ASC Design, Development &Construction, Part I

ASC Design, Development & Construction, Part I

Even as the American Institute of Architects revises its 2001 edition of the Guidelines for Design and Construction of Hospital and Health Care Facilities, healthcare architects are already taking to heart many of the elements and principles they know are essential to efficient, dynamic design of ambulatory surgery centers (ASCs). Some of the most important design imperatives are within the environment-of-care section of the AIA guidelines, as the built environment “has a profound impact on health, productivity, and our natural environment,” according to the guidelines. The guidelines advise, “Healthcare facilities shall be designed within a framework that recognizes the primary mission of healthcare, including ‘first, do no harm,’ and considers the larger context of enhanced patient environment, employee effectiveness, and resource stewardship.” Environmental components reach to the heart of issues relating to facility operations, patient outcomes and satisfaction, dignity, privacy, confidentiality, safety, medical errors, stress, and impact operations.

ASCs can be designed to be friendly to patients and staff members, industry experts say.

“Color promotes comfort, so step out of the sterile look,” advises Gayle Evans, RN, MBA, CASC, CNOR, president of Continuum Healthcare Consultants Inc. and Quality Surgery Centers, LLC.

One of the most important considerations of an ASC’s design is its ability to facilitate flow of movement. Every facility design, according to the AIA guidelines, should address the utilization issues, staffing patterns, departmental relationships, space requirements, environment- of-care components, key elements, and other basic information related to fulfillment of the institution’s objectives. The functional program should include a description of those services necessary for the complete operation of the facility, as well as addressing projected occupant load, numbers and type of staff, patients, residents, visitors and vendors. In treatment areas, the types and projected numbers of procedures should be described, as well as circulation patterns for staff, patients or residents, and the public, and circulation patterns for equipment and clean and soiled materials.

“Minimizing the transport distances and number of moves to and from ORs saves staff transport time, clean-up time, and room turnover, in addition to minimizing a patient’s discomfort during long and sometimes bumpy transports,” says Sam W. Burnette, AIA, senior project designer/principal of Earl Swensson Associates, Inc. “Design to allow maximum observations of a patient without compromising privacy and the need to discuss private matters; this can be accomplished with private partitions as sound barriers between rooms or private consult spaces for the patient’s and family’s pre- and post-op discussions. Design to minimize the distance between the patient beds and nursing care.

Provide staff with lounge and restroom facilities convenient to the workspace without taking bed space. Design the proximity of work areas to patient beds. Provide the ability to quickly turn ORs, such as having cleaning and the restocking of supplies conveniently located to each OR suite and having the appropriate mechanical systems to rapidly change temperature requirements.”

“Successful ASCs typically offer dual circulation loops; a patient loop which addresses the patient’s (and family’s) experience from the front door to discharge and a staff loop which addresses the staff’s experience from the employee entrance to the surgical suite and other patient care areas,” explains William R. Massingill, AIA, NCARB, chief operating officer of Polkinghorn Group Architects, Inc. Some experts suggest beginning a circulation matrix with the patient circulation pattern. “By establishing a uni-directional flow roughly in the shape of a horseshoe, the patient’s dignity is protected by eliminating embarrassing switchbacks,” says Wade C. Taylor, AIA, president of Wade Taylor and Associates, LLC. “These switchbacks encourage pre-op and post-op patient interaction, which can be profoundly undignified. The oval or circular patient pattern also provides for efficient staffing by centralizing nursing core activities. Finally, when the patient completes the pattern, they are greeted by family members and discharged relatively close to the waiting area. This reduces the sponsor exposure to the clinical elements and sensitive areas of the center, reducing opportunities for confrontations.”

“If a facility is designed to meet the needs of the patient from the moment he or she enters the facility until they are discharged, then most likely the patient will recall a pleasant and friendly experience,” comments Jay W. Boynton, AIA, director of Boynton Williams & Associates. “However, if the facility is confusing as to patient traffic patterns and the patient becomes confused and/or frustrated, they will recall an unpleasant experience. Likewise, an efficiently designed facility will also assist in creating efficiencies for staff in the care of the patient. The proper selection of finish materials can also provide a warm and friendly environment. Proper selection of finish materials also assists in the proper and efficient maintenance by staff. Materials which are difficult to maintain will increase man hours of staff and will most likely look worn out before their time.” Neil Terry, director of healthcare for The Orcutt/Winslow Partnership, observes, “Flows within an ASC should be conducive to the satisfaction of patients. Patients should never retrace their steps in the facility, but should move from one stage to the next in a continuous progression without crossing the path of other patients in different stages of the process. Family interaction with the patient should be accommodated in as many areas as can be permitted. Privacy is important and should be promoted as much as possible. For staff efficiency, having the preop and recovery nurse stations either next to each other or even combined allows nurses to be able to cover both areas. Make supplies convenient. Placement of soiled and clean utility rooms central to all ORs reduces travel time for staff. Locate the staff lounge convenient to the OR suite to where they have close access.”

John A. Marasco, AIA, NCARB, principal of Marasco & Associates Inc., advises ASCs to be foot-friendly for staff. “The key to winning the efficiency game is to minimize travel distances,” he says. “The fewer steps staff and surgeons must take to accomplish their jobs, the more efficient and financially viable your ASC will be. Staffing costs, at 25 percent to 35 percent of an ASC’s overhead, are by far the most design-controllable overhead component. You are much better off maximizing efficiency by minimizing their travel distances than you are by minimizing the facility size itself in order to save costs. The best money you can spend when developing your ASC is to hire a highly experienced architect who can help you accomplish this goal.” Advises Taylor, “Keep the recovery area close to the operating theaters and keep the turns to a minimum on the route. Provide a patient circulation pattern that is unidirectional with the clinical staff as the center.”

Regarding best practices for designing an ASC’s surgical suites and treatment rooms, Marasco advocates the “swing” design concept for its flexibility. “For example, gastroenterology and pain management surgeons do not want to deal with the sterility issues associated with a full-fledged Class C operating room (OR). As these cases are non-sterile in nature, treating them as sterile cases only slows down the surgeons’, staff’s, and patients’ through-put process. Accessibility to the OR should not be located off the sterile corridor, but directly across from the prep/recovery area. This can be accomplished in a multi-specialty ASC by placing the OR between the prep and recovery area and the sterile corridor. Then, by placing doors into the OR from both the sterile and non-sterile sides, the design can allow the OR to swing back and forth, depending on the cases that are being performed and what access door remains unlocked. Of course, this transition does not occur in every case, but instead per surgical block period. For instance, an ophthalmologist may use the OR 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 your ASC to be much more flexible without a surcharge ... a win-win situation.”

Adds Burnette, “Design surgical suites for flexibility so that they can be adaptable in size and in infrastructure. Design for operational efficiency, such as having the ability for serving as both pre-op and post-op procedure/ patient rooms so that they can swing either way during busy pre-procedural prepping and postprocedural recovery to minimize vacant rooms without compromising throughput. Where possible, design a separate front, main entrance and a discreet discharge exit.”

Massingill emphasizes the need for flexibility in surgical suites. “ORs and other treatment rooms should be designed so that they are as flexible as possible in order for these rooms to be utilized for many different types of procedures. Many new ASCs are designed for a finite number of physicians and are designed to accommodate a finite number of specialties, but often a facility will recruit a physician and must be able to accommodate that physician’s specialty with a minimum disruption to ongoing operations. For instance, by locating medical gases at more than one location in a procedure room where they can be conveniently accessed from numerous positions of the table in that room, a room can easily accommodate a wide variety of physician needs.”

“Don’t overbuild,” comments Evans. “Make sure there is enough storage space for future growth. Evaluate current specialties and opportunities for future specialties or desired future specialties and design space accordingly (taking into account the need to add pre-op, recovery and procedure rooms).”

There are numerous determining factors that dictate reconfiguration/renovation of existing facilities vs. new construction to increase OR space. “To determine how feasible it is to upgrade an existing facility, obtain estimates from a professional to compare the cost of upgrading an existing facility with building a new one,” advises Terry. “Costs should include possible downtime of any of your ORs during construction and what the loss of revenue might be. Look closely at how the construction work will need to be phased; if you need most of your spaces to continue generating income, the construction work will require more phases, more time and more supervisory costs to be completed. Upgrading existing space may be more costly than building new in the long run, both for construction costs and operation costs.”

Boynton says local and state regulations and building codes must be taken into account when considering any renovation vs. rebuild project. “A primary concern in any reconfiguration or renovation project is whether or not the existing facility meets the current state health department regulations and building codes. If the existing areas being impacted are not in compliance, the designer must evaluate existing conditions and determine (assumedly with input from the health department and/or local building official) what will be required as to upgrades of the existing systems.”

Boynton also says designers must not allow themselves to get boxed in by a design’s limitations. “The area requiring reconfiguration or renovation may warrant expansion for the area to properly function; however, this area may be boxed in where expansion is not practical or feasible,” he says. “When looking at a reconfiguration/ renovation project, the designer has to look outside the box as to how the area being considered for this project will affect other areas and/or systems within the facility. The designer must listen to the client to ensure he or she fully understands their needs. The designer must also discuss in an open forum the impact of the client’s needs on the various other elements within the ASC. Modifying the facility to add ORs to increase case load may not solve the problem if, for example, the soiled and clean processing areas are not adequate to accommodate the additional procedure load. The same can be said for pre- and post-operative beds. If, for example, additional ORs are added to accommodate eye surgeries but no additional pre- and post-op stations are added, a logjam may be created. Other factors may also affect the decision, such as current location vs. availability of alternative-site locations and accessibility. The client should ultimately make the final decision with all the information presented.”

Another consideration is the disposition of the property upon which the facility sits. “Although owning real estate is usually less expensive than leasing it, that option is not always available to our clients,” Marasco says. “About 35 percent of the ASCs we have designed are in existing leased buildings. The availability of the space is key, even if it costs a little more to produce. Although leasing space is generally more expensive, it impacts a relatively small component of the ASC’s total overhead; rent usually comprises only 10 percent to 15 percent of an ASC’s total overhead. Therefore, a 5 percent increase in rental costs will affect the ASC’s overall overhead by less than 1 percent — not a big impact on your ASC’s financial viability. That being said, it should be a major design consideration to allow for future expansion of your ASC when the initial design is done. When doing so, consider the ancillary spaces (such as waiting rooms and reception areas, prep/recovery, storage, etc.) needed to facilitate an additional OR. This is often much easier to accomplish with a new building vs. an existing one.”

Burnette advises ASC owners to consider caseloads when contemplating expansion projects. “How many services have to be affected for net increases of OR suites?” he asks. “A series of renovations of what has been impacted may be more costly than a new addition with minimal changes required. There is the perception that renovation is more economical than new construction, but this is not the case when extensive demolition must first be done in existing spaces before renovation can begin. When all components are weighed together, which option is most economically viable for a net increase of the OR capacity? Is the existing department too landlocked by other services to feasibly relocate? Is the existing department operationally obsolete, such as an undersized room or insufficient clearances? Is the renovation for more OR space compromising other OR services that need to expand? Is the geographical location appropriate as existing? Appropriate for patient access? Is this the right place to cultivate the base? Is the infrastructure support adequate to cover higher mechanical and electrical loads in existing spaces?”

Oftentimes, according to experts, existing space can be re-designated for new purposes. “This requires a fairly complicated evaluation; however, it is pretty safe to say that similar specialties can occupy similar spaces,” Taylor says. “For example, an ophthalmology group would likely be better off with new construction if the alternative is to renovate a previously designed orthopedic center. The reason is case volume. The high volume of the ophthalmologist will not easily be accommodated by the low-volume support spaces associated with the orthopedic center.” According to Massingill, “In renovations, the addition of new procedure rooms will often result in a required increase in the number of pre-op and PACU beds. In addition, a proposed renovation might trigger supplemental code-required improvements to other aspects of an existing facility. In new construction, the aforementioned issues are typically incorporated into the design of a project, but a facility’s design layout should be laid out such that certain core areas (such as pre-op and PACU) allow for future expansion.”

Smart design and development, of course, takes into consideration the special needs of single-specialty facilities vs. those of multi-specialty ASCs, including differences in space planning and equipment purchases.

“The space planning difference results primarily from the additional instrument trays and equipment,” says Taylor. “Different instrument trays require additional storage and sometimes additional sterilization equipment. Surgeons of different specialties require alternate equipment components for perioperative care. The instrument trays and the alternate equipment require additional space, and additional space results in a larger facility. Also, orthopedics requires more acute recovery while ophthalmology requires more secondary recovery. Again, this equates to additional space.”

“Most multi-specialty ASCs require more space to function than do their single-specialty counterparts,” Marasco explains. “A single-specialty ASC can be designed to handle the specific needs of a certain caseload; therefore, in most situations (especially with relatively minor cases like gastroenterology, ophthalmology or pain management) a single-specialty ASC can function properly with a minimum amount of space. Multi-specialty ASCs require more waiting spaces (due to the slower patient turnover), staff dressing area (due to the increase in the number of staff and surgeons), recovery stations (due to the more acute patients), general storage (due to specialized supplies/packs), sterilization (due to the use of multiple sterilization techniques), equipment storage (due to specialized case carts and equipment) and even the operating/procedure rooms themselves (due to booms/equipment/ staff and robotic technology). That being said, bariatric, otolaryngology or orthopedic single-specialty ASCs may be larger than some multi-specialty ASCs. This is because these specialties deal with the most acute patients or have patients with a relatively short surgery and long recovery need. A single-specialty ASC with the same number of ORs as a multi-specialty ASC can be up to 25 percent smaller and still maintain efficiency.”

“Typically, a single-specialty facility can be customized to meet the needs of a select group of doctors and their equipment vs. designing for several different specialty groups,” adds Boynton. “This can affect the size of the ORs, requirements as to equipment storage, soiled and clean processing areas and their related equipment, as well as the number of stations in the pre-, post- and step-down areas. However, the drawback of designing for a single-specialty group is that the dynamic of the group may change over time, with other specialty groups being brought into the facility, or the potential of the facility being sold to another group of different specialists. By not discussing the ramifications of the narrow road a client is taking, it may be looked upon as the designer not fully meeting their responsibilities during the program stage.”

Burnette advises designers to examine the adaptability of the OR for multiple specialties. “Sizing and equipment planning has to be looked at in a different light than just an orthopedic or surgery room,” he says. “Secondly, there must be an understanding of the average length of stay for a wide range of post-op patients so that surgery staging and post recovery stay is adequate. For example, eye surgery patients have quicker recoveries than orthopedic patients. The mix of specialties may dictate the need for more or fewer private rooms and toilets.”

“Designs for single-specialty facilities are typically streamlined to that specialty, minimizing or eliminating functions which might be appropriate for multi-specialty facilities but which aren’t necessary for the business operations of the single-specialty facility,” Massingill notes. “These single-specialty facilities tend to be smaller and perhaps more efficient, but can be difficult to expand or to be modified to accommodate another specialty after completion.”

Single- vs. multi-specialty ASCs have varying regulations placed upon them, Terry cautions. “Different specialties may require different requirements from a licensure and operations standpoint. Where an ASC has procedures that have the same requirements, ORs and support spaces can be set up similarly and will be more efficient in terms of utilization. In facilities that have specialties that have different requirements, several different OR types will need to be set up. An example of these differences is the endoscopy procedure. Most codes restrict having sinks in a typical OR, yet in endoscopy procedure rooms, a sink is required, so the endoscopy procedure room is limited to only those types of procedures. Additionally, the ASC may want to separate different types of specialties into separate suites to achieve the appropriate patient experience.”

The AIA guidelines state that “sustainable design, construction, and maintenance practices to improve building performance shall be considered in the design and renovation of healthcare facilities,” adding that essential considerations include minimizing negative environmental impacts, minimizing waste in construction and operation, use of water and energy conservation techniques, and ensuring indoor air quality, among others.

“‘Green’ architecture is all the rage right now and for good reason,” says Marasco. “Considering the initial and long-term environmental quality, energy and water conservation of your site and building’s design and materials is extremely important to the sustainability of our society. The Green Guide for Health Care has defined a comprehensive, voluntary self-certification system for the design, construction and operation of high-performance healthcare buildings. This quantifiable sustainable-design tool kit can be referenced at www.gghc.org. It is the first green-building best-practices guide created specifically for the healthcare industry and should be followed whenever possible. The principles contained in this guide can be implemented with a minimal increase (5 percent to 10 percent) in initial building costs over traditional, non-green methods. Although it probably won’t get additional patients to come to your ASC, the good PR and long-term savings are worth the extra price.”

“Newer sterilizing equipment can be incorporated to be efficient in processing without putting toxins into the environment,” remarks Burnette. “Highly efficient mechanical systems can be utilized that can effectively re-circulate and appropriately filter pre-conditioned air in the facility. Environmentally friendly finishes without formaldehydes and other toxins can be used. Specify sterilizing equipment that sterilizes supplies without gases or toxins released into the environment. Properly locate windows and window treatments that utilize natural light without adding heat gain. Oftentimes, windows are perceived as a luxury in a short-stay facility, but windows to the out-of-doors are integral in enhancing the recovery process.”

According to Massingill, “Environmentallyresponsible design which minimizes the depletion of our natural resources via design principles and building materials can be incorporated into facilities in a number of ways, such as the orientation of a facility on its property in order to take advantage of shade, sunlight, prevailing winds, topography, and other environmental qualities. From a utilities standpoint, ‘green’ design can be incorporated into a facility through the use of natural lighting as a supplement to light fixtures, the use of economical and efficient HVAC systems, motion-activated light switches in certain areas (not patient care areas, of course), provisions for onsite recycling bins, and employee practices.”

“The use of sustainable materials that emit a low amount of or no toxins can do wonders to your patients’ experiences,” says Terry. “These materials should contain no VOCs that will affect your patients’ health; surprisingly, many materials used in ASCs do and should be made from renewable materials made as close to the facility as possible with processes that do not harm the environment. Where possible, use natural daylight and design your artificial lighting to take advantage of this natural light. Natural daylight and the ability to see its source, such as a window, does a lot to promote a healthy work and patient environment and can reduce utility bills. The exterior skin of the facility should be designed to promote systems efficiency. Make sure the exterior walls and roof have good R-values. Roofs should be white to reflect the sunlight and reduce the ‘heat island’ effect of absorbing heat during the day and releasing it at night “Many components can assist in the design of an environmentally friendly and more utilities- efficient facility,” comments Boynton.

“Green design should be implemented where economically feasible. Proper and practical design criteria, in the placement of the building on the site, and recognizing all the elements and how the environment will impact the building will also assist. The proper selection of materials and the design of an environmentally tight envelope will also improve utilities efficiencies. The use of the most current energy-efficient equipment, lamps or ballast, motion sensors in various areas to control lighting, time-controlled setback of HVAC equipment, and heat-reclaim units are a few examples. The selection of equipment which properly meets the design criteria and is not under- or over-utilized is important. Proper selection of the best utility for the equipment is vital. Well thought-out and distinctive lighting design, allowing for fewer foot candles in an area to accomplish a task, can play a large role in the design of a environmentally friendly and still utilities-efficient facility. Even the selection of colors can affect efficiency.”

Most industry experts agree that technology and various medical advances are dictating a healthcare facility’s design today more than ever. “More cases which were once considered too complex and thus not within the scope of services of an ASC are now being performed on a routine basis,” says Boynton. “These complex procedures require additional space for the new medical equipment within the OR. What were recently considered adequately sized ORs may now be too small to accommodate the new demands of the equipment and the procedure. The computer is also being introduced in an increasing number of applications within an ASC; thus the need to provide adequate support for the IT system is critical.”

“With the increase in technology and surgical complexity comes the need for larger ORs,” Marasco observes. “What has traditionally been considered an inpatient case is suddenly an outpatient case. I even recently read about minimally invasive, outpatient-based total hip arthroplasty. The minimum requirement for a Class C OR is currently 400 square feet per the American Institute of Architects (AIA) guidelines, typically designed as a 20-foot by 20-foot room. This is too small for today’s complex environment. With all of the anesthesia and medical equipment, lighting and monitoring booms, as well as specialty equipment towers and even robotics, a 22-foot by 22-foot room is much more appropriate, with a 25-foot by 25-foot room not being out of the question.”

“ORs are becoming larger to facilitate the increase of equipment,” comments Burnette. “Ceiling-mounted, vibration-sensitive equipment requires more meticulously designed space above ORs. The above-ceiling space must be managed more carefully to handle ductwork, lighting, plumbing, equipment supports, information systems and PACS technology. Equipment storage also becomes more significant, as multi-specialties require safe housing near the ORs. The architectural/engineering response to these advancements is to plan rooms for adaptability, both in size and mechanical/electrical connections for future implementation of this technology. Examples include ceiling access to attach new systems, adequate infrastructure in electrical, plumbing and mechanical capacity, and adequate structural support above for future equipment loads. Examples include the ability to network medical images and information to a larger medical network off-site via advanced telecommunications, fiber-optic systems, etc. For example, a rural hospital sends medical images to its tertiary urban center partner for diagnostic consults during the surgical procedure in real time.”

Massingill says that greater emphasis must be placed on designing to accommodate the increasing importance of IT systems in an ASC. “The quantity and capability of information systems in ORs continues to be developed,” he says. “During the design phase of a project, the design team must consider whether equipment booms, video or other data systems, or other apparatus is going to be either designed into a facility or accommodated for future use. These information systems affect the project’s electrical system, mechanical system and structural system. Data rooms, which used to consist merely of a closet where the facility’s phone board was located, are evolving into larger rooms with considerable electrical and mechanical requirements.” “Although there are numerous advancements in technology, its impact on design has been no different than with earlier systems,” Terry asserts. “We typically request early in the process that the owner identify and select systems as soon as possible so that space, electrical and raceway requirements can be accommodated within the construction. This eliminates any delays in the construction schedules that result when system requirements are not understood in a timely fashion.”

With increasingly complicated medical equipment dictating design of a surgical facility, experts advise owners to anticipate equipment needs early into the process of building an ASC. “Medical equipment can have a significant impact on space,” Terry confirms. “Its location can be vital to the flow and operation of the facility. We find often that if the owner doesn’t understand an equipment’s impact on their space layout and that impact isn’t figured into the initial design, the staff usually are less satisfied with the building design. We always insist that equipment information be provided as soon as possible in schematic design and we work hand in hand with the users to ensure that the equipment is appropriately incorporated into the building design.”

“We try to get as much equipment off the floor as possible,” says Burnette. “The careful and strategic location of booms, surgical lights, anesthesiology gases and instrumentation is like piecing together a Rubik’s Cube without conflicts in and above the ceiling. We have to design floor-to-floor heights higher in an OR and design the structure to be capable of hanging heavy ceiling-mounted equipment. Vibration isolation also has to be taken into consideration for certain rooms. Equipment needs should be known in conjunction with the design of the ASC, which will determine ceiling height, room sizes and mechanical/electrical requirements. The ORs of the future will incorporate higher degrees of minimal invasive procedures, use of robotics, laser surgical instruments and 3-D images to assist surgeons/ OR staff. This technology will also produce higher success rates, reduce postoperative complications and reduce recovery periods for the patients.”

When it comes to securing equipment itself, Evans advises, “Be a shrewd negotiator; look at remanufactured equipment. If using a consultant, be sure that they can get you the best pricing and they are not committed to one vendor exclusively.”

“The best solution is to use an experienced independent equipment planner to select the equipment that will be used throughout your ASC,” says Marasco. “This process should be completed in conjunction with, not after, the early stages of the design process to assure a proper integration into the layout. The architects/ engineers will simply use the selected equipment’s cut sheets to allow for a proper installation during the construction of the facility.” Massingill concurs, adding, “An owner should consider retaining an equipment planning consultant early in the design phase in order to ensure that the facility’s equipment needs are met in an efficient and cost-effective manner.”

“More equipment is being introduced into the OR as well as into the pre- and post-op areas,” Boynton comments. “Providing adequate and convenient store space is critical to the design of a successful facility. Storage is always an easy target to reduce during the design phase with the budget being pushed. The facility should also be designed to allow ease of expansion of support services to accommodate future equipment needs.”

We asked industry experts what they thought are the most significant challenges to ASC design and development, as well as advice on how potential developers can avoid various pitfalls.

“With ever-changing United States Department of Health and Human Services guidelines, American Institute of Architects Academy of Architecture for Health guidelines, state health department requirements and local building code requirements, it is very difficult to stay current on what design/engineering requirements will be enforced when licensing and certifying your ASC,” comments Marasco. “Having the experience to gather these requirements is essential to a successful architectural firm; missing the mark can be disastrous. Clinical expertise is also very important. Being able to talk through your operational policies with inconsistent state and city officials in order to allow an ASC to use cutting-edge design techniques that may be new to the officials is critical.”

“At this moment, construction costs are very high,” says Taylor. “Attempting to compensate for this with more efficient design is the challenge. For the most part, ASC design (when performed by an experienced architect) has been maximized over the past three decades. Also, CMS regulations have become more stringent with the newly adopted 2000 Life Safety Code. This has increased the cost of construction as well.”

Evans says developers must heed realistic financial parameters. “Develop a budget and stick to it,” she says. “Make it realistic. Look for ways to come in under budget. Consider remanufactured equipment in some areas of the ASC. Put money in technology that is going to produce revenue. Obtain a commitment from physicians for procedures before spending money.”

“If your ASC is not financially viable, it does not matter how well-designed or constructed it is,” Marasco adds. “You should without a doubt have an experienced development firm prepare a full feasibility study prior to and in conjunction with developing your ASC. Without this tool, you could be setting your ASC up for certain failure.”

“Cost restraints are the biggest challenge facing ASC designers/developers,” Boynton concurs. “Construction costs are being driven up as regulations become more demanding relating to system performance and space requirements. Costs for material and labor are also rising. At the same time, the payment for services is either leveling out or decreasing. The vast majority of ASCs are being constructed for the for-profit client where a pro-forma must work. The client has to believe he has selected the best team of designers/developers who can meet his needs and understands all aspects of the process and has the ability to bring the finished project within budget. If not, the project will suffer and perhaps not survive the long haul.”

Terry adds that in addition to cost control, a significant challenge to designers is working on the owner’s timetable. “Often, owners want their facility within a period of time that challenges designers and builders to adequately plan and construct a quality facility,” he explains. “If you really need to have a new facility delivered in an aggressive timeframe, be prepared to provide the information required of you and make key decisions when needed. A good design team will develop a detailed schedule up front with key milestones that identify responsibilities that will allow each member of the team, including the owner, to work on their assigned tasks and complete them when needed. You should plan to have, from the time you give an architect notice to proceed to occupancy, an 18-month schedule for a new facility and 12 months for a remodel project requiring no phasing.”

While there are numerous considerations when designing and constructing an ASC, industry experts share what they believe to be the single most important best practice.

“OR suites and patient rooms should be designed to handle multi-specialties,” Burnette says. “Patient rooms should flex for varying levels of acuity. This minimizes underutilized and empty rooms and reduces staffing and utility costs.” Evans suggests, “Think out five years’ worth of needs at the time of development. Also, stick to the budget.”

“Listening to the clients’ needs and being responsive to those needs is key,” according to Massingill. “The ASC model as used successfully on previous projects may be a ‘tried-and-true’ layout that fit the needs of a number of previous clients, but that doesn’t mean that it’s appropriate for a new client — or even a repeat client. Design lessons can be learned by design and management consultants from each and every project.”

“Allow yourself the appropriate time to properly plan and construct your new facility,” Terry advises. “Owners often don’t understand that they have a big role in the process and don’t allow themselves the time in their busy schedule to interact with the designers and make those key decisions that only they can make. We can design a facility without this interaction, but every operation is unique enough that the owner’s role is crucial in ensuring they receive the facility that is best suited for their needs.”

“Know your product, rules, regulations and codes affecting your design and be willing to listen to all members of the design team,” Boynton emphasizes. “If you are fortunate to have members of the staff, other than the doctors, involved in the programming phase, attempt to draw all the information from their statements you can. They are the hands-on people who actually deal with the real issues of a facility on a daily basis.”

“Do not overbuild,” Taylor says. “Identify and illustrate an accurate case mix/volume analysis and then prepare a design that meets it. Only design for reasonable anticipated growth.”

Industry experts share their advice on how to select the key members of the architecture and design team. “A knowledgeable architectural firm must have multiple experiences with all surgical specialty ASC types,” John Marasco, AIA, NCARB, principal of Marasco & Associates Inc. emphasizes. “Designing an ophthalmic ASC doesn’t make them an expert in designing an orthopedic ASC or vice versa; in fact, it doesn’t make them an expert at all. A truly experienced architectural firm has helped develop 250-plus ASCs, not one, five, or even 25. The only way to learn what truly doesn’t work is to try it and fail. Without hundreds of ASC projects behind them, an architectural firm simply doesn’t have a big enough learning curve. Don’t rely solely on client testimonials; a satisfied client may not even know what they are missing and is perfectly happy with a poorly designed ASC.”

“An owner wants an experienced team in surgery center design and one that understands the difference in inpatient and outpatient models,” says Sam Burnette, AIA, senior project designer/principal with Earl Swensson Associates, Inc. “That experience translates into an understanding of design for maximum operational efficiencies with easy expandability and adaptability within the existing layout. An experienced team understands the need to be highly marketable without compromising internal staffing economies. The key factors include:

• Does the architect/team have a clear understanding of ASC operational needs and the importance of efficient design?
• Does the architect/team stay current on trends and advancements in the ASC industry?
• What surgery centers has the architect/team developed?
• Have the team members worked together on other projects?
• Do the team members’ strengths complement one another?
• What have team members learned from past projects that would save an owner from repeating others’ mistakes?
• Do the team members have existing facilities available for touring so as to learn from other owners what they did right and what they would do differently?”

Gayle Evans, RN, MBA, CASC, CNOR, president of Continuum Healthcare Consultants Inc. and Quality Surgery Centers, LLC, advises, “”Look for experience. Those who have been in the trenches can relate to the input from the client more effectively than those who have not been there. Also, there should be a team that speaks cost effectiveness and value engineering when necessary. Developing that budget ahead of time is important and coming in under budget is more important.”

“Past experience in the outpatient surgery market is essential for a design or management consultant,” says William Massingill, AIA, NCARB, chief operating officer of Polkinghorn Group Architects, Inc. “While generally offering healthcare services and while generally concerned with fundamental healthcare aspects, ASCs are designed, staffed, and utilized much differently than acute care facilities. Thus, an owner must confirm that any and all design and management consultants retained for a project are experienced in this outpatient industry and have a good track record on similar facilities for other clients. The outpatient surgery industry is a tight circle, and design and management consultants should be able to provide a prospective client with a number of references which can be contacted regarding their performance on previously-designed projects.”

“An experienced team understands how ASCs work and licensing requirements,” explains Neil Terry, director of healthcare for The Orcutt/Winslow Partnership. “Although we plan facilities based on user input, it’s important to have a good understanding of how ASCs work in order to validate the owner’s concept of their design. We can, many times, help improve patient flows and staff efficiencies. Often, users will request layouts that may conflict with licensure requirements and it’s important that designer be able to steer the user toward a licenseable facility. When interviewing prospective design teams, find out how much experience they have with ASCs, particularly with your types of procedures, and be sure they have done work in your state working with the authority that will ultimately license your facility.”

According to Jay W. Boynton, AIA, director of Boynton Williams & Associates, “The current and past experience of the team members is the key to the successful design of an ASC. While any experience could provide a foundation, it is important that the experience is current. The various codes and regulations which impact a facility are almost liquid in that they are constantly changing. If a design member is relying on what they did a couple of years past, they will be out of touch with today’s requirements.” Boynton continues, “Also paramount to the success is the communication between all team members and the willingness of both the architect and the client to listen to all other team members. It does little good for the client and architect to hire experienced personnel and not draw on this experience. As mentioned previously, many experienced architects fall into the trap of thinking they know best. They have done it before and there is no reason to listen and learn. If the architect does not truly listen to the client and takes the attitude they have done this many times in the past, they run the risk of not meeting the true needs of the client. They will design a facility in their own image and not that of the client. After narrowing the list of potential members of the architect/development team to members who have the expertise, a client should select individuals who they feel comfortable with. This does not mean a client is looking for their next best friend, but they should select individuals with whom they believe they can have an open and honest discussion concerning all issues. There will be issues which will arise at some point in the process, and the client has to feel all team members will provide an honest response. This includes the times when the response might not be the one the client or other members of the team want to hear. When selecting a firm, the client should verify who they will actually be working with throughout the process. Many firms have principals or sales personnel who the client meets during the interview process. They come to the interviews, but the client has no other contact with them until photo ops at ground-breaking ceremonies and open houses. This doesn’t mean that firms can’t have various levels of employees; the client just needs to be sure that they are meeting and interviewing the people with whom they will be working and who will be active in the day-to-day process of the design.”