I will now focus on clinical operational metrics really as it pertains to our ambulatory surgical centers. Again, I have nothing to disclose. Our first polling question, compared to the pre-pandemic levels, your current average monthly AIC procedure volume per MD is either lower or similar, maybe it's stabilized or maybe it's surging. That's really interesting. So most practices are doing really well. That's fantastic. All right. Okay. So where are we now? So similar to what I mentioned previously, we're all comfortable. Whereas last summer into the fall, there's a lot of debate that we had about room turnover settling, our ability to perform procedures at normal capacity, but that's really changed. I mean, I think we're all really comfortable and our patients are comfortable and our staff with what we're doing and we have supplies. And as we just saw, case volume generally is doing pretty well and that's a good thing. But similar themes here, staffing shortages and burnout may be affecting us. We may have higher supply costs and we have some new supply costs, right? Labor costs, that's an issue we will talk about. Patients have expectations about safety and trust is still essential. I think that's less of an issue, but there are still some patients that really are not necessarily ready to come in and have certain expectations. We have been impacted by a vaccine mandate in our ASCs. And globally, there are some supply chain delays that may or may not be affecting you depending upon your ability to contract with the vendors. There's been a significant impact on the health of our society. There's a term recently being used called the health debt as the accumulated impact of changes in health behaviors during the pandemic that will have long-term negative impacts as we know. Just relative to delays in colorectal cancer screening, this may lead to an additional 4,000 deaths from colorectal cancer potentially over the next 10 years. And some people are talking about a health debt tsunami of chronic disease and related morbidity mortality that will result from the pandemic. You may want to consider this from a catch-up standpoint, from a prioritization standpoint. Who's more important to get in, for example, a colonoscopy? Obviously, symptomatic patients, probably next high-risk surveillance, and less so those just in for average screening or 10-year recalls. This is obviously an issue. There's ongoing uncertainty stress that's experienced at all levels, right? Staff and the physicians, the providers, and certainly our patients. And that affects our ability to operate effectively as well. So let's dive into the KPIs. And Sukhya gave a really great explanation, introduction to KPIs. These are really important. Obviously, we need to understand which key financial operational KPIs we should be following and what's changed, what are the impacts that COVID-19 has had on that. We'll start with operational efficiencies. And these are some really key considerations. One key is just really matching ASC capacity with demand. You need to measure and model your demand and meet that demand with ASC capacity. And the other important metric is we want to utilize available ASC room capacity effectively, right? And we'll talk about that. We don't want empty rooms or rooms that are not utilized well enough. According to the ASGE surveys that Sukhya alluded to, it varies how many hours an ASC may be open. Some open 637, 730. It varies. And so obviously, that affects your ability to perform a certain number of procedures per day, per room. Scheduling is critical. So you have to have effective scheduling, right? There is scheduled churn, obviously, that we need to mitigate. But you need to effectively support access, deal with cancellations, fill the rooms that are available. And obviously, we need to have a robust recertification process. Communication is really critical. We'll talk about this, actually, in my next talk. But there's a higher expectation for communication, actually, because of the pandemic. And of course, financially, this is critical. Patient responsibility is a common reason to cancel a procedure or no-show for a procedure, right? And as Sukhya alluded to, this is a shifting landscape right now, right? People shifting jobs, changes in insurance, deductibles typically go up, and they don't go down year to year. And so it's really critical that you know early on what the patient responsibility will be and communicate that to them, right? And appointment reminders are key. Appointment reminders, I think this is one great example of how COVID has forced us to use electronic means to increase efficiency in the appointment process. And I don't know how many use texting, for example. There's various ways to communicate with patients. But what do you want to know? You want to know, are they coming in is one thing, right? And most patients know five days ahead of time if they're going to cancel or not. But they may not tell you until the day before or even the day of. And that doesn't help you at all, right? And putting someone else in that slot. Other questions they might have on preps and still COVID-19 check-in protocols, right? Do they know when to arrive? You know, that's really key. And so what are we trying to do? We're trying to reduce late arrivals, to churn as much as possible, no shows and cancellations. And you should track these metrics, right? Track how you're doing on these things. Because these are opportunities for improvement. So point to point, what about check-in to check-out, right? The two first metrics are really important. Check-in to ready time and on time first case starts. So you have to set yourself up for success, right? So you have to get patients in and to pre-op effectively. And you need to start on time. You know, start on time in a particular room. You're going to delay most likely all the other cases. And that has a lot of downstream impacts. So set yourself up for success early on. You know, turnover time is talked about a lot. But probably a more important metric is room readiness. So is the room ready for the surgeon or the endoscopist when the endoscopist is ready, right? A faster room turnaround doesn't necessarily help you if the surgeon's not ready, when the endoscopist is not ready. But you need that room ready, the endoscopist to come in and, you know, start the procedure. And then post-op time discharge. This may affect your availability of post-op beds. And if you don't have a bed, you can't take a patient out of a room, for example, right? Look for bottlenecks. So you should track these. If you have a bottleneck, you want to improve it. You may get input from physicians from a survey where they perceive the bottlenecks are. And that could be helpful as well. And as we all know, there may be, we all are variable in our personalities and how we practice. We may have certain positions that don't start on time. Take too much time in between cases. You do what you can to modify that. When so much of a personality is malleable, but you need to do the best you can. And so I think these are really important operational efficiencies to consider, right? And probably the most important is either episodes or procedures per room per day. You know, rule number one is you can't outperform your schedule, okay? Episodes per room per day may be better than procedures because that really is a good metric for your organization's scheduling process. Procedures per room per day may be diluted in variability when you're doing double procedures. But you can look at both procedures or episodes, but just really patient encounters per room per day. And one good rule of thumb is you want the episodes per room per day to be at least 12 per room, right? The goal is full, not necessarily available rooms. We track monthly average episodes and procedures per physician. Obviously, it may vary month to month and quarter to quarter for various reasons if you just look at procedures, for example. And we've been following Third Next Available Appointment, which is TNAA. It stands for Third Next Available Appointment for some years now. And if you're not doing this, I would consider doing that. It helps both on the practice side and the ASC side. It's the best reflection of true appointment availability for patients. So we look at offices individually, ASCs individually, and providers individually. And so the sweet spot is debatable. It may be between 7 and 14. But if Third Next Available is really high, then you had demand and you're not meeting that. You're not providing enough access. You need more availability, whether it's on the office or the ASC side. If it's low, then you need to be careful that you might increase your capacity too much or schedule too much, for example, in the ASC. You can also consider FTEs per room. We don't do this. If you do so, you can consider weighting it. This is not a metric that we look at. But again, it's one way to look at how are you utilizing your staff in a given room per day. What are some of the pandemic impacts potentially on efficiencies? Obviously, insurance coverage is an issue. We've already talked about that. There might be gaps for Medicaid patients in their shifting insurance, potentially depending upon shifting employment. That can cause, obviously, cancellations or no-shows. Safety concerns, probably not as much now, I think, as it was in the past. But we've had a few patients that are not willing to come in yet, or they're not willing to come in if everyone taking care of them are not fully vaccinated. I mean, these things do happen. Screening and throughput can be affected. And the check-in is still not the same. I mean, it takes longer. We're still symptom screening. We're spacing. You have to account for that, right? And we've had some patients come in with certain types of exposures or certain types of symptoms, and we've had to turn them away. And it's difficult when we do that, but it happens, right? We are still limiting drivers. So the drivers are, it's a drop-off pickup. They're not coming into the center. I think a lot of drivers actually like that because they're doing other things. But that also creates challenges because you may not be able to hold of them after the procedure. They might be getting a latte or on a conference call with work or who knows what. So the pickup can be a little bit delayed, potentially. And staffing shortages, which we've talked about. I mean, just staffing rooms and running rooms potentially can be a challenge. I'm not sure that disinfection affects us too much now. I think we're all pretty comfortable with the turnover of the rooms. Not so much as last year we were, but I think we are in good shape right now. Worst case scenario, obviously, is you have to close rooms for whatever reason. So if you can't staff it and you close rooms and you can't meet the demand, that's really worst case scenario. Unfortunately, we haven't had to close any rooms, though we have had some challenges with staffing in all our centers, right? And you want each room to be as productive as possible. Next slide. Another polling question. Are you fully staffed in your ASC or your ASCs right now? Well, that's really interesting. Most ASCs are not fully staffed, and that is our current experience. But it's great that 40% are. That's fantastic. You have a plan in place to comply with vaccine mandates. This may or may not be affecting you, and we're not sure what's going to happen, of course, right now with the federal mandate. Oh, that's fantastic. All right, everyone. That's really good, because that is key. That's great. OK. Let's dive into the financial KPIs, and these are certainly not exclusive, but these are some key metrics to consider acting on. I think it's really important. You can look at it monthly, and many of us do. It's really important to certainly look at the financial KPIs quarterly. You know, quarterly assessment helps, because fiscal quarters are roughly the same number of available working days. And medicine is a seasonal business, right? So right now, we're in a quarter where we generally have a push for more procedures, and we tend to drop a little bit in the first quarter of the year. And then the second and third quarter might be affected by more vacations, right? So it's good to look at quarterly, and certainly monthly, and then obviously annually. And what are some key metrics? You know, basically, per episode or per procedure, per episode or per procedure, net revenue. What's your clinical labor expense? What's your salary expense, right? Supply expense, rather. Look at your total expenses. Device expense might be something you might want to consider. There is some variability here, and one example is endoclips. Endoclips, that's really a lost cost. It's a sunk cost, and it's variable use, and we have looked at this. It's helpful to look for unexplained variability. It's helpful to educate the physicians. By the way, do you know how much these cost? And you happen to be someone that's doing way more than others. Maybe you don't need to, for whatever reasons, right? It's just one example. There may be some variability. It's really important to follow Medicaid percent right now, and average payer mix, as was mentioned earlier. That's shifting. That's definitely something you should follow closely in what your overall expense breakdown. So Suvyan is giving an entire talk on revenue cycle management, and so I'll just kind of set the stage for that. Best practice is really to create payer-specific profiles for each of these metrics, and that can actually help you in negotiating as well, when you're negotiating payer contracts. It's always easier to collect money at the time of service than later. You need to coach your staff on that. Track that, right? Point-of-service collections. And as we all know, days in AR, or AR is over 60 days, and so how efficiently are we collecting payments? Net revenue and collections per procedure. Clean claim rate, denial rate. Bad debt is something to keep an eye on, because that may be increasing for you. Right now, potentially, there may be delays in patient payments for various reasons, so that's something to follow. This is something I think that's really... Oh, I'm sorry. So what's the impact of the pandemic, right? Potentially on financial performance. Well, overall productivity may be affected in multiple ways. Supply costs, generally speaking, are up. We have PPE expenses we didn't have pre-pandemic, or we might have other increases in supply costs. We have had to rent out extra space for our two older. We have three ASCs. We've had to rent out extra space for two of our older ASCs, because let's face it, they weren't designed for COVID, and our break rooms were too small. And it turns out that we also really didn't have enough locker space and things like that, so we've had to rent out some more space. And that obviously has increased our overhead. And then just the insurance issue that we've already, I think, alluded to. You know, labor costs. I think this is a big one, right? And we have had to increase salaries. There are bonuses in place. Nurses are really difficult to hire. And we have had some nurses burn out on the inpatient setting that have come to the outpatient ASC setting. It's more attractive to them. But as you all know, it's really difficult to hire. I saw a study yesterday that predicts that approximately 500,000 nurses will be leaving the workforce by the end of this year, which is really incredible. If some staff may be working extra hours, that's overtime. Pandemic pay has impacted us in various ways. Advances. And again, there's so many reasons people may not be able to come into work, not necessarily them having COVID symptoms, but for other reasons, right? A child at home from school or exposed or et cetera. Travelers are expensive. And so if you need to staff with travelers, it's going to increase your overhead, right? And turnover is always expensive. And Kim really addressed this well. So everybody set this up fantastically. You may want to consider looking at your staffing mix. And as she noted, you want all your staff working at the top of their license. You don't want a nurse doing what a tech is doing. So this may be a way to be creative in mitigating overall staffing costs. So a couple of questions to ask ourselves. One is when and how can we rebound to pre-COVID expense levels? That's probably not realistic. And if not, what kind of improvement can we make, right? What kind of recovery can we achieve? And we can't afford to be complacent with a new cost profile. These are some key practice capabilities that you need. It has nothing to do with COVID or the pandemic. And as Sufjan mentioned, not everybody has it. It's good to have a dashboard. You know, financial statements can be pretty complex and may be difficult, you know, for position leaders to digest. They're important to review and they're important to focus on the important things, but it helps to have a dashboard of KPIs. You need administrative expertise. You may or may not have a JV partner. So you may have the AC on your own. You may have a JV partner with different resources. Whatever you do, as Sufjan mentioned, you need to follow. And if you're falling out somewhere on any particular KPI, you need to act on it. Implement change, close the loop, track success, but be proactive. So just a couple of thoughts relative to really many themes today. You know, we need to learn from the past, okay? So we've been through crisis management. Don't just look at what didn't work well, but focus on what did work well potentially, right? And so look for the positives. What new capabilities are we going to develop, right? What have we learned about implementing change that will help us in the future? What do we think is going to persist versus not persist? But how can we also be more competitive in hiring and retention, which we've discussed? And what new opportunities might we have? How would you design a new ASG now, right? We would certainly have other things into consideration. So COVID pandemic, I think, would impact that about how you would design from a spacing and throughput perspective. This is a shout out, and Sufjan did mention this briefly, but please participate in the ASG endoscopic operations survey. Now more than ever, it's important to understand what the current state of metrics are. Of course, you get a copy of the results. You can use that for benchmarking, but also your data changes the benchmarking results. So some practice pearls. As we know, the pandemic has altered ASC operations in some, but not all these changes will persist, but take lessons learned, go forward. Define what recovery means for you. Improve as best you can and recover as well as you can. The basics still apply, and I agree with Sufjan. I mean, these KPIs are important for you to follow. There are some modifications and changes relative to the pandemic, but you still need to follow them and you need to act on them. Staffing challenges I don't think are predicted to abate anytime soon, and consider ways that you can be more competitive and enhance your operational success and sustainability. Thank you.

clinical operational metrics

ambulatory surgical centers

COVID-19 pandemic

staffing shortages

financial key performance indicators

delayed screenings