30 Tips for Designing and Building an Ambulatory Surgery Center
Outpatient Healthcare Strategies.
In my 20-plus years of involvement with ASC operations, I have never seen two ASCs designed exactly alike, and none of the 150-plus I have visited or worked with was perfectly designed. Everyone has things that work well and don't work well from a design and construction perspective.
While perfection is likely an unobtainable goal, if you are planning to design and build a new ASC, there are certainly things you should consider before breaking ground on the project that will help put you — and your new facility — in a better position for success.
Based on my experiences, here are 30 tips for designers and developers of new ASCs.
1. Get the physicians' input up front. When I go to develop a facility, I interview each physician that will work there, whenever possible, and talk to them about their workflow, how they like to interact with patients, their equipment needs, etc. The more you can learn about what the physicians like and dislike, the better you can address these needs during design of the ASC.
2. Commit time to research. If you can spend significant time conducting research into your needs and options, you will put yourself in a better position to make educated decisions and provide guidance to your architect.
When interviewing architects, ask if they have learned from their mistakes by visiting any of the facilities they designed to see what worked well and what did not. More importantly, when checking references of an architect, request a floor plan from the reference to review while asking the reference questions such as, "From the way your ASC was originally designed, what did the architect do that was good and what doesn't work? What is your flow like? Have you had to do any workarounds? What is your supply storage like? Where is your equipment storage and how does it work?"
Ask the questions that speak to issues important to you, your physicians and what you want to achieve with your design. The key is identifying the most important things to you and then building for those priorities, especially if you have to build into an existing MOB and your footprint is somewhat determined for you. You need to make sure what's most important to you is done best.
3. Review multiple designs. Don't just consider one architect or look at one layout. You will want to look at multiple architects and their layouts. This is not only for cost comparison; as you view different designs for your ASC, you can identify the best of each layout and work with the architect you choose to integrate those elements into your final design.
4. Plan for a realistic case volume. I always tell physician partnerships that when they're thinking about developing a new ASC, determine where they are today with their case volume and cut that number in half. From that standpoint, build the ASC with an objective of reaching the number they think they have today. The reality is they're probably not going to be anywhere close to that volume figure from the beginning. This is an important consideration so they do not build the facility too small or too large to accommodate unrealistic volume.
5. Understand your structural opportunities and limitations. Building an ASC as a standalone facility in its own building is much easier from a design perspective, since you can essentially create the building — its shape, use of space and workflow — any way you want. This model seems to be more common in more rural and suburban settings vs. the typically more dense metropolitan setting.
In metropolitan areas, you're probably going to develop a new ASC in an existing office building and/or an MOB that may be under construction. In this scenario, you tend to run into more obstacles with your design plans, from structural beams and posts you have to work around to the pre-determined physical footprint of the building.
The optimal design opportunity is with a standalone facility because you can create the building to match the floor plan and closely mimic what you're trying to achieve. However, this option is more expensive, and the reality is that for most new ASCs, you don't need a facility large enough to justify investing in construction of a whole new building.
6. Understand your patients to plan your lobby. When considering the size of your lobby, it is helpful to know the patients who will use it. In markets with a larger percentage of minorities and individuals on the lower end of the economic scale, I have observed an increase in the number of people in the lobby. This may be attributable to a family-oriented culture and/or patients with family members who have no other place to go. In situations like these, you might have patients coming in with several family members, and will want to plan a lobby that is large enough to accommodate a greater number of visitors.
The same logic is true for ASCs planning to perform pediatrics. These young patients will often come in with a mother and father, and sometimes siblings and grandparents. Note: If you're treating children, you must take into consideration the potential for a crying child in all areas of your patient flow: in pre-op, recovery and your lobby space.
In addition to speaking with your physicians about their patients, consider visiting their offices on busy days to assess how many people join patients for an office visit. This will provide you with a better understanding of what you're likely to see in your ASC's lobby.
7. Place business office staff near patient check-in. You will want your business office close to where you check in patients. In the event that you have multiple patients checking in at one time, a member of the business team will then be in a position to step out from a cubicle to assist with check-in and help ensure there is never a long line of patients waiting for processing.
8. Position the scheduler(s) close to ORs. Scheduling, in my opinion, needs to be very close to the ORs, or at least where schedulers can easily reach the clinical manager or nurse manager if there are questions and/or problems with the schedule. This close proximity will allow staff members to more easily address concerns. Placing schedulers in the front of the building and far from ORs will require them to call back to the clinical area for assistance. It is easier for a manager to look over a scheduler's shoulders at the schedule rather than needing to log in at a separate computer station to view the schedule and assess the situation.
9. Keep medical records storage room small. I'm not a proponent of large medical records storage rooms. More facilities are going to an electronic version. You will want enough room to store no more than a year's worth of charts at a given time. It will help to learn your anticipated case volume and to assume you will need a paper chart for each case for a year. Make sure you have space large enough to accommodate just that much paper; if you make the room any larger, it's likely you will use the space to stock other items that should go elsewhere.
10. Who gets the corner office? Carefully select who receives an office and where offices are placed. I am not a proponent of many offices in an ASC. I think there is a tendency to overbuild offices, which typically results in leadership spending too much time in the office and not enough attention to where they should be. Obviously, it is necessary to provide the administrator with an office; just make sure it is not isolated and inconvenient for staff to visit. You also do not want it situated off the OR hall because the administrator will find it challenging to accomplish what is needed when faced with numerous possible distractions.
The nurse manager typically needs an office or private space where counseling can take place, and take care of required paperwork. Your nursing manager's office should not be in the administration area as that should be a fair distance from the ORs. Make sure the nursing manager's office is close enough to the ORs or clinical area to assist in monitoring the flow and be readily available to step out and assist if needed.
Does a medical director need an office? In my opinion, no. But do physicians need a workspace for everyone to use? Sure. Will that space be different from where they will dictate? It should be.
The business manager and other business office positions do not require a private office. The use of alcoves and/or cubicles with sound dampening features provides more flexibility to make changes to the layout.
11. Make sure pre-op can accommodate case volume. This is an instance where doing your homework and research up front by speaking with the initial physician investors is going to be critical. I recommend you do your best to learn exactly which procedures the physicians intend to perform, how many procedures they can perform in a day and the average length of time for these procedures. This information will help provide a framework to help determine how many pre-op stations and recovery bays your ASC should have, which requires knowledge of the types of procedures your physicians will perform.
It's not uncommon to see a four-OR/procedure room with 4-6 pre-op bays. This ratio can work, and will often meet building requirements, but is likely to present challenges for fast-paced ASCs with high volume of shorter cases. For example, if your ASC performs ophthalmology procedures, they can often schedule as many as 15-20 cases per day or more. Ophthalmology patients will often take longer to admit because they're often on more medications or have longer patient histories to review. However, the procedural flow of these patients is usually very quick, especially when you have ophthalmologists who can perform cataract procedures in 10-15 minutes. If your pre-op time is twice that long — 20 minutes, for example — and you only have 1-1.5x pre-op rooms ops per OR, you will face a situation where patients will become backlogged as pre-op team members work to get patients through their process and into the ORs.
A similar problem faces ASCs performing a large volume of gastroenterology and pain procedures. These procedures also tend to be very short in the actual length of procedure. The time between the first patient entering the OR and the next patient being fully prepared for surgery is fairly short. You will want to make sure you have enough pre-op spaces available so patients are ready to go into the procedure room or the OR, once the physician is ready for the next case. The time in between cases becomes even shorter when physicians are flipping rooms. You need to make sure you have enough pre-op spots to accommodate the anticipated physicians' flow and their preferred practice patterns.
12. Determine whether you want patient lockers. I'm not a proponent of the lockable locker for patients. There was a time when most facilities had lockers for storage of patients' belongings. Once patients locked the locker, we pinned the key to the lock to the patient's gown. That way, we knew those belongings essentially always stayed with the patient.
The reality is if the recovery room is not close to the lockers, you now need a staff member to go over to the locker, gather all of the belongings and bring them back, or if, during surgery, the gown is removed, and you now have to go search thru the laundry to retrieve the key These issues seem to negate the concept of securing and locking the patient's belongings. More and more facilities are going with the approach of putting the patient's belongings in a bag, making sure the bag stays with the gurney and the gurney stays with the patient.
13. Decide if enclosed rooms for pre-op assessment are necessary. There are two different mindsets on how to handle pre-op assessment and confidentiality concerns. Many people feel you need to have enclosable rooms with the ability to shut the door to ensure privacy. These are great, but they really eat up significant space — more space than I would argue is necessary. They also make it more difficult to keep track of what's happening with patients behind closed doors: are they dressed, do they need help, etc.
Conversely, the other option is bays with curtains separating one bay from the other. This scenario is not really conducive to privacy. A third option — and possibly the best depending on your circumstances — would be an amalgamation of the two described above. You could have bays, but with hard, full walls to help with confidentiality and privacy, and still have curtains for the front for privacy while changing. This option typically gives you the best of both scenarios. Make sure that you install enough bumper protection in these bays to keep the ASC looking pristine, and not have your walls dinged up from being hit by the equipment.
Note: Regardless of which model you choose, it is very important to have a restroom located near the pre-op bays. You don't want patients walking down a long hallway in their gown to use the bathroom.
14. Allocate appropriate and adequate nursing desk workspace. If you are planning to keep patient charts at the nurse's desk, you will need to consider what this will do your workflow. Physicians, including anesthesiologists, will likely want to have easy access to the charts. In a busy ASC, this may result in several physicians and staff members working at the desk at the same time, so the workspace will need to be big enough to accommodate a significant number of people. But you will want to avoid making the space so large that physicians are far away from their patients when viewing charts.
15. Identify which specialties will go in which ORs. Identifying which ORs will be primarily used for which specialties is very helpful from a design perspective. For example, if you're building a three-OR facility and plan to running ophthalmology out of 1-2 ORs, orthopedics in 1-2 ORs and pain in one OR, you're going to want your phacoemulsification system and microscope close to the ophthalmology rooms and storage for the C-arm close to the OR. If you're doing orthopedics in the same rooms as ophthalmology, for example, you will want a place to store the microscope or phacoemulsification machine However, moving equipment inordinately increases the likelihood of them being damaged or falling out of calibration, requiring increased maintenance.
16. Don't build ORs too small. One of the biggest problems I see in existing facilities is ORs that were built too small or not designed for the types of procedures performed in today's ASCs. For example, consider a big orthopedics case that needs a C-arm, and all of the carts and towers required. Try to perform one of these cases in a small or poorly designed room and it will become tight very quickly. With the advent of spine and other procedures requiring big equipment and more people, you need ORs large enough to maneuver in and accommodate several pieces of (often big) equipment.
17. But don't build ORs too large, either. Conversely, I have seen ORs that were up to twice the size they should have been. You must be reasonable in the assessment of how large to build your ORs. Should you build them to meet minimal code? Absolutely not! However, somewhere between that absolute minimum and doubling the size of the room, probably in the range of between one-and-a-third to one-and-a-half times the minimum. You want to have them large enough to accommodate the C-arm, microscopes, cart movement, the ability to switch from the left to right side of the patient, additional equipment (related to the specific specialty), etc. In some of the larger cases, you will need to accommodate more people — an extra physician, an equipment rep in the room, etc. It is extremely important to design the OR space to fit everyone and everything that needs to be there.
18. Don't place your ORs near the property line. You will want to build your ASC so that you can expand if you max out OR capacity several years down the road. Avoid placing your ORs on the sides of your building near property lines, where expansion into the space is not permitted. Flip the direction around so you have the ability to expand, for example, into the parking lot.
19. Consider future expansion "next door." If you're building the ASC in an MOB, and will occupy space on the same floor as other businesses, expansion will most likely occur by your taking space from the business "next door" if it becomes available as opposed to adding on to the building. As such, you will want to place your ORs or other clinical areas where expansion is most likely to occur along the walls you share with other businesses.
There are many people who are proponents of the concept of building out but not equipping an extra OR up front during construction. This may be a good idea, or you may end up paying rent on space for the next 10 years unnecessarily. Plan carefully.
Note: While you may never expand your ASC, you don't want to close off that opportunity. I come into facilities that are maxed to capacity and really need to look at ways of expanding. Unfortunately, layout makes it difficult to add new ORs without essentially shutting down operations and starting from scratch, which is cost-prohibitive. If you have an existing operation running, you're never going to just close down and remodel your whole facility for six months and then reopen. Plan carefully.
20. Keep anesthesia out of the corner. It is critical for your anesthesia provider to move around the OR and not be stuck in a corner near the gas outlets. If the anesthesiologist has limited mobility in the OR, you will need to position the patient around the anesthesiologist rather than designing the OR in such a way for anesthesiologists to move around and do what they need to for patient care.
In small centers, if your lead anesthesiologist is the medical director and someone needs to speak with him or her or during a procedure, if he or she is in the corner of the OR, staff members will need to navigate the room to get over to the anesthesia cart. This isn't conducive to good flow. Anesthesia providers are a crucial and critical part of the operative team, and you need to consider their placement and location just as much as the placement of physicians and scrub techs.
21. Avoid built-in cupboards in ORs. In many ORs, I see amazing built-in cupboards designed to house supplies for the OR. From an operations standpoint, I am vehemently against these cupboards in the OR, primarily for two reasons: 1) They're never designed in a manner to stock what you really need in a manner that you need; and 2) You end up having multiple locations for the same supply item. From a cost and inventory standpoint, it becomes extremely difficult to know how much of a given supply you have on hand if you, for example, have a specific type of suture in four different ORs. Add this to your main storage stock, and you end up with five locations for one type of suture.
Invariably, you will purchase five boxes of something to stock the four ORs and the main stock, when in reality you'll only go through one box in the next six months. That becomes problematic from a cost standpoint and in terms of inventory outdates, and it's a challenge to manage all of this from an operational perspective.
I believe facilities should maintain supplies in 1-2 locations, maximum. If ASCs do a good job of picking cases and making sure preference cards are as complete as possible and kept up to date, they should have 99 percent of supply items necessary for any case picked for the room from these 1-2 locations, thus eliminating the need to stock those supplies in the OR as well.
22. Plan for gurney flow and storage. Gurneys travel throughout the ASC, and it's critical when planning the building's layout to determine which path will permit the best flow for gurneys. The gurneys bring the patient from pre-op into the OR, then from the OR into recovery, then back to pre-op for the next patient. They also need to be cleaned before another patient is placed upon them. You need to determine how your flow is going to work relative to those gurneys and how far they have to go to get from one destination to another.
If there isn't enough storage space for unused gurneys, they may clutter the OR hall, which causes potential problems with fire safety. They may also become stacked in a corner, which makes it difficult to get the right gurney to the right patient and keep flow moving. It is valuable to build in alcoves for gurney storage, but this space should only used to store the gurneys.
23. Plan for sufficient OR equipment storage. Sufficient equipment storage outside of the OR is extremely important. Unless you're planning to equip your center so every room has its own tower, its own C-arm and every piece of equipment for every specialty you're doing, you have to store that equipment somewhere. Some facilities will have a space for the gurney and separate space for equipment overflow where they store C-arms and towers not in use.
24. Build equipment storage that addresses your physicians' needs. As mentioned earlier, it's valuable to learn which equipment the initial physician users will need; this will help ensure you're building enough storage space for the equipment you will purchase.
25. Design practical storage rooms. Design your equipment storage in a manner that ensures the equipment is easily accessible. Building a single, large, square storage room is usually not practical, as pieces of equipment will inevitably end up stuck in the back and sides of the room and accessing them will require emptying out much of the supply room. Long, narrow spaces in which you can access any space without emptying the room is much more beneficial from a storage standpoint.
26. Carefully consider other storage needs. While storage for surgical equipment is important, it's not the only storage you need to consider. You may want a storage area for all of your anesthesia supplies, and you need a storage area for your pharmaceuticals. The rules for storing pharmaceuticals now require ASCs to secure everything from IV solutions to syringes, in addition to making sure all medications are secure. Many facilities plan poorly to address these requirements; they typically put medications in a closet-type area, and then realize that there's no room left to stock IV solutions and syringes. This means they are forced to find another secure location, which may present challenges from a convenience and cost perspective.
With so many items requiring storage, designers of a new ASC may be inclined to plan for extra storage. The danger with this is if there is unassigned storage space, the space is unlikely to remain unused for long and may become the home for random pieces of equipment and storage overflow. Building appropriate-sized storage rooms for specific purposes is extremely important.
27. Place processing near supplies and receiving. I believe purchasing should be placed close to where supplies are received and stocked. It shouldn't be up in the business office area if receiving is in the back of the building and the supply room is nearby. Purchasing needs to be located close to where most of the purchasing- and storage-related work will take place.
28. Value the importance and needs of sterile processing. The sterile processing room(s) in your ASC will be extremely important. Your instrument trays need to be stored in a room where humidity can be controlled and monitored, so it can't be right around the corner or in the same room as your autoclaves. When you open the autoclaves, steam rushes out, and you will face the constant problem of trying to monitor humidity levels.
You will also want your sterile processing room near your ORs for convenience, designed so you have appropriate storage for your supplies and built large enough to accommodate personnel and instrument trays. The number of trays you need to sterilize will increase if your case volume is high.
29. Strategically place physician dictation alcoves. It's not uncommon to see really nice alcoves for physician dictation built in the OR hall or in recovery rooms. Unfortunately, these alcoves are often rarely used because their location doesn't work well with physicians' flow. When interviewing physicians, try to determine their preferences for where they like to dictate, and plan the alcoves accordingly.
30. Save space with one break room for physicians and staff. I'm not a proponent of separate lounges for physicians and staff. I think it's extremely important that everyone works together to encourage a team mindset. Separate lounges only encourage a separation between the two teams and foster an "us vs. them" concept.
I'm not a proponent of tiny staff break rooms, either. You need a room large enough to accommodate at least one-third of staff plus physicians and anesthesia providers. During lunch breaks, you will likely have as much as one-third or more of your staff at lunch, so make sure there's enough space to accommodate this number of team members, physicians, anesthesia personnel, and possibly a vendor or two, comfortably.
Although not a requirement, break rooms often will be used to host staff meetings, so if you plan to do so, you should also have enough space to accommodate staff members for training and in-services.
Overall, the long and the short of planning for the development of an ASC comes down to information data collection, planning and establishing the key points and issues and ultimately determining what is most important to you, your physicians and your patients.
Arthur E. Casey, CASC, is senior vice president of business development for Outpatient Healthcare Strategies (www.outpatienthcs.com), a provider of healthcare management consultancy services for ambulatory surgery centers, hospitals and physician group practices based in Houston.
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