I walked into the St. Augustine (Fla.) Surgery Center for the first time knowing I'd have to change everything. In 2006, an ASC management company hired me to help turn around the failing facility. My welcoming committee consisted of stained carpets, rainwater leaking through walls, demoralized staff sulking outside empty ORs and a business office littered with unlabeled file folders that contained accounts receivables 74 days out, bloated case expenses and a third-party payor mix that put us squarely behind the reimbursement 8-ball. My initial decision as the new administrator was simple enough: It was time to roll up my sleeves and get to work.

Job #1: Pump up morale. I'm not going to lie: My first few months on the job were rough. The staff was bluer than blue. Many wondered how their health benefits would be affected or whether they'd have a job the next day.

Trying to raise morale is always difficult, but it's especially daunting during ownership transitions. Although I wasn't present during the initial facility takeover, my newly inherited staff told me they weren't informed of the sale's progress by the prior ownership. That had to change. Being up front and honest with your staff over time establishes trust. It might take weeks or even months, but your employees will begin to buy into what you're trying to accomplish if you relay information in good faith that could affect their future.

Promoting an established and respected member of the current staff also helped smooth the transition. We offered the clinical coordinator position to an OR nurse who had been with the center since it opened, had excellent rapport with the staff and was trusted by most of her colleagues. I believe her promotion to a position of power was critical in rebuilding employee morale and trust in the facility's new management team.

As improvements are made and positive events start to outnumber challenges, you must find ways to reward and recognize the efforts of your staff. Thank them for their help at the beginning of each staff meeting. It's that recognition in front of peers that means a great deal and helps reinforce positive actions among the masses. Also get your physicians involved. Here at St. Augustine, our docs host a monthly "thank-you" lunch for the entire staff. We also send notes of appreciation to the homes of employees who go above and beyond in helping get our facility back on track and moving forward.

Job #2: Lead by example. Be engaged in the turnaround process and in all aspects of the center's functions. It's your role to share the facility's overall goals with staff, prioritize the steps needed to reach them, delegate responsibilities as appropriate, motivate staff, provide support and manage the focus of your turnaround efforts.

Be willing to handle responsibilities that occur outside of patient care, such as completing monthly infection control reports and ordering pharmaceuticals. Try to share the workload equally with your staff to maintain productivity and employee morale until the facility gets back on its feet. I worked countless hours alongside a representative from the corporate partner that helped turn around the facility. We got our hands dirty because we couldn't expect staff to make sacrifices and work harder without demonstrating that we were willing to do the same. Seeing us shoulder-to-shoulder with the frontline staff in clinical areas and the business office helped us earn their trust and respect.

Job #3: Ask for help. Physician involvement is key. You need to establish an open dialogue with surgeons about what is needed to improve the viability of your center without compromising quality patient care. We compared preference cards between physicians and enlisted their help in reducing our supply expenses. They made concessions on the supplies they requested, substituting less expensive options for pricier items on their preference cards.

Work with your physicians to compress the schedule. When this center was first purchased by the new corporate partner and physicians, it was open 5 days a week, and all the rooms were available. It was an unsustainable business plan. Our corporate partner convinced the physicians to use vertical scheduling. We opened 3 days per week, running 2 ORs on Monday and Tuesday and 3 ORs on Wednesday. It was a huge cost-saving move.

Be sure to meet with your staff and brainstorm expense-reduction ideas for every segment of your clinical and business services. We involved staff in the changes we needed to make, listened to their needs and implemented many of their ideas. For example, our facility inherited clinical and business office forms from the healthcare system that ran the center before us, forms that featured a great deal of redundancy and information not truly needed in an ASC environment. Our staff made suggestions to rearrange and streamline the forms, suggestions we used to improve work flow. Involving those closest to the issues you need to fix develops a sense of ownership on the front line and shows that you respect those who need to make the changes happen.

Job #4: Think outside the box. It's also crucial to obtain buy-in from your clinical coordinator and business office manager, and work as a team to follow up on ideas generated by the staff. I manage overhead expense-reduction ideas. My clinical coordinator follows up on surgical supply-saving concepts, and my business office manager ensures that office supply expense-reduction goals are on target.

During your efforts to reduce overall expenses, don't ignore seemingly small changes that can lead to big savings, and actively seek ways to challenge your facility's sacred cows. During staff brainstorming sessions we came up with several creative tweaks to our business and perioperative practices — including making sure suction canisters are full before disposing of them, limiting the amount of sterile water we use during endoscope flushing and covering access marks after IVs are removed with a cotton ball and piece of tape instead of name brand adhesive bandages — that helped pump up our bottom line. In the end, leaving no stone unturned in the hunt for savings paid — and continues to pay — dividends. In fiscal year 2007-2008, we cut costs by $146,872, and in 2008-2009 we trimmed another $122,953 in expenses.

Thinking big can also work to your facility's financial advantage. Consider combining roles or adding responsibilities to the job descriptions of current employees. For example, consultant firms charge between $10 and $15 to code a single operative report, while risk management companies (we're required to have a certified risk manager here in Florida) charge between $800 and $1,000 per month to perform the service. We sent our clinical coordinator to risk management certification training and our business office manager to become a certified coder, 2 moves that saved our center $56,000 annually.

Job #5: Target profitability. When we took over the center in 2006, our payor mix was 60% Medicare and about 20% Blue Cross and Blue Shield. Our highest volume services were GI, pain management and ophthalmology. When Medicare changed its ASC payment plan in 2008, which resulted in significant drops in reimbursement for our highest-volume specialties, our income-generating potential was hit hard. The shift in Medicare's payment rates meant it was crucial to get our expenses under control and reassess the types of cases we wanted to host and the surgeons we needed to recruit.

Thanks to current reimbursement bumps as we transition to full implementation of Medicare's new payment system, orthopedics, spine and ENT are money-generating services that floundering facilities need to target. For months during our ownership transition we had been trying to land an orthopedic surgeon. Finally in October 2007, he performed his first case in our center. Adding his specialty has greatly helped our reimbursement forecast. We now host 48% Medicare patients and 30% BCBS patients, a more balanced business structure that will help the facility remain profitable moving forward.

Job #6: Rely on a corporate partner. Good corporate partners provide guidance and training during turnaround efforts, holding administrators accountable for keeping the transition on track. They reward and recognize successes and offer support as needed. For example, when we were looking to fill vacant positions in the business office, a rep from our corporate partner trained me on billing and collecting, worked our collections until new staff was brought on board and trained the new hires.

Corporate partners also have access to benchmarking data and facilitate communication between centers in their network. We share benchmarking data with sister centers monthly, hobnob with fellow administrators at national conferences and communicate with our colleagues in other facilities daily or weekly via e-mail and phone calls. We learn from each other and share information that gives us the upper hand when haggling with vendors over supply- or capital-equipment pricing.

About face
My center has rebounded from running 1 or 2 ORs per day to having 3 to 4 in constant use. In 2006 we hosted 200 cases per month. Today we average close to 325. We've been able to replace broken equipment, purchase new devices and install computers in all clinical areas. We now maintain average accounts receivables between 32 and 34 days. The staff that thought about bailing on us now joke about needing roller skates to keep up with the hectic surgical pace. Our facility has turned a corner, and we're not looking back.