This article is written by Joyce (Deno) Thomas, Senior Vice President, Operations at Regent Surgical Health. The article was originally published by Regent Surgical Health and republished here with permission.
When we build a de novo surgery center, there is always a struggle between what is needed versus what is wanted, how much we should spend versus how much we will spend, and conflict between the physician partners. We can justify spending above and beyond the practical with phrases like "we don't want to outgrow the center," "we want to create a center of excellence that stands out from the rest," or "our patients expect the best."
In the words of a famous person I know, "You only need so many bells and whistles, the rest is for showing off." Having been engaged in over 15 construction projects during my career, experience has shown the ultimate success of your center hinges on the following recommendations:
1. Know your financial plan. Proper research and financial planning for a new facility may take up to a year. A first step is to determine who will utilize the center. During this phase you should only be counting members of the partnership. It's important to accept that the financial success of your center will depend on the doctors you have aligned with. Review the actual (not spoken) data for each physician's outpatient surgical practice. Work with your healthcare financial analyst to develop a preliminary proforma/budget that is solid. Use national benchmarking materials for the costs of doing ambulatory surgery business. Do not rely on hype from peers about easy money from high payer reimbursements. Financial prep time is necessary to set realistic expectations and to obtain loans for building and sustaining the enterprise.
2. Build responsibly. Overbuilding is an expensive mistake, both initially in added construction costs and later in fixed continuous costs that are determined by square footage, such as rent and utilities. Generally speaking, a well-utilized procedure room should be able to comfortably do 150 procedures per month, and each operating room should easily support 100 cases per month. This requires each partner to commit to flexible scheduling. Build your center based on the principle that it will open at 50 percent utilization, with the opportunity to grow to 80 percent. Eighty percent utilization is the time when a vibrant facility needs to begin thinking of expansion. Do not overbuild initially.
A lovely, clean surgery center is a true delight for our patients. Facilities that are ostentatious send a signal to patients, not about the high quality of care, but about the high cost. A nicely appointed, fresh environment with friendly staff results in high levels of confidence in care. Make sure to send the right message.
3. Choose the right architect. There cannot be enough emphasis placed on working with an experienced ambulatory surgery center healthcare architect. An architect with experience in building a healthcare medical office building, cath lab, imaging center or dialysis center without ambulatory surgery center experience may underestimate the building codes required for ambulatory healthcare occupancy. This can lead to expensive delays at the time of opening due to failed surveys and inspections.
4. Staff prudently. The coordination of the opening of an ASC is difficult and multi-faceted. There is a fine line between bringing on enough initial staff members to ensure an expedited opening that will generate revenues and too many staff members that are costly to the working capital. Each state varies in their willingness to coordinate the initial state licensure survey. The subsequent Medicare certification survey is unannounced and determined by coordination with either the state or an organization authorized to complete the Medicare survey. The lag can be six to 12 weeks before the survey occurs. The key people needed prior to opening a center are the administrator (four to six months); director of nursing (three months); purchasing coordinator (three months); one office person; one OR nurse, one surgical tech and one PACU nurse (prior to certificate of occupancy). Additional staff should be selected, screened and trained but in the wings waiting for a date of hire.
As your facility ramps up volume, schedule procedures vertically, adding the clinical and office staff according to good benchmarking standards. Always make sure to follow community standards of practice and nationally recognized criteria for nursing care. Hire the right people who love variety, thrive on challenge and are willing to do "other duties as assigned." The center is no place for prima donnas with attitudes of "it's not my job." Hire the right person and not your best friend.
5. Agree to consensus. The second most costly element of building your dream center is the purchase of equipment and supplies. Generally, part of the individual physician partner dream includes, "I want what I want, when I want, and I don't want to share."
Living out this idealistic dream is a costly endeavor and unrealistic. Work together to select high quality equipment that can be used by everyone, across specialties, whenever practical. An example would be video endoscopic equipment. Selecting only one brand of system has major advantages like a higher return on investment, decreased stocking of disposables used in conjunction with the systems, staff familiarity and redundancy in the event of malfunction. The specialty-specific attachments remain the same. This philosophy applies to supplies as well allowing for larger volume purchase discounts. Work towards the common good of the partnership.
6. Live up to your agreements. Simply stated, "Be a good partner." Support the center with your presence both in case volume and in the decision making processes. Serve on the board of managers or medical executive committee to ensure quality care is delivered. Follow the rules of the center.
The complexity of building a licensed, certified and accredited ambulatory surgery center requires a deep knowledge-based team pulling together for a successful enterprise.
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