Image by Lucent_Designs_dinoson20 from PixabayAt a time when hospitals and health systems are under intense pressure to deliver care more efficiently, ambulatory surgery centers (ASCs) are increasingly being positioned as the front door to surgical access.
For patients, the model promises convenience, lower costs and quicker recoveries. For providers, it raises a different set of questions: Which cases belong in the ASC? How do staffing and scheduling dynamics play into those decisions? And how does reimbursement ultimately shape what gets done where?
Tammy Straub, administrator of perioperative services at Lehigh Valley Health Network, has a unique vantage point on these issues. Overseeing surgical operations across both hospital and outpatient settings, she’s responsible for balancing efficiency with safety while ensuring patients receive care in the most appropriate setting.
In a wide-ranging conversation with Ambulatory Surgery Center News, Straub shares how her team approaches case selection, the strategies they use to overcome staffing shortages and how payer dynamics continue to accelerate the shift toward outpatient surgery. She also discusses the impact of Lehigh Valley’s merger with Thomas Jefferson University and why she believes collaboration — not competition — between hospitals and ASCs will be key to serving patients in the years ahead.
Highlights from that conversation are below, edited for length and clarity.
Allentown, Pennsylvania-based Lehigh Valley Health Network is a regional health system that includes multiple hospitals, outpatient facilities, and specialty care centers serving eastern Pennsylvania and western New Jersey.
ASC News: How do you see the role of ASCs evolving within the health system?
Straub: First and foremost is creating access for patients. As health care continues to be very costly, how can we do more with less? Our commitment to our community and our patients is to be able to expand access and care for those patients efficiently, effectively and safely. By creating that access outside the hospital setting, it allows patients the flexibility as well as the ability to be at home rather than being admitted to a hospital.
From a legislative perspective, do you see expansion of ASCs being supported, or are there barriers?
It varies state by state and the needs of the patient populations that we serve. I would hope that legislative bodies have seen the challenges that health care is facing – the future challenges and our existing challenges.
My hopes are that they will continue to look at the ambulatory arena as a way of providing health care efficiently, effectively and safely. We don’t want to admit patients to the hospital. It leads us susceptible to infection, extended length of stay, and it doesn’t promote patients that really need hospital care.
How do you decide which surgical cases are best suited for the ASC versus the hospital?
It’s all based on comorbidities – how sick the patient is – and the criteria that the ASC has set forth, whether it’s state regulated or center specific. If you’ve got a patient that doesn’t have heart disease and doesn’t have a high BMI or some other underlying chronic disease, they’re a really great candidate for the ASC setting.
Those patients that have comorbidities, that are sicker and need multiple practitioners involved in their care, would be better suited for the hospital setting.
Does staffing or scheduling play any role in that decision making process?
Nationally, we are all faced with staffing challenges, whether it be the availability of physicians, nurses, anesthesia. So all those stars have to align in order to be able to support the amount of patients that come through our front doors. That does, at times, prolong care – if we don’t have those resources available.
But if we have another site that has availability, we absolutely move patients around to get them in as quickly as we possibly can.
Is there overlap in staffing between outpatient and hospital settings?
Yes. It’s about work-life balance, and the outpatient setting is very attractive to a nurse. They work Monday through Friday, no call, no holidays, no weekends. Within our network, we absolutely share.
If we’re short staffed on the hospital side or the ASC, there are nurses that want overtime who can come to some of our other sites to take care of patients. Most of those sites are hospital departments, not necessarily free standing ASCs.
How do you coordinate between the OR and ASCs to keep things running smoothly?
Coordination comes through our business operations team, our scheduling team and our directors. We have daily communications that go out amongst our clinical directors that talk about staffing and shared staffing. If one site hasn’t fully booked their rooms or has open block time, we will look at staffing across the continuum and adjust accordingly. If we have to do a total joint on the hospital side, we’ll flip flop staff with their clinical expertise, bringing over staff that enjoy doing total joints and are proficient, and take some staff and put them over in the ASC setting.
What changes do you see coming in the mix of ASC versus hospital procedures?
We have to continually evaluate that. One example: With all the GLPs, we’re losing a lot of bariatric procedures on the hospital side. Can we take some of our general surgery volume and move it into the ambulatory arena? We continue to look at different orthopedic procedures, GYN procedures, vascular. It’s also going to be based off payer mix and insurance reimbursements. From a financial perspective, that has to be evaluated to shift volumes. If the perception is that we can do more cases at an ASC because they’re more efficient and lower cost, that’s a driving force to continue evaluating.
Do you feel like reimbursement trends are pushing more cases toward ASCs?
I do. Why bring them in the hospital if we can mitigate risk to a patient and give them the opportunity to be in the ASC setting?
Is there a procedure you’re fully equipped to do in an outpatient setting but waiting on reimbursement to shift?
That’s a tough one – not at this moment. We’re continuing to evaluate that, especially since we’ve merged. If we want to add an additional service line, we have to apply to the state. Sometimes it’s accepted, sometimes it’s not.
Could you talk a little bit about the merger with Thomas Jefferson University and the implications for outpatient facilities?
The merger has been beneficial for both organizations. It’s provided a lot more services that we can provide to our communities and our patients. Some of the procedures or treatments that maybe our organization at Lehigh did not provide, Thomas Jefferson does, and vice versa. It really provides us the ability to better serve our communities.
Do you have any advice you would share with ASC leaders about balancing hospital and ASC surgical volume?
We know what ASCs do well. It’s staying focused on efficiency, safety and financial viability. Networking and partnering with hospitals so that we’re not competing for that volume. It’s really what’s best for our patients, how best can we serve them efficiently, fiscally responsibly and safely. Staying up with trends, watching where reimbursement is going to take us and what availability we’ll have in the future, and working together and learning from one another. Networking is really important.
Can you give an example of something you’ve learned recently from networking?
It’s always interesting to understand what other people are doing at their centers. Comparing policies and procedures, looking at bylaws, talking about how other centers are more efficient at what they do. It might be certain equipment, supplies, medications, post-op care, getting patients up and out of bed early, and what their protocols look like. Sharing protocols to be more efficient, because there might be something somebody else is doing a better job with than you are. Their length of stay and connecting with resources in the community are big ones. Those conversations are really important.
