1. Getting started with a new ASC
James Gesler, MD, of Wooster Orthopedics in Wooster, Ohio, is experiencing the early stages of construction on a new ASC that will be flanked by two medical offices in a medical office building. The ASC operations will be physician-owned, and a group of physicians (some of whom own the ASC, as well as others who will be working in the ASC but who do not have office space) will own the MOB.
“We’re not far enough along yet to know what we should have done differently,” he says, but he does have advice for the all-important planning stages — which can take as much or more time than the construction itself (Dr. Gesler’s group’s project has spanned two-and-a-half years so far). Here are two bits of early-stages advice to consider.
Find ways to bring the physicians together
“The struggles we’ve had have been largely in organizing the doctors and getting them on the same page — it’s been described as being like herding cats,” says Dr. Gesler. “Physicians are fiercely independent in general.”
Naturally, building a new ASC means a lot of meetings that need attending, and myriad decisions that need making. So how do you bring the physicians together for these purposes?
• Keep the end goal in mind. “As physician reimbursement continues to decline relative to the cost of living, the only way to maintain that level is to see more volume,” says Dr. Gesler. “The only way to do that is to be more efficient, which the ASC, housed within the MOB, will let us achieve. I stress this to keep us on track. It also helps to remind them that the burden of financing is very much on the physicians — the more efficient we are, the better we make use of our money.”
• Maximize electronic communication. Dr. Gesler and his group use e-mail to schedule meetings, send reminders and to distribute summaries of the most recent meeting along with outlines of what’s anticipated at the next meeting.
“Without e-mail, I don’t know how we’d do this,” he says. “Not all docs use e-mail regularly, but for the most part they recognize that is a liability, because we have made it clear that communication is largely going through e-mail.”
• Use proxy votes. Some physicians are natural leaders who step to the fore early in a project. For those physicians not necessarily interested in the minutiae (or physicians who may not be able to make a given meeting), you may consider letting them give their say by proxy to other physicians in the partnership whom they trust to vote in their best interests. This can speed decision-making considerably.
Get your development team involved early
Dr. Gesler’s group brought in a design/build firm early in the game to advise on everything from choosing the building site to the light fixtures.
“We’re busy; we don’t have time for all the extra work of coordinating architect, contractor, builders and suppliers,” he says. “So we did our due diligence to find a strong, experienced firm, and brought it in early, after we’d determined that we were going on our own, without a hospital partner, and that we wanted to own. The physicians are well-informed about progress and all important decisions, but we are kept at a higher level. We can keep doing what we’re doing and, based on the consistency and support we have gotten, trust that things are going well, which has been invaluable.”
2. Building and remodeling of a medical office building including ASC
Don Schreiner, CEO of Rockford Orthopedic Associates in Rockford, Ill., has overseen the building of an ASC and medical office building in a highly restrictive certificate of need state, as well as the MOB’s subsequent remodel to add more clinic space. The 7,300 square foot ASC, with two ORs and a procedure room was finished in July 2004; the 43,000 square foot MOB was completed in July 2006; the remodel of the MOB’s lower level was recently completed — three months ahead of schedule and without a single change order — in July. Here’s what he’s learned over the course of the MOB’s development.
Do your homework to put together the right team The most important thing you can do is to find a good team —architect, contractor and builder — says Mr. Schreiner. Rockford Orthopedics had two important requirements that helped it achieve that end with the initial MOB construction (and subsequent expansion and remodel).
• The architect had to have built an ASC in Illinois within the previous three years. “We couldn’t build one inch bigger or go over budget because the CON here is very restrictive,” he says. “It forced us to be very disciplined and very efficient, but it also made it critical that the team we hired have experience in this state with ASCs.”
• The architect had to be based in the region. “When I was checking references, it became pretty apparent that we didn’t want an architect from, say, California,” says Mr. Schreiner. “It’s not that there aren’t architects there who are good and experienced in our state, but we didn’t want to lose time if something needed immediate attention. We chose an architect that is just a two-hour drive from the center, so we could have someone here face-to-face quickly.”
• The architect was to pick a local builder. “It’s a good idea to have one person in charge of coordinating everything, and we chose the architect in charge (some may choose to put the general contractor in charge),” he says. “We asked the architect to work with us to pick a local builder, so we could be sure the architect and builder were on the same page, and it worked out great.” Rockford Orthopedics ended up using both firms for the subsequent work on the MOB.
Listen to your builder
“One thing our builder recommended that we don’t do was build a 30-foot tower at the entrance,” says Mr. Schreiner. “It looks nice and makes the waiting room look bigger than it really is, but I wish we had listened.”
The tower, which resulted in a large open ceiling space above the waiting room and part of the offices, cost Rockford Orthopedics an extra $80,000 to build — and continues to cost the ASC in extra heating and cooling costs.
“It also required 15 to 20 feet of material for a sort of drop ceiling to install a sprinkler system; it’s hard to clean and maintain; and there’s an echo,” he says. “The architects are brilliant with getting everything up to code, compliant with the CON and designing elements that look great and that the physicians love. The builder has a practical, efficient side — if they tell you they have a better design or more economical way to do something, listen.”
See it before you build it
The big debate among Mr. Schreiner’s physicians when initially building was office space — some physicians wanted large offices, others wanted a bullpen-type area in which everyone would have a cubicle in a larger room. They eventually settled in the middle, on 10″ x 10″ offices, the same size as exam rooms; that way, if need be, the offices can be converted to exam rooms and vice versa.
“We did a cost analysis of 10 feet by 10 feet and 12 by 12 and took to heart the contractor’s advice to go smaller,” says Mr. Schreiner. “We were both thinking to the future and about how much time the physicians actually spend in their offices — the exam rooms are where physicians will really be spending most of their time.”
In order to understand what that size would mean in practice, he had the builder construct a prototype exam room in his warehouse.
“The builder built the room with the exact countertop, exam table, and lighting fixtures that the physicians had chosen,” says Mr. Schreiner. “The walls were painted the color we’d chosen, and everything — the computer and desk setup, cabinets, the door — was put where we’d planned. The physicians got to do a walkthrough and test how it would work in practice, long before it was actually built.”
A lot of tweaks resulted: furniture, lighting, the desk setup and location, the placement of the call button, and the exam table size were among the modifications.
“It was easy to make those changes at that stage, prevented our being left with a design that didn’t work for the physicians, and vastly cheaper than remodeling,” says Mr. Schreiner. “Even better, when they saw the size of the exam room, it calmed everyone down about the sizes of their offices; they knew how big that was going to be, too.”
Build for expansion — without overbuilding
It’s a good idea to plan for future expansion of your facility. After all, such growth in your business would be healthy. However, that doesn’t mean you have to shell out to build a utility area with the cost- and labor-intensive infrastructure necessary in case you want to turn it into an OR someday. After all, there is a chance “someday” might not actually pan out. Mr. Schreiner recommends a more modular approach.
“We built in such a way that, at the end of the hall, we have a big window, which is much easier to take out to extend the hallway than a wall,” he says. “All the HVAC and plumbing systems are capped off there. We purposely purchased an HVAC system powerful enough to handle another OR. So if we decide to add one, we don’t need to upgrade — we just need to knock out that window, extend the utilities and build.”
In the meantime, the frosted glass window lets more natural sunlight into the facility, he says, and “the docs love that.”
Think outside the building
When Rockford Orthopedic Associates underwent the remodeling to add more clinic space to the MOB, it had to contain the remodel within the existing footprint in order to comply with state regulations. To free up space, Mr. Schreiner moved the administrative staff — including transcription, coding and billing, accounts receivable, and customer service — to an off-campus rented office site. In addition, office space costs less per square foot than medical space, so it makes sense financially to use medical space for its intended purpose in order to make good on the investment.
“We didn’t want to stick them in a dark box, so we took all the people who don’t need to be on hand with the patients and put them in a nice professional building,” says Mr. Schreiner. “They’re much more productive because they aren’t interrupted by doctors or clinical staff; they’re in a business environment, which is really more appropriate, rather than a clinic environment. They love it.”
Because the MOB is fully electronic and IT connectivity is top-of-the-line, “it’s as if they’re right next door,” he says. Further, “if we decide to add a clinic in one of the surrounding communities, this will become our corporate office,” housing all the business activities of a far-reaching practice.
3. Expanding/remodeling your ASC
Margaret Acker, RN, MSN, has been through three expansion and remodeling projects during her tenure as the CEO of Blake Woods Medical Park Surgery Center. On the first, she headed up the certificate of need effort and worked with a general contractor to add a third OR to the center; on the second, a remodel of the clinic area, she acted as general contractor in addition to fulfilling her daily surgery center duties; and on the third, a remodel of the PACU area, she oversaw the project but handed the reins back to a general contractor. Here’s are four lessons she’s taken away from these experiences
“Do what you do well, and pay people to do what they do well.”
While Ms. Acker learned much about construction, plumbing, electrical wiring and more from acting as general contractor, the most important thing was that it’s incredibly difficult to handle all aspects of such a project (especially one outside your skill set) at the same time you’re trying to handle all aspects of an ASC. Which is why, for Blakewoods’ next project, a contractor was hired
“Not only did it take the pressure off, he knew what we could and couldn’t do, and what was economically feasible,” says Ms. Acker. “They were able to move the hopper to the janitor’s closet, showed us how we could move a wall to create the space we needed — things we wouldn’t have thought of on our own.
“The other component that made him really worthwhile was his ability to coordinate all the people you need to come in. Does the plumber need to come in first? Can the carpenter go any farther? This guy had it like clockwork.”
Ms. Acker says that coordination was probably the biggest challenge when she acted as general contractor.
“The contractors have that expertise, and a dependable one will have your best budgetary interests in mind,” she says. “My project certainly took far longer, and I think it actually probably cost more, because I was reluctant to pay for those skills. My No. 1 lesson learned is to do what you do well, and pay people to do what they do well. It may sound simple, but it’s true.”
Keep patients in the loop
When you are expanding or remodeling, it’s best to tell patients straight away that you are undergoing construction, the appearance of which patients may find discomforting in a medical environment. Assure them that, while the center may not look like itself, noise is being kept to a minimum and all infection protocols are being adhered to.
“Patient satisfaction scores went down for the month that we were undergoing construction,” says Ms. Acker. “We put a sign up and made a point to apologize, but we didn’t do that until about a week in — patient satisfaction dipped for that week. We learned how important it is to inform patients up front.”
In order to accommodate patient flow, Blakewoods also planned its PACU remodeling project for its least-busy month; the Michigan center performs mainly cataract procedures, and so choose a winter month when many of its potential patients would be vacationing in warmer climes.
Prep staff for the challenges
Unless your construction project is wholly separate from existing space, it’s going to interfere in lots of little ways with how your nurses and other staff go about their days. Inform staff of the changes you expect, and take steps to ensure they know how things will change before you start.
“We made a checklist of everything that would need to be done each day: wipe off all cupboards, wash all the gurneys every day, put away certain items each night,” says Ms. Acker. “We had very neat builders, but you still have dust to deal with. We also increased the hours of our cleaning crew for the duration of construction; they probably had the most frustration, because they were trying to work after-hours, when the construction crew was working.”
There’s not just extra work; workflow will likely be disturbed as well.
“We stored a lot of supplies on carts that could be pushed into unaffected areas at the end of each day,” says Ms. Acker. “It’s stressful, because you can’t just automatically reach for what you need. It was kind of like redoing your kitchen at home:
Your silverware might be in the living room, while the can of beans you need is on the porch.”
It’s also important to keep staff apprised when unexpected changes occur — generally on a daily basis.
“We would come in to find plastic up on a new area that was not usable; you never could get used to it all,” says Ms. Acker. “We have two doors from our PACU into our sterile hallway to the ORs, and we posted signs to direct traffic because it changed day to day. Some changes made it harder to turn a cart or a gurney, but nothing was unworkable.”
Watch the budget
When you look at your project, it’s wise to build end dates for each stage into the contractor’s contract, with penalties if the deadlines are missed — “it keeps them moving and helps keep you on budget,” says Ms. Acker.
She also advises tracking construction expenses separately, so you’re “not ordering supplies, for example, out of the same basket. This way, you know exactly what expansion really costs you, where your expenses are running high and low, and you can watch your money tighter,” says Ms. Acker. “If you have a constant in-flow of cash, you might not see your construction budget as shrinking. My accountant helped me set everything up. The added benefit is that, down the line, we’ll have a clear record of what we spent of fixed assets, building — everything related to the project.”
Contact Stephanie Wasek at stephanie@beckersasc.com.
