1. Perform proper site due diligence
"Before moving forward with final selection or acquisition of a site for the proposed facility it is important to do a thorough comparative analysis of the various sites under consideration including visibility, access, zoning, utility availability, future growth, cost, configuration and topography, setbacks, and other easements or requirements that affect usable area," says Rustin Becker, vice president advance planning with Madison, Wis.-based Erdman (A Cogdell Spencer Company). "Due diligence should include a formal survey, environmental site assessments and soil borings. Addressing problems that arise from these issues later in the development process can add significantly to projects costs or adversely affect your speed to market."
2. Seek an architect experienced in your state
The only thing that's certain when you build is that there will be myriad regulations to meet. But because they vary widely by state, it's important that your architect be well-versed in all the regulations imposed by your state's department of health, certificate of need board (if it has one), building codes and more.
"For example, in Illinois, you are only allowed to spend a certain dollar amount and build to a specified square footage, or else you risk losing your CON," says Mike T. Leopardo, vice president of healthcare construction for Illinois-based Leopardo construction. "Say you want to put an ASC into an existing building, and you have to upgrade the utilities and infrastructure to meet mechanical requirements — all those costs can really push the CON limit, so you need someone who is up to speed, especially as the regulations change."
3. Right-size the facility
"Many facilities have been designed around conceptual block scheduling or anecdotal utilization, such as 'orthopedics one operating suite, three days a week,'" says Mr. Becker. "Facilities developed in this manner tend to be oversized. Rather, they should be designed around anticipated or actual physician case volumes. Projected volumes should be discounted for factors such as payor contracts, acuity, and scheduling and convenience, then best-in-class ALOS factors and utilization rates should be applied to determine the number of operating suites and support beds needed. Facilities that are right-sized will have the lowest fixed costs, a big factor in positioning the entity for financial success."
4. Expect building costs to spiral
Currently and going forward, it's going to be difficult to use historical cost data to project building costs for any construction project.
"Materials and labor rates in our industry are volatile right now," says Mr. Leopardo. "Every June, with labor negotiations, those rates go up. That's nothing new. But now, because a lot of construction materials are petroleum-based, those costs are spiraling, especially when you factor in the higher cost of transport.
"Because of this, the time to build is as soon as you can get it built."
5. Design to suit the specialties
Here are some considerations for building, depending on the specialties that will utilize the facility, from John A. Marasco, principal of Denver-based Marasco and Associates.
• Gastroenterology and pain management. "These physicians do not want to deal with the sterility issues associated with a full-fledged, class C OR," he says. "These cases are non-sterile in nature, and treating them as sterile cases only slows down the surgeons, staffs and patients throughput process."
Accessibility to the OR should therefore not be off of the sterile corridor, but instead directly from the prep/recovery area. If you place this OR between the prep/recovery area and the sterile corridor, rather than on the other side of the sterile corridor, by placing doors into the OR from both the sterile and non-sterile sides, the design lets the OR swing back and forth, depending on the cases that are being performed and what access door remains unlocked.
"We call this a swing OR," says Mr. Marasco. "Of course this transition does not occur per case, but instead per surgical block period. For instance, an ophthalmologist may use the operating room in the morning as a sterile environment with the OR swinging in the afternoon to be used by a gastroenterologist as a non-sterile environment. This design technique takes no additional space, allowing a much more flexible ASC."
• Orthopedics. For more complex orthopedic cases (such as arthroscopies, spine and rotator cuffs), at least a class C, 400-square-foot (preferably 500) OR and plenty of equipment storage should be provided, he suggests.
• ENT. For ENT cases and their pediatric and adolescent patient base, additional privatized recovery stations should be provided.
• Ophthalmology. For ophthalmology cases (primarily cataracts) where several patients are blocked at once before entering the OR, additional prep stations should be provided.
"A little extra space now could save you a lot of headaches later," says Mr. Marasco. "In addition to the above-mentioned design issues, we recommend that any class B operating room (250 square feet —primarily used for minor cases such as gastroenterology and pain management) or above be at least piped with nitrous oxide anesthesia capabilities. All these issues are relatively inexpensive to address during the initial design process and can save you a lot of stress and potentially make you more money in the future when it comes to add specialties or sell to other specialties."
6. Consider the working environment
"Temperature and humidity control in the OR is one of the top complaints we hear about," says Mr. Marasco. "Although Medicare and state departments of health requirements allow for a 68-degree minimum temperature, to most surgeons this is unacceptably high. They typically like to have their operating rooms at 65 or even 62 degrees."
Depending on where you are located in the country, this temperature can be difficult to achieve with a standard rooftop HVAC mechanical unit while maintaining the required humidity level.
"Therefore, upgrading your HVAC system should be explored before completing the construction documents to allow for this control to be integrated into your ASC," says Mr. Marasco. "Do not let your architect or engineer design around the minimum requirements, which is typically their inclination, but instead use an experienced team that understands what levels your facility should meet in order to have happy users."
7. Select and integrate equipment.
"We find it is well worth the investment of engaging an equipment planner for proper and early selection of medical equipment and to effectively manage procurement," says Mr. Becker. "This will ensure that equipment has been appropriately budgeted during development of the financial pro-forma, allow for timely integration of the equipment needs into the construction drawings, and eliminate delays and associated change orders during construction of the facility."
8. Don't underestimate expansion
It's easy to approach expansion as a simple matter of adding an OR — but that's far from the case. Ancillary space, such as pre- and post-op bays, sterile processing, sterile storage, the waiting room and the parking lot will all have to be expanded as well, says Steve Dickerson, principal at Michiganbased Eckert Wordell.
Some rules of thumb for one-OR expansion:
• three more post-op cubicles at 100 square feet each;
• one more pre-op cubicle at 100 square feet;
• six to eight more waiting room chairs, depending on the lengths of procedures your facility performs; and
• four parking spaces per OR, plus one for each staff member, plus 30 percent (for a four-OR facility, this means a 51-space parking lot).
The idea he says, is to ensure there will be no bottlenecks created up or downstream from that new OR.
"Have the medical designer do a throughput study that takes into account the amount of time for each step in the process: check-in, pre-op, procedure,post-op and discharge," says Mr. Dickerson. "It will tell us if we have any bottlenecks in the whole flow system and how many patients the center has the capability to process. The number can be used to not only to determine construction requirements, but to finetune equipment and supply requirements, which in turn determine how big the supply room needs to be."
9. Consider the effect on day-to-day operations
It's likely you don't want to shut down entirely and lose out on revenue for any extended period of time, so it's important to consider how you can renovate or expand, without disrupting existing services or operations.
"I highly recommend pulling the contractor in earlier to work out a plan for phasing the renovation and keeping some of the ORs and pre- and post-op bays up and running during working hours," says Mr. Dickerson. "What we like to do is perform an infection control risk assessment and work with the contractor to isolate the noise and infection potential, dust and debris from the occupied area."
Some measures he recommends include
• building temporary partitions that are insulated for sound;
• separating mechanical systems so they can't circulate dust and debris from the construction area;
• shutting down affected ducts or covering them with filters
• putting HEPA filters into use in the construction zone;
• isolating the construction traffic from the ASC traffic, so patients don't see construction workers and vice versa; and
• setting a maximum decibel level, "so there's not interpretation as to what 'loud' is."
"Everyone has a job to do in these tight quarters during renovation, so it's very important to assign an owners' rep, one of the nurses or someone who is in the ASC day-to-day, who talks to the project manager and the contractor if there is an issue," says Mr. Dickerson. "If there's not a representative, nurses will often ask the contractor to stop what they feel is disruptive activity, but next time there's a project meeting, there will be a change order that will cost the physician owners money. Point-to-point communication prevents this common problem."
10. Know the pitfalls of existing space
Hurdles about if you are looking to renovate an existing building for use as an ASC, says Mr. Dickerson. Among the design changes you'll likely have to make:
• ensuring there are no combustible materials (i.e. upgrading to masonry and steel — the standard wood of an office building is not code for ASCs, he says);
• installing a full sprinkler system;
• adding an emergency generator to service the facility;
• installing a new air-handling unit (rooftop units are cheaper and easier to access, but the lifespan is usually about five to 10 years less than for those housed in a mechanical room within the building);
• if you are looking at space on the second floor or higher, upgrading to hospital-grade elevators; and
• raising the structure height (the office standard 10 or 11 feet is too low; Mr. Dickerson recommends 13 feet floor-to-top-of-structure in ASCs).
"That last one is actually the No. 1 problem I see with existing space; oftentimes the physicians have already purchased it, and you can't really raise the roof up," says Mr. Dickerson. "If the building is only one story, the solution is to look at putting the mechanicals on top of the roof over OR, which minimizes the amount of ductwork required."
He further advises that, with regard to existing space, you "look for buildings with separate, covered areas for entrance and discharge — or that are amenable to adding that feature. Also look for space that will allow natural light in the post-op area, whether through windows or skylights; the more ASCs we do, the more we find out how important that is."
Contact Stephanie Wasek at stephanie@beckersasc.com.