Beyond the work of construction, you must address issues of state licensing, Medicare certification, accreditation and basic preparation in order to open your surgical center. These issues may seem overwhelming, but outlining them and monitoring their progress can make them manageable. From nine months before opening, here's a month-by-month guide to a startup agenda.

Nine months out
Here's where it all begins. Submit your application for state licensure and, if you're seeking Medicare certification, the 855B application. Check with your state authorities, though, as some request this be given to the state surveyor during their licensing survey.

Get to know your state surveyors. Establish communication with them and see if your state offers a course on accreditation that you might attend.

Elect or appoint your governing board members, as established within your operating agreement or governing bylaws, identify your medical executive/ advisory committee and define your staffing plan. Research and select the information system and software you'll be running. A system designed for ASC application is preferable to a practice-based product.

Six months out
Begin negotiating with your third-party payors and, with assistance from experienced legal counsel, finalize your medical staff bylaws. You'll also want to begin drawing up the policies that will guide the personnel staffing your facility.

Develop your credentialing policies and procedures in support of your staff bylaws, a corporate compliance or business ethics plan (once again, the assistance of legal counsel is advised), a HIPAA compliance plan (the ASC Association offers a sample program to help), a risk management plan (consult your malpractice insurance carrier or the ASCA for advice) and an infection control plan, keeping your state and accreditor requirements in mind.

Write up your mission statement, a performance improvement plan (once again complying with state and accreditor expectations) and an information management plan.

Last but not least, define your scope of services and identify the specialties you'll offer and the patient populations you'll serve. These boundaries will have a major impact on equipment purchasing and staffing decisions to come.

Five months out
It's time to seek your board's approval of the staffing benefits you'll be offering, which you've determined by scoping out what your competition provides, and to send out your credentialing packets to the physicians you've targeted.

Prepare your equipment needs list. I highly recommend an experienced equipment planner to assist in this. Some planning companies offer to be present for major deliveries and can even arrange for the storage of equipment until it's needed on site. Also, draw up a list of supply needs and collect your physicians' preference cards.

Since you can't work on site until you receive your certificate of occupancy, you'll also have to establish an interim office location by this point.

Four months out
Now's the time to hire an administrator, if you haven't already done so. The ordering of equipment should also be underway by this point, although it's important to determine the lead time necessary to do so. Some pieces of equipment may take six months to ship, while others may only take two weeks. Retaining an equipment planner to monitor these details may be helpful on this front.

Lock in your agreements and contracts with the companies providing all the nuts-and-bolts services, including anesthesia and medical gases, lab work and pathology, housekeeping and linens, transcription and pharmacy consultation, radiology and medical physics, waste disposal and pest control, HVAC and safety alarm maintenance. On the emergency preparedness front, finalize your hospital transfer and transport agreements and order the 36 vials of dantrolene that most states and accreditors require.

At two months out, hire your clinical and business staff. Don't overstaff. Estimate your projected monthly case volume and allocate one full-time business employee for every 100 cases, but note that you'll likely experience a ramp-up time and physicians tend to overestimate case volumes.

One month out
If you've received your certificate of occupancy, begin staff orientation. Schedule patients for surgery to fulfill the CMS's survey. Notify local emergency services that you're opening. Complete any physician and ASC ownership disclosures that your state requires. Prepare your application for an accreditation survey. The state survey takes place in two parts: the announced fire safety and administrative inspection, and the unannounced state licensure approval, which follows the surgeries you scheduled for the CMS survey. Third-party payors may require the separate accreditation survey before they'll contract with you.

This timeline may be altered by a state's certificate of need requirements or by whether the ASC is occupying a freestanding structure or an existing, multi-unit building. There will always be surprises in scheduling. With careful planning, you can limit unexpected roadblocks.