WATERBURY, CONN. - For many years, surgeons performed in- and outpatient cases in the same ORs at Waterbury Hospital. As the outpatient case load increased to about 65 percent of total volume, however, this co-mingling of cases became increasingly problematic.

Wait times for outpatients became too long, and sometimes, we bumped or delayed outpatient cases for more urgent procedures. At first, we considered renovating our 'vintage' OR suite, but we quickly realized that the downtime during construction would cost us cases and market share. Ultimately, we constructed a new outpatient surgery center attached to the hospital. The facility's proximity to the hospital enables us to perform some high-acuity cases and use the hospital's radiology service. About 3.5 years from inception, the $9.9-million, seven-OR Reed ASC opened. We now do about 16 cases a day but project up to 35 once the transition is complete. Here are some of the important things we learned during the past four years:

	FACILITY: Reed ambulatory Surgery Center, a wholly-owned subsidiary of Waterbury Hospital, Waterbury, Conn. WEB: writeOutLink("www.waterburyhospital.org","1","sb") IN SHORT: This 18,600-square foot ASC features 7 ORs, 15 recovery beds, 8 step-down 2nd stage recovery Barcaloungers, its own central sterile supply and a viewing room for two ORs where students/others can view cases and communicate via voice. Still, some surgeons initially resisted the idea of segregating their inpatient and outpatient procedures.

Design the ASC as an independent facility, even when it's not.
Although we are part of the hospital, we can best serve our patients when we coordinate the patient's entire experience. For instance, we are not dependent on the hospital for equipment or sterilization. We have two 4x4x4 Steris washer/disinfectors, two large sterilizers, and a flash sterilizer in a full-size central sterile/supply area. AORN recommends allocating 50 percent of the facility to storage, as accessibility to supplies is critical for efficiency. On the downside, we could not create our own entrance. Our patients enter our ASC through the hospital proper, where they register, undergo preop assessment, and walk or are transported 30 feet to our ASC. Admittedly, this can hinder efficiency and turnover time.

Budget a 5 to 7 percent contingency.
Build in natural lighting.
Natural light is a morale booster for staffers. Seeing the light of day can lessen depression and provide a more energetic work environment. We placed a strip of windows in each OR, complete with automated internal blinds for arthroscopic procedures. We also placed skylights in the PACU.

Solidify managed care contracts early.
Conduct walkthroughs.

Think twice about hiring an equipment planner.
Given our hospital's long standing in the community, local suppliers were more motivated to please us than a 'for-hire' equipment planner. Our engineering and surgical teams also knew exactly what equipment they wanted, and this helped keep our purchasing effort organized. The person in charge of purchasing, however, must have the time to accomplish this critical task.

Hire a local architect/design consultant.
Toward the end of construction, the project team must make many seemingly minor but important design decisions -such as placement of paper towel holders and soap dispensers, and oversight of the mill work placement, paint and other cosmetic features. Although these specs are predetermined in the original architectural design and may look good on paper, there is no substitute for seeing them in person. For this reason, the architect or design consultant should be on site weekly to oversee the final phase of construction.

Don't assume surgeons will jump on board.
Although you might think surgeons would embrace the idea of segregating cases and appreciate the resultant efficiencies, we encountered resistance. In fact, many of our surgeons preferred to do their in- and outpatient cases back to back and in one location. When our new facility opened, we initially transitioned uncomplicated outpatient cases such as cataracts, podiatry cases and breast biopsies over to Reed. It may have been less traumatic on our medical staff if we had segregated cases in the hospital beforehand by designating specific ORs as ambulatory and others as inpatient.

Look to the future.
While you can't predict the future, think ahead when designing your facility. We have data capabilities that we believe will take us through the next 10 to 15 years. In our ORs, we installed phone jacks and state-of-the-art 'CAT 5e' data cables for computer networking and data-sharing.

Today, we are proud to say we have seven 21st-century ORs and a staff that has exceeded the challenge of starting up a new outpatient center.