In the old fee-for-service, not-for-profit days, buying an OR microscope was a simple - albeit expensive - process. The surgeons asked for and, in most cases, got exactly what they wanted. Today, while physicians' clinical preferences remain a crucial factor, savvy hospitals and ASCs consider a variety of issues when planning a capital equipment investment than can range from $15,000 to more than $100,000.

"While it still funnels down to physician satisfaction, it's crucial to have all the facts before we make the decision to purchase a microscope," says Susan Roland, RN, the administrator of multi-specialty North Florida Regional Medical Center in Gainesville, Fla., a limited physician partnership owned jointly with a community hospital. The center owns five microscopes (three for ophthalmology and two for ENT). Here's how Ms. Roland and other administrators make sure that their investment proves wise.

Crunch the numbers
While it's difficult to determine the long-term impact of buying a new OR scope, you can cost-justify the purchase with a high degree of confidence.

Ms. Roland says her facility's starting point is to trend the volume growth of the specialty requesting the new scope. "The first step is to look at the cases we're scheduling right now," she says. "Is it still practical to use the equipment we have on hand or would an additional scope make the surgical day run more smoothly?"

For example, 25 percent of North Florida Regional's volume comes from ophthalmology, and the center attempts, whenever possible, to dedicate two of its six ORs to ophthalmology on its busiest eye days. When case volumes rose beyond the facility's ability to have a ready-for-action OR set for ophthalmologists to finish with one patient and immediately move to another OR for the next, it became clear the time was right to add a scope.

North Regional's next step is to project the long-term viability of the scope. To do this, trend your annual volume growth for each specialty to predict future growth. Then compare that number to the cases you'd lose when your volume threshold exceeds what you can handle with current equipment. "Lastly," says Ms. Roland, "we look at our payer mix and trend our charge and reimbursement data to determine how long it will take to generate the revenue to recoup the purchase and turn it into a profitable investment."

Ultimately, of course, the ASC owners decide. Hospital outpatient departments can undertake a similar, if more bureaucratic process. "Our hospital has a technology assessment committee and value analysis committee. We get surgeon input on the technology committee," says the nursing director of an Ohio regional hospital. Before the hospital purchases a microscope, the two committees study the proposal. "They look not only at the projected value of the scope to the hospital but also at issues of cost, service and equipment quality relative to available capital equipment funds."

If your facility determines that now is not the time to purchase a scope or to seek less expensive options, you can break the bad news to the surgeon armed with a legitimate rationale for denying the request. If the decision is backed by hard data, most surgeons can live with it. "Surgeons are usually willing to alter or withdraw their request if they're provided with enough information," says the nursing director.

Rate scope characteristics
If now is the time to add a scope, the next step to getting the right instrument for your facility is uncovering the characteristics and features your surgeons truly value and which they can live without.

"We knew the brand we wanted because we got 18 good years out of two of [the manufacturer's] scopes. But with the new ones, we didn't know at first how much microscope we could afford or even wanted," says Teri McDougal, RN, the practice and ASC administrator for the DeHaven Eye Clinic and Surgical Center in Tyler, Texas.

Ms. McDougal found her docs did not really need video compatibility and motorized zoom magnification but were unyielding when it came to the scope's optical resolution, true-color rendering and depth of field. Plus, she says, "it was nice to be able to get a couple of things the old machines lacked, such motorized XY axis movement and sterilizable handles."

Similarly, the nurse manager of a recently opened ASC in Michigan urged her docs to emphasize only what they need, because "we're a new center and controlling our spending capital is still a major factor."

A reader poll rated these as must-have characteristics:

• a stable floor stand that will not wobble while the scope is used,
• easy maneuverability,
• conveniently located controls and
• a comfortable eyepiece (especially important to surgeons who wear spectacles).

When surgeons rate the optics of different scopes, be aware that microscopes feature either halogen or xenon illumination. Xenon is the hotter, brighter light. However, if ophthalmology is your bread and butter, halogen is typically recommended because the intensity of xenon can burn the retina.

When you assess the secondary characteristics of a scope, be mindful of the specialties and procedures you'll use the scope for. For example, St. Joseph's Hospital in Chippewa Falls, Wis., uses microscopes for GYN and hand surgery as well as ophthalmology and ENT cases. What was most important to them? Not only the optical quality and motorized XY axis movement of the scope they bought, but also a scope that offered the surgeon a stereo view. Meanwhile, staff at a teaching hospital in Illinois wanted a versatile scope they could add video and other attachments to for GYN surgeons.

Do not neglect your facility's needs before you make a final determination of the features you need. Surgeons (unless they are also facility owners) may not consider whether the scope is physically conducive to quick OR setup and turnover or whether the handle can be sterilized or placed over a sterile drape. Your OR teams and infection control personnel, however, may remind you of these features if you solicit their input in the process.

An increasing number of facilities tell Outpatient Surgery they factor the preferences of nursing staff and other personnel into the scope-evaluation equation, too. "Remember, everyone from your board of trustees to your housekeeping staff has a stake in the microscopes you use," says Ms. Rol-and. "The scopes are handled by a lot of different personnel."

Ultimately, though, your phys-icians' preferences still take precedence. "Physician preference was the single most important factor in why we chose our eye and ENT scopes," says Linda Nash, MBA, CASC, LHRM, the administrator and risk manager for Manatee Surgical Center in Bradenton, Fla. "They're the ones using the scopes and they must be satisfied with the quality."

Consider cross-specialization
One way many multi-specialty facilities cost-justify a new scope is by using it not only for the specialty requesting the scope but also to host microsurgery cases for other specialties. "It's a more cost-effective way to get more value out of expensive equipment, especially when you can't get a different scope for each area," says the Ohio hospital nurse administrator.

Ms. Nash's center, for example, uses its ENT scope (which cost $31,000) for micro-discectomy procedures. Likewise, Debbie Webster, RN, the OR manager at Maury Regional Hospital in Columbia Tenn., says GYN, general surgery and ENT share the same $70,000 microscope.

While cross-specialization is often a creative way to maximize profit potential, it isn't always possible or desirable. The Children's West Surgery Center in Knoxville, Tenn., did not get requests for procedures for which they could adapt their ENT scope, says administrator Deborah Womble, RN, CNOR. Other facilities have had outside requests, but the scopes were either not compatible to the procedure's needs or they lacked certain attachments or features the center could not cost-justify based on volume.

Try before you buy
After narrowing the pool by researching different vendors and determining the preferences of the physician-owners, Ms. Roland contacted the selected vendors and arranged equipment trials at North Florida Regional. The vendors brought in their scopes and the docs tried them out in live cases for 30 to 45 days. By the end of the trials, the facility built consensus on which scope best fit everyone's needs.

Likewise, doing your homework on a variety of business factors, apart from the scope's price, can help you reduce guesswork involved in containing some of the hidden costs of purchase. "It's par for the course to ask your colleagues experiences with the equipment," says Ms. Nash. For example, you can learn a good deal about factors such as service contract costs and preventive maintenance requirements simply by networking with your colleagues.

Armed with this knowledge, says Ms. Roland, you can drive a hard bargain with your equipment vendors and get the best scope at the best possible price, including maintenance.

While Ms. McDougal only considered one manufacturer's equipment for her center, she did bargain for the terms of the service arrangements and has been pleased that the vendor delivered everything promised. "The service has been very good. We're very happy all around with our purchase," she says.

Think long-term
Because most facilities expect to get a decade or more of use out of their scope, the right scope is one that suits your needs several years down the road as well as today, says Ms. Roland.

For example, before her center expanded in 1999 (it opened in 1992), the physician-owners at North Florida Regional figured their post-expansion capital equipment needs - including microscope needs - into their strategic and budgetary planning. Managers at a four-OR ASC in California, meanwhile, factored their long-term plan to add hand surgery to their case mix into their decision to defer a request for a new ophthalmic scope and to instead buy a new ENT scope that they could also use when they eventually add hand surgery.

Lastly, just because one of your old scopes is outdated doesn't necessarily mean it's useless. The oldest of the five microscopes at North Florida Regional is now in semi-retirement. One surgeon who is simply more comfortable with his tried-and-true OR equipment still wants to use the old scope, and the facility keeps it in commission for his cases.