Office Based Surgery (OBS) Part 1

Q: What is “OBS”?

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.

Residential Apartment Renovation’s Projects and Approvals Process in NYC

Q: What’s the typical approval process from start to finish for renovating an apartment in NYC?

A:The approval process is almost always the same with minor variations depending on the ownership status of the particular dwelling unit and the work being proposed. Most typical in our experience is that the work being proposed will need the approval of a Condo or Co-op Board as well as a building permit.

First you must engage either an architect or an engineer licensed in New York State to prepare plans, written scope of work including basic specifications describing “what’s existing, what’s being taken out & what’s going back in”. Most apartment buildings have an architect or engineer that they engage (and you pay for) that review the work proposed & render their comments or questions that must be likewise addressed by your architect or engineer until all issues are resolved – usually in writing – this is then presented back to the Condo or Co-op for formal approval to move onto the next step, which is application to The Buildings Department for approval of the plans. If you are located in one of the many Landmark Districts, you must obtain their approval first in most instances, get their OK & then submit to Buildings Department.

Most renovations and apartment combinations are filed as an “ALT 2” application, which is the City’s most common type of filing. If demolition is involved, an Asbestos Inspection Report is required, waiver for new buildings might be possible, but not for the average project. You cannot file without this report and if the report identifies asbestos containing materials (ACM) present and intended to be disturbed by the proposed construction, this material must be removed by an asbestos contractor and air monitoring company before permits can be issued to your contractor(s).

Once all this is in place, most Condo’s and Co-op’s have you sign an Alteration Agreement, which identifies “house rules”, deposit money against damages to the building and contractors indemnification and insurance policies to name a few specific items. Also most buildings have time limits for construction after which penalties may be imposed or in some very strict buildings, the project must stop (these are “summer only” buildings) and be allowed to continue at a later date.

As your project progresses, it must be inspected periodically as noted on your approved application and each inspection “signed off” by the professional assigned for this or a Building Department Inspector if so required. This process involves a lot of “paperwork” and so we retain building department consultants (“expediters”) to do all this legwork.

At the completion of the project, the architect or engineer files for and obtains a “Letter of Completion” which is the formal document issued by the Buildings Department that closes out your application. Special note to building and apartment owners – don’t allow these applications to either lapse through inactivity or not be properly inspected and insist the Letter of Completion be obtained – not doing this can hamper future financing or sale of the dwelling unit affected. Most buildings will not release deposit money without this document, so do not offer full payment to your contractor without your inspections signed off and visible online at nyc.gov/buildings. Without the inspection sign offs, your architect or engineer cannot get you the L of C.

Q: What’s the time frame for a typical apartment renovation project from very beginning to the very end?

A: Typically, once you’ve engaged an architect or engineer, it takes a few days to measure, a few more days to get a drawing to work from & a few more weeks to get to a basic plan or layout. Upon agreement on a basic plan, it takes a month or so to complete drawings needed for the various submittals – this part totals 2 to 3 months.

Approvals from Boards, Landmarks and then Buildings Department may take 2 to 6 months, say 4 to 5 on average. Construction bidding would be done concurrent with the approval process, so there’s no lost time here. The construction always seem to take 4 to 6 months, which is all the time most Boards will allow, so just make sure your contractor is well staffed!

The last of the minor decorating & “punchlist” is usually considered not to be part of the “construction”, so there is some relief here – allow a month or two for this aspect to be ready to “move in”.  Average time allocated is 16 months very beginning to very end.

Q: What does a typical apartment renovation cost?

A: This is usually the first question asked of most architects by almost all prospective clients. I approach this answer cautiously until I know more about what the client wants to do & the level of quality desired. It also matters a lot where the project is located and in what building. Projects in most of Manhattan are problematic for staging, access and deliveries & we see the cost reflecting this.

Some apartment buildings have more restrictive rules than others and/or limited hours in which not only construction may be done but “noise” may be generated and when! This may mean the workforce is only able to put in a 6 hour day – obviously this also adds to the cost. Most of our work is in Manhattan and we prefer “total gut” projects (everything is stripped back to the structure & the windows and doors replaced with new) of whatever project we get involved in unless the scope of work is truly minor in how much the apartment would be disturbed. We almost always recommend “clean it & paint it” or “gut it” for apartment renovations – getting caught in between can be frustrating to both owner, architect and contractor as the list of “hidden conditions” sends the budget into the unknown.

Regarding the average cost for what we consider excellent overall quality of workmanship, custom painted millwork, doors, casework, “reasonably” higher end finishes and fittings – no other decorating, special wall of floor coverings, fittings, furniture, media tech, security systems or window treatments to average $500.00 per net square foot as of this writing. It’s very difficult to get below this number for this product, if you’re considering doing this yourself. More exotic design & complex detailing can send the cost to four times this easily and also seriously affect the time in which this can be constructed to be forewarned.

Fees vary by architect or engineer, but it’s generally set by percentage of the construction cost – my knowledge of my peers is that the average for full services (which you may not need) is 18 to 25% plus engineering, consultants and travel expenses etc. My advice is to “shop around” for cost as much as “compatibility”.