Drawing on our experience planning several ambulatory surgical centers (ASC) in both public and private settings, RPG is pleased to offer insights into key planning parameters for successful operations. We share lessons learned and offer high level criteria to make early decisions about pursuing this model of surgical services.
Introduction and Key Drivers
Ambulatory Surgery Centers have been operating in the US for decades, with over 6,200 Medicare-certified centers, showcasing the effectiveness of this model. So why now in Canada?
We are all familiar with the well documented surgical backlogs, some preceding, and certainly many exacerbated by Covid-19. Metrics show many surgical wait times are outside the clinically acceptable window, resulting in negative impacts on health, anxiety, economic strain, and physical wellbeing. The objective of introducing ASC’s is to enhance system capacity, improve patient access and care experience, and optimize overall healthcare value.
Shorter case and recovery times have afforded us the ability to safely implement a shift in procedures across care settings. Enablers are the growth of minimally invasive surgical techniques and the broader range of available anaesthetic techniques e.g. localized regional nerve blocks. The aim is that ASC’s will improve sustainability of the health care system and free up capacity in hospital OR’s for longer, more complex surgeries.
London Health Sciences Center reports the following after implementation of their ASC, “….the hospital OR’s have narrower scopes and are less chaotic. Each level of surgeon now works in an environment that matches the acuity of the patient” (Cathy Vandersluis, Executive VP, CCO, LHSC). All team members can focus on scheduled surgical care with fewer distractions experienced in the main OR’s, such as emergencies.
Centers report increased patient and staff satisfaction. Patients feel service is more personalized. Shorter visit times mean it is the same team caring for them during their stay, from arrival through their surgical care, recovery and discharge. A smaller care team means familiar faces and interactions. Staff appreciate these personal connections as well as the benefits of working in smaller, integrated groups.
Nearly all provinces are adapting regulations to allow us to re-imagine the environments for care delivery. For example, in Ontario, the Independent Health Facilities Act has been replaced by Bill 60 to establish the Integrated Community Health Services Centres Program. In addition, the Canadian Standards Association (CSA) guidelines, particularly Section 9 – Diagnostic and Treatment Functional Services Requirements, should play an important role in planning ASC’s. Clause 9.2.2.1 outlines key factors to consider.
Key Questions
For organizations considering ASC implementation, key questions to ask include the following:
#1: Types of services and patient mix cannot be stressed enough for a successful ASC. Do you have enough volume for a critical mass of common surgical cases to regularly schedule a full day of a certain type of case, on a consistent basis in 1-2 OR’s? Best suited to an ASC are: low acuity cases, of typically one hour or less in duration, with minimal anaesthesia, and no intended overnight stay.
The table below provides examples of suitable surgical cases for ASC’s, including general surgery, urology, plastics, orthopedics and gynecology. Using the American Society of Anesthesiologists (ASA) physical status classification system, ASC patients should meet the criteria of categories ASA-1 or ASA-2 ie. healthy adults with no functional limitations or with one systemic disease and no substantive functional limitations. Some centers also consider category ASA-3 if the patient only has one severe comorbidity, and other conditions are met to minimize risk.
 | General Surgery | Breast biopsies, laparoscopic cholecystectomies, hernia repair, intra-abdominal, tonsillectomies |
| Urology | Urinary system procedures, prostate partial excision/destruction, bladder procedures |
| Plastics | Abdominoplasty, minor cosmetic surgery |
| Orthopedics | Sports Medicine, trauma (hands, feet, ankles), arthroscopies (knees, shoulders/rotator cuffs, ankles), arthroplasties (shoulders, hips, knees) |
| Gynaecology | Hysteroscopies, uterine ablations, hysterectomies, endometriosis resections |
#2: Leadership and Operational Model. Is there strong clinical leadership to establish an operational model, emphasizing a Lean philosophy for consistency and standardization? If you’re currently running OR’s in a hospital, simply duplicating these operations will result in a sub-optimal outcome at an ASC.
A physician champion can be key to buy-in by surgeons and help drive adoption of the ideal model.
LHSC talks about “a principled approach” to setting up their ASC. They studied what cases could safely transition from general anesthesia to regional anesthesia. They implemented a standardized set of instruments and equipment to decrease variances and costs. They explored smaller teams and implemented more of a self-serve model.
A new environment does not translate into a successful ASC without the right case mix and the right operating model.
Distinguishing Attributes
The following are distinguishing attributes of an ASC:
- OR’s are smaller in size than a modern hospital, they are typically 400-500 net square feet (nsf), with a compact overall footprint. The size is related to the types of procedures, types of equipment, and size of the team. Equipment should be carefully selected to maximize efficiency of room turnover.
- Emphasis on short procedures, scheduled concurrently, allowing for extended hours of operation.
- Patient-centric model with streamlined pre- and post-operative areas.
- Limited family involvement due to healthier patients, leading to fewer disruptions. Family members are able to come back at the scheduled time and the patient is ready! This translates into a smaller waiting room.
- Support services are streamlined. For example, pharmaceutical needs can be addressed with a regular delivery every few days. Most ASC’s locate MDRD onsite and report efficient operations with these staff being integrated both physically and operationally into the ASC team.
The Planning Process
- Data Analytics – Stratify surgical patients by complexity and resource intensity to develop a case mix list. Project future volumes/workload to inform planning.
- Develop an operating model and staffing requirements for optimal functionality and efficiencies. Consider what’s important to the patient and build this into the model, eg. conscious sedation. Test overall operating costs through a business case.
- Develop a Functional Program, articulating the results of data analytics and operating model development to establish design criteria and space requirements.
- Move ahead with developing site selection criteria, considering overall square footage and building occupancy types. Retest the overall operating costs and business case.
The Future of ASC’s
In the future, Artificial Intelligence can be applied to identify cases suitable for ASC’s, simplifying selection and scheduling processes. We anticipate increasing complexity of cases and a broader case mix, necessitating adjustments to OR and ASC sizes. The Advisory Board is forecasting U.S. growth in outpatient volumes by 2027 to include 50% growth in outpatient spine fusions, 45% growth in outpatient joint replacements and 35% growth in outpatient electrophysiology (2022). Canada clearly has many further opportunities ahead. Despite the U.S. context, their lessons learned about ASC’s are similar to what we have witnessed here in Canada:
- Each ASC needs a specific purpose that supports a broader strategic goal
- Hospitals need a principled approach to redistributing services to an ASC
- Success requires efficient operations
- Physicians are critical to ASC development
ASC’s offer a viable solution to address surgical backlogs and improve overall healthcare system sustainability. The key planning parameters and lessons learned from early ASC’s will help steer new projects along the path to successful implementation.