Planning the Perfect Space 
The Effort to Build In Clinical Efficiency and Flexibility

By Kris Ellis

The creation of an optimally functional space starts before the actual design and construction of the facility begins, according to John F. Stephan, AIA, senior project architect with Marshall Erdman & Associates. “Advanced planning is really the key to making all of this work well; getting together with the people who are going to use the space to talk about what their plans are, near-term and long-term. With that knowledge, ahead of any design effort, then the design starts to avoid problems of inefficiency short-term and helps us to plan for expansion later on,” he says. “Also, if we know exactly what it is they’re going to be doing, procedure-wise, that helps us with the flexibility of the space as well. If we know, for example, that there’s a mix of cases in the operating rooms (ORs) and we know what that mix is, it helps us decide the size of the ORs in order to get the greatest flexibility inside the room. Advanced planning is really the key to making all of this work.”

Kirk Jiannacopoulos, MBA, project coordinator with Marshall Erdman & Associates, reiterates the benefits of advanced planning. “It’s very important to get the specific user groups of this surgery center on board years in advance, as you start this early planning process, because each user group that goes in there and uses the space has their own idea about what’s efficient and what isn’t,” he says.

Stephan points out that the planning effort should involve the person who will oversee the day-to-day operations of the facility. “We’ve had so many cases where a physician group, or a hospital, or a combination of the two has determined what they want to do — they know what their procedures are going to be and they start planning, but they don’t yet have a person designated to manage the facility. Invariably, that person will have some very keen insights as to how they think the center should be run.

The owners of the facility often hesitate to hire that person early on, because that means they have to pay them during a time period where they don’t yet have a facility that is producing revenues. But what happens is they don’t hire that person and they start building the structure, and before you know it they’re spending all that money during construction to make changes to make the facility adhere to what that manager is expecting it to be. Advanced planning also means hiring the right people at the right time to make sure that all of their ideas are incorporated into the facility before construction starts.”

Getting the most out of the ambulatory surgery center (ASC) also involves a detailed business plan. “Another pre-construction planning note to keep in mind has to do with a pro forma —25 that really needs to be done before people like us get involved,” Jiannacopoulos says. “If you understand your demographic base, your increase of physicians in the future, and the amount of revenue that you’re going to produce each year, that will make it easier for us to plan for future expansion from a preop/ post-op standpoint, and an OR standpoint. The people who don’t look at that come back a couple years later and want to add a couple ORs, for example, and sometimes the systems don’t allow it, the building doesn’t allow it, and the site doesn’t allow it. Understanding, from a financial standpoint, a five-year to 10-year projection is very important prior to us putting pencil to paper. Indirectly, that’s all tied into potential inefficiencies and inflexibility of the center.”

In terms of specific layout and space planning with an eye toward increasing efficiency, Glenn Dean, AIA, vice president of healthcare planning and design for Lillibridge Healthcare Services, Inc., frequently suggests several ideas. “I try to encourage a central sterile core that’s located in the middle of each of the ORs. For example, if you have a cluster of four ORs, in the middle of that cluster would be a central sterile core that houses sterile storage, drug distribution, and flash sterilizers,” he says. “It does require a little more corridor space in the facility, because the patients are entering the ORs from corridors that are on the outside of the core; they’re coming in from one side, where the central core is accessed from the middle. However, I think the efficiencies in the facilities that have utilized it seem to be very beneficial.

“Secondly, I try to encourage a centrally located nurse station that, if the governing authorities will allow it, will not only manage the pre-op phase and prep, but also the recovery,” Dean continues. “The nurses are usually cross-trained to deal with both protocols. Lastly, discharge directly from recovery, if the facility is set up to operate that way. Architecturally we need to respond to give the facility that capability.”

There are pitfalls that may be encountered in the midst of the design and construction process that can derail efforts to promote optimal efficiency. “I would think the single most detrimental aspect of this process would be if the players change,” Dean states. “If we’re working with a client, preferably they’ve identified who the director of the facility will be, hopefully from the beginning, but at least five or six months from when it opens. That person can then verify that everything that’s been done to date is valid for the way they want to operate the facility. If a new director comes in sometime during the process and says, ‘No, that’s not the way I want to do this,’ what latitude do they have to change direction? That’s assuming that all of the code compliance issues are dealt with and all the fundamentals are taken care of.”

Stephan points out that the location of the facility must also be considered carefully from the perspective of all potential users of the space. “I’m talking about physicians and staff as well as patients,” he says. “It depends upon where the referral base is. For example, if the physicians who are using the center are coming from a hospital, there’s a commute time to that location, and minimizing that commute is key to making sure that the physicians’ time is used most efficiently. If it’s not hospital-based and the physicians are based in this unit — maybe they have their exam spaces within the unit attached to the ASC — the location is less important as it relates to the hospital. Whether or not the patient referral base is such that they’ll go to a place that’s more centrally located to them or whether they go to a place simply because that’s where they’re referred to, that information is important to know when choosing the site.”

An ASC’s case mix may have a significant impact on how the interior is designed and laid out. Owners may also want to consider the possibility of selling the facility in the future, or changing its clinical focus. “If you do high-end cosmetic surgery, that moves into like a spa-type atmosphere,” Dean says. “The cost and uniqueness of that kind of facility makes it kind of a whole separate entity. We’ve done that, and if it does turn into a general surgery center facility at some point, it’s just very upscale. Most facilities, even if they focus on a specialty such as orthopedics or cosmetic surgery, they want to account for the future capability of selling the facility if they should choose to; they want to make it available to the open market.” In this sense, catering too much to a certain specialty, space-wise, could make it difficult to sell.

The future of ever-evolving technology and surgical techniques must be evaluated in order to allocate space properly as well. “For example, in the OR these days, I don’t think you can get by with 400 square feet or 450 square feet,” Stephan explains. “That used to be very common, but so much has been happening in terms of robotics and other equipment that needs to find a place in the rooms, so you need to plan a room that’s large enough to accommodate some of these extra modalities and then also plan storage space outside the ORs in case you need to get that equipment out of the room to fit something else in. All of those things need to be thought through in terms of what is the proper size of the OR.”

Accommodating Growth

Planning for the future expansion of a facility to integrate increasing case volume is something that should be considered in its initial design. “The most successful ASCs that we’ve seen expanded are those that allocated the space at the beginning of the project for expansion,” Dean offers. “For example, during construction of a particular surgery center, they went ahead and decided to finish that space out, so it actually opened with the newly expanded area that was built simultaneously with the rest of the facility. In other instances, we’ve provided space for six ORs and they opened up with four. Within a couple years went ahead and equipped the other two, so all of the recovery and pre-op areas were set up for a six-OR facility, but they just didn’t equip the other two immediately.”

“A lot can be done in organizing the flow through the suite so that when additions do occur, and if you’ve planned for them, you can add on to a space by going through what we call soft spaces,” adds Stephan. “In other words, you don’t want to tear down an OR in order to get to the other side of a wall to create a new OR. Instead you might want to go through an extension of a hallway that you know you can take out a wall and just keep going with the hallway. If you’re going to take out a room, maybe it’s a storage room; something that has less intense things going on than an OR or a soiled work room, or things of that nature. You want to take all of those big pieces of equipment and just stay away from them as much as you can when you add on to a building.”

“One thing that physicians don’t want to do is ever shut the center down,” Jiannacopoulos comments. “They want these additions to go on and they don’t want to know about it. Mechanical systems — we will usually size our mechanical systems such as fire protection, HVAC, med gases, for expansion, and that really doesn’t work if it’s such that you have to shut these systems down in order to tie into them. They don’t even want to shut down for half a day. If you need to shut the med gases down for a week to update those systems, that doesn’t go over very well.”

“As far as going in and taking out an exterior wall and extending a facility, I’ve never been involved with a facility that’s done that, but every facility we go in to talks about doing it,” Dean says. The potential of new construction projects to disrupt a facility’s current operations is a concern for him as well. “It’s best to just allocate the space [at the beginning] and then build out the size of the building to accommodate it, and then buy the equipment later.”

A good business plan can also be an asset in this sense to identify current and future needs in terms of space. Stephan explains that gauging how long it will be until expansion is needed is key. “That duration might determine whether you build some shelf space in order to infill it easily, or whether you want to just build what you need now and add on completely at a later time. It costs money to carry shelf space, but if the duration is short and the business plan can support it and afford it, it’s the least intrusive way to add on to the building. Oftentimes the revenue stream is such that they can’t afford empty space for any length of time. That pro forma is very critical to determine what can be done now and what can be done later.”

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