NACOGDOCHES, TEXAS - Five years ago, I practiced alone in an older building that had been both an office and a residence for an ENT specialist. I had a fully outfitted oral/maxillofacial surgery operating room where I performed procedures such as wisdom tooth extraction. We also did some minimal facial cosmetic work. It wasn't ideal in many ways, but it served my purposes.

But when Greg Tate joined our practice out of fellowship, everything changed.

	FACILITY: Oral and Facial Surgery Group of East Texas, Nacogdoches, Texas WEB: writeOutLink("www.eastexoralfacial.com","1","sb") IN SHORT: When an oral/maxillofacial specialist brought in a junior partner, things were too close for comfort. The only realistic solution was to construct a brand-new office with two ORs so they both could fulfill their potential.

Cramped quarters
First of all, having only one room created a bottleneck for our oral/maxillofacial work: I had to confine my procedures to the morning so that Greg could work there in the afternoon.

Second, it inhibited us from offering procedures that Greg was trained to do in the office. In addition to oral/maxillofacial procedures, Greg can do a wide range of plastic procedures, including flaps for skin cancers, blepharoplasties and brow lifts. It's possible to do many of these procedures in the office, and doing so often produces better patient care and better healthcare economics. Unfortunately, though, our operating room was simply not ideal for these procedures. The chair was a traditional dental chair and so it prevented Greg from positioning patients properly to do the cases. We didn't have a surgical light in that room; we both use headlights for oral/maxillofacial procedures, but for plastic procedures, Greg needed an overhead surgical light that would provide more diffuse illumination.

Third, because the walls in the old house were plaster, it was difficult to gracefully network our office to take advantage of new digital X-ray technology that helps improve quality of care and efficiency in oral/maxillofacial work.

Building out the old office was impractical; the only realistic solution was to construct a brand-new office with two ORs so we both could fulfill our potential. So we hired a local architect and got to work.

Design and accreditation
Because we knew we wanted to get the operating rooms accredited, one of our first steps was to consult with an accrediting agency (JCAHO) to see what requirements we would need to meet prior to design. However, the agency had not yet developed an office surgery accreditation program. Ironically, we ended up actually working with JCAHO through our state association to develop the office-accreditation standards that they now use nationally.

Not surprisingly, JCAHO had little guidance for us regarding the size of the ORs, so I asked our architect to pencil in two 18' x 18' ORs, one for me and one for Greg. I thought they should be roomy because we normally need four people in the OR, and because I wanted plenty of space for an anesthesia machine in case we decided to start using general anesthesia with an anesthesiologist or CRNA.

I informed the architect that the rooms needed to be plumbed for suction, oxygen, nitrogen and nitrous oxide, in such a way that it would be convenient to deliver anesthesia from the head of the chair. We also needed the room networked for our computer system. In our old room, as I mentioned, we used an X-ray box, but in the new rooms, we wanted to implement a digitized system for convenience and better quality of care. If you scan X-rays in and then magnify and add contrast, it really helps you find tiny details like nerve canals that course through the mandible. It's also great for precision measuring for implants.

Greg's OR ceiling needed additional reinforcement for an overhead light. The doors needed to swing, so that we could back through them after scrubbing. Both floors needed to be constructed of seamless linoleum, coved up at the walls.

I asked the architect to make the hallways wide enough to get gurneys through. We added a recovery room. And we placed our substerile room right between the two ORs, so that it would be convenient.

We added a consultation room so that Greg could talk privately with patients about plastic procedures.

Texas's requirements for office-based surgery are considerably less stringent than those for ambulatory surgery centers or hospital ORs. In Texas, you do not have to purchase a backup generator unless you have more than four patients sedated at one time. We did not need to install tile walls or washable ceilings. The state also did not require an expensive filtered air-exchange system.

The design phase of the project went very smoothly; the architect simply took my plan and converted it into architectural terms. We did have some surprises, though. We get a lot of rainfall in this part of Texas, and as a result the community required us to build a retaining wall and a "detention pond" to help prevent runoff, to the tune of more than $60,000. During the construction phase, the builders plumbed the gas incorrectly, forcing them to recut the concrete floor and redo the piping. Somehow, we also had a miscommunication with the builder regarding the air conditioning; we had wanted the southwest half of the building (the one with the ORs) zoned separately from the northeast portion. The builders claimed we had told them to zone east and west, and refused to redo the ductwork unless we paid them an additional $3,000. We have not done so yet, and as a result our ORs are warmer than we want.

Flying colors
We did get a break on equipment. We already had monitors, a crash cart and a hospital-grade sterilizer, so we didn't need to buy any of these items. We bought Greg a $6,000 operating table/chair so that he could do plastic as well as dental procedures in the office. The table lets him lay the patient flat if he wants, adjust the headrest and strap the patient's arms down for an IV. It's also much easier to wipe down than my dental chair. We also purchased Greg a $3,000 overhead OR light.

Our facility was completed two years ago and since that time we have been preparing for our office accreditation. This took place just recently, and we passed with flying colors.

Other than the air conditioning issue, we couldn't be happier with our new facility. We feel it helps us help more patients in more ways than before, with superior outcomes and considerable comfort and style.