Joseph Sziabowski, CEO of Hardaway Sziabowski Architects, and Ken Rosenquest, CEO of Constitution Surgery AllianceA driving force behind current ambulatory surgery center (ASC) construction and renovation is the push to accommodate higher-acuity cases, particularly orthopedics and spine procedures, that traditionally took place in a hospital setting.
Yet another driving force is steering in the other direction; lower-acuity cases are being moved into the outpatient setting to capitalize on more favorable reimbursement.
To make it all happen under one roof, it takes careful planning, thoughtful design and an experienced team.
“The biggest trend that’s driving a lot of ASC development right now is the inclusion of higher-acuity cases at the facilities,” Ken Rosenquest, CEO of Constitution Surgery Alliance, recently told Ambulatory Surgery Center News at the Investment & Operations conference. C“Complex spines and, certainly, total joint arthroplasty are driving a lot of our design decisions.”
Connecticut-based Constitution Surgery Alliance is an ambulatory surgery center developer.
When it comes to more complex procedures, physicians often expect the ASC environment to mirror or even surpass what they’re used to in a hospital, Rosenquest said. This can mean larger operating rooms (ORs), specialized equipment to accommodate complex procedures and creative ways to handle infection control.
“We’ve really kind of internalized a lot of the infection control concerns that [physicians] have,” he said, adding that orthopedic and spine specialists may be reluctant to leave the familiarity of a hospital OR for an ASC, especially if they have concerns about infection control.
“Moving those cases out of the hospital setting into the ASC setting, … it’s not a seamless kind of approach,” Rosenquest said. “Making sure that we are actually giving their patients as safe an environment as we possibly can, that we’re providing them a quality experience, and that [physicians] are operating in a state-of-the-art facility, is what’s driving that.”
Creating dedicated scrub areas or spaces that are separated from the main OR by glass, allowing vendors and other observers to be close by without necessarily crowding the sterile field, is one approach, Rosenquest said.
“One of the things that we’ve done is essentially set off our scrub areas into ante rooms, where, if you have vendors or other people who are not necessarily needed in the room but need to be at the ready, they can be there behind the glass, in a different area,” he said. “They’re not standing out necessarily in the hallway.”
This design element addresses both physician concerns about safety and the realities of modern procedures that may require on-demand technical support or additional equipment, he added.
Larger operating rooms are often necessary to accommodate the influx of technology, robotics and specialized instrumentation, Rosenquest said.
“With those larger OR [designs], you know, that’s intended to drive the ability to bring in larger spine equipment to accommodate robotic procedures,” he said.
Measure twice, cut once
There is a balance to be struck between the latest equipment and designs and what works for physicians, Joseph Sziabowski, CEO of Sziabowski Architects, told ASC News at the conference.
While some physicians might initially be excited about extensive digital integration or multiple monitors, the novelty can wear off.
“We find that most of the surgeons are less enamored with that over time,” he said. “They find that they’re back to just using our boom-mounted lights and, you know, the one video screen up on the wall as they go.”
Hardaway Sziabowski Architects is a Massachusetts-based health care architecture firm.
At the same time, lower-acuity cases are also moving into ASC settings as reimbursement shifts and physicians seek new ways to improve efficiency.
“There are cases that traditionally have been done in the office space that want to move to the ASC space due to reimbursements,” he said. “It introduces an interesting set of questions.”
And balancing both ends of the acuity spectrum can be challenging, as design features may differ significantly from one specialty to another. So a comprehensive pre-design phase is important to avoid pitfalls later, Sziabowski said.
“I think when we look at it, we kind of take a measure-twice-cut-once approach as we go through the early stages of planning,” he said.
For Sziabowski, adequate due diligence and site selection are paramount.
“Site selection is critical, especially when you’re doing fit-outs,” he said. “It’s due diligence. That’s certainly important in a new site, but when you’re going into an existing building, taking the time to carefully verify that there are adequate utilities, [and] … all things that you need to check out before you sign a lease.”
Designing for scalability, flexibility
Once the location’s viability is established, a well-documented functional program and basis of design can help direct the architectural process.
This documentation ensures that everyone understands the technical and clinical requirements before the blueprint stage, Sziabowski said.
“Equipment planning is also key,” Sziabowski said. “There’s a tendency to look for the best fit or best price, … but knowing the equipment that needs to be integrated … can really impact the cost and the timeline of design and construction.”
ASCs often find that the cases and volumes they plan for in the earliest stages evolve over time.
To future-proof a facility, Rosenquest and Sziabowski both suggested building in room for expansion. Many ASCs see a natural volume ramp-up by their fifth year of operation and should plan for that growth from the outset, Rosenquest said.
“Don’t overbuild your facility, and don’t underbuild your facility,” he said. “What we’ve learned is to design for the number of ORs you might need at Year 5, … and then maybe add another area that is a shell.”
Still, options will differ dramatically between ground-up construction and multi-tenant buildings.
“When you’re designing within the footprint of a building, you don’t always have those luxuries,” Sziabowski said.
In multi-tenant scenarios, operators might need to plan to “borrow” from administrative space. For instance, moving billing off-site, to recapture square footage for clinical needs.
“Storage can also become additional procedure space,” Sziabowski said. “But it can be challenging.”
Striking the balance between efficiency and comfort often means finding the “just right” amount of space, Rosenquest said.
In a recent musculoskeletal-focused, four-OR ASC, his team landed at about 16,000 square feet, including two large ORs at 650 square feet each and two slightly smaller ORs, plus a shelled-out area for future growth.
A more typical multi-specialty, four-OR center often hovers around 10,000 to 11,000 square feet, though the specifics depend heavily on the specialties, case volume and expansion strategy, Sziabowski added.
“It really depends on the situation, the client’s needs, and the specialties,” he said.
