ASC Benchmarking

ASC Benchmarking
Data-Collection Process Evolves

By Michelle Beaver

When clinical administrator Wanda Spacht recalls the 17 years that Peoria (Ill.) Day Center has been open, she identifies a turning point that occurred about seven years ago when the center’s staff started benchmarking data. Being able to compare and contrast the center with its competitors helped staff members be more realistic about how they were performing and about what needed to be improved.

“I do see a difference now in that I have data that says ‘I am doing this well,’ whereas before I didn’t have that data,” Spacht says. “Before, I could say, ‘Oh I think we have a very good infection rate,’ but I didn’t have any data to back that up.”

Spacht is interested in statistics about complications, hospital admissions and patient satisfaction rates, but found most benefit in looking at how many labor hours her staff was spending. “I had always wondered about my labor hours per case,” she says. “The first time I looked at that I was surprised that mine were kind of high. I worked on it and did bring my numbers down.”

Spacht describes benchmarking as a vital process. “When I present my benchmarking results to my board it shows them how well we are doing,” she says. “It reflects on the surgery center and staff. Sometimes the board doesn’t always see how well we’re doing because they’re here one or two days a week but this shows them that we are doing very well. We also like to use this information to say to our patients, ‘Well, we have a very low infection rate.’ That helps attract patients to the facility.”

Benchmarking in the ambulatory surgery center (ASC) industry is simply the collection of clinical and financial data that shows how one facility is faring compared to other centers. As with any survey, a large sampling typically results in a more accurate picture of the subject matter. Benchmarking should be done at every ASC, according to Spacht.

Indeed, the information is useful, says Craig Jeffries, executive director of the American Association of Ambulatory Surgery Centers (AAASC). He remarks that an ASC staff that does not benchmark is not using a standard process for validating the clinical as well as financial efficacy of their operations.

“I have no doubt that there are some very successful, very efficient businesses that don’t do benchmarking, but I would surmise that there are a lot more unsuccessful, inefficient businesses that aren’t doing benchmarking that could benefit from it,” Jeffries says.

Jeffries offers the following analogy: “It’s like driving on a highway when you’re the only car out there and then all of the sudden you encounter a pack of cars you’re zipping past,” he says. “So what do you do? You look at the speedometer and say, ‘Oh, I’m 20 miles above the speed limit.’ You’re benchmarking your ability to look at some quantifiable data — meaning your speed limit — and it helps bring you back into the norm.”

Benchmarking might be slightly more advantageous to some ASCs than others, says Susan Hollander, BSN, MBA, FACHE, vice president of National Surgical Care. “(Benchmarking) may be more important for a smaller center in that aberrations or outliers can be more detrimental,” Hollander says. “There are many centers that are Accreditation Association for Ambulatory Health Care (AAAHC) accredited and with the expanded benchmarking standards are using external information to improve at both the clinical and non-clinical levels.”

Benchmarking in ASCs has been required by two major accrediting bodies since 1999, so it behooves facilities to consider implementing some kind of data collection process that demonstrates quality care. The Outcomes Monitoring System, developed by Surgical Outcomes Information Exchange offers an ongoing benchmarking system that can be integrated into an ASC’s everyday operations. In addition, a facility may immediately compare itself with the aggregated performance of peers by accessing reports prepared especially for that member facility over the Internet. The indicators for ambulatory surgery benchmarking include preoperative complications, pain management and patient satisfaction. Patient-level procedure-specific data collection and analysis facilitates “apples to apples” comparisons. 

Benchmarking patient outcomes clearly shows the position of a surgery center among other similar facilities in the industry, and offers a powerful marketing tool distinguishing a center from the competition.

Why Bother?

Don’t ASC managers and operators have enough to worry about without the added task of gathering, organizing and submitting data? Sure, but in the long run these steps can actually save time if the results are used properly. At the very least the results can strengthen what an ASC team may already know about its facility.

But more so, benchmarking teaches a staff about what others are up to, says Sandra Jones, CASC, principal with Woodrum ASC and Ambulatory Strategies Inc. “It is difficult to judge how well you are doing or how different it could be unless you have information about how others are doing,” Jones says. “Benchmarking gives you tools to assess whether particular areas should be the focus of improvement activities.”

Jeffries agrees. “If you’re performing well — if your infection rates, at less than one percent, are better than at the local hospital — then a consumer may very well want to choose the ASC as opposed to the hospital as a setting for their surgery,” Jeffries says.

“I think benchmarking is helpful and important to anybody, whatever business you’re in and whatever size you are. Each (clinical and financial benchmarking) are very important and they’re important to different managers or drivers within the surgery center and they serve different needs for the health, growth and profitability of a surgery center. Just to see how (an ASC is) doing compared to others is pretty fundamental.”

More Than One Right Answer

If ASC team members decide to participate in a benchmark survey, they certainly have options, including programs run by the Foundation for Ambulatory Surgery in America (FASA), AAASC, and the Medical Group Management Association (MGMA), among others.

Spacht believes it is advantageous to benchmark with more than one group.

“I do different benchmarking with a few associations and that’s always helpful,” she says. “They don’t all collect the same data so for me it’s valuable to deal with a couple associations so I can get the most data.”

It took Spacht a while to work up to the task, but now the compilation and sending of data is status quo for her, even though she’s participating with multiple associations. “It took a little while to do it consistently,” she says. “It does require some work to gather the information. It was very easy at the beginning to not do that work and just let the deadline pass. But now I make it a priority to do it on a consistent basis.”

The following is a closer look at various benchmarking programs in the ASC industry.

The FASA benchmarking system compares national data such as total annual expenditures, profitability, patient volume and time in the operating room. Participants receive a personalized summary of their ASC in advance of publication for $155 (member price) or $395 (nonmember price).

Last year’s surveys included more financial and specialty-specific data (for 20 specific procedures) than ever before.

FASA leaders say the data can help answer questions such as, “how does the number of staff my ASC assigns per patient case compare to other ASCs? How does the percent of my ASC’s overall expenses dedicated to staff compare to other ASCs? How do my ASCs per-procedure costs for specific procedures compare to other ASCs?”

The AAASC has been compiling financial benchmark data since 2002 and clinical benchmarking data since 2004. Financial benchmarking is done annually and clinical is done quarterly, Jeffries says.

AAASC clinical benchmarking saw significant growth during the fourth quarter of 2006, he adds. Participants who are AAASC members receive benchmarking reports for free in return for their participation.

For more than 50 years MGMA has conducted annual surveys that revolve around compensation, revenue, expenses, etc. MGMA literature states that benchmarking “relies on measurement, comparison and metrics to facilitate management. Because benchmarking measures performance at different times, it’s an important tool for observing changes in practice or physician activity. Knowing how peers code procedures, or that other practices are more cost-effective, can persuade administrators, physicians and others to implement change.”

Many ASC administrators use the data when they audit their practice’s performance.

“Practices refer to MGMA survey reports nearly every day to help develop budgets and business plans, facilitate organizational change, launch strategic initiatives and illustrate organizational performance,” the literature continues.

MGMA benchmark reports are free to MGMA member organizations.

Prioritizing Data

Some information is more paramount than other information, according to Jones.

“In general, expenditures are probably more within our control than revenue, depending upon specialty and payor mix, so we might find expenditure data more helpful in managing the surgery center,” Jones says. “However, clinical benchmarking data can also significantly impact our cost of doing cases. When a process change results in both improved patient outcomes and financial results, it calls for a celebration.”

While benchmarks often tell ASC administrators what they already know, the data can at other times be a big surprise.

“When you find out your supply costs are 32 percent higher than at another surgery center for the same procedure, it makes you look hard at supply usage and what you are paying for each supply item,” Jones says. “I also know clinical benchmarking studies have surprised some providers who thought their complication rate was low. It made them take a hard look at their patient care processes.”

The surprises are usually modest, according to Jeffries. “Mostly it’s incremental,” he says. “It’s not huge. Maybe their infection rate is at 1.5 percent (whereas) the average is at 1 percent. That’s not an alarming difference but it’s one that requires some action. Maybe their cost for supplies is 35 percent and the average is 28 percent. There’s opportunity there, but it’s not like anyone’s going to get fired because the numbers show such a big difference.”

Benchmarking is only a first step, he says, and does not provide all the answers. For instance, one ASC may have higher costs than a competitor, but there could be good reasons for that. The same goes for clinical benchmarking.

“It may well be that the 1.5 percent infection rate is because they have a patient population that’s more at risk,” Jeffries says. “It’s more of an incremental tool rather than a draconian ‘wow’ type of tool. I’m sure they’re surprised but I think the scale of the surprise (is moderate).”

Some indicators are more useful than others, such as infection rates, admission to inpatient hospital, or discharged-to-death data, Jeffries says. ASCs generally do “very well” on all of the above, he adds.

Benchmarking is useful but is not a panacea, according to Hollander. “It has been my experience that revenue data is reliable but cost data is not reliable,” she says. “A center must be extremely careful when comparing cost data as there are great variations and interpretations on what is included in direct cost measures. Also, there are great variations in cost data tracking, such that the reporting may not be verified through the actual accounting of the costs, but merely guessing.”

Sizing up the Competition

Knowing where one stands with — or away from — the competition can certainly be valuable under the right circumstances, Hollander says.

“Benchmarking data is powerful information if it is reflective of quantifying the exact data across the board,” she says. “If your center has a measure of days in accounts receivable at 25 days when the benchmarking is showing 35 days as the average, then the center can feel comfortable that it is outperforming the pack. However, if the center’s patient transfer to hospital rate is 10 percent, then there are clinical issues that need immediate attention. Standing away from the pack can be a good point or a bad point.”

Sometimes, however, one must shut out the competition and instead look toward internal data for guidance.

“A center can use internal benchmarking and improve its performance by comparing its own results, like a golfer,” Hollander says. “The golfer has a handicap and his goal is to improve that number. He does not necessarily need to compare himself to other golfers to know that he is progressing. If his handicap is decreasing, than it is safe to assume that he is improving.”

What’s Next?

Sometimes comparison data can catch an ASC staff off guard, but this is no time to panic, Hollander says. “It is more important to react and examine why there are variances than to try to make excuses why their center(s) are different,” she says. “It is a common tactic to deny the existence of opportunities for improvement. It takes an open-minded administrator to grasp the data and investigate how to meet and exceed it.”

Indeed, negative information should lead to a metamorphosis, Jeffries says.

“If they’re performing below what others are doing then it gives them an opportunity to install a process to discover more closely why they’re below,” he says. “It gives them an opportunity to correct or make changes to improve, and if they’re above, it gives them an opportunity to brag or reward employees or otherwise alert people to their success.”

Every ASC staff member should value his or her ASC above others, but it’s important to balance this with the view that each center is part of an industry. Communication can therefore be more helpful than an isolationist attitude.

“Benchmarking is a trigger but what they (ASC managers) do with that trigger depends on the research they do in their own company or through talking to others to find out how they’re doing it,” Jeffries says. “(Staffs) should be, and do talk to other surgery centers.”

Even if results are positive, ASC staffs can still make improvements, Jones believes.

“Instead of the ‘if it isn’t broken, don’t fix it’ mentality, we should always strive to ‘fix it better,” she says. “Of course, there are priorities and something that is okay may have to stay okay until you can find time to make it better. Benchmarking can help you focus on ‘fix it better’ projects by helping see how far away you are from the norm and from best practices.”

Transformation

The idea behind financial and clinical benchmarking in the ASC industry hasn’t changed since the first survey was administered, but the process has. It is a bigger, faster, more comprehensive and technologically dependent process than ever before.

“Currently, there are two very important changes taking place,” Jeffries says. “One is automation. AAASC benchmarking is completely Web-based.”

Jeffries points out that if, for instance, the due date for ASC administrators to submit information is on, say, Nov. 15, the information can be available to the participants on Nov. 20.

“The process of uploading data automatically into the Web-based system is a huge efficiency savings,” Jeffries says. “The ability to have almost instantaneous results is super. The other aspect of our clinical benchmarking (that has changed) is that because it’s Web-based and all electronic (it’s easier to share with an ASC board or management team). It’s now instantaneous distribution. That automation has been a fantastic benefit and has increased participation.”

Technology has also made it easier for the staffs at ASCs to gather data and solutions.

“Let’s say that an infection rate is higher than average,” Jeffries hypothesizes. “It used to be that the management of that surgery center used to have to laboriously pull medical records and figure out why. (Now) with most surgery centers in an automated system or moving to more of a clinical management system, they can research why their infection rate is up much more quickly. The shelf life of a problem is shortened, which is good for patient care and good for financial strength.”

The AAASC benchmarking system is experiencing other forms of evolution aside from becoming more technically inclined. “AAASC has led an effort to establish national standard bench indicators or measures of AAASC safety and we’re right in the process of getting National Quality Forum (NQF) approval and validation for ASC specific measures,” Jeffries explains. “AAASC is a member of NQF and what that means is that we’re trying to be proactive and ahead of efforts that we see going on with the federal government, state government and many payors to provide consumers, patients and beneficiaries with quality information that they can use to make a judgment on what provider they want to utilize.”

AAASC leaders submitted to the NQF about 10 measures that they think the government, consumers and payors should use to measure surgery centers.

“The reason it’s important for AAASC to establish these national standardized benchmarks is it makes the comparisons more robust,” Jeffries says. “It’s a benchmarking on steroids. It’s taking the best interest of benchmarking from an internal ASC perspective and allowing us to do that in a more transparent way.”

Patients are certainly interested in hearing how a particular ASC stacks up, but it is board members — not patients — who usually motivate an ASC team to acquire benchmark data, according to Spacht. Curiosity from Spacht’s board is what motivated her to involve Peoria Day Center in its first survey.

“We knew we did certain things well,” Spacht says. “Our board (and our staff) just needed proof that we did them well, and now we have what we need.”