As the administrator of a new surgical center, you have much to do, not the least of which is finding an anesthesia provider. My advice is to begin your relationship with an anesthesia provider as early as possible. Here are just a few of the ways that the proper provider can be a vital partner in your center's development and management.

1 Construction consultant
While your architect and contractors are very knowledgeable and your primary resources for all physical plant decisions, your anesthesiologist is an expert in operating room safety and environment. You should consult him regularly during your buildout.

Should you plumb for nitrous oxide and air? Do you need expensive line isolation systems or cheaper GFIs? (Do you know that stands for ground fault interrupters?) Do you really have to worry about explosive anesthetics? Are those gas outlets in the right place? Does that pre-op/PACU layout seem quite right? While in most cases a central gas supply for oxygen is necessary, plumbing for other gases may not be and electric safety solutions when not dictated by code may be interchangeable.

On a final walkthrough of a center, an engineer suggested that the lightswitches might be too low for flammable anesthetics. The idea of moving switches two days before state inspection caused a minor panic until I informed him - apparently for the first time - that no flammable anesthetics have been used in the United States for more than 20 years.

Poorly positioned suction and gas outlets aren't the only things that will negatively affect clinical functioning. So, too, will poorly planned spaces. I think back to one pre-op/PACU plan that required newly admitted patients, half-clothed from the dressing room, gowns billowing behind them, to parade past recovering patients and their families in order to get to their beds. When we asked why this was the case, the architect said it was the "best use of space." Best use for him, maybe; our treatment room is configured 90 degrees off the direction we need it.

While some of these issues may be unavoidable for structural or other reasons, reviewing construction details with your anesthesiologist can be a significant help in resolving errors before they are fixed in steel and sheetrock.

2 Purchasing pro
You'll need to purchase anesthesia machines, monitors, equipment and supplies, all very expensive. You'll court disaster doing this without consulting your anesthesia providers.

For example, monitors that a management company purchased cost $10,000 more than the ones my anesthesia group would have requested - had we been consulted. The monitors were a problem from the beginning and had to be replaced within the first six months of operations, at a premium, when they failed during surgery. Our group requested inexpensive refurbished anesthesia machines, instead of new and significantly more expensive ones, because they best fit the practice.

3 Medical director
You'll need a medical director to oversee the clinical care at your facility. This person should have a broad range of medical knowledge; be available for consultation; be knowledgeable about others on the medical staff; be willing to work with your clinical and office staff; and be familiar with and involved in policy and procedures development. The most natural choice for this position is your anesthesiologist. You should look for these medical director skills when considering your anesthesia provider.

Pay your medical director, whether anesthesiologist or otherwise, a fair market fee for his professional services. Skills, efforts and hours will vary greatly depending on the demands of your center. An important note: Your center must indemnify and insure your medical director for these activities, as his professional malpractice insurance won't.

Selecting the proper provider
OK, so how do you find this person? You want a partner. A provider with interests aligned with those of your center, committed to providing superior care in a profitable environment. Here are some questions to consider:

• Should you consider a locums or out-of-town provider? These providers may be necessary because of an unwillingness or unavailability of local providers. However, while these can fill an acute need, you'll find your center runs much smoother with a committed provider. My advice is to recruit a full-time provider when available. You'll probably look to a local individual provider or group. Your surgeons are likely to recommend someone they already know and a local provider's reputation in the community should be easy to obtain. Additionally, most local providers are probably already participating with the significant payers in your area, making it easier to schedule and bill patients and avoiding large out-of-network charges.
• Should you contract with an individual or a group? A skilled individual with contacts in the community who can help you get started when you're small and is willing to grow the anesthesia practice with the growth of your center may be just the partner you need. On the other hand, a large group with outpatient surgery experience may offer you turnkey coverage. If you're contracting with a hospital-based provider, do they have ASC experience? (Yes, an ASC practice is very different from a hospital practice.) If not, are they willing to recruit someone with ASC experience to help them learn?
• What special skills will your center require? Regional anesthesia and especially continuous regional analgesia techniques speed patient flow through recovery, improve patient satisfaction and may let you perform procedures that would otherwise require a hospital stay for its post-operative pain control. Will you be caring for pediatric patients? If so, at what complexity or age? Does the group have providers that are skilled and comfortable at caring for these patients? Are they willing to hire people if they do not?
• What type of provider model should you look for? An anesthesiologist-only group; a team anesthesia group of anesthesiologists and CRNAs - and, in some states, anesthesia assistants - working together; or CRNAs practicing under the medical direction of a physician other than an anesthesiologist? Although provider models vary significantly by locale, they're often dictated by community standards and tradition. In most situations, your center is going to follow these community standards. That said, as an anesthesiologist of 20 years and experience with all these models, my advice is that, at minimum, you should have a board-certified anesthesiologist in your facility whenever a patient is receiving an anesthetic or recovering from one.

Hammering out the contract
Now that you've made all of these decisions, all that remains is to formalize them in a contract. Remember that, just as in your selection process, in contracting you're seeking a partner with interests aligned with those of your center - committed to providing superior care in a profitable environment. An agreement is strongest when both parties understand the needs of the other and are freely willing to supply them. A forced agreement will be resisted and waste everyone's energy.

Your anesthesia provider will need accurate information to assess the viability of your project: payer and case mix, procedure type and volumes, realistic estimates of expected growth over time, the number of locations to be covered each day and your hours of operation.

What will be your self-pay, co-pay and balance billing policy? Will the center collect self-pay fees up front? An arrangement to collect anesthesia fees at the same time is wise.

Do you plan to have overnight-stay capability? If so, for what purpose? Is the overnight stay for comfort, nursing care and patient teaching; or are you planning procedures that may require emergency re-operation in the middle of the night? This is a profound difference, one you should carefully consider when contracting your services. If re-operation is a probability, will you be transferring the patient to the hospital or do you expect emergency anesthesia and OR support to be available at night? This topic deserves a discussion all to itself but, put very simply, there's no way that an ASC callback schedule will pay for its costs for anesthesia. If this will be required, you should expect to pay for this service.

In some situations, you may need to provide a floor or financial guarantee, especially to a smaller provider or where case volumes are inadequate to support a practice. While the idea of a financial floor causes administrators to cringe, if you've done your homework and your predictions are correct, then you'll never have to pay a floor or guarantee. In other words, you've just negotiated a cost-free way to secure the group you want by ameliorating their risk.

Anesthesia is your partner
Regardless of whether your anesthesia provider is a formal partner, he is a partner in your project, intimately involved in the daily clinical operations and success of your center. So begin your relationship early, take advantage of all the skills your anesthesiologist has to offer, clearly understand what you need and who you're choosing and, finally, contract rationally to enjoy a mutually rewarding relationship.