The Finer Points of ASC Growth and Expansion

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Higher volume doesn’t translate to higher profits without meticulous analysis of your market and full buy-in from your staff.

The ambulatory surgery center (ASC) industry is hyper-focused on growth. It is also, however, littered with the carcasses of facilities that failed by attempting to grow too quickly without enough honest forethought and solid strategic planning.

Failure isn’t an acceptable option for ASC owners and investors as well as their patients, leadership and staff. Growth-minded facilities need to consider not only how but why they should grow — and whether that growth would be profitable.

Embedded into the facility’s fabric

Sean Rambo, a 20-year veteran of the ASC industry, is president and cofounder of Compass Surgical Partners in Raleigh, N.C., a full-service ASC management and equity partner. He encourages administrators of his partner ASCs — both physician-owned centers and those affiliated with health systems — to embody a growth mindset every day.

“Something we preach a lot — both to our administrators and our regional operators — is embedding your growth strategy and your physician recruitment strategy into the fabric of how you run your facility,” says Mr. Rambo.

That philosophy should apply whether you’re looking to grow an existing specialty or add an entirely new service line at your center.

Turn up the volume

Mr. Rambo calls growing volume in an existing specialty the “low-hanging fruit” for ASC expansion.
“If you grow with your existing partners and existing specialties, that’s the easiest, fastest way to constantly create growth,” he says.

However, a well-managed growth strategy is not just a decision to add more surgeons, open more ORs, expand operating hours and bring in more patients. It requires an analysis of your current business and providers, with a heavy focus on whether the financial numbers will work.

Start by speaking with your current surgeons. “The easiest thing to do is what I call ‘selling behind the red line’ — having an ongoing dialogue with your existing physician partners to see if you’re getting 100% of their business,” says Mr. Rambo. “Are they bringing every case they possibly can — and if not, why? What’s leaking out, and why? Is it availability? Equipment? Turnover time? Convenience to the hospital? What is driving it? They’re already operating at your ASC, so you want to capture as much of their business as possible.”

Growth-minded ASC administrators should always be looking for new physicians who fit well with their existing caseload, says Mr. Rambo. That can minimize new equipment costs and require little or no changes to your policies and procedures, he says.

Mr. Rambo believes marketing and surgeon recruitment should be integrated into the daily duties of an ASC administrator. “Yes, you’re managing within the four walls, making sure the trains are on time and all that good stuff, but recruiting should be ingrained in what you think about every day, every week, every month, to build the business,” he says. “A lot of administrators are used to showing up, managing cases and going home, but you need to really get out and market the center.”

To that end, he suggests developing a target list of the other physicians of your specialty in your market and looking at how you currently interact with them. “Are you talking to them? Are you setting up meetings with them on a regular basis? They may not always be interested, but there needs to be a constant cycle of just showing up and talking to their office manager,” he says.

Even if you’re not actively recruiting, or if physicians you’ve targeted aren’t interested, Mr. Rambo says it’s vital to stay connected with outside surgeons in your market. “An administrator at a GI center should know every other GI physician in the market and have a relationship with them, whether they’re going to come to your center or not,” he says. “If you make that a regular part of your job, at some point you’re going to run across a new GI physician, or one who is disenchanted with where they are. Maybe they can’t get OR time. Now you can tell them, ‘I’ve got availability on Tuesday at 1:00.’”

Behind the scenes

The multispecialty, physician-owned Bayou Region Surgical Center in Thibodaux, La., added total knees to its existing orthopedics line a year ago. Administrative Director Serena Ledet, RN, BSN, says it was a natural development. “We have a very strong orthopedic group, and our doctors are very good at patient-centered approaches,” she says. “The surgeons were able to discharge total knee patients on the same day at the tertiary hospitals, so they wanted to make the move here. We did it and, knock on wood, it’s been going very well.”

Ms. Ledet and the center’s stakeholders put a lot of work in before the first total knee patient entered the ASC’s doors, however. “We started by looking at our patient population to be sure we would have patients who would be healthy enough to have a total knee procedure and go home the same day,” she says. “We then started coming up with the clinical criteria patients needed to meet to have this procedure at our ASC.” This includes diabetic status, A1C below a certain level, previous strokes, history of falls, BMI and more.

“Our orthopedic group is also affiliated with a physical therapy group,” says Ms. Ledet. “Our surgeons wanted physical therapy to come and get the patients up for the first time, so that was another thing we had to explore.”

A natural extension

There were obviously capital purchases to make but, because Bayou Regional already did ortho cases, many supplies and instruments were already on hand. Some additional equipment was still needed. “We purchased instrument sets,” says Ms. Ledet. “We contracted with a vendor for implants. We purchased drills. We purchased larger stretchers so the patients would be more comfortable, because their recovery times are a little longer than our typical patients.”

Although new staff wasn’t necessary to add total knees, existing staff needed training on the procedure. 

We did a lot of training on spinal anesthesia,” says Ms. Ledet. “We already had experience with many different types of blocks, but we did refreshers on that.”

She says the OR crew added a couple labs with one of the total joint companies and went through an entire procedure step-by-step a couple times before they scheduled their first patient.

“We were lucky because a lot of our staff had done total joints in the past and were already familiar with the procedure,” says Ms. Ledet. “We trained our recovery nurses on the post-op process, and the physical therapists came to do some training with them. We did a lot of education on the preoperative side of things; our nurses needed to learn what to educate patients on prior to surgery. It was important to be sure our patients had everything they needed when they got home.”

All told, the process from conception to execution took eight months, and the ASC was then deliberate about activating the line. “We slowly ramped up the volume, because not only did staff need to become comfortable with the procedures, but also the surgeons had to be comfortable with doing them here. We wanted the surgeons to trust their patients were being taken care of the way they would be elsewhere,” says Ms. Ledet. “We carved out more time in the OR and in recovery and had extra staff on hand to get the program going and make sure we didn’t have any hiccups.”

One procedure at a time

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JUST DROPPING BY Growth-minded ASC administrators should connect with all the local surgeons in their specialties — even those who aren’t likely to join their facilities.

After some adjustments and experience, efficiencies have improved and volume has increased.

The ASC currently is only doing total knees, with hopes to add hips and shoulders later. “Our ortho group was sending total knees home the same day, even from the tertiary hospitals, so for them, this was the easiest transition,” says Ms. Ledet, who says ASCs of all kinds should be similarly deliberate and practical about expansion.

“Do one procedure at a time,” she says. “If you try to do hips, knees and shoulders all at once, that’s a huge investment on the front end, and a lot of different education for your staff. By picking one total joint and adding the other procedures later, it’s been much more manageable. You can start getting ROI before you get overwhelmed with all the other capital purchases.”

Ms. Ledet believes everyone at an ASC needs to embrace and dedicate themselves to the expansion to successfully launch a new service line. “I’m very lucky that I have surgeons and staff who were on board with this and very involved in the process,” she says. “They were willing to make the transition, educate themselves and be open to the education we offered on starting a total joint program. All our surgeons gave input on patient criteria and supported slowly building the service line instead of overwhelming the staff.”

Bayou Region Surgical Center had forecast it would take a year for the line to become profitable, but it’s ahead of schedule. “We actually have done a lot more joints than we originally forecast,” says Ms. Ledet. “We’re doing well with the program.” OSM

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