red flag rules. Unfortunately, ignorance of the law is not defensible. Organizations, such as the AAD, can serve as a resource for guidance regarding these regulations.

Summary: Reception Area

•To be efficient and patient friendly, an office needs to be well planned with adequate work and reception areas.

39.11 Reception Area

To facilitate patient flow and give some sense of privacy, it is important to have separate areas for patients to check in and check out. Although not always possible, it is ideal to have a small office, within the reception area, where bills and payment arrangements can be discussed in private.

A fax machine and a high-quality printer are essential items. There should be adequate phone lines so that the patient does not constantly get a busy signal.

A Rolodex with important and frequently called telephone numbers is also a must.

There should be two restrooms, one for the staff and a separate one for patients, which should be handicap accessible.

Summary: Waiting Area

•A sub-waiting room for Mohs patients is ideal.

•Recliners allow Mohs patients to wait in comfort.

•A television can help make waiting easier.

•A beverage center is appreciated by Mohs patients.

39.12 Waiting Area

Ideally, there should be two waiting areas, a larger general waiting area and a smaller sub-waiting area for Mohs surgery patients who are awaiting the results of the microscopic examination of their tissue. This sub-waiting area should have recliners and a beverage area, which has at least a coffeemaker and a source of water. Ideally, hot water should be available for those

who prefer tea or hot chocolate. Soft drinks, juices, and snacks can be kept in a separate area and made available upon request. An extravagance but nice touch is a machine that dispenses hot water and also makes individual cups of different flavored coffees and teas. If the waiting area tends to be rather cold, blankets should be available. There is a blanket warmer, which can be used to heat the blankets and which also comes in handy for patients undergoing liposuction. A television can help entertain patients while they wait and can also be used for educational purposes.

Summary: Exam/Surgery Rooms

•There should be at least three surgery rooms.

•Tile floors are easier to maintain.

•Double surgical lights are ideal.

•There should be adequate cabinetry and surfaces on which to work.

•Power tables should be comfortable.

•Suction should be available.

•Consider having music in the rooms.

•A floor or wall-mounted buzzer system can allow one to easily call for assistance.

39.13 Exam/Surgery Rooms

At the very least, there should be three rooms available for patient care. Two of these should be set up for surgery so that while one patient is having surgery, another patient can be gotten ready for surgery. The third room can be used as a general exam room or for suture removals, etc. In anticipation of growth or the addition of a physician assistant (PA) who might assist with simple repairs, this third room should be of adequate size and designed similar to the surgery rooms so that very little needs to be done to convert this to a fully operational surgery suite. Although three rooms would suffice, we would suggest having four rooms, two of which are outfitted for surgery to allow for growth. Of course if one later added a PA or aesthetician or decided to use lasers, additional rooms would be required.

The exam/surgery rooms should have adequate cabinetry and counter space. A soap dispenser should be mounted over the sink, and by the door, there should be a dispenser with some type of soapless disinfectant

for quickly disinfecting the hands before and after examining the patient.

Wall-mounted mirrors should be available for the patients to view themselves, and full-length mirrors are good if you are doing liposuction. Hand mirrors are a must for identifying the biopsy site, viewing the lesion preoperatively and viewing the Mohs defect. If the Mohs specimens are going to be color-coded and mapped in the operatory, a work area needs to be available where one keeps the dyes, Q-tips, cutting boards, and trays for transporting the tissue. Ideally, this needs to be a counter that is lower, so one can be seated while they process the tissue. If the counter/work space is of adequate size, a computer terminal can be located in this same area.

Music can be quite soothing and relaxing. However, there are times when either the patient or physician prefers to have it turned off. Each room can have a volume control, which allows this to be done.

During sterile procedures, the physician and his/her assistant may find that they need something or situations may arise where they need assistance with the patient. A floor switch, which activates a buzzer or light, is very useful at such times. A light or flag system is also essential to alert the physician to which room they need to go to next.

The surgical table needs to be capable of assuming multiple positions. Although tables, which can be programmed, are nice and efficient, they always seem to require reprogramming. The table needs to be well padded and comfortable. Patients often prefer tables with armrests. These need to be able to be moved out of the way when necessary. If one plans to sit and do surgery, one would opt for a narrower table and a dental chair-type headrest.

To have adequate lighting, we would suggest two overhead surgical lights, with handles, over which one can fit covers.

The electrosurgical machine should be capable of both cutting and coagulating. The cutting mode can be used to sculpt patients with rhinophyma and also can be used to debulk vascular tumors. A machine capable of bipolar cautery can be useful in patients with a pacemaker or deep brain stimulator. However, since this mode may be used infrequently, it is necessary to only have one such machine.

Each surgical room should have a kick bucket as well as large trash cans for hazardous and nonhazardous

waste. A sharps box also needs to be available. Nonsurgical rooms also need to have containers for the disposal of waste and sharps.

Equipment for suction and the delivery of oxygen needs to be available. These can be portable sources, but if the cost is not prohibitive, wall-mounted sources are preferable. Cost would determine how many rooms were so outfitted. Chart racks need to be placed on the door or next to the door to each room. Coat hangers should be attached to the door for hanging clothes.

Although carpet looks nice, it is easily stained and can soon look shabby. We would suggest tile floors in the operating and exam rooms.

Summary: Physician Office

•The physician needs a private, quiet area for consultations, dictations, paper work, and phone calls.

39.14 Physician Office

The physician needs an office where he or she can dictate, do paper work, make and receive phone calls, read, and have private consultations with patients and families.

Summary: Nurses Work Station

•Nurses need a work area to make phone calls, access lab reports, and to carry out other required tasks

39.15 Nurses Work Station

The size and complexity of this area could vary from a simple counter to a larger area where meds could be drawn up or surgical trays could be prepared. At the very least, there should be adequate counter space for writing and computer terminals and for telephones. The station should be in close proximity to the surgery/ exam rooms so that the nurses can monitor the rooms and patient flow and be readily available. Ideally, the

nurses should also be able to see when charts are put in the “rack” so that they can get the patients back in a timely fashion. If this is not possible, a light system needs to be in place, which alerts the nurses when a chart is placed in the “rack.”

Summary: Personnel

•Good personnel are essential to establish a practice that is efficient, productive, and patient friendly.

•Personnel should be well trained, efficient, show initiative, be team players, and be patient advocates.

•Personnel is not where one wants to economize.

with no background can be trained to be excellent histotechnicians.

All too often there is an attempt to save money when hiring a receptionist. This is the first person patients come in contact with, either in person or on the phone, and so it is important to have someone good. This is not the place to skimp.

Summary: The Laboratory

•A well-equipped and well-run laboratory is the cornerstone of a successful Mohs practice.

•The laboratory is a lifetime investment, and one should not try to economize.

Summary: Space

•The lab needs to be large enough for two people.

•The lab needs to be kept cool.

•There should be adequate storage and work surfaces.

•The floor should be tile.

•A backup cryostat is ideal.

39.18 Space

The laboratory should be large enough to accommodate two workers. There should be an area to receive gross specimens. Always have the sink near the staining setup for easy access and connection to an automatic stainer.

It is very important that the laboratory be cool. Minimize the number of windows so that less heat is transmitted from outside. If possible, the lab should have its own air-conditioning system.

There should be adequate space for one or two cryostats (AC outlet), shelves, cabinets (including a cabinet for flammables), counter space (at least five feet) along one wall, a sink for staining, and a microscope to check slides while cutting. Bright overhead lighting and a magnification light are essential for the grossing area. Depending upon your state regulations, a fume hood over the staining setup may or may not be required, but is highly suggested. A separate counter space is needed for all paperwork, including a computer terminal. There should be space for a liquid nitrogen tank under one counter.

The floor should be linoleum or tile for easy cleanup.

Summary: Personal Protective Equipment

• Provide protective equipment

39.19 Personal Protective Equipment

Gloves, an impervious gown, and protective eyewear should be worn when processing fresh tissue because all tissue is considered to be a biohazard.

Summary: Mapping and Grossing the Tissue

•Either the Mohs surgeon or histotechnologist can gross, color-code, and map the specimens.

39.20 Mapping and Grossing the Tissue

The laboratory technician or the surgeon may gross, color-code, and map the specimens. This can be done in the operatory or in the laboratory. Precise orientation and mapping is essential. The tissue can be transported to the laboratory on a small metal tray or in a plastic gauze container. For the grossing of the tissue, one needs a cutting board with grooves on its borders where knife handles can be placed when not in use. A magnification light at the grossing station will aid in viewing the tissue samples more closely.

Marking dyes should be available in a variety of colors. A key should be on the map that indicates which colors are being used to color code the specimens. In addition to a key for color-coding, the map should also include the patient’s name, the date, and the accession number. The type of tumor and its location can be written in if one map is used for multiple lesions, or there can be blank spaces for this if each tumor has its own map. The map should also include the preoperative size of the lesion and the size of the final surgical defect. There can also be blanks for the type of repair and the length of the suture line.

There are assorted forceps from which to choose depending on the height and size the laboratory technician prefers. One will need #15 and #10 surgical blades, and tissue scissors may also come in handy. A wide mouth thermos, without a lid, can be used to store liquid nitrogen in the cryostat and used in conjunction with sponge forceps when cutting fatty tissue.

Summary: Embedding Mohs Specimens [1]

•Embedding is critical to cutting good sections.

•There are a number of methods for embedding tissue.