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Building Plan
CHAPTER 5
Building Plan HWA KHO, PHD, MBA • SAM AHN, MD, FACS, MBA • MAGEAN WHALEY, RN
Building out an office-based endovascular center (OEC) is an expensive and time-consuming project, and it is critical to get it right because the practice will be stuck with it for a long time. Below, we go over some of the most important things to consider for the OEC.
ZONING AND PERMITS Make sure that the intended location is zoned and permitted for operating an OEC. Getting the zoning law changed or getting a new permit is costly and takes a very long time. It is usually not worth it to look at locations that are not already appropriately zoned for an OEC. Since it is an extension of practice it may be easier to get the permit than getting permit for an ambulatory surgery center. Certificate of Need (CON) usually does not apply to OEC but the practice should check if it does in their state as well for other licenses or permits required by the local city or state. Fig. 5.1 below shows states with some form of CON laws (in blue).
LOCATION The OEC should ideally be situated within 5 miles or 15 min of a major hospital in case of an adverse event, and a patient needs to be urgently transferred to a hospital. Though this should rarely happen, it is, nevertheless inevitable that over the course of time in the life of the OEC, complications will occur, and when they do, it is crucial that patients can be transported to a hospital in a timely manner. It should be easy for patients to reach, and, especially in metropolitan areas, have adequate and convenient parking for patients when they arrive. A ground floor location is desirable, with a separate emergency entrance for ambulance personnel. If it is on an upper floor, make sure the elevators are big enough to accommodate stretchers. Depending on the type of your practice it may be desirable to have OEC close to dialysis centers and/or wound care clinics.
SPACE Procedure Room The more space that can be allocated to the procedure room, the easier it will be to configure the space to work efficiently for the physicians and staff. When you have the performing physician, scrub technician, circulating nurse, X-ray technician, anesthesiologist or certified registered nurse anesthetist, the patient, the C-ARM, the laser machine, anesthesia cart, and bunch of other machines in the room, it can get crowded very fast. It should be at least 600 sf but preferably larger so that there is space for storing devices and other disposables for easy access during a procedure. If a room is used exclusively for vein ablation procedures it may be smaller than the main procedure room. Number of procedure rooms will depend on the projected volume of cases and number of physicians working in the OEC. The walls will normally need to be lead-lined. The requirement for lead-lining depends on a number of factors, including occupancy of the space behind the wall, size of the room, radiation pattern and power of the C-ARM, and the procedure volume or radiation time. The practice should consult with a medical physicist to determine if lead lining is needed. It also depends on state board of health regulations. In general, it is advisable to lead line the walls. The floor of the room may need to be reinforced to support the weight of the C-ARM and other machines such as the laser machine. This is especially an issue to bear in mind if the room is not located on the ground floor. Make sure that there are enough power outlets with the right voltage and current for the machines to be used in the room. There is usually no special HVAC requirement for an OEC but for the comfort of the procedure room staff and the patient, provide for adequate air conditioning to keep the room cool. The room can feel very warm for the physicians and staff with heavy lead aprons in a crowded area under the OR lights. There should preferably be a separate temperature control for the procedure room so that the
Office-Based Endovascular Centers. https://doi.org/10.1016/B978-0-323-67969-5.00005-8 Copyright © 2020 Elsevier Inc. All rights reserved.
29
30
SECTION II
Opening a Center
FIG. 5.1 States with some form of Certificate of Need laws (in blue). (Source: National Conference of State Legislatures.)
temperature there can be controlled independently of the rest of the facility. The machines may also be temperature sensitive.
Preop and Recovery Rooms The sizes of the preop and postop areas depend on how many beds are to be placed there. It should be at least 100 sf for one bed or 80 sf each for multiple beds with space on the wall for mounting patient monitors and space to install curtains around the beds for privacy. In addition to that, allocate some space for a nursing area in the recovery room and space for an attendant, usually a family member, to sit with the patient.
Clean Room and Dirty Room The clean room and dirty room should be at least 100 sf each. The clean room will be used for storing clean linens and clean supplies. The dirty room is for procedure room trash and hazardous waste.
storage. It is easy to underestimate the amount of storage space needed when the OEC is fully functional. Wall spaces should be utilized efficiently with built-in cabinets. A separate storage room(s) capable of accommodating large boxes, gas tanks, miscellaneous equipment, wheelchairs, etc. will be needed. They will probably take up another 200 sf of space. There should also, preferably, be a dedicated area for receiving supplies so that the staff can keep track of new deliveries and they are not mixed with older inventory items before they are logged in.
Changing Room and Locker Area An often-overlooked area is a place for staff and patients to change clothes and keep their valuables. It is good practice to provide patients with a secure locker where they can keep their belongings, including jewelry, when they are being treated in the procedure room.
Other Storage Area Some supplies can be stored in the procedure room and clean room but usually more space is needed for
In addition, of course, the OEC will need spaces for reception area, exam rooms, patient and staff bathrooms, break room, and work areas or offices for staff
CHAPTER 5 Building Plan
31
FIG. 5.2 Layout of an existing office-based endovascular center.
and physicians. If a noninvasive vascular lab is needed, it would need at least about 150 sf at the minimum and more if it needs to accommodate more than one patient at a time. Since the OEC is an extension of the office practice the spaces for various functions can be shared with the office, e.g., break room, billing area, bathrooms, etc. Fig. 5.2 below shows the layout of an existing OEC (the reception area is not shown). It is not meant to represent the optimal layout but rather to show the typical components of a working OEC.
Backup Power Backup power is needed for the procedure room, recovery room, and emergency exit lights. Unlike a hospital, an OEC does not have to have backup power to stay fully operational for an extended period of time. It just needs to have enough power to safely terminate any procedure, and to evacuate patients safely, if necessary. A battery-based UPS (uninterruptible power supply) that kicks in automatically when the main power fails is usually the most efficient and cost-effective way to provide for backup power. The battery should be
sized to provide adequate power to the most critical devices in the procedure room so that the physician can safely terminate the procedure. Normally, this is about 30 min to 1 h of operation.
LAYOUT AND PATIENT FLOW
The practice will need to consider how patients flow through the facility, and plan for adequate clearances with regards to doors and corridors bearing in mind that patients may be on stretchers from the preop room to the procedure room and from the procedure room to the recovery room. The practice also needs to plan for nonambulatory patients arriving and departing the facility in wheelchairs and access for emergency vehicles. Another consideration is patient privacy. The space should be laid out to provide as much privacy to each patient as possible. This includes things such as curtains in the preop and postop areas if the patients share the same rooms, and a separate exit for patients after their procedures, if the location allows. In an OEC preoperative area and post operative area can be shared.
32
SECTION II
Opening a Center
WORKING WITH ARCHITECTS AND CONTRACTORS It is very important to select an architect who has experience in medical buildings, especially in office-based surgery offices. They will be able to guide you through what works in other practices and know about regulations that you may not be aware of, such as placement of eye wash stations. If the architect has limited experience, it is worthwhile hiring a consultant to review the plan. Similarly, with contractors, there are many small details that may not be specified in the plans, such as which type of locks should be used on which doors, that having an experienced contractor who understands these things will make the building project go more smoothly and painlessly. The contractor should have familiarity with the permitting process in your
city. Many times, a project is delayed because of permitting and inspection issues. A contractor who understands the red tape in your municipality will greatly help. Building an OEC usually takes longer and costs more than the contractor’s projection, and you will need to build in some buffer in the project time line and the budget. If you are planning to build a brand-new building for your practice and the OEC, the project, will obviously take much longer and will be much more expensive. It is important to plan the patient flow in your practice if you are expanding your current office to accommodate an OEC. Unexpected issues will arise and interruptions and delays are almost inevitable. Be patient, it will eventually be completed and it will be worth the effort.
Building Plan HWA KHO, PHD, MBA • SAM AHN, MD, FACS, MBA • MAGEAN WHALEY, RN
Building out an office-based endovascular center (OEC) is an expensive and time-consuming project, and it is critical to get it right because the practice will be stuck with it for a long time. Below, we go over some of the most important things to consider for the OEC.
ZONING AND PERMITS Make sure that the intended location is zoned and permitted for operating an OEC. Getting the zoning law changed or getting a new permit is costly and takes a very long time. It is usually not worth it to look at locations that are not already appropriately zoned for an OEC. Since it is an extension of practice it may be easier to get the permit than getting permit for an ambulatory surgery center. Certificate of Need (CON) usually does not apply to OEC but the practice should check if it does in their state as well for other licenses or permits required by the local city or state. Fig. 5.1 below shows states with some form of CON laws (in blue).
LOCATION The OEC should ideally be situated within 5 miles or 15 min of a major hospital in case of an adverse event, and a patient needs to be urgently transferred to a hospital. Though this should rarely happen, it is, nevertheless inevitable that over the course of time in the life of the OEC, complications will occur, and when they do, it is crucial that patients can be transported to a hospital in a timely manner. It should be easy for patients to reach, and, especially in metropolitan areas, have adequate and convenient parking for patients when they arrive. A ground floor location is desirable, with a separate emergency entrance for ambulance personnel. If it is on an upper floor, make sure the elevators are big enough to accommodate stretchers. Depending on the type of your practice it may be desirable to have OEC close to dialysis centers and/or wound care clinics.
SPACE Procedure Room The more space that can be allocated to the procedure room, the easier it will be to configure the space to work efficiently for the physicians and staff. When you have the performing physician, scrub technician, circulating nurse, X-ray technician, anesthesiologist or certified registered nurse anesthetist, the patient, the C-ARM, the laser machine, anesthesia cart, and bunch of other machines in the room, it can get crowded very fast. It should be at least 600 sf but preferably larger so that there is space for storing devices and other disposables for easy access during a procedure. If a room is used exclusively for vein ablation procedures it may be smaller than the main procedure room. Number of procedure rooms will depend on the projected volume of cases and number of physicians working in the OEC. The walls will normally need to be lead-lined. The requirement for lead-lining depends on a number of factors, including occupancy of the space behind the wall, size of the room, radiation pattern and power of the C-ARM, and the procedure volume or radiation time. The practice should consult with a medical physicist to determine if lead lining is needed. It also depends on state board of health regulations. In general, it is advisable to lead line the walls. The floor of the room may need to be reinforced to support the weight of the C-ARM and other machines such as the laser machine. This is especially an issue to bear in mind if the room is not located on the ground floor. Make sure that there are enough power outlets with the right voltage and current for the machines to be used in the room. There is usually no special HVAC requirement for an OEC but for the comfort of the procedure room staff and the patient, provide for adequate air conditioning to keep the room cool. The room can feel very warm for the physicians and staff with heavy lead aprons in a crowded area under the OR lights. There should preferably be a separate temperature control for the procedure room so that the
Office-Based Endovascular Centers. https://doi.org/10.1016/B978-0-323-67969-5.00005-8 Copyright © 2020 Elsevier Inc. All rights reserved.
29
30
SECTION II
Opening a Center
FIG. 5.1 States with some form of Certificate of Need laws (in blue). (Source: National Conference of State Legislatures.)
temperature there can be controlled independently of the rest of the facility. The machines may also be temperature sensitive.
Preop and Recovery Rooms The sizes of the preop and postop areas depend on how many beds are to be placed there. It should be at least 100 sf for one bed or 80 sf each for multiple beds with space on the wall for mounting patient monitors and space to install curtains around the beds for privacy. In addition to that, allocate some space for a nursing area in the recovery room and space for an attendant, usually a family member, to sit with the patient.
Clean Room and Dirty Room The clean room and dirty room should be at least 100 sf each. The clean room will be used for storing clean linens and clean supplies. The dirty room is for procedure room trash and hazardous waste.
storage. It is easy to underestimate the amount of storage space needed when the OEC is fully functional. Wall spaces should be utilized efficiently with built-in cabinets. A separate storage room(s) capable of accommodating large boxes, gas tanks, miscellaneous equipment, wheelchairs, etc. will be needed. They will probably take up another 200 sf of space. There should also, preferably, be a dedicated area for receiving supplies so that the staff can keep track of new deliveries and they are not mixed with older inventory items before they are logged in.
Changing Room and Locker Area An often-overlooked area is a place for staff and patients to change clothes and keep their valuables. It is good practice to provide patients with a secure locker where they can keep their belongings, including jewelry, when they are being treated in the procedure room.
Other Storage Area Some supplies can be stored in the procedure room and clean room but usually more space is needed for
In addition, of course, the OEC will need spaces for reception area, exam rooms, patient and staff bathrooms, break room, and work areas or offices for staff
CHAPTER 5 Building Plan
31
FIG. 5.2 Layout of an existing office-based endovascular center.
and physicians. If a noninvasive vascular lab is needed, it would need at least about 150 sf at the minimum and more if it needs to accommodate more than one patient at a time. Since the OEC is an extension of the office practice the spaces for various functions can be shared with the office, e.g., break room, billing area, bathrooms, etc. Fig. 5.2 below shows the layout of an existing OEC (the reception area is not shown). It is not meant to represent the optimal layout but rather to show the typical components of a working OEC.
Backup Power Backup power is needed for the procedure room, recovery room, and emergency exit lights. Unlike a hospital, an OEC does not have to have backup power to stay fully operational for an extended period of time. It just needs to have enough power to safely terminate any procedure, and to evacuate patients safely, if necessary. A battery-based UPS (uninterruptible power supply) that kicks in automatically when the main power fails is usually the most efficient and cost-effective way to provide for backup power. The battery should be
sized to provide adequate power to the most critical devices in the procedure room so that the physician can safely terminate the procedure. Normally, this is about 30 min to 1 h of operation.
LAYOUT AND PATIENT FLOW
The practice will need to consider how patients flow through the facility, and plan for adequate clearances with regards to doors and corridors bearing in mind that patients may be on stretchers from the preop room to the procedure room and from the procedure room to the recovery room. The practice also needs to plan for nonambulatory patients arriving and departing the facility in wheelchairs and access for emergency vehicles. Another consideration is patient privacy. The space should be laid out to provide as much privacy to each patient as possible. This includes things such as curtains in the preop and postop areas if the patients share the same rooms, and a separate exit for patients after their procedures, if the location allows. In an OEC preoperative area and post operative area can be shared.
32
SECTION II
Opening a Center
WORKING WITH ARCHITECTS AND CONTRACTORS It is very important to select an architect who has experience in medical buildings, especially in office-based surgery offices. They will be able to guide you through what works in other practices and know about regulations that you may not be aware of, such as placement of eye wash stations. If the architect has limited experience, it is worthwhile hiring a consultant to review the plan. Similarly, with contractors, there are many small details that may not be specified in the plans, such as which type of locks should be used on which doors, that having an experienced contractor who understands these things will make the building project go more smoothly and painlessly. The contractor should have familiarity with the permitting process in your
city. Many times, a project is delayed because of permitting and inspection issues. A contractor who understands the red tape in your municipality will greatly help. Building an OEC usually takes longer and costs more than the contractor’s projection, and you will need to build in some buffer in the project time line and the budget. If you are planning to build a brand-new building for your practice and the OEC, the project, will obviously take much longer and will be much more expensive. It is important to plan the patient flow in your practice if you are expanding your current office to accommodate an OEC. Unexpected issues will arise and interruptions and delays are almost inevitable. Be patient, it will eventually be completed and it will be worth the effort.