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On Time and Under Budget!
How we upgraded and relocated our ASC
BY PAUL S. KOCH, M.D.

In 1981, I courageously hung out a shingle in my home town of Warwick, Rhode Island. We had a very modest beginning, and for many months saw fewer than 10 patients a day and operated at a loss for over a year. I still have the nearly empty appointment books to remind me. Then, rather suddenly we got very busy, and soon the local community hospital could no longer accommodate me. It was time to build my first surgery center. I was 32 years old.

When I was a second-year resident, I decided to build a 6,000-square-foot office building, and broke ground during my third year. I occupied most of the building, but I still had some space available for the center. I called on Lou Sheffler, who had designed small, yet incredibly efficient surgery facilities for Drs. Dick Mackool and Paul Pender, to draw up the plans. We fit everything in 1,500 square feet, and spent a whopping $220,000 for everything — design, construction, equipment and supplies.

Until we got insurance coverage, we ran the facility as a practice extension, paying all the bills out of surgeon's fees. Moonlighting nurses from the hospital came over after their shift and we operated through the evening. It took several years before we could afford to work during the day.

If you could jump ahead more than 20 years, you would still find me in that same facility, using much of the same equipment I purchased in the early 1980s. Some of it was rebuilt, some held together with duct tape, but still doing its job day after day. Our one little operating room hosted a whirling choreography of patient throughput. Supply boxes filled the corridors. The storage rooms were overflowing. It was time to move on.

Drawing up a budget for a new facility was an interesting exercise. We were bound by state requirements to spend less than $2 million or else we would have to apply for a new Certificate of Need (CON). That meant we could not build or buy a building, so we would have to lease. If we did not own the building, we did not want to go crazy on the design, so we budgeted half that limit for everything — build out and new equipment, and came in comfortably under.

So, with that bit of introduction, what did we do to upgrade our systems in the new facility? Here is my top dozen, in no particular order.

A New Identity

We grew up in West Warwick, R.I., a town of 19,000 inhabitants, 23 textile mills, 23 villages and 23 Catholic churches. Our family could walk to St. James Church, and all the kids went to St. James School. About the time we were planning the new surgery center, the Diocese of Providence closed St. James and merged the parish with St. John the Baptist down the street. Rumors circulated that our church building was going to be torn down and replaced with a pharmacy.

Quickly, my brother contacted the Diocese and got permission to salvage the interior of the building. We included saved objects in the interior of the new facility, and added vintage photos of the turn-of-the-century parish obtained from the town's historical society. However proud we are of our St. James Surgery Center, we are perhaps most proud that we were able to preserve the memory of our church.

Scheduling

We knew that inefficiencies developed not only when cases took longer than their slotted time, but also when patients took longer in the preparation or discharge. We had already compensated for the first by allotting longer times for different operations, but we did not have a system for identifying slower patients. We developed a system wherein we classified patients into two categories, express and special.

Express patients are those who are fully ambulatory and coming in just for cataract surgery. They do not require special nursing attention.

Special patients need more time. We defined several medical categories, such as "Patient owns his own wheelchair," or "Patient has his own oxygen." Some fall into communication categories, such as "Patient cannot hear," or "Patient requires interpreter." Others will have an operation other than straightforward cataract surgery. We schedule special patients each week on Tuesday, planning a day commensurate with their needs. Special surgery day has been a big success. No one is rushed because we have extra time and additional staff ready for them.

We have several plasma screen monitors in the waiting room showing travelogues and animal documentaries. It is a pleasant way for families to while away the time.

Waiting Room

In our old waiting room, patients could watch instructions on our ancient 1983 video monitor. We showed one short segment on what to expect in the operating room, and another on what to do once they got home. These two clips were separated by television commercials my brother and I did for a local furniture store, so patients had a laugh and paid attention. Still, after hearing the instructions a few zillion times, someone would turn down the volume, so it was not a great plan. In the new facility, we installed several beautiful plasma monitors and show, very quietly, gorgeous films such as aerial travelogues of Italy, or feature films such as Winged Migration or The March of the Penguins. Patients love them, and the time passes very quickly.

We replaced the old check-in window with two private counseling and instruction rooms.

Scanning Medical Records

I cannot imagine how many hours were spent filing surgery charts alphabetically, almost all never to be looked at again. Rarely did we need a record for legal reasons. Still, every night someone leafed through the cabinet, putting everything in the proper order. In the new facility I installed a non-network, stand-alone computer and attached an inexpensive scanner. At the end of each day we scan the medical record — it takes about 30 seconds per chart — and that pdf file is what we look at when we need information on a patient. The hard copies are wrapped with a rubber band, labeled with the day of surgery and placed in a storage box labeled by date.

Preparing the Patient

New nursing station.

We decided it was more cost effective to give patients a bottle of cyclopentolate when they booked surgery and have them use it before coming in. This cost us a few bucks per patient, but it has been well worth it. Patients come in fully dilated and ready for surgery — and they self-mark the site of surgery to help avoid errors.

We added four more stretchers for surgery, selecting from a vendor that offers one with a 500-lb. capacity. The old ones with the 250-lb. capacity were beginning to wear down from transporting our more beefy patients.

The new preparation area is not only larger, but has a few amenities that were missing in the old facility. We now have a handicapped-access restroom for those last minute winky-tinks, whereas before the patient had to return to the loo in the waiting room. There are privacy curtains between each station, and though they are rarely used, they have come in handy more than once. 

Perhaps the biggest improvement in patient preparation is TetraVisc, a viscous anesthetic eyedrop that works as well as lidocaine jelly, but it is a lot easier to use and costs less, too. Now, topical anesthesia is obtained with a few drops instead of a ribbon of jelly. From the first day we used TetraVisc, my nurses let me know they would never apply lidocaine jelly again.

Staff Amenities

We added all the usual stuff, bigger locker rooms with more lockers, and showers. I thought the staff might begin their day at the gym, coming to work all refreshed and vigorous. Instead, they use the shower stall as a place to put their snow boots, and the shower rod to hang their winter coats.

We did add two very large nurses' stations, one in the patient area and another around the corner for administrative work. For the first time, they have a computer terminal to look up patient information, do research, and order supplies — and, I understand, do some Christmas shopping, but I am not supposed to know about that).

Storage

What can I say?

We went from stacking boxes in the hallways to having a full-sized storage room, a shipping/receiving area, a sub-sterile storage room, and tons of cabinets and closets all over the place. We needed more storage room, and by golly, we got ourselves more storage room.

We used to have a tiny corner for our cleaning and sterilization area. The new room holds six autoclaves and plenty of counter and storage space.

Sterilization Area

In the old place, we had a corner where we stacked three autoclaves, and a two-by-four-foot table on which to clean/organize/wrap instruments. The entire area took up less than 15 square feet. St. James has a sterilization area that runs the length of the two operating rooms, with full-length counters and cabinets above and below. We run six autoclaves with several feet between each, so for the first time there's more than enough space. We look back now and wonder how we ever did it before. We used to blow out the tubing with a 50 cc syringe, but now we added an air compressor we picked up at Pep Boys and blow them out in a fraction of the time.

Built-in Gases

We always had oxygen and nitrogen tanks taking up space — in the patient areas, in the operating room, or in storage areas. Finally we could put in a gas room accessible from the outside, and we pipe the gases into the rooms. We made one colossal blunder, however. Somehow, despite putting in a suction pump the size of a medium-sized car, we forgot to pipe suction into the operating rooms, only the recovery room. How I missed that, I will never know.

Operating Rooms

One of our two new operating rooms.

We've gone from one to two, and put a swinging door between them. The door got in the way and prevented staff from being aware of how the case in the other room was progressing, so when one of my nurses got her thumb jammed in the door we took that as a sign to remove it completely.

When we added the second microscope, we upgraded our camera to a three-chip, and in both rooms record surgery directly onto DVD instead of videotape, and show surgery on 36-inch plasma screens. A large storage rack was placed behind the phaco machine, so the circulator can help set up and grab extras without moving more than a few feet. Our 20-year old cardiac monitor was replaced with a pair of tiny digital monitors, and out full-sized monitor/defibrillator was finally retired. We now have a small portable defibrillator hanging on the wall serving the operating rooms and the patient areas.

Patient Records

When the surgery center was in the office building, we could easily share records between the two entities. Now that we are away, we needed a system that would be sure every patient's information was available to the surgeon without removing the office record from the office. We developed a special cataract history and exam form that can be filled out by a technician in less than a minute. We streamlined it by making graded lines for vision and refraction. Instead of writing in numbers, she only has to make a hash mark through the line indicating the appropriate vision or spherical equivalent. It notes if the patient has some feature of note, such as a shallow anterior chamber, pseudoexfoliation, or guttata. I review it ahead of time and select the lens and its power, and then I review it again before beginning each operation to refresh my memory.

Pictures of the Eye Drop Bottles

Most of our patients elect to have a Kenalog/gatifloxacin suspension placed in the anterior chamber at the end of the operation in lieu of eye drops, but for those who want to use the drops, we prepared an instruction sheet with pictures of the bottles. No longer do we have to talk about the "white bottle" or the "purple bottle with the white liquid" because they have the image right in front of them. Why this took us more than 20 years to figure out, I will never know.

More Work with Less Effort

Our old surgery center is still vibrant, but with different activities. During our last Christmas party we had a ballroom dancing instructor teach the tango and the merengue in one room, and put a bingo caller in another.

Right now it is a good place to go when you need a good scream and do not want to bother anybody. The echoes are very refreshing.

The new surgery center, on the other hand is very quiet. Instead of up to a dozen people working in one room we have them spread out in different areas. Even though we are doing more work, it takes less effort to get it done. I know I am much more relaxed, and I suppose that is the best upgrade of all. 

Paul S. Koch, M.D. is the chief medical editor of Ophthalmology Management. If we cannot find him at Koch Eye Associates, we can always track him down at the St. James Surgery Center, both in Warwick, R.I.