The Challenges of Opening a Community’s First ASC
Administrator offers tips for those considering a new facility or expanding an existing ASC
When Green Mountain Surgery Center opens in Colchester, VT, in the spring, it will become Vermont’s first multispecialty ASC.
An independently owned facility that is governed by a board, Green Mountain successfully navigated the state’s certificate of need (CON) process, sought Joint Commission accreditation, and started the survey process, according to John Paoni, administrator.
“We have to perform 10 procedures first. Once we pass the survey, we’ll be fully operational,” he says.
One of the reasons the Green Mountain’s founders decided to open a surgery center in Vermont was because local wait times are long for some surgical procedures, Paoni says.
“There is a huge need to offer ambulatory outpatient surgery procedures in the state of Vermont,” he says. “I stayed in a bed and breakfast for several months, and one person I stayed with said, ‘I just scheduled a colonoscopy, and it was four months before I could get in.’”
Like other ASCs nationwide, the new Green Mountain will offer a lower fee schedule than hospital inpatient and outpatient procedure fees, Paoni says.
“One of our prime missions is to deliver affordable healthcare to citizens of Vermont,” Paoni says.
The Green Mountain facility will include four procedure rooms and two ORs. Even obtaining permission for two ORs was a challenge as the organization navigated the CON process, Paoni notes. The easy part has been finding surgeons interested in working in the ASC setting. “The doctor culture here is totally amazing,” Paoni says. “They’re very down to earth, and they want to work with you and are very open to suggestions and ideas.”
In fact, the idea for opening the ASC came from surgeons who were tired of surgery waits at the hospital, he says.
“The doctors got together and said, ‘I’m getting bumped at the hospital. I go in to do a procedure, and I have to wait around until I can get in the OR, or if I finish the colonoscopy in 30 minutes instead of 40, they penalize me on my block time,’” Paoni says.
Paoni has received numerous calls from physicians interested in hearing more about the new ASC. Physicians employed by health systems have expressed interest in becoming independent, he says.
“A lot of doctors are very dissatisfied with being employed because they lose control over many different areas of practice,” Paoni says. “They’re starting to pull back and become self-employed.” Hiring nursing staff has been another challenge, although that also is going well, Paoni notes. Nurses interviewing at Green Mountain Surgery Center have been unfamiliar with how ASCs work differently than hospital ORs.
When interviewing nurses with specialization in gastrointestinal surgery or another type of surgery, Paoni explains that at an ASC, one nurse will learn pre-op, post-op, GI, ophthalmology, and every other area with the goal of becoming skilled at it all.
“When there’s time, you will be asked to clean the waiting room chairs because that’s how an ASC runs. Everyone jumps in and does everything,” he says.
Nurses also must be well versed on ASC regulations, including infection control rules, as a separate infection control or compliance department will not exist at Green Mountain, he adds.
“The nurses we’ve interviewed so far have been very excited about the idea of learning more and not being stuck in one specialty all the time,” Paoni says. “The hours are much more convenient for them. We run eight to five, Monday through Friday, with no on-call or nights or weekends, although we may do some Saturday procedures.”
Paoni offers some advice for those who may be considering opening a new ASC or expanding an existing facility:
• Know life safety requirements. “Make sure all fire-rated doors have the maximum allowable space on the bottom between the door and the floor,” Paoni says. “You need to know where the fire walls have fire-stopping insulation, which is a fire caulk applied inside the one-hour minimum fire barrier wall.”
When a fire’s temperature rises to 165 degrees, the wall material expands and completely fills the space inside the fire barrier wall, he adds. “Fire caulking is a big initiative, and it has to be done correctly.”
• Prepare for emergencies and disasters. Increasingly, ASCs must incorporate emergency preparedness into their building design, which includes active shooter and other terrorism events. “Our world changed [after] 9/11, and we all have learned to think differently,” Paoni says. “I was at another ASC when there was an active shooting event down the road from the building, and we had to put the facility on lockdown.”
What Paoni learned from that experience is that surgery centers often are not designed with this potential crisis in mind. ASCs can be made safer. “When we had an active shooting event, I had to post [employees] at the doors to let people in and out because we had to lock the doors,” he says.
One possible structural solution would be to design the facility to lock easily when there is an active shooter event. The door system could use employee badges to gain entry. This could prevent a shooter from entering, and it could allow all employees and patients to stay away from the doors and potential harm.
“We need to be prepared for an active shooting event,” Paoni says. “When you’re building and designing a new surgery center, you have to take these things into consideration. It’s all about the patients. At the end of the day, when you have greater patient outcomes, everything else falls into place.”
• Follow federal rules. ASCs must follow rules related to the Americans with Disabilities Act (ADA) for signage and design. For example, ADA-accessible countertops must be 28-34 inches high with at least 24 inches of space from the floor to the bottom of the counter to enable someone using a wheelchair to maneuver comfortably. Also, each door must be labeled with a Braille sign, Paoni says.
“You want your facility to be a shining example,” Paoni says. “If I brought my mom here, how do I want her to be treated? How do I want my facility to be presented?”
Adhering to all infection control requirements also is very important.
• Focus on marketing. “We have a website that will list all of the different types of services and procedures for the community,” he says. “We want people to know we’re here.” Becoming the first multispecialty ASC in the state is advantageous.
“There has been a tremendous amount of publicity and news articles regarding the opening of Green Mountain Surgery Center,” Paoni says. “The community is excited about this and is welcoming us.”
• Emphasize quality assurance. Since the Green Mountain ASC could test Vermont’s uncharted regulatory waters, Paoni also anticipates greater scrutiny by state regulatory officials. This makes it imperative to institute a quality assurance program and to be accredited according to nationally recognized standards.
“We want to make sure we do everything by the book, follow the rules, and set up a great facility to take care of everybody the right way,” he says.
(Editor’s Note: In 2018, Vermont lawmakers crafted legislation that would define ASCs and outline rules for obtaining a license, maintaining records, following health department rules, and more. However, the bill remained stalled in committee throughout the year and its future is uncertain. Still, Paoni says the bill’s status has not affected Green Mountain’s planned opening. Read more about the legislation at: http://bit.ly/2BcHCwi.)
Vermont is about to welcome its first multispecialty ASC. The facility's administrator explains what it's like to be a pioneer.
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