ASCs promise to offer high-value services in a cost-effective environment. This is leading to tremendous growth, with the latest figures showing more than 50 percent of all surgeries in 2017 were performed in ASCs, compared to 32 percent in 2005. Organizations looking to capitalize on this trend by building new ASCs can do so, yielding expanded access, greater convenience and improved efficiency.
However, these benefits can only be achieved through careful analysis and preparation. Six ideas healthcare systems should consider:
1. Improving access. Bringing surgical services from the hospital campus to other communities may disconnect the ASC from ancillary support services. Consider what ancillary services are provided locally or served from the hospital. For example, centralizing sterile processing and pharmacy at the hospital may reduce costs, simplify staffing and maintain quality control standards. However, this may come at the cost of increased transportation demands, insufficient instrument and equipment availability, and an inability for staff to react to immediate needs. Recruiting and block timing can also be a challenge, as surgeon preference and access to outpatient clinical spaces for pre- and postoperative visits may be limited. This may result in patients bouncing between different facilities for everything from perioperative examinations to medications and durable medical equipment. Consider the thresholds that would trigger building redundant systems at the start of a project.
2. Cost considerations. Because ambulatory patients are typically healthier and undergo less complex surgeries than other populations, infrastructure requirements and room sizes are significantly less for an ASC. Even escaping the robust seismic and life-safety requirements of an I-2 hospital construction type can result in cost savings when compared to the cost of constructing a hospital surgery suite. But don't expect all these savings if the ASC is expected to support more complex procedures. Building codes are slowly adapting to the trend where procedures historically performed in a hospital are moving to outpatient settings; and a certifying body can require the ASC to meet the standards of an inpatient surgery suite. Add in the high cost of construction and redundant staffing for local sterile processing and pharmacy, and the result can easily tip the cost scales. Consider whether accommodating more complex procedures erases the cost benefits of building an ASC.
3. The 23:59 rule. CMS states procedures requiring more than 24 hours (from intake through recovery) are not candidates for ASCs. As technology permits the execution of more complex cases in an ambulatory setting, organizations should consider providing additional provisions to patients who can go home within 24 hours but may want more time on site for education and physical transition. Some states already allow for extended recoveries, while others require that any such accommodation be distinct from the ASC and not offer direct medical care. ASCs considering this approach should talk to their local certifying body to work through the many details, ranging from clinical staffing to food services.
4. Flexibility is key. Designing a single-specialty ASC can maximize efficiency and reduce the need for extraneous storage, equipment variation and general overbuilding. However, this approach comes at the compromise of future flexibility, as elements not accommodated on day one may be cost-prohibitive to add later. Also, if an organization desires to lock in the future flexibility to perform many different procedure types by including them under their license or certificate of need, a certifying body may limit or revoke that license if the design only supports a subspecialty. Consider whether procedural flexibility is likely needed in the near future or just nice to have, and whether those components can be accommodated in other ways — like with a building that can be expanded.
5. Building beyond essentials. One appealing aspect of an ASC is the ability to build only what is essential. Operating room sizes can be reduced, perioperative spaces can be built for limited hours of service and infrastructure does not need to be as robust. With increased competition in the marketplace, though, an ASC should consider providing amenities for both the patient and caregiver. Adding a café can be good for families and staff, electrical outlets in furniture can keep people connected and comfortable beds to sleep on — not just a stretcher — can differentiate ASCs. Even a well-done integrated ceiling system in the OR can improve aesthetics and promote a cleaner environment. Consider what features might differentiate your ASC and attract more customers.
6. Planning for emergencies. Working with healthier patients does not mean procedures always go according to plan. As more complex cases are performed in the outpatient setting, relying on 911 for emergency situations may prove insufficient. A nurse call system may be necessary to augment communication among staff, and training a team to stabilize a patient while waiting for help may also be needed. Moreover, an ASC may find itself informally or formally designated as the default center for an individual or public health emergency due to proximity. Consider the difference between what is required versus what is likely to happen in the ASC, especially in rural areas.
The cost of constructing and operating an ASC depends on many factors. So, as an organization settles on the type and scope of a new ASC, a comprehensive analysis should be performed to confirm that this new project will provide the care patients deserve, and either increase revenue and lower costs, or alternatively move volumes from the main campus to another location.
Mackenzie Skene is a partner and Hao Duong is a senior associate at global healthcare architecture and design firm NBBJ.