Here are 10 factors I've observed in 20 years in the industry that you should focus on to maximize your success. If you can check off at least six or seven of these factors, you'll have a solid foundation on which to grow your surgery center.

Unilateral commitment
The commitment of the parties involved, specifically physicians, must be 100 percent to the project. The attitude can't be one of "that sounds like a good idea, let's give it a go." The physicians must commit to meetings and planning on the front end, making decisions during the process and, subsequent to the facility's opening, following through by bringing cases to the center, staying involved with quality-control issues, credentialing and accreditation, and watching supply costs, to name a few duties.

If a hospital is involved as a partner, and it's been dragged into the mix with little or no enthusiasm about the project, stay away from that relationship. The hospital, too, must be committed to the project's success. If you're looking at involving a third party - any individual or company that's not a physician or hospital - make sure it isn't trying to cobble together a few ASCs to flip to a bigger company a few years down the road. The third party, too, must be committed.

If everyone isn't unilaterally committed to the center, that fact will reveal itself in time after the ASC opens.

Management experience
Be careful when it comes to choosing a partner, because some out there who are not deeply experienced are trying to catch the ASC wave. You really need to peel the onion back, check references and go the extra mile to evaluate the management experience of the party with whom you're thinking about partnering. How much experience does the third party have? And if it's not a lot, is it quality experience (two or three successfully run ASCs)?

Even if you're not looking for a partner, but you're looking to a third party for management, beware. Some companies will try to get the front end of the deal done (mostly financing and work in the construction phase) for doctors who are concerned about simply getting the ASC open. Once the ASC is open, the infrastructure to make the facility run soundly and efficiently is sorely lacking, and the project suffers operationally.

In conversations with bankers and others in the industry, I've learned of more failing centers in the past 12 months than I've known of in the past few years. More often than not, the culprit is weak management or weak strategy.

Proper incentives
When you talk about the proper incentives to maintain a good, committed staff, you should be talking about quality care, not economics. If you provide quality care and sound management, the dollars will follow, and job satisfaction will be high. Centers built to make a quick buck are shallow in their clinical investments and equipment, and ultimately will struggle.

Culture of compromise
This doesn't mean that you should compromise quality and integrity, but that you should be willing to compromise on issues to assure quality and integrity in your ASC. Recognize that you're not going to get your way all the time and that others have valid points of view worth taking into account. Don't keep physicians, staff or a third party around if they're not willing to participate in your culture of compromise.

Local management
Look for a management company that will allow you more autonomy, but that will be there for high-level decisions, such as those involving managed-care contracts. If you want to buy a new copier or schedule block time, you shouldn't have to go through 14 levels of decision makers.

Sound financial footing
If things get a little wobbly, it's critical that the physicians and third-party partners have enough money so that the ASC doesn't topple. Don't build on a shoestring and hope that everything works perfectly - that doesn't usually happen. Physicians should be confident that the lender is sound and is going to be around. Regardless of what the partners put in on the front end, they need to go into their pockets again if necessary.

Managed-care contracting
Lately, I'm seeing more centers signing managed-care contracts but not understanding what they're signing. More in these deals is not necessarily better - even if you get more case volume, if the reimbursement is not attractive, it's still a losing contract. In addition, using the out-of-network platform could be a short-term contracting strategy. When this happens, a center usually isn't happy with what the major payers are offering, so the ASC doesn't sign and then charges patients (and thus the insurer) the higher out-of-network fees. Insurers are starting to take steps to counter this tactic, so I don't believe it will work over the long run. Negotiate a good managed-care contract instead.

Billing and collecting
Spend the money to get a top-notch billing system. If you go cheap, you'll be like many of the centers I see that are 60, 70, 80 days in accounts receivable. You can get that down to 40 days with a good system, and that's cash in the bank.

Information system
You need a good information system, period. For example, you need something that will show you trends in supply costs and OR times. That way, you can pick up trends before they impact your bottom line negatively - or you can capitalize on good trends to maximize profits.

Patience
One of the things I tell people they need to have, particularly on startups, is patience. Ninety-eight percent of the time, the ASC is not going to be profitable from day one. Instead, it'll build gradually; after about 12 to 18 months, the ASC should become profitable - if everything else is sound. If anyone promises instant rewards, be leery. There are no shortcuts to success in this business.