If you think the surgery center market is saturated, think again. Non-CON (Certificate of Need) states are still seeing a proliferation of surgery centers, according to Daniel D. Chambers, MBA, COE, who sat on an expert panel at last year’s ASCRS·ASOA annual meeting in Washington, D.C. “Surgery centers are clearly in play right now,” he says. Why? Compared to hospitals and HOPDs, surgery centers offer more value for physicians, payers, and patients alike. And with the increased variety of procedures becoming available on an outpatient basis (like TJR), the sector is only growing.
It’s a career goal of many ASC administrators to open a new surgery center, says fellow ASCRS panelist Todd D. Albertz, who has opened two new centers in the past year. But developing and launching an ASC is fraught with perils and pitfalls, not the least of which is the design and construction of the facility itself. The potential for success and profitability of a center is determined to some degree before you even open the doors—it is literally built right into the facility.
Avoid These Seven Surgery Center Design Mistakes
The right design will optimize your staff efficiency, patient flow, and even your level of patient satisfaction, explains John Marasco, AIA, NCARB, who presented a course on ASC design and development at ASCRS. But a sub-par design will do the opposite, and you’ll see the effects in your revenue. During his presentation, Marasco shared several common missteps he sees during the design and development process.
Mistake #1: Your team isn’t experienced enough.
When it comes to your design firm, “experience is the key to success,” emphasizes Marasco. Experience doesn’t mean five, 10, or 15 projects, he says. A firm that’s done at least 50 ASC projects is your best bet. “You shouldn’t be teaching [them], you should be learning,” he notes.
The same goes for your real estate professional, who plays an important part in site selection. Before you choose a location, “you need to have your experts review that environment to make sure a surgery center is an acceptable use,” warns Marasco. You may think that renovating an existing structure is easier than building from scratch, but that’s often not the case. A real estate professional who specializes in medical space can help you assess whether an existing building will meet your needs
“An elevator shaft isn’t something you change,” Marasco says. You don’t say “Oh, we’ll just put in a bigger one tomorrow” he quips.
Mistake #2: You don’t follow directions.
You (hopefully) have a successful ophthalmology practice. You may even have a slew of locations. But when you’re building an ASC, what you know goes out the window. “It’s not a practice. It’s not a surgical environment in a practice, but [an ASC] is a whole different animal,” Marasco says. For example, “there are only a few types of flooring that are acceptable in the OR of a surgery center,” Marasco shares.
You need to know what the requirements are, who’s applying them, and how they apply to your facility. Your first call should be to the state to find out whether they use CMS’ State Operations Manual—often referred to as interpretive guidelines—or not, and if so, which edition they use. Counterintuitively, the most up-to-date version is not necessarily the one you must follow. And every state is different—there are no national guidelines. “Now what we have, unfortunately, [are] 50 different requirements,” laments Marasco. And when it comes time for final inspections, “if you can’t check that box, you don’t have a surgery center. You have a very expensive procedure room.”
Mistake #3: You fail to plan ahead.
Will your ophthalmic surgery center always be a single-specialty center? Have you thought that far ahead? Adding a specialty can help diversify your risks, say, if reimbursements in ophthalmology take a cut. And as more procedures are approved for the surgery center, you can increase your case volume and revenue. Eventually you may want to add a specialty, but “as soon as you jump into a multispecialty surgery center, it’s a different game,” says Marasco. “By and large, if you’re going to look at a multi-specialty scenario, you’ve got to plan for it early,” Marasco says.
During the design process, think about what specialties might be a good fit. Non-general anesthesia specialties like podiatry or gastroenterology are often complementary—and less expensive. It’s going to add at least $100,000 to the construction cost to fit a facility to general anesthesia versus non-general anesthesia,” warns Marasco. You must consider everything from the size of the operating rooms to the ability to pipe in medical gasses.
And it’s not just the ORs that you need to worry about. Marasco recommends an additional 50 square feet of general storage and 25 SF of specialty equipment storage per specialty. Some specialties, like orthopedics, need even more. Also consider specialized sterilization needs (i.e. a scope washer). Do you have room?
Mistake #4: You assume more is better.
Look at the types and volume of cases your center will be handling to determine how many ORs you need. One-OR ophthalmic surgery centers are a “pretty common scenario,” according to Marasco. If you’re thinking only about profitability, you’re better off with one than two, he says. Yes, two ORs enhance the physicians’ efficiency and ability to see more patients in a certain time frame. However, if you’re an owner, the cost of providing the physical space and staffing for that type of environment will lower your profitability per case, he explains. “We’ve run this number a hundred times and it’s never come out anything other than that.”
The number of operating rooms affects other aspects of the facility design. “Once you get beyond two ORs, we extend a hall across the back so you can get to all three ORs from central dirty/clean rooms,” he explains. Some centers have staff moving across the hall in a hospital-type setup, but “you’re really breaking down your efficiency by doing that.”
Much of the time, the size of the OR is a personal preference of the surgeons, but it can make a difference in how your center operates. Some centers opt for one smaller and one larger OR, notes Marasco. The larger one is for general anesthesia (you need at least 400 SF), while the other room is basically a cataract room. “But you can still have the cataract surgeon using both rooms. [It] gives you a lot more flexibility,” he explains.
Mistake #5: You forget the details.
During the design process, ASC owners often focus so much on areas like the ORs and the lobby that they overlook seemingly minor features. This is where a skilled designer can help. One such area is the delivery area, notes Marasco. “Where are your trucks parking [and] unloading? Where’s the stuff going g to go?” Having a nice delivery area with space for boxes is essential.
Soiled holding discharge is another overlooked area, according to Marasco. This way, the person collecting it doesn’t have to come in to the facility at all; they can pick it up from the outside. And speaking of soiled, the connection between the soil, OR, and clean room should be a circular flow, advises Marasco. “In ophthalmology, there is a lot of back and forth between [those areas]—don’t tell your state health department,” he jokes.
He gives another example of a small detail that would go unresolved by a designer not familiar with the ASC environment. One client wanted to add a door between the OR and clean room, but they couldn’t because the guidelines state that both rooms must have positive pressure. “You can get double positive pressure, it is a matter of stacking [intake and exhaust fans],” he says.
Mistake #6: You fail to see other perspectives.
Of course, you want your surgery center to be well-suited to the surgeons and staff who use it every day, but don’t forget to look at it from others’ points of view. Marasco gave an example of one surgeon client who had other ophthalmic surgeons who wanted to use his ASC, but didn’t. Why? They didn’t want to bring patients through the practice office downstairs. Why? Usually the office looks so nice and expensive that, the surgeon(s) want patients to see it. So, they set it up so that patients have to walk through it to get to the surgery area. “That is something that is often tried and very, very often unsuccessful,” Marasco warns. “If [other surgeons’] patients can see your environment, the likelihood of another surgeon using your center is very, very minimal.” His solution is to create a separate entrance where the other surgeons’ patients come in. They have “a whole different waiting room so they can come in and out of the center without seeing [your] practice.”
Mistake #7: You think inside the box.
A good designer can help devise creative ways to get the best flow, the most efficient use of space, and the highest profitability out of your center. For example, Medicare requires separate pre-op and recovery areas. “But that doesn’t mean that your nursing staff has to be separated. Centralize the nurse’s station so they can operate for both.” You sometimes have pre-op patients in recovery areas and recovery patients in pre-op areas. “We get it signed off by the state having it separate, but the use is very different,” says Marasco.
Get creative with firewalls. For example, there are some procedures (like some retina procedures, for example) that earn relatively low reimbursements, but gain a facility fee from Medicare if done in the surgery center. So those rooms are technically in the practice, but they’re wrapped within the surgery center’s firewall. There could be one firewall that wraps two rooms, and one that wraps all four. So you can separate those rooms off from the practice and then it’s part of the surgery center depending on who your patient’s are at that time (Medicare vs. non-Medicare). For the Medicare patients, they’re in the surgery center, for the non-Medicare patients these are treatment rooms.
You must pay particular attention to the location of the laser room, because there’s a facility fee at stake, says Marasco. Your physician may get paid less because of the site of service differential, but you receive the facility fee—that $250.00 for YAG.” Most clients will opt to put their lasers in the ASC so they can bill and collect that facility fee, reports Marasco. It’s common that the doctor may not even be in the ASC at that point. The patient checks in as a surgery patient, but the doctor is actually coming from the practice side. “He pops over does the two- second YAG, collects $250.00, goes right back into the practice, and continues on.” But you have to design it so it’s an easy transition and the doctors don’t mind coming over from the other side, Marasco advises. “If you don’t have the connection, it creates a difficulty for physicians and they won’t do it.”
What about the FEMTO room?
Do you need one? “What’s going to happen to that tech[nology] over time?” asks Marasco. Technology usually gets less expensive and smaller. You might have one OR in the future that does it all. One recommendation is to size the current FEMTO rooms to be a full OR in the future.
In some cases, the LASIK room has merged with the FEMTO into one room, but that entire room is sandwiched between the ASC and the practice and encircled by a firewall. That way, the room can transition from the practice side to the ASC side without having to have duplicate technology. Depending on the day, the FEMTO can be used from the ASC perspective but it can also do the flap on LASIK patients. The surgeon could be taking patients from the ASC into the OR, or coming from the practice side and having LASIK. “Same room, dual function, but not all states will allow you to do that,” says Marasco.
If you have a laser clinic, think about having a separate waiting room just for the laser patients, suggests Marasco “You can’t introduce that type of volume in the ASC waiting room,” he notes.