Getting to 18,000 Cases a Year: 8 Steps to Increase and Accommodate Case Volume

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Brent Ashby, administrator of Audubon Surgery Center in Colorado Springs, Colo., leads two surgery centers that perform a combined case volume of 18,000 cases annually. He discusses eight strategies the ASCs use to attract, accommodate and maintain robust case volume year-over-year.

1. Take advantage of a relationship with a hospital partner. Audubon Surgery Center uses a unique operational and ownership structure, with the most significant difference from typical ASCs being the operation of two separate surgery centers about 15 miles apart. The two surgery centers are jointly owned by an LLC and the local hospital; the hospital owns 43 percent and the physician-investors own the rest. Physicians are credentialed at both facilities and can choose to work at either or both of them, and specialties are divided between the centers so that certain specialties — such as urology — are entirely contained in one center. In the case of urology, it makes sense to keep the specialty in one center because the cost of equipment is too great to justify purchasing equipment for both locations.

Mr. Ashby says the second facility came to fruition when the local hospital decided to build another campus in a different part of town. "They decided not to build any operating rooms to accommodate outpatient surgery," Mr. Ashby says. "We built our surgery center on the hospital campus, attached to the hospital, and we have eight operating rooms while the hospital has four. Their focus is on inpatient surgery, and the intent was that we would be the source and location of the bulk of outpatient surgery." When the second surgery center opened, it captured all the outpatient surgery that had been going to an old hospital campus, boosting volume significantly.

2. Concentrate on specialties that will bring additional volume through sub-specialties. Mr. Ashby's surgery centers place a large emphasis on orthopedics, partially because the largest orthopedic groups in the community were the first to drive construction of the facility. Since the first center opened, Mr. Ashby has attracted three orthopedic physician groups to the center — the bulk of orthopedics in the community.

"[The presence of orthopedic physicians] has driven some of our pain management volume as well," Mr. Ashby says. He says controlling much of the orthopedic outpatient case volume in the community is useful because the physician-investors talk up the surgery center to related sub-specialists and then benefit from their colleagues bringing more cases to the center.

3. Establish relationships with physician practices in the community.
While some physicians still maintain solo practices, most have gravitated toward large group practice or hospital employment, Mr. Ashby says. This means surgery centers must build relationships with entire practices, not just standalone physicians, if they want to maintain robust case volume over time.

In his community, he says surgery center ownership and participation generally falls down practice lines: If a certain practice uses a certain surgery center, most of the practice's physicians take their cases there and not to a competitor. This means Mr. Ashby has worked to attract entire practices to his surgery center — for example, building a relationship with the major orthopedic groups in town.

4. Shift employees to other areas on slow days. While Mr. Ashby's employees work at two separate surgery centers, they are all under the same employment umbrella, meaning ASC leadership can move staff members from center to center (and within areas in the same center) when volume fluctuates.

"They're happy to work at either location, and this way, we don't have to call them off and look for replacements if volume drops at one facility," he says. "That's been really effective at keeping costs down." With 18,000 cases to perform every year, he says the surgery centers also have to staff "ample" nursing and clinical staff. Audubon Surgery Center also uses block scheduling to predict high- and low-volume days and distribute staff accordingly.  

5. Accommodate increased volume by shifting cases to low-volume days. Mr. Ashby expects a volume increase of approximately 1,000 cases in 2012 — a challenge for a surgery center that's already one of the busiest in the region. To accommodate the increased volume this year, he says he plans to move certain cases and block times to low-volume days.

"For example, on Mondays we're not as busy, so I've asked some physicians to move off days that are busier to open up times for guys that really need them," he says. "That will help to balance out the volume."

6. Schedule more complicated cases in the morning. A busy surgery center needs to stay efficient to keep cases running on time and control costs, Mr. Ashby says. He says his surgery centers schedule more complex cases — such as orthopedic cases — in the morning to allow patients a longer recovery time. He says they also try to schedule children in the morning because younger patients don't tolerate fasting as well as adults. The surgery center has 23-hour capabilities, so patients that might stay overnight will be scheduled later in the afternoon.

Mr. Ashby says his physicians are usually very accommodating about scheduling. "Most of the time, they give us flexibility," he says.

7. Expand into new specialties when appropriate. Mr. Ashby says Audubon Surgery Center may expand into a specialty like spine if it can attract the necessary volume from physicians. Surgery center administrators must constantly look for opportunities to expand into new specialties, especially newly profitable ones like spine, to promote growth.

8. Ensure that volume will make up for case expenses.
Mr. Ashby says surgery centers expanding their case volume should make sure that equipment and supply expenses do not exceed profits earned from increased volume. For example, one of his surgery centers performs urology cases, which generally require a C-arm and flexible scopes that can each cost $30,000-$60,000.

"Dollars can go really fast for not a whole lot of stuff with urology," he says. He says it may be easier to increase volume for specialties that don't require such a significant capital investment. For example, general surgery physicians may perform laparoscopic procedures that use the same equipment and supplies as orthopedic cases.

Related Articles on Surgery Center Operations:
5 Priorities for Surgery Centers in 2012
20 Statistics on Physician Specialties With the Most ASC Investors
4 Ways to Boost Surgery Center Profitability This Year

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