Building an Ophthalmic ASC? Read These Design Tips First.

Don’t become an ambulatory surgery center casualty — Find the right architect, choose the right location, and perform sound due diligence

Building an ambulatory surgery center is a business risk. If you’re developing an ophthalmic ASC, you’ve likely already conducted a feasibility study to prove its financial viability. But how else can you ensure your ophthalmic surgery center’s success and longevity? There are plenty of things big and small you can do to ensure your ASC is positioned for success and profitability from the day it opens. No, there are no guarantees that your venture will be a success, but there is plenty you can do to help. Follow our lead:

Ophthalmic ASC Task List

A profitable ophthalmic ASC is one that you design to maximize efficiency. It gives patients, staff, and caregivers the environment they deserve, says architect John A. Marasco, AIA, NCARB.

There are plenty of reasons to jump on the ASC bandwagon. With a dedicated ASC, you can focus operations on patient-centered, higher quality of care, and do so with better control over your working environment and economics. And those economics are compelling: shifts in Medicare allowables in recent years means more and more of your income may come from ASC ownership.

Here’s where to begin:

Finding the Right Architect for Your Ophthalmic ASC

A knowledgeable firm should have experience designing ophthalmic ASCs. “A truly experienced architectural firm has helped develop 250+ ASCs; not one, five, or even 25. Without hundreds of ASC projects behind them, an architectural firm simply doesn’t have a big enough learning curve,” according to Marasco.

“Don’t rely solely on client testimonials; a satisfied client may not even know what they are missing and [be] perfectly happy with a poorly designed ASC.”—John Marasco, AIA, NCARB

Tips for finding the right architect for your ophthalmic ASC:

• Understand clearly what it is you want from your project before you begin
• Understand what value you want an architect to bring to your project
• Solicit referrals from colleagues — particularly those with ASCs you admire
• Survey their prior work designing ASCs
• Research tirelessly to ensure a good fit for your goals

The right architect will not only be able to design an ASC that works well today, but one that will serve your practice well far into the future. With modern healthcare constantly changing, a proactive design will create a flexible and convenient environment that works well for both staff and patients. Further, a good design will use your financial resources wisely while providing results that support future growth and the wellness of the community as a whole.

Ophthalmic ASCs necessitate design tweaks that an inexperienced architect could miss. In ophthalmology, you’ll want to have more space for prep than for recovery, especially in the morning. At the end of the day, the opposite may be true. “The pre and post op areas should be developed for flexibility,” advises Larry R. Brooks, AIA, principal of design firm Practice Flow Solutions. “Cataracts are the majority of surgeries in most eye ASCs and that is high volume, doing 20-30 per MD per day. The bays need to be flexible to be used as needed.”

Location Decisions for Your Ophthalmic ASC

Don’t over-prioritize cost of land, Marasco advises. “Often people just buy what they need and no more and that’s a huge mistake,” he says. Concerned about the cost of not-yet-needed space? You don’t necessarily need to shell out for an expensive, premier commercial lot. It’s not really important that an ophthalmic ASC be highly visible or attract a lot of foot or drive by traffic—that’s not where your business is coming from.

But the cost of land alone is not the only consideration when thinking about the location of your ASC. How close do you want to be to your current operations? That cheap land may not actually be that cheap in the end if you are constantly rushing to drive across town in time for an appointment.

Is the site close to your core customer base? Many patients, of course, will fly around the world to get the standard of care they need, but not all will, and centers with a higher proportion of older adults may experience patients who are reluctant to drive far, or drive at certain times of day. Is your site convenient for other reasons? Will you have easy parking, and will patients who want to be able to park close to the door? Is your site easily accessible for those who rely on public transportation, or who walk or bike to their appointments? Is it convenient for those who want to shop on the way to or home from an appointment? And what about the neighborhood itself — is it a nice, safe place to be, or will patients be concerned or uncomfortable visiting you?

Go Big or Go Home?

There’s no data that tells us the number of ASCs that have failed because they overbuilt, but it’s a common mistake. To right-size your facility, think about your needs, not your wants or expectations, Marasco says. Your architect should be asking a lot of questions about your needs.

Building too big for your case volume can quickly put your ophthalmic ASC on shaky financial ground. Be cautious, make your projections based on the actual cases your physicians do, and then round that number down.

Also look at your physicians’ payer mix, and what types of cases he or she is doing, and what the reimbursement trends for those cases are. Come up with a conservative estimate, then build based on that.

When you draw up your plans, make sure you’re able to add on to your building later. “It’s far cheaper than starting from scratch,” Marasco notes.

How many cases do you need to justify owning your own ASC? And what happens if you build for that number but fail to reach it? Of course, if you fail to reach that threshold, you can always partner with another surgeon and develop the center as a group. Keep in mind that you’ll need to get along with that person not just from medical terms but also in business terms. Do you have similar goals? Do you play well together? If you do partner to extend the size of your center, keep in mind that you’ll need agreements to be negotiated and signed regarding equipment, personnel, supplies, management, and ownership.

A general rule of thumb is that a center needs one operating room per 1,000 to 1,500 cases. A typical two-room ASC can be built on about 7,500 square feet. Currently, average ASC size in the U.S. is approximately 14,000 square feet. Now, the median ASC includes four operating rooms and two procedure rooms.

Think, too, about how the size of your building will impact what you do with it down the line. Having an ambulatory surgical center where costs are controlled, where care is top notch, and where quality can be documented will make that building a hot commodity on the real estate market (and business sales market) when it comes time to retire, build anew, or simply move on. The value of your practice when you approach retirement will be a lot higher if you are including a right-sized building in the deal.

Due Diligence Needed Before You Buy and Build

If you buy a piece of property to build on, do your due diligence to confirm zoning requirements. One big mistake? Assuming that a space used for an ASC in the past is automatically qualified to support one now. Zoning requirements and building codes change frequently, and new ownership will trigger the need to meet current specifications. That could be expensive, or even impossible.

Most state health departments have a fairly sophisticated group of people who deal with ASCs. “It is very difficult to stay current on what design/engineering requirements will be enforced when licensing and certifying your ASC,” Marasco notes. If your architects aren’t going to the state to review your plans early and often, they aren’t doing their job. “Missing the mark can be disastrous,” he warns. You’ll need an understanding of local building issues, planning and zoning, parking ratios, loading zones, landscape percentages, waste management systems, and more.

The steps involved in building an ASC will vary depending on many factors, but in general can be summed as:

• Feasibility analysis: Is it economically feasible, and will the land permit it?
• Development and design: Architect hire and building size decisions.
• Bidding and begin construction: Using a construction manager will likely save you money.
• Equipment selection and acquisition: Consider a consultant to research options and make recommendations.
• Licensing and certification: Select a consultant with a proven track record of managing this process.

Equipment Concerns

Don’t forget equipment budgeting and planning. Marasco advocates using an independent, experienced equipment planner in conjunction with the early design stages to ensure proper integration of the equipment into the layout. It’s all about limiting staff steps and placing equipment to keep things efficient.

“You are much better off maximizing staff and surgeon efficiency by minimizing their travel distance than you are by minimizing the facility size itself to save costs.”—John Marasco, AIA, NCARB

“The addition of the femtosecond laser has created a little wrinkle in that the surgeon and patient have another stop,” Brooks notes. “We place it so patients can enter from the pre-op area and exit into the clean corridor at the ORs. The surgeon can enter and exit from the clean corridor and stay close to the ORs.”

Equipment needs should play a role in building design from the initial conception phase. You should consider steps to:

• Coordinate equipment selection with staff and vendors.
• Evaluate and price equipment options.
• Manage the purchase, receipt, installation, and servicing of all medical equipment.

Is There Potential for Additional Income?

Another important consideration when building an ophthalmic ASC is the opportunity to earn additional income. Although potentially more complicated than building a single-use or single-practice building, there could be opportunities to use the building to earn additional income, such as partnering with other providers and opening the center as a group, or allocating all or portions of the building for use by other parties or providers. An operation which is owned by one party then leased to a second could allow owners to earn passive income in retirement, for example. Yet another option is an ophthalmic ASC which is part of a mixed-used development. For example, the building could house your ASC practice on one floor and physical therapy office on another.