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The Right Ingredients for Building an ASC
A husband-and-wife team blend their knowledge in creating a successful practice.
BY PAUL N. ARNOLD, M.D., F.A.C.S. AND PRISCILLA P. ARNOLD, M.D., F.A.C.S.

The Arnolds' distinctively different past ASC experiences helped them meld the design of their own successful ASC/practice.

Our surgery center is somewhat unique in that we came to this project after years in separate practices with different surgical facility models.  

Paul's former practice in Springfield, Mo., was based almost entirely on cataract, cornea and glaucoma surgical care. He was performing surgery at a local hospital, and when he decided to leave this type of setting, he went on to design and build the first free-standing ophthalmic ASC in southwest Missouri. This clinic/ASC facility was award-winning in design and rewarding in function. He was the only surgeon of that ASC. He sold this practice in 1999 and temporarily retired.

Priscilla's practice in Monroe, La., was more comprehensively based, although surgical in orientation. After years of operating in a hospital-owned free-standing ASC, she became an equity partner in a joint venture, large multispecialty ASC. This ASC model had strengths that made it a positive practice and business experience, including working with numerous surgeons, multiple payer mix, excellent administration and a strong contract negotiating position. 

Our decision to develop an entirely new clinic/ASC in Springfield together was carefully considered. The experience we had previously enjoyed with ASC participation/ownership demonstrated that another ophthalmology practice could be enhanced with a new surgical center. Control of the design, staffing and operation were obvious advantages as well. Maximum efficiencies and more defined quality assurance processes could be achieved in a single-specialty facility. Lastly, facility reimbursement could provide an additional source of income for the beleaguered and undervalued ophthalmic surgeon. With this background, we decided to forge ahead to develop and build a clinic/ASC.

The Second Time Around

At the Arnolds' practice, they allow a family member or friend to accompany the patient to the ASC on the day of surgery. That person can see the surgery from a remote viewing room on a TV.

A primary goal of the whole design and construction process was to incorporate all the lessons that we had learned from our prior practice experiences. We developed a pretty extensive "Do & Don't Do" list. 

Step one was location. Paul was very familiar with the community and identified a vacant lot with two unique advantages. First, it was in the "Medical Mile" of Springfield, located between the two large hospitals of the city, and just one block from one of the major intersections in town. Secondly, this was the last island of undeveloped land in this desirable location.

Interestingly enough, since our purchase, four other major medical construction projects have been completed within the Medical Mile, and three of the facilities have associated ASCs.

We decided to design a smaller facility than either of us had worked in previously, yet still wanted to incorporate an OR, excimer laser room and an Nd:YAG/diode laser room. With our architect, who had designed Paul's first center, we determined what the minimal space and design requirements for state certification included. When designing an ASC, this is a crucial early step. Requirements such as handicapped bathroom access must be considered.

We worked long and hard to create a compact, efficient design for patient movement and work flow. Our ASC is 4,500 square feet and meets all state requirements. The only unnecessary, but state mandated, space is a "dirty instrument" room and three of the four changing rooms required per OR in Missouri, so we have four very nice patient changing rooms and use only one of them.

On the "do" side of the list, we both expected the facility to be attractive and inviting to our patients, and a pleasant atmosphere for our working day. The physical environment was a high priority for us, so we added top-quality furniture, carpets, wallpaper and local artwork. Our ASC is an integral part of the building housing our clinic, each having a similar canopied driveway entry. With the help of our architect, designer and PR firm, we developed a visual theme, which was used in our logo, signage and interior details throughout the building.

As some of their patients use wheelchairs, the Arnolds have created "wheelchair garages" to save office space.

Maximizing Space

We planned to have lots of storage, so we designed cupboards and cabinets in preop/postop, the sterile hallway, the OR and the sterilizing room. Happily, we still have some unused space for future needs.

The OR cabinets are built into one wall. The top second and third shelves are glass fronted; this allows direct visibility of the contents for easy access. These shelves contain items like IOLs, sutures, knives and drugs. The bottom drawers have large labels on each one indicating the contents. These drawers are filled with individually packaged instruments like specula, hooks and gauze.

The doctors have a small desk built in the sterile corridor for doing paperwork between cases. This contains reference manuals, all the scheduled patients' charts and a phone.

Since some of our patients need a wheelchair to move easily, we have built "wheelchair garages" into the walls. This allows easy access to the chairs, yet they can fold up and be parked out of the way.

We built a blanket warmer and refrigerators into the cabinets in preop/postop. We believe it is important to cover patients with a clean, warm blanket to help comfort them. The only part of their bodies that is exposed is the face – and this is then covered with a sterile drape prior to surgery.

Our goal was to build whatever we could into the walls to free up floor space. Why not apply this idea to the ceiling as well? Having worked with both types of operating microscopes, we prefer the ceiling-mounted style. Seriously consider where you install the ceiling mount; we would change the position of ours now, if we could. The open floor space makes navigating the OR easier, especially for the uninitiated visitor or new employee.

We also placed two speakers in the ceiling of our OR; this allows us to play soothing music during surgery, relaxing both the patient and the surgeon. We call this therapeutic type of music "audio Ambien." 

We have been able to economize on the OR space devoted to the anesthetist. We built our anesthetist's table into the wall. It can fold down when not in use, thereby making more floor space available. We have eliminated the anesthetist's cart and monitoring station by means of our self-contained patient gurney. We will delve into that next.

Equipment Recommendations

Within the sterile corridor, there is a work area that can be utilized by surgeons for making notes or doing paperwork in between cases.

Space-saving devices. Our stretchers have a battery-powered monitoring unit mounted at the foot of the bed (for monitoring blood pressure, heart rate/EKG pattern, oxygen saturation and respiratory rate). Oxygen is delivered in a "blow-by" fashion from a refillable tank that rests beneath the bed. Once the patient is hooked up to all the leads, there is no further need to change anything — until the procedure is finished. This Stryker self-contained, moveable eye gurney has worked very well for us.

In our attempt to keep as much space available as possible, we decided to use two tabletop sterilizers in our instrument prep/sterilizing room. Each of our Tuttnauer units can hold several trays of instruments. For us, that usually means one instrument tray and a phaco/I&A handpiece tray. The time involved for each autoclaving cycle is about 20 minutes —
10 minutes at 273Þ and 10 minutes to cycle up and down. If another surgeon is working seamlessly out of two ORs in such a facility, a third sterilizer may be required to keep up. We have counter space for the third unit when we need it.

Time-saving devices. One of the best new "devices" we have come across lately is the lopsided headrest. For surgeons who perform temporal surgery, there is the reoccurring problem of patients rolling their heads to the side opposite the operative eye. No matter how lightly the surgeon's hands rest on the patient's face, there is the annoyance of the moving head. This headrest prevents the problem and we no longer have to tape patients' heads and constantly remind them not to move. The headrest looks like the letter L on the outside and the letter C on the inside – the vertical component prevents the patient's head from turning away from the surgeon. We replace our standard headrest, fixed only by Velcro to the gurney, with this one prior to surgery.

To improve efficiency between cases, we employ several sterile covered metal trays or pans. One of them holds syringes of viscoelastic, non-preserved lidocaine, and intracameral antibiotic (when used) for all the cases that day. This is prepared before the first case is brought into the OR. Prior to each case, as the scrub is preparing the back table in gown and gloves, the circulator offers her the open tray. She selects the appropriate syringes from the sterile interior of the tray. The circulator then covers the tray again. 

Similarly, another covered sterile tray holds the sterilized phaco handpieces. We have found our phaco handpieces last longer if we wait until they are cool before using them in surgery. So, after the handpieces have been sterilized, they go into the sterile tray to cool before their next use.

Facility Suggestions to Improve Patient Relations

As surgery is a stressful event for patients, having a beloved family member or friend present can be reassuring. We found that one of the best public relations tools at our disposal is to help maintain the connection between the patient and his or her family during the surgical episode.

We allow remote viewing of the OR and the surgery.
A trained patient liaison accompanies the family member or friend into the viewing room to describe what is happening in the OR. In Paul's previous ASC, we had direct viewing by means of a room adjacent to the OR — with only a glass wall separating the rooms. Our present ASC employs a video connection to a viewing room adjacent to the reception room. Both ways work well.

Our video setup employs a computer with a large hard drive for coordinating video input/output and recording our surgery. The video input comes from a Canon room camera and a Sony 3CCD ExwaveHAD microscope camera. The output goes to a large plasma TV in the OR to a plasma TV in the family viewing room, and to an LCD TV in the doctors' library for visitors or staff in our clinic. One might also consider putting a monitor in the preop area so the nurses can see the progress in each operative case.

It is very important for the surgeon to speak to the family after surgery. In the hospital, this required that we change shoes, cover our scrubs, and walk to a distant family waiting room. In our ASC, we simply pick up the speakerphone after surgery without having to leave the OR — the family can see us and communicate with us directly. The patient and the family appreciate this openness.

After a brief recovery in the postop area, patients join their families in the postop counseling room, right next to the recovery room. The patient liaison sits down with the whole crew and goes over the postop instructions while they all enjoy a light snack. The patient and accompanying family and friends are all kept in the loop. This is reassuring to the patients who may not remember all their instructions.

The Benefits

The single best piece of advice we can offer is to visit ASCs of respected colleagues and don't forget to bring along your notebook and camera and ask lots of questions. The decision to invest in or build an ASC is one of the most important an ophthalmic surgeon will make in a practice lifetime.

A well-designed ASC can be a joy to work in, provide unparalleled efficiency and leave patients and their families with satisfied surgical experiences — even leading to patients looking forward to having their second eyes treated.

Paul and Priscilla Arnold, M.D.s are principals in their Springfield, Mo., clinic/ASC. Paul edited a book, The ABCs of ASCs, along with other ASC expert contributors. It is published by ASOA and can be obtained at www.ASOA.org. He has no financial interest in this publication.