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As ambulatory surgery centers (ASCs) increase their market share, they often need to expand and renovate to meet new demands. Designing new space and living with adjacent construction can be challenging.
More surgeries are moving to ambulatory settings, helping create market pressure for surgery centers to expand.
Growth projections for the ambulatory surgery center (ASC) market suggest the value could reach $40 billion by 2020. As of 2017, the proportion of outpatient surgeries performed in an ASC setting has climbed to more than half, up from 32% in 2005. (Editor’s Note: Read more information about ASC growth at: ).
Market forces on the reimbursement side are driving demand for procedures in ASCs, according to Deb Sheehan, ACHE, EDAC, LEED, executive director of firm strategies for CannonDesign in Chicago. She says surgeries are moving from inpatient to outpatient, largely due to pressures on cost reduction and improving outcomes. Also, ASCs are expected to be more efficient, but many facilities are decades-old and unable to support the newest surgical technology. All these factors have led some ASCs to expand through new construction or renovations and expansions that will make room for more surgeries.
“The surgery center industry is maturing; some centers are 20-plus years old,” says Michael Patterson, FACHE, president and CEO of Mississippi Valley Health in Davenport, IA.
Mississippi Valley Health’s surgery center has been undergoing an extensive expansion and renovation. “Ours opened in 1996 ... and things have changed,” Patterson says. “We used to have one big open bay with curtains pulled between patients.”
The new renovation is nearly doubling (to 29) the number of pre-op and post-op rooms. Instead of curtains, there are walls dividing patients. There will be seven operating rooms in the facility — some brand new, others updated, reconfigured, moved, or expanded to accommodate future technology such as robotics, Patterson says.
“We’re adding new flooring, new paint, and new cabinets to the ORs one at a time,” he explains. “There are three brand-new ORs and four updated ORs.” The ASC’s renovation, which is ongoing, will increase Patterson’s facility space by 16,000 square feet for a total of 40,000 square feet, he says.
One of the chief challenges of adding new space and renovating existing ASC space is maintaining the surgery schedule while construction is underway, says Jamie Oldfather, manager of administrative services for the Mississippi Valley Health. “You can’t shut down your business for several months,” she says. “For me, it was important to not only work with contractors, but to work with staff to know exactly which sections we could phase off so we still had patient flow and staff flow without shutting down too many patient rooms.”
A key step when planning a surgery center renovation is to compartmentalize construction to adjacent occupied spaces, using HEPA filters. ASC leaders should be cautious with phasing to make sure they do not create any crossover paths with patient movement, supply movement, and staffing accommodation, Sheehan advises.
“It leaves us with little sequences of construction,” she explains. “Maybe we get 500 square feet at a time for the change, which is often the case, to maintain critical flows around construction space.”
Keeping construction dust and dirt away from workspace is crucial. ASCs must prevent hazards, but doing so will slow the project, Sheehan notes. “Whenever you have to daisy-chain like that, it elongates the time and cost of construction,” she says. “Often, there is some temporary move you end up doing, whether it’s displacing supplies or putting up contemporary barriers. That drives up both time and costs.”
Despite the challenges, ASCs can expand both their business and space simultaneously. Mississippi Valley Health performed 350 more surgeries in 2018 than in 2017 all while construction was underway on the expansion, Patterson says. “There continues to be patient demand, and you’ve got to pay for the expansion.”
Patterson worked with doctors to adjust procedure schedules. “Physicians were very patient and understanding during all of this,” Oldfather explains. “As long as you’re communicating with all of them upfront, it goes smoothly.”
Beyond these measures, there are other tips to help ASC leaders successfully plan and implement a facility expansion:
• Experts, technology help with design phase. A firm with experience in healthcare architecture and design assisted with the planning and design phase, Patterson says of his facility’s renovation. “We had multiple meetings for months with the architect and our staff — everyone from the front desk, OR nurses, pre-op team, post-op team, and others,” he explains. “We looked at what workflows were through the facility, what works well, and what facility issues were creating problems and not optimizing our patient flow.”
The renovation and expansion design was staff-driven and occurred over five to six months. Technology helped make the changes real to staff. “We had the privilege to work with a contracting tool where we could see the existing facility in a virtual world,” Oldfather says. “We had architectural drawings and a virtual piece where we could put on virtual goggles and get a feel for the flow of how things would work.”
The multidimensional aspect of design made it possible for people to see how workflow would work in the renovated space. “Some people can’t look at a blueprint and know what they’re looking at,” Oldfather says. “They physically have to see it. The virtual tool was a great advantage for us.”
The ASC also used a cardboard model of the renovated recovery room, pre-op room, and prep room, she notes. There were beds, stretchers, and chairs in the model recovery room for the staff to see how the furniture would fit into the workflow. “That helped them to see where they wanted the monitor hung and where the oxygen would be located,” Oldfather says. “It was a morale booster to see the model. And it was a good thing we did it because we made a couple of changes from what we thought would work.”
Staff learned that the space would be tighter than imagined. “We wouldn’t have recognized that on the drawing,” Oldfather notes.
• Make changes to maintain infection control and sterile processing. “We completely relocated sterile processing,” Oldfather says. “We relocated three operating rooms and recovery. We moved the post-op department and pre-op department.”
The new sterile processing area was moved to the existing pre-op department, and there would be a sterile corridor for the operating room. This put the new sterile processing room in a more central location.
“It’s difficult to put sterile processing on a different floor,” Patterson says. “We were adamant about it staying on the same level as the operating room. Everything is in a sterile corridor so no one is going up and down stairs with sterile equipment.”
Construction activity and dust create some issues for ASCs as they continue to work. Additional infection control measures must be followed.
“If you are working in the OR or in the sterile processing department and you’re cutting and creating dust, there is another set of protocols and barriers to follow,” Oldfather says. “Some require plastic tape barriers and some require temporary walls and HEPA filters and a series of requirements that come with the initial assessment.”
• Plan everything in phases. “The project was phased; Jamie worked with the general contractor to put together a plan,” Patterson recalls. “If you can shut down the place and rebuild it, things can be done much faster. But no one can afford it.”
For most ASCs, the renovation and expansion must occur in phases. “It takes longer because we’re growing our business while doing a large construction project,” Patterson says. “We don’t want to sacrifice patient satisfaction, quality, and employee satisfaction. The doctors still need to give care.”
The best way to meet all these objectives is to plan construction in various phases that fit in well with operational goals.
• Anticipate staff and space disruptors. “The biggest lesson we learned was to not underestimate the power of change to your team,” Patterson says. “We have a very tight-knit clinical team, but when you add square footage, you change the working plan. You cannot underestimate how that could potentially impact operations.”
This aspect of construction was a surprise. “Everyone was involved in the design and all wanted the change. When the new facility opened, the question was, ‘What do we do now?’” Patterson says. “Do not underestimate in your planning the amount of change required; nurses get set in how they care for patients, and now you are asking them to change all of that.” The same is true for doctors and other staff, he adds.
The ASC helped staff deal with changes through frequent huddles and fun activities. “When we opened new phases, we had scavenger hunts with prizes to ensure [staff] knew where all emergency equipment was,” Patterson says. “They got a tour and could ask questions. We did a lot of that before we opened.”
Once the renovated ASC opens, it could take a couple of weeks for employees to develop new workflow habits.
“You can bring online one new area and then shift to another area and bring another one online,” Patterson explains. “Each time you bring something online, it’s a new dynamic that needs to be dealt with.”
Leading staff through the change was a leadership team project. “The entire team was deeply involved in that,” he says.
Financial Disclosure: Consulting Editor Mark Mayo, CASC, MS, reports he is a consultant for ASD Management. Nurse Planner Kay Ball, PhD, RN, CNOR, FAAN, reports she is a consultant for Ethicon USA and Mobile Instrument Service and Repair. Editor Jonathan Springston, Editor Jill Drachenberg, Author Melinda Young, Physician Editor Steven A. Gunderson, DO, FACA, DABA, CASC, Author Stephen W. Earnhart, RN, CRNA, MA, Accreditations Manager Amy M. Johnson, MSN, RN, CPN, and Editorial Group Manager Terrey L. Hatcher report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.