Today's SurgiCenter - Upgrading Your ASC Options

Upgrading Your ASC Options for Adding Surgical Capacity

By John A. Marasco, AIA

When an ASC has no room for additional surgical capacity, what can be done? Assuming the facility functions adequately, how to fix a poorly designed facility is another article altogether; you have three basic options to consider. The facility can be remodeled, expanded or replaced. This article will cover the issues associated with these options.

Unless a facility is poorly designed, a remodel, even a major one, will do little to improve surgical capacity. More space equals more time, which equals more cases. If there is not enough tangible space to make a real impact acquirable by a remodel, there is little reason to consider it at all. A better solution is to add extended hours to the facility.

Evenings and weekends are quite popular with patients; it’s getting the surgeons and staff to show up that poses the real problems. Extending facility hours requires no remodeling and therefore no construction costs, only increased staffing and operational costs: a good solution if you can make it fly.

A major remodel can, however, allow for additional specialties to use a facility. For instance, if a facility was originally designed for high-volume cataract surgery, it likely does not have the privacy desired or the number of prep/recovery areas to accommodate tonsillectomy patients. A 15-minute surgery and 30-minute recovery patient has very different space needs than a 30-minute surgery and a three-hour recovery patient. A remodel can allow for this type of facility transformation; therefore, if a major remodel is in your future, here are a few issues to keep in mind.

Code updates can cause major problems. Over time, state/local building, fire and Medicare requirements have become stricter and in most jurisdictions a major remodel triggers the need to bring a facility up to current standards. The first code issue to consider is the Americans with Disabilities Act (ADA). The ADA assures handicapped accessibility of a facility. Everything from wheelchair ramps, door swings, toilet sizes, elevators and much more, all come into play here and they have a tendency to add up quickly.

The second upgrade to consider may be the heating, ventilation and air conditioning (HVAC) system. Facilities may have to maintain higher humidity and filtration levels in the operating rooms or generate additional air changes throughout the facility. Additionally, certain jurisdictions may require the entire HVAC system to run during a power outage. This demand often jumps a facility up from a battery backup to a gas-powered generator system. Additional upgrade requirements may come from state health departments.

Generally, requirements for operating room sizes, clearances between and numbers of recovery beds, numbers of medical gas outlets and zone valves and many more issues have also become more stringent. In addition to just the sheer size of rooms, this may lead to the requirement for a larger/modernized vacuum pump, medical gas manifold or zone valves.

All this and I haven’t even discussed the biggest issue of all — downtime! If you are considering remodeling a facility, most likely you need more surgical time; therefore, losing access due to construction is counterproductive. Unfortunately, with any remodel — even the best-planned — comes some downtime. To minimize this downtime, have the architect work with you and the contractor to create a plan for phasing the construction. This means you construct a portion of the design while arrangements have been made to offset that portion’s function during its remodel, allowing the facility to remain operational during construction. Often the final design is slightly compromised, but few facilities can afford to lose several months’ revenue to shut down during construction. Having the contractor work 24/7 also helps expedite this process, but is costly. Make no mistake — this process is much harder that it sounds and can be quite expensive as well, so make sure the by-product is worth it.

It’s likely that any facility expansion will also include a partial remodel of the existing facility; therefore it’s likely that the issues mentioned previously will also apply to this option, as well as having additional hurdles to jump through.

Unless your architect paid attention to the possibility of an expansion and incorporated additional space into the original design, it’s likely you will have to also expand/remodel your existing reception/business/medical record area, waiting room, patient toilets, family interview/consultation rooms and staff break and locker area in addition to any clinical expansion. With additional surgical capacity comes additional patients, surgeons, staff and additional support space, too, so don’t do one without the other or you will regret it.

Another code issue that applies primarily to an expansion is the existing facility’s construction type and its associated allowable building area. Every facility is constructed to meet a required construction type based on that facility’s size and function. If a facility is expanded, it may become necessary to upgrade its construction type due to its increased size. One of the easiest ways to achieve this needed area increase is to add a fire sprinkler system if the building does not currently have one. This option can be hard or easy depending on how much thought originally went into the design.

If a decision is made to replace a facility, odds are that it was poorly designed in the first place and a more desirable expansion/remodel was not feasible; don’t make that same mistake twice. Facilities can be designed to expand in order to add surgical capacity, or other services (extended recovery or imaging) for that matter, with minimal interruption to the existing facility. By simply aligning the sterile corridor, operating/procedure rooms and clean workroom/sterile storage area to be extended into the new clinical area, the expansion of a well-designed facility is simple.

First, build the entire clinical expansion, including the new operating/ procedure rooms, sterile corridor/clean workroom/sterile storage area extension, prep/recovery area and all other ancillary spaces. This, of course, includes independent HVAC and electrical systems. Second, over a long weekend, connect the existing sterile corridor/clean workroom/ sterile storage area to the new one. Then get ready to open the next week with a fully functioning expanded facility. It’s really that simple if done correctly to begin with. If, during the initial design process, you think future expansion is a possibility, give consideration to having the architect upgrade the reception/business/medical record area, waiting room, patient toilets, family interview/consultation rooms and staff break and locker area to handle the potential size as well as construction type of the future facility.

This sounds like a lot of space, but the increases to each area, for future capacity, is typically quite small. Building them now will not be prohibitively expensive and will save you numerous headaches later. Hopefully, your architect already designed this into your existing facility and you are just expanding onto, not replacing, your facility.