Sometimes it seems as though I do the same thing every day, only with different people. The good news is that the days are fast-paced, and they go by quickly. I negotiate with equipment and supply vendors, talk with the builders and try to impress upon our physician-owners that the time before we open is much shorter than they think. It's only in looking back over the weeks and months that have passed that I realize just how far we've come - and how far we still have to go until we're ready to treat our first patient.

Sept. 22, 2003
Today is my first official day as the manager of the endoscopy and surgery center at Elkhart Clinic in Elkhart, Ind. There is a tall challenge ahead of us to get the ASC ready for our scheduled opening on April 1. Our 12,500-square-foot center hasn't even been built yet. We're gutting the existing building (which had been a physical therapy-rehabilitation center) and adding onto it to construct our ASC, which will have two ORs, two endoscopy suites, one procedure room and 22 pre- and post-op beds.

Our three physician-owners have been great so far. I was hired through the consulting firm they're using to oversee the project. I must say that the docs have been very responsive. They recognize that I'll take their wishes seriously and spend our budget as though it's my own money.

The center, after all, is their baby. I don't even want to get into the complex arrangement necessary to put the practice they own within a building owned by the clinic physicians. This process pre-dated my arrival and took several years. They were already working with the architects by the time they hired me as manager.

At the end of August, I had a couple of preliminary meetings with the architect about patient-traffic flow and day-to-day practice in the center.

Oct. 13, 2003
I've been pleased - and a bit surprised - at how much weight my suggestions about the center's traffic flow carry with the design team. From my years as a nurse and administrator in the clinical setting, I noticed many little things I'd change in their drawings. For example, I thought that more needed to be done to protect patient privacy and improve efficiency. You don't want your patients escorted through a lot of common areas at bad times, and their route from one phase of surgery to the next needs to be as direct as possible.

Moreover, as I've gotten more familiar with the design plan, I've noticed that we'll need a more workable front-reception area. I'd like some doors located a bit differently in the OR corridors. And one crucial adjustment I requested is that the scrub sinks be moved closer to the OR doors. I've seen people fall in the OR and I don't want that to happen here. Once the plumbing is in, after all, it's too late to change it.

I realize that some of these design changes are expensive, but they're best made in the design-and-construction phase before the center opens.

Oct. 28, 2003
I spent much of today reviewing the generic policy and procedure manuals we obtained. I'll have to customize them for our center and I want to get a jump on the process, although we'll deal in much greater detail with specific practices and standards in coming weeks and months. The physician owners have decided to use AAAHC to accredit our ASC. Previously, I've only dealt with JCAHO, so I also have to get up to speed on AAAHC's accreditation process and think about compliance expectations.

Nov. 12, 2003
You win some, you lose some. We've been having software demos and came to a consensus on the billing software we'll use in the ASC. But there's a problem. The clinic uses a different type of billing software and doesn't want to change now. Staff there are understandably concerned about retraining and the potential short-term revenue losses as they adapt to a new system. I had the same situation in a previous job and I hoped we could avoid it here. Using different billing software systems makes it difficult to generate reports or quickly obtain other key data. I'll keep an open mind and adapt. At least the physician-owners and the clinic acknowledge that we may have to eventually change the system.

On the other hand, during a discussion about certain gases we'll need in the OR, I convinced everyone to go with my recommendation. The doctors initially said they wouldn't need them in the OR. I convinced the design team and the physician-owners that we do.

Nov. 24, 2003
I've dealt with vendors all along, but lately I've been inundated with contacting vendors. I've started to compile an equipment and supply log and collect contract bids. Vendors are an interesting lot. Through the years, I've learned that you need to get tough when you deal with them. I don't like vendors who behave like car salesmen - talking down their competitors' products, being coy about the discounts and service perks they're willing to offer and disappearing after the sale. Much like buying a car, you need to establish a bottom line and stick to it. You also have to be willing to walk away if you reach an impasse. That's not always as easy at it sounds. If you truly want or need a certain item, you'll often pay the asking price. The vendor knows that, too. I'm willing to pay a bit more to buy from a vendor I can trust. I want someone who'll not only include training and in-servicing as part of the deal, but someone who's willing to be on site. That's why I generally prefer dealing with local vendors.

The first equipment decisions: sterilizers, washers, lights and cabinets. The reason these bids take first priority is that they need to be worked into the room design. Our purchasing manager has been a huge asset. She's terrific at keeping track of how many vendors have given us bids and making sure the bids specify all the services the vendor promised. We also decided on our OR tables at this time.

Dec. 1, 2003
Recently, I negotiated a bid with a monitor vendor selling the make and model we preferred. His quote was decent but nothing overwhelming. I thanked him for his time and told him we were still reviewing other bids.

"What will it take for you not to look at those other bids?" he asked. Turns out he still had a better deal to offer.

Even though I would have preferred to get his best bid to start with, because this monitor was our first preference, we were able to hammer out an agreement.

Dec. 10, 2003
After answering e-mails from salesmen and looking over product samples that were overnighted to me, it was off to a hectic day:

• 10 a.m. Meet with the designer and architect to discuss the design of the nurses' station. We need to finalize the design of the cabinets, which will take a few months to arrive.
• 12 p.m. Speak with a microscope rep about arranging a product demo in our ASC.
• 12:30 p.m. Lunch with reps from the company selling us most of our major capital equipment (Steris).
• 2:30 p.m. Meet with potential anesthesia provider.
• 4:15 p.m. Return calls and tie up some loose ends.

It looks like we're set with buying new equipment, rather than refurbished. Initially, most of the owners wanted refurbished equipment and told me to be as frugal as possible with the lights and tables. One owner, however, wanted new equipment for the new practice.

I decided to explore both possibilities. I located four vendors who sold refurbished equipment. I compared their quotes with the cost of new equipment. With bulk purchase discounts, buying new came out to be about the same as refurbished. I plan to buy remanufactured carts and electrosurgery units because the new equipment quotes aren't even in the same ballpark.

Dec. 31, 2003
With the calendar about to turn to 2004, I've been thinking a lot about the work that we still have ahead of us. The physician-owners now have a real sense of urgency. That's good, because many of the upcoming decisions require strong input from them. For example, at the end of January, we'll hold an instrument fair. I'll bring in three or four vendors and let our docs look over their instruments. This will let the doctors make their selections as well as force the vendors to compete to give us the best possible deal.

I'd like to add an office manager to help with the administrative tasks that lie ahead. We'll have to credential surgeons and input preference cards, retype our policies and procedures, and sit down with docs to spell out some of our clinical processes. By March, I'd like to have our nurses, techs and office staff hired.

We've come a long way these last few months. But we still have a long way to go and no time to waste.