An ambulatory surgery center is indication to the surgery that conducted without the need for overnight hospital stay. This term also recognized as outpatient surgery or same day surgery. This surgery in general not type of complicated surgery, it is simpler than the one which requiring hospitalization. This kind of ambulatory surgery is widely used in present time, where the cost of such surgery is low, simple and required less resources where for the inpatient it is essential to keep the patient in the hospital; that mean reserve bed for that patient in the hospital . Another definition can be used here, that ambulatory surgery is “the performance of planned surgical procedure with the patient being discharged on the same day” .
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The ambulatory surgery first found in 1909 by James Nicoll, a scottish surgeon, it was called by “day case surgery”. In 1912 Ralph Walter in the USA adopted this surgery type in the USA. It was unpopular until the 1960s and 1970s when the traditional surgeries became a bottleneck for most of the USA’s Hospitals, where keeping the patient on holding list and admitted them in the hospital became more expensive, in addition the availability of beds decreased. Walter Reed introduced the ambulatory surgery to USA’s hospital, since then patient manages improved significantly and rapidly with ensuring the patients’ fitness after discharge . Ambulatory surgery form about 90% of all surgery performed nowadays in Canada and USA . The day surgery can achieve high level of quality, cost effective and safe which lead to high level of patient satisfaction . University of California at Los Angeles developed a hospital based on ambulatory surgery unit in 1962, then other units in the USA were opened in 1966 At Gorge Washington university, until big number of ambulatory surgery is opened now in the USA and Canada .
Several associations created to developed a strategies and plans to adopt and improve the ambulatory surgery, one of these association is the Federated Ambulatory Surgery Association (FASA), this association founded in the USA since 1974, another 12 national association formed and become member of the International Association for Ambulatory Surgery (IAAS) 
The advantages from ambulatory surgery system are varied in type, some of these advantages related to patient and their family and some related to the hospitals and the healthcare system as whole. Those advantages for the patient that they will receive more attention from the healthcare team, because the ambulatory surgery designed to serve that patient . The ambulatory patient will return home after receiving the treatment, so it is better to well manage the day surgery units and provide the patient with treatment which allowed them to continue recovering at their family home environment. Small mistakes that could happen for inpatient will not occur to the ambulatory surgery patient, like missing drug or shot or give different medicine for patient, because in the ambulatory surgery patient is always having everything in plan and no mistakes there .
Day surgery is better for children than inpatient surgery where the children will not be separated from their family for long time. The children will be less stressful and feel more comfortable because they can join back their family after that surgery finish . In the European Charter of Children’s Rights states that “children should be admitted to hospital only if the care they require cannot be equally well provided at home or on a day basis” .
Other main important advantage is that scheduling for ambulatory surgery is much easier and less complicated for registration. Furthermore the day surgery will not be cancelled because an emergency admission likes what happen to inpatient surgery. The recovery period for ambulatory surgery patient is faster than inpatient, this allowing to patient to return to the normal life sooner .
For the hospital the benefit is more in way of management way where the efficient for providing surgery and the flow is less risky where everything is scheduled and prepared without facing cancelation, this offer more utilization for the facility and resources and give the patient more booking choice . All healthcare organizations are having problem with budgets and limit funds and the patient demand also increased at the same time, the new treatment way for making same day surgery operation is cutting down the cost and reduce the demand for saving beds and resources for inpatient who waiting their surgery to place; while the ambulatory surgery patient receiving high quality and effective treatment those inpatient having shortage sometimes because limitation and long scheduling .
(b) Discuss their evolution in the United State.
The first found of ambulatory surgery was between 1864 and 1921 by James Nicoll while his working in Sick Children’s Hospital and Dispensary in Glasgow, Scotland. Most of his operation was on special condition like phimosis, mastoid disease, cleft palate and spina bifida that all were done in daily basis, where the children received treatment within the same day. James Nicoll reported that 8988 paediatric cases were success in 1909 .
Since that time to 1948 nothing changed and the ambulatory surgery did not change in the way to adopting it, in 1984 British Medical Journal reported that surgeon allows a patient to leave hospital within 14 days of an intestinal operation . The idea was adopt by different surgery around the world but none designed a unit for ambulatory surgery, until 1962 when a hospital build a unit at the University of California at Los Angeles, USA based on Nicoll’s concept . Another unit opened within USA at George Washington University in 1966, after that in 1968 another unit designed in Providence, Rhode Island . Reed and Ford both opened their Surgicenter in Phoenix, Arizona in 1969; it was the first similar idea to what Nicoll’s units was .
In period between 1970s and 1980s a large number of day units opened in Canada, the USA, the UK and Australia and started reporting in medical journals the benefits of having day surgery and the procedures and the way of adopting them. The key elements of those publications were the quality, cost effectiveness and safety of these ambulatory surgeries, and they published in different places like Orkand Corporation in the USA, the Royal College of Surgeons of England and the Audit Commission in the UK and the Royal Australasian College of Surgeons of Australia [18-22].
Different association started to form in order to organize the work of ambulatory surgery units and deliver the new technique and methods to other units and maximize the benefit of having ambulatory unit attached to the hospital and separate surgery unit. Their Main goal is to promote quality standard expansion, education and research in the field of ambulatory surgery centers. The first foundation was the Society for the Advancement of Freestanding Ambulatory Surgery Centers (FASC) which now known as Federated Ambulatory Surgery Association (FASA), that association founded in the USA in 1974. Another 12 American association decided to form in 1995, and all become members of the International Association of Ambulatory Surgery Centers (IAAS) .
(c). How do ambulatory surgery centers influence healthcare delivery?
In healthcare delivery system it is important to provide the patient with the appropriate treatment according to his/her case with high quality and effectively. The inpatient facing some difficulties in booking a date and time for his/her surgery and sometime they need to stay in the hospital for recovery, this amount of load on the hospital may lead to some mistake in healthcare delivery process where mostly happened in medication is.
This scenario cost the hospital a lot of resources and dollars in order to fixing them, this misleading in manage the inpatient, most likely, not found in ambulatory surgery patient. The amount of accuracy the treatment deliver is high, moreover the quality and efficiency also acceptable.
According to the nurse who their ages averages between 41 year in the UK and 45 in the USA, the ambulatory surgery unit is more attractive to them, where they need more time to spent with their family and the needs for weekend and overnight will decreasing. With fixed schedules for surgery in ambulatory surgery unit it gives the opportunity for nursing to work overtime with more efficiency and effectiveness. The efficiency of nurses in surgery is important where it cannot reach the highest value in the normal inpatient surgery which may be taken over night or weekend. .
According to the cost of inpatient surgery compared to the ambulatory surgery it can be significantly different, usually for inpatient surgery reserving bed for patient is important without knowing the period of time that patient need for recovery and weekend and night staff is necessary, these two facts added cost to the hospital where if it is ambulatory surgery the need for hospitalization time will be reduced and night/weekend staff is not required. In the ambulatory surgery units the time and staff are used more intensively and effectively. The average unit cost savings of between 10% and 70% is documented in case of having ambulatory surgery rather than inpatient surgery [8, 18]. The improvement of patient throughput is one of the advantages of having day surgery unit , another benefit is to provide an enhanced patient service in a cost effective manner .
For Children most cases are performed in ambulatory surgery unit, it is rule, unless it is necessary to consider them as inpatient. This will reduce the stress on the patient and their parent’s also elder people will recover fast in their home after having one day treatment in the hospital. The way of deliver the treatment in that way will improve the patient satisfaction and improve the efficiency of the healthcare .
If we consider the study of patient turnaround time and length of stay, these two measurements are good indicator of how effective is the healthcare treatment was, less length of stay is the case where we have ambulatory surgery unit working and the aim is to reduce the time that spend between starting the triage until the patient discharge. The quality of treatment is also a case where we need to consider less variability of process and high patient satisfaction, less autonomy is the key point in the ambulatory surgery units where everything is schedule and designed in way to have best treatment without mistakes.
The load inside the hospital to reserve beds and prepare the beds, is major problem in present time where the demand is increased, the ambulatory surgery unit has fixed amount of resources and can server special cases (minor surgery) more efficient and effective.
Inpatient surgery may facing a case where their scheduled surgery may canceled because emergency case come, the other cases can also be seen where the operation is canceled because lack of resources. Either case cannot be found in the ambulatory surgery units. All these leads to better quality, resources effective, cost effective, more satisfaction, time utilization and decrease the demands.
(d). Describe the factors that impact the establishment of an ambulatory surgery center.
Two main factors should be considered in order to establish a successful ambulatory surgery unit:
“It must provide operative service of high standards of quality and safety at least equal to those of inpatient care.
It must be both patient and cost efficient such that it provide high levels of patient satisfaction and is financially sustainable.” 
The ambulatory surgery centers usually formed from different facilities in the hospital, each facility has it unique characteristic and because of this uniqueness the ambulatory surgery units has to fulfilled these need. In general there are four categories of facility:
Hospital integrated facility: in this type of facility the patients of ambulatory surgery are treated in partial or total through the inpatient units.
Self-contained unit on hospital site: in such units the ambulatory surgery is performed in separate units, units build only for one day surgery and they are total separate from inpatient units.
Freestanding self-contained units: those units look like the units which existed in the hospital.
Physician’s office-based unit: this is a limited resource units it can operate small surgery.
Several criterions can be used in designing the ambulatory surgery centers; one of these criterions is the surgical, there is wide range of procedures followed the surgery and attached to the operation. The resources needed and space for this kind of surgery is important factor effect establishing ambulatory surgery centers .
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Other criterion is social, it is important criteria because the patient discharge to the environment, the social should be prepared for receiving patient and provides him/her with the suitable resources for recovering, and most of the cases the nurses asked the ambulatory surgery patient to keep the center updated to his/her status .
The patient age is another criterion affected the establishment of ambulatory surgery center, two ages range can benefits from ambulatory surgery centers the children and extreme ages . Type of patient is also another factor, which patient is appropriate to considered as ambulatory surgery patient, if the patients need more attention they should be admitted as inpatient.
(e). What are the challenges that hospitals face while implementing an ambulatory surgery center? Please (very briefly) describe them.
As the demand on the ambulatory surgery increasing it is become necessary to discuss the challenges that facing the hospitals while implementing an ambulatory surgery center. It is important to identify these challenges and trying to control them to keep the quality and performance level high in the ambulatory surgery centers.
Patient satisfaction is one of these difficulties that challenging the hospital to implementing the ambulatory surgery, it is hard to measure this amount of satisfaction and there is no certain baseline for this measure, but in general the patient is satisfied as long as that process goes as his/her expectation, which vary from patient to another according to their background and educations .
The productivity in the ambulatory surgery units can be measured using five types’ indicators :
Labor: because the nature of work in health care is based on labor, then the outcomes commonly represent service, with labor as input to the system the outcome could be clinic visits.
Supplies: the output from this could be ambulatory surgery procedures.
Equipment: Diagnostic tests are one of the possible outcomes.
Facilities: that leads to home health and visits.
Capital: Physical therapy treatments.
One of the challenging is the ensuring employee motivation, with the amount of work they have in ambulatory surgery units the employee performance can be reduced by time, then the quality will be reduced because the employee is the key element here. In order to keep the employee as good as they could be, then one suggestion can be applying a Japanese management techniques “happy employee is a productive employee”. This idea has been discussed by Tabatabai in 1983 . Another important terms is the motivation, the managers should provide the ambulatory surgery centers with a staff which motivate the employee during their works in that health care centers .
Improving the productivity of employee will not be separate from keeping the same level of quality or improving it, that is one of the challenges that facing the ambulatory surgery centers now days. The quality in the ambulatory surgery units should be taken from customers’ perspective, here the customers are both patient and physician; for example the waiting time from customers’ point of view is important and that duration should be very low.
Scheduling is one of the problems in ambulatory surgery centers. All of the participants in health care (Patient, physician, and employee) should be prepared at the same time and processing the health care for same period of time, that is hard part to ensure the that load is distributed along the day, for some cases the maximum load at the morning and noon, but at midnight the load is less. Some engineering and system engineering tools and techniques are useful to solve this problem .
The number of outpatient and the patient in ambulatory is growing rapidly; the managers should manage the growing without direct them to another hospital or clinic is important strategy need very good management skills. That is one of difficulties that facing the ambulatory surgery centers. The challenging can be summarized as follow:
Scheduling which can be happened because the numbers of patient is growing so fast and the need for good scheduling.
Motivation: the employee performance is reducing while the number of patient is increasing and in the nearly future the needs for new strategy to motivate the employee.
Patient satisfaction: with the number of patient increasing the number of different type of surgery in ambulatory surgery will increase. The need to standardized the procedure is growing.
(f).Briefly illustrate the role of Industrial and Systems Engineering or Operations Management tools such as total quality management, process mapping, scheduling, etc., in establishing an effective and efficient ambulatory surgery center using at least two case studies or applications based on the literature.
In the ambulatory surgery center the quality is essential rule to keep the performance and outcomes at acceptable level, also customer satisfaction is important in way to provide him/her with the wide range of treatment they required. At this step a continuous improvement and evaluation tools are the key element for ambulatory surgery centers to survive. A study suggested having a clinical indicators and acceptable thresholds that are relevant to daily practice, that will lead to easy measured and analyze the process parameters .
Modeling and simulation tool is good in way to provide the managers and the leader of ambulatory surgery units with virtual units where they can check the effect of increasing the demand on this type of surgery, where the most of hospital are looking to move their minors surgery to be done in separate units and leave the operation theater for the cases which need high attention and care.
Enterprise-management tools, other useful tools to manage the ambulatory surgery units the idea is that units need to be managed as subsystem of the biggest system (Hospital). The interaction between hospital and ambulatory surgery units can provide these units and hospital with large amount of information of different cases and symptom that comes daily to the ambulatory surgery units and emergency department. In general industrial and system engineering tools can help the ambulatory surgery centers in different way, decrease the cost by decreasing the length of stay for patient: because most of the cases in the day surgery unit is normal and repeatable surgery (most of them are easy not complicated surgery) then the procedure can be standardized, this standardization will reduce the cost by removing the unnecessary process from the units. It is know that the nature of hospital is not same and there is high level of variation between different cases, this problem can be reduced in the ambulatory surgery centers.
Any engineering and system tools or techniques can be very useful in ambulatory surgery centers, in mean of the capabilities of providing the patient with excellent treatment within short period of time, both will result to patient satisfaction and improving the patient recovery time after leaving the ambulatory surgery centers, and also reduce the cost on ambulatory surgery center by reducing the number of employee and resources needed, because the good engineering tools mean less waste and more efficiently for both employee and resources. It can be summarized into following points:
Decreased salaries expense by reducing the staffing requirements.
Greater patient satisfaction through reduced waiting times.
Increases employee satisfaction because workload is evenly distributed and activity levels do not create a “hurry up and wait” environment.
Increases physician satisfaction because operations are more efficient and patients are more satisfied.
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