Regardless of repeated advice and recent history, physicians notoriously make three mistakes when they build surgery centers. They overbuild, overequip and overstaff. Any one of these mistakes can single-handedly sink a surgery center. Here's how to spot these errors and correct them before they can do too much damage to your project.

You've overbuilt
This problem becomes obvious as you examine the facility's overhead and analyze the fixed expenses. The telltale signs: excessive utilities, inappropriate rent and underutilized space. Your beautiful building that looked so good by design will become a cavernous drain on the budget soon after you officially open the doors. The easiest fix would be to put up walls and redesign your space, but that's not really practical. So make the most of what you need and minimize what you can't control.

Begin by asking your local utility companies for an energy evaluation. Think conservation. Install temperature-control methods and minimize heating and cooling when the center is closed. Consider adapting water users (faucets, toilets and autoclaves, for example) with timers and water-saving methodology to reduce usage. Have the security monitoring service install motion detection where feasible to turn off lights in unoccupied areas.

Take a hard look at the terms of the lease for the facility. Try to renegotiate. Consider the space currently underutilized and ask for a reevaluation of the leased space. You may be able to pay for less now with the agreement of increased payments as you expand the business. Be creative with your ideas. If you can close doors and isolate space, your landlord may allow for a minimum period of lease reduction in exchange for a long-term increase.

Consider renting the space that's not being used. Physicians may value the opportunity to expand their office space if very little re-work of the facility will allow for patient visits and exams. Keep in mind that you must rent to doctors at fair market value, but any income from this opportunity will help in creating cash flow and decreasing expenses.

You've overequipped
Let's face it: Surgeons like their tools and toys. And they tend to get stuck in the thought that they have to have everything they want and as much of it as they can. Oftentimes the result is an abundance of instrument trays and complimentary equipment crowding the space of your building and providing little return on your investment. And, most likely, you've established an equipment loan payable over many years for equipment you'll hardly use.

Take a hard look at what's being used and what's the true need for each piece of equipment. Determine how you could minimize any redundancy by standardization and sharing equipment time. This requires great compromise, strong coordination and communication between your offices, the scheduler and your fellow surgeons. Make do with less and be flexible in your needs.

Once you've determined that you may be able to live with less, at least for the time being, have a valuation done of the excess equipment and begin searching for a buyer. You may be able to return some equipment to the initial vendors. Their restocking fee may seem high, but better to pay the fee than to be stuck with the minimally used equipment long-term. And, if the vendors won't allow for a return, there are many used-equipment companies that would love nothing more than to buy yours and add it to their inventories.

Once you have the cash in hand, consider your options. The most logical direction for the money would be to pay down the equipment loan, restructure the payments and minimize the debt. Having a good relationship with your lender will make the transactions possible. The need to purchase additional equipment in the future may be the carrot you need to make the deal attractive to the bank as well.

You've overstaffed
You've handpicked the employees and made every attempt to get the brightest and most talented in the area. But your case volume (notoriously low in start-up centers until managed care contracts are in place) doesn't pan out as you had hoped. The realization becomes apparent that your employees' salaries and benefits are out of line with the benchmark in your area. It's obvious that you need to reduce staff hours.

Registered nurse salaries will encompass the biggest percentage of your salary structure, so start here and analyze the abilities of these key players. RNs can cross over to many duties and allow for amazing flexibility in your staffing plan. An RN can perform the duties of pre-op patient processing, circulating the OR, scrubbing the procedure and monitoring patient recovery. The ability to schedule one person in different areas allows for a reduction in the total number of RNs staffed.

Determine how many staff members have the ability to work per diem rather than full time and create options for their flexibility by offering increased wages for minimal work time. Consider adjusting benefits to fit the needs of those that need the coverage but can live with smaller paychecks. If you fear you may not be able to cover all the duties once you've minimized the full-time employees, talk with area temporary agencies and see if you can negotiate short-term staffing coverage.

The key is to share
If working at a time you don't necessarily like will allow optimum utilization of building, equipment and staff, then do it. Adjusting your schedule to accommodate someone else's will come back to you as a payoff if you've helped minimize expense for the business. Standardizing equipment and supplies may be somewhat inconvenient at first, but long-term success will be more rewarding than having the best of technology and a mountain of debt.