TAKING CARE

TAKING CARE
Environment-of-Care Issues Remain Critical as Surgery Center Competition Increases and Reimbursements Get Slashed

By Michelle Beaver

Environment-of-care issues in ambulatory surgery centers (ASCs) are as vast as they are important. The main features include light, security, safety, temperature control, privacy, ease of navigation, and aesthetics such as colors, patterns and textures. If an ambulatory surgery center balances all of these factors, chances are good that success will follow. Aesthetics go a long way to helping patients feel comfortable, calm, and safe. Looks, however, should never trump safety.

An Ounce of Prevention …

One of the most important factors for the safety and comfort of an ASC patient is proper supervision by the staff in pre-op and post-op, says Rice (Sandy) Jacobs, vice president of development and sales for HBE Medical Buildings. Jacobs has developed healthcare projects (many of which were ASCs) for more than 20 years. HBE is based in St. Louis, and its employees focus on the planning, design, engineering and construction of healthcare and financial facilities. HBE’s teams have developed more than 900 healthcare projects in dozens of states.

“The design needs to provide good sight lines in prep and recovery from the nurses station(s), as well as an effective nurse call system that can effectively summon help to a patient when needed,” Jacobs says.

A properly engineered and installed HVAC (heating, ventilation, and air-conditioning) is also necessary to provide healthy movement of clean, quality air.

“Another area of potential safety concerns is with flooring,” Jacobs says. “The proper selection of material is required to reduce slip and fall incidents as well as providing ease of cleaning of spills to reduce the risk of infection for the patient.”

Proper flooring is indeed essential, as falls and deaths do occur from inadequate surfaces, according to The Joint Commission. Fires and medical-equipment related failures are also consequences of environment-of-care problems. The Joint Commission offers the following tips:

• Consider installing exit alarms and bed alarms (and conducting related tests), as well as self-latching locks on utility rooms and exits.
• Inspect all fire alarms regularly. Enforce smoking policies.
• Implement an emergency management plan. Designate an alternate care site to use in the event of generator failure. Equip all floors with disaster kits that contain items such as batteries, walkie-talkies, water, and flashlights.

As far as medical gas, The Joint Commission recommends that this substance be stored in medical-grade products separate from industrial-grade products. Designate one area for receiving full cryogenic vessels and another for storing empty vessels. The commission further recommends that handlers do not change fittings on cryogenic vessels under any circumstances.

“After a cryogenic vessel is connected to the oxygen supply system, but before introducing the product into the system, have a knowledgeable person make sure that the correct vessel has been connected properly,” Commission documents state.

Guidelines

The American Institute of Architects (AIA) provides helpful environment-of-care guidelines to the healthcare industry, and provides information specific to the ambulatory surgery community.

The AIA’s “Guidelines for Design and Construction of Healthcare Facilities” is referenced by architects, engineers, The Joint Commission and healthcare professionals throughout the U.S. and abroad, on new and renovated healthcare construction. The guidelines are updated every four years by a committee of nurses, doctors, architects, engineers, facility managers, and state and federal personnel. The 2006 edition has been completely reorganized and includes the following changes:

• The addition of an appendix on green design 
• New material on infection control risk assessments and recommendations 
• Revised chapters on freestanding surgical facilities, birthing centers, and primary care outpatient facilities 
• New chapters on urgent care facilities, gastrointestinal endoscopy centers, dialysis clinics, and psychiatric outpatient centers

ASC Aesthetics

In the design of an ASC, it is important to reduce any “institutional” feel that is commonly associated with medical facilities. This can be a difficult feat, since one also wants medical facilities to be clean, easy to use, and sterile. Those elements don’t necessarily make for a country kitchen set-up.

Still, the right balance can be found, Jacobs says.

“One of the factors contributing to the popularity of ASCs is that they are not hospitals, where the setting tends to be more cold and impersonal,” Jacobs says.

When an ASC is inviting, the patient feels more comfortable that the procedure that are having is not as ‘serious’ as those they might have at a hospital, he says.

“By providing a layout and finishes that provide an inviting and calming feel, an ASC can accomplish that non-institutional environment that raises the patient’s comfort level that the procedure they are in for will have a successful outcome,” he adds. “As important as the design and aesthetics is the attitude of the staff and physicians to enhance the inviting, noninstitutional atmosphere of the ASC.”

Patients should feel safe, secure and informed in a healthcare setting, says Marie Cuzzone, operations manager at Elmhurst Outpatient Surgery Center, in Elmhurst, Ill. Elmhurst opened in 1999 and features opthalmology, orthopaedic, pain management, gynecology, gastroenterology, podiatry, urology and plastic surgeries.

Facilities should be organized and efficient, and these features should be apparent to patients, Cuzzone says.

She suggests that designers, “decrease walking distance for nurses and plan for appropriate space for supplies, etc.,” she says. “If nurses are rushing or trying to avoid obstacles, it gives the appearance of inefficiency and disorganization which may lead to the patient not feeling confident.”

Elmhurst goes above and beyond with one of its features Cuzzone explains: “In our lobby, we have a water wall which provides white noise for privacy and a calming effect for our patient’s well being,” Cuzzone says. “This experience is a warmer, homey touch. The setting is more like an upscale hotel and not a typical clinical outpatient hospital setting. We also provide private pre-operative rooms for each patient.”

She offers the following advice:

• Avoid harsh lighting 
• Include windows when possible 
• Make rooms private by including doors or curtains that close completely 
• Assure that signs are clear and prevalent 
• Choose soothing colors, but step away from typical beige tones

Forming a Team

The design or renovation of a surgery center should be a team effort and should include input from employees from throughout the facility, such as administrative and clinical areas. This input, under the leadership of reputable architects, engineers and construction workers who follow AIA guidelines, can result in a strong team.

A diverse group is beneficial, Jacobs says. “Since many new ASCs today are partnerships made up of physicians and in many cases of physicians in separate practices, developing an owner decision-making protocol is very important,” he says. “The process works best if the owners hire key staff members early in the design and development process. An alternative is to hire or partner with an experienced development/operating company that has staff members that know the ASC business. It seems to work best to form a facilities committee (of doctors and key staff members) within the partnership group to review designs and make decisions for the whole partnership.”

The most important decisions involve budgets, layout, schedules and equipment set up.

“It is very important for the group to make early decisions concerning owner provided equipment — OR lights, sterilizers, washers, medical gas requirements, specialized procedure equipment, etc. — since these items will impact the design and engineering of the facility in a significant way,” Jacobs says. “Many startup ASCs will hire an equipment consultant to help with matching the proper equipment with the procedures planned for the ASC.”

Medical Expertise

Partnering with design and construction professionals who do not have experience with ASCs can create a host of problems.

Jacob’s company includes about 450 architects, engineers and construction specialists who work on projects from the design phase to the building phase and who understand HIPAA (American Health Insurance Portability and Accountability Act of 1996) requirements, patient flow and practice integration,” Jacobs says.

Some mistakes that inexperienced designers make are to plan buildings that are too big, will not pass state and federal inspections, are poorly scheduled, out of budget or that do not coordinate with equipment needs. Some inexperienced designers and builders are also unable to give realistic time and cost estimates.

“Even if the owner is partnering with an experienced ASC development/operating company, the experience of the designer and builder is critical to guiding the owners through the many decisions concerning the design and construction of the facility,” Jacobs says. “If nothing else, an experienced designer/builder … knows the questions to ask during the design and development of ASCs.”

Mother Nature

While much of the nation only recently started to make environmentally sensitive choices, some healthcare designers and builders started making such choices years ago, Jacobs says.

“For several decades, smart designers and engineers have been making buildings more energy efficient, healthier for the occupants of the buildings and using more sustainable materials,” he says. “What has brought this movement to the forefront has been the LEED (Leadership in Energy and Environmental Design) certification guidelines that have codified, as it were, what is meant by ‘green’ design.

“Some owners now require that their buildings meet some level of the LEED certification requirements,” he adds. “These Owners tend to be larger institutions with the extra resources to spend on facilities that can be LEED certified. There is no question that a desired LEED certification will add cost to a project because of some of the design and material requirements. However, some believe that there can be some savings over the life of the building through energy and other savings.”

A “green” design, according to HBE team members and other companies, conserves energy, uses materials that are safe for the environment and human health, and is efficient in that it uses the least amount of square feet as is reasonably possible.

Good environmental choices work in conjunction with environment-of-care issues, and not just in name alone. Clean, non-toxic surroundings aid patient peace-of-mind and perhaps their healing too.

And fortunately, “green” design decisions are often cost effective, which is more important than ever in this era of reduced procedure reimbursements.

“(Environmentally friendly environment-of-care choices) mean providing the most program in the least square footage, utilizing layouts that minimize the number of FTEs (full-time equivalents) needed to safely and effectively run the facility, and to compress the design, development and construction schedule as much as possible allowing them to open (produce revenue) in the least amount of time possible,” Jacobs says. “There is still the desire to provide a warm, caring environment for the patients. The challenge is to do this in a cost effective manner in terms of overall design and finish materials that still provides this environment.”