Surgeons usually get involved with surgery centers because they want control. The question you need to ask yourself right up front: How much control?

We know that you don't want to be nailing the drywall yourself, but whom you hire for your development team will be determined by how much you want to do. You can hire a developer/consultant who'll do everything, so all you have to do is review and approve such major details as the blueprint and equipment purchases. Or you can hire a host of professionals, and manage each aspect of the project yourself, from accreditation to zoning, from your certificate of need to your certificate of occupancy, from managed care contracts to IT equipment, from medical gases to crash carts. Or you can (and probably will) do something in between, letting your building and professional services contractors do their thing and then supervising their work.

"Check to see that the water is clear. Close doors and make sure they shut," says Monica M. Ziegler, MSN, administrator of the Physicians Surgical Center in Lebanon, Pa. "Go through the construction facility frequently and see for yourself that things are working."

Perhaps the most crucial part of hiring a development team is making sure your team is multitasking rather than knocking down one task at a time. "It's like building a house," says Terri Gatton, RN, CNOR, CASC, surgicenter manager for Cascade Surgicenter in Bend, Ore. "As soon as you do it, you'll say, ?I'll never do it again.'"

Shopping for your team
The good news is that the outpatient surgery industry has progressed enough that you can find all your development team within it - dedicated professionals who've already made the mistakes you'll not want to make (many times these folks are all working for the same company). For example, you don't have to hire a hospital builder to do your surgery center. You can get lots of contractors with ASC-building experience. The same goes for developer, architect and equipment contractor. This is not to suggest there won't be problems.

"Things will go wrong," says Ms. Ziegler. "Address them as quickly as possible to get them in the warranty phase or on the punch list. Involve all staff in the generation of the punch list and monitor it closely, staying in contact with the contractor until all is 100 percent complete."

Whether you do no more than sign up a consultant/developer or you personally hire every position, you'll need to do your homework. You should check the references of every person you hire. If you're getting a consultant/developer to do most everything for you, you should call as many of the consultant's clients as possible. "It's a basic, but people still don't do it," says Ms. Gatton. "It's like buying a car. Everyone knows they should get on the computer and do research, but how many of them do?"

You'd better do it. Gayle R. Evans, RN, BSN, MBA, the president of Continuum Healthcare Consultants of Kennesaw, Ga., urges you to check references, concentrating on new centers and those under construction. "No reference is as good as the last reference," says Ms. Evans.

Professional services
Here are some things to think about when you're assembling a few of the members of your development team:

• Healthcare consultant. A consultant/developer is a mandatory part of your development staff. But that might be all you need. Some consultants can hire everyone you need, structure your ASC, supervise the building and equipping of your facility, and handle all the paperwork. These consultants come in all shapes and sizes. You can find them through advertising, on the Web or through word of mouth. This person could do it all for you, or might handle everything but the parts of the project you want to involve yourself in.
• Lawyer. Most folks don't use a lawyer much beyond the organization papers. That can be a mistake, says Ms. Gatton. There are a lot of issues that have legal ramifications, where lawyers experienced with surgery centers can be a big help. "Safe harbor laws are complicated," says Ms. Gatton.

Whatever you do, don't use a rookie for the legal documentsthat organize your center, says Fred W. Ortmann III, of Ortmann Healthcare Consultants in Columbia, S.C. "You don't want to pay for the learning curve of a lawyer," he says. "An operational agreement should cost you no more than $20,000 to $25,000. But I've seen bills four times that much."

• Architect. You should get an architect who has experience building ASCs, of course, but you should also try to find one who has designed a facility of your specialty, says Ms. Evans. For example, when William Cast, MD, and his partners built the country's second freestanding ASC in 1972, they designed their facility like a hospital operating suite. "In essence, like Henry Ford's assembly line," says Dr. Cast. "Patients entered at one end and came out the other, though later experience taught us to design our flow in a circle so that a smaller staff of nurses could see both incoming and outgoing patients."

An experienced architect helps in other ways. A good one will scrutinize your business plans and see if you've made any obvious mistakes. You might only need one OR, and an experienced architect can be the one who lets you know.

• Builder. You might want your architect to take handle your relationship with your builder. Or you might have your consultant/developer handle both your architect and builder. But if you do get involved, there are a couple of things you should think about.

First, review blueprints and envision movement of people and stretchers in the space provided, says Ms. Zeigler. Also, review the credentials of the general contractor and all the sub-contractors. "Where certifications or licenses are required, see them up front before hiring a contractor," she says.

Keep in mind that builders will design contracts to offload as much risk as possible. If possible, look at a builder's books to see if you can get a clue as to its costs and its profits, says Donald R. Able, associate principal of BSA LifeStructures, an Indianapolis architecture and engineering firm that specializes in healthcare.

• Equipment planner. An equipment planner should be more than someone who gives you a price list. An equipment planner should be able to find solutions and steer you right if you're purchasing more than you need. Ms. Evans suggests looking into remanufactured equipment, which can represent a tremendous cost savings.

400 steps
While surrounding yourself with highly trained, experienced professionals can help you make your way though the vast array of tasks involved in making a surgery facility successful, from start-up through operations, it's not the only option.

If you do decide to go it alone, though, make sure you do it intelligently. "Determine how much time your staff has," says Mr. Ortmann. "Usually your staff are better off in doing their jobs."

Mr. Ortmann has documented 400 steps to open a surgical center. These steps are all twisted into a complex whole. Often you'll find dozens of steps have to wait on early crucial steps. For example, before you start construction, you'll need city planning approval. Before you can order drugs, you'll need to complete a DEA applications. "You figure it out by trial and error," says Mr. Ortmann. "There's a sequence. You can't get a managed healthcare contract before you have your insurance written."

Good consultants who do it all, soup to nuts, are getting scarcer, says Mr. Ortmann. More and more, they want some equity for their efforts, forcing docs in some areas to choose between going it alone or giving over ownership to corporate partners (see "Scrubs or Suits: Are You Dressed for Success?" on page 38).