Let me start with a disclaimer. I can't draw a stick man (so I am not an architect), never built a birdhouse that stayed together more than one season (not a builder), nor have I ever been able to put the toaster back together (no equipment consultant here). I'm the "dummy" here. But in my 27 years in the outpatient surgery industry, I've been involved in the planning, design and construction of more than 100 surgery centers. Along the way I have picked up a few concepts I thought may be helpful to those of you crazy enough to be embarking on the all-too-fun process of developing your very own surgery center.

The business plan
That's right, the business plan. Not the architectural plan. All successful projects begin with a solid business plan or pro forma (used interchangeably in the business). That's "pro forma," not "please perform this way." A pro forma should be an honest representation of your project's projected cost and operating performance. Base the underlying assumptions relative to both capital and operating costs and expenses on industry benchmarks, not best guess estimates from your brother-in-law who runs the local lumber yard. Use the business plan or pro forma as a foundation to run various scenarios of the scope of the project, projected patient volumes, mix of procedures, financing options, staffing costs, capital equipment and other project parameters. The best pro formas challenge your thinking. They don't confirm your back-of-the-napkin conclusions from the night before. In 20 percent of the projects I have evaluated at the planning stage, I recommended my client not proceed with developing the surgery center. There are proven benchmarks for ASC design criteria, construction costs and operating performance. Be sure you measure your project against these criteria before making the "go" decision.

Selection of architect or development firm
There are various ways to approach the planning, design and construction of your surgery center: the traditional design-build approach, turnkey (all-inclusive) approach, and other custom or hybrid models the various firms have developed over the years. In the early years of surgery center construction in the 1980s, we were forced to work with hospital architects and train them to think small, lean and mean, and not over-design the space so that it morphed into a hospital-like setting. Fortunately, a growing number of qualified surgery center design and development firms are available to you. Here are some thoughts on selecting a firm to partner with from concept to first patient:

• Experience. I interview only those firms with at least 10 surgery centers under their belt (perhaps during the past five years).
• References. Call each firm's last three clients and ask them how their projects went. Was the project on budget and on schedule? Did they receive adequate on-site support? How did their architect get along with the builder, developer, owners and others? Did you pass your inspections and accreditation survey with limited deficiencies? How did they handle problems? Would you hire them again for an expansion project? How did their fees and expenses measure up against their initial proposal? Were they invited to the open house?
• Site visits. Yes, this is a hassle and costs a few bucks, but it may well save you from making the wrong decision on a multi-million dollar venture. Visit two surgery centers if possible, and ask to speak to the medical director, clinical (nursing) director, key surgeon and executive director while on site. You will get a firsthand view of the patient, staff, material and physician flow. In addition to addressing some of the questions outlined above for your reference calls, there's no substitute for touring a project and forming your own impressions of the building's general theme, image and function.
• RFP and presentations. I typically assist my clients in creating an RFP (request for proposal) that provides architectural and development firms with an overview of the proposed project, scope of the project, organizational and legal structure, project schedule and general expectations of the owners. We send this RFP to several (pre-qualified) firms that are expected to provide a comprehensive proposal, inclusive of references.

The next step in the process is to invite firms to have one or more of their executives make presentations to the owners. I like to prepare a matrix of selection criteria for my clients that they can use during the Q&A period following the presentations. This serves to focus our inquiry and create a standard tool for ranking the prospective firms at the end of the day. Criteria would include, but not be limited to: experience, feedback from references and site visits, proposed relationship or business model, price, terms, commitment to schedule, knowledge of local market, established relationship with local and state agencies and in-house capabilities (will any of the deliverables be outsourced to another firm?).

The design phase
So, you've hired a firm and are now ready to start drawing the plans. How exciting!

If you're working with a corporate partner or management company, hired a consultant or selected a experienced surgery center design and development firm, this phase of activity will run very smoothly, and result in a plan that is functional, affordable and aligned with your projected operating performance and business objectives.

But if you selected a "healthcare architect" that told you all operating rooms are created equal, chances are that a few years from now you'll be using two ORs to store "excess" medical equipment and supplies, your medical director's mountain bike and a Bowflex.

Your goal is to right-size your surgery center with an appropriate blend of pre- and post-op space, operating room capacity and streamlined flow. There are rules of thumb (benchmarks) available in the industry that can serve as a guide in the design process (see "4 Construction Guidelines to Live By" below) but site, local and state building codes and regulations, project scope, owner expectations and the budget will all ultimately affect your building elevations, footprint and internal flow.

In my experience, architects commonly employ two approaches:

• they meet with surgeons and management to obtain their wish list and draft a preliminary design around meeting each of these expectations, or
• they educate their clients during the design phase, providing them with design concepts for each area of the facility and the costs associated with each alternative.

I prefer the latter approach, which streamlines the design timeline, ensures efficient flow, reduces the likelihood of over-building and serves to reduce the project's budget.

Make your mistakes before you dig the hole
Years ago I worked with a large healthcare delivery system that was developing five surgery centers adjacent to its hospital campuses. The facilities VP told me that while the design process can be challenging and frustrating (particularly for physicians), it's critical to make your mistakes on paper before you break ground. Other lessons learned:

• All surgery center projects (designs) are based on a series of compromises. There are no perfect surgery center designs.
• All new construction projects will encounter problems. It's how your firm responds to these problems that separates the good firms from the "Lexus" firms.
• The costs of equipment and instrumentation commonly mirror the costs of construction. Surgery center equipment consultants are valuable members of the development team and more than pay for themselves given their ability to provide equipment specification, procurement and coordination with the architect and general contractor.
• Not all builders are created equal. Be sure they have significant healthcare and preferably surgery center (operating room) experience.
• Very few remodeling projects result in significant cost-savings over new construction in my experience. Complex air handling systems (floor to ceiling heights), code issues and other challenges affect the viability of a remodel.
• Build expansion into your design.
• Avoid shelling in space (ORs). Many surgery centers have excess capacity. You can solve capacity challenges operationally.
• Get help. As I've said many times before, if you think hiring an expert is expensive, try hiring an amateur to do the job.

The voice of experience
So, there you have it: A few lessons learned from a dummy who has made more mistakes than all of you combined.