Developing a physician-owned outpatient surgery facility can be a rewarding professional and financial venture. A well-run center provides an opportunity to create an ideal surgical environment for patients, to increase your efficiency, and to have a stream of income above and beyond standard professional fees. This can be a winning situation for everyone. Patients receive the best care, and physicians may increase their income substantially through improved time management and generation of facility fees. Medicare and other payers enjoy substantial savings, relative to hospital-based surgical care.

I've had the experience of running my own facility for 18 years. Over time I've watched some facilities sail along effortlessly and thrive. Sadly, I've seen other centers struggle to stay above water. As I reflect on this, it seems that success or failure has little to do with luck. Successful centers all seem to understand four basic fundamentals that should be taken as steps in the creation and management of an out-patient surgical facility.

Regina Matthews, surgical scrub technician, assists Dr. Colvard at his surgery center.

Step #1: Hire both a medical space planner and a business attorney who have experience in developing physician-owned surgery centers.

Taking a surgery center project from inception to completion is like piloting a riverboat down the Mississippi. The trip is not intrinsically dangerous, but you need people at the helm who have made a successful voyage. As an ophthalmic surgeon, you are superbly equipped to make all the important clinical decisions regarding your center. Do not imagine for a moment, though, that your medical expertise will enable you to build a surgery facility on your own!

Many ASC projects capsize immediately because of costly initial missteps in design and construction. Never begin a project without the guidance and oversight of a medical space planner with a track record of successful centers, preferably in your area (local and state regulations vary). Constructing a surgery center, either freestanding or  within an existing building, is not difficult, but the process is full of potential pitfalls. For instance, a common error is misunderstanding fire codes. A project, developed with meticulous detail with regard to health-department regulations, may founder when the final fire inspection occurs. Regulations for firewall protection in surgery centers are far more demanding than those for medical office facilities. Major reconstruction costs to replace fire walls can get a facility into financial difficulty before it has a chance to generate any income.

Sound legal advice regarding the business structure of your project is also essential. A key consideration is the mechanism to distribute profits. It must be legal in terms of state and federal regulations. In general, it is best for the investors to be the physician-users. Profits from the surgery center, however, must not be tied directly to the individual users' productivity. Physicians with larger surgical volumes may be allowed to buy a larger share of the facility's stock, but a direct link of profits to productivity may not be established. This is not as complicated as it sounds, but few physicians completely understand these rules. An experienced attorney can steer the project away from difficulties and keep your facility out of dangerous waters.

Step #2: Chose your surgery center partners carefully.
After practicing in a community, one tends to have a good idea of which physicians are likely to be the best and most compatible partner candidates. The ideal surgery center partner is a colleague who practices high-quality medicine and has a busy surgical practice. Character and personality is just as important. A physician who is honest, fair and pleasant to work with will allow the center to run more efficiently and with less strife. The best surgeons also tend to be less wasteful. They're efficient in the OR and have fewer complications, and so, less center cost per case. If no one in your area seems to fit this description, do not be afraid to go it alone. No partner at all is better than a bad one. A surgeon who needs two viscoelastics for every case and who pulls out the vitrectomy device once a week will quickly send a surgery center into negative numbers. A small, tightly run single-physician surgery suite can be very profitable. I ran one successfully for many years. There is an economy of numbers. Profits are potentially higher with multiple users practicing quality surgery and fully utilizing capacity.

Step #3: Pick the best nurses in your community to be your crew.
All of us who work in hospitals can identify the great nurses. They're cheerful, careful, hardworking and focused. They do not read People magazine and chat among themselves, while ignoring their recovery room patients. We notice these talented nurses because everything runs smoother where they work.

Most importantly, they make patients happy and comfortable. Fortunately, they tend also to notice us. Ophthalmologists are generally polite, amiable and not self-important. We don't scream, we don't throw instruments, and we don't tend to work weekends or at night. Nurses love this. Given a choice between working day and night while being yelled at by neurosurgeons vs. working with us in a peaceful surgery center, they tend to choose us. Once at work in your center, they help create a nurturing, stress-free environment that is wonderful for the patients, the staff, the surgeons and the success of the center.

Like quality surgeons, quality nurses tend to be efficient and as careful with supplies and instruments as they are with patients. A careless nurse who mindlessly opens unneeded viscoelastics, suture packs or the wrong IOL can drain the profit from an individual case in a blink, and this pattern can sink a surgery center. Good nurses tend to be team players who want their center to succeed. They are a critical element in the overall effort to provide high quality cost-conscious care.

Step #4: Manage your costs per case with great care.
A surgery center can be very profitable, but the global fee paid to surgery centers for a cataract procedure contains no fat. A surgery center cannot succeed financially without cautious supply purchasing and good management. The art of running a surgery center is to choose the best products at the best cost while eliminating wastefulness.

Years of experience have taught me a few fundamentals about wise purchasing practices for cataract procedures.

First, you can usually negotiate the best deals in surgical products if you direct all of the facility's business to one manufacturer. Cost discounts can be established as a function of volume. The manufacturer must offer a range of products to suit the needs and proclivities of all physicians using the facility. Ideally, it should provide both acrylic and silicone IOL product lines with edge technology to reduce capsular opacification and injector systems that obviate the need for incision enlargement. Both cohesive and dispersive viscoelastics should be available to meet the surgeons' needs in a full range of clinical settings.

Secondly, the phaco equipment you select must provide the highest technology without requiring wasteful single-use cassettes. Today's devices provide safe, dependable, cutting-edge technology with reusable tubing and have the potential to allow significant cost savings in every case. This increases profitability while maintaining the highest quality.

The practice benefits of a good surgery center can't be overstated. A well-managed center enhances patient satisfaction and increases referrals by fostering high-quality, personalized care. It increases physician satisfaction by providing a pleasant surgical environment, and increased productivity. Cases start on time, the OR turnover is fast, and scheduling is done at your convenience. The most tangible benefit of the center, however, is increased income. As surgeons, we have little opportunity to increase our income without doing additional cases. A well-managed surgery center can allow a surgeon to double his net surgical income without performing a single additional case.

The key is a good start. Once a center is built, the business structure formed, the partners chosen, the staff selected, and a culture of prudent, thoughtful purchasing established, you will be on your way to one of the most rewarding ventures of your professional career. 

Dr. Colvard has operated his own ASC since 1985. He is in private practice at the Colvard Eye Center in Encino, and is an assistant clinical professor at University of Southern California School of Medicine. Ms. Colvard works as a medical writer for the Colvard Eye Center and is an undergraduate at Duke University.