Round Rock Surgery Center Case Study

1. A Newly Licensed ASC in an Existing Building-
Processes, Challenges, Insights & Lessons Learned
AIA AUSTIN
COMMITTEE FOR
HEALTH
ASC PRESENTATION
September 18, 2009

2. Agenda
I. Introduction
II. Preplanning, Accreditation,
Licensure and Operation
- Nan Finch, RN, MSN, CNS – Diverse
Heath Consulting (President)
III. PreDesign/Design Considerations
- Craig Puccetti, AIA – Lawrence Group
(Associate Principal)
-Tamara Toon – Lawrence Group
(Associate)
IV. Construction Intricacies
- Seth Bonnecarrere, LEED AP-Flynn
Construction, Inc (Project Manager)

3. Preplanning, Accreditation,
Licensure and Operation

4. Game Plan
**Note: Importance that all players
specifically have Licensed
Surgery Center Experience
Education
-Physician
-Realistic Timeline
Financing - Proforma
Mission Statement
Specialties - Partners
Number of Rooms
Timing Expectations - 1 year PLAN
RFP

5. Team Selection
** All major players on board early on
Owners Rep/Construction/Program
Manager
Contracting - Insurance Consultant
Clinical Consultant
Equipment Planner/Consultant
General Contractor (as early as
Schematic-Never TOO early)
Credentialing Consultant
Marketing Representative
HealthCare Architect and Consultants
-MEP
-Structural
-Civil
-Interior Design
-Interior Finishes,
Furnishings, Artwork & Signage

6. Concept Plan (Test Fit)

7. Application to DSHS, CMS &
Accrediting Body
• Timing
• Info Requested
• Flexibility to change info provided
Fees
• Info required from Other Parties

8. Policies, Procedures &
Administration
Establishing programs to meet
licensing requirements
• Pharmacy – DEA
• Lab - CLIA
• Contracts – Laundry / Pathology /
Janitorial Services / Anesthesia /
Pharmacy
• Logs
• Internal Policies
-OSH
-Clinical
-Administration
-Business Office
-Environment of Care
-Anesthesia
• Staffing
-Hiring
-Job Descriptions
-Employee Handbooks
-Types of Staff and Plans
-EHR use and training

9. Final Inspection and
Operation
State/Life Safety Inspection
-Timing/Preparation /Fees
-Process
Accreditation / Medicare Inspection
-Timing/Preparation /Fees
-Process
Open For Regular Business
Type of Patients for reimbursement
Staff Competencies / Training
Reimbursement/Timing
State Licensing/Accreditation / Medicare Certifications
Insurance Contracts
Open House / Marketing
Continuous Follow-Up and Availability for Quality and
Success

10. DSHS Documentation-Maint. Logs

11. PreDesign and Design
Considerations

12. Site & Building Evaluation
(Physical Attributes)
Construction Type
Covered Canopy – Patient Drop off/Pick up
Compliant Elevator
Accessible Parking and Site
Ambulance and Fire Dept. Access
Common Areas/Patient Friendly Access
Separated Use (vertical and horizontal)
Building Envelope
MultiStory Configurations-Patient Services on
more than 1 level
Egressing
Access Control
Hazardous Locations
Zoning and Use Designations
Shared Services (Space and Systems)

13. 4 Story Existing POB

14. Site
N
IH-35
HIGHLAND
PROFESSIONAL
MAYS

15. Ground Floor

16. Roof Plan

17. Site & Building Evaluation
CHECKLIST
1. Need to have a covered canopy or awning the will cover a car for patient drop off and pickup
near the main entry point. Canopy or awning will be submitted for approval. Flatwork
outside this entry could also be required to be accessible and provide accessible route from
drop off/pickup to entry and discharge areas. Will a patient drop off and pick up area be
possible?
2. Need location along back side of building adjacent to ASC where the diesel emergency
generator can be placed. Will possibly need to access drives for refueling and add bollards
or screen wall. A dumpster will also be required. A service area for deliveries of supplies
and medical gas will also be preferred.
3. Will possibly want to add windows in facade at Operating Rooms and other Business areas.
Additional doors for egressing may also be required on the ground level.
4. Will want to modify some storefronts for installation of new door systems including the main
entry on the surgery center side. Main entry door will be upgraded with design approved by
landlord.
5. At least 2 exterior doors from the ASC will need to be min 44" wide for wheelchairs.
6. Consider getting a certain number of dedicated patient parking spaces near entry (where
applicable)
7. Ensure that all site elements and entry points are accessible as per TAS requirements.
8. Ensure that adequate water pressure is available to support the the ASC when part of larger
development. Many times an ASC domestic water line is larger to handle the larger fixture
demand.

18. Site & Building Evaluation
CHECKLIST
9. Ensure that we are able to locate new hvac equipment on the roof, penetrate the roof, and
upgrade structure to support units
10. When Multistory building with ASC on 2nd Level, Ensure that provisions are made to allow us to
and accessible 5'x5' minimum cab size gurney elevator within lease space serving ASC if
ASC is going to be located on 2nd floor. .
11 Ensure we have adequate electrical service and capacity to serve the ASC. A surgery center
requires a larger service than a typical lease space
12. Verify construction Type. Is the building steel? If so, is it fireproofed or wrapped to be a rated
assembly? Is there anything unique about the construction type like tilt wall exterior walls or
post tensioned slab.
13. Verify if the building has a fireline/riser to the building if the building is fully sprinklered.
14. Verify if possibility of modifying and or reinforcing floor /roof structure for new rooftop
equipment and clearances from existing exhaust fans and vents that are existing.
15. Make sure we are not in a flood zone.
16. Verify designed parking ratio.
17. Verify that stairwells are strategically located so more than 1 means of egress is possible from
2nd floor occupancy.
18. Verify Structural Clearances (floor to floor heights). 15 foot top of steel preferred.
19. Are there any nuisance areas surrounding the site, high power lines, underground fuel
tanks....etc.

19. Site & Building Evaluation
(Utility Infrastructure)
Available Building Services
Medical Gas
Domestic Water including RO, DI or
Softened Water
Water Pressure to Building-Flow Test
Fire Sprinkler System
Telephone/Fire Alarm System
Electrical Service/Generator-Type 1
Essential Electrical System
Building Air/Fresh Air/Pressurization

20. Building Construction Type
and Structure
Vertical Clearances
Structural Considerations
Ceiling Heights/Plenum
Clearances
Modifications to allow for
Vertical Connectivity
(Elevator)
Fire Rating

21. Building Section

22. Clearance Analysis

23. RCP

24. Plan Configuration & Code
Issues
DSHS Licensing Rules
JUNE 2009 REVISION
IBC vs. NFPA 101
Occupancy Type
I-2 or B Occupancy???
Mech/Support Room Locations
Staff, Patient and Support Flow
Min. Facilities, SF Requirement,
tied to # of OR’s
Windowless Anesthetizing
Location – Smoke Evacuation?

25. Fourth Floor

26. Rendering

27. Consultant Selection
MEP – Most Important
Prior Experience with Licensed ASC –
Not just Hospital
Equipment Overlay and MEP
Coordination - CRITICAL
Selection of Major Systems – Desired
OR Temperature
Air Change / Fresh Air
Requirements/Pressurization/Pre
and Final Filtration of Air
Annunciators and Alarm Systems
Piped or Portable Medical Gas
Design Build of MEP Systems (Fire
Protection)

28. Construction Intricacies

29. Pricing/Establishing Contract
Price
Early Involvement – Team
Approach
Pricing at Schematic, DD and CD
(GMP Established)
Reconciliation of Actual Cost to
Budget
Opportunities for Savings-Value
Management Versus Value
Elimination

30. Contracting – CM at RISK
Preferred Types of Contracts
Managing Changes
Responding to Owner Initiated
Modifications / Options
Savings Split – Money Back to
Owner!!

31. Establishing & Maintaining
Schedule
Critical Path
Tracking
Identifying Long Lead Time Items
Submittal Timing

32. Managing Day to Day
Construction Activities
Subcontractors and other On Site
General Contractors
Inspections/City Requests
Process and Communication
Common Issues /Encountered
Resolutions
Project Specific Challenges/Resolutions

33. Project Challenges
Electrical conduit, Plumbing, mechanical routing through
occupied floors to surgery center and roof level
Precast floor and wall construction, and precautions that arise
from this design
Installation of exterior elevator shaft in an occupied area,
traffic and safety concerns
Above ceiling conditions and clearances at Operating rooms
Locating roof top unit with existing cell tower equipment and
cabling

34. Project Close-Out/Post
Occupancy/Successes
DSHS Documentation
Final Test and Reports
As Built Documentation
O & M Manuals
Substantial Completion and Post
Occupancy
Merit Award-Flynn Construction
EXCELLENCE IN
CONSTRUCTION

35. DSHS Documentation

36. “Without reservation I would recommend Flynn Construction in the special
and complicated area of Surgery Center planning and building”
-Dr. Mark Malone, Advanced Pain
“Lawrence Group worked closely with us from beginning to end resulting in a
well coordinated project that exceeded Dr. Malone’s Goals and Expectations”
-David Wardell, Advanced Pain
“Nan was a great resource with getting us up an running quickly”
-Caroline Domin, Advanced Pain
Testimonials

37. Before and After