Now that the dust has settled and the sound of hammering is but a distant memory, three surgical administrators who recently expanded their facilities shared with us the trials and tribulations they endured, and the triumphs they enjoyed, while increasing the number of ORs at their command. If there are architects and contractors and equipment planners in your future, this article's for you.

Knowing when it's time
Since case volume is the lifeblood of a surgery center, a sustained rise in volume commonly leads to expansion. For the Castleman Surgery Center in Southgate, Mich. - once a 20-year-old ophthalmology practice with an attached OR - the demand of an aging population called for the efficiency of a second OR next door to the first.

"While the first procedure goes on in one room, the second patient and OR are prepared," explains Linda Phillips, RN, Castleman's administrator. "When the first procedure's done, the doctor walks over to the other room, the staff walks with him, and they're ready to go."

At the Ambulatory Surgery Center of Western New York in Amherst, N.Y., the boom in minimally invasive ophthalmology, orthopedics, podiatry, ENT and plastic surgery led the two-OR facility to double its ORs just four years after it opened.

"Five new physicians wanted to join the 12 already on board," says Joan Dispenza, RN, MSN, CASC, the center's administrator. "Physicians had cases they weren't able to bring here. There wasn't enough block time, and our surgery schedule was as compressed as possible."

Capacity was also a factor at the outpatient department of Advocate Lutheran General Hospital in Park Ridge, Ill., where utilization of the five ORs often topped 90 percent. "That's pretty tough to manage, when it's that high," says Cindy Mahal van Brenk, RN, MS, the director of operations for surgical services, GI and central processing. "We were having to shift some of our [same-day] patients into the operating rooms we kept open for trauma and emergency cases."

Adding on a few new ORs wasn't a workable option, though. First of all, the existing rooms were old - part of the building's original 1959 design - and small. "Technology is constantly changing and bringing in more equipment," says Ms. van Brenk. "It made the rooms very tight."

Second, the old rooms conformed to old state codes. "To build anything new, the only thing we could do was gut the whole thing," she says.

Look at what's out there
"Have you visited other facilities?" asks Loren Lamprecht, AIA, NCARB, president of Altus Architectural Studios in Omaha, Neb. "Administrators ought to come in prepared to say, 'We've visited three other surgery centers, and we like what they did there.' They just have to know what's out there."

An awareness of medical construction trends is as important as a pre-expansion analysis of needs, priorities and forecasts, says Mr. Lamprecht, though he warns against limiting yourself solely to what's out there right now.

Says Ms. van Brenk, "The way technology changes, you'll have built something for today, but you want to build for tomorrow, for two years out, if you want to keep up-to-date."

You don't want to just hire your architect brother-in-law to design your new ORs. Hire a firm that specializes in medical architecture and keep in mind that there is no shortage of firms that have designed surgical facilities. "Having somebody with a medical background makes all the difference in the world," says Ms. Phillips. "A history and experience in the business can really help them to understand your issues and better utilize your space."

Prepare for the pain
Todd Larson, AIA, a principal at the Denver-based medical architectural firm Marasco and Associates, always warns his clients early in the planning process. "You guys need to know," he says, "this is not going to be a simple or a painless process. Especially for remodeling situations."

Agreed, says Ms. Dispenza: "Early on, you learn that you have to have a sense of humor."

The warnings should likewise make their way to your staff, because everyone's routine will likely be altered. Mr. Lamprecht says this aspect should be thought out well in advance. "If you add an OR, are you breaking the flow of care?" he asks. "How do your instruments get from central processing to the OR, for instance? You may break the technique that's been established."

Ms. van Brenk agrees. "In healthcare, we're all creatures of habit," she says.

Ms. Phillips knows about the pain of renovation. The construction of Castleman's second OR was originally scheduled to take about two months. It ended up taking five. "It took longer than I think it should have," she says. "Be patient. Expect that it will cost more than you're quoted, and take longer than they say. Whatever the contractors tell you, you should double it."

To close or not to close?
In Castleman's case, the extra delay was especially painful. The practice had to shutter its only OR during construction of the second, due to their right-next-door design for scheduling efficiency.

"That meant we completely lost revenue," says Ms. Phillips. "We really didn't have a choice. Doing ophthalmology, you cannot take that chance of dust getting into the room."

Closing for construction versus working around the renovation is perhaps the most critical decision administrators planning an expansion have to make. While you may hear some architects boast about the times they've added ORs without sacrificing a single minute of OR time (the facility closes 3 p.m. Friday, contractors work round-the-clock through the weekend and the new ORs are ready for business Monday morning), Mr. Larson notes that "there will be downtime no matter what." Mr. Larson sees the decision as a balance: The amount of construction being done will directly affect the degree to which your center can function as normal.

"We actually went into the project thinking we'd be closing for a week or two weeks," says Ms. Dispenza. "The staff was concerned about this. But during this entire time, we didn't shut down." Continuity at the ASC of Western New York was maintained, she says, through temporary walls and rerouted access to maintain a sterile corridor, a contract that included a bonus for closing only a week (and a larger bonus for not closing at all) and the flexibility of contractors, who occasionally worked overnights and weekends.

Ms. van Brenk's hospital saw a similar contractors' schedule. "You pay double time for that, so you have to budget for it," she says. "But it's very unrealistic to think that all the work can get done during the day."

At Advocate Lutheran General, making seven ORs out of a five-OR footprint was a matter of pacing. First they eliminated one adjoining department and relocated another, doubling the available space. Next they got four new ORs up and running, renovated the largest of the previous five ORs, and moved pre-op and post-op into two more new rooms. They gutted and renovated the old pre- and post-op areas and ORs, moved the new pre- and post-op areas into the space, and made the two rooms they'd temporarily occupied into the sixth and seventh ORs.

"It was tough. I'm not going to say it was easy," recalls Ms. van Brenk. "But there was only about six months of actual displacement (for pre- and post-op)."

Remaining open was worth the temporary chaos, she says. "I don't recommend losing the revenue. In that period of time that you're closed, people could go elsewhere and become accustomed to the care they get at those places. I'm in a competitive market here."

What's it all cost? That depends on whether you're adding on or building out. The cost of building an OR in an existing medical office building may range from $120 to $195 per square foot; adding on may cost $180 to $290 a square foot, says Brian Shearer, a principal at Marasco & Associates. Include within your budget a pretty ample contingency fund - maybe as much as 10 percent of the total, says Mr. Larson.

Expect the unexpected
"Be ready for surprises," says Mr. Larson. "Things are going to come up that you aren't expecting ' so you've got to have your eyes wide open and work around them."

Those surprises may include documentation that doesn't accurately reflect the structure - as when plans to tear down a partition are suddenly complicated by the discovery of a long-hidden support column - or renovation plans that end up requiring the whole facility to be updated to code.

Then there's the utilities that keep the place running. "Do you have adequate mechanical and electrical systems to support the expansion?" asks Mr. Lamprecht. "Do you have enough supply there to meet the needs of the addition?" If the system was done "cost-consciously" when it was installed, you may have to choose between maintaining the old system while adding a new one, or redoing the entire system.

"At the very inception of projects, (clients) sometimes don't have these things settled," says Mr. Larson.

More than you originally thought
Keep in mind that you're most likely not just adding an OR. "The expansion that you're looking at is always going to involve more than just the space in question," says Mr. Larson.

By adding an OR, you're inviting in capacity that will need to be served by larger pre- and post-op areas, including allowances for privacy and family members, and a larger locker room for surgeons and staff. "It's a portion of the project that's often overlooked at first," he says.

"It's amazing, the amount of space you need just to add an OR," says Ms. Phillips. "Even for such factors as do you have enough parking? Or storage space for supplies and linens and records."

It's essential for these extra expansions and their role in the flow of patient traffic to be drawn up early, says Mr. Lamprecht, because they're not easy to include later. "While ORs are generally built on the perimeter, it's harder to add on more room in the middle, where pre-op and post-op have been landlocked," he says.

Lines of communication
As two months of closure turned into five at Castleman Surgery Center, "I can tell you, the surgeons were not happy," says Ms. Phillips. "I had to smooth a lot of ruffled feathers."

The key, she said, was constant communication. As the doctors saw patients in the practice's exam rooms and commuted to the hospital for surgery, "I was promoting the convenience for physicians and patients of having two rooms, of getting done faster," she says.

Ms. van Brenk recalls that, aside from seeking your surgeons' and staff's input and concerns and keeping them aware of timelines, changes and milestones, morale building is the most important communication you can conduct. "They were, of course, very excited to get a new department," she says. "That was their motivating factor, knowing that there was a light at the end of the tunnel.

"Keep your staff involved," she urges. "They're the people who are going to be living in this house. Keep them up to date. Then you can get their buy-in. They can own the project then."

Ms. van Brenk says she met at least weekly with the architect and contractor to discuss the timeline, budget and obstacles for Advocate Lutheran General's renovation. "You have to stay in close contact," she says. "And don't be afraid to push for what you want. They can give you what you want."

"I don't think you can ever communicate enough," adds Ms. Dispenza, something the ASC of Western New York staff even took to a personal level. "We sat and ate lunch with the contractor's crew. We invited them to our happy hours. I mean, they really kind of lived here with us during the renovation. When you bring that kind of personal component to it, then it's not just a job for them. Then they 'don't want to disappoint Joanie.'"

The aftermath
Once the hammering stops and the dust settles and is swept away, "construction is actually quite fun," says Ms. van Brenk.

Or, in the next-best scenario, effective. For Ms. Phillips at Castleman, "it was a hardship to close for a couple of months, but in the long run, it's benefited us." In the years immediately before the expansion, the center performed about 2,000 cases a year. In 2004, the number was 3,700. In addition, it's doubled its shareholders from four to eight.

"It can't have been that bad," she remarks. "Because we're doing it again." Her center is currently awaiting a certificate of need approval to build two more ORs. This time, however, closing up shop won't be necessary. Since the new ORs will be separated from the existing two by the pre- and post-op areas, temporary walls will provide protection. In addition, Ms. Phillips intends to avoid last time's delays by taking a more active role in the project's contracting, government and accreditation inspections. "You can avoid that time delay if you preplan these things well in advance," she says.

The ASC of Western New York is also planning to add two more ORs for a total of six. "Construction can be a scary thing if you've not been exposed to it," says Ms. Dispenza. "But expansion reflects the care that patients get here. It reflects the good outcomes we've had. We've built up a reputation for ourselves in the community, and it's a positive one."