Mackenzie Skene

Mackenzie Skene

Partner, NBBJ
Throughout his more than 35 years of healthcare design experience, Mackenzie Skene has led projects for some of the country’s top academic medical centers. He lives in Seattle.

Want to Build a New Ambulatory Surgery Center?

Six Items to Consider Before You Start to Build Your Next ASC

January 27, 2020

Partner, NBBJ

Editor’s Note: This post was coauthored by Mackenzie Skene and Hao Duong. It was originally published in Becker’s ASC Review.

Ambulatory Surgery Centers (ASCs) promise to offer high-value services in a cost-effective environment. This is leading to tremendous growth, with the latest figures showing more than 50 percent of all surgeries in 2017 were performed in ASCs, compared to 32 percent in 2005. Organizations looking to capitalize on this trend by building new ASCs can do so, yielding expanded access, greater convenience and improved efficiency.

However, these benefits can only be achieved through careful analysis and preparation. Six ideas healthcare systems should consider:

  1. Improving access. 
    Bringing surgical services from the hospital campus to other communities may disconnect the ASC from ancillary support services. Consider what ancillary services are provided locally or served from the hospital. For example, centralizing sterile processing and pharmacy at the hospital may reduce costs, simplify staffing and maintain quality control standards. However, this may come at the cost of increased transportation demands, insufficient instrument and equipment availability, and an inability for staff to react to immediate needs. Recruiting and block timing can also be a challenge, as surgeon preference and access to outpatient clinical spaces for pre- and postoperative visits may be limited. This may result in patients bouncing between different facilities for everything from perioperative examinations to medications and durable medical equipment. Consider the thresholds that would trigger building redundant systems at the start of a project.
  2. Cost considerations. 
    Because ambulatory patients are typically healthier and undergo less complex surgeries than other populations, infrastructure requirements and room sizes are significantly less for an ASC. Even escaping the robust seismic and life-safety requirements of an I-2 hospital construction type can result in cost savings when compared to the cost of constructing a hospital surgery suite. But don’t expect all these savings if the ASC is expected to support more complex procedures. Building codes are slowly adapting to the trend where procedures historically performed in a hospital are moving to outpatient settings; and a certifying body can require the ASC to meet the standards of an inpatient surgery suite. Add in the high cost of construction and redundant staffing for local sterile processing and pharmacy, and the result can easily tip the cost scales. Consider whether accommodating more complex procedures erases the cost benefits of building an ASC.
  3. The 23:59 rule. 
    CMS states procedures requiring more than 24 hours (from intake through recovery) are not candidates for ASCs. As technology permits the execution of more complex cases in an ambulatory setting, organizations should consider providing additional provisions to patients who can go home within 24 hours but may want more time on site for education and physical transition. Some states already allow for extended recoveries, while others require that any such accommodation be distinct from the ASC and not offer direct medical care. ASCs considering this approach should talk to their local certifying body to work through the many details, ranging from clinical staffing to food services.
  4. Flexibility is key. 
    Designing a single-specialty ASC can maximize efficiency and reduce the need for extraneous storage, equipment variation and general overbuilding. However, this approach comes at the compromise of future flexibility, as elements not accommodated on day one may be cost-prohibitive to add later. Also, if an organization desires to lock in the future flexibility to perform many different procedure types by including them under their license or certificate of need, a certifying body may limit or revoke that license if the design only supports a subspecialty. Consider whether procedural flexibility is likely needed in the near future or just nice to have, and whether those components can be accommodated in other ways — like with a building that can be expanded.
  5. Building beyond essentials. 
    One appealing aspect of an ASC is the ability to build only what is essential. Operating room sizes can be reduced, perioperative spaces can be built for limited hours of service and infrastructure does not need to be as robust. With increased competition in the marketplace, though, an ASC should consider providing amenities for both the patient and caregiver. Adding a café can be good for families and staff, electrical outlets in furniture can keep people connected and comfortable beds to sleep on — not just a stretcher — can differentiate ASCs. Even a well-done integrated ceiling system in the OR can improve aesthetics and promote a cleaner environment. Consider what features might differentiate your ASC and attract more customers.
  6. Planning for emergencies. 
    Working with healthier patients does not mean procedures always go according to plan. As more complex cases are performed in the outpatient setting, relying on 911 for emergency situations may prove insufficient. A nurse call system may be necessary to augment communication among staff, and training a team to stabilize a patient while waiting for help may also be needed. Moreover, an ASC may find itself informally or formally designated as the default center for an individual or public health emergency due to proximity. Consider the difference between what is required versus what is likely to happen in the ASC, especially in rural areas.

The cost of constructing and operating an ASC depends on many factors. So, as an organization settles on the type and scope of a new ASC, a comprehensive analysis should be performed to confirm that this new project will provide the care patients deserve, and either increase revenue and lower costs, or alternatively move volumes from the main campus to another location.

Banner image courtesy Sean Airhart/NBBJ.

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Hurricane Harvey Shows the Danger of Not Planning for Healthcare Resilience

In the Absence of Government Leadership, Healthcare Providers Must Take the Initiative to Secure Their Patients’ Health

August 31, 2017

Partner, NBBJ

Editor’s Note: Portions of this post previously appeared on Modern Healthcare.

President Obama’s Executive Order 13690 — signed in 2015 — made it the official policy of the U.S. government to improve the resilience of communities against the impact of flooding. This included special requirements for federally-funded healthcare projects, including adding three feet to base flood elevation when building federally-funded hospital facilities in flood-prone areas. But it also extended to other types of projects, including assisted living facilities and even power generation facilities.

Unfortunately, President Trump revoked this policy on August 15, 2017 — ten days before Hurricane Harvey made landfall near Houston, Texas, and shut down at least 21 of the region’s hospitals.

Growing research that shows climate change will cause hurricanes of greater intensity, as well as increased risk for flooding, in coastal communities across the United States. In a flood event, every foot counts. Building three feet above flood elevation — as required by President Obama’s regulations — could mean the difference between full hospital functionality and a complete failure of electrical, plumbing and mechanical systems.

Take, for example, Hurricane Katrina. Flooding during that disaster closed more than half of the region’s hospitals — and all of the hospitals within New Orleans itself — immediately after the hurricane. Over a decade later, some of those facilities remain closed. We saw a similar event after Hurricane Sandy in New York City, which damaged numerous hospitals, including five which remained closed a month after the disaster hit.

Even after these storms — which combined killed at least 1,400 people and caused $183 billion in damage — there are relatively few formal protections in place to safeguard healthcare facilities from storms. We believe the solution to creating more resilient healthcare facilities requires a partnership between healthcare institutions, government agencies and professionals in the building industry. We understand that additional regulations are not always the right answer. But we are concerned with President Trump’s decision to revoke the executive order without adding any protections or considerations in their place.

My firm worked on two major hospital replacement projects in New Orleans after Hurricane Katrina. There, we instituted an “upside-down hospital” design strategy which placed critical infrastructure typically relegated to the basement high above flood stage, in some cases seven floors up. At University Medical Center in New Orleans for example, the first “mission critical” floor is located 21 feet above base flood elevation.

While it’s possible the rollback of President Obama’s regulations will save money in the short term, it will likely cost healthcare systems more in the long run. A study by the National Institute of Building Sciences found that every $1 of public funds spent on disaster mitigation saves society $4. LSU’s Hurricane Center also found that stronger building codes related to wind damage before Katrina would have saved $8 billion alone. It is generally cheaper to retool infrastructure before a disaster hits.

One bright spot: only projects with Federal involvement were covered by President Obama’s executive order — and by President Trump’s rescindment of it. We continue to work with private healthcare institutions, particularly on the Eastern Seaboard, who understand the stakes and are willing to make the necessary investments. And even Federal projects, with client approval, are permitted to exceed the current requirements — but they are no longer required to, and therein lies the danger.

Healthcare systems in the United States face a myriad of challenges, including increased operating costs, switching to a value-based reimbursement model, an uncertain political environment and rapidly advancing technologies. So it’s understandable that hardening against climate-caused disasters may fall to the bottom of the priority list. But we’ve seen what can happen when that is the case.

Image courtesy of Pixabay.

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