A - "OBS" is "Office Based Surgery" and is essentially a suite of rooms and a set of work procedures under which medical doctors & surgeons can do hundreds of authorized operations under variable levels of patient sedation thus avoiding the wait and expense of going to the local hospital. The most important distinction from hospital procedures is that the patient arrives by appointment, is generally healthy otherwise and does not stay for any great length of time and certainly not “overnight”. These are known as “ambulatory procedures”.
Q – Are office based surgery (OBS) practices the same as “ambulatory health care facilities”?
A – No. Here in New York State and NYC, “centers, clinics and/or “facilities” are defined words in the Code and have specific meaning legally. Those two words cannot even be used in the naming of an OBS practice. The ambulatory facilities are larger (about 4,000 sf or more minimum) & utilize many different types of surgeons and surgery procedures operating under a common corporate entity licensed by the State, after applying for and obtaining a “Certificate Of Need” (CON). The Building Codes for these facilities generally replicate those of a hospital environment, even though patients served are also generally healthy, come & go in a single day and do not stay overnight. These facilities are also known as “hospitals without beds”.
Q – What are the advantages of office based surgery (OBS) verses ambulatory healthcare clinics?
A – Size, cost and convenience to both patients and doctors is the primary advantage to OBS. Most clinics still capture much of their surgical staff from nearby medical doctors that also maintain their own private offices & use the clinics by appointment as must their patients. The construction and operating cost of a clinic verses OBS is about a factor of ten times! An OBS procedure room adds about $100,000 to the cost of a regular doctor office build-out verses at least $1,000,000 for a single operating room in a clinic or hospital. This huge cost differential is due to architectural layout considerations of things like circulation clearances & access to spaces (need a bigger floor plate) as well as the mechanical handling of air circulation, air filtration, anesthesia gas evacuation and emergency power. OBS follows some similar design constraints, but at a much more simple level and more practical response to the needs of what the individual surgical specialist wishes to perform. The convenience factor to both patient and doctor cannot be under-stated with OBS. The doctor controls the scheduling of his procedures and the organization of his or her patient flow. Think of a doctor enroute in traffic to the clinic & then waiting for the previous surgeon to clear the operating room, check-in his next patient with a nurse that may not be on his or her employ…then wait with everyone else for the system to grind along – if there’s an emergency, all bets are off & the day’s lost.
Q – What are the main differences in the design of office based surgery (OBS) verses a hospital or clinic?
A – The main difference between hospitals and OBS is the physical state of the patients entering the premises. Hospitals and now some clinics must maintain and provide for emergency care across the entire panoply of patient needs that may walk in or arrive by ambulance at any time of day or night. Also, the hospital patient may have an infectious disease, accident, gunshot wound or any other severe trauma event. They must be prepared for the entire universe of patient needs and thus are heavily regulated & codified as such. OBS practices are specifically designed and certified only for the procedures identified in their applications, thus eliminating the extreme needs of a general patient population.
Q – Who certifies office based surgery (OBS) verses a hospital or clinic?
A – Independent certification agencies authorized by the State of New York, here where we practice and similarly in most other States and jurisdictions. Each practice or facility must contract one of these entities to conduct the requisite reviews of plans and procedures as well as conduct a post-construction survey and certification. They also do follow up surveys over the specified time period to make sure the practice or facility is operating as certified.
Q – Who are the authorized independent certification agencies for office based surgery (OBS) in New York State?
A – There are three as of this writing (2015) – they are American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF), Accreditation Association for Ambulatory Health Care (AAAHC) and The Joint Commission (JC). We have used all three in our projects & the difference is more to the tailored needs of the particular doctor & what procedures they wish perform. We find that JC is the most stringent, mostly in the delineation of work documentation, but some slight variations in the mechanical considerations of the procedure room itself regarding gas evacuation & positive air pressure standards. JC is the current “gold standard” for hospital and clinic certifications to date. Since most of our doctors are within existing buildings, some of the JC considerations can be more problematic, but usually solvable at least on the architectural/mechanical end of things.
Q - Do all office based surgery (OBS) practices have to be certified?
A – Yes, as of 2009. We obtained certification (plastic surgery practice on Long Island) of our first OBS (AAAASF) in 2008, ahead of the legislation. This affects all 50 States by now.
Q – What are the main architectural/mechanical design elements that comprise a typical OBS project?
A – The most important design element of any medical office, but specifically office based surgery is “flow” of both patients and staff (particularly the doctor). Here in New York City, there are all the usual privacy and access requirements common to all doctor offices, but with surgery being performed, we find the best placement on a floor plate is “in the back” farthest from the front door and ideally a back exit out of the space when persons are OK’d to go home. Since most offices are already defined & the needs must fit the space, compromises must be made, but usually if you follow the basics and do the best with what you have – the design will be optimized. On the mechanical side of the design, the biggest issue is supplementary air conditioning! Often overlooked, even with LED task lighting (cooler temperature bulbs), the procedure room will overheat unless mechanically cooled. Most buildings do not have air conditioning available “on demand”, so planning ahead for this is paramount. Also, the patients in the recovery area want to be warmer, so zoning of the HVAC environment is very important. We usually specify (3) independent HVAC zones with separate controls – one for procedure room(s), one for recovery and then one for the main office space at a minimum.
Q – What are the most common planning misconceptions regarding office based surgery (OBS) architectural or mechanical specifications?
A – Since OBS planning is relatively new, the architects and engineers that either design or review the designs of others often don’t appraise themselves of the Codes and Regulations that govern OBS, specifically “procedure rooms”. We’ve had to conduct what amounts to teaching “continuing education” to large engineering firms that specialize in “hospital design” to adapt to the rules of OBS – they have a hard time relating to the notion of a “healthy” patient. This leads to a common misperception on “air handling” and air filtration systems – basically, it’s just a system of “normal” air filters changed & cleaned regularly utilizing normal commercial grade HVAC package units or central systems – air isolation & ducted returns are not required. This is because the patients are not infected with contagious diseases! A hospital operating room air scrubber (HEPA) is about the same size as the operating room with a complex series of filters that literally remove almost all particulate matter & dust from the air entering and capture this with metal ductwork on the return end as well for recirculation – very similar to computer assembly “clean rooms” and the like in manufacturing. This is not a requirement of OBS.
Q – Do office based surgery (OBS) areas require emergency backup power?
A – Yes. NYS as well as most other jurisdictions require back-up for most procedures where a patient is anesthetized and power interruption would endanger the patient. For most procedure rooms – back up power is required for all equipment, power and lighting for the express purpose of maintaining the “essential” components of a surgical procedure and/or recovering patient(s) that may yet be incapacitated or under anesthesia – these devices would be identified as such. In addition this part of the electrical system must follow the rules of NFPA 99 etc. in which extra color coded redundantly grounded wiring is specifically required. This to help prevent an incapacitated patient from being accidentally electrocuted or a fire started in the presence of oxygen & other gases that may be in the area.
Q – How much backup power is required in an office based surgery (OBS) suite?
A - Emergency backup power must provide the designed power load for the amount of time the surgeon believes he or she will need in order to shut down or close out a procedure and bring the recovering patient back to normal ambulatory status. Usually this is at least 2 hours, but sometimes more. We specify packaged UPS (Uninterrupted Power Supply) systems – basically a series of Lithium-ion batteries in a “box”. This “box” is connected to the ordinary service panel in the office via a service switch. The “box” in turn is connected to a second service “sub-panel” and from there the protected circuits are wired to the procedure suite. Since the procedure suite is running on an ever re-charging battery system, the surgeons & staff will never lose power – if main power goes out & the system is not being re-charged, the staff will get an audible alarm and/or alert on the computer system that they are in “outage mode” and must start the steps and schedules for stabilizing their work in progress – this becomes part of the certification statement.