attached to the surgery center," says Ms. Phillips. "Outside doctors are afraid to bring a patient here because they think we might steal the patient. But we've made our building generic - the sign says 'eye center' and 'surgery center.' And we put every single doctor's name on the door.

"It's a must to have some kind of financial incentive. You can't just pay them, because you run into Stark law violations. So we gave them partnership based on percentage of ownership."

By pulling the files on the newly recruited physicians' office-based surgery cases for the prior year, Ms. Phillips compiled enough to add to Castle-man Surgery without encroaching on area hospitals' territory.

"Lesion removal, lasers they did in their offices - that was acceptable," says Ms. Phillips. "Plus the office procedures my ophthalmologist was doing, that gave us 1,200 more cases."

Design sense
The CON process includes the design of a floor plan for the new OR. The first OR in Castleman Surgery's ophthalmology practice was built 20 years ago, long before facility fees. It was cramped and not exactly user-friendly. So Ms. Phillips knew what she didn't want; figuring out what she did want was a bit more difficult.

"I had to decide everything," she says. "I picked everything from all the different finishes to all the new equipment."

Ms. Phillips also chose an architect and an engineer and reviewed bids from contractors.

Coming to fruition
With variables in place and requirements met, she prepared the 90-page CON application for the state and won approval.

"Once I did all that, I had to send in the application to Blue Cross," says Ms. Phillips. "And then they approved us."

She estimates the project cost $400,000 but that she saved $100,000 by forgoing a consultant for the accreditation and CON processes. In March, the more patient- and user-friendly two-OR, six-bed pre- and post-op suite finally opened.

"Now I can have two doctors operating at the same time," says Ms. Phillips. "I have Blue Cross, the biggest provider and a big secondary to Medicare. I have new procedures, more doctors. When I walk back there, it's personal. It's such a sense of accomplishment."

- Stephanie Wasek