By Don Sadler
The first outpatient surgery performed in an ambulatory surgery center (ASC) occurred in 1970 when Wallace Reed, MD, and John Ford, MD, opened Surgicenter in Phoenix. Five procedures were performed on the first day the facility opened, with four of them requiring general anesthesia.
Today, tens of millions of outpatient surgeries are performed in ASCs across the country. Up to half of all surgeries in the U.S. are now performed in ASCs on an outpatient basis, and ASC volume is projected to grow by 24% over the next decade.
“Ambulatory care has changed dramatically over the past decade,” says Tess Poland, RN, BSN, MSN, senior vice president and chief clinical officer for the Accreditation Association for Ambulatory Health Care (AAAHC). “The focus is no longer limited to moving procedures out of hospitals. Instead, it’s about making sure ASCs have the clinical expertise, technology and quality systems to safely care for more complex patients.”
Multifaceted Advantages of Outpatient Surgery
Paula Johnson, RN, BSN, administrator, DISC Surgery Center at Newport Beach, lists a number of advantages of having outpatient surgery. “For starters, ASCs provide a more intimate, focused environment where patients can receive highly personalized care,” she says. “ASCs can also maintain tightly controlled processes for infection prevention and environmental safety.”
According to Colleen Becker, senior director of perioperative education at the Association of periOperative Registered Nurses (AORN), ASCs offer patients more convenient scheduling, easy access, shorter wait times and easier navigation. “The benefit to the patient can be less stress and anxiety along with lower costs compared to hospitals,” she says.
“Meanwhile, surgeons appreciate the ability to specialize on outpatient procedures, which leads to greater efficiencies and the ability to conduct more procedures in a day,” says Becker. “And staff enjoy working in ASCs because they can focus on a specialized and streamlined environment.”
“In the ASC setting, physicians can schedule procedures more conveniently for patients, assemble teams of specially trained staff and ensure that equipment and supplies are best suited to their techniques,” says Kara Newbury, chief advocacy officer for the Ambulatory Surgery Center Association (ASCA). “ASCs reduce frustrating wait-times for patients while enabling maximum specialization and patient-doctor interaction.”
DISC Surgery Center at Newport Beach tracks both internal and external benchmarks, says Johnson.
“We know that patient education and early ambulation are some of the key components of a successful recovery. Our focus is on getting patients ambulating as soon as it’s safe to do so, educating them and safely preparing them to recover at home,” says Johnson.
Improved ASC efficiency comes from having a focused environment, specialized teams, standardized processes and a strong emphasis on preparing patients before they arrive.
“By the time they check in, our patients understand the procedure, postoperative plan, mobility expectations, pain-management strategy and follow-up care,” says Johnson. “This preparation allows the perioperative team to focus on providing care rather than answering basic questions that could have been handled beforehand.”
At DISC Surgery Center at Newport Beach, patients are discharged approximately 150 minutes after admission to the postanesthesia care unit (PACU).
“This is possible because the entire process – from preoperative education through surgery, recovery, discharge and follow-up – is designed around the outpatient model,” says Johnson.
Newbury says ASCs are more efficient because they specialize. “The majority of CMS-certified ASCs are single-specialty and even those that are multispecialty focus on a few service lines,” she says. “Operating rooms are set up with efficiency in mind and staff are specifically trained on the case being performed in that center.”
Poland says the design of ASCs around scheduled procedural care enables them to deliver more efficient care for appropriately selected patients and procedures. “Focused services, specialized teams and standardized workflows can reduce delays and create a more predictable patient experience,” she says. “The real value is delivering safe, high-quality care to the right patient in the right setting.”
Expanding Range of Surgeries
The range of procedures deemed appropriate for outpatient settings is continuing to expand. “Surgeries once performed routinely in hospitals are increasingly performed safely in ASCs,” says Johnson. “This includes some complex orthopedic and spine procedures.”
Becker lists a number of procedures that are now commonly performed on an outpatient basis:
- General surgery – Includes cholecystectomy, appendectomy, hernia repairs and some cosmetic procedures
- Ophthalmology – Includes cataract, LASIK and other minor eye surgeries
- Gastroenterology – Includes colonoscopy and endoscopy
- Orthopedics – Includes partial or total hip, knee and shoulder replacements and rotator cuff repairs
- Cardiac interventional procedures – Includes angioplasty and angiography
Patient selection is critical to successful outpatient surgery outcomes. “Younger and healthier patients tend to be the best candidates for outpatient surgery,” says Becker. “Therefore, ASCs require rigorous patient selection to support the care, patient monitoring and follow-up necessary to maintain safety and compliance.”
Johnson agrees, stressing the significant role that hospitals still play, despite the benefits of ASCs. “Patients with significant or unmanaged comorbidities, higher medical complexity or a need for inpatient monitoring or resources may be better served in a hospital environment,” she says. “The key is selecting the right patient and procedure for the right setting.”
Total Joints Are Migrating to ASCs
One recent trend in the outpatient boom is a growing number of total joint replacement surgeries that are migrating to ASCs. Until recently, the vast majority of these surgeries were performed in hospitals, requiring hospital stays of up to a week or longer.
Today, 65% to 70% of primary total knee arthroplasties are performed in an outpatient setting, compared with just 15% five years ago. In addition, more than half (55%) of total hip replacements are performed on an outpatient basis, and this is projected to exceed 70% by 2028.
“Total joint replacement procedures have been performed on private pay patients in ASCs for more than 15 years,” says Newbury. “But the shift has accelerated since Medicare recognized their appropriateness by adding total knee arthroplasty and total hip arthroplasty to the ASC Covered Procedures List in 2020 and 2021, respectively.”
In 2025, more than 30 major commercial payers expanded outpatient eligibility criteria for joint replacement procedures, especially for low-risk patients. The cost savings of this shift are substantial: ASC pricing for total joint procedures typically ranges from $14,000 to $22,000, compared with $28,000 to $38,000 for hospital-based total joint procedures.
Johnson attributes the migration of total joint procedures to the outpatient setting to several factors beyond cost. “Advancements in surgical techniques, anesthesia, multimodal pain management, patient selection and enhanced recovery protocols have changed what is possible in the outpatient environment,” she says.
“These advancements, including Enhanced Recovery After Surgery (ERAS), have allowed appropriately selected total joint patients to recover more quickly and return home the same day rather than automatically requiring a multi-day hospital stay,” says Johnson. “Keep in mind, however, that outpatient joint replacement may not be appropriate for every patient.”
“Success depends on an appropriate candidate, standardized protocols, strong preoperative education, effective pain control, early mobilization and a well-coordinated plan for recovery at home,” she says.
Higher-Acuity Cases in ASCs
Robert S. Bray Jr., MD, FAANS, founding director and neurological spine surgeon, DISC Sports & Spine Center, built his first DISC Surgery Center 20 years ago. The center was designed specifically for higher-acuity cases, including spine, orthopedics and total joint replacements.
“When I first proposed the idea of doing outpatient spine surgeries, everybody looked at me sideways,” says Bray. “High acuity cases like these are now common in ASCs and they’ve really accelerated over the past five years or so. Everybody’s catching on and realizing that yes, we actually can do this.”
The use of spinal anesthesia, regional nerve blocks and multimodal pain management has significantly reduced length of stay for high-acuity cases. Same-day discharge rates exceed 90% for total knee replacements and 85% for total hip replacements in carefully selected patients.
Meanwhile, complication rates for outpatient surgery in ASCs remain low: 30-day readmission rates for outpatient joints range from 1.5% to 3%, which is comparable to hospital-based procedures, while infection rates remain below 1% in most ASCs.
“It’s a tighter environment in an ASC with fewer patient contact points,” says Bray. “In a hospital, patients go from the admitting department to a pre-op area to the OR, and then from the OR to a recovery room. There are different contacts at each point. In an ASC, patients are admitted to a room, then proceed to the OR and then go back to their room before discharge.”
Bray attributes the shift to outpatient surgery for higher-acuity cases to several factors, including the rise of minimally invasive procedures. “We’ve also learned a lot of things when it comes to nursing protocols, patient mobilization and tight team management and control,” he says. “In outpatient cases, the perioperative team handles patients differently from start to finish, which results in a much better patient outcome.”
Johnson concurs: “Our nurses, surgical technologists, anesthesia providers and surgeons work together frequently and develop a high level of familiarity with one another. We specialize in a defined range of procedures and perform them regularly, so our team knows what to expect. This consistency can contribute to improved efficiency, better communication and a highly coordinated surgical experience.”
Challenges Presented by the Outpatient Boom
While the outpatient boom is good news for ASCs, it also presents a number of challenges. “The continued migration of care to outpatient settings creates tremendous opportunity, but workforce capacity is a real challenge,” says Poland.
“ASCs need clinicians with increasingly specialized skills at a time when experienced perioperative nurses, anesthesia professionals and procedural staff are in high demand,” Poland adds. “This makes retention, professional development, cross-training and a strong workplace culture increasingly important.”
Raghu Reddy, MBA, BS, CMR, chief administrative officer of MiOrtho Surgery Center and secretary of the ASCA board, believes that the outpatient boom is outrunning the resources ASCs have to support it.
“Two things stand out to me,” says Reddy. “Staffing is the biggest problem, and it’s really two issues in one: general workforce competition and a more severe anesthesia/CRNA shortage, where unreliable coverage directly caps OR case volume and turnover time.”
“The other big squeeze is money moving in opposite directions,” says Reddy. “Reimbursement is structurally capped below hospital rates and payers are tightening further, such as narrow networks and more prior authorization and audits. At the same time, costs such as supplies, implants and wages keep rising.”
Medicare payment rates through the ASC Quality Reporting (ASCQR) Program also present financial challenges for ASCs. “The ASCQR Program creates cost pressure in two ways: directly through a payment penalty and indirectly through the compliance work itself,” says Reddy.
As Reddy explains, the Centers for Medicare & Medicaid Services (CMS) ties the annual ASC payment update to whether a center reports the required quality measures. “If you miss any required measure – even leaving a blank instead of submitting a zero – CMS will cut your update by a flat 2 percentage points versus compliant centers. The full update in CY2026 is 2.6%, so non-compliant ASCs effectively get only about 0.6%.”
In addition, there’s the cost of compliance itself. This includes designating and maintaining a security official, keeping the Hospital Quality Reporting account active, hitting quarterly OAS CAHPS patient-survey deadlines and submitting annual web-based measures. “These are all recurring administrative overhead expenses that have to be staffed and tracked accurately since a single missed or blank measure erases the entire two-point cushion for the year,” says Reddy.
To adequately support the outpatient boom, ASCs need to clearly understand what they can safely support. “Clear patient selection criteria, staff competencies, coordinated care and emergency preparedness are essential,” says Poland. “As patient acuity rises, leaders need to continually reassess whether their people, equipment and infrastructure are appropriate for the care they provide.”
This assessment goes beyond the procedure itself. “ASCs need clear discharge criteria, effective communication with patients and caregivers, coordination with other providers and reliable processes for follow-up and escalation when concerns arise,” says Poland.
Technology can help.
“For example, AI-enabled tools may support risk assessment, flag patients who need further evaluation and identify patterns linked to adverse outcomes,” says Poland. “But these tools are most effective when they support, rather than replace, the clinical team.”
Becker says that AORN supports ambulatory surgery as a nursing specialty. Courses specific to ASCs are available, as well as online resources such as the Accreditation Assistant in eGuidelines+ and the soon-to-launch AAAHC Accreditation Assistant. “Also, CineMed video content includes content focusing on the care of the ambulatory surgery patient,” says Becker.
To learn more, visit aorn.org.
