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The Journey to ASC Leadership: Q&A With Robert Knox of Texas Orthopedics Surgery Center

Robert KnoxRobert Knox, RN, is the surgery center director of Texas Orthopedics Surgery Center in Austin. Mr. Knox has been with the center for nine years. He has worked in a number of hospitals and traveling companies, but his current center is the only ASC he has worked with full-time.
Texas Orthopedics Surgery Center was founded in 2002 and is owned and operated by the physicians of Texas Orthopedics. The center is fully accredited by the Joint Commission.

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Mr. Knox discusses how his career in healthcare led to working in ASC, the challenges and rewards of his position and his goals for the future of his surgery center.

Q: How did you begin your career in healthcare?

Robert Knox: Compassion is the biggest reason I became a nurse. When I was a teenager my grandfather suffered from a stroke on Christmas Day leaving him debilitated and completely dependent on others. I was very close to him. My aunt was a RN, so naturally she stepped up to the plate. I was intrigued by the caring and knowledge she displayed while attending to his everyday needs. She treated him with so much compassion and provided him with unbelievable strength, strength not only physical but emotional strength, so that he wouldn’t give up. I was moved and learned quickly what compassion meant.  

Upon graduating high school, I had to decide what I wanted to do with my life. I thought about photography or going to culinary school. I lived with my mother and stepfather, who were always extremely supportive. They encouraged me to seek out a career that would allow me to be successful and would always be in demand. Still undecided, I moved to south Texas where my father and stepmother lived. They offered me room and board while I attended college. My stepmother was already an RN. She is one of the strongest and kindest women I know. She recommended that I enroll in a class to become a nurse's aide so that I could work at the hospital where she worked. While working at the hospital as a nurse's aide, it wasn't long before I was promoted to be the unit clerk at the medical/surgical unit.  

My father was a paramedic and provided private care for a man who was so grateful that he offered to help us both with monetary support if my father attended nursing school. This gentleman extended the offer to me as well. My father and I both applied for the RN program. As a backup plan, I signed up for the LVN program at the same time.

The school had limited slots for nursing students. My father was accepted and I wasn't at this time. However, I was accepted into the LVN program. After completion I started working for a home health agency.  
The next year I was accepted into the RN program. Throughout this RN program I worked as an LVN, seeing home health patients in between my classes.  

After graduating from the RN program my stepmother encouraged me to become a circulating nurse. She said, "You will love it."  I then applied at every hospital in Austin, Texas, and got accepted into an internship program that would train me to become a circulating nurse. Within two years I could circulate any case that came through the door.  
Afterwards, I went to work for a nationwide traveling agency for a couple of years. I worked mainly in the northeastern part of the US. This experience allowed me to see how other organizations perform, what works and what doesn't.

After 9/11, I moved back to Austin, Texas. I heard that Texas Orthopedics was the best place to work. It was around Christmas when I went to the Texas Orthopedics' annual holiday party to seek out the director, Mrs. Norma White. A few days later Mrs. White interviewed and hired me. Texas Orthopedics trusted in me and provided me with the opportunity to grow in directions I had never dreamt. I have remained loyal to Texas Orthopedics since that day, as a staff nurse, and now as the director of the surgery center.

Q: What are the most challenging aspects of your position as surgery center director? What are the most rewarding aspects?

RK: The most challenging aspects of my position are (simultaneously):

•    Providing oversight and management of the center while maintaining compliance with the laws, rules and regulations of CMS, The Joint Commission and Pharmacy Board.
•    Abiding by all federal, state and local laws
•    Balancing the needs of the surgery center, physicians, staff, anesthesiologists and upper management.
•    Making smart decisions that lead to successful operations
•    Efficiently and effectively juggling a plethora of duties and putting out fires
•    Sustaining a pleasant and rewarding work environment
•    Staying physically fit and allowing time for a pleasant personal and social life

The most rewarding aspects of my position are:

•    Being accessible to staff. The involvement and interactions with the staff is the most rewarding aspect of being a director.
•    Reading hundreds of patient surveys explaining their wonderful experience at Texas Orthopedics. The surveys consistently praise the care the nurses provided.  
•    Knowing that I help Texas Orthopedics go above and beyond other ASCs in providing high quality care for our community.

Q: How do you think your surgery center stands out?

RK: Texas Orthopedics Surgery Center has 27 credentialed physicians on staff. They perform 300 to 500 cases per month. We focus on providing high quality care at a significantly lower cost than other facilities. We have consistently received patient satisfactions above 95 percent. Safety is also at the top of our list. Our quality assurance process improvement committee takes a proactive approach in curbing any potential problems before they occur. We are well-known in our community to have the best staff in the city. We have a very low staff turnover rate and a competitive pay scale.

Q: What goals do you have in mind for the center in next year?

RK: I hope to have our physicians be compliant by completing medical records within the 30-day industry standard. This is currently a challenge. Completing medical records in a timely fashion is essential to speed up the coding and billing process, which in turn results in ASC payment. This process is often delayed because physicians fail to complete dictation on the date of service, or at least within a few days post surgery. When a physician procrastinates on dictation for a week or two, the average number of days for medical record completion rises and reimbursement is significantly delayed.

Along with all the reporting requirements we are subject to, it will be important that we be ready to take on the new ICD-10 coding that is coming in 2014.  In addition we have payers continually trying to cut our reimbursement or "bundle" our implants with procedures, so the management of expenses has been a top priority for us. We’ve simplified our implant vendors down to two major trauma and two major sports vendors and that has generated significant savings. However, our equipment is getting to end of life and we must assess our equipment needs and the best way to negotiate those terms, whether it be through one our current implant vendor or going out and establishing relationships with new vendors. We currently use our PM system for inventory management, but we will need to perform some due diligence to ensure that is the best mechanism for management our second largest expense, our inventory. All in all the name of the game for 2014 will be to become even more efficient with less revenue and ever increasing reporting regulatory requirements.

If you are interested in sharing your accomplishments as an ASC administrator or would like to recommend an administrator, staff member or surgery center for a feature article on the Becker's ASC Review website, please email   

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