Culture, People, and Technology in the ASC w/ John Goehle

Erik Sunset: [00:00:00] Hello and welcome back. I’m Erik Sunset, your host of the DocBuddy Journal. Here at DocBuddy, we deliver healthcare solutions that take the pain and cost out of broken workflows like Op Note, which gives ASCs the power of instantly generated operative reports, approved from the point of care. You can learn more about Op Note and all of our solutions at docbuddy.com.

Erik Sunset: And today we’re joined by a guest that really needs no introduction. We’re joined by John Goehle. John is one of the nation’s leading ASC experts. These are in eight books on the industry, including the survey guide for ASCs, a guide to the CMS conditions for coverage and interpretive guidelines for ambulatory surgery centers. He is also the host of the ASC podcast with John Goehle. John, thanks so much for joining us.

John Goehle: Thank you so much. Yeah, I always, when people introduce the titles of my book, I always realize I really have to come up with shorter titles. It just takes too long, um, to bring those up. But thank you so much for inviting me to, uh, to talk with you today.

Erik Sunset: Oh, you know, our pleasure to have you here. Thanks [00:01:00] for making the time and related to the book topics or the book titles, rather great for SEO. I say go longer if you can.

John Goehle: True enough.

Erik Sunset: Hopefully that was a fair shake on the introduction, but what else should listeners know about you before we dive into the meat and potatoes of our show today?

John Goehle: Yeah, you know, I was kind of shocked. I just came back from the, uh, I’m a triple A C surveyor on this last weekend was our, uh, biannual get together. We get together every two years on. This is the first time that all 250 plus surveyors were together the same time. Usually they split us up. It was a wonderful weekend on just a lot of great learning.

John Goehle: A lot of, you know, great Uh, time spent with my colleagues. And I realized I’ve been a surveyor for about 20 years and I’ve been in the industry for 35 years. So now I’m starting to feel really old here. Uh, and, and the people that I’m running into, uh, you know, are so much younger than I am. Uh, you know, there’s, there’s not that many of us that can, can count 35 years in this [00:02:00] industry.

Erik Sunset: Yeah, that’s something. And that, I don’t know if you feel the same way, but we post COVID and even kind of running up to COVID all, let’s do it remote. We can all do it on zoom and it’s the same. That’s really not, there’s nothing like the energy of being together.

John Goehle: And that’s, you know, the, the, the sessions were not nearly as important. They were important, but not nearly as important as that interaction, the stories that we tell, you know. And, and of course, it’s very important as surveyors that we learn from each other. Uh, and, and a lot of that learning occurred in between sessions and at lunch and at dinner and our, our cocktail parties.

John Goehle: By the way, you get a bunch of surveyors together, there’s usually some alcohol involved. So, uh, and then you really get some good stories.

Erik Sunset: Not, not hard to believe. And we’re DocBuddy is actually coming off of our team retreat in Denver just last weekend. And it’s a group that you see on zoom week after week, you’re talking to your, your coworkers on Slack or Slack

Erik Sunset: huddles or whatever, and it’s great. You love the folks you work with, but there’s just nothing like being together.

Erik Sunset: It’s irreplaceable.

John Goehle: Well, and, uh, you know, I own a [00:03:00] company called Ambitory Healthcare Strategies, too, as well as the podcast in ASC Central, and we get together twice a year for our retreats, and we try to encourage everybody to come together. Um, we have about 27 employees, uh, you know, between those, uh, three entities, and, uh, You know, we, we cannot get everybody together.

John Goehle: I mean, it’s impossible to coordinate the schedules. We have employees and I think six different states, you know, so first of all, the cost, the sheer cost would be enormous. But but nonetheless, you know, that that hybrid model we’re starting to get used to. And You know, I think that’s an interesting point I should make too, is how rewarding it can be for your organization and ambulatory surgery centers out there to, to get your employees away from the workplace or at least away from work, you know, to spend some time in a retreat, uh, talking about what’s going on, you know, developing a long range plans, which are required, you know, for accreditation purposes, uh, but make sure everybody’s on the same, uh, You know, path forward in your organization.

John Goehle: It’s also a good time, of course, to [00:04:00] do the mandatory annual education and any other education that you might need. But, and, and if you can sneak those doctors in, or at least a few of the doctors in, that makes it even better to hear directly from them what they expect of that organization.

Erik Sunset: That’s kind of a nice lead in, John. One of the things we wanted to talk about today was overcoming staffing challenges in the ASC, and it’s not unique to the ASC. You see it across all industry. Medical seems to be pretty hard hit though, whether we’re talking about the practice or the surgery center or beyond.

Erik Sunset: We’ve had guests of the show come on who are leaders in the space, folks like Todd Currier up there in Bend, Oregon. Where culture is so important

Erik Sunset: to the center that he runs and that helps him overcome some of the staffing challenges and those being both being able to make hires and being able to retain staff, uh, from where you sit, how does culture play a role in, you know, maintaining headcount?

John Goehle: well, that’s that’s very good question because, you know, especially right now with our challenges of finding staff and it’s not just nurses anymore. It used [00:05:00] to be, you know, nursing was our, our biggest challenge, but, you know, I mean, even receptionist, you know, if you, you know, that, you know, we’re, we’re fighting, uh, a lot of, uh, You know, lower and, you know, lower income type, um, positions out there that are creeping up very quickly, which means that our costs are getting more and more expensive and it’s, and of course, our costs are going up faster than the inflation rate and we know that, well, for example, the 2025 payment rule update that CMS just put out in early July, uh, proposed an increase of 2.

John Goehle: 6%. And yet, The inflation rate is 3. 0 percent as of the end of June, but that’s irrelevant when you consider what we’re paying, what we’re finding, you know, demands for, uh, you know, higher, uh, you know, cost, you know, for higher salaries for, you know, for our staffing at all levels right now, which means getting to your point, you know, developing a culture.

John Goehle: We can’t always compete with, [00:06:00] um, you know, with, you know, other organizations out there. So we have to develop a culture that makes people want to come, you know, work with us. And it really gets down to, I want people coming to us not because we pay a higher salary, but because they’re really passionate about, um, what we’re doing in the industry and the environment that they work in.

John Goehle: And I think many surgery centers, I see it every day. Many surgery centers have been able to develop a, a real culture there of quality, a culture that brings people together in a, in a truly team oriented, uh, situation. Um, and that, that way, you know, they, they might not be able to pay the most, but people don’t want to leave their family, right?

John Goehle: We, we don’t want to give up on our families. And, and if you truly have a family in your organization that keeps people on board. I. And another part of culture is making sure that people really feel they have a voice in your organization. You know, that they have the opportunity to speak up when they think something has to change.

John Goehle: Um, that they’re part of the quality improvement process. Quality improvement is what it’s all [00:07:00] about in, in ASC. It’s one of those passions that I have. Anybody hears me speak about quality improvement knows that I start, You know, waving my hands and making all kinds of gestures because it’s just something I get so excited about.

John Goehle: And because I’ve seen how it can really improve, you know, everybody’s, uh, attitude about their work day. Um, and, but on the flip side, if they’re, if it’s not there, if they don’t feel like they’re engaged, if they don’t feel like they’re part of that team, if they don’t feel like they’re being heard, um, then the flip happens and they’re, They’re looking for another job where, where that they’d have that, that satisfaction.

Erik Sunset: When you’re, you’re speaking to all the markers of burnout that you see, you know, pick your source for the study or for the survey, you know, having autonomy within your role, that’s huge feeling like you’re important to the overall mechanism, the overall organization and not a common machine, you know, having agency in your role.

Erik Sunset: That’s, that’s huge. And, you know, burnout’s a hot topic in healthcare, whether we’re talking about. Providers, surgeons, nurses, or the front desk staff. [00:08:00] And in this climate of being unable to make a hire, no matter how much you’re willing to pay or not pay, or how good your culture is versus how lacking your culture may be, you gotta do everything you can.

Erik Sunset: Otherwise, you’re, you’re, uh, shorthanding yourself.

John Goehle: Well, and it’s not just our employees too, you know, of course we’re, we’re probably speaking to the people that manage those employees and, and your jobs are extremely valuable and finding you is not always easy. You know, we, at any given time, I think, you know, we have 87 centers. Um, and I think at any given time, we probably have five to seven.

John Goehle: probably even more vacancies or interim positions that need to be filled at some point. And we’re hiring younger and younger people, um, you know, with a lot less experience than our, our seasoned professionals out there. Uh, and that requires a lot of training. That’s what, you know, that’s how we started our training.

John Goehle: pretty famous boot camps out there, our administrators and director of nursing and business office managers boot camps, because we realized there was this huge, uh, [00:09:00] gap in knowledge, uh, and understanding about, um, you know, what it takes to be an administrator, director of nursing in these positions. And, and for, for the doctors that are listening, I hope many of you are listening.

John Goehle: You got to keep them happy. Uh, and, uh, and, and the same thing I said about your staff. Uh, it goes for them to, um, you know, they need to feel like they have the authority to be able to make change. They have the resources to be able to do it, uh, and they have your support, you know, the owner support, the governing body support.

Erik Sunset: We’re, we definitely need to get to this physician engagement aspect at the surgery center, but there’s, there’s kind of an interesting dynamic and it, it happens all across business, but there’s sort of a, a playbook where you lose an administrator at a surgery center for whatever reason, oftentimes you’re looking to backfill that position by promoting maybe your director of nursing, somebody else facility, a known quantity to you. Um, and they’re great at what they do. They’re great as the director of nursing or whatever their title may [00:10:00] be. And they find themselves thrust into this new administrative role. There’s regulatory blind spots. There’s compliance blind spots. There’s emergency preparedness blind spots. What do you do to fix that?

John Goehle: That’s great. Great, you know, core interesting, uh, story. I’ve been, uh, I’ve been teaching nurses since the the 90s. I taught in a master’s program here in Rochester. Now I live outside of Rochester, New York, uh, and one of our major colleges here had a program to take, uh, registered nurses, uh, BSN up to master’s degree.

John Goehle: And I taught in that program. I was teaching them a couple, two things, uh, finance and accounting, um, which, uh, you know, You don’t get any of that in college, you know, in your RN program, your BSN program. And I also taught them, if you think about the 90s, I also taught them about how to work a computer, you know.

John Goehle: Half my class was just telling them where the on button was, and then, um, and helping them to understand that a virus couldn’t be caught by [00:11:00] the floppy disk that they inserted into the computer. True story, by the way. Um, But, you know, we’ve come a long way since then, but the problem still remains that, that, you know, The nursing education that they receive, uh, you know, doesn’t include finance, doesn’t include a lot of human resource management, uh, certainly doesn’t include the regulatory aspects and all of those things that are important, you know, even to become a director of nursing, let alone to move into administration, I would argue, you know, to your point that you’ve got to have some good financial background, even to be a director of nursing.

John Goehle: Now, when I teach our administrators, I say, you only control half of of the budget. If that, you know, the, you know, you need to get together with your director of nursing and, and make sure that because that, that individual is going to be controlling your, um, your, your nurse staffing, you know, clinical staffing, uh, and probably controlling your supplies cost also.

John Goehle: Uh, and which is one of the reasons I think DONs often become administrators is because they have that, [00:12:00] that background, but there’s so much that has to be done. And, and the problem is realistically now with everything that is going on. Um, they don’t have the time often to do that. They need other resources.

John Goehle: They need to be able to, um, you know, work with other individuals. And of course, you know, they’re not necessarily going to get the support from the owners. You know, maybe financially they don’t have the financial resources to have both an administrator and director of nursing, which means that, you know, the, the D.

John Goehle: O. N. slash administrator is going to have to learn all of these positions and then have some real good support systems, you know, hire additional staff or, Or, you know, identify individuals in the organization that can take on some of those responsibilities. For example, if you’re a D. O. N. slash administrator, um, you know, maybe you’re going to have, uh, one of your stronger nurses be your infection control nurse.

John Goehle: Maybe somebody else is going to be in charge of the quality improvement program. Um, or maybe you don’t even have those resources and you end up having. to hire a company like ours, you know, to come in and provide that back support. Um, and, [00:13:00] and at the very least, you know, making sure that you’re on top of the news.

John Goehle: I’m very passionate about something else, and that is supporting the state associations out there. I know you and I were talking about that before we came on. And, um, You know, your state association can provide you an incredible, uh, uh, wealth of information, uh, not always on site, you know, not always on their, their website, but definitely at their conferences and, and of course, again, just like I was talking about with AAAC last weekend, uh, Um, being able to to meet with people.

John Goehle: I mean, the conferences are important. The content’s important, but getting together with other like minded people, your colleagues out there, knowing somebody to call, you know, when you when you run up against something you haven’t run up against, you know, before is so valuable. And if you can afford it, you know, become a member of the National Association, the ASC Association, which gives you even more information.

John Goehle: Uh, but, but without those resources, um, you know, our, our administrators, our directors of nursing are going to have a real challenge. And in [00:14:00] particular, nursing, I, I feel for them. I’m, I’m surrounded by nurses all the time. You know, I, I live with two of them here. Uh, and, uh, and it is, uh, it is a, a, a huge challenge.

John Goehle: And it, you know, And, and there’s, you know, their training is different than mine. I was trained as an accountant, you know, they’re, they’re much more, uh, into, uh, you know, taking care of the patient, recognizing the importance of that. Um, you know, admittedly, mine is a lot of finance background and I’ve, I’ve learned over the years, you know, to, to understand what’s going on in that.

John Goehle: Uh, you know, in their, in their minds, um, but having them pick up finance is not a natural. It’s not something that they, they’re very comfortable with. I do joke with them though. I got to tell you, uh, you know, when, when they come back to me and tell me that they, they can’t handle the math that’s involved in finance, I said, then don’t give me an injection because you’re going to mess up, you know, that, uh, the, the amount that you’re going to give me, you know, I, I think their math is probably more complicated than much of my math in, in the finance area.

Erik Sunset: Uh, it’s too funny. And yeah, we’re going to go off, off script a little bit here. You’re [00:15:00] there’s sort of in any business, there’s line item management, which needs to happen dollars and cents. What is it costing us? What’s our return for the spend, or is it a spend that we have to just make? Like Rent on the building or utilities. Um, but then there’s everything else. Not everything can be line item management. And I think that’s where those really gifted directors of nursing really shine. Uh, the ones that can pick up the finance, you know, and not, I got to poke a little fun to little additions, subtraction. That’s not too tough.

Erik Sunset: We’re not talking about milliliters. We’re talking about dollars.

John Goehle: That’s right. Just put a dollar sign in front of it. It’s the same thing. It’s the same math. It’s the same algebra that they have to do.

Erik Sunset: Exactly. But then you can, uh, have those, I don’t want to call them soft skills, but people skills, HR skills, you know, building that culture, cultivating a team and that family. Cause to your point, there’s always somebody that will pay more, but are you willing to sell your soul potentially to the health system to make a little bit more money and then get ground to a pulp day in and day out, it’s not always worth it.

John Goehle: Well, and you bring up an interesting point, too, is that I think, uh, what I’ve been seeing [00:16:00] lately is people do chase the dollars. And then often come back or sometimes come back. I don’t know if I often is the right word there. Um, but when they realize that it’s not all about the bottom line, that the culture is just as important.

John Goehle: Uh, you know, I know we have, we have to pay the bills and I know that that sometimes is challenging, but you know, how long can you survive in an environment that you just, you know, don’t feel like getting up in the morning to go to work? Uh, and, and I think, Um, you know, and that brings up another important point, the importance of making sure you never burn your bridges behind you, both from the employee that’s leaving or moving on to another position as well as the organization that’s letting them go.

John Goehle: One, one thing that I’ve always said to, you know, when we do, uh, training for our staff is that we have to be prepared to let people go and encourage them on their journey moving forward, because this is not, you know, You know, many of our organizations are very small. There’s not a lot of upward mobility, except [00:17:00] into your position, you know, as a director of nursing.

John Goehle: So, you know, when it’s time for them to move on because they, you know, they really want to do much more in an organization, there’s no further positions in your organization. You shouldn’t be discouraging them. You should be encouraging them, uh, and, and, and, because then you’ll become known as that. Uh, nurturing organization that is helping people, um, you know, to, to succeed, regardless of whether it’s going to be in that same organization.

John Goehle: Uh, and I, I, I really am very, uh, feel very strongly about that. And I think from the employee standpoint, you just never know, um, what it’s going to be like on the other side there and, and how valuable, um, you know, that, that experience you had that you came from was. And also, you know, people retire and move on.

John Goehle: Uh, you know, so who knows, you might not have a position there now, but you know, five years later, uh, they might be looking for people that had been there before and, and that know that organization and would love to have you back.

Erik Sunset: Healthcare ends up being very much like the [00:18:00] NFL. We’re getting to the point of the year where we can start talking about preseason. I don’t know if we have any NFL listeners in the audience or college football fans, but you don’t really ever see head coaches leave the profession unless they retire.

Erik Sunset: They’re going to go be an offensive coordinator in L. A. Now, after leaving Buffalo, healthcare is the same way we see it on some of the automatic email responses that we get. So and so left on. Then you see him pop up again at the center downstream. So that’s such a great point not to burn bridges because you just you never know.

Erik Sunset: And that’s huge for culture. And I’m jumping around a little bit on you, John.

John Goehle: No, no, it’s no problem. I do it.

Erik Sunset: talking about compensation at the core here. Do you see a split in the age of those folks that are leaving for nominally higher compensation, or maybe even significantly higher compensation, and can gut it out for a period of time and then come back, maybe with their tail between their legs, maybe not just going, I didn’t like it. I would imagine that as that type of position ages, you know, money isn’t everything.[00:19:00]

John Goehle: Absolutely.

Erik Sunset: you get, the more clear that becomes.

John Goehle: Yeah. No, I, I definitely feel that, uh, just even from our own company, you know, we have a lot of retired semi-retired or, or you know, people that are a little bit later in their careers who are coming into, you know, work for amateur healthcare strategies and, uh, we, I’m just. I’m probably going to get in trouble.

John Goehle: We don’t pay as well as an administrator position does, uh, but, you know, we have a very different lifestyle here. You know, everybody is remote, uh, you know, a lot of the work is, is, by the way, this isn’t a way to try to recruit people. We’re all right right now, uh, but, um, but, you know, but it’s a different lifestyle.

John Goehle: You know, one of our employees says, you know, just she still wakes up at four o’clock in the morning, but now it’s going down to the, uh, you know, to the office or to the kitchen where she can start working and not have to get into the car. Doesn’t even have to get out of her pajamas if she doesn’t want to.

John Goehle: Um, but I, you know, and that’s what I think we’re seeing is that a lot of those individuals that get, um, [00:20:00] um, up there, you know, You know, latter part of their careers are looking for these types of positions where they might not be, um, on the floor all the time, you know, rushing to do, you know, quick turnover and we know that that, that can be a challenge, you know, especially as you’re getting older to, you know, hoofing around the, uh, the surgery center.

John Goehle: Now, I don’t want anybody to get the impression that you’re not going to be hoofing it if you’re a director of nursing or administrator, but, you know, definitely there’s, there’s a lot more time in that office and in front of a computer, uh, you know, than there is when you’re on the floor. And, and I think.

John Goehle: To your point Um, money is not often the issue there. Uh, by the way, and a good point I should make to, you know, those of you that are making major decision in your organization, benefits, uh, are sometimes as important as or more important, um, you know, than salaries too, especially as you get later in the years when people start to realize that they, you know, that they, they need retirement.

John Goehle: You know, money, they, you know, need health insurance, uh, et cetera. And those are, uh, those are things we need [00:21:00] to spend time on, uh, looking at. We’re, uh, actually we’re looking to put together a human resource conference and, uh, probably early next year where we’re going to talk about more of these topics. I, I really don’t know.

John Goehle: Of anybody that has done a full day conference about human resources in the ASC industry, and, uh, I think it’s time, you know, that, that we have that conversation and, and run the gamut, you know, talk about the legal aspects of it, the human resources management, um, you know, paperwork. Nobody wants to talk about that, but we do have to talk about it and, and benefits, you know, 401k plans, how, how, how, how many administrators or director of nursing even know, you know, what goes on in that, that, uh, 401k plan happens to be one of those areas that I, I did know quite a bit about before I came into administration, but I spent most of my time explaining it to my colleagues, uh, and other, you know, surgery center administrators so that they had that knowledge too, but it’s very rare to have that type of background going into it.

Erik Sunset: Yeah, and the longer I’m in my career, the more apparent it becomes that HR is [00:22:00] generally, if not the most important aspect of a business, it’s, it’s top two, top three. Without people, businesses don’t operate. ASCs are businesses, as you well know, reminder for those in the audience, they don’t exist without the people there.

John Goehle: That’s absolutely right.

Erik Sunset: And that’s all, you know, we’re still talking about the culture of an ASC, you know, in essence. One of the other really important pillars of this culture to operate as a successful ASC is around physician engagement. And you had a couple key thoughts on that before we started to record that that can be a challenge, whether it’s due to education, whether that’s recalcitrance and following through on a plan, whatever it may be.

Erik Sunset: But to take it from the top, I think it starts with physicians and physician owners needing to understand what an ASC actually is.

John Goehle: Yeah, we do. We never put ourselves out there as an organization that does does startups, but it’s amazing how many we have going on at any given [00:23:00] time. And, and often what we’re finding is that we’re, we’re, we’re dealing with physicians who got the great idea to build a surgery center or might have had an office based surgery center practice and, you know, talk to, uh, you know, some consultant out there or, or worse yet, one of their friends on a cruise ship, you know, told them that they made billions and billions of dollars, you know, running the surgery center.

John Goehle: And, uh, you know, they, they go out and do this and they don’t do a good feasibility study beforehand, or more importantly, it’s not even the feasibility study. They don’t understand the regulatory requirements that are behind, you know, running a surgery center. So, um, we’re rarely brought in at the very beginning stage.

John Goehle: A company like ours usually brought in after the, sometimes after the building has been completed or is almost, you know, constructed. And then, you know, we spend, you know, three to four months explaining all of the things that need to be done. I, you know, you and I talked about this before we started recording that, you know, helping a doctor to understand that a surgery center is really a hospital without, you know, a You [00:24:00] know, all that additional infrastructure out there all, but the regulations, and this is important for people who understand the regulations around surgery are more complex in an ASC environment than they are in the hospitals area.

John Goehle: And the reason for that is because in the very beginning, in the night, you know, the eighties and the night, actually seventies, eighties and nineties, um, you know, regulatory authorities were concerned that, you know, people would. you know, shortcut, um, you know, the system to, uh, to be able to provide those services.

John Goehle: So they put a lot of regulations in place in order to avoid that. Um, so, uh, individuals that, uh, you know, are building surgery centers, physicians that are building surgery centers have to understand that they are, uh, they’re going to be spending a lot more time on, Uh, governance, uh, you know, dealing with the regulations, making sure that they’re hiring the right people in those positions, get back to what we were just talking about, you know, putting the right people in the in positions.

John Goehle: Otherwise, they’re going to be, they’re going to be, um, you know, having regulatory issues all the time. You know, we know that at least every three years, [00:25:00] You’re going to have a CMS survey, uh, in some form. If you’re accredited, you’re going to have an accreditation survey. And if you’re, and if you’re unlucky enough to be in some of those states like Pennsylvania that have, um, annual, uh, you know, state surveys also, you know, there’s a lot of oversight going on and you got to be prepared for that.

John Goehle: And you got to, and since I, I know none of the, uh, the doctors, none of the owners really want to be dealing with all of that. Uh, you know, documentation of the meetings, you know, uh, uh, pulling together all the resources you need in order to pull off a, you know, a good quality improvement program, emergency plan, safety program, um, uh, et cetera.

John Goehle: Infection control plan. I, I, I, uh, I can’t spout ’em all off the top of my head right now, but, uh, but, but all those programs have to be put in place as well as a very robust education program, not only for the staff. that are, you know, uh, in your organization, but for your leadership and for the owners. You know, one of the things that we’ve tried with the podcast is, uh, to actually provide a, uh, a short, um, you know, governing body, [00:26:00] uh, version of our podcast.

John Goehle: Uh, uh, we’ve only, I think, had a couple over the last, you know, four or five years, but, uh, uh, we do hope to ramp that up. We, we know that they don’t have a lot of time to, to listen to that sort of thing, but what I would encourage, uh, organizations to do is, is to have at least one board meeting a year where you spend a good 15, 20 minutes going through the regulations, uh, have a nice PowerPoint administrators and deal wins out there, have a nice PowerPoint or do a nice video or let them listen to one of our podcasts where we talk about governance issues.

John Goehle: Um, but make it short. You know, one, one thing I’ve never been accused of is being short with anything. So I, I try my, uh, my best. Uh, but there is a lot of regulations and of course, you know, failure to follow those regulations could. could end up being catastrophically expensive. Uh, you know, losing your, uh, accreditation, your certification, or your state licensure, uh, could be very, you know, expensive to get back, uh, as well as the loss of revenue from not being able to bill and do those procedures.

John Goehle: Or even [00:27:00] if, even having a survey that doesn’t, um, cause you to lose your license, but causes you to have Like condition level citations or high level citations is going to require another survey and the cost that’s associated with that. So, uh, being on top of that, making sure that you’re hiring staff that are always on top of those issues, uh, is extremely important.

John Goehle: The toughest decisions you’re going to make as a governing body is who’s going to be your administrator, who’s going to be your director of nursing, and of course who’s going to be your medical director.

Erik Sunset: You’re, I think you’re answering my kind of follow up question here is that ASCs are a different breed of cat because you’ve got either a management company owning the majority of it or you have physicians that have invested their money into building the center. They want to treat patients. This paperwork, I’m a physician, I’m the surgeon, what do I need to do all this for?

Erik Sunset: But they do, they do need to do that. So is there a way around uh, getting significant physician buy in or is this just the way that it has to be? Can you hire around it?

John Goehle: You know, that’s a really good question and one I’ve put a lot of thought into over the years. I think, [00:28:00] um, I, you know, there’s no way to avoid the responsibilities that the governing body has, uh, but you need to have a champion. And this is what I say to my admin, my administrators and DONs. You got to find somebody, hopefully one of the members of your governing body, one of the owners is going to be passionate, you know, about quality.

John Goehle: Now, you know, and I don’t mean to infer that doctors are not passionate about quality.

Erik Sunset: No, no, no, no.

John Goehle: But, but many, governing body members really think that quality improvement, risk management, emergency preparedness, infection control is all about the paperwork, and it’s not at all. Uh, it’s creating an environment that makes all that paperwork easy to deal with.

John Goehle: Uh, you, you’ve got to really have a good culture out there, you’ve got to believe that Um, you know, it’s important to document anything that doesn’t go quite right. I mean, one of the challenges I always have with doctors is they never want anything to be written up as an incident report. And, and a comment that I make to them, especially when I’m a surveyor on a, on survey, is that, you know, my, as a surveyor, I’m not going to penalize you for Writing [00:29:00] up an incident that occurred, even if it involved, you know, patient harm to some degree.

John Goehle: Uh, but I am going to write you up if you don’t do any, any incidents reports. And I’m certainly going to write you up if you, if you had a situation that you didn’t resolve as a result of, of, of an incident that occurred. You, you want to learn from anything. That’s what quality improvement is about, is you want to learn from everything that happens.

John Goehle: And that’s why you want to, you know, I, when I was an administrator, I was an administrator for 17 years. When I was an administrator, I encouraged people to write up every single thing. Now it came back to me, you know, I’d have 50, 60 incident reports a year, which I had no way of being able to, you know, go through all the time and, but I, I much rather.

John Goehle: You know, look at an incident report and say, that’s not really an incident. You know, just because the coffee machine didn’t work yesterday. I think I’ll let that one go. Um, but you know, those other situations where, you know, patient harm occurred or, or we had a near miss, those are the things I want to learn from.

John Goehle: Uh, and, and often I have these aha moments with these doctors. If I can identify [00:30:00] a situation that really benefited them, um, you know, you know, no, no doctor wants to ever be in a situation where they almost, You know, do an operation on the wrong limb, you know, so those are often that that’s where That’s where passionate doctors.

John Goehle: That’s where your champions You know suddenly Show up. We had a situation many many years ago where doctor was doing a pain management procedure and At the end of the procedure he turns around and says, you know Miss Smith, everything’s all fine. And then, you know, the patient turns around. She was on her front and he says, Oh, you’re not Mrs.

John Goehle: Smith here, Mrs. Jones and, uh, I’ll tell you, you know, and he had not done a proper timeout. Um, you know, the nurses in the room were culpable also because they didn’t insist that they do a proper timeout. And the funny thing, well, it’s not funny, but what came out of that is this became the champion. He never wanted that to happen again.

John Goehle: He was a champion. totally [00:31:00] all right with the investigation, with the root cause analysis. Uh, and, and so we caught him, you know, months later where he would be, uh, you know, uh, sneaking into a room before a procedure and telling the doctor not you do a good time out there. Uh, and, uh, he became our champion.

John Goehle: Um, I, I hope that that’s not the way we get champions all the time. I hope people hearing a story like I just gave, you know, get, gets those champions out there, but the rule number one, to your point is that you’ve got to, you’ve got. to get them to understand that this is not paperwork. This is something that, and it’s not just something that’s required from a regulatory standpoint.

John Goehle: You know, when I got into the industry, there wasn’t a lot of competition. I think, I think the first surgery center I built, we were one of two surgery centers in the community. I can’t even count how many are in our community now, but two surgery centers in the community. I was practically best friends with the administrator of the other surgery center in town.

John Goehle: Uh, we did not compete with each other. We, you know, we, we, you know, we had lunch on a regular basis. We, you know, [00:32:00] collaborated on things. We were very careful making sure we didn’t do, you know, things like talk about how much we were being reimbursed. Um, but we, we collaborated on, on a lot. That’s not the environment that we have today.

John Goehle: Um, which means that we have to compete. Um, not only on price and, you know, getting, you know, the best employees, but also quality. And we want to be able to demonstrate to people that our organization is, is a high quality organization. People, you know, patients are treated, you know, like gold when they come in and, and, uh, uh, and that’s how we differentiate.

John Goehle: And the trick to that, the, uh, the bottom line comes down to being able to provide, you know, good patient care, even more so than price, to be honest with you. You know, many times those decisions are not made, uh, you know, based upon price when it comes to health care. Uh, they’re looking for a place that’s got a good reputation, it doesn’t have a history of, you know, bad outcomes, uh, that’s not in the newspaper, um, and, and to do that, the only way to improve quality is to make sure that you’re identifying every, every situation in which you didn’t quite reach that level of quality that you wanted.[00:33:00]

Erik Sunset: Yeah, this, this is a little bit tongue in cheek, but you know, as a patient making a decision where you need an outpatient procedure, you know, this is maybe just me, but is the parking lot easy to park in or do I need to pay for parking? Is the building clean? Is this physician well known with a good reputation?

Erik Sunset: And then price obviously is a factor at some point. I would very rarely would that be top of the list unless you’re just in dire streets, which I do understand. Yeah,

John Goehle: I, I’ll tell you, parking could be a deal killer. I’m, I’m going to the city tomorrow and, you know, one of our centers is located in an area where I’m probably going to have to walk a half a mile to get to the center from, you know, the nearest parking lot. Um, that is not convenient. Now, you know, I, I have to have a very different attitude when I’m in an urban center, you know, without a lot of, uh, uh, parking right in the surgery center.

John Goehle: Um, but, but it is definitely something that people think about, uh, and, you know, uh, even being able to, uh. Um, ease of getting people in my mother, you know, is older now. And whenever we’re going somewhere, doctor’s offices, we ask questions [00:34:00] about how easy is it going to be to get her out of the car into the center, especially if it’s snowing or if it’s raining or anything like that.

John Goehle: And those are things we need to think about also as part of quality.

Erik Sunset: very, very much so, very much so. And with all this talk about quality, you know, depending on who you ask and we’re leading into the big digital question here, John, depending on who you ask, having a digitized. facility with a great practice management system and matching EHR, some would have you believe that that will make all this tracking and trending easier.

Erik Sunset: And I think to an extent that they’re right, but being withheld from meaningful use and no real reason to go buy an expensive EHR, the number one, the surgeon’s already on their third or fourth or fifth or greater at their clinic. Uh, they don’t like using it. Medicare is telling them you need to use it or else.

Erik Sunset: And then you’re at the facility at the surgery center thinking, if I don’t need one, why would I buy one? Is that the prime resistance to these EHRs and ASCs, or what do you think’s going on?

John Goehle: Well, I I think [00:35:00] some of it is old people like me. Um, I’ll be honest with you. If I’m a surveyor, I want a paper record because I can, you know, I can go through that paper record and no time flat, you know, go back and forth in the record. I’ll be, um, and and but of course, I’m not the one creating it. So I’m speaking as a as a surveyor who wants to be able to get that, you know, through that record quickly.

John Goehle: And trust me, when we’re going through an electronic medical record, it is it is not a quick thing. So and I’m not alone. I get it. There’s a lot of administrators out there and deal ends out there who who aren’t necessarily creating the records, but they’re the ones that are reviewing them and making sure they’re ready for, you know, a survey to look at him.

John Goehle: So there’s a little bit of resistance there. I think the physicians are not Usually the people that are resistant to the system until they see the price tag. And the problem, as you well know, in the industry, in the ASC industry, uh, we’re not as big as hospitals. We’re not as big as the physician practices.

John Goehle: And there’s not a lot of options. You know, there’s really two major systems out there, two major companies that are producing, you [00:36:00] know, the vast majority of those systems. And, uh, you know, they’re all, You know, they’re, they’re great systems, but they don’t, neither of them will, will make everybody totally happy out there.

John Goehle: And I, I hate to say that, but you know, that’s the reality is that, you know, we have to make compromises because there just isn’t a lot of competition for really high end, you know, uh, EMR systems at the present time, and probably won’t be in the future because of the size of our market.

Erik Sunset: Yeah, I think you’re right about that. And just to go back to not being able to make everybody happy. If you look at the best in class scores, and for those not familiar, that’s class with a K, K L A S, they’re sort of the Yelp of medical software. For the last 10 years, the winning scores have been like a B minus.

John Goehle: Yeah.

Erik Sunset: The very best software out there is, uh, getting by with a B minus. There’s a lot of room to improve. And having come from the, uh, the clinic side of the EHR world for most of my career, you know, on the clinic side, you had vendors just begging for mercy. Hey, we’re trying to keep up with Meaningful Use 1, now Meaningful Use 2.

Erik Sunset: And now they’re [00:37:00] switching us to Macro MIPS. And we have to make all these changes to our product that you actually don’t get to see and feel and touch except for the reporting dashboard. But my gosh, this is tons of development

Erik Sunset: time. And now they’re just starting to be able to work through their backlog of, uh, functionality improvements, feature requests that are finally being handled since we’re kind of steady, steady state, um, in terms of Medicare reporting. The ASC doesn’t have that. They didn’t have that meaningful use pressure to

John Goehle: financial kind

Erik Sunset: certified systems.

Erik Sunset: I kind of scratched my head and love our friends at, at these, at these vendors, you know who you are, dear friends in the space, but that the systems aren’t more well regarded comes as a little bit of a surprise to me.

John Goehle: Yeah, very well said and I, you know, to your point, I mean, now I kind of gave the, I don’t want anybody to get the impression at all that I’m against EMR systems. I’m, it’s quite the opposite because there’s a quality guy, as somebody that is, wants lots of quality data. [00:38:00] it’s it’s hard to extract that data from a a paper record.

John Goehle: Well, it’s really impossible without, you know, without spending the resources to get somebody to, you know, manually pull that information off. And that’s the beauty of these newer systems. Even the ones that aren’t that great, you know, hopefully have some way to be able to pull data together from a quality standpoint to help you understand your cancellations, why things are canceled, you know, the average length of time in the operating room, why you have complications, what types of complications you have.

John Goehle: You know, how the discharge works, the time from patients entering the facility to when they get into the operating room, to when they get to the discharge area, to when they actually get out the door. All of that data is extremely meaningful, uh, in improving quality. It helps us to understand what, what, what’s happening and, and we can take that data and start to make marginal, you know, changes, uh, and at each incremental step that we are, uh, our, our, our.

John Goehle: are making based upon the data. We can constantly go back and double check that data, make sure those changes are occurring without [00:39:00] getting additional resources to it is so valuable. But I got to tell you, more importantly, I don’t know if I should say more importantly, just as important out there is our other stakeholders want this data.

John Goehle: The government wants this data. They want to know that you’re providing good quality care. And how do you do that? You know, without Solid data that’s coming out of your EMR systems and payers care about this. But, uh, an up and coming area is employers. You know, we as employers, you know, you and I are both employers.

John Goehle: You know, we, we want to make sure, uh, that our, um, our, our employees are getting the best bang for their, you know, for their dollar. Uh, and of course I, I can’t just, I’m a small guy, you know, I’d like not, not very big business. Um, uh, but those big employers out there, um, you know, they can, they can make or break, uh, you know, a business.

John Goehle: And if you don’t have the data, they’re not even going to look at you. Um, so the time is coming. Uh, even though there is no, uh, deadline right now, there’s [00:40:00] no, uh, Requirement that at least I’m aware of, and there might be in some states, but certainly not nationally, um, you know, to move toward an EMR system, uh, the clock is ticking, and, and we’re going to have to do that as we are required to have more data, as employers are asking for more information, uh, as, uh, accrediting organizations You know, CMS, you know, your states are looking for those quality improvement programs that you all have to be more robust and, and data oriented.

John Goehle: When I, when I do a survey of an organization, one of the weaknesses I sometimes see is that they’re not gathering relevant data. Uh, I might go into an eye surgery center and not even gathering data on unplanned anterior vitrectomies. Well, it’s the most basic thing that you do. How can you even, you know, ignore that?

John Goehle: Um, or they’re not really properly gathering information from the infection control plan to determine how well you’re doing in that area. And, you know, we know, we learned some lessons from COVID, of course. Um, that I, I keep telling my staff, let’s not talk about COVID anymore. Let’s talk [00:41:00] about, you know, emerging infectious diseases.

John Goehle: Uh, but we learned so much from You know, from that experience, it used to be that we would say, well, I’m not going to worry about, you know, communicable diseases because I’m just not going to allow anybody in my center that has a communicable disease. Well, that was a big lesson from COVID is that sometimes you’re not going to know.

John Goehle: And in fact, I would say often you’re not going to know, uh, and, and there’s no reason to believe that that’s trend’s not going to continue. So now we’ve had to revise our quality improvement, our infection control programs to be able to track that type of information, to be prepared, uh, you know, to do, um, Um, you know, some, uh, you know, monitoring to be able to make sure that you’re being able to handle that situation.

John Goehle: Should it occur again?

Erik Sunset: And I want to go on record as well, that both as a patient and as a member of the ASC sort of vendor community, I’m very much pro EHR. So that was a little bit of a dig earlier, earlier on, but to your point about being a surveyor, you know, And this is true for the facility. This is true for payers. This is true for management companies that, [00:42:00] that operate these facilities. It’s way easier to extract data, uh, out of one chart on paper. There’s no dispute about that, but what about at scale? What if I want to see everything for this quarter, for this year, for 10 years? You can’t do that without software. It’s an impossibility.

John Goehle: That’s absolutely true. Yeah,

Erik Sunset: This, this is just conjecture, um, but I think it’s, I think it’s meaningful for this discourse that as you are seeing like these cardiologic procedures come off the IPO and are being allowed in the ASC, I think you got your head in your sand if you don’t think something is coming. Uh, in terms of some sort of electronic requirements, and I’m not hoping for that, I’m not necessarily guaranteeing that, but you have to think about the mechanisms in play here where you have the only win win win in healthcare, which is the ASC venue for care, as much as it can be, um, and you don’t think that Medicare wants to sink its teeth into that data and figure out why this exactly is, I just think you’re fooling yourself.

John Goehle: totally agree. And [00:43:00] it’s certainly from, uh, you know, from surveyor standpoint, you know, now again, I work with Triple A. C. We just, Um, you know, had a major upgrade to our, uh, accreditation software. Wonderful upgrade, by the way, I do want to go on record of because unfortunately, I haven’t always been happy about the change that’s involved because change is tough for especially old people or people that have been a surveyor for a long period of time, but the new system is wonderful.

John Goehle: But. You know, it, it, it made me realize how important it is to, to have electronic, I can see in the future that we’re going to be having our systems interface with your systems, your EMR systems. So we can be much more efficient with our, our, um, our surveys, uh, and you know, that’s the next generation.

John Goehle: We’re nowhere near that right now. So you know, for now, I’m talking to a very limited audience out there, but for those people that are creating these EMRs, recognize the importance of having them. I know your company, for example, you’ve been developing [00:44:00] relationships. Um, that’s one of the reasons you and I have been talking is that I, I love the concept of that interoperable interop, the ability to work together as software to be able to work together.

John Goehle: Um, and, and, and we have to do that. Um, but. As for those software developers out there that are creating these EMRs, please recognize all of the stakeholders. It’s not just the people that are in the operating room. It’s going to be the lawyers who are defending, you know, the surgery centers. I do expert witness stuff and.

John Goehle: Oh, man, trying to understand or look at these electronic medical records, you know, from an expert witness standpoint, it, it, it, it is a nightmare. Um, and, and as a surveyor, you know, why should it take me so long in front of a computer screen, you know, two to three times as long to be able to go through an EMR, uh, based medical record than I do on paper.

John Goehle: Um, you know, we have to find ways to be able to make those interfaces more, um, uh, understanding to the people that are using it. I, I think there needs to be different interfaces. [00:45:00] You know, for a surveyor, you could easily, everybody knows what a surveyor is looking for, maybe have that interface there. When you’re doing peer review, getting back to the physician’s responsibility in an organization, uh, none of the physicians, I know, and I know I’m talking to some out there, I, I get it, you don’t want to do peer review, It’s a lot of paperwork.

John Goehle: Well, I want to take that paperwork away from you. I want to focus you on the screen To the issues that have been brought up forget about the fact that it’s on a piece of paper Uh, look at what’s what’s occurring on on the screen there and be able to help identify whether that was good quality care Or whether there’s some improvement room for improvement there um I’m, not an expert on computers, but I know that that’s the beauty of that is that you can you know create interfaces that Will make it Easier for each of the different stakeholders of that E.

John Goehle: M. R. Information to be able to interact with it in a in a timely way to be able to gather information that they, they, they want to, uh, that they need to work with and they want to work with and to be able to make positive changes.[00:46:00]

Erik Sunset: I’ll only add to that to all of our EHR friends in the surgery center space and the practice space and the inpatient space. It’s high time to move towards an API. Let’s get out of the 80s with HL7, please. That will make everything John just described way easier. The one thing that is going through a rapid advancement, rapid adoption, more interest, Then anything I’ve ever seen technologically in healthcare is AI, artificial intelligence, or so called artificial intelligence.

Erik Sunset: Listeners of the show will know I’m a little bit of a skeptic in the terminology, but the software solutions are very real, some of them. And it appears to be here to stay. Uh, so John, AI in healthcare, your thoughts, what are you seeing?

John Goehle: Well, I find it fascinating. We, we have been early adopters of AI. Um, you know, it helps us when we’re doing our research to be able to gather information. It’s another way of gathering information. Um, you know, our, our job is tough, you know, try to try to gather, you know, all the regulatory requirements, you know, from the [00:47:00] different states, from the different accrediting organizations, uh, you know, from OSHA, from CMS.

John Goehle: I could go on for a couple hours here. Uh, and, and AI is helping to gather that information in a much more usable format. I mean, we still have to go to the original source, uh, but AI can be very helpful. So those are, if you are not familiar with AI or haven’t even, you know, uh, experimented with it yet, uh, definitely, uh, start working on, uh, please, however, don’t send me emails that have been generated by AI.

John Goehle: I’m getting. Especially, or if you’re going to do that, at least take the headers off that indicate that you’re, you know, created it from AI. Uh, but I’m seeing more and more of that, by the way, I, I taught a class. I still am teaching and, uh, the best reports, the best final reports that I’ve ever had were generated this year, uh, by my class.

John Goehle: Uh, by my classes, and I suspect that, uh, many of them had a lot of assistance by AI to create it. And our software wasn’t able to be, to determine that if, you know, where those, those, uh, the [00:48:00] original source was for a lot of that. So that, so as an educator, I’m frustrated by it, but I definitely, uh, see some radical changes occurring.

John Goehle: Um, when we were at ASCA 2024 this year, we had a number of speakers talking about, Some of the real benefits of AI, especially in billing. Imagine a scenario where you have artificial intelligence having a huge database of what it takes in order to code and bill a case for a given insurance company.

John Goehle: given past rejection. In other words, they have all this history of past rejections, you know, what the, uh, how the coding was done, et cetera. Uh, so that, uh, you know, and, and that’s integrated into your coding and billing system, uh, to be able to get that, um, that, um, claim out there, right. The first time around.

John Goehle: And that blew my mind right there. That blew my mind that, that, and there, I’m being told that that is already starting to occur out there now. Unfortunately, I have a I used to teach [00:49:00] coding. Um, you know, um, college level coding. I can’t do that anymore because it’s gotten way beyond my capabilities. But but I have a lot of dear, dear friends who are in the coding area and the billing area.

John Goehle: And I do think that in the future we’re going to find a I. You know, making major inroads into that area, and I don’t think it’s going to be slow. I think it’s going to be happening very rapidly. So, um, you have to be prepared to adapt to it. Um, adopt it as much as you can be wary of it. Um, you know, because, you know, data in.

John Goehle: You know, garbage in, garbage out is so true, um, in all of our computer systems out there. Um, but I do think it’s going to have a dramatic impact on our industry. Even simple things like, you know, we use it sometimes to help us write, uh, policies, or I should say rewrite policies. Not, not so much to change the content, but to make it more readable, you know, to people, you know, I think that’s important.

John Goehle: Many of us are, you know, we’re way too technical and, uh, you know, I’ve learned [00:50:00] how to be able to say, you know, write this at a sixth grade level, you know, not because I think you guys can only read it a sixth grade level, but it makes it more understandable to everybody else. And particularly when we’re creating forms for our patients, or if we’re trying to create forms in different languages, AI can be a huge benefit to that.

John Goehle: So, um, I, I think. I’ve already seen the advantages. I’m amazed. Isn’t it true? I don’t think we were really talking about A. I. last year. I think a lot of the A. I. conversations started in January of this year, if I remember right,

Erik Sunset: Yeah, you’re, you’re all over it. The sort of the, the very bleeding edge was Q3 and Q4 of last year, but it wasn’t really being discussed for healthcare. And,

Erik Sunset: you know, the only thing I’d add to your, to your statements there is that for those shaking in their boots that AI is going to take my job, AI is going to replace me for the most part. No, it won’t, but you need to be, uh, you need to have a little bit of your own agency that [00:51:00] what John, you just mentioned, right? This rewrite this at a sixth grade level, that’s prompt engineering to be able to wield these AI tools to give you the outcome that you desire. That’s going to be the have and have nots.

Erik Sunset: Uh, can you, uh, sort of put into print and put into place. These prompts, uh, that’s, I guess that’s the only way I know to say it is the prompt engineering aspect of it.

John Goehle: Yeah, I can see, uh, in my future, uh, uh, uh, doing courses on how to use AI effectively, um, because to your point, you know, I’ve had to learn a lot about just writing those prompts out, being able to, you know, uh, engineer them in a proper way. And that’s really the whole secret to getting good information out of the system.

John Goehle: So it used to be, we had to figure out how to put a good Google search in there. Uh, now very different, very different, uh, uh, approach.

Erik Sunset: And that’s, that’s a challenge. I know we’re, we’re coming up on our time here, but the, uh, there’ll be some exciting news on the DocBuddy front there, but the real, the real key in developing these AI based products is can you make it [00:52:00] usable for a non, a very non technical user that doesn’t care about prompts, maybe they’re a physician that. Couldn’t care less about the prompt. Just make it do what I want it to do. And then give that tunability and scalability to those that are into it. And that do you understand the prompt engineering to give them exactly what they want, but to be able to do that in both cases. So more, more to come there.

Erik Sunset: It’s what they call a teaser, uh, in the business job.

John Goehle: Well, I’m certainly interested.

Erik Sunset: And as we, uh, as we wrap up our show, John, where can listeners connect with you online? Where can they find out more about what you’re doing?

John Goehle: Absolutely. So we have a couple of websites, um, are, if you’re interested in the podcast, it’s available just like yours on all major podcast channels. Ours is only audio. So, uh, you know, who wants to look at this face all the time? Sorry. Um, you know, so ours, our, our podcasts are audio and, uh, if you can’t load it on your, uh, Your cell phone, you can always go to ASCPodcast.

John Goehle: com. We also have a website called ASC Central and that’s ASC Central. com. That’s where all of [00:53:00] our educational programs are located, including our very well known, and we have over 300 graduates from our boot camps over the last four years. So definitely you can, can look that up. And of course, if you, if you really need a lot of help and, and, uh, need to, uh, to have ongoing assistance, uh, Ambitrary Health Care Strategies is always there for you.

John Goehle: And that’s at AHC. Dash strategies. com. You can always email me at Jay Goehle at, I know you’ll give that information out. So I’ll, I’ll let them, uh, uh, figure it out from your show notes, but feel free to email me. I’d love to love to talk to you.

Erik Sunset: John, I’ll, I’ll save you the spelling. Of course, all of those links will be, uh, provided in the show notes and the show description. And on behalf of the entire DocBuddy team, John, I want to thank you for joining us and to our audience. Thank you for listening. Be sure you’re subscribed on Apple Podcasts, so you always get our newest episodes.

Erik Sunset: And until next time, I’m your host, Erik. We’ll talk soon.