It was 2022, and the 25-year-old, 2-room Vision Surgery Center in Jefferson, Indiana, was looking a little tired. The carpets were worn. The walls were dull.

“We needed paint, we needed flooring,” recalls Kristopher Pugh, MD, co-owner of Dr. Black’s Eye Associates, which operates the ophthalmic ambulatory surgery center (ASC) and 9 clinics in Kentucky and Indiana. “We just needed an overall facelift.”

Three years later, with the ASC approaching maximum capacity, Dr. Pugh is now exploring the construction of a new, 4-room ASC. “There’s no debt, we’re lean and mean, and we’re efficient, but it’s not the best thing for the practice to stay in that space,” he says.

Like Dr. Pugh, you may be thinking it might be time for a change. But be careful. There are right ways and wrong ways to level up your ASC. Exercising due diligence on the front end can prevent frustrating and expensive mistakes on the back end. Read on for advice from those who have been there.

 Weighing the Options

From a physical plant perspective, aging infrastructure, changing regulations; insufficient capacity for technology, patients and procedure volumes; and improving staff and patient satisfaction can all spark the need to revamp an ASC, says John Marasco, AIA, NCARB, a Denver architect.

But whether to do a basic cosmetic refresh, a larger remodel, or build an entirely new ASC depends on your goals and budget, notes Mr. Marasco, who specializes in health care facility construction.

“If you're talking about [updating] the aesthetics of your existing surgery center, that's one thing. If you're looking at adding a technology, like a femtosecond laser, that's another thing. And if you’re looking at adding capacity, that’s yet another,” Mr. Marasco says. “It really depends on what you're trying to do and where you’re trying to do it.”

For some ASCs, particularly older ones that still function well and accommodate current patient and procedure volumes, minor upgrades, such as adding a fresh coat of paint or installing new tile in the surgery suite, may be all that’s needed, says Todd Albertz, CASC, director of health care solutions at Eckert Wordell, a Kalamazoo, Michigan, architectural firm.

“It’s just like your house,” Mr. Albertz explains. “There’s nothing wrong with where you’re at now, but the colors are outdated and things like that. You want to keep your facility looking as fresh as possible. We’re all working to recruit and retain staff these days. People like to work in a clean, well-lit, pleasant environment.”

Amanda VanHoose, director of nursing at Vision Surgical Center, Jeffersonville, Indiana, adds that a well-executed update positively impacts patients. “Patients today expect a clean, well-maintained, and state-of-the-art facility. The environment directly impacts their overall experience and confidence in the care they receive,” she says.

Indeed, studies show that an attractive physical environment enhances healthcare staff well-being, job satisfaction, and productivity. A poor environment, on the other hand, increases stress and burnout, reduces productivity, leads to higher error rates, and even gives patients a negative perception of care quality.^1-3

One thing to keep in mind while making cosmetic changes is to avoid major modifications, says Mr. Albertz. Although ASCs are grandfathered into construction codes and standards when they are built, major changes such as moving walls require bringing the entire facility up to current codes and standards set by the Americans with Disabilities Act among other federal and state regulations.

The question then becomes whether to remodel/expand the current ASC or build a new one. Some operators may simply want to add room for new equipment, while others may want to expand the number of surgery suites. Still others are looking to add retinal, oculoplastic, and other specialties to their repertoire. For these reasons, Mr. Marasco says, a feasibility study of construction costs, staffing needs, equipment, and projected patient/procedure volumes and revenue is essential to making an informed choice.

“Every situation is specialized: what you’re trying to do, where you’re trying to do it, what state you’re in,” explains Mr. Marasco. “There are so many factors that are going to go into deciding, ‘Is this a good idea or not?’”

Don’t Begin Until You Count the Cost

Deciding whether to renovate, expand, or build a new ASC is often a matter of affordability, says Mr. Marasco, noting that it isn’t unusual for either approach to reach millions of dollars.

Mr. Marasco, who has developed a matrix for estimating current ASC construction costs based on square footage and location in the United States (Figure), says performing a thorough cost analysis at the outset is the only way to nail down a precise figure.

“There have been times a client wanted to expand an existing ASC into a vacated suite next door. After determining the requirements and thus the cost of making that happen,” he says, “the next question was, ‘If I go buy 2 acres of land and build a new one, what's that going to cost me?’ When the cost delta between options starts to narrow, projects can quickly move from an expansion to a new build.”

Keep an Eye on the Details

In all cases, ASC leaders must be mindful of logistics and regulations around materials and finishes. Except for building a new facility, for example, cosmetic updates may have to take place outside of ASC hours. This can mean paying a premium for night and weekend work, says Mr. Albertz.

It may or may not also require temporary downtime during more extensive remodeling, depending on whether sections of the ASC can be closed off to maintain the sterility of the surgery suites.

In addition, all materials must be compliant with state and federal health care facility regulations and codes. For instance, the industry standard for surgery suites is seamless welded flooring for infection control. Floors must also be able to withstand extremely heavy weight and usage, says Mr. Marasco.

“Clients like the real wood look of luxury vinyl plank floors, but for less money and easier maintenance,” he observes. “Although they work great in the waiting area, a general interior designer might think, ‘Oh, we’ll just throw that in the OR.’ You can’t do that. OR’s need a seamless coved flooring that can withstand the heavy point loads from movable equipment. There are approved flooring materials that are manufactured specifically for the tolerances of an OR, and if your interior designer does not know that it can be a costly mistake.”

Don't Go It Alone

Indeed, executing every level of improvement requires specialized expertise in numerous steps, from the feasibility study to space planning, schematic design, securing financing, regulatory compliance and managing construction. Working with architects and consultants experienced specifically in ASC design and development is essential to prevent costly errors, says Michael Patterson, DO, managing partner of Eye Centers of Tennessee, which operates an ASC and 8 other eye clinics in southeast Tennessee.

“There are too many regulations to mess up,” says Dr. Patterson. “If it costs you $200,000 for an architect, but it saves you $800,000 on the back end because you didn’t mess something up, you’ve got to do it.” Mr. Marasco agrees.

“I heard of someone who built an ambulatory surgery center and never once talked with the state health department, the fire marshal, an accreditation organization, or any of the jurisdictions that were going to approve its use for Medicare patients,” he says. “You need to make sure that you are doing it right or else you may have to do it over again—and at a huge cost.”

Complex and challenging as an ASC improvement project can be, all the work will be worthwhile in the end, says Dr. Pugh. “The single specialty outpatient ASC for eye care is the best business and patient care model for delivering high-quality surgery,” he says. “It is a great problem to have to size up, and it’s worth every minute of your energy and resources.” OASC 

References

1. l-Ghwary AA, Al-Oweidat IA, Al-Qudimat AR, Abu Shosha GM, Khalifeh AH, ALBashtawy M. The impact of work environment on structural empowerment among nurses in governmental hospitals. Nurs Rep. 2024;14(1):482-493. doi:10.3390/nursrep14010037
2. Shetty RS, Kamath GB, Rodrigues LLR, Nandineni RD, Shetty SR. The impact of the physical environment on staff in healthcare facilities: a systematic literature review. Buildings. 2024; 14(9):2773. https://doi.org/10.3390/buildings14092773.
3. Lundstrom T, Pugliese G, Bartley J, Cox J, Guither C. Organizational and environmental factors that affect worker health and safety and patient outcomes. Am J Infect Control. 2002;30(2):93-106. doi:10.1067/mic.2002.119820