Davis, Davis, & Harbin: Conquering the Risks and Savoring the Rewards of Anesthesia Business Ownership

Starting up an anesthesia business can be equal parts daunting and rewarding. Just ask Ashley Davis, DNAP, NP, CRNA, her husband Nate Davis, DNAP, CRNA, and Steve Harbin, MSN, CRNA, partners in the rapidly growing anesthesia practice Advanced Anesthesia Solutions, Inc. (AAS) headquartered in Kingsport, Tennessee.

With AAS now in its 12th year, the three partners—and close friends—marvel at how far they’ve taken the company in a relatively short span of time. What’s their secret? When you talk with them, it becomes clear they don’t have a secret formula. Instead, their success has been the product of good, old-fashioned business acumen, a roll-up-their-sleeves work ethic, a willingness to embrace risk as opportunity, and a little luck.

Find People to Work with Who Share Your Entrepreneurial Vision

The partners met as SRNAs at the University of Tennessee (UT) Knoxville, where Steve was a year ahead of Ashley and Nate. They bonded quickly. “Steve expressed interest in entrepreneurship and a willingness to take risks,” says Ashley. “We had similar training, shared experiences, and a great friendship.”

Steve graduated in 2006 and went to work for an anesthesia group in Kingsport; Nate and Ashley graduated in 2007. “The anesthesia group asked if I would help recruit more providers to the hospital we were contracted with,” Steve recalls. “We recruited Nate and Ashley as soon as they graduated.”

The three worked together for the same group until 2012. “When the idea of starting our own anesthesia group came up, it was just a natural thing between the three of us,” says Nate. He adds with a chuckle, “We all had similar ideas about how it was possible, and we all had the ability or stupidity to take this huge risk!”

From the get-go, the partners have thrived on sharing each other’s success, helping each other out, communicating with one another, and blending their unique attributes and skill sets. “We always worked great together,” says Steve. “In fact, I would say hard work brought us together and hard work makes it easy for us to stay together.”

Identify a Need in the Marketplace and Fill It

While working at the hospital, Ashley, Nate and Steve recognized a need for more outpatient anesthesia provider options in the Kingsport area. “We had built great relationships with surgeons during our time at the hospital,” Nate recalls. “We started talking to GI docs and surgeons about how we could provide anesthesia services in their offices or outpatient centers and make life easier for them. Eventually a GI group approached us about potentially providing anesthesia for their outpatient facilities.”

The ability to identify this outpatient anesthesia need in the Kingsport market provided the opportunity they’d been looking for to venture into entrepreneurship. “It was a calculated risk leaving comfortable jobs to go out on our own, but it was worth it,” Ashley says.

“It felt good being able to fill that gap,” Steve remembers. Twelve years later AAS works with its partners to ensure a holistic and unique approach to anesthesia needs, staffing in both the collaborative and CRNA-only models.

Be Ready to “Jump” when the Right Opportunity Comes Along

When Gastroenterology Associates approached the three entrepreneurs about the possibility of providing anesthesia for their outpatient facilities, they were ready to act. “We jumped off the cliff,” says Nate. “We created AAS using LegalZoom, convinced some CRNAs to work with us, took out a line of credit to pay salaries…and much to the shock of many, left the hospital and started our group.”

The company started small, contracting with one ambulatory surgery center (ASC). Over the next few years they added other small contracts with dental and plastic surgery practices. “We had some successes and some failures, but we were doing well,” says Nate. “And then in 2017-18 we were approached by a large medical group that had plans to open three different ASCs in the area. They offered us the chance to bid on the contract. We did, and we got it.”

Nate explained that at the time AAS didn’t have the infrastructure in place to execute the huge new contract, so they immediately got to work ramping up their business. “We hired people, took out more loans, figured it all out.” The ASCs opened during 2019-20.

As AAS’s reputation grew, so grew the business. Shortly after the three ASCs opened, the partners were approached to bid on another huge surgery center contract. As Nate puts it, “We won that, hired people, opened the center, and here we are.”

AAS in 2024

Currently, AAS provides anesthesia services for the Tri Cities area (Kingsport, Johnson City, and Bristol, plus surrounding counties), with an estimated population of 514,899. The company’s team photo includes three partners/full-time staff, 13 full-time CRNAs, nine PRN CRNAs, three full-time anesthesiologists, and six PRN anesthesiologists. Each valued member of the AAS “team,” if you will, has a deep respect for what the rest of the team brings to the table, including the anesthesiologists who have been vital to the company’s success.

“I imagine there are medical doctors who are not interested in working for a CRNA group,” says Ashley. “But many of the doctors who work for us say we are the best employers they have ever had.”

According to Nate, any anesthesiologist who is open to working for a CRNA-run business “will easily see the group we have built and the contracts we have won over time through our performance and reputation. They will realize that we are skilled businesspeople who know how to successfully manage people as well as large contracts. The anesthesiologists we have hired appreciate the opportunity to work with employers who have their backs and support them. If it’s a problem for an anesthesiologist that we are nurses, we get that out of the way first thing during their interview and just tell them we aren’t a good fit for them.”

Steve points out that the anesthesiologists who work for AAS often recruit for the company or recommend their anesthesiologist colleagues to do locums work for AAS. “We take these endorsements as a source of pride,” he says. “And we are pleased that working alongside us hasn’t led to any issues for our physician employees with their anesthesiologist peers.”

Looking Ahead

Achieving success has been one thing, sustaining it is another. So far so good, but all three partners fully understand what it takes to keep moving AAS in a forward direction. After all, it doesn’t just happen.

“One of the sources of our success is the quality of people we employ,” says Ashley. “Our providers are not only the best in the field of anesthesia, they are phenomenal people.” Nate concurs with his wife’s assessment, adding that “I think people should understand how challenging it is to hire and retain great people, compete with hospitals and large corporate anesthesia groups, compete for contracts, and hold it all together. The daily challenges are immense, but advocating for our group and our staff is a passion we take seriously.”

Steve offers a somber reminder that just when their business was taking a major leap forward in 2019-20, the Covid-19 pandemic rocked everyone’s world. “We weathered the storm of COVID with zero layoffs or furloughs,” he says. “We are extremely proud of that accomplishment. Our standing in the anesthesia community has allowed us to grow, as witnessed by our joining Watauga Orthopedics when they opened their brand-new surgery center in July 2023. We feel blessed, but hard work always rewards.”

All three will tell you the future is bright for AAS. Moving forward, the company’s game plan is to continue growing to meet the changing outpatient anesthesia needs of Kingsport and the surrounding area. “I believe surgical cases will move more and more to outpatient settings which will open up many new opportunities for our company,” Steve says. “Growth seems inevitable within the next 3-5 years.”

Advice for Business and Life

Each partner has their own take on whether they prefer the clinical or business side of their careers. “For me it’s the clinical side, but mainly because it makes the business side easier,” Steve opines. “When we are on-site doing the work of anesthesia, it is easier to assess the needs from the administration side of anesthesia. We work directly with the surgeons and facility staff, so we can assess and address issues before they need to escalate to a quarterly meeting, and I believe that sets us apart.”

The Davis’s both enjoy the clinical and business sides of their AAS experience equally. “I love the science of anesthesia and the challenge of making a patient’s experience with anesthesia better than they expected,” Ashley explains. “Entrepreneurship has peaks and valleys. There are times when the workload and stress levels are excessive. This is usually during a period of growth followed by more success and gratification. As an administrator I have some flexibility to work around family obligations, but it also means I often work on vacations and when others are sleeping.”

All three agree that the ongoing positive feedback they receive from their partner facilities is a constant source of affirmation and motivation. “It has been exciting making our company not only successful, but stable,” says Steve. “Often people are afraid of something new, and we were, too. But we made it work.”

For CRNAs considering a jump into the unknown, i.e., what starting and running a business is really like, the partners offer sage advice from their own experiences. “The three of us have no formal business training,” says Nate. “To get into business you have to be able to relate to people, form good relationships, and build a reputation around yourself that you are smart and intense but also reasonable and easy to work with. You have to realize that you can’t make everyone do exactly what you want–you have to be flexible. Most importantly, you have to be able to take risks and put yourself out there with the potential to fail.”

Ashley emphasizes the need for a backup plan and to clearly identify the risks involved with starting a business. “Be prepared to work harder than everyone else without ever discussing it with others,” she advises. “Identify a need or a void in the market that fits your skillset. Diversify your skillset to be adaptable and marketable. Observe and learn from other high achievers. Network with others and don’t burn bridges.”

“We all make mistakes, so use mistakes as a chance to learn and grow,” adds Steve. “We made plenty of mistakes when we first started, but in the end our company has only improved from them. Your staff is the life blood of your company. Treat them how you would want to be treated. Be the first to take the hardest assignments and always listen to your staff’s feedback. The business side will come if you have a solid staff and great communication.”

And always keep family in focus. For the Davis’s, family includes their two teen-aged sons, Liam and Houston, and three shih tzus. For Steve and Andrea, who met as undergrads at East Tennessee State University, family includes daughters Caroline and Ella Kate. The kids attend the same schools and are in the same grades. Not surprisingly, the Kingsport-based Davis and Harbin families are close-knit, having grown together through the countless challenges and adventures of owning a business.

Looking back, Nate emphasizes that it’s impossible to list everything the partners have been through. “Staffing issues, personal challenges, lost contracts, gained contracts, crazy board room negotiating scenes, money on the line, holding it together through Covid and not getting rid of a single employee, just on and on,” he says, ticking off the list he keeps in his head.

“It hasn’t been easy, but we are so blessed with the best group of CRNAs and MDs in the entire USA. I firmly believe that. They are the reason we can do what we do so well.”

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