For many OR directors, building a new operating room suite is a once-in-a-lifetime project. A few have the opportunity more than once.

Directors often embark on a building project without much expertise in reading blueprints or working with an architect. But they face a series of decisions that will govern how well their surgical suite functions for years to come.

In this article, OR directors who have been involved in construction projects—in most cases, more than one—share their survival tips.

Be involved from the start. "You can’t come in after the plans are laid out. You have to be involved from the beginning," says Pat Kroesch, RN, director of surgical services at Rush-Copley Medical Center in Aurora, Ill, who has been involved in two building projects. "You are the one who knows how the OR works. You are the voice of functionality. You have to be able to talk to the architect and builder. You almost have to educate them."

Darlene Astuto, RN, who has participated in building or expanding three facilities, comments, "I see my role as representing all of the interests—patients, staff, and physicians—to the architects so we will get the facility we want."

Nursing’s role is keeping the team focused on the needs of the patient, in the view of Renae Burchiel Battie’, RN, MN, CNOR. She is perioperative service line manager at the University of Washington, Seattle, which is building a big new ambulatory pavilion with 11 ORs. For example, one of her values is giving the family space to meet with the surgeon, not in a big waiting room but in a more quiet space.

"We learned early that form must follow function. You must talk first about the flow of patients, staff, and supplies—think functionality, then space," says Dru Beedle, RN, MN, CNOR, CNA, a perioperative nursing consultant and past director of perioperative services at the University of Colorado Health Sciences Center in Denver, where she participated in building of a 12-OR inpatient suite and was involved in the planning the university’s new outpatient pavilion.

If the architects haven’t built an OR before, consider having them visit an OR that works well to observe for a couple of days, Kroesch suggests. Educate them about the sterile field and flow of patients, instruments, and materials.

Have a knowledgeable person show you how to read architectural drawings and plans, Battie’ advises. "Check the plans carefully, and don’t be afraid to ask ‘dumb’ questions." Have a knowledgeable person show you how to read the plans. She learned that the actual location of the surgical lights was not where she thought it was in the drawings because the symbol for the lights was offset.

By any means necessary, directors suggest. Of course, you will include physician representatives on the design team and encourage them to attend meeting whenever possible.

Says Astuto, "I can’t stress this enough: If you have a strong physician group, you had better have them at the table. You don’t want them feeling they weren’t consulted."

Several managers suggested hanging blow-ups of schematic floor plans in lounges and hallways. Provide notepads so staff and physicians can make comments. Be available for conversations about the drawings. At the University of Colorado, department chairs were included on the committee. As critical issues came up, they were invited to the meetings. Beedle also attended the surgeons’ section meetings to keep them up-to-date.

The staff has expertise that should be tapped on issues involving the functioning of the suite, layout of ORs, patient care, and materials handling. For example, circulating nurses should help decide what supplies will be stored in the ORs, the sterile core, and the central service department.

If you will have a case cart system, they should help decide which supplies will be stocked on the case cart and which will be added in the OR. They should help determine how the OR will be linked to the case cart area.

Don’t forget to involve other key people, such as the risk manager and infection control professional. Ask if they foresee problems with the plans. For example, in one project, the planners had placed the ultrasonic washer on the wrong side of the decontamination area.

Identify your critical issues for the finished suite, directors suggest. Follow these issues through each stage of the project to make sure they are addressed. Examples are location and designation of electrical outlets and negative and positive pressure flows from the air-handling system.

Insist on receiving detailed minutes of each meeting with the architect and contractor. It’s also a good idea to keep your own record of each meeting and conversation.

"I kept a diary of every meeting, contact, and conversation," says Astuto. "That way I had a record of what everyone had said and who was supposed to get back to me. As things were finalized, I highlighted them. "This was a pain, but I found it helped more than anything else. A lot of paper comes from the architects, but I felt I needed my own notes."

A mock OR is helpful for determining spatial relationships, such as the location of the door, cabinets, and ceiling-mounted arms. But it can be pricey, and it isn’t foolproof.

"We built a mock OR, and we still made mistakes," comments Beth Suriano, RN, CNOR, director of surgical services at Jupiter Medical Center in Jupiter, Fla, who was involved in building a new eight-OR suite. The mock OR, built in a classroom at a cost of about $3,000, had walls with Styrofoam plaques to represent outlets, light switches, and film boxes. The articulating arms were positioned overhead. Even so, was hard to anticipate all of the relationships between doors, wall cabinets, and equipment.

An alternative is to visit other OR suites that are well designed, preferably with other members of the design team. Other options are computer simulation and the low-tech method of moving paper pieces around on a floor plan.

• Planned dedicated equipment space so equipment does not clutter the hallway. The University of Colorado built a long, narrow room so equipment could be lined up against both walls. "We traced a footprint of each item, such as microscopes, and labeled the spaces," says Beedle. At Jupiter Medical Center, equipment is stored in 4-foot alcoves in the OR’s 12-foot-wide back hallway. The alcoves have signs indicating where equipment is to be parked.
• Organized the sterile core by specialty. "We have signs hanging from the ceiling so anybody can see the area where they need to look," says Suriano. "We get a lot of compliments from travelers who say how organized it is because of the signs."
• Organized the sterile core for case cart assembly. Central service staff assemble the case carts in the evening. In the old OR, this work was done by RNs and surgical techs. The CS staff has been educated about the OR inventory and computerized pick lists and is supervised by an "OR core RN."

• When planning cabinets in ORs, consider all specialties that will use the OR. Will the OR table block access to the cabinets during certain types of cases?
• List all equipment that will be used in each OR to ensure electrical power is adequate.
• Fight for storage space. There is never enough, and it is always the first item crossed off the list if more room is needed or the budget is tight.
• Think about the communication system. Think of all the ways in which phone lines will be used and plan for enough lines. Consider other technologies. Will you use pagers? If so, will signals penetrate lead-lined walls? Will you use a computerized patient-tracking system? Is it compatible with the information system you currently have?
• Waste disposal should not be an afterthought. The OR produces more medical waste than any other department. Build an efficient area to dispose of waste. Plan a dirty utility room large enough for Dumpster-type containers. Make sure the room is properly located for your system, for example, not behind the red line. Will you need an elevator to transport waste? Look at high-tech options, such as self-washing chutes designed for contaminated waste. This could be a time saver for your staff, but it must be built in to the design.
• Be aware of room numbering. This may sound trivial. But Beedle learned that once the rooms were numbered on the drawings, the numbering was keyed to the plumbing, HVAC, and fire control systems. It was too complicated to change the numbers later even though they were not in the order she and her team would have chosen.

• Use your network. Talk to other OR directors who have been through a building project. Have them look at your plans and give their advice.
• Be assertive. "If you know something is right, don’t give up," Astuto asserts. "Fight for it. Don’t let them tell you there is not enough money.

"You may think the architects are the experts, but you are the expert in the OR."