Narrator: 0:01
Welcome to the Advancing Surgical Care Podcast brought to you by ASCA, the Ambulatory Surgery Center Association. ASCA represents the interests of outpatient surgery centers of every specialty and provides advocacy and resources to assist them in providing safe, high-quality, cost-effective patient care. As with all of ASCA’s communications, please check to make sure you are listening to or viewing our most up-to-date podcasts and announcements.
Bill Prentice: 0:27
Hello, and welcome to the Advancing Surgical Care Podcast. My name is Bill Prentice, I’m ASCA’s CEO and the host of this episode. My guest on this podcast is Deb Yoder, vice president of clinical operations for Surgical Management Professionals. By education and training, Deb is an accomplished nurse with frontline experience in operating rooms, cardiac cath labs, ICUs and surgery centers. In her current role, she is responsible for overseeing the design and construction of new surgery centers and she has assisted with the development and equipment planning and successful Medicare surveys for 13 new facilities. Deb is also a frequent contributor on clinical and operational topics for ASCA and she’s joining me today at ASCA’s annual meeting in Louisville, Kentucky, where she was invited to teach a continuing education course on the planning and development of new surgery centers—something I thought would make for a great podcast for any ASCA member who was unable to attend her seminar. And with that introduction, Deb, welcome to the podcast.
Deb Yoder: 1:26
Thanks, Bill. I appreciate the opportunity and look forward to what we have to discuss today.
Bill Prentice: 1:32
Great. Well, thanks again for taking a few minutes to talk with me about your great presentation here at our annual meeting in Louisville. There’s obviously a lot to consider and a lot to learn for anyone considering the development of a new ASC, and your presentation was packed with so much useful information. I’m eager to talk about a lot of the useful advice in your presentation but before we begin, could you share with our listeners some of your background and experience, particularly as it relates to developing surgery centers?
Deb Yoder: 2:01
Well, I think it started as a child. When I was young, I wanted to be an architect and my mom said, “You can’t be an architect, if there’s ever another depression, you won’t have a job. You have to be a nurse.” And she had always watched General Hospital, so I’m like, “Okay, what the heck, I guess I’ll be a nurse!” And so, I was a nurse. I was an operating nurse for many, many years. Ran an OR department in a hospital and then started at a surgery center—multispecialty, really busy surgery center—and then started working at this management company about nine years ago. Since then, I had the opportunity to open eight, nine new centers. The first two were within two months of working at SMP and I guess it was kind of like nursing: see one, do one, teach one. I just had to jump in and learn as I went. I’ve always had a lot of interest in design and best practice, how you can make things work efficiently and flow, and then learning all the life safety requirements over the course of the last nine to 10 years. So, from that, I’ve learned from my mistakes, and I just wanted to share those and help others learn.
Bill Prentice: 3:11
Well, that’s excellent, and sounds like you have plenty of experience from which to pull. So, let’s talk about one of the first decisions a potential surgery center owner and developer needs to make. And that’s deciding whether they want to build a freestanding surgery center or locate their center in an existing multiuse medical facility. Can you talk about the pros and cons of each of those options?
Deb Yoder: 3:34
Well, new ones allow you to just start fresh, you have a blank slate, you have all sorts of creative ideas. It allows you to build as you need to—you typically have a blank slate of land or an open floor of a building and you can kind of move things around as you need to. If you go into a remodel, you have demolition cost. Sometimes you have ceilings that are too short, you have space constrictions with equipment and booms, lights, carriers, moving in sterile processing kind of things. So, even an existing multiuse medical building, while it’s easiest for the providers if they’re in that location, sometimes the actual square footage and access to that building makes it difficult with where supplies are going to come in and how they’re even going to move in some of the big OR structural kind of things as you’re doing it. In an older building that you’re refurbishing, you don’t always know what you’re going to find until you start tearing away the drywall and the ceiling and getting down to the studs.
Bill Prentice: 4:44
Yes, that’s obviously true and that’s, I think, really good food for thought for someone. So, Deb, we need to take a short pause to hear a brief message from our podcast sponsor. I’m going to ask our listeners to stand by and we’ll be right back.
Narrator: 4:57
This episode of the Advancing Surgical Care Podcast is brought to you by AMSURG, a national leader in the strategic and operational management of ambulatory surgery centers. AMSURG partners with more than 2,000 physicians and health systems and more than 250 ASCs operating in 34 states. Learn more by visiting amsurg.com.
Bill Prentice: 5:18
So, Deb, before the break, we were talking about freestanding facilities versus constructing a surgery center inside an existing medical office building or medical facility. Let’s talk for a couple of minutes about both the regulatory and practical considerations that set surgery centers apart from, say, a physician’s office or an urgent care clinic. Like any new construction, a developer would of course need to comply with local building and zoning codes, but ASCs also have additional unique compliance requirements. Can you talk about those considerations and regulations?
Deb Yoder: 5:53
Sure. New ASC builds have to meet all the current Medicare life safety requirements. That can be related to electrical, HVAC, mechanical and structural, engineering, the National Fire Protection Association needs—they’re going to tie back to the year the building was constructed. Remodels, once in a while you can grandfather them in back to earlier years for construction, but typically, they’ll hold you to all of that. That can be your number of air exchanges and ventilation in specific parts of the area, temp and humidity monitoring, number of outlets in certain rooms, biohazard—you know, each state has different rules that you have to adhere to too. In the medical office or an office-based lab, urgent care, even though they’re paid by Medicare, you don’t have to meet those building codes in that building design. We see that typically the ASCs are built as a commercial-type building with really high-level implementation of structure; an office building or a medical office building may be built more as a residential-type structure.
Bill Prentice: 7:15
So, just a lot more considerations, a lot more things in boxes to tick and things you have to do if you’re building a freestanding surgery center, but also some benefits in terms of having it built the way that you want. So, in your presentation, you stressed the importance of not rushing that design phase and the need to bring all the affected parties into the process. And you also provided a great deal of detail about space allocations for every facet of a center’s operations, which you kind of touched on earlier, from reception to surgical suites to recovery rooms. And you emphasize getting it right on the front end, and avoiding the delays and costs that result from change orders during construction, which I know can be death to a budget. Talk with me about the design process, about choosing the right architect and what a novice developer can learn from other people’s mistakes.
Deb Yoder: 8:05
It’s really important to find an architect that has ASC or hospital design experience and understanding. They have a much deeper, broader knowledge base of all the codes requirements that are needed. They understand what Medicare is looking for specifically and those health facility guidelines. They know that if health facilities and Medicare say it has to be done, it has to be done. It doesn’t matter if it makes sense to them, it doesn’t matter if it makes sense to the surgeons or any of the owners, you just have to do it. Not adhering to those codes will delay the opening because as a Medicare surveyor comes through and does that exam, they could say, “Nope, that’s a conditional level, we’re not opening. You got to fix it and then we’ll come back and re-survey you again,” which is an additional cost usually well above $10,000. And it delays the opening, it delays getting those managed care contracts in place. It’s also really important to have contractors who are familiar with health grade work in that regulated environment. Offices don’t have that; they’re built a little differently. It just makes it much easier—there’s less explanations, there’s less discussion on why we’re doing things if you have people with experience at the table.
Bill Prentice: 9:26
That makes a lot of sense. And kind of embedded in everything you’ve been talking about are two concepts: budget/cost and time. And the two are obviously very dependent on each other. What lessons have you learned about budgeting and constructing a realistic timeline for the entire process, from conceptualization through putting the key in the front door, that you can share as some final words of wisdom to our listeners?
Deb Yoder: 9:51
Well, I think doing an initial feasibility study is really key. The owners have to understand what those key costs, or at least estimated high-level costs, are going to be to build the building and how they’re going to cash flow the payment of the building through the course of the next five years. Not only will the banks require it for their construction loan, their equipment loans, their operating loans, but it also helps you establish that budget and that benchmark that you have to meet. It also gives the architect and the contractors an idea where you have to land at. When we do a feasibility, we pretty much know on average how much it is, while it’s regional, what the square footage of an ASC is going to cost, and we can right size it based on the kind of service line and the kind of cases you’re going to do and based on those surgeon volumes. Surgeons will overbuild every time they can until they see what it costs and understand the operational flow. They know what it takes to work in the operating room; they don’t always understand how the ratios for preop and postop and those procedure rooms work. It’s also important to have your contingency dollars built in. There’s always going to be unforeseen things that come up, there’s going to be costs that are higher than anticipated. So, having those experienced people at the table really helps that, it helps the timeline, it helps the delays, it helps understanding. I think in today’s current environment, it’s really important to have people who are experienced equipment planners. We’re seeing huge lead times in generators, door frames, hardware, the chips for badge access, electrical panels just for those electrical outlets. And so, knowing that, you can start that design process and get those things ordered. Some of the things have well over a year lead time, up to 10 months, which was unheard of in the past. A good design process is going to take six to nine months and a building will take 10 to 18 months, depending on the size of the facility, depending on where you’re at in the country and any weather kind of issues. One of the vendor’s SPD equipment has taken approximately a year to get products to here with some of the logistics. So, I think knowing and understanding all of those things and how they work together on the timeline is key to the budget. We don’t want delays in ordering our equipment, so then we can’t open while we’ve rushed to meet our building timeline. It’s like the dominoes—they all have to fall right in line, or they all just start shuttering.
Bill Prentice: 12:37
So, one last question related to what you’ve been talking about, and you kind of touched on it, is how do you manage that expectation for future growth? Having capacity for, hopefully, a very successful surgery center that may grow over time, how do you get to that realistic conclusion so that you’re not overspending and overbuilding, as you touched on saying this, often something a physician starts out from, how do you end up at that the right endpoint with that?
Deb Yoder: 13:08
I think really doing your due diligence in the feasibility study. When we come in to do those feasibilities, we ask the docs, “What are your recruitment strategic plans for five years and 10 years? Who’s in the queue to come on? Who’s in the queue to retire?” And then we look at those volumes and how they are. We then work with the architect and say, “What direction can we go if we build this way in the OR and how do we add more pre/post rooms?” Rarely do we run out of operating room space, but we almost always have a headache in that pre/post flow. So, designing with a Stage 1 PACU enough pre/post rooms for expansion. Sometimes it means shelling out space for an operating room. And then we have to decide, is it a true shell cement floor with nothing else, or is it finished with the gases and it’s just not equipped? And knowing that and going all the way back to that feasibility, knowing and understanding the volumes. Also being aware of what ASCA is doing and what those codes are that are coming into that ASC space is essential, because that can definitely change those volumes coming in and out of the surgery center.
Bill Prentice: 14:24
Well, Deb, this has been a really, really informative discussion, and I want to thank you for being on this podcast and obviously for your presentation at ASCA 2023 here in Louisville.
Deb Yoder: 14:35
Thank you, Bill. I appreciate you and all the work you and the ASCA team and board members are doing for the community, all your advocacy work on the Hill, with Medicare and moving codes into this ASC structure, or into our ASC world, and just appreciate the opportunity to share some lessons that I learned, hard-learned lessons sometimes, and insights with the ASC community. So, I hope the information will be helpful to all of those listening.
Bill Prentice: 15:03
Well, thank you for those kind words. And finally, before concluding, I would once again like to thank our podcast sponsor AMSURG, a leading ASC management company with more than 250 ASC partners in 34 states. To learn more, visit amsurg.com.