Becker's ASC Review

13 ORTHOPEDICS The new outpatient spine advantage: Dr. Kern Singh By Sophie Eydis K ern Singh, MD, professor and chief of spine surgery at Chicago-based Rush University Medical Center, has been performing outpatient spine procedures for almost two decades, long enough to see the shi from edge-case to expectation. Now, with more spine procedures moving into ASCs and hospital outpatient departments, he believes the transition is forcing programs to rethink not only where care happens, but how it is engineered. In his view, outpatient spine surgery is less a technological race than an operational one, shaped by reproducibility, patient selection and cost discipline. e barriers to outpatient spine As spine care moves outpatient, Dr. Singh said many programs run into the same foundational obstacles: the need for predictable anesthesia support, and the surgeon's willingness to change technique to enable same-day discharge. "No. 1, is anesthesia, getting predictable anesthesia that can transition to outpatient surgery," he said. "And then No. 2 is introspection of the surgeon. Are they going to change how they do the surgery?" Outpatient success, he said, is oen determined by details that compound aer surgery, from pain control to bleeding and so-tissue management. What might be manageable in a hospital setting can become a discharge barrier if systems and techniques are not aligned around predictability. "It's a compounding thing," Dr. Singh said, "where pain, bleeding, all that can prevent a patient from being safely discharged." 'Operational discipline' is building a reproducible day Dr. Singh uses the term "operational discipline" to describe a system built for repeatability, one where anesthesia, sterile processing, nursing workflow, recovery and discharge are treated as a coordinated production line rather than disconnected steps. To explain what that looks like, he pointed to an example from his schedule: a high-volume endoscopic day of 10 cases, all executed within a compressed timeframe. at kind of throughput is not just about operative speed. It requires staffing models, instrument strategy and perioperative flow designed to support continuous turnover without bottlenecks. Rather than relying on traditional metrics like "wheels in, wheels out," Dr. Singh said he evaluates performance across the full outpatient episode, from the moment a patient arrives through discharge. at approach, he said, reflects the real operational question outpatient spine surgery presents: whether a program can deliver safe care at scale without overwhelming the system that supports it. Standardization is a culture shi spine can't avoid Standardization remains a loaded concept in spine surgery, where many surgeons maintain highly individualized preferences for instruments, setup and workflow. "I think when surgeons say they don't believe in standardization, that's ego taking over," he said. In his view, most routine spine procedures are already positioned to run as repeatable events with consistent steps and consistent setups, the same way joint replacement has long been structured. "I believe 80% of spine surgery can be standardized," he said. Standardization, he added, is not about limiting surgeon judgment. It is about reducing variation that creates inefficiency, slows turnover and increases the risk of error when teams and staffing shi day to day. When instrument trays, back tables and workflow remain consistent, he said, performance becomes less dependent on who is scrubbing or assisting. Outcomes data isn't optional — and it can change payer behavior Dr. Singh said outcomes are most valuable when they're treated as infrastructure, built into the day-to-day workflow to guide patient selection, preoperative planning and long-term improvement. "Outcomes are invaluable," he said. He said his practice has recorded patient-reported outcome measures for more than 20 years, using them to identify issues that can quietly undermine recovery, including untreated anxiety and depression. "ose patients that may be suffering from greater levels of anxiety and depression, we may have them get treatment beforehand," he said. e data can also influence payer behavior more directly than many surgeons assume. "Major payers track your outcomes," Dr. Singh said. "ey look at the cost per surgeon for every ICD 10 diagnosis. So if you're very expensive, you may get flagged for more pre-authorizations … so I typically don't have many pre-authorization requests for my surgeries." Technology must earn its place in outpatient spine As spine technology accelerates, from robotics to advanced imaging and new digital tools, Dr. Singh said his filter is straightforward: if it does not improve safety, speed and cost, it does not belong in an outpatient model. "Technology has to enable me to perform the surgery faster, safer and cost effective," he said. at calculus, he said, is one reason he does not routinely use robotics. "People ask me all the time if I use a robot," he said. "e answer is, no, it slows me down and it costs a lot of money." He added that expensive tools may make sense for complex cases that require hospital resources, but for the bulk of outpatient work, cost- heavy technology must justify itself with measurable operational or clinical benefit. AI's near-term promise is patient selection While he remains skeptical of expensive technologies that slow workflow, Dr. Singh said AI is already proving useful in a more targeted way — helping clinicians identify which patients are appropriate candidates for outpatient spine procedures. "We're using AI right now to predict or to identify patients that would be good for outpatient lumbar fusions," he said. In his view, AI's most immediate opportunity is not replacing clinical

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