How We Shut Down Our ASC...And Opened An Acute Care Hospital

If your ASC has the surgeons and equipment to perform complex surgical procedures, it can be frustrating to lose cases that require an overnight stay to a local hospital. Some facilities build 23-hour or 72-hour recovery centers to handle overnight patients and increase the types of cases they can do, but at our center, we've gone many steps beyond that. We've just finished expanding our facility into an acute care hospital (we're also known as a surgical specialty hospital), and now we're one of less than 20 acute care hospitals nationwide specializing in surgery. We can keep patients for as long as they need to stay, perform almost any type of surgery, and still serve patients and surgeons with the same customer-focused "surgery center philosophy" that has always been our hallmark.

A complete reconstruction may not be in your ASC's future, but even if you're thinking of expanding your facility on a smaller scale, perhaps you can glean some lessons from our experience.

Beginnings
Thirty-five surgeons built our multispecialty, 16,000 square foot facility in 1984; I became CEO in 1985. Our center included four ORs, two minor procedure rooms (used for GI and urological procedures), and two eye laser rooms for YAG laser and argon laser procedures. Over the next twelve years we attracted a staff of more than 190 surgeons, built up our volume from 3,200 cases in 1985 to 7,500 cases in 1999, and became especially strong in general surgery, orthopedics, gynecology, and urology.

We handled fairly complex cases such as ACLs, laparoscopy-assisted vaginal hysterectomies, and some back surgery by offering home health care. For us, this was more cost-effective than building a 23-hour or 72-hour recovery center. More advanced cases, including hysterectomies, total hip and knee replacements, and trans-urethral resection of the prostate gland procedures were beyond our capability only because we could not provide the necessary post-op inpatient care.

How and why we expanded into an acute care hospital
In 1996, we performed an eye-opening feasibility study to evaluate the current and future surgical needs of our community. We worked with a local consultant with expertise in health care development to create a comprehensive feasibility plan and evaluated our primary service area (pop. 200,000) as well as the surrounding communities. We found that we were losing about 1,200 cases a year to two local hospitals only because we could not keep patients longer than 23 hours. Home health care and a recovery center would only take us so far - if we really wanted to provide the services we knew we were capable of and become a full-service surgery facility, we had to convert to an acute care hospital. In October 1996, we decided to start the process.

The design phase

After submitting an application to the California Office of Statewide Health Planning and Development (OSHPD), we quickly learned that building a recovery unit would be only a small part of the process. To be licensed as a hospital, we would also have to add and/or enhance our laboratory, imaging, pharmacy, and social services, accounting methods, clinical and nursing standards, medical record-keeping, and dietary services. We would need to meet stringent requirements for our governing body to ensure that they actively participated and reviewed all aspects of the operation. To enable us to focus on only non-emergent cases, we chose not to offer emergency services, obstetric services, open heart surgery, brain surgery, intensive care unit or cardiac care unit services.

Designing the center was truly a collaborative effort. We met with surgeons of all specialties to determine what they needed in the new facility, and we held town meetings and distributed surveys to involve community leaders and get feedback from current and prospective patients. We also met with insurance providers to ensure that we would meet their requirements for reimbursement.

We submitted our design to the OSHPD in October 1997. It took them 11 months to review every aspect of the plans, but they granted us a partial release ahead of time, allowing us to start building the foundation prior to final plan approval.

Construction begins
Since we planned to add almost 32,000 square feet to our facility, we fully expected to have to interrupt our services, but we never had to do so - in fact, we never even closed an operating room. We did this by keeping the existing patient areas and ORs largely untouched; instead, we built a large addition behind our main facility and connected the two buildings with two non-sterile corridors. Later, we added a sterile corridor connecting the four existing ORs with four new ORs. We also scheduled construction in the patient areas of the facility on the weekends and either before or after cases started. Throughout construction, our case volume actually increased - from 4,400 in 1997, to 6,100 in 1998 to 7,500 in 1999. By December 1999, our new facility was complete.

After completing construction, we went through several licensing and certification procedures, including state licensure and Medicare certification. We plan to become accredited by the Joint Commission on Accreditation for Healthcare Organizations next year.

The finished center
Our finished center has eight ORs, six treatment rooms and 12 patient rooms, with a maximum capacity of 23 patient beds. Here are some highlights:

- Safer, more efficient ORs: We designed all our ORs with anesthesia booms to keep the gas hoses and electrical connections off the floor. The booms keep our staff from tripping over the connections and allow our anesthesiologists to position themselves more effectively, depending on the patient's orientation.
- State-of-the-art sterilization: We collaborated with infection control specialists to design our central processing department, which has a series of three connected rooms that allow for a one-way flow of instruments. Dirty instruments are placed into a washer/decontamination unit in the first room, then sterilized in the adjacent room, and stored in the last room. Instruments are taken directly from sterile storage to the OR, preventing cross-contamination.
- A patient-centric environment: We worked with an interior designer to incorporate several innovative features to make our patients feel comfortable. Carpeted hallways and cheerfully wallpapered rooms are part of our decor. Our rooms give patients maximum control over their environment - for example, remote controls for lights, the TV, and a nurse call button are built into the bed rails. Special phone siderail attachments keep the telephone within easy reach. Each room has an easy chair that folds out into a bed, so relatives can stay overnight, and a chef runs our dietary department. Finally, a private elevator and discharge area allows us to release patients directly into the covered drive-up area.

Our motto at Stanislaus is "Idem Tamen Mutare," which is Latin for "same, yet different." We have the same license and meet the same standards as other acute care hospitals - the difference comes in how we deliver our service. We believe that our ASC background and philosophy enables us to be more focused on servicing our surgeons and patients with a warm environment, more personal service, and an involved, caring staff.

If you decide to convert your ASC
If you are considering expanding your facility to an acute care hospital, here are some things to keep in mind:
- Perform a comprehensive feasibility study: You need to make sure you will have the surgical volume and commitment from the physicians and community to support the facility.
- Know what is required: Remember that some states, such as North Carolina, require all hospitals to have emergency rooms; other states may have more stringent requirements as to what constitutes a hospital. Adding inpatient beds is not all that you'll have to consider.
- Make sure you are already strong in cases that may require inpatient care: If your facility is a single-specialty center, or you don't perform many complex cases, converting to a surgical hospital may be too big of a step. Offering home health care or building a 23-hour recovery center may be a better option.

This year, we project that we'll perform about 8,500 cases, including many advanced procedures that we were never able to attempt before. Even though we'll surely get busier, our main priority will be to continue to provide individualized care. We believe that this philosophy, in addition to our state-of-the-art facility, will help us become the premier provider of surgical services in our community.