A bad hire, an underused robot or a budget built on hope can cost an ASC far more than it saves. Many leaders say their costliest missteps of the past year looked like sound decisions at the time.
Twenty-four ASC leaders and physicians shared the decisions they would take back, from holding on to the wrong manager to converting a traveler who later left.
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Editor’s note: Responses have been lightly edited for clarity and length.
Question: What’s one decision your ASC got wrong in the past year, and what would you tell other ASC leaders to do differently?
Peter Bravos, MD. Chief Medical Officer of Sutter Health Surgery Center Division (Sacramento, Calif.): Our mistake was setting a reduction target on hospital transfers. Two years of focused work taught us we were measuring the wrong thing. A transfer is often the right call, and when a patient needs a higher level of care, no one should be thinking about a scorecard target. Transfers are now a balancing measure for us, not a goal. This matters as we push day-of-surgery cancellations down. Tighten cancellation rules and more marginal patients reach the OR. Some will transfer. My advice: Separate the metrics you drive from the metrics you watch. Target the process, monitor the outcomes, and never put a number on a decision clinicians must make freely.
Charlene Cioe, MSN, RN. Chief Nursing Officer of Summit Center for Surgery (Oakbrook Terrace, Ill.): One decision I got wrong this past year was keeping a manager in a leadership position longer than I should have, hoping I could coach and develop her into the leader our new ASC needed. During the interview, she said all the right things about teamwork, supporting staff and doing whatever was necessary to help a new surgery center succeed. However, once she was hired, her attitude was very different. I frequently heard, “That’s not my job,” or “You, as the CNO, should be doing that.”
When you’re opening a new ASC, everyone wears multiple hats. As the CNO, I oversee three departments and often step outside my own responsibilities, including periodically checking the generator to ensure regulatory compliance. Our surgical techs were cross-trained to help with sterile processing, equipment checks and other operational responsibilities. I would never ask my staff to do something I wasn’t willing to do myself. Unfortunately, this manager viewed many responsibilities outside the OR suite as someone else’s job. Rather than helping bring the team together, she was creating silos in an environment where teamwork was essential.
My mistake was thinking that, with enough coaching and support, I could change that mindset. She was an excellent OR nurse and well respected for her circulating nursing skill set. I waited too long to recognize that the problem wasn’t a lack of training or experience, but a lack of willingness to be part of the team.
My advice to other ASC leaders is to hire for attitude, accountability and teamwork, not just experience. Be very clear about expectations during the interview, but also recognize when someone’s actions don’t match their words. Address those concerns early, and don’t hold on to the wrong person simply because you believe you can develop them. I can teach someone our processes and expectations, but I can’t teach them to care about being part of a team. My mistake was waiting too long to recognize this in the manager that we hired. Especially in a new ASC, one leader unwilling to pitch in can affect the culture of the entire organization. I’ve learned that protecting that culture sometimes means making a difficult decision sooner rather than later.
Todd Currier. CEO and Administrator of Bend (Ore.) Surgery Center: I wouldn’t characterize it as a wrong decision, but one area where we gained valuable insight was during the rollout of a new service line about a year ago. Looking back, I would have invested more time upfront aligning stakeholders, defining expectations and communicating what success would look like. We were understandably focused on operational readiness, but bringing physicians, staff and other stakeholders along the journey earlier would have accelerated adoption and engagement.
My advice to other ASC leaders is to spend as much time on change management as you do on implementation. A new service line isn’t just an operational initiative; it’s a cultural and organizational change. The more alignment you create early, the smoother the execution. Our recent adoption of a new service went very smoothly and achieved all of our success markers. Most of all, the addition of this service line has increased our ability to provide award-winning outpatient surgical care to our community.
Bruce Feldman. Former Administrator of Eastern Orange Ambulatory Surgery Center and Current Founder of an ASC Consulting Firm (Cornwall, N.Y.): The one decision my ASC got wrong in the past year was purchasing equipment without making certain that we would have the appropriate case volume to support it. As we know, surgeons have a tendency to promise bringing cases if certain pieces of equipment and instrumentation are available at the center but don’t necessarily fulfill those promises, and the equipment goes unutilized. I would just caution my fellow ASC leaders to do their due diligence before purchasing new equipment, especially large-ticket items such as robots and navigation mapping systems.
Megan Friedman, DO. Chair and Medical Director at Pacific Coast Anesthesia Consultants (Los Angeles): One decision I have seen ASCs get wrong is expanding operating room availability without adequately evaluating anesthesia staffing, case volume and the financial implications of that expansion. There is often pressure to accommodate surgeons by opening additional rooms or extending operating hours. While the intention is to increase surgical volume, doing so without sufficient case density can actually increase costs without generating meaningful additional revenue. Anesthesia coverage is a significant fixed expense, and underutilized rooms can quickly erode an ASC’s profitability.
My advice to ASC leaders is to approach operating room expansion strategically rather than reactively. Evaluate actual utilization, consolidate cases when possible and involve anesthesia leadership early in scheduling and operational decisions. The goal should not simply be to open more rooms, but to maximize efficiency and profitability within the rooms already available.
Gloria Gardner. Senior Administrator at Physician Partners of America (Apollo Beach, Fla.): Sometimes we overlook our best employees because they are not the “squeaky wheel.” They come to do their work, ask if anyone needs help, float when needed and leave quietly. These are our true heroes.
Ramis Gheith, MD. Chief Medical Officer at Dxtx Pain & Spine (Chicago): Having the appropriate leadership in place is essential to fostering growth and development. Strong, dedicated leadership provides the strategic vision, direction and support necessary to identify opportunities, establish clear priorities and drive meaningful progress. It is important to have leaders who are focused not only on maintaining current operations but also on developing people, expanding opportunities and positioning the organization for long-term success. Without the right leadership and a clear commitment to growth, even the most promising opportunities can be difficult to realize.
Michael Graziano. Administrator at Clifton Surgery Center (Clifton, N.J.): One decision we got wrong this past year was waiting too long to repair or replace aging mechanical equipment and building systems such as vacuum pumps and HVAC units. In an effort to manage costs and avoid unnecessary disruption, we sometimes continued repairing equipment that was reaching the point where replacement would have been the better long-term decision. Deferred maintenance can ultimately cost more — not only in repair expenses, but also in staff time, operational disruptions, and the potential impact on patient care and scheduling.
My advice to other ASC leaders would be to take a proactive approach to facility maintenance. Establish a regular assessment of critical mechanical systems, identify equipment approaching the end of its useful life and create a capital replacement plan rather than waiting for something to fail. In an ASC, reliability is critical, and investing proactively in the facility can prevent much larger problems down the road.
Steve Hockert. Chief Development Officer at Solara Surgical Partners (Southlake, Texas): If I could revisit one decision from the past year, it would be a hiring decision made too quickly. While every ASC is committed to delivering outstanding patient outcomes, each facility has a unique culture that supports that goal. Hiring in haste can have lasting consequences. My advice is simple: Prioritize cultural fit and long-term alignment over speed when filling critical roles.
Narasimhan Jagannathan, MD. Professor and Division Chief of Anesthesiology at the University of Arizona College of Medicine (Phoenix): One area ASC leaders may underestimate is the increasingly competitive ambulatory surgery landscape. While access, efficiency and patient experience are important differentiators, pediatric ASCs also benefit from dedicated pediatric anesthesia and surgical specialists with quaternary-care experience, as we have at Phoenix Children’s. This expertise supports appropriate patient selection, high-quality care and the safe expansion of ambulatory services.
Thomas Jeneby, MD. CEO of Palm Tree Surgicenters, Chrysalis Cosmetic Surgicenter and Maximus Plastic Surgicenter (San Antonio): Many regrets. The biggest is trusting a small vendor to invoice and show proof of delivery throughout the entire purchase loop. We used a smaller, less-expensive vendor, a “one-man show,” and are now deciphering the bills.
Natasia Jones. Clinical Operations Director at Pegasus Surgery Center (Anaheim, Calif.): One decision I think we could have handled differently was allowing certain operational processes and communication practices to remain informal for too long. In a smaller ASC, it’s easy to rely on relationships, verbal communication and people simply knowing what needs to get done. But as the center grows, that approach can create confusion, inconsistencies and a lack of accountability.
Looking back, I would have pushed earlier for more clearly defined responsibilities, standardized workflows and stronger communication across departments.
I also think an important part of leadership is being willing to have uncomfortable conversations. Whether it’s with staff, physicians or other members of leadership, avoiding difficult conversations doesn’t make the issue go away. More often than not, it allows small problems to become bigger ones. Leaders have to be willing to address concerns directly, set expectations and hold people accountable, regardless of their position or title.
My advice to other ASC leaders would be not to wait until something becomes a problem before addressing it. Build the structure, communicate expectations clearly, and create an environment where accountability applies to everyone. You can have a great team, but without clear communication and leaders who are willing to make difficult decisions, even the best teams will struggle.
Judith Kazy-Garey. Executive Director of Algonquin Road Surgery Center (Lake in the Hills, Ill.): One decision I would handle differently as a new administrator was the development of our annual budget for the current fiscal year. At the end of last year, I anticipated that we would face significant challenges after losing our orthopedic surgeons to their own surgery center. Despite that concern, the board wanted to project growth as they have historically done rather than budget for a reduction in volume. Looking back, I should have advocated more strongly for a budget that reflected our realistic expectations, even if that meant presenting a less optimistic financial outlook.
The experience reinforced an important lesson: A budget needs to be built on realistic assumptions, not the growth we hope to achieve. When projected volumes do not materialize, the financial impact can affect cash flow, staffing decisions, vendor obligations and the overall stability of the surgery center.
My advice to other ASC leaders would be to use historical performance, known changes in case volume, payer mix and realistic growth opportunities to develop your financial projections. If leadership or the board pushes for more optimistic numbers, present the supporting data, clearly outline the risks, and develop both a conservative budget and a growth scenario. Most importantly, have the courage to challenge assumptions when the numbers do not support them. As an ASC leader, it is my responsibility not only to support the board’s vision but also to provide an honest assessment of the center’s financial outlook. I learned that advocating for a realistic budget is not being negative or lacking confidence in the organization; it is being a responsible steward of the center’s financial health.
Earl Kilbride, MD. Orthopedic Surgeon at Austin (Texas) Orthopedic Institute: One big mistake is the disconnect between the administration and the providers. Everyone should be rowing in the same direction, but in order to do this, there has to be transparency and communication between the two. As a provider, knowing the contracts (implants specifically) can really turn the financials in a good way.
Maher Kodsy, MD. Chair of the Department of Anesthesiology at University Hospitals Elyria (Ohio) Medical Center: Healthcare providers depend on business professionals to provide them with the necessary advice and appropriate recommendations. ASC stakeholders trust that they receive the best services that best suit the interests of the ASC. However, ASC advisors prioritize their own interests over those of the ASC.
Here are some examples of how ASC leaders make incorrect decisions:
- Taking on excessive debt and loans based on inaccurate projections and pro formas. This lowers the share’s value and reduces the revenue per share to fund the debt before incurring additional interest on the loan.
- Receiving incorrect legal advice. With every attempt to correct it, you will incur more legal expenses. It becomes evident that a wrong decision was made from the beginning, resulting in mismatched business partners or a deal that cannot be terminated without losing the majority of the investment.
- Some management companies may attempt to sell you that your return on investment is 200%. They are skilled in convincing you that you are “special” and will outperform market norms. Be realistic and aware that your business is part of an industry with a small delta of 5% to 10% above or below the average.
- A clear understanding of market dynamics is crucial. The notion that an ASC will continue to operate successfully indefinitely lacks merit. Having an exit strategy when you are at the peak of your profitability will provide various attractive options.
- Continuing to operate at a loss after multiple attempts to address deficiencies is not advisable. Draw a line in the sand, set a time limit and outline clear goals.
These are the most common incorrect decisions an ASC could encounter. Objectively addressing these issues among shareholders earlier rather than later is the most practical approach to move forward with the next steps.
Jessica Lam, PhD. Practice Manager of Pacific Coast Anesthesia (Los Angeles): One mistake we’ve learned from is underestimating how important early communication and coordination are between ASC leadership and anesthesia management. Too often, staffing needs are addressed after surgical schedules have already been finalized, leaving little opportunity to make adjustments efficiently. From a practice management perspective, even small communication gaps can have significant operational and financial consequences. Anesthesia staffing requires advance planning, and unexpected changes can affect provider availability, costs and the overall flow of the surgical day.
My advice to ASC leaders is to treat anesthesia as an integral part of operational planning rather than simply a service that accommodates the surgical schedule. Regular communication, shared expectations and involving anesthesia management in decisions early can prevent unnecessary expenses and improve efficiency for everyone.
Benjamin Levy III, MD. Gastroenterologist at University of Chicago Medicine: Many ASCs and hospitals across the country have been slow to adopt artificial intelligence technologies into clinical practice due to the cost and waiting for these new technologies to improve. However, AI in gastroenterology offers many opportunities to help train fellows (through GI Genius software), improve polyp detection rates and accelerate endoscopy turnaround times. In particular, new technologies such as Argus’ EndoSoft offer AI voice-activated reporting to describe polyps and polypectomies in real time during procedures, which reduces the time needed to write detailed procedure reports after colonoscopies.
Andrew Lovewell. CEO of Columbia (Mo.) Orthopedic Group: Our mistake was treating a signed contract and an approved prior authorization as a guarantee that we would be paid for services that we had provided. We scheduled and performed cases on the strength of both, and too often payers denied or underpaid claims after the fact, in ways the contract did not allow. We are working harder for the dollar that we are contractually entitled to.
To other ASC leaders: Verify, don’t trust. Audit every payer’s actual payments against contract terms, document each authorization at the time of approval and be ready to enforce your contract, including walking away from the table. A contract is only worth what the payer will honor.
Sandra Oglesby, RN. Administrator of the Surgery Center at Tampa General Hospital’s Brandon Healthplex (Brandon, Fla.): We underestimated how difficult it would be to translate a hospital financial model into an ASC model. A procedure that makes sense clinically and financially in the hospital may look very different once you apply ASC reimbursement, payer contracts and cost structure. My advice to other ASC leaders is to validate the economics before migrating the volume. Clinical appropriateness gets the case to the ASC, but understanding the reimbursement and cost structure keeps it there sustainably.
Raghu Reddy. Chief Administrative Officer of MiOrtho Surgery Center and a Member of the Ambulatory Surgery Center Association’s Education and Quality Committees (Southfield, Mich.): Our biggest mistake last year was not closely evaluating new hires during their first 90 days. We had several other initiatives going on, and we missed early signs that some weren’t a good fit. A couple didn’t work out, so we had to recruit again to fill those roles. That put extra strain on our existing staff and added a month or more to the hiring cycle.
My advice to other ASC leaders: Put most of your effort in up front, with 360-degree interviews, job shadowing and thorough reference checks. Once someone starts, hold formal 30-, 60- and 90-day reviews so expectations are clear on both sides and problems surface while there’s still time to fix them.
Matthew Ryan Reeder. Administrator of Ambulatory Surgical Center at LBJ (Houston): One decision we got wrong was treating block schedules as fixed assets rather than an actively managed asset. We discussed concepts and how to correct wayward block utilization but, in the end, held on to underutilized block time too long; we assumed utilization would improve with moderately active management. We learned that every unused hour represents lost access for patients and lost opportunity for the ASC. My advice to other ASC leaders is to establish clear block utilization expectations, review data consistently and often, and create a transparent process for reallocating time. If surgeons are available and willing to do more cases, don’t let historical block assignments become a barrier to access.
Tammy Smittle, RN. Chief Operating Officer and Chief Nursing Officer of Northwest Hills Surgical Hospital (Austin, Texas): We learned that even the best business decisions can create distrust when the organization’s investors do not feel included in the conversation. In a physician-owned facility, trust and alignment are critical to success, requiring open, honest communication about financial performance, operational challenges and strategic decisions. We learned that physician owners don’t just want to be informed of decisions — they want to understand the reasoning behind them and have a voice in the process. Transparency isn’t just good communication; it’s the foundation of a successful partnership.
Alan Wagner, MD. President and Founder of Wagner Kapoor Institute (Virginia Beach, Va.): It’s not something we got wrong, but it sure was something we didn’t expect. We are hyperfocused on “green” along with Six Sigma, safety and hospitality. For our buildout, we never thought that there would be an upfront cost of nearly six figures to engage a green consultancy to help guide us through construction! Totally unaffordable, and we had to do it ourselves.
Kevin Youmans. CEO and Administrator of Casper (Wyo.) Surgical Center: One decision we would approach differently involved converting a traveling surgical technician into a permanent employee as part of our effort to stabilize OR staffing. At the time, it appeared to be a practical solution. We had an experienced individual who was already familiar with our team and operations, and the conversion offered an opportunity to reduce our dependence on contract labor. Unfortunately, the employee subsequently left, and we incurred a recruitment expense without achieving the long-term stability we anticipated.
The lesson for us was that filling an immediate staffing need and building a sustainable workforce are not necessarily the same thing. In hindsight, I would have placed greater emphasis on evaluating long-term retention and the financial exposure associated with the conversion before making that commitment. My advice to other ASC leaders is to look beyond the immediate vacancy. When making staffing investments, consider not only whether the individual can meet today’s operational needs, but also whether the arrangement supports the organization’s longer-term workforce strategy.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
