When dealing with physicians on your surgery center's board, rejection is inevitable: Either they will deny your request for more staffing or higher salaries or you will have to reign in their enthusiasm for a new piece of equipment or service. Here's how to navigate your way around these delicate situations.

1. Know thine board
You likely have regular interactions with board members at monthly business meetings, quarterly medical staff meetings and periodic executive committee meetings. The board members' decisions affect the daily operations of the facility and impact your ability to do your own job effectively.

The key to persuading the board? Do your homework. As administrator, your requests are usually held to a higher burden of proof than those presented by a fellow physician on the board. Most physicians listen to physicians; even if they are receptive, they tend to be more skeptical of non-MDs. To overcome this, you must know how to speak their language. In medicine and science, the name of the game is presenting hard data and explaining your methodology. The same holds true when you approach the board to get them to spend money as you request. Present supporting evidence for your requests logically and thoroughly and you'll usually get results.

2. Be ready for rejection
If you understand the reasons why the board may turn down or defer your requests, you are ahead of the game in knowing where to spruce up your presentation. For example, when you gather supporting documentation for a capital equipment request, keep in mind the following:

• How many surgeons/specialties will use it?
• How much data exists to show improved case volumes or profit?
• Is there peer-reviewed clinical data showing strong medical desirability?
• How much would the purchase stretch the existing budget?
• Why add this piece of equipment and not a potentially less expensive alternative (for example, a laser rather than an electrosurgical unit)?
• Could the existing equipment suffice?
• What would the consequences be to the facility if the request is deferred or denied?
• Have your competitors successfully added this equipment?
• What is the reimbursement scenario for procedures done with the equipment?

What about requests for adding more full-time staff? Physicians often view staffing differently than the clinical staff and managers. Boards view staff salaries as a disproportionately large expense for the ASC and often want to move more slowly on new staff positions than the administrator would like.

Before you proceed with requests to add full time employees (FTEs), you need to establish that the problem with current staffing levels is not a temporary situation, that the existing staff is sufficiently busy and they can't fairly take on added tasks, and that the problem isn't something scheduling can cure.

3. Help docs and staff help themselves
If the surgeons - especially non-board members - and staff members don't help you make the case on their behalf, the chances of a successful request are much lower. When you present capital equipment requests, enlist the requesting surgeon to provide you with the supporting data you will need to convince the board.

4. Play devil's advocate
Sometimes the board wants to add a service or purchase a piece of equipment, and the administrator needs to discourage it. Yes, the board is spending its own money, but part of the job of the manager is helping them spend it wisely.

Whenever MDs attend their national specialty meetings, I can count on a request for new equipment or a lively discussion about a "new" procedure that will add lots of money to the bottom line. When the board discusses capital equipment enthusiastically favored by one or several board members, I see the administrator's task as being the one to raise the possible negatives, so that the discussion is balanced.

If the board wants to add a new procedure, I want to know about the training, how often it is being done in other places, what the reimbursement is, what will it cost the surgery center to do it, will additional staff be needed, how will the MD be trained and can it safely be done in an ASC. For example, I remember when laparoscopic cholecystectomies were just being discussed as an outpatient procedure. I was slow to accept the premise that this "new" procedure would ever be common practice, that patients would accept it and that we would recover our investment. In that case, I was wrong and the physicians were right.

5. Accept defeat gracefully
Ultimately, the board members make their own decisions. It is, after all, their money. As administrator, you have no recourse if the board turns down your request or overrules your objection. Even if you disagree with the decision, it's counterproductive to argue it.

Never take sides against the board. Consider that factors outside of your purview may influence the matter at hand. As manager, you need to support the board's decisions to the staff and/or requesting physician. If you present bad news honestly and keep emotions out of the discussion, the staff and MDs can usually live with the board's decision.