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Breathe New Life Into Your Facility
Three administrators explain how they successfully completed renovations and expansions at their surgical facilities - and lived to tell the tale.
Irene Tsikitas
Publish Date: January 10, 2009   |  Tags:   Facility Construction and Design

Expanding or renovating an existing surgical facility isn't easy. It's an expensive undertaking and, without proper planning and foresight, can disrupt your center's day-to-day operations. But if executed well, renovations can help rejuvenate your surgical facility, making it a more pleasant place for patients, visitors and staff and creating new opportunities to expand and diversify your caseload. Here's some advice from three facility administrators who've helped steer surgical renovation projects to success.

Perella Ambulatory Surgery Center at St. Mary's Hospital
Amsterdam, N.Y.
Before: 2 outpatient ORs; 4 main ORs; 16 patient rooms and 18 beds.
After: 3 outpatient ORs; 5 main ORs; 25 patient rooms and 27 beds.

Leave no stone unturned
The expansion of the ambulatory surgery center at St. Mary's (located on the second floor of the hospital's east wing) took place between 2003 and 2005 as part of a larger hospital renovation project. The ASC was originally added to the hospital in 1993, and the expansion was needed to accommodate the growing number of surgical procedures being done on an outpatient basis, says Director of Surgical Services Theresa DeCarlo, RN.

The expansion was planned with input from all stakeholders in the ambulatory care unit, from the administration and top hospital executives to the physicians and staff. "That was one thing we were very happy with," says Ms. DeCarlo. "The staff and physicians were able to have good input on our work area." It wasn't easy, though. Physicians, in particular, can be hard to corral, says Ms. DeCarlo. She sent personal letters inviting them to planning meetings and tried to schedule those sessions at convenient times, such as during lunch or dinner (with meals provided). "Be honest in telling people that if they don't give their input on the front end, they can't complain about things later," she says.

Planning for an expansion means "looking at every single little item that goes into each area and each room, from the garbage cans to the curtains," says Ms. DeCarlo. "Don't leave a rock unturned." Once you've determined all the new equipment that will be needed and any upgrades you want to do in existing rooms (they added flat-screen monitors at St. Mary's), Ms. DeCarlo recommends getting the manufacturers in to conduct trials well in advance. If you decide to go wireless or incorporate a new technology that's going to require special engineering and planning, you don't want to figure that out after the new rooms are built. However, Ms. DeCarlo cautions that once word gets out that you're renovating, you can expect a deluge of inquiries and even surprise visits by vendors. "I made a policy that I wouldn't see anyone without an appointment," she says. "When directors or managers get involved in these projects, you have to be diligent to make sure you're utilizing your time wisely, because you still have your everyday duties to attend to."

Workflow is another factor that shouldn't be overlooked in the planning process. The surgical department did time studies before the expansion to determine the average length of cases and length of patient stays. The results helped them map out how much additional bed space and work space they'd need to accommodate the projected increase in case volume. They ended up doubling the size of the waiting room, expanding the workrooms where endoscopes are reprocessed and physicians do their dictations, and expanding the outpatient teaching area where patients go for pre-op assessments.

Once the construction was complete, Ms. DeCarlo says, the new outpatient OR and additional pre-op and PACU beds allowed for a more steady, streamlined workflow, and the expanded work area helped clear out bottlenecks that had occurred when physicians lined up to do their dictations. Perhaps most importantly, patients and their families no longer felt cramped as they waited their turns. "Just to have a bigger waiting room was so wonderful for staff," says Ms. DeCarlo. "People weren't complaining as much."

How to Avoid Construction Chaos

During the renovation of our ambulatory surgery facility, we worked very hard to keep things running as normal as possible. Here's how to prevent new construction from disrupting your day-to-day operations.

  • Spread the word. Post lots of signs and talk to patients and their visitors about the project so they won't be alarmed by the construction. Keep staff informed by giving them occasional tours through the construction zone to see the progress.
  • Tone it down. Work with your construction crew to schedule the loudest work for weekends and evenings. You may need to build temporary walls to soundproof certain areas during the noisiest times.
  • Keep it clean. Soundproofing walls can also help prevent dust from traveling to your clinical and patient areas. Keep an eye on your entrances and exits; the comings and goings of construction personnel may leave you vulnerable to more dirt and dust finding its way into your facility. Have an infection control nurse make regular rounds to check the air and ensure that construction areas are walled up properly.
  • Know your builders. Have your construction personnel wear badges and make sure everyone on staff is familiar with who they are. You may also have to remind them that they're working in a healthcare institution — they need to be mindful of their language and careful not to leave tools out in the open.

— Theresa DeCarlo, RN

Ms. DeCarlo ([email protected]) is director of surgical services at St. Mary's Hospital in Amsterdam, N.Y.

Andover Surgery Center
Andover, Mass.
Before: 2 ORs; 1 procedure room; 4 PACU beds
After: 2 ORs; 1 procedure room; 9 PACU beds; private pediatric waiting area; 1,400 square feet of physician office space.

When ORs are off limits
A staple of its community for more than 25 years, the Andover Surgery Center is one of the oldest freestanding ASCs in Massachusetts. Because of the state's strict determination of need rules for ASCs, the multi-specialty facility doesn't have much leeway to build more surgical suites, says Executive Director Nancy Aucoin. In 2006, the 5,000-square-foot, physician-owned facility, which is managed by United Medical Systems, acquired an additional 5,000 square feet of space from a condominium directly adjacent to it. With twice the size but no legal ability to add operating rooms, the facility's leadership opted to overhaul the waiting room, recovery and work areas.

Andover's facelift wasn't just about size; it was about attitude, says Ms. Aucoin. The planners decided to turn the dark, aging facility into a brighter and more comfortable environment for patients and their visitors. Ms. Aucoin says they kept Andover's diverse patient population in mind when designing the waiting and recovery areas. "We didn't want to portray a wealthy, very high-end center. We did everything very soft and comforting." The new recovery unit, which had been getting crowded before the expansion, incorporates lots of natural light and warm, earthy colors. "We were fortunate that the building was originally built with lots of windows and skylights," says Ms. Aucoin. "When the patients are waking up from surgery on a sunny day, it's beautiful." The new waiting area is a bit splashier, with modern cabinetry, flat-screen TVs and a built-in fish tank.

Another major element of the renovation was privacy. The reception area now has a section separated by a wall where patients can register and fill out their paperwork, and a new pre-op work area lets nurses conduct phone interviews and do assessments in private. Ms. Aucoin estimates that about 10 percent of the multi-specialty facility's caseload is pediatric ENT. Taking that into account, the planners added a separate waiting room for pediatric patients — outfitted with toys and small tables and chairs — and two private pediatric areas in PACU.

Ms. Aucoin advises that you hold contractors to a strict time frame and build penalties into your contracts. The Andover project took less than a year from when the plans were drawn up in July 2007 to when the ASC reopened in January 2008. The ASC did have to shut down for the last five weeks, when the existing PACU was gutted and rebuilt, but most of the work was accomplished beforehand, says Ms. Aucoin. Upon reopening, the facility held an open house for patients and surgeons in the spring that was "met with huge success," and patient satisfaction surveys have been overwhelmingly positive, says Ms. Aucoin. "Our volume has increased 50 percent since we reopened," she adds.

The Ambulatory Surgery Center at University of Iowa Hospitals and Clinics
Iowa City, Iowa
Before: 6 ORs; 29 pre-op and post-op bays
After: 8 ORs, each equipped with new LED light systems; 29 pre-op and post-op bays

Never too early to upgrade
This freestanding, hospital-affiliated surgical center, originally opened in March 2007, wasn't even open a full year when it became apparent that it was going to need an upgrade. "We found ourselves in December of that year realizing we were running into capacity issues," recalls ASC Director Douglas Merrill, MD. The planners anticipated that the 45,000 square-foot facility would accommodate about 6,000 procedures per year; at nine-and-a-half months, it was up to 5,174 procedures. "We were getting in the upper 70s of percent utilization," says Dr. Merrill. "In my experience, when you hit the mid-80s of percent utilization, you start to see declines in efficiencies." Fortunately, the ASC was designed with future upgrades in mind: Two shell ORs were left at the far end of the surgical wing. To accommodate the growing caseload and intercept any potential capacity problems, the hospital began developing those rooms before the ASC's first anniversary.

A key feature of the ASC's design from the outset was standardization. Unlike many facilities that have mirror-image ORs, every outlet, lighting unit, cart and piece of equipment is in the same place and on the same side of the ASC's eight ORs. "Having everything built exactly the same way means any one of the surgeons can lock into any capability," says Dr. Merrill. In keeping with the standardized model, the expansion project created an opportunity to upgrade all eight of the facility's ORs with new LED light systems. Dr. Merrill says they had their eye on LED lights from the outset, but the models they wanted didn't have FDA approval by the time the center opened in 2007. Instead of just outfitting the new ORs with the LED lights one year later, they decided to upgrade all the rooms at once, giving everyone the same state-of-the-art technology to work with.

The two new rooms opened in July 2008, and the ASC is now averaging more than 30 cases a day, compared with about 24 cases per day before, says Dr. Merrill. The expansion also let the center diversify its caseload, freeing up OR time for retinal and GYN surgeons who hadn't been able to bring their cases over from the hospital due to time and capacity constraints.

Dr. Merrill points out that additional capacity brings additional challenges. When you add space and patients, you've also got to add staff, and most communities don't have a huge pool of people with freestanding ASC experience, he says. "When you do an increase in capacity, you're pretty much set with asking hospital folks to come in and do the job." Dr. Merrill says he was fortunate to find people who quickly bought into the ASC model, but keeping efficiency levels high is still an ongoing battle. "Once again we're approaching 70 percent utilization," he notes, adding that management has to be more diligent about monitoring throughput and making decisions about which cases are brought over from the hospital.