An outpatient surgery facility whose schedule is regularly booked and whose case volume is rising will inevitably face the question of whether to increase its surgical space to accommodate the growing business. While building new rooms onto an existing structure is a common solution among facilities of all sizes, there are a few factors that can keep surgery centers or outpatient departments from choosing that route. Adding surgical square footage to a facility without expanding its structural footprint is a comparatively rarely chosen option and can be a challenging assignment, but it is possible. Here, a panel of healthcare architects discuss where they found the space to expand in place.

Facing the limitations
Adding a surgical suite or a procedure room from the inside isn't unheard of. "The question always comes up, and it's always studied," says John T. Mills, AIA, ACHA, the hospital planning and design studio leader for Marshall Erdman & Associates' Madison, Wisc., office. "Providing additional capabilities without building on is always a starting point option that's compared to what building on would take. But many times it's left on the table because of the compromises it would bring to bear on the quality of the work environment and the quality of patient care."

In the end, the decision often comes down to a comparison of costs between building on and building in - which option's interruptions and changes in workflow would be less painful in the short- and long-term future - though there are more intractable factors that can force the issue.

"Certainly, cost is one of the main issues influencing whether to build out or renovate," says Curtis Chong, AIA, a principal at Boulder Associates Architects in Boulder, Colo., since the leadership of a growing surgery center may still plan and budget conservatively. "To what level of renovation do they want to go, at what cost and in what time frame?"

Physical space is another key issue. It's not always possible for a facility to expand out. Perhaps it's located above the ground floor in a multi-tenant building, says Mr. Chong. Perhaps it's landlocked in a hospital structure. If it's a ground-level facility, perhaps limited land, zoning restrictions or a required number of parking spaces will keep the exterior walls where they are.

Operational options
"There's no way to magically make space appear in an existing structure," says Todd Larson, AIA, a principal at Marasco & Associates in Denver. "Typically, if there's a facility that needs additional capacity, it doesn't have it."

There are ways, however, that a facility can accommodate additional volume without expanding its structure. For starters, the architects recommend conducting an initial investigation of your facility's operational strategies before you begin redrawing your blueprints.

Tom Stevens, a senior hospital planner for Marshall Erdman & Associates' Plano, Texas, office, says a changeup in your work processes can free up some OR space even without renovations.

"If your ASC extends its hours of operations an hour a night, or opens on weekends - even if it's just a half-day on Saturday - you'll increase your volume throughput," says Mr. Stevens.

While he acknowledges that this option may create staffing struggles, an administrator would be advised to weigh the costs of overtime pay or new hires against those of construction or, in the most desperate case, facility relocation.

Mr. Stevens notes that operating after standard business hours might be used as a benefit to your facility's advantage. "It can be part of your marketing campaign," he says. "Patients don't have to take a day off work on Friday for a minor procedure. They can come in on Saturday and recover over the weekend."

Another possibility involves undertaking a critical, revenue-focused review of your facility's case mix, says Mr. Stevens. By comparing the procedures that you host on the basis of how much you're reimbursed for them and how much OR time they tend to occupy, you can optimize the use of the surgical space you have by shifting the longer and less lucrative procedures for performance at hospitals or other facilities, thus freeing up space in your OR for the shorter and more highly reimbursed surgeries.

Additionally, he says, take the time to look at your scheduling process, both how it's planned on the page and how it plays out in reality. In particular, observe the efficiency of your recovery area when your ORs are working at capacity. While they're the last stop in the same-day surgery chain, recovery beds - if there aren't enough or if they're not used efficiently - can be "a speed bump in the surgical process" that causes traffic bottlenecks as far back as the waiting room.

Reduce, reuse, recycle
Admittedly, operational changes will only take you so far in accommodating more volume in an existing format. If those efforts have already been enacted, and if they aren't enough, the experts agree that you're going to have to explore your options in repurposing your space.

This is going to require some sacrifice, since most small surgery centers and more than a few large ones don't include much architectural filler and are often designed as efficient machines from opening day. "Most facilities don't initially build in wasted space," says Mr. Larson, remarking that unutilized square footage is difficult to design into the original plans and perhaps overly expensive to carry once it's been built.

An ideal situation, he says, would have been to plan ahead using the following rule of thumb: if you're building new and you project the need for expansion within three years to five years, build the expanded space now, but don't equip it, since it makes no financial sense to outfit an OR that will stand largely unused. If the need for expansion isn't anticipated until five years to seven years into the future, a better option would be simply building the shell for or drawing up a master plan for the additional structure.

Sure, designing in flexibility might have been a smart way to plan ahead for expansion or renovation, says Mr. Mills, "but anyone who's spent time in the facility management end of healthcare knows that most folks' crystal balls don't look too far into the future."

In the event that a facility faces unanticipated need, he says, you'll need to prioritize your space. Since expanding one area likely means displacing another when you're limited to the existing space, your analysis must determine what rooms and what functions are most critical to be left in place, and which can be consolidated, condensed or otherwise handled differently.

Mr. Stevens suggests considering whether the opportunity for spatial conservation exists in your pre-op and recovery areas. "The most critical time of day for pre-op is first thing in the morning," he says. "Recovery ramps up later." If it's possible, consolidating pre-op and recovery beds into a single area not only opens space that might be used for an additional OR or a new procedure room, but it also presents the option to share staff and support for increased efficiency in the pre- and post-surgical processes.

Soft space
While certain functions of a surgery facility are required on site for licensure or simply for effective day-to-day operations, others are convenient but not absolutely essential to house under the same roof.

For most outpatient facilities, the surgical suite is located toward the back of the structure, "behind several layers of other functions that patients and staff filter through before reaching the sterile area," says Mr. Mills. The objective, he notes, is determining how much of this "soft space" can be re-utilized for clinical needs.

Business operations, such as coding, billing and collecting workspaces and their attendant files, could easily be relocated off-site to other office space, says Mr. Larson, since they consist mostly of movable equipment and furniture and don't involve fixed infrastructure such as plumbing or gas pipes. Some administrative offices, meeting spaces or break rooms can also be moved outside or inside the building or reduced in size.

It's not uncommon for storage space to take a hit during any renovation, which always presents a thorny trade-off. "Storage is generally at a premium in surgery centers," says Mr. Larson. "You never have enough storage space until you use every bit you ever had."

The question is: how much of it do you need? "What is your most-used equipment?" asks Mr. Stevens. "What supplies need to stay close? It's great to have everything in one place, but you don't have to keep everything 10 feet from the OR door."

Depending on your location and your distributors, it may be possible for your materials manager to contract for "just in time" delivery of supplies, which can reduce the amount of surplus you'd need to warehouse at your facility, thus reducing the amount of space your general storage requires.

At the Longmont Surgery Center, an 11-year-old, four-OR, physician-owned, multispecialty ASC in Longmont, Colo., Mr. Chong's firm converted a 300-square foot general storage room into a GI procedure room and adjacent clean and soiled workrooms. In Mr. Chong's view, the 2003 renovation was a case of "the right room in the right space."

The main factors that made Longmont work, he recalls, were that the storage room was located at the back of the building, near the loading docks, allowing construction to co-exist with clinical operations without intruding on the sterile area, and that the storage room had two doors for dual access.

Mr. Chong says his firm repeated the success earlier this year at a surgery center in Santa Rosa, Calif., by relocating the business office to off-site quarters and converting it, and a staff lounge, into a 320-square foot OR No. 6.

Possible complications
A note of caution: Anyone considering expanding their surgical square footage in place must keep in mind the possibility that they'll face many of the same potential sticking points that show up in any healthcare construction project.

First and foremost, what impact will it have on your day-to-day operations? Can your facility deal with it? "When you expand in place, you're guaranteed a multi-phased project," says Mr. Mills. "Construction will be going on around you that you'll have to work around, or you'll have to close." Since outpatient surgery has clearly defined hours, he says, a third option may be arranging for contractors to get to work after hours.

Second, be aware that your changes may demand changes of their own. "We see this a lot with doctors buying buildings for ASCs," says Mr. Stevens. "When you go into a facility and start moving walls and updating things, whatever you touch is going to have to be brought up to code" - pre- and post-op bays may have to be wider, for instance, a new generator may be required, plumbing or ventilation may need an upgrade - "and that may cost you more space," not to mention more from the budget.

Also, he says, think ahead to consider the ripples your OR expansion may cause in other areas. "As a facility moves through this exercise, there will be upstream and downstream effects," says Mr. Stevens. "Not just in the number of pre-op and recovery beds, but in how the process works." Think of how an increased case volume would affect your scrub sinks and sterile processing department; your patient waiting room, with its reception desk line and seating; even your parking lot, with its dropping-off and picking-up traffic. These functions are all connected, he says. "Looking at the whole picture here, you can see that these are not money-makers, but they are satisfying patients."

Finally, be prepared for the unexpected, particularly when your builders are surprised. "We learn lessons, too," says Mr. Chong. He recalls a project during which an OR's old flooring was pulled up and new flooring put down. But the adhesive wasn't the same as what was used previously and absorbed moisture, causing the flooring material to buckle. "So you'll want to put a sealer on the concrete slab if you're on the ground floor, as surgical centers often are," he says.

Go with the flow
Adding surgical space without expanding your facility's footprint is not always an ideal option, the architects agree, and very center-specific even when it does work well. It's a project that's likely to only work one time. But if you find your workflow and patient flow haven't aged as well as your surgical center's business has, it can revitalize the way things work.