Picture this. You've spent six months working like a dog on your new surgical center, and despite many hurdles, the drywall is up, the paint is fresh and you're ready to install your new equipment. You're home free. That is, until you discover your sterilizer can't fit through the three-and-a-half-foot-wide doors of the new facility, and you have to rip out the doorways and reframe them. Then, once you get the sterilizer in place, you can't set it up right away because you discover it needs a special water conditioning system. A week passes, you get the water conditioner installed, and now you're ready to go. You test-run the sterilizer, and it works! But because the fire-sensing system on the ceiling was installed about a foot in front of the unit, the heat sets off the water sprinkler system, causing water damage facility-wide.

Don't think this can happen to you? Think again, because each of these scenarios is true. "There are so many ways in which equipment choices cause unexpected consequences," says Scott Blair, director of medical equipment planning services with Surgery Center Services of America in Mesa, Ariz., "and there are thousands of ways to outfit a center." The good news is, you can prevent problems like this with some forethought and good planning. Here are six of the most important tips we gathered from a sampling of top equipment planners.

1 Plan early
If you don't decide exactly what equipment you'll need early on during the design phase, you'll lose time and money. Early planning is the most important rule of equipment planning, say our experts.

In many cases, the equipment helps define the design, and if you build your facility without knowing exactly what equipment you're going to be installing, you're asking for change orders later and long-term logistical problems. "If you don't define the size and nature of the spaces early on in the design process based on the specific equipment you plan to use, change orders will cost you in time, opportunity and money," says Ron Scales, director of equipment planning with FDI (Facilities Development, Inc.) in Phoenix, Ariz. Commonplace problems include

• overly narrow doorways that don't accommodate mobile C-arms and stretchers;
• processing areas that are improperly plumbed or too small to house new autoclaves;
• HVAC systems that can't compensate for the heat generated by autoclaves;
• too few or improper outlets (even for rented equipment like lasers) and
• a lack of equipment storage space.

Al Davis, FDI's senior project manager and equipment planner, offers this example: "There is a tendency to purchase a C-arm and design a storage alcove for it, yet forget about the need to house the CR reader. It is terribly difficult to realize late in the game that you failed to identify needs like this." Adds Mr. Blair: "After selecting a piece of equipment, you need to know more than just the size. You need to understand the specs - like the amount of heat loss, type of plumbing and water quality required by a new autoclave - because you need to know what to tell the engineers and architects. Getting the equipment is the easy part. Making it fit and function is the tough part."

Importantly, you also need to plan OR lights, AV needs and equipment booms as early as possible because these systems require infrastructure above ceilings and behind walls. Boom systems, for example, need to hang from reinforced beams, and you want to ensure that the beams are properly positioned in the OR. "This is what we harp on the most," says Larry Hampton, CEO of HELP International in Plano, Texas. "Are you going to consider booms and AV integration? If so, everyone needs to know now."

In a digital OR, he says, every piece of integrated equipment down to the OR tables will need compatible interfaces. "Not every system is compatible with every vendor, and every piece you buy can affect costs because you may be paying for wiring or telemetry as well as software licenses above and beyond equipment costs," says Mr. Hampton.

Another concern with waiting too long to order equipment is that you simply may not get it in time. "Many people don't understand that ASC projects usually start and finish much faster than the typical healthcare construction project," says Mr. Hampton. "The typical hospital project takes 18 months to 24 months, but the typical surgery center takes six months. And if you're working from an existing building, we can complete that faster than it takes to build a sterilizer or vacuum pump. If you don't have your equipment specified and bought early, you'll have an empty building."

Mr. Hampton says you'll be reasonably safe if you enter your purchase orders four months before you plan to start using the equipment. "The average manufacturing lead time is 90 days, but you need to account for other factors like credit approval, shipping, assembly, installation, biomedical certification and staff training," he says.

2 Budget for contingencies
Too often, say our planners, physician-owners and project managers compromise on their equipment needs halfway through their projects because they just don't have enough money in the budget. To prevent this, they recommend, always budget for contingencies. "Lots of attention goes into the construction budget, but surgery centers don't spend enough time with equipment budgets," says Mr. Davis. There are typically three reasons for inadequate budget planning, he says:

• not knowing exactly what you need early enough,
• not knowing the real cost of equipment, and
• not allowing for hidden costs such as inflation, installation and freight.

"Expectations can be unrealistic in the beginning," says Mr. Blair, "and it's important to do your homework up front. It will hurt you if you face big overruns and need to go back to the bank to ask for more money." Adds Mr. Davis: "In the past 16 months, we have had surprises because of the rising cost of energy and steel shortages, and you need to consider these possibilities in the budget." In addition, our planners universally recommend having the vendor, not the contractor, install certain pieces of equipment that require installation expertise, like OR lights, and ensuring that the budget reflects this up front.

3 Focus on functionality
When buying new equipment, it's a common tendency to want to overbuy. Check yourself, advise our planners. "Think about what type of surgeries you'll be doing and what you really need to get them done," says Mr. Davis. "You don't need to buy a Cadillac if a Volkswagen will suffice." Mr. Blair, who has expertise developing ophthalmology centers, offers an example: "Ophthalmologists who go to trade shows can walk away wowed by the new technology of an operating microscope. I saw this happen at a new cataract center, yet once the expensive new scope was operational, half of the surgeons couldn't even get a red reflex out of it. They were hesitant to return to their old-model scopes, even though these older scopes performed very well for their purposes, and they ended up replacing the scope with yet another high-end retinal scope. But, honestly, it often makes sense to buy what you know will work and save money in the process. Once you get up and running, you can always bring in a new scope and demo it to see if it works in your environment. I don't think it makes sense to be experimental when you're just starting out."

Another common trap, says Mr. Blair, is thinking too big - literally. Surgeons who come from hospital environments, he says, are so used to huge autoclaves, $20,000 to $30,000 OR lights and monster-sized scrub sinks that they have trouble downsizing. "Huge hospital-sized scrub sinks are overkill in an ASC, and they add six inches to eight inches to the cross-section of the entire building because you need a wider hallway, bigger sink insets and a bigger building overall just to make them fit the natural template of the facility," says Mr. Blair. "This represents a huge construction cost. Don't be oversold."

4 Coordinate
When deciding on your equipment, our planners agree, coordination is key. In part, this means getting everyone on board with the same basic OR equipment. This will not only aid training and workflow, but will prevent significant problems during construction. One of our planners provides this real-life example: "I recently had two surgeons who wanted a fully digital OR so they could do things like lower room lights, alter the OR table position and perform other functions with voice activation and touch screens. Yet, they both wanted their AV integration and equipment booms from different vendors."

Sixty days before the scheduled opening of the new ASC, and well after the walls and ceilings were in place, these surgeons opted to go with three different vendors - one system in one OR, one system in the other OR, and a third vendor who worked to integrate the equipment and ORs. The end result, he says, cost a lot of time, money and re-work. "We had to re-evaluate structural mounting issues, conduit runs, heat loads and electrical power requirements," he says. Among the changes: custom-built boom cabinets to hold equipment; new isolation power transformers to replace the less powerful ones already purchased and installed in the ORs; additional electrical outlets; and second sets of OR lights and tables to replace those already purchased. "The OR lights that were already installed and the OR tables on order were incompatible with the AV integration," says the planner.

Coordination also means buying compatible pieces of equipment so everything functions well together. For example, says Mr. Hampton, if you know what anesthesia machines you're buying, you can coordinate them with the medical gas system. "We have seen people run into problems making sure their anesthesia machines have the proper fittings for the medical gas systems installed in their facilities. Different manufacturers use different fittings, and while many gas system installers keep various fittings on their trucks, you end up with a pieced-together system that may not be aesthetically appealing, can be more subject to leakage and will definitely cost more," he says.

This may be even more critical when it comes to endoscopy equipment. Piecemealing these systems together, warns Mr. Davis, virtually guarantees image degradation. "When you're talking about endoscopy, you're talking about a system, and it needs to work together," he says. "Salespeople may tell you that different parts from various vendors will work well together, but customers invariably learn the hard way that this isn't so." Be sure, too, he says, to decide very early on if you're going to use a cart system or equipment boom to house your endoscopy equipment.

5 Investigate equipment prices
Find out the real value of the equipment you want to buy before committing to a price, say our planners, or you could get taken for a ride. "There are huge pricing variances in this industry," warns Mr. Hampton. "We have seen the same piece of equipment sold for double the price from one facility to another in the very same town." To be sure you're paying a fair price, he says, try benchmarking with other centers, issuing a professional bid or bringing in a reputable third party. Throughout any bidding process, advises one of our planners, keep a professional distance from the vendor. "A vendor might raise the price if the rep takes you to lunch and it goes well," he says. Adds Mr. Blair: "The most compelling sales pitch is usually the last one. It has nothing to do with how good the equipment is; it's how good the salesperson is."

It's also essential to evaluate costs beyond the list price. This includes freight, warranty coverage and preventive maintenance. "The service contract is crucial," says Mr. Hampton, "because if they ?give' on the price, they will ?get' on the contract." The same warning applies to add-ons, like OR table accessories.

If you're bringing in an equipment planner or other third party, be sure he is reputable. Mr. Blair recalls encountering an equipment list for a two-OR center that had a bottom line of more than $950,000 for the most basic OR equipment, excluding specialty items and other equipment like the medical gas system. "We took a look at it and couldn't get our price over $450,000. One piece of advice I always give is this: When you put the word out that you are building an ASC, it's as if you put blood in the water and you're surrounded by sharks. Everyone around you will be living off of you. Be careful whom you do business with."

6 Plan for the future
Finally, our planners all advise thinking ahead. When purchasing a new equipment boom system for one of her hospitals, Sydney Nye, an Illinois-based equipment management specialist, decided on a system that can be expanded in the future without reworking support structures or replacing any existing parts. "We didn't buy all of the features up front, but knowing we have this extra weight capacity and versatility is very important as the facility grows," she says. "I recommend avoiding an overly narrow focus on the procedures you know you will perform, and instead considering the possibilities, like which new surgeons might use your facility and what new specialties you might bring in."

This goes for the information technology infrastructure, too. "Technology planning is crucial for ASCs," says Mr. Scales. "Sit down and think about what you ultimately want to do with your information, your images, your data. The digital OR is much more than a simple electronic medical record." Concludes Mr. Davis: "Run adequate data lines and then run as many more as you can afford, and install data ports for future use. This will allow you to evolve in the future. Don't be short-sighted. Give yourself the ability to grow easily."