Anesthesia: Driving Surgical Volume

Ep. 122: Anesthesia: Driving Surgical Volume

Here’s what to expect on this week’s episode. 🎙️

What happens when anesthesia isn’t just a vendor, but a true partner? 

That’s exactly what Colleen Ramirez (Chief Administrative Officer) and Dr. Michael Bernard (Director of Anesthesia) have built at Bone & Joint Surgery Center of Novi. In this episode of This Week in Surgery Centers, they shared the strategies that keep their ORs full, partnership thriving, and center profitable.

Six quick wins:

• Include anesthesia in scheduling decisions, equipment discussions, and executive committee
• Collaborate closely and frequently on admission criteria
• Encourage direct communication between your pre-surgical team and anesthesiologists
• Educate schedulers and offices (only 10% of cases should go to the hospital)
• Share cost info between anesthesia and purchasing
• Align investor incentives with OR optimization 

Listen to the full discussion on your favorite podcast platform or YouTube to learn even more tips for how to build a culture of shared ownership.

Episode Transcript

[00:00:00] Welcome to this week in Surgery Centers. If you are in the ASC industry, then you are in the right place every week. We’ll start the episode off by sharing an interesting conversation we had with our featured guest, and then we’ll close the episode by recapping the latest news impacting surgery centers.

We’re excited to share with you what we have, so let’s get started and see what the industry’s been up to.

Erica: Hi everyone. Here’s what you can expect on today’s episode. Colleen Ramirez is the Chief Administrator Officer at the Bone and Joint Surgery Center of Novi, and Dr. Michael Bernard is the Director of Anesthesia at the same facility, and he’s also the Chief Medical Officer at Ambulatory Anesthesia Solutions.

Not only have they figured out a way to work seamlessly together, but they have also figured out a way to stay profitable. So together they’ll share how they work with one another to drive case volume and collaborate on which cases to accept. In our news recap, we’ll cover the first ever ASC in the Dominican Republic, a new ASC joint venture, the rising demand for dental surgeries, and of course, and the new segment with a positive story about how engineers have discovered a way to turn dental floss into a vaccine.

I mentioned this last week, I but want to remind everyone again that there are some very exciting changes coming to This Week in Surgery Centers. Starting next week, I will be handing over my hosting duties to Alex Larralde. You heard her last week when she interviewed Wes Battiste, and I’m so thrilled that she’ll be handling things moving forward.

I have, of course, loved every minute of hosting this podcast for the last three years, and I am very sad to be stepping away, but I can’t wait to just become an avid listener myself and hear Alex’s fresh perspective and take on the industry. So, for the final time from me, I hope everyone enjoys the episode and here’s what’s going on this week in surgery centers.

Erica: Hi, Colleen and Mike, welcome to the podcast.

Mike: Hi, how are you?

Colleen: Hi. Welcome to you too.

Erica: Colleen, let’s start with you. Can you please share a little bit about your ASC experience?

Colleen: Sure. I’ve been a perioperative nurse for just under 30 years in the ASC industry, for 18 currently working in an all-orthopedic six-OR facility in Novi, Michigan.

And Mike, how about you?

Mike: So, I’ve been an anesthesiologist for a little over 20 years now, and about seven plus years ago, I transitioned to a group that just covers outpatient surgery centers. So, and I’m their medical director for the practice, so I cover a lot of different centers at Colleen’s Center.

I’m the director of Anesthesia, so I work with her real closely.

Erica: Perfect. Thank you. And I’m so excited to be sitting down with both of you today because you have managed to build a very, you know, symbiotic and successful partnership. So, what are some effective ways that ASCs can build a strong relationship with their anesthesia group, and how can you stay on the same page and just keep cases moving through the center?

Colleen: Well, I think no matter what. You know, you have to build a relationship with your anesthesia providers, all of them. They have to be a part of the decision-making process. From start to finish. You have to go through potentially adding them to your medical exec committee.

And of course, having constant communication with them. It really makes for a lot of effective communication. As we all know, things pop up throughout the day. And the week. And so, having that person and point of contact daily, it really helps things throw flow through quite nice.

Mike: Yeah, I think at Colleen’s Center, she does a nice job. They involve anesthesia on their executive committee. There’s myself and then we have like a lead CRNA as well. So, there’s two anesthesia providers that are involved in decision making processes. We’re not voting board members as, we’re not owners, but we’re involved in decision making.

They involve us in scheduling things because a lot of things that — you know, people — that doesn’t affect anesthesia, they might be important things for us in terms of what makes cases flow quicker, that ultimately gets us out at the end of the day quicker — getting us involved in equipment decisions or medication decisions.

So, they support us, you know, we want to try to get as many cases through the center as possible, but that, you know, they have to work with us to, to have the right equipment and supplies to help us do that.

Erica: Yeah, I think that’s such a good mindset. because I feel like when I talk to a lot of surgery centers, they still think of their anesthesia group as this third-party vendor instead of, you know, someone who is a true stakeholder in the facility.

So, I think that’s a great foundation and culture that you guys have going on between your two groups.

Mike: Yeah, I would say I, I’m in the back dealing with schedulers and administrators a decent amount of the day, you know, on a constant basis.

Colleen: Yeah. And I think too if you can change your mindset when you’re, if you’re the administrative center, you know, please treat anesthesia as if they’re your employees.

They’re a big part of your team and, you know, invite them to lunches, have them you know, work closely with you on all aspects from do they have enough supplies do they have the right supplies? And you begin that foundation and it just blossoms from there.

Erica: Yeah. That’s great. How does involving anesthesia and collaborating on admission guidelines affect how many cases the ASC can take on?

Colleen: Oh, I think that’s the biggest, the one of the biggest, most important things you need to do. As a starting point and I’ll let you talk about that how we did that at our center, Mike.

Mike: Yeah, well we took over the contract at Colleen Center about five years ago and like one of the first things she tasked me with is she showed me the boarding criteria that they were currently using.

And I looked at it and my just knee jerk reaction was, this is very restrictive. So, we looked at it, you know, for example there was a strict BMI cutoff. We removed that and that’s been kind of taboo when we tell other people that we really don’t have a BMI cutoff. Not saying we accept every patient, but you know, I said to her, I’m willing to increase the BMI limit, but we have to have support from the center’s end.

If we’re positioning a patient, you know, it’s a lot to ask of two people in a room to move a patient that weighs 350 pounds. So. You know, they have to provide the proper support so we can admit those patients. Or if we’re taking in a patient that has a pacemaker or a ICD, her pre-op surgical testing department needs to do the proper due diligence to make sure those patients are, you know, properly vetted.

And we have the required documents from the, you know, the cardiologists that manage those devices. So, we’re willing to bend, but they’ve got to give us the proper support. To allow those cases.

Colleen: Yeah. Agree. And I think too, you know, it’s just pivotal to have. You know, those experienced PST nurses that are working closely, they have to be comfortable to, to approach anesthesia.

They have to know, you know, when and how to quickly ask them questions and to move cases to get their approval ahead of time to keep the flow going. But that relationship between them is key and they have to know the guidelines. And one of the things I love that Mike always tells them is, you know, let’s look at why we couldn’t bring this person here.

Well, give me those reasons first, because all we’re looking at is, let’s say a lot of red on the chart, which sometimes means they answered yes to something. And when you have a lot of that, it can really cloud your judgment. And I think it’s important that they are dissecting through that with people that have a lot of comorbidities so that they.

We can always have the mindset of, you know, how can we bring this case here safely? And we do that in conjunction with them every day, all day. I see my PPSU nurses going out. They’ll set a chart on the, you know, anesthesiologist desk and it’s in minutes, they’re back looking at that chart just to, to make sure we can capture every case.

There should be a real, real good reason they can’t come there and they need to go to the hospital. And so that’s what we do all day to keep that flow.

Erica: Yeah, that, and you answered my question. I was going to ask you, how often do you look at, okay, here were like, say 10 cases that we decided not to perform here.

Are you retroactively looking at them or are you proactively looking at them?

Mike: Well, our PST nurses will bring us charts on a daily basis. Okay? Any total joints we review no matter what, even, they’re perfectly healthy, but they’ll bring me charts all the time. And that’s that, that’s a process that takes a while to develop.

Like they have to learn what we look for. There are certain medical problems that are more concerning to me than others. And they’ve learned over time what those are, or certain cases that are lower acuity, I’m going to have a threshold that’s a lot different than a higher acuity case. You know, if I’m doing a total joint versus a carpal tunnel, you know, some medical conditions aren’t going to concern me as much.

So those are things that are learned over time and working with them.

Colleen: Yeah. And let’s not forget, you know, we, there’s a large portion of education that has to start at the office. It just has to, it has, you know, your surgeons, your, you know, PAs, whoever’s the one who says send that one to the surgery center, you’re hoping that they’re doing that 90% of the time.

We’ve got to look at those benchmarks. It has to be 10% or less, go to the hospital as a rule and to have those schedulers, some of them are not clinical, so they don’t understand what half of, you know, the diseases are that the patient has. And so, we want to make sure there’s.

Continuous education you know, their ability to pass a case to the hospital to fill up a block, let’s say could be a great case that the center can do safely. And so, it’s really just really breaking down those walls and building that mindset that. You know, only 10% should go to the hospital, try to bring us everything else and if we’re reactive and we can answer their calls, even if it’s questionable, you pick up the phone and tell them to call someone and have, you know, have managers, have anyone I’ll answer the phone, you know, the phone and find out, you know, if this is something that we can get a quick answer for them so they can begin and board the case.

Mike: Yeah. And every surgeon has my cell number. So, they’ll often text me and say, Hey, I got this person in the office. Do you think this is a fit? And the answer, you know, 95% of the time is yes. You know, sometimes we might need a little due diligence, but, you know, so they’re encouraged to bring everything.

Erica: Yeah, I love that. because what I’m hearing is, one, there’s. They know how to get in touch with you. And then they’re also not intimidated by having to ask and collaborate and say, should we admit this patient or not? And I think that’s huge. Now, you mentioned the pre-surgical team, and I don’t want to lose that.

What role do they play when working with anesthesia to minimize last minute cancellations?

Mike: Yeah, they’re invaluable. Often, they’re the liaison to the patient and also to the primary care docs or a specialist doctor. And a lot of times they’ll come to me with a patient that has a really ugly looking chart with a lot of medical issues.

And it might scare you at first look and my response to them often is, what does the patient say? And usually if the patient’s reliable and they’ll say, oh yeah, I walk two miles a day. I’m like, okay, they’re fine for a carpal tunnel, or they’re fine for that knee scope. I don’t really need for them to do a lot of digging.

So just often by them communicating and asking questions and talking to the patient, or sometimes they do have to reach out to a doctor but they’re your first line of defense to get those patients in.

Colleen: And from an administrative side, you know, all of the administrators out there, you know, make sure that your PSD department is robust.

If you’re performing higher acuity cases, you know, these nurses need time, and they can’t feel overly rushed and just with not enough staff in that department it is key if you think of it from a financial standpoint. You know, they’re the gatekeepers to being able to allow for this, these, the majority of these cases to come through.

And so, they can’t constantly feel pressured because they’ll miss something. And so that’s when you get a last-minute cancellation. So, you want to make sure you’re putting in, at our center we have six ORs. You know, five to 6,000 cases a year. I have four and a half FTEs. In my PSD department, and I could always use one or two more.

To perform joint camps and education for staff, so, or for patients. So, it’s key to that is where payroll dollars need to be invested especially when you have your guidelines that are a little more lenient just to provide that nice blanket of safety.

Erica: Sure. And, okay, so let’s say someone from the presurgical team comes to you and says, hey, I, I don’t know, I’m unsure what to do with this specific case.

How can having deeper conversations with maybe the patient’s primary care physician or specialist help get those borderline patients cleared?

Mike: Sometimes you’ll have a patient that’s just not reliable. You know, they could be totally of sound mind, but they just don’t really understand their medical issues or you know, how in depth if it’s a valve problem, if it’s severe or mild or maybe they’re just not physically able to walk because they’re coming in for a knee replacement and they have too much pain.

So, we, they don’t really know clinically what their activity level is because they’re limited by their pain. So, in those cases, you know you’re going to have to reach out to their doctor, whether it’s a primary doc or a specialist, to get more information. So that’s that can be the difference between that patient being a no versus a yes.

Or sometimes I have to get on the phone with the doc because they might not be relaying clear information to the presurgical testing nurse or, you know, we had a case recently where a cardiologist wrote a clearance note and all they wrote was high risk. And I’m looking through the information and nothing seemed that high risk.

And I never got in touch with a cardiologist, but his office manager told me that’s how he classifies everybody. So, you know, I called the patient and the patient says, yeah, I’m walking doing this and that. And I said, okay, no problem. I’ll see you tomorrow. So, you just got to reach out to people and can’t be scared by initial view of something that might seem like a no.

But if you really dig deep, you can find that they are actually, you know, more than suitable.

Colleen: Yes, I can’t agree more. And again, you know, speaking on terms of the PST nurses, it’s. If you look at, and I encourage everyone, go through your questionnaires. If you’re using an online platform, you know, even ask for that company to give you a couple comps and look at what other centers the questions they’re asking you would be so surprised at.

You know, like at our center we’ll have the physician office send over. The patient’s health history that they filled out there. So, we get a glimpse and we do a pre-review of their health history. In the event we have to pull a clearance or whatever, but. Overall, it starts with those questions, and I encourage you to look at every single one of them.

You can elicit all this information that the patient does at home themselves and get a lot of answers out of those questions as a starting point. And it saves a ton of time. So look at your questionnaire and revise it. And then of course you can always look at mine and use our questions. because we try to put that time in on the front end that the patient is.

You know, preferring themselves so that I’m not using payroll dollars in that arena.

Erica: Sure. And how often do you guys revisit the guidelines themselves? Was that kind of a one and done thing, or are you constantly making tweaks? I, for sure.

Colleen: Every year at least. It’s not more. We, I think, you know, with our quality improvement program, you know, you’re always looking at.

I guess if there’s an event, right? So, if we have a case that goes to the hospital, we’ll say, okay why do we transfer this patient? Were they, you know, which everyone’s supposed to do anyway, but, you know, we look at it deeper and say, you know, would we have thought this on the front end that this was going to happen?

The scenario was going to happen in, let’s say the recovery room or even in pre-op. And so, you know, our cancellations are very low proud of them, quite frankly, and a lot of them are just a new onset. Arrhythmia, you know, cardiac arrhythmia or something like that, that we wouldn’t have known otherwise.

So, so it’s just vital to do that.

Erica: Sure. So, any final tips on how anesthesia ASC leadership and the physician investors can all work together to just keep that schedule full?

Mike: I think they really got to just work together closely. Especially nowadays where anesthesia, five years ago or more was never really a cost for a center where nowadays, fortunately our center is still a profitable anesthesia contract.

We don’t require a stipend, but I feel like that’s more the norm is to have a stipend nowadays. So, if you’re not working together. To try to find ways. For example, if a surgeon has four joints and they’re accustomed to getting two rooms at the hospital, that’s not really feasible at an ASC to bring in two separate anesthesia teams for two rooms.

Where if you have a quality turnover team, you can probably provide the same amount of time to get those four cases done as opposed to what they do in the hospital where they have, you know, slower turnover. So, everyone’s got to discuss how do we accomplish that? Having enough staff for turnover. You know, there’s little things that might not seem like a big deal to the surgery center, but when I brought them up to them, it affects the quality of life of the anesthesia department where, you know, if someone has seven or eight total joints in a day, and one knee scope, they used to board the knee scope first just to get it out of the way where my answer to them was, why not book it last?

because I can’t leave until that last patient leaves the center. So, we might as well get the joints done where I’m waiting for a joint. For roughly two hours of recovery time, we can knock out the knee scope at the end of the day. So that saves Colleen probably 30 minutes of recovery time and it saves, you know, the anesthesia department, we’re free labor, but it still saves us 30 minutes of our day.

So, it’s like a win-win. And by just not by having that dialogue, we’re able to accomplish those things.

Colleen: Yeah. And again, you know, really in, have those discussions with your investors and just, you know, explain how distributions. Are directly related to efficiency and a full schedule. Hands down.

And that means everyone has to, you know, play ball when it comes to condensing the schedule. And if a surgeon doesn’t have a full block and you know, they only have six, five or six hours full in a nine-hour block, you know, they need to follow another surgeon. Either go first or go last, and you can keep track of that to make sure it’s fair and equitable.

And but overall. It’s really looking at that schedule all the time. I am constantly talking to my scheduler. Probably take, I take an hour and a half to two hours a day looking at my surgery schedule for the week ensuring that we are communicating with our surgery schedulers, et cetera.

And then of course, I tie that all in with my conversations with our investors and our physicians so that, you know, they’re understanding why we are doing this. And that the bottom line comes down to profitability and that’s our goal. So

Mike: Yeah, and the anesthesia department also can help the center.

I’ll interact with the purchasing manager to find out, you know, if certain supplies are more expensive or less expensive. And if it doesn’t change the outcome, I try to encourage the provider. You know, they might not be educated or just aware that a certain product costs a lot more than something that’s equally efficacious.

So just by simply finding that out and communicating it, you could save money and have no difference in outcome. So you’ve got to be able to communicate and interact with the staff to know those things.

Erica: Yeah, I think the level of transparency and collaboration and just open lines, you know, of dialogue going back and forth between all the parties seems to be what is really has made this partnership a success.

And I hope everyone listening can take that away and see how they could build that culture within their own facility and, you know, with their own anesthesia partners. All right. Final question. We do this every week with our guests. What is one thing our listeners can do this week to improve their surgery centers?

Mike: I, I would say, you know, I would say pull out your boarding criteria. That’s a quick thing. Just look at it and say, are you outdated? Is there things, there’s reasons that you can maybe say, instead of not bringing this case, find a reason why to bring a case. You know, if your BMI cutoff is artificially low, and can you provide the support to allow cases that are, you know, heavier patients?

If you’re doing total joints, the morbidly obese patients tend to be the ones that are young and well insured. So, to, to kick those cases out of your center just purely on that criteria, you’re really losing a lot for the center.

Colleen: My answer is to grab some baked goods and visit every single physician office that provides cases to your center and sit down with their schedulers even for 15 or 20 minutes, bring them some swag, whatever you have to do.

But definitely they are the ones that’s a ticket to bring in cases to your center. So I highly advise that you sit down periodically with them, but. And ensure that they want to bring cases and they understand which ones can come.

Erica: That is great advice. Thank you both so much for coming on today.

We really appreciate it.

Mike: Alright. Thanks Erica.

Colleen: Thank you for having us.

Erica: As always, it has been a busy week in healthcare, so let’s jump right in. One world Surgery just opened the first ever ambulatory surgery center in the Dominican Republic, a major milestone for healthcare access in the region. The new 25,000 square foot St. Mother Teresa Medical Center includes a surgery center, a primary care clinic, and visitor center.

With services led by a local medical director and orthopedic surgeon. This is the nonprofit’s second, ASC. The first opened in Honduras in 2008. The Dominican Republic project began in 2019 but was delayed by COVID hurricanes and contractor challenges. Despite the setbacks, the facility began seeing patients through mobile missions that same year and received its official surgical certification in late 2024.

Since then, the team has performed over 30 surgeries focusing on orthopedic, general and ophthalmology cases based on local need, especially injuries among sugarcane field workers. The facility also serves as a training hub, supporting local staff with education and upskilling.

Now there are tons of inspiring stories if you are one, familiar with one world surgery. And two, if you read this article. But one example was they had an amputee that they actually turned and trained in to become a radiology tech. And it really just highlights the project’s community impact one world surgery hopes to expand faster in the Dominican Republic than in Honduras, and is actively seeking clinical volunteers to train staff and grow services.

This is super exciting to hear. The ASC outpatient model is really helping to transform care globally. One world surgeries. Work shows how ASCs can bridge critical healthcare gaps, even in underserved areas. If you’re inspired by the work they’re doing, ASC leaders can make a real impact by supporting OWS with donations, clinical expertise, or even joining a mission. All right, in our second story, so Lara Surgical partners in Orlando Health are the latest to join forces.

The two organizations announced a national joint venture aimed at expanding ASC access and streamlining surgical services across the country. Orlando Health is a major nonprofit healthcare system in Florida with a network of 20 plus hospitals, ERs and ASCs, and then SOA Surgical Partners. Founded in 2003, focuses on ASC development, operations, and joint ventures.

Both organizations say the partnership is grounded in aligned missions, delivering excellent care while supporting surgical teams. The goal is to build a nationwide ASC footprint by combining all the operational experience and resources and clinical strength. This move follows a rising trend. 2025 has already seen similar joint ventures between Cleveland Clinic and Region Surgical and then Mount Sinai and Merit Healthcare.

So, what does this mean for ASCs? Joint ventures are not slowing down. They’re just accelerating. More hospitals are recognizing the value of partnering with seasoned ASC operators. So, for ASC leaders, especially those who are looking for an exit plan, now is really the time to explore partnerships that can, you know, get you to where you want to be, but can also offer both local impact and national scale.

Okay, third story. There’s a growing momentum behind dental surgery in ASCs and this article from ASC Focus, they interviewed a few folks to try to understand why. So, first was Dr. Robert Morgan, a pediatric dentist in Texas, and he says safety is the top reason he uses ASCs for procedures like dental, rehab and abscess treatment.

It’s efficient and parents feel confident with the care their kids get. He explains, in fact, some of his cases that used to take two hours. Now wrap up in just 22 minutes. Adult patients are also reaping the benefits. Dr. Dane Jensen, an oral surgeon in Utah, highlights the consistent scheduling and tailored case cards as major advantages.

We’re not getting bumped by hospital cases and everything’s ready to go when we arrive. And ASCs, like the one in Dixon, Tennessee, are packed with demand. They serve both pediatric dentists and surgeons offering a steady operating room schedule. Something not always guaranteed at hospitals, especially for Medicaid patients.

And more procedures are being added to the C-M-S-A-S-C covered procedures list, and that’s helping drive this growth as well. But challenges remain, you know, inconsistent insurance coding, low Medicaid anesthesia reimbursements and billing delays are still frustrating providers. Some insurers even use outdated fee schedules, ignoring newer dental.

But still, there’s still lots of progress. Insurance companies now have divisions just for dental surgeons and CMS is adjusting its requirements to better fit dental care in ASCs. And so, it’s all just great signals that dental surgery and ASCs isn’t just growing but also evolving. And lastly, HST recently pulled data from dental clients who gave us permission to do so.

So, we analyzed 15,610 unique cases across 35 centers from 2023 to 2024, and we saw that net revenue per case increased by 8%, rising from $1,566 to $1,696. And then monthly case volume also grew from 59 to 69 cases on average. So, this data just supports the article’s, conclusion that the demand for dental cases is really there.

And to end our new segment on a positive note, researchers have developed a vaccine coated floss that when used on mice triggered strong immune responses and even protected them from the real flu virus. The floss targets the area between your teeth and gums, which is highly absorbent. In experiments, mice that flossed with protein or flu coated floss showed elevated antibody levels in their lungs, noses, feces, spleens, and even bone marrow. Now it’s really funny to picture mice flossing. Sure, they had some help, but nonetheless to explore humid potential 27 volunteers flossed with dye coated picks.

About 60% of the dye was absorbed and most said they preferred this method over a traditional shop. Experts say more testing is needed, especially in people with gum disease, but the concept is certainly promising. This could really reshape how vaccines are delivered, so no needles, no syringes, and could open the door to low barrier, non-invasive preventative care.

And that officially wraps up this week’s podcast. Thank you as always for spending a few minutes of your week with us. Make sure to subscribe or leave a review on whichever platform you’re listening from. I hope you have a great day, and we’ll see you again next week.