How to Start an Outpatient Joint Replacement Program in a Hospital

Outpatient joint replacement centers are typically owned and operated as private health care practices. Often times, the physicians that perform surgeries at these same-day centers are also the partners who own a stake in the ambulatory center. Other times, ambulatory surgery centers are affiliated with large outpatient surgery corporations who partner with local physicians to run the operations and carry out the procedures. SurgCenter, USPI, and Amsurg are the largest outpatient corporations in the US with hundreds of locations nationwide.

However, there is another variation of the same-day surgery center that is picking up steam and becoming a viable option for many surgeons. This variation is the same-day surgery program that operates within an established hospital. Outpatient surgery centers that operate within hospital walls, can have opportune support, patient trust, and marketable brandpower. This can offer hospital-employed physicians the best of both worlds.

To discuss starting an outpatient joint replacement center within hospital framework, we spoke with orthopedic surgeon, Dr. Ravi Bashyal, M.D. Dr. Bashyal has been leading the initiative to bring an outpatient total joint replacement surgery program to NorthShore University HealthSystem, a large 4 hospital system based in the northern suburbs of Chicago.

Here's how Dr. Bashyal recommends other hospital physicians jumpstart an outpatient surgery program of their own.

Why a Same-Day Surgery Center within Your Hospital?

First and foremost, we think it's important to touch on why an outpatient center within your hospital is beneficial. If you're reading this article, chances are you're well aware of the benefits, but here's a brief refresher.

  1. It Can Benefit Patients: Patients who are weary of same-day elective surgical procedures appreciate the safety net of a traditional hospital. In addition, some patients prefer the concierge feel of outpatient surgery over a traditional hospital procedure. Dr. Bashyal explains, "Patients have a fully-functioning hospital as a safety net. This is slightly different from just a hospital or an ASC....I've learned how savvy patients are. More and more they're understanding the benefits of going home."

  2. Greater Control Over the Whole Process: Although physicians who own a stake in an ASC have the greatest control, even surgeons operating an outpatient center from a hospital have greater end-to-end control over the surgery process. Although some of the visibility into the bottom line (like staffing costs and implant costs) are blurred in a hospital setting, you will have greater insight into the business side of operations and more ability to steer a patient's full episode of care.

During the process of starting an outpatient surgery program in his hospital, Dr. Bashyal shares an observation that, "As surgeons, we don't do a good job of owning the whole process. To our own detriment we've been ignorant to business side and logistics. This process has really made me more aware of how the entire episode of care works."

  1. Better Compensation: Depending on the hospital system you look for, this may or may not be true. However, generally, outpatient surgery allows a physician to up their surgical volumes, cuts down on hospital post-acute care costs, and can boost patient reported satisfaction. Each of those things can translate into increased compensation and reimbursements for the surgeon.

  2. It's the Future of Orthopaedic Surgery: Although the predictions for how widespread outpatient surgery (like joint replacement surgery) will become, there's no doubt that same-day surgery is the future of many elective procedures. Dr. Bashyal elaborates, "Outpatient total joint replacement surgery is cutting edge. In 10 years, it is possible that a significant portion of total joint replacements will be done in the outpatient setting. Some say as many as 50-60% of joints will be done in an outpatient setting. I think this is high, but there's massive opportunity to be on the frontend of the curve."

First Steps to Start an Outpatient Program at Your Hospital

1. Make Sure You Fit the Bill.

Not every surgeon is in the position to kickstart an outpatient surgery program at their hospital. In order to spearhead a potentially revolutionary program, you'll need to be at the top of your game. This means you know the surgical procedures in and out, you're efficient at performing the procedure, you've got the numbers to back you and you may practice the latest techniques to reduce recovery times (e.g. minimally invasive).

If you're a new surgeon who doesn't yet have high annual surgery volumes, it may not be the right time to drive this initiative. When citing critical factors for successfully launching an outpatient program, Dr. Bashyal immediately enforces that a surgeon must be "comfortable with the procedure and is already doing a high-volume number of cases. This isn't typically something for new surgeons."

Here are the key characteristics Dr. Bashyal identified of surgeons who launch outpatient centers (in or out of hospitals):

  • High-volume caseload

  • Highly experienced surgeon (very comfortable with the procedure)

  • Practices cutting-edge techniques (e.g. minimally-invasive)

  • Efficiency-driven (fast at the procedure)

  • Entrepreneurial spirit (wants to shape the future of their speciality surgery)

  • Business-minded (those who want to control more than what's going on in the operating room, but  to have a say in the logistics, operations etc.)

Dr. Bashyal sums up the type of physician he'd recommend to start an outpatient center as,

"A physician who is efficient, confident and good at the procedure, who wants to control more than what's going on in the operating room--they want to control the surroundings as well. A surgeon who has an entrepreneurial spirit and wants to manage the business side too."

2. Identify Partners and Internal Champions

Building an outpatient program from the ground-up will be an uphill climb. Even if you're not met with resistance, there will be a lot of bureaucratic roadblocks to overcome. In order to be successful, you will need to partner up with other physicians and members of administration who believe in the mission.

Finding hospital admin that will champion an outpatient surgery center is absolutely critical. Aligning goals and the interest of key surgeons, executives, nurses, and staff is the only way for a program to materialize. Gauge interest, hold a meeting, and identify the key, influential players who can move this to the finish line.

3. Have Patient Selection Protocol in Place

If you've gotten the greenlight from admin and your outpatient center is moving forward, it's important to nail down a patient selection protocol. This will be a later step, that will undoubtedly evolve as you run your program.

Not every patient is comfortable with outpatient surgery and is not a candidate. With this, Dr. Bashyal stresses the importance of patient selection by saying, "making sure that you're very careful and specific with patient selection. Outpatient surgery is not for every patient. It's for patients that fit the medical and social profile."

Building a replicable and standardized playbook for how patients can be optimized for surgery, get better pre-op education, and are identified as being at the appropriate risk-level before surgery is massively important. Indicating the right patients who have at-home support and can truly benefit from a same-day procedure is at the heart of a successful outpatient program.

Why is Now the Right Time?

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In wrapping up our conversation with Dr. Bashyal, we asked him "why is now the right time to start an outpatient center at your hospital?". His reply was a convincing argument that more and more healthcare providers and executives are leaning into it.

Dr. Bashyal, explains "outpatient surgery is a revolution. It's a soft product, but it's the next advancement. I think this is what is new and exciting."

He continues, "So, why now? Now is the time to be on the front-end of the curve. It's an opportunity to get in at the groundfloor. We will be the people who can shape and mould the future--to be the movers and shakers. Outpatient surgeons are the ones who have the ability, knowledge, and experience to shape what the future of joint replacements will be."


Are you a physician interested in outpatient surgery? Are you currently performing same-day hip and knee replacement surgery? Reach out to have your center listed on our directory.

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Hi, I'm Grace. I write all things surgery for the PeerWell blog. You may remember me from such titles as: "Diabetes & Joint Replacement 101" & "Sex After a Joint Replacement".

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