Since the 2008 ASC reimbursement restructuring, the fastest growing new specialty in ambulatory surgery might surprise you. It's retinal surgery (see "Retina and ASCs: Perfect Together?" on page 40). Follow these 5 golden rules to successfully add vitreoretinal surgery to your facility.

1. Assess whether retina's right for you. Yes, the reimbursement picture is rosy, but you can't just jump in and add retina. There's much to consider, including lengthy cases, substantial equipment and instrument investments, and the issue of physician recruitment, says Andrea M. Hyatt, CASC, administrator of the Dulaney Eye Institute in Towson, Md. She says you should only consider adding retina if you're already performing lots of cataract cases. Otherwise, you won't have sufficient volume to get needed pricing on supplies. "The cost of retinal supplies is very high," says Brooke Day, chief executive officer of Blake Woods Medical Park Surgery Center, a multispecialty facility in Jackson, Mich. "We do a lot of cataracts, so we have a very good relationship with our vendor and can negotiate good pricing on retinal supplies." Ms. Day pays about $500 for a standard retina pack, not including such items as silicone oil ($495) and Perfluron ($525) for complex retinal detachments. Ms. Hyatt adds that while the newer, small-gauge systems shorten surgery time and improve patient results, they add a considerable amount of disposable costs to a case.

2. Get inside the mind of the retinal surgeon. Retinal and cataract surgeons are breeds apart, says Ms. Hyatt. "The mindset varies dramatically among the subspecialties, especially those of the vitreoretinal surgeon coming from the hospital setting versus the cataract surgeon accustomed to fast turnover at the ASC, marginal disposable costs and higher profit margins," she says. To get a clear picture of a prospective surgeon's skill, speed and preference cards, have frank conversations with the OR nurses and techs familiar with his cases at the hospital, says Ms. Hyatt.

Seek out efficient surgeons. "You can't have a surgeon who's going to take 2 or 3 hours of OR time for a case," says Ms. Day, who typically schedules retina cases for 30 to 45 minutes.

Watch for these red flags: late start times, unpredictable OR times, high resource use and an inflexible personality, says Beth Hurley, RN, BSN, CRNO, COE, of Ophthalmic Surgery Resources in Phoenix, Ariz. Know what kind of case volume you can expect a surgeon to bring to your center. Use retrospective data for the past year, says Ms. Hurley, rather than their predicted numbers (which tend to be inflated). You'll also want to know if they'll be available for evening hours in the event of emergency add-ons, she says.

3. Minimize supplies and equipment. The minimum investment to equip a retina room with a vitrectomy machine, microscope and instruments is $350,000 and probably closer to $500,000, says Margaret G. Acker, RN, MSN, casc, administrator at St. Mary's Southwest Surgery Center in Grand Rapids, Mich. Your retinal docs must be willing to use the same supplies and equipment. "The supplies for the cases add up very quickly," says Ms. Day. "Your surgeons must agree on 1 standard retina pack."

Meet with vendors to explore opportunities to partner. "They may offer programs to assist in set-up and delayed payment plans," says Ms. Hurley. Ask vendors to provide free supplies to trial your first few weeks. "Avoid making purchase commitments until you have had a chance to trial products from alternative sources," says Regina Boore, RN, BSN, MS, president of Progressive Surgical Solutions in Poway, Calif.

4. Use regional anesthesia. Your surgeons should agree to perform the procedures with a block only. "General anesthesia adds time to the case and may not be conducive to an outpatient surgery setting," says Ms. Day.

5. Train your staff. In-service your staff so that they understand the nuances of retinal surgery. "Retina is a nice change of pace, but it's a stiff challenge for staff," says Ms. Acker. "You just don't waltz in and know retina." Be proactive in developing an education plan for your clinical staff before you do your first case, says Ms. Boore. Consider providing your administrative staff with at least a basic exposure to retina surgery. "If you have only been doing anterior segment surgery, your staff does not expect patients to arrive in pain," she says.