Design of the Surgical Suite, Including Large Equipment, and Monitoring Devices

Types of outpatient surgical facilities

Many dermatology offices have a specific room, often designated the “procedure” or “minor surgery” room, where any procedure more invasive than skin biopsy is performed. The typical layout has the advantage of being easy and relatively inexpensive to construct and has flexibility for a general dermatologist ( Fig. 51.1 ). It is ideal for a practitioner who has a primarily medical-based practice with some minor surgical procedures such as excisional, laser or minimally invasive cosmetic surgery. For a general dermatology office, this set-up can allow multiple physicians to use common procedure rooms on an as-needed basis. The disadvantages are that this design will not work for a primary surgical practice. In addition, if one anticipates that the surgical component of the medical practice may grow over time, this type of design may not be ideal.

A step up from the dedicated surgical room in a standard medical office is the office-based surgery practice ( Fig. 51.2 ). Offices can be designed with multiple surgical rooms depending upon the size desired and the number of practitioners. The layout can be similar to the floor plan shown in Figure 51.1 with multiple rooms centered around a common space such as a laboratory (for Mohs micrographic surgery) or a clean/dirty room. Smaller rooms that can be used for consultations or follow-ups can be admixed with office-based surgery rooms. This office design is more suited to surgical-based practices, such as Mohs micrographic or cosmetic surgery. When designing an office-based surgical suite, consideration should be given to constructing the suite with the possibility of upgrading to a licensed ambulatory surgery center (ASC) if so desired in the future (see below). One should also decide whether office-based surgery accreditation will be pursued, as this will impact on the construction of the surgical suite (see Ch. 52 ).

Accreditation is a way to demonstrate the delivery of high-quality care to the public and medical community. Others believe that the added expense and preparation time for accreditation are not worth the benefit. Some third-party payers will allow facility fees for procedures performed in accredited offices, but usually ASC licensure and certification are necessary if facility fees are to be collected. Some states have regulations on office-based surgery, specifically with respect to requiring accreditation or state-mandated inspections. Usually these regulations exclude facilities that administer only local anesthesia. Currently, accreditation is not required in any state when only local anesthesia is used in offices.

ASCs, which are the most sophisticated of outpatient surgical facilities, have garnered attention in recent years. ASCs can be broadly classified as physician owned, partially hospital owned, and fully hospital owned. Dermatologists are most familiar with physician-owned, office-based ASCs. These tend to be extensions of a dermatologic surgery practice in which the ASC is a separate entity within the larger medical office. Most dermatologic surgery practices with ASCs will have one or two operating rooms that are used only part of the time. This is in contrast to the larger partially or fully hospital-owned freestanding ASCs that may have as many as 10–15 operating suites with a large full-time staff. The traditional ownership structure of joint-venture ASCs involves a hospital- (or national management company-)owned majority stake (51–90%) and a physician-owned minority stake (10–49%). As the majority owner, the hospital controls the facility and usually processes the billing. The ownership interests of the minority stake are spread among many physicians. Therefore, the ASC is not overly dependent on one physician's volume. More recently, hospitals have begun to take a minority stake in ASCs and physicians have emerged as the primary shareholders. ASCs have become extensions of the physicians' practice, with ASC ownership and dividend distribution taking on a group practice dynamic.

Specific requirements for ASCs vary greatly from state to state. ASC licensure occurs on the state level. State licensure is separate and distinct from Medicare certification. Generally, facility fee reimbursement from third-party payers requires both state licensure and Medicare certification. Accreditation is a separate issue and is usually optional. However, some third-party payers require accreditation for reimbursement. In some states, accreditation is given deemed status for Medicare certification.

Many of the general specifications for ASCs require extensive preplanning. This may not be feasible in some office suites. Some of the requirements include a separate entrance, a separate waiting room, a dedicated recovery room, automatically-activated fireproof doors, and a ceiling sprinkler system. Other ASC design features include 1-h firebreaks in the walls, 2-h firebreaks in the floor, and a back-up emergency power source for key equipment (generator or battery power). Sinks are not permitted in the operating room of an ASC, but are allowed in the recovery room. Exceptions in the fire safety code may be allowed for offices that use only local anesthesia. Medicare and independent accrediting agencies usually require that the fire safety code for ASC construction be followed. Most local zoning boards, states, and office accrediting agencies require that a physician's office meet the commercial building code standards, which are less expensive. From the dermatology perspective, the benefit of incorporating an ASC into a surgical practice is the opportunity to offer a higher level of care and the ability to collect a facility fee. These and other specific reimbursement issues are discussed later in this chapter.

The last outpatient surgical venue is the hospital outpatient department (HOPD). This is a term for ambulatory offices owned wholly by a hospital. Any outpatient surgical service of a hospital, such as dermatologic surgery, would be considered an HOPD. The design of the HOPD surgical suite is similar to the office-based surgery practice. The Joint Commission usually accredits these facilities as they are considered part of the hospital. Physicians and staff are typically employees of the hospital or hospital-owned practice group. The hospital is often able to bill a facility fee for care that is delivered in an HOPD.

Design