Joe, Dave, I want to talk about leadership for just a minute, especially since I think many of our attendees here today are practice administrators. As practice leaders, how do you view your role specifically alongside your practice administrator? And in what ways, if you can be specific, do you achieve with collaboration? I know we talk about leadership and we work at different sites of service, so this could be your office, it could be your endoscopy center, it could be collaboration with administration at the hospital. Joe? Colleen, as you know, we have, we're an independent group. We have currently 15 physicians, seven nurse practitioners, four bed ASC, about 20 clinical rooms, and the way we've always operated our practice has really been through horizontal decision-making. We are more of a horizontally-integrated decision-making practice as opposed to top-down, so not vertically. So we give our manager, our business manager from the administrative standpoint and our clinical manager a lot of power in decision-making. So we really are working in tandem as a team in a horizontal fashion. Obviously, the physician owners of the group will make some of the bigger decisions or provide guidance to our administrators, but they really have a lot of independence in making decisions because they know from our meetings what we vision for the practice, what we vision for our culture. So I think they have a lot of independence in decision-making. David? Yes, hi. So I'll be able to come on video in a second, but yeah, I'm sort of straddled between hospital duties, fellowship duties, clinical duties, and then being, in my case, medical director at the ASC. So perhaps out of survival, I've really tried to empower, as Joe said, the leadership at the ASC. I'm only there one day a week. A lot of the mentoring happens sort of trial by fire. So I think the last message is the primary means of solving rapid solution type questions. We encourage nurse leadership and business operations to attend ASGE leadership courses, but those types of courses just provide a framework for real-world application. And we have been fortunate not to be in a situation where we've had both new nursing leadership and new administrative leadership at the same time. That would be a small disaster for us because of the physician leadership really wants to do what they do best, which is taking care of patients and not running the daily operations of the center. Thank you for that. Joe, back to your critical conversations as we learned about your campaign around value of colonoscopy. We find ourselves in a value-based environment, and most primary care practices, whether they're independent or employed or hospital-based, realize a large part of their income now from shared savings. Have you worked to leverage your ASC or some other, as may apply to Dave, some other opportunity to discuss how you bring shared savings back to that partnership? Yeah, so we've had some pretty good success with direct interactions with larger businesses, specifically around bundling for colonoscopy. Many of these practices had traditionally sent their patients to hospitals where the expenses were very high because of the hospital outpatient department. And as their relationships with some of the hospital administrators changed and they started looking at the bottom line, they actually, a couple of them, came to us to look for ways to save money. And the way to do that was to take advantage of the cost efficiency of the ASC. And we've now kind of grown the model a little bit to an area that's growing. I think you can really leverage colonoscopy if you have an ASC with payers, especially those that are self-paid, in a way, to decrease their costs. Yeah, so we have had a similar experience here with employers who are self-insured or even in a captive. I think that's a conversation that is going to really get more legs as time goes by. Yeah, that's why I was looking for self-insured. I couldn't find it, but those are the organizations that really find value in us. Yeah, and for those who are self-insured or even partially self-insured, there may be even direct contracting opportunities to expand on that. Dave, have you had an opportunity to talk with payers or referring practices about value and shared savings? Yeah, we're in a very different environment. So our payer contracting negotiations are thankfully offloaded to our management company. Our ASC, so we do get updates, but I'm not involved in those discussions. We forward our quality data to our managing partner, and they use that as leverage. But we're so scattered. We have about 14 different practices, and we're not working under a unified tax ID. So the idea of going out, and we've long sought a solution to this, but the idea of being able to go out and market our ASC as a unified group has proven challenging. Not to mention, what do you do with the extra volume? How do you divvy that up? So I think we're like the last bastion of sort of private practice probably in the country, and I'm looking forward to the day that that changes and we can work more efficiently together. So we're about 10 years behind you guys. Colleen, if I may, I just want to add one final word on the value of colonoscopy. I have a proposal that I'm making to the board tomorrow about a new program we hope to release in March that will help practices put together their value of colonoscopy campaign locally and hope them achieve some success in promoting the value of colonoscopy and learn more about referral patterns for FIT, for multi-target stool DNA testing. We're pretty excited about it. So hopefully we'll have approval, and there'll be more to it. That's fabulous. I personally look forward to it very much. Joe, back on that topic, have you ever been caught in an awkward situation where, or how can we avoid the awkward situation that it might be viewed as self-serving? How do you introduce the topic being Joe Vacarian? Is it appropriate for practice managers to work this information with staff? So obviously it can come off as self-serving because we're the ones doing the colonoscopy at least with, you know, we've had success by presenting the data to our referring physicians. You can't win all of them over. There's a couple of physicians who just for various reasons think that gastroenterologists do this, do that, and then we're all driven by economics and the economics of endoscopy. Those are the people I don't think we can worry about, but we've had really good success with our referring physicians who wanted to learn about the data. Use the test correctly, and we in no way make negative comments about other screening methods. We just want them to understand that there are other colonoscopy and other screening methods, and you've heard this phrase before. In the end, we leave them the best screening test is the one that gets done. We think it should be colonoscopy, but if it turns out it's a fit test, they should understand the implications of it, or if it's multi-target stool DNA. Or if it's multi-target stool DNA. I think one of the problems we see with those tests is converting that positive test to completion of colonoscopy, and that has negative implications. And so that's really the discussions we have, and if they don't want to do colonoscopy, they can choose another test. We're okay with that. You're just reviewing the literature and the data. Have you ever charged your practice administrator with having a similar conversation with staff members? Uh, no. All the conversations we've had both in our office and outside have all been done by one or two physicians. One of our partners is really passionate about this. He's been our champion. He's very energetic. He's done really great work. And so it's physician-driven and provider-driven. There's practitioners that have also been involved. Having said that, I think it would be very beneficial for the practice managers and endoscopy site managers to become familiar with the package and the program that the Society's put together, because it really is terrific. Dave, I want to ask you a broader question that bubbled up from the audience that had to do around sustaining efficiencies around staffing. So can you talk about some ways where you've created and sustained efficiencies around staffing? It may be some that were pre-pandemic. Certainly, we learned some during the pandemic. But what can you teach us about that? Yeah, I mean, I think working backwards from any state and local regulations, you know, which obviously vary case by case. But when I compare the resources utilized by the hospital unit versus the freestanding ASC, there's a big difference. And so, for example, at the hospital, we've got one, sometimes two nurses in the room, one technician and an anesthesiologist, myself, and often a fellow. At the ASC, we're running a much leaner machine. So just in terms of room personnel, there's no dedicated nurse in the room. We have a nurse rotator who will come in and help us, you know, for example, if we have to do a submucosal injection. So the room is simply the anesthesiologist, myself, and the technician. So we've eliminated the staff on that level. That was pre-pandemic. We found that efficiency and happiness go together. And so to keep the technician, for example, in the reprocessing room all day and then have a dedicated person in the rooms, there's some fatigue just associated with that. So we rotate within the day our own staff, so maybe half a day in reprocessing, half a day in the room. We had to go even further. As I mentioned, we have this, admittedly rare, but this difficult position problem. And so we've had technicians say, I don't want to work with Dr. X. They just come right out and say that, which I actually appreciate. And so, OK, we're going to rotate you as well. So there's a lot of movement in the center to keep people in fresh positions so no one gets too bored, too stale, or simply just too annoyed. We found that we can increase efficiency by doing some of the interviews off-site, telephone calls the day or week before, filling out the H&P pre-populated. That's a big bottleneck for us. But at the end of the day, we're still plagued by having to dive into overtime. Dive into overtime, salary, and then just finding people who want to stay late is certainly harder than ever. Although I started out with my talk saying on-time starts, I want to talk about life beyond the on-time start. That's kind of where it all starts, where it all begins. And if I had to pick one unifying indicator, that's probably what it would still be, is the closer we can get to every room starting on time, working backwards from there, everything else seems to flow. Thank you for that. For both of you, have you found any particular areas lend themselves better to outsourcing or work from home? Those were specific questions from the group. Yeah, so I can just start briefly. So certainly the nursing pre-calls, there's no reason for that to happen. I don't know why it took a pandemic for us to realize that, but certainly the pre- and the post-calls can be done off-site. There was no reason that we'd have our billers on-site. On the other hand, we had previously sort of allowed nurse leadership to come in a little bit later, and then we realized that that's not a good plan either. So not only did nurse leadership need to be at the center when the center opened, but they also needed to keep not only the door open, but have the nurse, typically nurse leadership, be rotating throughout the center. The idea that staying in the office and getting work done would be more efficient, actually, that their very presence helping with everything from structure management to recovery bay to being in the rooms was very valuable. So I think we learned a few lessons there, but we still haven't caught up with the staffing problem, which I'm wondering how much of a problem that is for anybody else. I think it's universal, honestly. That graph fell, I think, across the entire United States. So I think that that challenge is going to continue to confront us, and one of the silver linings is we will realize more staffing efficiencies, when I think we thought we were squeezing that lemon about as hard as it could be squeezed. Joe, would you go over your staffing, your typical staffing in the room, maybe pre and post-op? Yeah, so we've always been quite efficient, and I think it's been because we've kind of found the sweet spot for staffing for us. We are probably 90% to 93% traditional sedation, so in the room, it's a physician, in the endoscopy room, it's a physician and a nurse, an RN, because she's administering or he would be administering the sedation. And then we have kind of a free agent, so to speak. We have a tech or two that's available to float around to help with other things that are needed, perhaps a difficult polypectomy, a change in patient position. dilation, so we've just been efficient with that two-person in the room in a traditional sedation. I'm trying to remember the ratio. I think it's somewhere around three, three and a half, maybe, yeah, about three and a half FTEs per room, if I believe, to make a room run from kind of front to back, if I remember correctly. So we kind of run lean, but we've made it run efficiently with our model. The bigger challenge is just staffing, as you alluded to, and that's, I think, going to be a real struggle moving forward. So just in follow-up, this is a good segue to that. One of the questions that came up, and I think it might be a little easier for us in the office, given OSHA pulled back last night, but it's still an issue if you take care of Medicaid or Medicare patients. What are you doing to help manage employees through the vaccine mandates? Yeah, this is... Go ahead. Yeah, this, I think it's a real challenge for us, and it has us concerned. We already need staff, and we cannot hire anybody. We've been looking for schedulers, coders, and billers, and I think over the last month for both of those areas where we need multiple people, we've had one person apply and then that person didn't even show up for the interview. We have 120 full-time equivalents. 85% are vaccinated. So we have about, if I remember, I think 21 that aren't vaccinated. Our ASC and clinic, our physician office clinic, is connected. So our problem is that there's lots of commingling of the staff, and the staff in the clinic portion does provide services for the ASC. So we're hoping, they have previously met under state mandate religious exemption, and they'd wanted to with medical exemption. That's really our only hope. Otherwise, if we lose some of these people, we could have a devastating blow to scheduling and billing, and that could make us have to tone back to as low as 75% of operations. If we lost those people, we'd have a significant operational problem. So it's really going to come down to the one or two that we know will meet a medical exemption, and we're hoping the others. Then the religious exemption is fairly vague in a way. It's a deeply held religious, sincerely held religious belief, practice, or observance. I don't know how to define that. I don't know that even clericals can define that. So we're hoping some of the vagueness in that will help us. We think it can, but I think all bets are off. We're not sure what's going to happen come early January. Dave, your experience is a little different, is it not? Oh, my gosh. I mean, thankfully, New York State mandated 100% vaccination for any healthcare worker, and that extended all the way down to the level of the ASC. The religious mandates were harder to navigate. So we're actually at 100%, I'm happy to say. But that was a problem for us, and then I had a physician holdout that complicated matters and was relying on a prior infection as rationale for not needing to get vaccinated. So when you have someone in a leadership position who's unvaccinated, it really took the state to come in and help us with that. I see this, I don't think the problem's over, though, because obviously we're going to have to, we're going to be in a position of hiring again. And I don't have a clear path forward. As I mentioned briefly in my slide, there is this suspicion. There was a broadcast email in my group from one of the physicians saying, we should not be allowing employees or patients who are not vaccinated to walk in the door. And that was a reply all situation. The only thing that saved us on that was the fact that no one reads their emails. But yeah, this is going to be, I don't see a path forward unless you have a state mandate. But, and unless you can offload the unvaccinated to these work from home positions. Yeah, unfortunately, in the South, mandates are less likely to move forward as a solution. We started in our practice educating back when the phase one clinical trials were going on. So we tried to get out in front of it. We had weekly educational phone calls, literally weekly with all of our providers. So our group watched the phase one, phase two, phase three studies as they enrolled and have kept track with the subgroup or the subpopulation clinical trials. We've had a live Q&A, HR at every site. We give vaccines, so access has not been a problem. But I think we've probably taken that almost as far as we can. I make myself personally available as does the rest of our team for private conversations, if people have concerns that they want to discuss. And I would recommend all of that to anyone who's still struggling with it. I think that's just the very basics. But it does have to be a relationship where they really trust you. And we're a long way down that path at this point. I wanted to end maybe as our time is growing close with kind of incorporating some things that Kostas said with some things that Amrita said. How have your practices been front facing to diversity, equity, and inclusion? I live in a community that's 36% African-American. And I view my African-American teammates as essential to helping make a connection with our patient population. Unfortunately, there are not as many physician partners in my group that reflect that diversity. So how have you tackled that, whether it be that group, women or Latinx or others? So I can start. We've had minorities in leadership positions since the beginning. I think that's just representative of the workforce around us. So we've had nurse leadership roles. There are two physicians in our group. Again, we're not a unified practice. So again, we're an amalgam of different practices. But there's two minority physicians in our group and one of which has volunteered to be on our board, fortunately, with excitement over the last five years. So that has not been a problem. I think our struggle, however, is promoting invariably. We're somewhat limited as an ASC. We're not a hospital. So there's not a lot of room for growth. Either you're rank and file or you have your nurse leader or lead tech. But that's about it. There's no other place for us to go. Our management company has stepped in, however. And there are opportunities within the management company. But that leaves us with need to fill that spot. And we're happy to do that if that's what the employee wants. So I think it's an ongoing struggle for us. But not something that I think is a burning issue in Manhattan. But I'm curious how you're tackling that, Joe. So our experience in Rockford is actually probably not too far off from a combination of both yours and Colleen's. I think the African-American population in Rockford is about 20%. We have a large Hispanic population. So as far as our employees, it's been easy for us to maintain a diverse workforce because it represents the population at large. And leadership, it's been interesting. We have just, over about three years ago, hired our first male administrator. Probably in 35, 40 years, it had been two female administrators back to back who were fantastic and were at our practice for a long time. And our clinical, our nurse clinical administrator. And I think all of our major departments except IT are females. And so we've been pretty good on the diversity front just by the circumstances of our population and the workforce that we have as far as nursing and nurse leadership. Obviously, we could always do better. We have a fairly diverse physician population. But we're looking to the ASG for some of the new DEI initiatives that they have that they're working on and producing. I think ours is kind of a blend of both of yours. Thank you both. I want to, again, thank Dr. Bruce Hennessey and Latha Allaparthi, my co-directors, as we move into the next session. The speakers from the previous session, that was just superb. And I look forward to hearing more from you at the fireside chat.

leadership

collaboration

staffing

efficiency

diversity

representation