William F. Mulhall, RN, a partner with Merritt Healthcare in Somers, N.Y., offers eight points to ensure safe and seamless operations when an existing ambulatory surgery center undergoes construction for renovation or expansion.
1. Choose the right construction partner. "Selecting the right construction partner can make all the difference in the overall success of the project," Mr. Mulhall says. The ASC generally has two options, both of which Merritt Healthcare has used. The first, the traditional model, is to select an architect to prepare the design, identify an engineer and send plans out to possible general contractors who they have selected. In this model, however, each participant is working independently, which means that the ASC leadership has to act as middlemen, serving as job site managers. In this model, "if there is a dispute between the parties, the ASC has to resolve it so that it won't delay the project and add extra costs," he says.
The second option, Mr. Mulhall says, is for the center to engage a design-build firm that provides all the necessary architectural, engineering and general contracting. The firm uses its in-house team, supplemented with subcontractors, and everyone works directly under the firm's supervision. Superintendants from the firm coordinate day-to-day work and resolve any issues that arise. One potential downside of this option, he says, is that the bid process is not usually transparent, as it would be if an architect sent plans for bid. To determine charges, the ASC client needs to consult with an expert who has experience in generally acceptable ranges of cost.
2. Understand the risks of staying open. "When a surgery center plans a renovation or expansion, closing down operations is not always an option, due to potential financial loss," Mr. Mulhall says. But staying operational carries risks, too, such as lack of patient or staff safety, difficult working environments and noise, to name just a few. Also, structures have to be put up at extra cost to keep the construction zone separate, he says. For example, the work area needs to be in a negative-pressure environment and temporary walls may have to be erected so that dust and other contaminants don't leak out. Staff movement will also be constricted, with some areas entirely off limits to them as the work progresses.
3. Carry out construction in phases. Projects can often be undertaken in phases to limit disruption and keep surgical volume high. "The beauty of doing a project in phases is that you can maintain surgical volume," Mr. Mulhall says. However, phasing requires working out a detailed plan and communicating each phase to staff. "The order of phases is important to reduce disruption," he says.
Mr. Mulhall says Merritt Healthcare, serving as management company for an endoscopy center that was expanding, recently participated in a five-phase construction project that added two more ORs and a total of 3,000 square feet of new space. Work started with demolition of the intended expansion space, then construction of new administrative offices, a business office and a waiting room. Once these areas were completed, ASC functions were moved into them. "Keeping the flow of patients moving through the existing two rooms was paramount to the overall success of this project," Mr. Mulhall says.
4. Engage staff early in the process. When the design team is formed, one of its early actions should be to start providing feedback on proposed plans to key staff members and gathering input from them. One critical mistake, Mr. Mulhall says, is not allowing staff to get sufficiently involved in planning. "Nothing can be worse than having staff that feel left out of the process," he says. In Merritt's recent project, three staff members were designated to serve on the construction committee. During the heaviest parts of construction, they met every week with the project superintendant, architect and management team.
"The staff was expected to deal with a certain level of adversity and disruption to their normal operations during the project," Mr. Mulhall says. Having staff representatives involved in the construction process helps staff members understand its impact on them. "It is important to spell out to staff how construction would affect operations, such as removing patients from the building," he says.
At certain phases of the endoscopy center project, "we had to be creative to get patients out of the recovery area after the procedure," he says. "Staff members were helpful in figuring out the best solution on how to do that." Staff representatives also helped disseminate updates on construction progress.
5. Include physician-owners in design details. Physician-owners should be involved in planning and choosing design details. "The finishes are important," Mr. Mulhall says. "In addition to floor plans and patient flow, physicians will want to approve details like wall coverings, paint and color patterns."
6. Designate an internal safety officer. When a center stays open during construction, a safety officer should be chosen from the ASC staff. This person should be trained by the safety liaison from the design-build firm in duties such as use of a safety checklist covering jobsite conditions. When construction takes place on evenings or weekends, the safety officer tours the facility the next day shortly before opening and goes through the safety checklist. "This person should have the authority to stop the work flow until the problem is fixed," Mr. Mulhall says.
One of the safety officers is in charge of modifying fire evacuation routes in the transition from one phase to the next. "New evacuation routes are required with each new phase and staff needs to be updated on them," he says.
7. Maintain documentation. The ASC should document compliance with all requirements during construction. "There should be detailed minutes of all meetings and other interactions with project representatives," Mr. Mulhall says. The documentation should be ready to show to OSHA inspectors and other officials who might be called to the facility in response to a complaint.
8. Inform patients before arrival. Inform patients of the renovation work well before they arrive at the ASC. Patients should be told of the project during the office visit with the surgeon and be reminded of it in the pre-procedure phone call from ASC staff and the call from the ASC business office, before they come in. "The patient should be afforded the right to ask questions," Mr. Mulhall says.
Make sure patients feel comfortable that the project will in no way impact their experience at the center. "Avoiding a negative reaction from even one patient is well worth the effort put forth by the physicians and staff," he says.
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