T h e S u c c e ss f u l O p h t h a l m i c A S C

Administration, Operations
and Procedures

Product #012400V ISBN #978-1-61525-238-1

T h e S u c c e ss f u l O p h t h a l m i c A S C :

Administration, Operations
and Procedures
Written by:
Louis Sheffler, MPS, Maria Tietjen, BSN, and Carl Desch, MBA
Louis Sheffler, MPS, is the Chief Operating Officer of American Surgisite Centers. He started working
as a developer of ASCs in 1980 and has been involved in 135 ASC projects nationwide. He serves on the
Board of the Outpatient Ophthalmic Surgery Society (OOSS), and participated in the AAO subcommittee
to review EMR standards for CCHIT. Maria Tietjen, BSN, works as Executive VP Nursing and Clinical
Services at American Surgisite Centers. Her background as an Operating Room Nurse spans a 35 year career,
specializing in Ophthalmology for 26 years and Orthopedics for 10 years. Carl Desch, MBA is the Chief
Administrative Officer of American SurgiSite Centers. He spent over 30 years in the financial industry at
JPMorgan and then Goldman Sachs where he focused on operations, risk management and administrative
roles internationally. He currently coordinates various aspects of managing ambulatory surgery centers,
including billing and collection functions, insurance, purchasing and center governance

Reviewers:
Dawn Followell
Donna Lock
Paul Lucas
David Miller, MD

Academy/AAOE Staff:
Heather Serginia, Print Production Manager
James Frew, Senior Designer
Peggy Coakley, Administrative Manager
Sangeeta Fernandes, Program and Content Manager

Other titles in
The Successful Ophthalmic ASC Collection:
Complete Guide to Coding (#012405V)
Designing and Building (#012401V)
Financial Reporting and Management (#012400V)
Managing ASC Quality and Performance (#012402V)
Save 10% when you buy the entire collection
Disclaimer and Limitation of Liability: All information provided by the American Academy of Ophthalmology, its employees, agents, or representatives
who authored or contributed in any way to this publication, is based on information deemed to be as current and reliable as reasonably possible. The
Academy does not provide legal or accounting services or advice, and you should seek legal and/or accounting advice if appropriate to your situation.
The Academy shall not be liable to you or any other party to any extent whatsoever for errors in or omissions from any such information provided by the
Academy, its employees, agents or representatives.

© 2011 American Academy of Ophthalmology

A dm i n i s t r ati on, Ope r ati ons and Proc edures The Suc c essful Ophtha lm ic A S C

Administration, Operations and Procedures | Efficient, quality

operations — the minute-by-minute, day-to-day interactions of
people and systems — are essential to the administrative, clinical
and business activities of an ambulatory surgery center (ASC).
Attaining this goal is a challenge: operations can always be improved.
Past successful surgical results, positive profit margins and smooth
administrative routines do not ensure future success. Every day
presents a set of new challenges, with patients, doctors, regula-
tions, insurance carriers, nursing personnel, supply costs and
others all thrown into the mix. Optimizing ASC operations
requires a consistent routine and on-going review. This module
identifies important quality markers that owners and managers
of ophthalmic ASCs need to be on top of to keep clinical quality
at the highest level, to ensure that administrative procedures are
seamless and predictable and to maximize profits.

Administrative and benefits management, technology infrastructure

management, equipment and supply procurement,
Business Support billing and collection services, financial reporting
and control, legal services and facility maintenance.
Services These, among other vital operational components,
are discussed in the following sections.
Many support services are required to operate an
efficient ophthalmic ASC. Everything from the Human Resource Management
gleam on the tiles of a properly equipped OR’s floor Depending on the size of the ASC, it may be neces-
and the well-stocked supply rooms to the consistent sary to have staff dedicated solely to human resource
flow of revenue, dependable information streams and benefit functions. Payroll tasks and overtime
and reliable technology infrastructure comes about calculations can be time-consuming and tedious,
only through planning and precise execution on the but accurate paychecks and records are very impor-
part of the team running the center. tant to ASC staff, so these tasks must be performed
Depending on the volume of business an ASC with the utmost care and precision.
conducts, some centers find it more efficient to ASCs of all sizes should seriously consider
outsource several of the requisite support services, contracting with outside payroll and HR depart-
while other centers provide them in-house. Either ment vendors for these functions — because these
way, it is essential to factor these services into the firms are efficient and inexpensive. Such firms can
ASC operations equation. Failure to do so can also assist in providing help lines or websites where
significantly impact costs and impair efficiency. employees can get answers to questions they may
Among the major services that need to be considered have concerning pay, benefits or employee policies.
in the operational plans are human resources and Structuring benefit plans and insurance coverage for

1
A dm i n i s t r ati on, Ope r ati ons and Proc edures The Suc c essful Ophtha lm ic A S C

ASC employees generally requires regular interac- Positions with Management

tion with benefit specialists and providers. Addi- Responsibilities
tionally, a structured, timely enrollment process is Specific management responsibilities should be
essential. given to the following three positions:
• The OR Nursing Director (OR Supervisor)
Staffing is responsible for what happens in the ASC
When new employees come on board, a good assi­ on the day of surgery;
milation process makes a lasting impression; the • The Head Nurse is in charge of clinical issues
HR manager should be a part of this introduction. when the Nursing Director is absent; and
Strength in the human resources area is a great way
to build employee morale and allegiance. • The Administrator (Office Manager)
Traditional recruitment methods, such as assists the OR Nursing Director and also is
advertising in newspapers, websites and journals, responsible for the administrative and busi-
are one option for finding new recruits, but a better ness affairs of the ASC, acting as the liaison
way is to encourage high-performing employees to with the various ophthalmology practices to
recommend candidates. Most OR personnel come coordinate scheduling issues, insurance pre-
from a hospital environment and know OR techs certification clearance and patient relations.
and nurses who are qualified to work in an ASC.
Some ASCs give an incentive bonus to employees Technology Infrastructure
who refer candidates. Once these new employees are Management
hired, the referring employee can assist with orien-
tation and training. The software systems and hardware an ASC puts in
Job descriptions should represent job respon- place make up its technology infrastructure. That
sibilities accurately, and new employees should infrastructure is increasingly an integral part of
be provided with an orientation. (See the sample the center’s day-to-day operational flow, affecting
orientation agenda in Appendix B.) A competency- everything from scheduling and billing to electronic
based checklist should be used to review skills health records (EHRs) and basic operational func-
annually. tions. Required equipment may run the gamut of
capability and technologic advancement: sophis-
Personnel Manual and Policies ticated centralized servers, desktop workstations,
Management should also review the ASC’s person- monitors, scanners, signature pads, faxes, telephone
nel manual annually. The purpose of this review systems and copiers. Wired and wireless Internet
is to evaluate the ASC’s personnel policies against and other connectivity, as well as responsiveness of
those of other ASCs and hospitals in the area. It is technology support personnel during and outside
common in tight nursing markets for health care the ASC’s operating hours, should be considered in
institutions to change policies to provide employees the big picture of technology management. Find-
with incentives to leave their current employer. ing the right people to manage the software and
Review paid time off and other benefits annually to hardware is as important as buying the appropriate
ensure that your ASC’s offerings are competitive in systems and equipment. The size of the ASC, as
the marketplace. Increasing the amount of paid time well as owner level of commitment to technology
off after three years of employment and again after and performance, determines whether technol-
five years will encourage staff to stay with your ASC. ogy requirements should be managed internally or
Some ASCs provide lunch for the staff during the outsourced to a technology consulting firm.
surgery day so that employees can remain in the ASC
all day and be available for any medical emergency Issues to Consider
that may arise. This is a benefit that is always popular Important issues to consider are the initial costs of
with staff. equipment and installation, ease of use, training,
A labor attorney should review the personnel ongoing maintenance and upgrades, integration
manual to ensure that its policies are consistent with with other software systems, customization and
current federal and state laws and guidelines. backup. Owner/manager involvement in these
conversations and openness to new developments
in the IT space can benefit the overall success of
any operation. Technology should be considered a

2
A dm i n i s t r ati on, Ope r ati ons and Proc edures The Suc c essful Ophtha lm ic A S C

tool: having the right tools for the job yields a more to communicate with physician office software (inter-
efficient and more profitable operation. operability) so that required patient information
Effective planning and management of an ASC’s will flow easily from office to ASC.
technology demands a high level of attention. With- Required forms and features of an EHR system
out a specific plan and ongoing oversight — activities should include the following:
that include all members of the ASC staff — technol-
ogy can end up frustrating daily operations, rather • Compliance with federal initiatives for
than facilitating them. ASC ownership/management “paperless” physicians
should expect to take time getting everybody to buy • Chart notes (physician/anesthesiologist/sur-
in to new systems so that staff welcomes the transi- gical nurse)
tion to a new system. • Automated billing, accounting and reporting
External Communication • Electronic consent forms
Good communication with the community (both • Preop health questionnaire
surgeons and patients) should include maintain- • Pre/Postop nursing records
ing a website. Effective communications programs
can enhance ASC profitability by getting the ASC’s • Pre/Postop surgeon’s records
name out into the marketplace, and drawing addi- • Fully automated general and monitored
tional doctors and their patients to the center. anesthesia care (MAC) anesthesia records
• Intraoperative records
EHR and Related
Information System Support • Discharge summary (“super” bill)
Medical practices and surgery centers have been • Automated generation of operative reports
utilizing electronic practice management (EPM) • Quality assurance of electronic charts
software systems for years. The function of these sys-
tems is to set appointment schedules and to provide • Full auditing features and reports
a platform for electronic insurance reimbursement • Automation and management of patient
submissions. records and documents
For most ASCs, the gap between scheduling and • HL7/DICOM connectivity to medical
billing has been filled with paper surgical charts. equipment
Recently, software companies have introduced
electronic health records (EHR) to interface with • Integration with third-party products
the scheduling and billing functions.
EHRs have many advantages over paper charts. Equipment and
A well-designed ASC EHR system should permit Supply Management
remote block-scheduling from each surgeon’s office,
transmission of forms to the ASC medical record There are many different avenues for staying current
over a secured Internet protocol and remote access on the latest ASC equipment in the marketplace
to charts for surgeons. These features greatly reduce and on the buying opportunities that exist. Trade
the workload of creating paper charts in the ASC, publications, industry conferences, manufacturers’
while making the scheduling job easier for surgeons’ representatives, independent research and the anec-
offices. dotal experiences of colleagues are all good sources
EHR software pricing varies greatly. ASC manag- of information. Once the ASC is operational, it is
ers and owners should therefore carefully check out advisable to maintain continuous vendor contact to
various systems and weigh the features and benefits review how equipment is operating and how it can be
of each. (See Resources section at the end of this better utilized and maintained.
module.) Systems that are easy to use and that reduce A regularly scheduled program of preventive
workload should be benchmarked against paper chart maintenance is necessary for all highly utilized
costs and work flow. An ideal EHR system should be equipment to ensure optimum performance and
easier, faster and less expensive than paper records. longer life span. Equipment upgrades should be
The Centers for Medicare and Medicaid Services considered and are usually included in maintenance
(CMS) provides incentives and subsequent penalties agreements offered by the various OR equipment
for the use of EHRs. Make sure that the software companies. A log should be maintained to record
platform you choose for the ASC has the ability utilization of equipment so that outdated items

3
A dm i n i s t r ati on, Ope r ati ons and Proc edures The Suc c essful Ophtha lm ic A S C

can be removed from the ASC in a timely manner. purchasing and management, despite the incre-
The market for used equipment and instruments is mental cost, often yields significant savings because
large; if equipment has been properly maintained, of the discounts these companies are able to extract
much of it can be resold. By the same token, not from suppliers and the warehousing capabilities they
everything that is purchased for the ASC needs to be offer. Before rejecting the idea of going outside
new. Nonelectric equipment, such as stainless steel to get the services of a purchasing agent who can
ware, can be purchased in the secondhand market. represent its interests, an ASC should perform a
Mechanical equipment should be purchased used thorough cost analysis.
only if it is backed by the original manufacturer. ASC managers should establish internal proce-
The cost of medical supplies has become increas- dures and centralize ordering to contain costs. For
ingly difficult to control in the wake of the federal example, surgical glove costs can vary widely. Proce-
government’s publication of Medicare Conditions for dures should dictate how products are ordered and
Coverage (www.cms.gov; then search “Conditions what products are approved for purchase.
for Coverage”). Items labeled “single use” cannot
be reprocessed; this has driven supply costs up. Billing and Collection Services
Purchasing personnel need to be on top of these
requirements and should examine competitive OR Revenue is the fuel that runs the ASC engine. How
products and utilize multiple supply vendors to efficiently an ASC collects the insurance claims that
extract the best prices. are due to it determines the fate of the business.
Competition for sales always exists in the mar- Failure to expend adequate effort to collect revenue
ketplace: the largest supplier does not always offer can greatly harm the ASC. Good ASC management
the best terms. To start the process of selecting a starts by having the right people in place in the col-
supplier, purchasing staff should obtain several lections role — or a qualified firm under contract to
quotes for the items that are used most frequently. perform collection tasks.
Payment terms should be negotiated to maximize Make certain that the billing and collections staff
cash availability. In certain instances, there may understand the role they are performing and are
be flexible promotional consignment terms for properly trained to identify the procedural codes
IOLs. The purchasing staff should leverage available they will be using, as well as what different insur-
information sources to learn about alternative sup- ers require on claim submissions. Billing is not a
pliers and products. New products should be priced mechanical process: the more the billing specialists
before being evaluated in the OR. ASC staff should understand about the procedures that are being
be open to trying new products: such flexibility can performed at the facility and the subtleties of a
contribute to efficiency and help the bottom line. discharge summary and use of modifiers, the greater
It is also important to manage inventory levels the revenue stream will be and the faster it will flow.
properly so as not to tie up valuable capital. High It is important to have contracts in place and to
inventory levels of slow-moving items eat up stor- review them annually for the group of insurance
age space, and unused stored drugs can expire. In providers who are in-network. The credentialing
high-volume ASCs, warehouse management software process can be cumbersome and time-consuming; it
systems can precisely manage inventory levels and set requires a knowledgeable person who stays on top of
automatically triggered reorder points. Such systems the insurance company to complete the contracting
are also integrated with the ASC’s accounting system process. Initial rate schedules often entail multiple
to allow for the posting and updating of invoices and rounds of negotiation and, once in place, are also
payables. Even a single- or a double-OR ASC is not subject to review and adjustment at different times.
too small for such a system. Many firms offer ware- At least one person should be charged with staying
house management and related accounting packages; current on developments related to various contracts
the costs of these systems have been coming down and also on industry trends and proposed changes in
in recent years. The systems can be customized, but legislation or regulations.
customization is usually not necessary for effective The billing function should be organized such
operation. that claims are submitted as quickly as possible
When examining the supply management after the procedure has been finished and patient
function, ASC management/ownership must also records completed. The staff must monitor submit-
consider another dimension: the staff hours that ted claims and quickly turn around those that are
are being expended maintaining data records and rejected. The staff should also look for any patterns
supply flow. Using a purchasing agent for supply in the rejections to see if something is consistently

4
A dm i n i s t r ati on, Ope r ati ons and Proc edures The Suc c essful Ophtha lm ic A S C

wrong or if something has changed. The submission Good reporting is frequent reporting — namely,
of secondary claims is more difficult to track and a monthly closing and reconciliation, followed up
control (compared with Medicare primary claims), with quarterly reporting of financial results and
but it is vital for profitability. Monies received must variance analysis. The reporting packages generally
be quickly posted and cleared, and daily proofs consist of several income statements with compari-
need to be conducted to minimize reconciliation sons to other time frames, balance sheet compari-
headaches at month’s end. Duplicate payments or sons and also several forms of activity comparison,
overpayments should be refunded when discovered. best sorted by either CPT code or physician name. If
The insurance companies will either request return they are being distributed to the ASC shareholders,
of the funds or ask for them to be applied against a these reports are generally accompanied by a com-
subsequent claim. mentary on the results.
As receivables start to age, the staff should not Sharing the results with the center’s shareholders
hesitate to escalate the issue and begin the collec- and other key individuals who assist in running the
tion process if needed. Waiting too long to get a center is a good practice. It allows all involved to
payment from a patient, even if staff is in contact better understand the dynamics of the operation and
with the patient, only decreases the probability of to see how their actions and those of others translate
eventually getting paid. Working out payment plans into the financial reality of the ASC.
for select patients may be an acceptable alternative to Additional functions such as the handling of
demanding full payment of an open balance. ASC payables, cash management, bank account reconcili-
management/ownership must set metrics for the ations and banking relationships, interactions with
billing and collection functions with respect to the the outside accounting firm and preparation of tax
timely completion of tasks and for the receivables returns are also part of the financial life of an ASC.
aging profile. Billing/collections staff should meet Seeing that these activities are taken care of expedi-
regularly to review the metrics and identify ways to tiously is an essential element of a good operation.
improve performance further. The investment of (For more information on these subjects, see the
time will yield significant returns. If collections Financial Reporting and Management module in this series.)
fall behind, paying overtime hours to the billing
department is worth the investment; additionally, Benchmarking
hiring an outside consultant to review fees and bill-
ing practices is wise. (See the Complete Guide to Coding Benchmarking the ASC’s results against the per-
module in this series for more information on formance of other eye surgery centers will assist
reimbursement.) the managers of the ASC in determining how well
the surgery center is performing. Joining the state
surgery center association, as well as a national
Financial Reporting and Budgeting organization such as the Outpatient Ophthalmic
An ASC needs to have a good budgeting process in Surgery Society (OOSS), will provide valuable tools
place — and produce regular reports of financial for business, administrative and clinical benchmark-
results for review. Timely financial reports enable ing. (See Resources for more information.)
the managers of the center to see how they are doing
against their annual plan, to spot where assump- Other Services to Consider
tions or market conditions require changes and to
track revenues and expenses throughout the year. There are a myriad of other business-related func-
Whether budgeting and reporting responsibilities tions and services that are part of running an ASC
are assigned to full-time ASC staff or are outsourced efficiently. These include having good legal support
does not change the fact that they need to be com- to review contracts, analyze regulations, prepare
pleted and that the information needs to be updated legal documents and give counsel when needed on
frequently. Management also needs to be aware of compliance matters and related questions. The
seasonal variations. In the Northeast, for example, lawyer or firm providing such services should have
the busiest time is from the start of autumn until the experience in the industry and should be prepared
end of the year. Scheduling and staffing may need to offer support on short notice. Carefully consider
to be adjusted for time of year, and financial results and outline the specifics before agreeing to any fee
should be benchmarked by month or season against arrangements.
the previous year’s performance. Also necessary are reliable and experienced
contractors who provide building maintenance and

5
A dm i n i s t r ati on, Ope r ati ons and Proc edures The Suc c essful Ophtha lm ic A S C

cleaning services. No facility wants to receive a poor work for them, too. Surgical complications that may
result following a surprise inspection or encounter occur with the anterior segment doctors Monday
environmental infection control problems that show through Thursday can be managed on Friday by the
lack of regard for patient care or safety. The services posterior segment surgeons.
of a reliable, experienced company are well worth For pediatric surgeons, Friday is an excellent day
paying a premium for. An ASC should also maintain to perform surgery. Children should be scheduled at
a strong relationship with transportation companies, a separate time from adult patients. Usually the par-
archiving services, waste disposal companies, electri- ents are allowed to be in the preop and postop areas
cians and plumbers who know the ASC complex and to comfort their children and spend time speaking
are on call for unforeseen emergencies. with the doctors and nurses. Friday is usually a
convenient time slot for working parents, too.
In dealing with the anterior segment practices,
Scheduling it is best to survey the practice to find out what days
the surgeon has office hours and what days he or she
is in the OR. If a doctor is moving surgery out of
Efficient coordination of the OR schedule is of the hospital setting and into the ASC, the surgical
the utmost importance to efficient ASC operation time block will likely be reduced because ASCs have
because personnel expenses are a major overhead shorter downtimes between cases than do hospitals.
category in the ASC. Gaps in the schedule are costly. It is a good idea for the ASC Nursing Director to
The best way to manage the daily schedule is by observe the surgeon in the hospital OR, if possible,
block-booking time for each surgeon. to evaluate case time. Doctors performing cataract
surgery in less than 15 minutes would be best served
Block-Booking Considerations by supplying two tandem ORs, so the nursing and
anesthesia staff have adequate time to prepare the
If you make your ASC available to outside surgeons,
patient for the surgeon. Ideally, there should be
here are some suggestions. It is important to get
only a few minutes’ downtime for the surgeon
accurate data from a surgeon who wishes to join the
between cases. For rapid procedures this can only be
medical staff of the ASC to determine how much
accomplished consistently and safely by having the
time that surgeon will require. It is wise to obtain
surgeon migrate from one OR to another.
the surgery volume history from the surgeon’s prac-
Long procedures, like retina and plastic cases,
tice by requesting a report of all surgical procedures
generally need an individual dictation for every case,
performed during the previous year. The surgeon’s
so procedures of these types should be scheduled as
electronic billing program in his or her practice
single-OR cases.
should be able to produce this information easily.
Because changing the OR to accommodate a new
If both eyes require surgery, most doctors want
surgeon later in the surgical-day schedule produces
to perform both surgeries within a month’s time
downtime, it is advisable for one surgeon to fill the
because Medicare requires a general history and
entire day. As an example, if a surgeon is used to
physical examination within 30 days of a planned
working four Wednesday mornings a month and
surgery. Performing surgery on both eyes in one
completing surgery at noon in the hospital setting,
month means that the patient will not need to
it is more efficient for the doctor to operate two full
return to the primary care provider for a second
Wednesdays per month at the ASC.
exam for the second eye surgery. Most doctors
Most surgeons prefer morning OR time. Having
should be block-booked into the surgery schedule
surgeons work a full day opens up more mornings
twice a month.
for other doctors on staff. Surgical centers that serve
Cataract patients need to be seen by the surgeon
multiple, lower-volume practices will need to deal
postoperatively one day after surgery. Fridays usually
with afternoon time slots. A fair way to allot after-
are not popular surgery days with anterior seg-
noon time is to assign each surgeon a morning slot
ment surgeons because most doctors do not have
and then an afternoon slot on another day.
Saturday office hours. Fridays are ideal for oculo-
One issue that can improve afternoon scheduling
plastic surgeons, however. Their patients are seen
is to meet with the anesthesia staff to discuss NPO
postoperatively 72 hours after surgery, which would
protocol. Many anesthesia groups, knowing that the
place a Friday surgical patient in the doctor’s office
anesthesia technique employed on cataract patients
the following Monday. Retina practices commonly
is either topical or a peribulbar block, allow patients
operate seven days a week, so Friday surgeries can
to take their normal medications and also permit

6
A dm i n i s t r ati on, Ope r ati ons and Proc edures The Suc c essful Ophtha lm ic A S C

them to eat a light meal in the morning before If you allow other surgeons to use your ASC,
arriving for afternoon surgery. This makes for here are some suggestions for minimizing cancel-
happier, less-stressed patients, especially those with lations. When the same practice is the source of
diabetes. Under these circumstances, many surgeons repeated cancellations, an investigation should take
will accept afternoon-block time. place to determine why this is happening. A review
It is important for the Nursing Director to of the office charts is helpful to see if a pattern can
prioritize the cases to be handled. This can be done be identified. Repeat cancellations can often be
by marking each surgical preop chart with the level attributed to unsatisfactory communication between
of difficulty anticipated in the surgical plan: office and ASC. It is good practice for the ASC
Office Manager to visit the problem practice with
• Marking the chart with a 1 indicates a the ASC Surgical Coordinator to study all cancelled
routine case. cases and reach a mutually agreeable solution.
• Marking the chart with a 2 indicates a more Unresolved problems should be referred to the ASC
difficult surgical case, such as a glaucoma Medical Director for further investigation.
patient requiring iris hooks.
• Marking the chart with a 3 indicates an
unusually difficult and long case. Required Documents
The surgeon should start the day with all the cat-
egory 1 cases. This should ensure that the beginning
for Surgery
of the schedule will move along on time and with
Patients need to supply, complete or review a
minimal difficulty. Once those cases are completed,
number of consent forms and other materials before
the category 2 cases should be performed. Assign
surgery. The surgeon’s office provides the patient
a longer time block for these procedures. This will
or a member of the patient’s family with a folder
allow the surgeon to take the time required to attend
containing the ASC forms that require attention
to the anticipated extra steps for the more compli-
and notifies the patient of the deadline for mailing
cated cases.
any required documents to the ASC. The surgeon’s
Category 3 cases should be performed on a
office should also give the patient the phone number
separate day. Cases of this sort are unpredictable and
of an ASC staff person to contact with any questions.
should be carried out without the pressure of also
The ASC calls the patient preoperatively to review
having to perform numerous routine surgery cases.
the forms and answer any questions that the patient
A time gap should be established before the
or family member may have. (Any surgery-specific
day of surgery to give the ASC the ability to add
questions the patient might have should be referred
slots for non-blocked cases of other doctors and to
to the surgeon performing the procedure, not to the
open time for emergency cases, such as retina cases.
nursing staff at the ASC.) Perioperative-type ques-
Generally this would be a two-hour time slot in the
tions may be directed to a nurse to handle.
afternoon for an emergency case. In multiple-OR
Medicare Conditions for Coverage regulations
facilities, the extra time needs to be reserved in only
(www.cms.gov; search for “Conditions for Cover-
one of the ORs. Without a time gap, OR time will go
age”) require that patients be fully informed before
unused, reducing profitability and efficiency.
having surgery at an ASC. The following are some
of the forms patients must review, supply and/or
Cancellations complete. Templates for most of these forms appear
Cancellations are an inevitable part of ASC opera- in Appendix A. The checklist in Figure 1 summarizes
tions. Random patients cancel because of comorbid common ASC forms and their functions.
conditions that require treatment before eye surgery
can safely be performed. Surgeons cancel because Patient Rights and Responsibilities
of personal emergencies. It is difficult to manage
As of May 18, 2009, CMS requires that each patient
around last-minute cancellations. Publishing the
be given a copy of his or her rights verbally and in
schedule one year in advance so that each practice
writing prior to the procedure date in a language
can double-check for conflicts such as vacations or
or manner the patient or his or her representative
religious holidays can help reduce cancellations.
understands. (See the Managing ASC Quality and Perfor-
mance module in this series for more information.)

7
A dm i n i s t r ati on, Ope r ati ons and Proc edures The Suc c essful Ophtha lm ic A S C

Figure 1: Common ASC Forms: A Checklist

Form Name Description Timeline Who Provides or Receives?

Patient Information Sheet Education and answers to Given to patient at least 24 Patient must acknowledge
commonly asked questions hours in advance of sched- receipt with signature.
for the patient. uled surgery (preferably,
when surgery is scheduled)
Patient History and Primary care physician’s ap- Within 30 days of surgery Primary care physician must
Physical
proval for surgery. Lab work sign.
is not required.
EKG Verification Form All patients over age 60 must EKG performed within 6 Primary care physician or
provide. months of date of surgery cardiologist signs, dates, and
interprets.
Patient’s Informed Consent Describes the risks and Completed by physician and Physician and patient must
benefits of the proposed patient at least 24 hours in both sign.
surgery. Should be specific advance of surgery
to the physician and the
procedure. Should identify
the eye as right or left, not
OD or OS.
Financial Interest Notes that surgeon has a Given to patient at least 24 Patient must acknowledge
Statement
financial interest in the ASC. hours in advance of sched- receipt with signature.
uled surgery (preferably,
when surgery is scheduled)
Advance Directive Legal documents that ensure Provided by patient at least Patient must provide to ASC.
patient’s wishes are followed 24 hours in advance of
if patient cannot make deci- scheduled surgery (prefer-
sions for him- or herself. ably, when surgery
is scheduled)
Patient Bill of Rights Document outlining patient’s Given to patient at least 24 Patient must acknowledge
rights. The ASC’s policies, hours in advance of sched- receipt with signature.
procedures and actions uled surgery (preferably,
must be consistent with when surgery is scheduled)
protection of the patient’s
rights.
Ocular History Substitute for a dictated Provided to ASC at least 24 Referring physician provides
preoperative note. hours in advance of surgery to ASC.
IOL Diopter Form Provided to ASC 1 week Referring physician provides
before surgery, to allow to ASC.
time to order IOL if out of
stock and avoid costly rush
delivery charges.
IOL Order Sheets Order form for the intra- Provided to ASC at least 3 Surgeon provides to ASC.
ocular implant for cataract days in advance of sched-
surgery. uled surgery
Driving Directions to ASC Clear, written instructions Given to patient at least 24 ASC provides to patient.
including a telephone hours in advance of sched-
number. If ASC is at same uled surgery (preferably,
location as practice, patients when surgery is scheduled)
should be given instructions
for entering the ASC.
Consultation Letter Confirms patient’s upcom- When surgery is scheduled ASC provides to medical
ing surgery and requests clearing physician.
general history and physical
information from patient’s
physician.
Patient Insurance Form Serves as the assignment of Day of surgery Patient completes.
benefits.
Preoperative Health Permits evaluation of health A couple of days before Patient completes.
Questionnaire
and risk factors. surgery for ASC staff to
review

8
A dm i n i s t r ati on, Ope r ati ons and Proc edures The Suc c essful Ophtha lm ic A S C

Advance Directives a precertification before surgery can be performed.

Failure to get the required approvals may result in
Advance directives are legal documents that ensure denial of the insurance submission.
that patients’ wishes are followed if they are unable Patients who are unable to pay out-of-pocket
to make decisions for themselves. All Medicare and expenses, such as the Medicare copayment, must
Medicaid certified ambulatory surgical facilities are sign a hardship waiver form so that the ASC can
required by federal law to provide information on legally comply with CMS’s collection requirements.
advance health care directives to their patients. Post-surgery, patients are often confused when they
The patient should provide a copy of his or her receive separate bills from the surgeon, the ASC and
advance directive(s) to the ASC prior to the date of the anesthesiologist. To prevent confusion, patients
surgery, and the advance directive(s) should be kept should be made aware that this will occur when they
in the patient’s chart. schedule their surgery, and they should be given
Check with your state medical society to deter- written notice of this fact on checkout.
mine the advance directives recognized by your state.
Examples may include a Health Care Proxy, a Do
Not Resuscitate Order and a Living Will.
Cancellation Policy
Advise patients and surgeons using your ASC of
Disclosure of Financial Interest your cancellation policy and of penalties for late
cancellation and no-shows.
Pursuant to law and proper disclosure, physicians
who have a financial interest in a health care service
or health care facility, such as an ambulatory surgical
Checklists for Surgeons and Staff
facility, should disclose that interest to their patients You may also find it useful to develop reminder lists
who will be undergoing a surgical procedure. for surgeons using your ASC and checklists that can
help other ASC staff do their jobs effectively.
Patient Acknowledgment Form ASC staff should contact all patients before the
day of surgery to answer all questions regarding
When patients receive the Patient Bill of Rights, arrival time, scheduled surgery start time, allergy
financial interest and advance directives informa- information, paperwork issues and any concerns
tion, they must sign an acknowledgment form that the patient or family members may have.
indicating that they received these materials prior to Special requests should be relayed to the Nursing
the date of surgery. Director for review. The Nursing Director should
communicate with the anesthesia department and
Patient Instruction Sheet the surgeon regarding any new medical information
that does not appear on the patient’s preop chart.
Patients should be given a sheet instructing them
how to prepare for their surgery. The information
should include a telephone number patients can call
for answers to their questions. Postsurgery Activities
Consultation Letter ASC staff should provide each patient with postop
instructions and a reminder of his or her postop
The ASC should provide the medical clearing physi- appointment time, along with a phone number to
cian with a consultation letter confirming the details call should the patient have questions.
of the surgery. Once surgery is completed, a responsible adult
should accompany the patient out of the ASC build-
Patient Billing and Payment Notice ing. It is helpful to have an orderly assist in getting
the patient safely into the car.
Insurance benefits should be verified when the Patients should be sent a survey to evaluate
surgery is scheduled, and they should be confirmed patient satisfaction and outcomes. (See the Managing
two days before surgery. Because health insurance ASC Quality and Performance module in this series for an
coverage can change, it is wise to verify that patient example.)
benefits are valid for the procedure for which they
are scheduled. Some insurance companies require

9
A dm i n i s t r ati on, Ope r ati ons and Proc edures The Suc c essful Ophtha lm ic A S C

ASC Operating Policies Resources

and Procedures Manual ASC Supplies
An ASC must have a policies and procedures manual SimplifEye Ophthalmic Purchasing Program:
that has been approved by its governing body. Because This Academy/AAOE program from Henry Schein,
each state has different rules and regulations govern- Inc., the largest distributor of health care products,
ing ASCs, it is essential that those charged with pro- features a special formulary, developed with the help
ducing the ASC’s policies and procedures manual of ophthalmologists, to provide you with the best
familiarize themselves with their state’s codes before possible prices on the medical, surgical and front
beginning. The ASC’s governing body should review office supplies you need. www.aao.org/simplifeye
outcomes annually.
The policies and procedures manual is the basis Benchmarking Information
for all activities that occur within the ASC, so the Outpatient Ophthalmic Surgery Society’s (OOSS)
policies must reflect what actually happens during Benchmarking Survey: Visit the Society’s website to
the normal course of business. It is common for participate in or access the results of the OOSS oph-
ASCs to change their routines when new opera- thalmic ASC benchmarking survey. www.ooss.org
tions are introduced, new equipment is purchased
and staffing changes are made. It is essential that Electronic Health Records
the policies and procedures manual be modified to
reflect these changes when they occur. EHR Central: Academy and AAOE members can
Based on the rules outlined in its policies and use this online resource to help select, implement
procedures manual, the ASC develops protocols and make the most of an EHR system. Resource
to standardize its surgical organization routines to also includes EHR vendor and system information,
ensure safety and efficiency while maintaining con- including vendors offering a surgery module.
sistent clinical core competency. From the medical/ www.aao.org/ehr
legal perspective, any activity that results in litigation
will be researched to confirm that the ASC followed Other Organizations
the policies and procedures outlined in its manual. American Society of Ophthalmic Registered Nurses
See Appendix B for a recommended table of con- (ASORN): www.asorn.org
tents for such a manual, as well as sample language
from selected sections of a hypothetical manual. Association for Professionals in Infection Control
and Epidemiology (APIC): www.apic.org
Association for the Advancement of Medical Instru-
mentation (AAMI): www.aami.org
Association of periOperative Registered Nurses
(AORN): www.aorn.org
Centers for Disease Control and Prevention (CDC):
www.cdc.gov
Medicare Conditions for Coverage: www.cms.gov;
then search “Conditions for Coverage”
Occupational Safety and Health Administration
(OSHA): www.osha.gov

10
A dm i n i s t r ati on, Ope r ati ons and Proc edures The Suc c essful Ophtha lm ic A S C

Appendix Guide
Visit www.aao.org/ascadmin for the following
appendixes, which contain customizable templates
for common ASC forms and documents.
Appendix A: ASC Paperwork Templates
• Patient Rights and Responsibilities
• Informational Document on Advance
Directives
• Disclosure of Financial Interest
• Patient Acknowledgment Form
• Patient Instruction Sheet
• Consultation Letter — Medical Clearance for
Surgery
• Patient Billing and Payment Notice
• Surgeon Reminder
• Patient Record Documentation
Appendix B: ASC Policies and
Procedures Manual
• Recommended Table of Contents for an ASC
Policies and Procedures Manual
• Sample Content for an ASC Policies and
Procedures Manual

11