Lessons From 35 Years in the ASC Industry: Q&A With Cypress Surgery Center Administrator Judy Graham

Judy Graham, the administrator and cofounder of Cypress Surgery Center in Wichita, Kan., stepped down in late November after 35 years in the ambulatory surgery center industry. Ms. Graham began her surgery center career in 1976, as a registered nurse at the second surgery center in the nation. She started there as a PRN and moved quickly into the role of clinical director. While at Surgicare, Ms. Graham was named by HCA — the ASC's majority owner — as the company's "operating room director of the year."

In 2000, Ms. Graham left Surgicare to help a group of physicians start Cypress Surgery Center. She helped build the center from the ground up, filling the ORs with cases and eventually expanding to a multi-specialty ASC with six ORs and two endoscopy suites. In 2010, the center performed 10,900 procedures; Ms. Graham expects more than 11,400 in 2011. Here she discusses her career as an ASC administrator, the lessons she's learned and the importance of physician and employee satisfaction to a well-run center.

Q: How have you seen healthcare change in the last 35 years? What has been the most challenging time in healthcare during your tenure?


Judy Graham: I think I'd have to agree with other ASC leaders that this is one of the most challenging times in healthcare. I think the last four years in our industry have been the toughest due to the economy. Folks don't have insurance, and elective surgeries go to the back burner until they have more money or insurance coverage comes back into the field. That's probably the time I've seen it be the most challenging.

Before the last four years, I think the industry as a whole and locally was quite productive. We were successful here in Wichita. The surgery center I worked at in the beginning [of my career] — Surgicare — was the second ASC in the nation. The biggest thing to happen since then has been the transition of cases that you can do in an outpatient setting. The complexity of the cases has increased, and we've seen advances of anesthesia drugs that have made it easier for patients to wake up and get out of the center after an hour or two.

The acceptance of the ASC industry has also increased. In the beginning, ASCs were seen as a place to do wisdom teeth and other small surgeries. They were seen as a "flash in the pan" that wouldn't last. I think it's phenomenal how far we've come in this many years, especially considering the kinds of cases we do now. In some states, being able to keep patients for 23 hours has also changed our complexity of cases tremendously. [In Kansas], we can now do hysterectomies and other surgeries that require a 23-hour stay. That has been a good change for us.

Q: What has been your most significant success in terms of cutting costs?

JG: The one thing I can think of off the top of my head is trying to educate physicians as to what things cost. In most centers, the surgeons are investors, and I think if they know and can see what things cost, they tend to realize that it's going to cost them in the long run. This doesn't mean cutting costs in terms of jeopardizing patient quality of care, but instead doing things that are more cost-effective. Physicians don't always need the extra fluff that they think they need.

I think you can educate surgeons by being visible in the center and just by talking to them. If you see one surgeon's case costs going up, pull him aside and say, "Hey, we don't want to limit you on what you use, but we want you to realize what these things cost. If you do understand, we're more than happy to use them. We want to accommodate your needs." Just have a personal conversation with them without being confrontational. Most of the time, if they understand how much supplies cost, they're willing to make a change.

Of course, with new advances in surgery, there are devices nowadays that you just can't cut costs on. If you're using [Gynecare Thermachoice] or MyoSure, those devices are expensive and there's no way to cut the costs. You just have to grin and bear it.

Q: How has your case mix/specialty mix changed over the years? Have you found some specialties are more successful or profitable for your ASC than others?

JG:
This doesn't apply to every state, but in our state, one new specialty we added that we found fit really well — and had good reimbursements — was dental rehab. I had never looked at it before because I thought it tied up your operating rooms for a long period of time. But with our reimbursements here in Kansas, it's been a really good fit for us, and we do a pretty high volume of those cases.

Other cases that have always worked well are orthopedics, ENT and GYN. Those are the three basics we've found to work best. Our case mix has shifted a bit, and we do a lot more pain management now that we didn't used to do. That's a good fit for us. But for the most part, the basic cases have remained ortho, ENT, GYN and general surgery.

Q: What was the process like for adding dental rehab to your ASC?

JG: It's pediatric dental rehab, so we just looked for a pediatric dentist that was performing those cases and would be interested in doing it at the center versus the hospital. A lot of dentists do the cases in their offices, but we just went out and recruited our dentist and explained how good it would be for patients to do cases at the center. I've always thought that if you get a surgeon into our center and show him how things go here, we'll be able to keep him. The pediatric dentist has been very happy.

There are some costs involved in implementing dental rehab, but we were very fortunate in that he brought all his own equipment. We had no upfront capital expense.  If you don't have someone who will bring in their own equipment, there will be an upfront capital expense — but your payback would be very quick if reimbursements were like they are in Kansas. 

Q: What have been your biggest challenges as an ASC administrator? How did you handle them?

JG: I always think the biggest challenge is to keep your surgeons happy. You need to make them feel special, and you need to make them want to come to the surgery center. They have a lot of choices, and you need to respond to their needs and not waste their time because there's always someone looking for them elsewhere. Our biggest challenge has been to keep volume up and be responsive to physicians. You also need to be responsive to employees, so that they stay at your center after you train them. It's costly to train new employees. And of course, we always concentrate on giving great patient care.

Q: What do you find physicians want to know about, and what would they rather you took care of by yourself?

JG: They want to hear what's going on in the center. If they're investors, they want to hear how the center is doing and whether there are any problems. But most of all, they want to come to a place where they know the staff knows their routine, where patients get quality care and where their time isn't wasted. They should feel special when they walk in the door. They should feel that we want them there and we love them and we'll do everything we can to make sure their time there is enjoyable. If you don't have the surgeons, you don't have the cases.

Q: What have you learned about leading people as an ASC administrator?

JG: I think building relationships over the years has been really important with the staff. Staff members are the strength of any organization, and they really are the heart of the organization. If they're not happy, your center will never be successful. I think one thing I've found is not to sit in an office — to instead put scrubs on, know what's going on in your center and get your hands dirty. There's nothing worse to me than an administrator with "princess syndrome" who doesn't know what's going on in the center.

We do what it takes to get the cases done. When the staff sees that I'm [willing to pitch in on a case], they realize that anything I ask them to do, I'm willing to do also. I think that's wonderful — I know administrators have a whole other side of the job, where they have to crunch numbers and do the financials and sit in the office a certain amount of time. But being in the OR and the clinical areas where staff can see you makes a huge difference. And of course, they all want to be treated with respect.

Q: What advice would you give to new ASC administrators coming into the industry?

JG: Know your business. Study your business and know what goes on in your center. Know the ASC industry. Know your physicians, take good care of them and learn what they want and what they like. As far as taking care of your employees, understand them, know them well and make sure they know that you'll do whatever it takes to get the job done in the center. Pay attention to detail. You need to know all your key cost indicators to keep your costs where they need to be. Understand what drives a center's success. Keep supply costs under control as well as salaries and benefits, because those are your two biggest costs.

Achieve a vision for the future of the center. Know where you want to go and what your goals are. This means understanding your caseload volume, what your costs are going to be, how you're going to recruit new physicians and what you can do to keep salary costs down. Flexible staffing has been very important for us in this economy. Nobody wants to let people go, so you need to help your staff understand that on slower days, you have to flex staffing a bit. It's huge to keep those costs under control. And finally, just make sure you keep getting physicians and cases in the door.

Related Articles on ASC Operations:
5 Business Lessons for ASC Physicians
11 Ways to Improve ASC Patients' Experience in 2012
Using ASC Benchmarking Data Properly: Q&A With Aaron Murski of VMG Health

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