We use cookies to maximize your online experience with us. By closing this window, you consent to our cookie policy. You can change your cookie settings in your browser any time. For more information, please see our Privacy Policy located on the footer of this site.
Recap of Virtual Healthcare Round Table October 2020
Healthcare facility construction is influenced by many factors that range from development costs to patient satisfaction. We brought together industry leaders to discuss the challenges and solutions they predict will change the way healthcare facilities will be built going forward. Our conversation covered recent lessons learned in healthcare construction and ideas on the future of the industry.
You can watch our webinar here or read the transcript below.
Steve Lang:
Good morning, everyone and welcome. Thank you for joining the Virtual Healthcare Roundtable. We’re excited to spend the next hour with you on what will probably be a concise and powerful agenda. We’ve received some really great questions as part of your sign up for today, that definitely helped shape today’s agenda. So briefly, these are the subjects that we’re going to talk through a little bit on:
- emergency conditions in a COVID environment.
- Some modular and prefab construction options
- technology and it’s powerful impact on our businesses today.
- And as a result of those, what other changes are we finding in the industry.
Just so you know, in taking all those questions we also are asking that if you have questions during the presentation that you can use the Q&A button. And if we don’t get to a question today in the Q&A, we will definitely follow up with you in a summary document that we will compile and share at the conclusion of today’s presentation.
We have assembled a powerful group of panelists and we have comprised the group of some very senior seasoned veterans and I’m going to allow them to each introduce themselves in a moment.
But I just want to let everyone know that just yesterday, our very own Rita Lemley and Chris Perruna got an article published in Healthcare Facilities Today and many of the topics in that article are some of the same things that we’re going to talk about today as a group. So, if you want more information or to find out that article, we’ll put a link in the comment section and are happy to get that information to you.
So, to begin, without further ado, I’d like to start with Rich Steimel and ask Rich to introduce himself to the group.
Rich Steimel:
Thanks very much and thanks everyone at dancker for pulling this event together. And I think most importantly, thank you, the audience for taking the time out.
God knows we’re all busy with these one-hour increments of working and it’s certainly appreciated, and we hope to make it a worthwhile event for you.
My name is Rich Steimel, I’m the principal in charge of the healthcare group here at Lend Lease. I actually started in construction management healthcare back in 1984 with Morse Diesel and nine years later in 1993 I started with at the time Lehrer McGovern, and here we are at Lend Lease right now current day.
Over those years we’ve had the good fortune of working with some of the major healthcare providers here in New York, some in New Jersey and for myself, personally, it’s been a wonderful opportunity for all these years, decades even, of working in the healthcare environment and seeing the way projects are delivered evolve.
And quite frankly, some of the other co-speakers and co-panelists today have been instrumental in making that happen. And again, it’s a pleasure to be here. And with that, I’d like to pass it off to a co-worker and friend Charles Maggio
Charles Maggio:
Thanks Rich. I am Charles Maggio, Managing Director with CBRE and I am delighted to be here especially with people that I consider not only great colleagues in the industry, but friends as well.
I’m CBRE’s Northeast Regional Leader for healthcare services based in the tri state area and as you can see, I’m working in my house in New Jersey.
We provide project delivery planning and real estate solutions to the healthcare industry and we’re probably the largest provider of these services in the country. I am a recovering architect, so don’t hold that against me!
For the last 10 years I’ve been a member of the FGI Health Guidelines Revisions Committee which develops the content for the guidelines that you get every four years. I’m currently a Steering Committee Member and I chair the Benefit Cost Committee. Recently I chaired a subcommittee as part of a larger group that will provide guidance to hospitals during emergency conditions like COVID.
Steve Friedman was involved in that as well and we’ll probably talk more about that later. Speaking about Mr. Friedman, Steve it’s yours.
Steve Friedman:
Thank you, Charles and good morning everybody and the dancker folks. Thank you for having me on. I’m happy to participate.
I am Steve Friedman, Director of Facilities Engineering at Memorial Sloan Kettering. I’m responsible for the entire enterprise, about seven and a half million square feet. We have our main campus and neighboring sites in New York City. We also have three regional sites in New Jersey and three regional sites on Long Island and in Westchester.
Like Charles I am a committee member of the FGI Guidelines. I also help chair the Emergency Conditions Committee, which is working on a white paper that will be coming out as Charles mentioned to help all the healthcare professionals in an emergency condition. That will be about a 500-page white paper coming out just around the end of October, beginning of November.
I’ve also been a member of ASHRAE Standard 170 which is the ventilation guidelines for the FGI Guidelines. It is mechanical code for all of healthcare. I have been on since 2003. So, with that, I’m going to turn it over to Chris.
Christopher Perruna:
Thank you Steve and thank you everybody for joining today. I want to thank the panel host here and everyone joining as well. I’m Chris Perruna. I currently serve as the Vice President for ForBuild. We’re a modular construction firm based here in the tri state region, we’re wholly owned by our host dancker.
My background, similar to Charles Maggio, I’m a recovering architect. I started out as an architect, practiced for about seven years and focused a little bit on historic preservation and some higher end residential. Then I made a transition into the owners rep/PM field.
I spent nearly a decade with Gardner and Theobald and I had the luxury of working on a lot of high end healthcare and pharmaceutical projects during my time at G&T, both in New York and in the tri state region. Following Gardener & Theobald I went to JLL and I led their PDS business in New Jersey, for a couple years which gave me a great opportunity to actually meet and work with the dancker folks which allowed us to start the idea of possibly starting off and running this new modular business within the industry. It was very exciting at the time I took a leap. I haven’t turned back and met some great people, which is our newest host, Rita Lemley.
Rita Lemley:
Thank you, Chris. I’m Rita Lemley from ForBuild. I’m a Manufacturing Construction Specialist. I specialize in delivering healthcare construction solutions. And if we’re not working with you yet hopefully after this call we will have an opportunity to. So, for the last 14 years we’re pretty much going to talk about today everything that we do in construction.
I’m really looking forward to being a part of the panel. Thank you.
Steve Lang:
Thanks, everyone. So, let’s jump right in. Beyond COVID-19 we’re learning that we need to plan for the next emergency or natural disaster that’s going to affect our ability for the healthcare system to deliver on its patient experience.
So, let’s start with Charles, what can you share about your work with FGI and the guidelines that you’ve been working on lately?
Charles Maggio:
Sure. Steve talked a little bit about it before. First of all, I think everybody is probably aware of Facility Guidelines Institute (FGI). It’s the code document that comes out every four years. It is a collaborative effort in terms of how the book is put together and Steve and I are both involved with that. Back in I guess it was May, Steve can confirm that, the chairman of FGI decided that he was getting a lot of requests from people in the industry saying what kind of guidance can FGI provide regarding how to handle a global pandemic like this. And so, he assembled a committee of about 140 people, brilliant people by the way, and then there’s Steven and me involved in this as well!
He asked several of us to chair some committees. So, the result will be this 500 page white paper that Steve referred to that is intended to provide guidance to the healthcare community in the event of an emergency condition, and I should preface that and say an emergency condition is not just a global pandemic. It could be an earthquake. It could be a fire. It could be a flood. It could be a hurricane or tornado. And that document should be published in a month or so.
We’re also going to develop some code language or guideline language that will be incorporated into the next edition of the guidelines in 2022. It remains to be seen as to whether or not it’s going to be within the main body of the text or whether it’s going to be a separate document. Eight subcommittees were put together regarding that included everything from alternate care sites to resiliency to planning and construction and operations group and so on.
I actually chaired Modular Subcommittee, which I know nothing about, and I learned a lot in the last four months or so. It was a great experience that I had such a great subcommittee of talented people that just help us deliver an incredibly good document.
There’s not a lot I can share in terms of what the text is because it’s still in draft mode and we’re still trying to decide what makes the final white paper or not. But one thing we did come up with in the Modular Subcommittee, which will overlap a lot of the other committees and may have an impact on the overall draft, was we defined the durations of temporary facilities. So, in a situation where you need to create something that’s temporary, we wanted to provide a little bit more structure around it. Because people were building things that were not only not code compliant, but they weren’t safe. And so, we ended up coming up with four durations: short term immediate, short term temporary, intermediate and long term.
And real quickly short term immediate are, you know, facilities, they’re going to triage, treat and sustain life and immediate response to an event within days, like a MASH unit. Those have no code requirements. It’s just about keeping people alive.
Short-term temporary is no more than say 90 days after a declared emergency. It’s essential code requirements only. Picture these as being tents or butler buildings.
Intermediate is no more than six months from when it’s in service. Those are code compliant, but with exceptions and modular construction falls into this really nicely.
And then long term is exactly what it sounds like. It’s permanent facilities, which means it’s fully code compliant.
That’s all I have to say, Steve, I don’t want to add anything to that.
Steve Friedman:
That’s perfect Charles. The only thing I can add is that from ASHRAE Standard 170 we’re going to follow behind this document. Once this document comes out, we’re going to be working in tandem with FGI to make sure that our terminology is correct and that we can support all the engineering that needs to go behind building these facilities, including the modular group.
One of the things I could share with everybody that we’re working on right now is our ability to be flexible with emergency conditions. So, a good example, the best example I could give is where you have, say you want to create isolation rooms on a floor that is sandwiched in three to four to five different floors in the middle of a 20 story building. Typically, you’d have to run a brand-new exhaust riser up out the building to accommodate these types of rooms. We’re going to look to allow tying into existing exhaust systems through HEPA filtration to make it easier for folks to design and also for folks like Rich to go and build in the horizontal footprint as opposed to having to drive the risers straight up through the middle of your program space and out the building. So that’s about what I could share relative to what we’re doing with FGI at the moment.
Steve Lang:
Steven in your experience just real quick, how did the regulatory agencies react during this crisis?
Steve Friedman:
Great, great question, Steve and I will say that the State has been very, very cooperative. For us here in New York, we were hit first and it was just a real-time go, and to use the term loosely, I would say we went ahead and built something and then we begged for forgiveness afterwards is probably one of the best things I could say. But we didn’t do anything that was going to compromise patient care or life safety. So, what we did is we went and in tandem or in parallel with the State, we went to build something, we kept them apprised of what we were doing, but we followed through with paperwork later. So, the regulatories I would have to say, including the Department of Buildings, including the Fire Department they worked very well with us because they saw that this was not about us going around regulatory. This was about a crisis here in New York and we all had to do it and make it work. So, I would say it went very well, quite honestly.
Steve Lang:
Yeah, I was going to say Rich go ahead. We talked about this.
Rich Steimel:
Yeah, I want to add to that, because I think Steve covered it very, very well. I mean, the bottom line is everyone, healthcare providers were put in in emergency situation to address a pandemic and, you know, I found that our healthcare providers, including Steve were in a level of unprecedented communication with those agencies, along with the DOH. And in my opinion, there was unprecedented flexibility and it was really sort of like a partnership that was all driving towards the same goal and that was to address the immediate concern at everyone’s hands.
Steve Lang:
Rich I was going to ask about hospital beds and that early in the pandemic we heard a lot about capacity. When we think about future crises and things that could happen, can existing rooms be adapted to handle that and adapt to that crisis that may come in the future?
Rich Steimel:
Yes, yes, they can. I can tell you just quickly again, you know, towards the beginning and towards the peak, most of the providers needed more beds and it was an emergency situation that Steve kind of touched on where we were literally converting common spaces or even ORs into suitable bed areas for the influx of the patients. But I think more importantly as time shifted things and things somewhat stabilized the hospitals have all increased the infrastructure to support the expansion of a single bed room to actually accommodate a single bed, along with a gurney, let’s say. So, the head walls, you know, the medical gas, the infrastructure, and also the power, emergency power and normal to handle a ventilator or whatever else was necessary to support the care of the patients. So, a typical one patient room was converted to two and continues to be converted to accommodate to an emergent situation.
Steve Lang:
Perfect, yeah that brings us to an interesting point. Overwhelmingly the questions that we received in advance from the audience were focused on learning more about the benefits of modular construction and prefabricated solutions.
I’m wondering if the group can tell us a little bit more about your own experiences using prefab or modular construction in the crisis and I think probably want to start with Steve.
Steve Friedman:
Sure. I guess one of our best examples is, as you know, we’re a specialty hospital, our patients have a much higher acuity than most in other hospitals, so we had to really think out of the box here. With our main campus, we’re able to control the flow of traffic on I’ll call it the Super Block which is about 1,300,000 square feet. But then a lot of our patients who come in for treatment, they go to the regional sites. That was the whole purpose of us building these regional sites is to bring healthcare a little bit more locally to folks, so they don’t have to travel into the city. So, our first thought was, okay, well, we have to make sure that our staff is healthy in order to treat these patients. And then it went from screening our staff, okay now, what about patients? What if they’re sick and they’re coming into our regional facilities? So, we partnered up with Rich Steimel and Lend Lease and I can tell you it was an unbelievable effort. We put up six modular buildings at six of our regional sites in approximately three weeks!
And so, we went through Lend Lease and they were able to secure these trailers for us, they were able to slightly retrofit them to meet our demands of what we’re looking for as far as screening and we put the stuff in. I went out to the sites with the Lend Lease folks and we located domestic water and emergency power, so we powered up these trailers. We put water to them, self-contained air conditioning, and off we went. So, I would say the benefits of modular construction are enormous when it comes to a pandemic scenario. And I would say in some of our sites, they’re still there. We’re going to prepare for the fall and the winter and these things are still there.
One of the biggest challenges that we had was bringing our IT from the building out to these trailers. You’re going from a parking lot to a building and we had to bring this massive group of wires out and once we have that in place, because you need the patient access and the portals to be secure, you cannot treat patients in these trailers and then let them into buildings without accessing their files which are obviously inside the building.
One of the other things that was very important is the Wi-Fi capabilities. Because without communication between these trailers and your buildings, it’s like the Stone Age. You would have to go back and forth between the building and the trailer.
So I would say that that’s one of the greatest benefits of these modular buildings is you’re able to bring them on site and you can prepare beforehand to bring your sources out there, your energy sources and your water sources and it’s plug and play. It was beautiful.
Rich Steimel:
Steve, I can add just a tiny bit to that. I mean, even at the early stages of this, you know, there was quite a bit of onus on yourself to locate these trailers in a way that was number one functional but also allowed the facilities to remain operational. I mean, you still have to maintain the flow of pedestrians and vehicular traffic and deliveries and everything else that’s normal, and you know, everything you cover the utilities, it was amazing how the IT probably proved to be the most challenging and obviously we got it done. But again, it was a good partnership, you know, and I think with modular that kind of fosters the whole partnership arrangement. So, we could probably show the audience pictures and all that it was for me personally was a good experience, and certainly I believe it met the needs and met the goal of MSK.
And if I could just add one more thing. Steve, you know, for the folks in the audience, if you’re going to utilize trailers at your facilities, be very cognizant of your proximity to your building some of these trailers are made from a wood structure and your authorities, like your Fire Department and the Building Department may come at you a little bit to make sure that you have good fire separation from these temporary facilities to your new building or your existing buildings.
Steve Lang:
Hey Rita, can you touch…I’m sorry go ahead.
Charles Maggio:
Now, that’s okay. I just wanted to add a little bit of color to that. So, my experience with that subcommittee taught me a few things about modular that helped me as well.
You know, we found that the drawbacks of traditional solutions during this period, you know, including supply chain issues, preexisting conditions, suboptimal layouts, unsatisfactory performance of a temporary facility and extreme weather and kinds of stuff like that. Stick build construction, you know, can easily be impacted by reduction of local available labor, materials, I’m sure you saw that Rich. Tents have limited performance ability and weather events and aren’t suited for long term use. Reopening mothball facilities, which we got involved in a few of those, really comes with risks associated with conditions, including mold and other pathogens, leaky roofs, and exterior walls. There’s a reason why those places were closed.
On the other hand, mobile and transportable were readily available, right. You were able to get trailers that were already assembled and fully equipped and could be brought to a site and positioned. If they weren’t assembled, you could fabricate it off site while you’re actually working on site building, you know, building the infrastructure to support it. So that would be built concurrently. So, in the end modular really was able to meet code requirements and provide a better healing environment than tents. Nobody wanted to go to alternate care sites. I mean I’m making a generalization. A lot of money was spent. You guys saw what was spent at the Billie Jean King Tennis Center. It was $52 million, and they saw 79 patients. People did not want, they wanted to be at a hospital.
Steve Lang:
Rita, I was just going to ask you to comment on, you know, speed and safety and flexibility with your expertise.
Rita Lemley:
So, I’m very grateful that we had the opportunity to install a project for NYU during this time. Lend Lease was the construction manager on the project and in March, we received a floor plan that was sent to DIRTT and it was a 16 bed ED expansion. And the question was, how fast can you build it. So DIRTT’s lead time for delivering are pretty quick. In two to three weeks they can build it. But what takes the time ahead of that is all the pre-construction work trying to understand what the needs are, putting together the drawings and getting the approvals. So, we did a schedule for them and we said, well, we can expedite that to four weeks, and we can have it built at the factory in two and then ship to site and assembled.
We were able to accomplish that period ahead of time, not knowing what their standards truly were because it was the first headwall project we were delivering for them. We accomplished it in two weeks. And we did that because of the commitment of NYU and Lend Lease and the architects and the engineers. The dedication that they had and the time that was spent. So that was the quickest we’ve ever turned it around. We had our partner DIRTT with us every step of the way, waiting for the order. And when we finally got through the details, we put the order in, it was a late Friday evening and that following Saturday morning the DIRTT team had turned it over to the manufacturing floor so we were able to install a 16 bed project for them. It’s a permanent installation, it’s not temporary so very proud that we were able to do that that quickly. DIRTT delivered it to us in three weeks. We received it at our warehouse where we were able to inspect everything to ensure that everything was exactly what it needed to be before it got to site. Our logistics team helped us to pull what was needed so we bought material to site just on time and with a very small crew, because at that time not too many people wanted to go into New York to work, we were sending them into kind of a hot zone and with a very small crew were able to safely bring them to site and assemble the head walls when needed, and worked along Lend Lease’s team every step of the way. So I’m just very proud of the project and so grateful that during that time, when everything was so chaotic, we had such an important project to deliver and to be able to help NYU deliver care and save lives was just probably the highlight of my career to date.
Rich Steimel:
Well, Rita you really uncovered a lot there. There are a couple things that I would add. Number one, you were challenged with matching up your 16 head walls with the existing ones – most people would consider that to be custom, so obviously that went right into the manufacturing, but also while we were putting up the tent and all the facilities that go along with that, I mean, as a full contingent of HVAC, medical gas I mean it’s a negative airspace, which is pretty remarkable for a tent, but really it is it ultimately became a permanent installation and it’s being utilized to this minute
But while that was being done, you are actually into the manufacturing of those head walls so the minute we needed them it was basically a plug and play that they were ready. They were delivered, and they were installed. So, it couldn’t have worked out any better. And I can tell you that from, you know, from all perspectives, it was considered a successful project. I mean, we, you know, the teams were literally working 24/7 and I think everybody walked away equally as rewarded as you are for, you know, mission accomplished.
Steve Lang:
Hey, Rich when you think about comparing the benefits of the cost of conventional versus modular any insights there that you could give to the group?
Rich Steimel:
Well yeah, I do have insights. See, I have an opinion on that. We’ve done more than our share of partitions and we introduced it to one of our other healthcare provider clients and it was new to them. We actually were challenged with doing a comparison between the stick build version and the prefab or the modular version of your partitions and the DIRTT walls and everything that goes along with that.
The pricing actually ended up within 2% in that comparison and we factored in everything, like you know there were some intangibles we factored in like the quality of the finished product, the flexibility of any modifications that have to be made after the fact and they both came into play and, but also, you know, we’ve all done our share of aluminum studs and sheet rock partitions and you know demolishing the old or modifying and even doing the cutting in the field – the bottom line is, it ends up with a lot of debris and you know unless I’m mistaken, when the DIRTT wall is delivered the limit of the waste is whatever it was wrapped in for the delivery and that just sends a loud message.
And you know what, there’s less work that has to take place in the field, because you’ve taken care of the physical wall and the infrastructure that goes into it and it’s again another plug and play. In addition to that, it’s safer to do it in a factory than it is to do it in in the field on ladders and everything involved with that. There’re hoists involved. There’s elevator usage. It’s all those components that are basically eliminated when you compare it to the conventional stick build.
So, in my opinion, I happen to be a strong proponent, it’s all beneficial.
Steve Lang:
Chris I’m interested with your background, I wanted you to add with your background of managing large projects and budgets, any other insights to add here?
Christopher Perruna:
So, everything’s Rich mentioned is definitely true. And one of the key points he said was that 2% difference from a conventional construction build to a modular construction build. And you have to close that gap because when you have a capital budget that a client has to spend, I mean 2% can still be pretty significant when you’re talking about millions of dollars. So, you need to close that in the day one build cost, if you will. So, one of the things that we looked at with a couple of clients both Rich and we’re also looking at this with Chares with another client is escalation.
Escalation has been relatively low over the past several years. I mean, maybe it’s a percent, possibly a 2% depending where you’re at, what vertical you’re in. But we’re going to see a spike going forward now because of the COVID pandemic. You’re going to be looking at least 2 to 3% year over year and that’s due to material costs going up, commodity costs are going up, and then, of course, your labor is going to increase because of social distancing measures and maybe just lack of certain labor at certain sites.
And the fact one of the great aspects of DIRTT and the fact that we get to work off site in a factory, we maintain little to no escalation both pre COVID and during COVID. And we anticipate this is going to remain the case for the foreseeable future. And one of the questions that folks will ask is, well, how do you do that? And one of the things that our partner DIRTT does is they stock their material really well, they buy through their supply chain really well, and our labors controlled in the factories. So when you’re spending millions of dollars on a project and you’re looking for that 2 or 3% savings, we believe we can grab that significant savings of 2 to 3% when you’re talking $5, $10 $12 million on our portion of the project through non escalation at this point.
So, it’s worked out great. We’ve seen it with Rich. We put it in front of a client, and I think that was part of the reasons we got it over the line, by showing that savings day one in addition to a lot of the savings you’re going to have day two in the operations, which I’m sure Steve Friedman and others see when they’re working in the hospital with modular components after day one.
Steve Friedman:
So, if I could add to that. Where it’s applicable and where it works as Rich was saying I’m a big proponent of modular construction. Rich and I put an entire IT MDF building up on the roof of our hospital and the benefits that Rich was talking about of us seeing this on paper and then going to see this thing built before it showed up to the building. It’s just, it was such a massive time saver and this building is L shaped and it was rigged up into pieces and this thing was bolted together in less than four hours.
So, I don’t, I don’t see how in a really good application where it works for your facility, how you can’t find a way to use this type of construction.
It takes the anxiety out of absolutely everything. It is built. Everybody knows what they are getting. Then it shows up. You plug it in, and we go. It’s perfect.
Charles Maggio:
And the quality control right and the site safety, the less accidents on site. I mean, all of it is a benefit.
Steve Friedman:
Absolutely.
Rich Steimel:
True.
Steve Lang:
So a couple of questions are coming in and since we’re on this subject, and we’re doing okay on time, some may have commented, but anything a little deeper on the impact of schedule and scheduling improvement using modular construction versus stick build.
Christopher Perruna:
So, I might start if you don’t mind. Rich we both can go here. From a lead time or supply chain issue, I mean, for the main products coming out of most Partners and I’m going to use DIRTT for example, there hasn’t been any significant increase in lead times supply chains have been fine. There’s been a couple outliers, for example, flex gas suppliers due to the increase for respiratory equipment throughout all the healthcare facilities throughout the country, that’s kind of gone out lead time by a few weeks, but for the most part, everything we’ve seen our projects with all our healthcare providers, both in New York and New Jersey locally here getting everything from our Savannah plant or Phoenix plant and our plant in Canada, the lead times have maintained no more than four weeks. I think going forward, there might be some extensions of some millwork lead times, but DIRTT for the most part has reeled that in and by the end of this month we’re going to maintain that four week lead time even for their Thermofoil millwork going forward. So, we haven’t seen it from a modular construction standpoint although we have seen it from some conventional construction standpoint. So, I think we’re in a pretty good spot at this point. And as long as you don’t see a major spike, we don’t anticipate any further creep, if you will, from schedule standpoints.
Rich Steimel:
Chris, I would add, because I can’t help myself. I keep adding points here. But I would add that the schedule impact that we see Steve is on the installation side. I mean, the comparison that we did for the other health care provider between the stick built and the modular, the savings were in the time. I mean, it’s simply faster to have these partitions that are built simultaneously with the normal flow of construction go in, have them installed, plug them in and your operational so we actually realize the savings on the finish date of this project and that was factored in to the financial equation because our general conditions were retired earlier. The job finished earlier. And I, you know, one thing that we didn’t factor in, which is not ours to do is I guess is the revenue stream is actually given the opportunity to start sooner by completing a job sooner.
Steve Lang:
So, this whole COVID experiment has definitely accelerated digital transformation in every industry and I’m curious from a healthcare perspective, what are you seeing specifically in the rise of Telehealth? For example, knowing that telehealth is anywhere between 30 and 70% I know that’s a pretty wide gap, but it is a big part of the future of healthcare. So maybe Charles, could you just give us an idea of what you’re seeing from a, you know, an exam room perspective and how that digital transformation is going to have an effect
Charles Maggio:
Yeah. So, let’s start with a little data for those nerds out there that like data.
So according to the Department of Health and Human Services prior to 2020 Telehealth accounted for one 10th of 1% of primary visits. That’s one out of 1000. Think about that.
By April, three months later, 43 and a half percent of Medicare primary care visits were provided through Telehealth, which is both remarkable and understandable under the circumstances. Now that rate is going to drop, of course, over time, but it did prove that telehealth can work and then the overall trend is upwards certainly far greater than one out of 1000. So, with that in mind, we’re seeing hospitals and clients of ours rethinking their ambulatory on real estate needs, you know, how is that going to impact the AEC community. I think we have to make lemonade out of lemons in a situation like that, right. You know if a client feels through projections that they’re going to have a reduction in exam rooms, you know, we can provide alternate solutions. On one of our clients currently developing a very large ambulatory care center was able to reassess their long term needs on this project and they reduced their exam room requirements by 10 to 20% which is significant on a project size, over 600,000 square feet, and that was because of Telehealth projections. But instead of reducing the project size, they added more program into the building. So, there are alternate solutions that can be done.
I’ll turn it over to somebody else wants to add to that, but we are seeing that Telehealth is here. It’s real and it’s having an impact on the industry.
Or nobody else could add anything to it!
Steve Lang:
Steven Telehealth and physical health care facilities. I mean, from a client perspective what some insights or what do you gleaning as of late?
Steve Friedman:
So, when you when you look at your existing facilities, all of the IT and Telemedicine capabilities are already in place. In our facilities, we’re so high tech in our exam rooms and our infusion rooms so that for Telehealth in the physical environment it’s already in place. When you look forward to where Telehealth and Telemedicine is going, it’s twofold. For our institution, in particular cancer care, there’s only so much that you could do through Telehealth. There is only so much that you could do through the computer. There are patients that need to be seen. The cancer is an internal illness, it’s not topical other than maybe skin cancer. So, we’re looking to balance out our needs based upon our patient population and based upon what’s going on in the healthcare community. But I would say that with Telehealth we are utilizing that ideology and it is going very well. A lot of patients are afraid to come into the city for their checkup, and so on. So, they will go to the regional sites, so telemedicine is here as Charles said. It’s here. It’s not going anywhere. It’s become a very efficient process, but it’s also got to be, because it’s so new, vetted out to the point where it needs to be viable and there needs to be solutions in place so that there aren’t any hiccups and nothing goes backwards.
So, there are a lot of folks that say telemedicine is awesome until telemedicine is not. That’s really a very telling sign just like anything else that’s new in technology.
So as for our new facilities, we are not in the process yet of putting anything up that is new, but I’m sure, just as Charles said, we’re going to be just like one of his clients, we’re going to be thinking the same way. Do I need 200 exam rooms? Can I get away with 120 or 130? So that’s the kind of approach that we’re taking as owners to make sure that we’re making very efficient use of our physical space and buildings.
Steve Lang: Rita or Chris. Anything else to add, relative to the accommodation of technology and changes in that technology over time?
Rita Lemley:
Well that’s what we do every day. So, we provide a solution that’s adaptable. I think an example of that is what happened during COVID for one of our clients, Englewood Hospital. They had a serious concern about keeping their staff safe and so what they did is they made a modification to move ventilators and IV out of the rooms to keep the staff separate from the patients, but still able to keep an eye on them. So instead of having to go in, you know, so many times in an hour to hit a button on a machine, they didn’t have to put PPE on they can monitor them from the hallway. So being able to adapt that luckily we have a ICU that’s being built right now for them. Taking that process that they went through during COVID and adapting that into the solutions we’re providing so now the nurse servers on the outside of the rooms are adaptable to be able to move and plug in all the equipment that’s needed in the hallway, if this happens again for a second wave. So, it’s just learning from these experiences and making the most out of that adaptability. Englewood is just a great example they adopted it early on, and they’re always going in and making changes and upgrading their technology.
Steve Lang:
Excellent. A little bit of a slant on technology, I’m curious from a constructability and a code perspective, we had the need for these drive through applications because of the pandemic.
To our panelists, does anybody see the potential for the continuation of more permanent drive through applications and any facilities?
Rich Steimel:
Steve, I would say, from a builder standpoint that’s not our area, you know, to be honest, it would really be probably better answered from the perspective of somebody in healthcare operations.
Steve Friedman:
I would think that it’s going to be on an as needed basis. Charles pointed out earlier the amount of money that goes into these facilities. In the hospital sector here in New York everybody took a big hit financially through this crisis so i don’t i don’t think that would be first on anybody’s radar to put up a permanent alternate care site. It’s going to be on an as needed basis. If you look at what they’ve done at the Javits Center, I worked with one of the gentlemen was on the FGI committee, he’s a good friend too and the head of the New York State Department Health. He asked me to help step in and opine with the Army Corps of Engineers and Governor Cuomo over at the Javits Center. So, as you know if the Javits Center they put up 2200 beds in record time. It was just, it was unbelievable. But we had to help them put the infrastructure resources in place to make these beds very functional and they come with a very expensive price tag, but you know when you are in a pandemic and there’s a crisis, money is not your first priority. Priority is the health and safety of patients and also your staff and also the folks who live in the immediate area.
So, I would say that that is not going to be, first and foremost, Steve. It’s going to have to be in on an as needed basis and we’ll be following along this COVID crisis in the spike, if there is one in New York, and that’s will start to rethink this stuff.
Charles Maggio:
Yeah, and the industry is going to have to rethink weather conditions right because, you know, we erected facilities in the spring and in the summer and they weren’t really impacted. What happens in the winter? What happens if we have heavy snow? So that has to be more well thought out, but I agree with Rich. I think that’s more of an operational issue.
Christopher Perruna:
And Steve, I think it’s the agility of having the flexibility of using modular inside the permanent facilities to kind of scale up scale down as these emergencies or pandemics happen from time to time and then have the integrated technologies that work within the systems, that’s going to allow the hospitals to kind of combat whatever may be facing them at that point in time.
Steve Lang:
Yeah, which is which is a really good point which leads us to another part of our discussion and that is future and how do we future proof and what changes do we need to consider relative to this entire industry of constructability and code, etc.
So, you know, from a lesson learned perspective, what outcomes would you like to see the design and construction industry adapt moving forward? And I think this time let’s start with Rich.
Rich Steimel:
Well you know we all experienced shortages, you know of PPE, right? That was unfortunate and we all scrambled and you know ultimately we’re successful but you know, there came a point I was involved with the committee from the greater Hospital Association of New York and we were looking at some of these facilities of the type that Charles referred to, you know, they were either defunct, or, you know, in various stages of construction and they were under consideration for you know, immediate remedial work and there got to be a point, this was something that took place over a couple of months, but we got to the point where it was feasible to do and it could be done. But the problem was, was there enough staff available to support the introduction of 40 new patients or 140 new patients and that actually became a soft spot and this is while, you know, if you were in the city. At the time, I was at New York Presbyterian and they were bringing in buses upon buses of staff from the hotels wherever they were staying just to support the needs at that facility. So, if you can imagine compounding that by having some ambulatory facilities opening up elsewhere. You know it from where I could see things, it appeared to be you know, a weak link in the chain.
Charles Maggio:
Yeah. Construction could have actually provided solutions, but we didn’t have the staffing solutions.
You know, I thought, you know, it’s funny, first of all, is an absolute terrible and terrifying time, especially at the peak but many good things that come out of it, right?
We can work from home. I don’t have to shave every day. I don’t to take NJ Transit to Penn Station. Virtually happy hours. All of that was a positive. But in all seriousness, you know, we experienced an incredible level of teamwork in the industry, and that is something that you can’t discount. It was truly like IPD without the tripartite agreement and there were no RFP submitted and so in many ways I think that, you know, there’s no reason why something like that cannot continue to happen in the industry and why we wouldn’t see that.
I also think that you know the going back to the point from before, which is related to this conversation, which is about, you know, patients didn’t want to be at the Billie Jean King Tennis Center. People wanted to be on a campus. And so, I’ve been on a lot of these webinars. I’ve heard a lot of people speaking this common theme. The hospitals wanted to expand from within, or at least on their campus. And the only way to expand from within, would be to reduce on your campus administrative and support services. And by doing that, you have to centralize them elsewhere and repurpose that space for clinical needs.
There’s no reason for there to be a COVID 19 or any other emergency for that to happen. Healthcare should be doing that right now. It creates operational efficiencies, reduces costs, frees up space. It’s just so much smarter to do. And I know we’re in the middle of financial crisis and hospitals are constrained in terms of their dollars in terms of Capex. But that to me is a trend that should continue going forward.
Well, I’ll turn it over to Steve or anybody else.
Steve Friedman:
Yeah, definitely. That’s great. It also has the adverse effect too. Because Rich put six trailers up in three weeks, any project going forward, if he gives us a construction schedule beyond 15 days, I’m firing him. Just putting it out there. If he can put six trailers up and he can’t build something for me in three weeks, he’s out of here. I’m just kidding!
All kidding aside, it has been an unbelievable coordination effort and, as Charles said, I think it has woken up the entire industry to say, hey, maybe there are alternate solutions here where we can build together and build better. The IPD process seems to be a great process to come back to and revisit in healthcare, especially in the New York area. Rich and Chris, they can tell you how difficult it is to build just from a maneuvering standpoint, just mobilization in and out of these tall buildings, and in a short time frame and getting through traffic and permits, bridges, all sorts of stuff.
So, I think we’re in a good place just as Charles said, it has really given us a new opportunity to recreate how we’re going to design and build.
Christopher Perruna:
I think it’s important. If we can maybe steer away from that are hardcore RFP process a little bit and really focus on working together as cohesive team from day one with the client and all the consultants and experts, if you will, kind of with that same goal in mind, it’s going to pay dividends in the end. I mean that day one costs maybe sometimes it gives you some sticker shock, but it truly is going to pay those dividends when it’s one group working together with that common goal.
Steve Friedman:
Absolutely.
Steve Lang:
Hey, Steven, how soon do you think we’re going to see changes in national and local building codes?
Steve Friedman:
So local I don’t know. Local building codes are ever changing. And I don’t think that we have a good strong hold on that stuff as far as the New York City building codes go and so on. But I can speak on the national level, for ASHRAE standard 170 and Charles could certainly chime in on the FGI guidelines we have the 2022 version of the FGI guidelines coming out and ASHRAE Standard 170 Ventilation in Healthcare Facilities is always one year ahead in the publish but is part of the 2022 guidelines. We publish every four years, but we are continuous maintenance document as opposed to FGI who only publishes every four years. For ASHRAE standard 170 we’ve sent out all these addenda so we can confuse everybody and get yelled at.
Charles Maggio:
You do a good job of that.
Steve Friedman:
Thank you. Thank you. But for us, we have an opportunity that if there’s a technology out there, there is a solution that’s viable that people can use to design and to build, we don’t wait to publish it every four years, so it’s got its pluses and minuses, but we’re in a good spot right now we’re in the tail end of 2020. We’ll finish up our document sometime mid-year of 2021 and I’ll let Charles speak about the FGI guidelines, but that’s where we are nationally right now.
Charles Maggio:
Yeah, I mean, you said it pretty well. I mean, I think one of the differences between the structure of ASHRAE and FGI, is I think you have like eight or 10 voting members. FGI has something like 100-130 voting members and it’s a different process. But, you know, this processes is something that’s been going on for quite some time for at least a couple of decades and then layering in all these emergency conditions, you know, could possibly have an impact on the publication schedule, but we’re still targeting you know, on or about January 1 of 2022 it coming out and it and it’s showing not only the emergency conditions that we talked about, but obviously, the latest and greatest in terms of new code language for healthcare industry.
Steve Lang:
Rita I’m curious, from your perspective, behavior on clients as they think about new ways of building new ways of thinking about building. any insights?
Rita Lemley:
Just challenge us and all your partners. Trust in them to really think about what the future holds. We learned a lot through this that we needed to adapt, and I think the best innovation will come from this time if we can all work together.
And also, for us and you know people that specialize in construction the way that we do, involve us early. I think Owners will get the most out of their investment if they involve all their partners early.
We had the opportunity to talk with all the trade partners during the process at NYU, and I just think there’s a better outcome in the end, when you bring everyone together. So definitely challenge your trusted partners moving forward.
Steve Lang:
Perfect. Great segue to what seems to be about seven minutes left. And I want to get some closing or final thoughts from our panelists. You know, I’ll leave it very open ended.
Flexibility as a buzzword. How would you define flexibility in the future to be more meaningful and practical and then if you could include in there anything based on your experience and your tenure that you would describe that we should be thinking about for the vision of the future of healthcare, you know, go out to 2030 and talk about it from that perspective, if you would.
And we’ll start with anyone who has a perspective on that with our last six or seven minutes.
Steve Friedman:
Steve I’ll chime in. I just recently spoke about this as well. I think you hit the nail on the head. In today’s world, flexibility has to be the greatest use of language right now. If we’re going to put a specific program space in the middle, into a program in our hospital, it can’t be built specifically for that program. It has to have tremendous flexibility. Rich was talking a little bit earlier about creating negative pressure rooms on the fly. We have to look at putting our infrastructure into place so that we can change rooms from positive to negative without having to go into the physical building, ripping space apart.
So I think in the very end that our design professionals, our project management professionals, our builders, we all need to come to the table to say, hey, this all looks great, but let’s look at this a little bit more globally. And this is how we could build this space and you have plenty of flexibility. I think that’s the greatest bang for the buck.
I don’t think it’s viable to build a temporary space anymore. It’s just not financially viable and it certainly takes program space out and you’re not only losing revenue, but you’re also doing construction and middle of a health care facility.
Charles Maggio:
Yeah, I think the catch phrase there Steve is acuity adaptable. Right?
Steve Friedman:
Absolutely.
Rich Steimel:
Yeah, I just want to jump on that because the flexibility issue is a big deal. And what you just described is absolutely what is going to take place moving forward. We happen to be involved in the very early planning stages of a new bed facility. And right now, they’re looking at the ability to create the positive to negative swing over it through the BMS for a bed unit. But to take it a little bit further, they want to take it to multiple units on multiple floors, stack them. And then even in the advent that it’s bigger than that, take over the whole floor. That flexibility is, I believe, going to be built into the design of those future bed facilities out of pure necessity.
And, you know, when you talk about the temporary facilities. The thing that drove that, in my opinion, was absolutely pure necessity, that was done as a reaction as opposed to let’s plan for the, you know, we just experienced the “What If” so now it’s incumbent upon all of us as the client, the designers, the builders to contribute to a solution to that what if scenario because we experienced it.
Charles Maggio:
Yeah and that solution Rich that you just talked about, that’s for a building that will be built in the next few years, and certainly I think we’re seeing the same thing on all of our planning and design assignments right now. We’re seeing that people are talking about how to prevent, how to react to COVID 19, I think the big challenge is what do you do in existing facilities and a lot of what you and Steve talked about is important how to go in there and make them adaptable. I think certainly what I mentioned before about reutilizing space properly within the hospital makes sense as well.
Regarding 2030, Steve Lang, that’s a great question. I think that all the trends that we’re already seeing that people are familiar with are going to continue. People are going to be focused more on health outcomes, analytics, and technology. All that’s going to affect our industry, the design and construction industry.
You know, healthcare is going to continue to become more and more decentralized with, you know, with local and specialty services. Baby boomers, like myself unfortunately, are the largest demographic cohort and we’re aging, creating a need for more senior living more, you know, better insurance solutions, more accessible healthcare, continuum of care will continue. Just in time waiting, right, using technology to reduce wait times is going to be important. So, you know, what does that do. That reduces the size of these inefficient large waiting rooms. Other the technology, you guys hear about all the time and you probably have it on you, apps, wearable technology monitors, surgical innovations. All of that is going to result in two things. And I think it results in the threat of technology disruption. We are relying more and more on technology, and how many times have each of you had a situation where you lost your internet for a few minutes and you wanted to kill yourself, and it was on an important call with a potential client. You know so, in all seriousness, you know, technology disruption is going to be very important as a part of this and I think that’s going to be the big trend over the next 10 years. You know more secure servers, redundant points of entry, and other technology investments that I certainly am not qualified to invest in. In addition to that, what we’re also starting to see is a common platform as a backbone for all systems, right. And I and I’m definitely not qualified to talk about that, but we’re seeing that as well. That’s been evolving over the last few years. That’s what I think we’re going to see in terms of health care as it relates to the AEC community, not necessarily in terms of patient care.
Christopher Perruna:
Yeah, I agree. I concur with that I think having the right technology in place, you’re going to use that to leverage your resources in your facility. As Steve Friedman said earlier, you need permanent facilities that are adaptable not temporary facilities. I think Charles, even you might have mentioned wearables and healthcare trackers and sensors. I think eventually we’ll get into AI/VR. If we can kind of combine that into the actual the built environment and put the two together, that’s where healthcare is going in the future. It’s taking that virtual world in the built environment, putting together. And that’s how we adapt to these emergencies going forward.
Steve Lang:
Excellent. Well listen, we are just about out of time. So with that, on behalf of our entire virtual audience. I want to personally thank Rich, Charles, Steve, Chris, and Rita.
Great team, great questions. Thank you to the audience that submitted all those questions that allowed us to prepare for hopefully what was a very insightful hour.
As I mentioned on the onset, we will compile and share a summary document for everyone that signed up for the seminar and that will include all the questions that we reviewed. And any questions that we may not have answered, and we’ll send that to you via email in the next several days. So with that, I want to thank you and hope that you enjoy the rest of your day.
Thank you very much.