Texas A&M Architecture For Health

Design, Delivery, & Transition of Operations During Pandemic

Season 2021 Episode 3 | 52m 10sVideo has Closed Captions

Antonio Suarez and Michael Hatton talk about Design, Delivery, & Transition of Operations

09/22/2021

Texas A&M Architecture For Health

Design, Delivery, & Transition of Operations During Pandemic

Season 2021 Episode 3 | 52m 10sVideo has Closed Captions

Antonio Suarez and Michael Hatton talk about Design, Delivery, & Transition of Operations

Antonio Suarez and Michael Hatton talk about Design, Delivery, & Transition of Operations and the complexities of healthcare expansion projects.

09/22/2021

Problems playing video? | Closed Captioning Feedback

Texas A&M Architecture For Health is a local public television program presented by KAMU

Texas A&M Architecture For Health

Design, Delivery, & Transition of Operations During Pandemic

Season 2021 Episode 3 | 52m 10sVideo has Closed Captions

Antonio Suarez and Michael Hatton talk about Design, Delivery, & Transition of Operations and the complexities of healthcare expansion projects.

09/22/2021

Problems playing video? | Closed Captioning Feedback

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- Start by introducing Tony. And then at the conclusion of that, we'll get Michael up there. But Tony is Director of Facilities at Texas Health in Arlington. He's been an old friend, he and his wife Rue and I have been to many ASHE meetings together through the years. And he's always played a leadership role, not only in Tatham and local and regional health facilities, ASHE programs, but he has been recognized for that leadership and is now the 2021 President of ASHE. And his leadership has created quite a tremendous support for the mission of ASHE and everything that we're trying to do. So, we're all excited to hear that Tony's available and is gonna talk to us today about the team approach from his point of view. Tony. - Yes, Michael, could you go to slide five? - Okay, about ASHE, slide five. - I'll tell you a little bit about ASHE. ASHE's mission is to optimize the healthcare physical environment. The organization is made up of all types of professionals play a role in the healthcare physical environment. That includes architects and engineering who designed the care spaces, instruction professionals who build them and healthcare facility managers who operate the hospitals on a day-to-day basis. One of ASHE's program that is especially helpful for those in the design and construction world is the PDC summit, this brings together healthcare leaders, healthcare architects, healthcare engineers, and construction leaders to discuss key topics related to healthcare planning, design, and construction. So please save the date for the 2022 PDC Summit in New Orleans, Louisiana, my childhood home, this upcoming year. Michael, we can go to slide six. - Slide six. - All the managers work in optimizing healthcare physical environment. We wanted to understand how hospitals were responding to the COVID pandemic. So as you created the COVID response tactic sharing, knowing as the CRTS, a tool that is continuously evolving, we first conducted a survey in early 2020 to see what facility leaders were doing. And I share some of those key findings here. ASHE reports this information so it could be used to assist professional in overcoming these challenges and aid in future disasters planning. The facility managers across the US who are invited to participate by filling out a survey, it took between five and 20 minutes to complete. More than 1200 professionals participated, which came from a represented example of healthcare facilities to cost the United States. Most participants were facility managers and engineers who reported on working with a single health care organization. And 90% of the participants were at or above the manager/supervisor level. It's important to know that these findings represent data collected through the initial surge of the crisis. However, data collection for this project is ongoing and updates will be available in the near future. The data here shows what was being done through July of 2020. ASHE worked in this areas and has been nationally recognized as part of the National Institute of Health, Disaster Recovery Research or DR2 program. Michael, could we go to slide seven? - Next slide. - The survey asked about what a facility manager or leaders who are included in COVID decision-making. As showed, almost three quarters of the respondents reported that they were involved and most on every part of the process. Slide eight, Mike. - Next slide. - So what were the common activities within the hospital walls? The survey found that 80% of the responders reconfigured non-clinical spaces within the hospitals to respond to the pandemic. 37% added patient rooms, accounting for an additional 22,467 patient treatment beds. Almost 90% of the participants reconfigured spaces. Most of them using medical office space and buildings, parking decks or lots, Gifts shop, lobbies, shell spaces, ambulance bay, auditorium, chapels, and conference room, basically any space that they could use to accomplish (indistinct). As suspected, respondents reported adding protective barriers and making several changes to allow for social distancing in clinical spaces. While all this work was going on, day-to-day activities continue, however, 90% of all respondents did not see any of the normal daily operation. 21% reported policy know not (speech garbles) structure projects, and less than 10% cost aesthetic improvements. Almost 40% of those survey reported reconfigured patient rooms or anterooms, as well as entire hospital floors and all wings. While reconfiguring patient rooms, HEPA and negative air pressure machines will use. However, the negative air machines will most often use method to create all anterooms bottled by HEPA to corridor and HEPA to the outside. Slightly less than one quarter reconfigured, at least one hospital floor or wing. And now these three quarters of the respondents reconfigured the spaces to negative air, most often using HEPA and outside HEPA to the outside. Slide number nine, Mike. - Slide nine. - As stated earlier, I'll turn it to care sites for wildly use. 62% of the respondents considered adding space outside of the hospital for quarantine and treatment. Space most often considered were hotels, schools, gymnasiums, and convention centers. One third of the respondents that have temporary tags for treatment or quarantine of both COVID suspected, COVID positive, and other types of patients. Slide 10, Mike. - Slide 10. - So how are alternate sites of care built? At the time of the first report publication, 61% of the responding organizations surveyed had designed and built an alternate care site. As reflected in the table here, construction of alternate KSI projects were often never completed because of surge demand forecasting and available resources remain in constant flux. It's important to know that these data are reflective of activities taken during the initial surge stage only. It is highly likely that we will see these numbers have much high numbers, as we continue to collect data and report data. For example, even though not covered here, we expect to see PAM trans responses to the crisis and activities that differ by waves and by geographical areas. Given the rolling nature of the COVID surge where the initial surge impacted areas on the east coast and mostly in more densely populated urban areas in the early stages of the pandemic, we expect to see the numbers increase or other geographical areas and more rural suburban hospital settings. Mike, could you go to slide 11 slide, please? - Slide 11. - When asked how long the construction took, on average, most projects took two and three quarter weeks of construction time, and these projects were often considered temporary solution. Other projects were more permanent were previously planned and has to be reconfigured to meet the needs of both the current crisis and the future strategic and emergency plan for the healthcare organization. Slide 12, Mike. - Slide 12. - So I'm sure you're aware if the pandemic continues to impact healthcare organizations. As noted several times in this presentation, the data represented is only a portion of defining. ASHE is still collecting data. The data will be used to inform lessons learned and best practices with healthcare engineering field. The pandemic continues to require more of us, both Texas Health and Memorial Hermann are now or will be soon requiring all contractors and design team members to be fully vaccinated in order to enter all facilities with very few exceptions being allowed for this mandate. You can find the entire report and participate in this survey by going to the website listed here, www.ashe.org/CRTS or by contacting ASHE Senior Research Strategist, Lisa Walt whose email is also shown on the slide. Slide 13, Mike. - Here we go. - Finally, I would like to ask the students at Texas A&M, but especially those in the college of architecture, engineering, and construction management to consider the possibility of a career in healthcare facility management. Not only do careers in healthcare facilities management pay well, but they allow one to work in an environment that offers a diverse responsibility, it's often in the cutting edge of technology, and provides an opportunity to work every day and personally impact the healing and bonding for patients. Two things can be more rewarding than helping those in need. Michael and I get to do this every day, consider joining our industry. With that, I will first apologize for not being able to log in correctly on the Zoom model, it's having technical difficulties, but I will turn this over to Mike for his portion of the presentation. - All right, well, thank you, Tony. Joe, would you like to introduce me, please? You're on mute, Joe, Joe, you're on mute. - I don't see Joe on the screen. - He's on the screen. He's on mute. - Okay, there we go. - Here we go. Yes, Michael, I guess, it really takes a team with you and Tony to even do the slide show, dancing back and forth together, you following and leading well, and it was pretty impressive. As I mentioned that the ASHE board is made up of several region that go across the country. And we're fortunate to have the ASHE regional seven board member today, to share with him his experience with the coordination of team in the planning, design, construction, operation process. Michael is VP for facilities, engineering, construction, and health services at Memorial Hermann in Houston, Texas, Michael. - All right, well, thank you. Joe, how's the volume. Can everybody hear me okay? - Yeah. - All right, just a brief outline on the screen. We're gonna talk about some virtual team building, some thoughts on communications when we're doing projects in this environment. Again, the remotely part of the planning design, and then the focus of that. Talk a little more about collaborative design, which you do in your industry very well, and our industry, it's very new to us. And I would argue the new importance of BIM modeling due to the COVID remoteness of how we're building buildings these days and designing them. And then finally, a few thoughts on architectural design considerations and lessons learned, the same for MEP engineering systems, perhaps a little bit of discussion on codes, and standards, and the flexibility or lack thereof that they give us an industry. And then we've got some cute little photos and floor plans of some current projects that we're working on here at Memorial Hermann. So, without further ado as some of you have may been involved in large projects before COVID days, we always had an in-person kickoff, the project, we tried to set up some significant milestones that was always an in-person event. We would typically have a live facilitator. It's like kind of a get to know you type event where we'd set up goals. Some people would call it pointing the project due north. Usually, it was done over a meal and there was usually a happy hour or some other social gathering involved, or it could be a sports activity or a treasure hunt. At the end of the day or the two-day session, we would always have a commitment poster... Put us on mute there, please, folks. There you go, thank you. We would always have a commitment poster or a photo op where the whole project team, whether it was the architect, the engineer, the owner's rep, the construction team, and the other significant consultants, we would all get together and determine some of the key goals of that. The good news of face-to-face events is unlike items like we're doing today with Zoom where everybody's got distractions, the multitasker, there's probably one or two people on the phone now I would guess that are probably on your sales and there's other people, there's always meetings going on. There's also those folks in groups, those, I call them the, I don't wanna be here, I'd rather be somewhere else. We've got those folks. We would always have these at neutral locations or remote locations. And then, of course, a third-party facilitator like Professor Mann is today, and in person, their job was to keep the focus and ensure that both introverts and extroverts amongst us always contribute, that we draw out everybody. So that was before COVID. Nowadays, it's the team building and the virtual world like we're doing today with an educational session. There's a lot of distractions with Zoom or Microsoft Teams, whatever you're using. We're probably still at our remote workstations or home perhaps, or in your automobile. There's lots of distractions for those of us who are multitaskers. You've got your cell phone, you've got texts, you've got telephones ringing. It's awful difficult for me to read Joe's body language or for you to read my body language when we've got web cameras and we may be halfway around the world. So, that's another problem with remoteness. And therefore, it's tough to keep focused on an agenda in today's virtual project meetings. There are so many platforms out there, WebEx, Teams, Zoom, there's several others. We've tried to think Blue Bird in some of those others. We've got the IT compatibility, no matter where you're at, there's always some new software that you've gotta download at the last minute. So, I think, we have a problem at Memorial Hermann. We use Zoom, but if we go to Microsoft Teams, we have to download a whole new browser every time we go on. So you've got those distractions. What does that mean? It's awful difficult to make sketches on white boards or virtual documents like we did prior to COVID, awful difficult for someone like Professor Mann to moderate. And it's pretty easy to turn into a one-sided lecture, which is not what team building exercises are supposed to be, versus truly sharing ideas. And then how in the world do we celebrate hitting a milestone or a goal on a webcam? can you really do that without personal interaction? So, I think that's the hardest part of this new method of communication when you're building a project or designing a project. Your industry, the architectural engineering the design community, I think we work fine for virtually, you collaborate around the world with different software platforms. You can coordinate buildings with various BIM modeling and things like that. You've done it for years. And I think Zoom has only made that better or the virtual world. As owners, Tony and myself, it's fairly new to us, especially if I'm trying to get some feedback from a nursing director on, perhaps up in an ICU unit, their first competency is not sharing design elements across the internet platform. So how do we get those people to truly understand what you're designing and what it's gonna feel like when it's done? This type of virtual platform is great for working across time zones. We've got people on Paris in Europe now, which is what, six hours behind Texas, it's real or ahead of Texas, so it's real easy for you, even, this is a recorded session, so they could go on at their own time and pick up these notes and work through. It's difficult for those of us in real time working on that. It's really hard, and I think we've found to keep up with milestones and critical path task, your daily weekly focus areas, proposal requests, change orders, virtual invoicing, lien release, receivables, accounts receivables on the accounting side. I think that can work, but that's another dynamic we've all had to learn. A lot of your customers, your architects, and engineers, and design professionals, you work in 3D and 5D every day, but most of your customers, i,e.

the administrator at the hospital, the nurse up in the ICU unit, the OR director, they're probably much more used to physically touching, seeing, feeling, they're much more two-dimensional than the folks on this phone on the Zoom interface. So, I think you've gotta realize that your customers are working in a different plane with probably different technical skills than you have. So what does that mean? I call it, means a lot of frowny faces at the end of the job when the design team and the construction team finish that new operating room suite. And it's not like they envisioned working on Zoom or Microsoft Teams because they weren't able to really see that rendering or what it's really gonna function like in the end. Why your virtual customer, Tony and myself as owners, we're probably behind the times with technology compared to architects, and engineers, and people who collaborate every day across time zones. How do we communicate better to that customer, user, especially things like interior architects, how do you really get the texture of a wall surface? How do you truly get the color? We're all using, some are using iPads, some are using laptops, some are using phones. If you'll notice, there's huge variations in colors and textures, depending upon what internet device contact you are, what bandwidth you have, how does the architect or the interior designer really get the look and feel of that furniture or that reception desk, or that lobby, the scale and the size of proportions of that main lobby virtually? It's very difficult to do. There are tools like virtual reality glasses, and I know the industry is probably still somewhat in the infancy, I'm coming with really user-friendly tools for that, you probably study that in your design classes. And then, of course, the time and effort, the money involved in producing and trying to communicate to your users compared to the days when Joe or Perry would just go to his design, his customer group and they would be able to lay out plans and show presentations in a conference room or the boardroom to the customers. Now you've gotta do all this remotely because of COVID and other issues that we've all had to do. So I guess the summary of this is how do you as design professionals make sure you've captured the customer's vision for a project? Again, this is not a new process to those on the phone, practicing architects. I would argue that COVID has maybe forced all of us, including myself, and Tony, and Professor Mann to probably learn new things. Now we're learning Zoom and various other platforms. So, that is probably good to make us collaborate more. We can talk to our peers across oceans and really coordinate a lot of project efforts. However, I would still somehow, an important part of a project for every project I've been on is that page flip, where the architect and design team sit down with the customers and page by page, we go through those key design elements as drawn, whether it's an old-fashioned blueprint type sheet of paper, or whether it's virtually on a laptop in a screen in a conference room, but that's still an important part of a process of getting the users to understand what you design and what we're gonna build for them. It needs a facilitator. And I think it's all for risky to project the skimp on this feedback milestone, the architect needs some validation that what they've designed is actually what the customer's vision is. And before we show up with heavy equipment and start putting concrete in the ground, we all need to make sure that a customer group and the users are truly on the same page with what that project is gonna look like at the end. Then ultimately, I know for every architect and project team, before you move out of the schematic and design document phase, we typically traditionally always have sign off on the actual documents by the key user groups. How do you do that and move to that next design phase if you're all trying to work virtually. So I think that's some of the challenges we have today. Mechanical, electrical, plumbing, the engineering folks of the world, which is my background, now it's real easy to focus on the wow elements, those architectural elements, but we still need to make sure we're getting the supporting MEP details into these projects. I think it's a little more difficult to do the deep dive coordination discussions for phasing, the spatial needs, the utility support, if we don't watch. I think there are some great tools out there that we're using in the industry. And there's probably others that you're aware of that I'm not in tune with, the BIM 360. We do a lot of that for field work, punch list working, sharing information back and forth, Adobe's platform. And then CxAlloy is a good commissioning database that you can also import drawings, and photographs, and things like that. But I would argue that field reviews when an architect or an engineer is showing a progress observation on a project, that's still requires eyes on out in the field work to do. That's awful difficult to do with a webcam and truly understand what's happening out in the field. And then project commissioning towards the end of the job, I would suggest, that still needs to be 100%. I call it, "Show Me.

" You're not gonna be able to effectively commission a job and make sure things are functioning right, remotely. And I think that's some of the challenges we have with COVID now since we're limiting visitor interaction, we're worried about infecting other people and things like that. The authority having jurisdiction or the AHJ, whether that's a municipality or a city, or it could even be the state of Texas or whatever, municipality that is your health department, those are still 100% "Show Me.

" Although, just yesterday, for the first time with the department of health, here in Texas, we had a virtual 100% project inspection, never had that before. We walked around with an iPad camera and the inspector from the state, the architect wanted to see several features in a new emergency department we are opening up. So, we would show webcam pictures back and forth. And we had a virtual punch list by the inspector and got virtual sign-offs. So that was kind of a new wrinkle to us. In my mind, that's pretty clunky. And I'm not sure that you really communicate the details that's needed to prove out a project to a authority having jurisdiction. But I think that's the way of the future, especially with COVID as it continues and whatever the next pandemic may be. And I think from a design point of view, a lot of the ratios and rules of thumb for both the space square footage area, and also maybe capacities of utilities like oxygen, medical air, some of the emergency power, I think, COVID in these latest go round of pandemics has probably altered a lot of those rules of thumb or design parameters that we've used for 20 or 30 years on our business. Oxygen has been a big issue in this latest pandemic surge. I mean, we're using five times the need as we had before. So we're taxing those systems, the design ratios that we've been using for generations, just does not seem adequate in this business, same with makeup air, isolation rooms, things like that. Building information modeling in the virtual world, I think, that has saved the day. We would have never gotten through a pandemic and gotten anything built without BIM. And thank goodness, we're not in the infant state like we were 10 or 15 years ago. Laser scanning of existing conditions, we use that extensively in our Woodlands job, which I'll show you a photograph of. That's actually we replaced the entire central plant. That was a 7,000-ton central plant. We replaced every wire, every pipe, every chiller, added generators, one system, one pipe at a time and kept the hospital 100% fully operational. They basically laser scan and dimmed all those systems and we replaced component for component. So, it works. It's a fabulous tool. And then a contractor actually used those same documents, that same model to fabricate most of those systems offsite and bring them in to really save the and reduce the exposure of the trades craft. More importantly, it actually works when I say that with a exclamation point, that when those sub assembly show up in the field, they fit because I remember 10 or 15 years ago, when we first started doing the BIM modeling and things like that, it still needed a heavy hammer and a good paint brush to make it look right at the end of the day. But these days, that's really come along. And in your industry, I think the industry has now probably circled their wagons. And now Revit, I think, is the design standard, if I recall correct in the architectural community, I think Revit has taken over that software. So, that's good. I think that's evolved just in time for industry. I know, five years ago, there were still a lot of design professionals that didn't use the Revit package. There were several various versions of their BIM software. And I think now, thank goodness, that all of that has really coalesced around Revit modeling. And I think, again, in that Woodlands project, we're building that new tower up there. We've got a architect design, a monumental stairwell in the lobby, very high-end, a big curver lineature, it's a gorgeous structure. And we're able to take a laser scan of that assembly as it's installed. And you're just now sending that model over to New Zealand to get a glass balcony, hand rail system fabricated and then sent back over here. So, I mean, we're able to BIM model and send and fabricate something 5,000 plus miles away and get it shipped back to our project and it's gonna fit. I mean, that's the miracle of BIM modeling and modern design elements. However, I would argue that BIM still doesn't solve quality control defects in the field, the skilled trades craft. We know there's a challenge getting enough skilled trades crafts out there. So you still have gotta get out in the field and do the real time review of field observations by the architect engineer to make sure you're getting the quality that you need. Now, there's also a lot of COVID and visitor risks, especially now in this Houston area in Dallas and other areas, probably around the world, versus quality control. By definition, it takes a lot of skilled craftsmen working very closely together to build a building. You don't get electrical systems installed or low voltage systems installed virtually, you still need trade crafts people working together very closely. And, of course, that's an infection risk when you get something like COVID and other types of communicable diseases. We had one project here in the med center for Memorial Hermann, I'll show you some photographs and a floor plan where we actually were building a new ICU unit directly above, an active COVID ICU unit, where we actually had to do the plumbing tie-ins below. We actually had to prove out that the shower and bathroom waterproofing was functional while we still were treating COVID patients below. So that was quite a challenge to coordinate as well. And I've got some diagrams of that later. There's a lot of fear out there, probably a number of design professionals, probably is still among people on this Zoom meeting. And even the skilled crafts are working around active cases of COVID, and in the healthcare business, that's what we do. We take care of sick people. So, our business is inherently risky when it comes to things like that. And even within a firm, such as Joe's firm with an HKS or another design firm, you've gotta be careful that you could have an entire problem if the leadership of that firm all got COVID or had challenges, it could very easily from a business continuity, a disease like this could take out an entire firm, especially if you're in the middle of a big project. So I know most of our architects, and engineers, and consultants, we worked off site. We had virtual meetings through the entire last 18 months just to make sure that we didn't lose key people and that we could still have some business continuity as people got ill and had other issues, which happened. So there's still a lot of hands-on work. And I think it's a good reminder that while screening for temperature, and COVID, and PPE, and vaccinations work, it's still pretty intrusive. And it only reduces the risk that peak infection periods like happened again, 45 days ago, there's always after work activities, vacations, holidays, families get-together, people get on airplanes and right away we've got another surge on the pandemic again, and that's what's happening now. So, it's still a risk with a project team. Some lessons learned, best practices. I think if you're planning a project, I would argue it's gonna take additional time and money to make sure that you're getting the feedback you need at various design elements prior to sign-off, as you go through schematic and design development, you're not gonna be able to have a group meeting all at one time, you may be doing a lot more face-to-face interact, you may be doing a lot more Zoom. You may have to prepare other drawings and other, either in virtual reality type devices to try to get people to really vision what that lobby is gonna look like or vision what that OR room's gonna look like. We found out that on something like this, that we lost a lot of our audience after about 20 minutes on Zoom or Teams, people got distracted. There were other things they were doing. So, it was awful tough to keep people's focus after about 20 or 30 minutes on these calls. And I'm sure if I could see your hands now, there's probably one or two of you that are multitasking and texting, but I won't call you out, I promise, because I've been guilty of that myself. I think we've learned things like FaceTime or still something you can use in a field, right, you can take your iPhone. And if you're trying to show something in a field from a quality control, there's an easy way to actually feed that information back to an office somewhere. A lot more photos and videos for communication. Also, COVID is real as regard to supply chain disruptions. A lot of these key components that you need in your project are just not available, or it's very limited supply, like this week, we've got a problem just trying to get some of the pigment for acrovyn for our doors and for our wainscoting on some of our ICU units. You cannot get certain colors of acrovyn van because the dyes and the materials to make that are just not available in the supply chain. So instead of weeks, you're talking months to get simple products that we use every day in healthcare design and architecture. And I think it's real important, actually, these meetings that we're all guilty of, we have an hour Zoom meeting for a project meeting that should really takes even more discipline to come up with a focus set of takeaways. Tony is gonna do X, Y, and Z by Friday, or Professor Mann is tasked with doing this, that, and the other, make sure you've got a good list at the end of these meetings as we move on to the next Zoom platform. I know this morning, I've already been on four Zoom meetings since about 7:30, and Fridays are supposed to be our quiet day. So, again, you've gotta take some time and really prioritize that take away from these virtual meetings. So, there's a lot of sales stuff out there and proven technologies, how do you, as designers, especially the engineering group architecture as well, how do you really go through the list of everybody selling you items on something that's really evidence-based and proven. Every air conditioning or HVAC manufacturer has some widget that's reported to stop or kill COVID, there's dozens, and dozens, and dozens of UV specialty lighting systems that stop COVID if you listen to the salespeople, isolation rooms, PPE, we try to cohort at risk population in certain areas, what's best from an evidence-based design. None of this has got any real research behind it. So, how does an architect make a good decision on how I should design the next type of ICU or the next type of treatment area. ASHE, as Tony says, has a good library of mechanical, architectural, and patient care isolation, temporary renovations, and I think has proven itself to work well during this pandemic. In fact, the CDC, I think often refers to that body of knowledge that ASHE has done. I know AIA has also put together some white papers on that as well with some of the best practices. I would argue that the code versus a need for most of these hospital rooms, we've probably turned into double occupancies. We've turned patient units into awards. We've made whole units wards and hold up wings of buildings and isolation units. This'll be an interesting look back in research study years from now on what worked, what didn't work, what truly is a best practice. Then I would say, how do you make a appropriate future decision in today's world. Just yesterday as reading the ASHE Journal, which I try to keep up with. And they had a whole article about the current literature and peer reviews about the efficacy of all of the various sales widgets out there, and the HVAC salespeople and what's reported to stop or contain COVID. And I think everything that they've seen is, there's not enough evidence yet or research out there that I think they claim everything is pretty much inconclusive, but yet you've got salespeople out there influencing architectural designs and engineering designs on things that are yet to be proven and could well be dangerous to some of the public as well. A few final thoughts maybe for the next pandemic, 'cause I'm sure there's always something comes up every five or 10 years, we have another crisis. So those of you that are students in your career, this is probably the first of many that you'll see. Oftentimes, we don't have enough extra capacity and exhaust systems, and more importantly, that duct work that's hidden above the ceiling and in chases. So when you get the crisis like today, how do Tony and I quickly modify some of these exhaust systems so you can make an entire wing or an entire unit negative. If we had a little more duct work, if we didn't VE projects a tight and made sure we had a little extra fan capacity or a motor horsepower, there's a chance that we can survive better and be more flexible. When you're doing wards and rooms, I think the quality, the capacity, the sizing, I think we've proven during the last six months that the oxygen systems as designed for these hospitals are wholly inadequate and grossly undersized. As I mentioned earlier, I've got real-time data from our hospitals at the peak a few weeks ago, we're using five times the volume of the oxygen, but just because of the respiratory disease that COVID causes, which means the actual pipe size, the diameter of the pipe is not big enough to move the oxygen, even if you actually had the oxygen available. So from an engineering point of view, instead of putting in 1/2 inch med gas main to patient room, maybe as best practice is to put in a 3/4 inch piece of med gas copper, or something. So I think those are the kinds of details that our industry really needs to reflect on and try to change those old ratios and design criteria from years past. We do not have enough redundancies in some of the systems, i.e.

the heat exchanger, the oxygen vaporizer, is what it's called, but it's actually a heat exchanger that flashes that cryogen, liquid oxygen to a gas. There's no redundancy on those. So as you get different temperature differentiation, those units ice up, and that further limits that capacity, modern systems, we probably ought to have multiple evaporators actually work with those systems. Medical air systems, the same way in order to power these respirators that takes a large volume of medical air. And we probably don't have the redundancies that we would need for a disaster such as this. A lot of code implications that I'm sure you and the architectural industry are already thinking of. The state of Texas and our department of health does not let you switch an isolation room from positive to negative, yet all of us have had to do those and make on the fly negative pressure rooms, and negative pressure wards, which is fine and is allowed now by temporary codes under the emergency order. But I would argue that from a design point of view, and those of you involved with codes and standards, we really need to fight to make sure that we have those flexibilities in your designs for the future on these items. And again, we talked to Paige before, how do you separate the sales technique from the evidence-based regarding filtration as far as COVID, Plasma Rx, UV lighting, there's various peroxide, generators, ozone generators, all those are reported to kill the COVID bacterium and other types of microbiome activity. Alvarez has also proven a lot of those are very dangerous to humans and are quite irritating to those of us with respiratory systems. So, how do we make sure we're not inducing something into the built environment that is yet to be proven that it truly is effective and safe to the patient and visitor? Commissioning field review process improvement, I don't know how we can make sure our buildings are actually functioning until you actually get out of those buildings and do the commissioning, which is still largely hands-on and things like outside air systems, the more systems we exhaust from these buildings, the more we have to add outside air and in Houston and Dallas, that means conditioned air. So we don't induce a heavy moisture load and cause mold and things like that. Another design trend that no architect and even engineers, we don't wanna give up floor space for an actual air handler for every unit, so what do we do? We put in very large central station, air conditioning units, air handlers. We hide those up in a mezzanine unit or up in a penthouse. So instead of having two air handlers per floor, like we may have done 20 or 30 years ago, we have giant central station air handlers. That's fine until we get something like COVID when we're trying to convert perhaps one wing on three south and make that a cohort ward, it would sure be nice if I had an air handler, I could then convert over so I wouldn't contaminate an entire building or wouldn't have to modify a system. So again, space considerations, value engineering costs, I really think we need to look at a little more flexibility in that built environment behind the scenes. Well, a few architectural observations, and again, I'm not an architect, but I enjoy poking fun at your profession every once in a while, just for fun here. But I think the biggest change from an architectural design is we make these nice grandiose lobbies. We have multiple entrances and exits, and I think we've proven through COVID and also, let's face it, at airports for security screening and things like that. How do you make a pleasing design that meets the life safety code for egress during an emergency? You have to still be able to route people and visitors through some sort of a screening, whether it be for COVID and temperature checks or in an airport from a security point of view. I think we have so many entrance and exits from our hospitals the codes mandate all those. How do we work on hardware systems and redesign some of the lobby elements to better allow us to actually screen and choke down entry exit, but still make a pleasing space? I think the talk about a universal room in our business, that's probably more important today than ever, even if we're using those rooms for a single occupancy, with a lower acuity, such as a med surge patient, I know Tony and I would sure like to have rooms that had enough med gas and electrical power, and ISD outlets in there, and data points that we can convert those to double occupancies and have some of the higher morbidity types of medical devices in those rooms for these types of disasters. How do I quickly convert maybe a set of ICUs or a patient wing and turn it into a ward where I would cohort an infectious disease population. It doesn't matter what the disease is. Today it's COVID, it's been SARS in the past, it was HIV 15 years ago. So, we have these recurring touch points with various diseases, and I think it's with us forever. So, how do you as architects and how do we as owners work through those items? We build some gorgeous waiting rooms, some fabulous lobbies, some nice lounge spaces for our doctors, but lately, we've had to take out all the furniture. And now, instead of having 25 people in a lounge area, now we have six seating places in there, same with dictation stations, waiting areas, is that here to stay? How do we do that? The near term, we've hung plexiglass everywhere and removed half the furniture. I'm not sure humans wanna live that far apart. So, are there ways that we can work on that architecturelly in the future? More capacity as much as no one wants to talk about that, everybody that goes to a hospital doesn't come back. Whenever we do these large campus expansions, no one ever focuses on the morgue, and I know we've spent a lot of time in the past eight months getting refrigerated trailers and expanding more capacity because you get diseases like this and you have a much higher death rate, and there's just no place to actually put the actual bodies while you're waiting on funeral homes and things like that. So, as much as none of us like to talk about those things, that's a realistic issue in these pandemics that you need space for, and we need to think through. I know OSHA recently published a document, I think four or five months ago on their temporary emergency measures on how to best mitigate COVID and other diseases. And one of the issues they preached about, we had to have are open windows for patient care in Houston. Now, anybody who's been to Houston in August understands you probably don't want an open window in an ICU unit in Houston. That's probably not gonna help the patient family. And I know we don't have enough air conditioning to overcome all that. So, you have to kind of chuckle at some of these regulations that have been put together. Age old issue among design professionals and owners is do we have any rooms? Do we not have any rooms with isolation rooms? Do you group all your isolation rooms together or do we distribute those on the corners of floor or on different floors? I think all those things are your profession, and our profession really needs to work through what a best practice. And then more importantly, I know Joe is heavily involved in this and his firm, but the codes and standards of support, these flexible environments, FGI, CMS, joint commission, the local authority having jurisdiction, I'm sure it's the same in Europe and other areas as well. There's oftentimes the codes and design standards work against those of us, especially when we have to account for things like we're doing now with COVID. How do you get some commonalities and get the flexibility you need in the codes. And then since all of us bill things that bricks, and mortars, and colors, and texture, I'm not sure how we get around the fact that you've gotta have a touchy feely to really know the texture of that. It looks like George has a antique brick wall behind him there. And again, how do you really get the true color rendition of that and the true texture of that? It's awful difficult to visualize that when we're looking on a Zoom screen and we may be on an iPhone. So I think our industry is still probably light years behind on how we try to bring some of that touch and feel and texture type stuff to our industry. Here's a few photographs. This is our Woodlands job on the left. No matter what, we still felt building a cath lab needed some touchy feely visuals. So our design team actually built a cath lab all out of nice cardboard models to scale. And even though we all had mask on, we walked the cath lab leaders, the physicians, the nursing units, and we built this all at a scale, and you can see a cute little C-arm there. So I think we still determined that even though a lot of this was done with virtual reality of Zoom, surgeons, and nursing, and people who do these kinds of things for a living, they still like something is to scale and that they can visualize where they stand during a procedure and where all their equipment's gonna be. The piping system as part of that central plant project, that's a piece of 30-inch chilled water pipe. Again, we've been modeled an existing central plant. This was the up-size replacement pieces. And we built all of that off site. It was all fabricated based upon laser scans and the contractors, BIM manufacturing interface, all of that was fabricated offsite. We brought it in pieces and assembled it up. No more welding in the field. I bet we made no more than about 10 welds in an entire central plant on site, which means we had a lot better quality control. More importantly, we had a lot less trade crafts working close together. So we didn't have as much risk of infection of losing the entire pipe fitting team during a phase. And you know what, even more importantly, from an owner's point of view, it actually worked when it showed up. It's amazing. So we love that oxygen on the right, that was real quick. Over the weekend, we had to install another bulk system at one of our hospitals because we were having to add 50% more patients just because of the sickness in that region than we had capacity for. So, I think as design professionals is that behind the scenes, support service items that we really need to think of going forward and be careful about, how much of that we cut out of a program budget when you're doing a campus or a big expansion. On the left is me in a virtual topping out party. Anybody who's built a building before got about time. Okay, you can see the virtual topping out. This is our Woodlands job that we did a 100% virtual design on. It was done during the heat of the pandemic. And you can see, we still had 500,000 hours of working safely on that job. And this is just about three weeks ago. We did all that in 11 months and it was all done remotely. This is actually our new Herman Pavilion here on the left. This is the Sarofim Pavilion. That's a million square feet. It's actually a Bill (indistinct) of, let's see, formerly WHR, now CYP Bill has since retired, unfortunately, one of the best, what I would say nuts and bolts architects out there. This was Bill's baby. This is added to our campus. We were opening it up just as the pandemic hit. And we had to finish that building in the middle of the pandemic. This is actually that floor where we had to do all the plumbing and all the waterproofing and get all the piping tie-ins with a COVID floor below us in that building we just looked at. And there were multiple, multiple phases of trying to get in there during low census times and put on our space suits and our bunny suits and work in an active COVID unit to get that done. Also, that same project, backfilling LRs and renovations we had over 20 various phases of renovating operating rooms and gutting operating rooms. This is the main emergency department that we also had to renovate all this during the ongoing pandemic. In fact, we got the last few phases now. And I think that's just the end of what our formal comments are. Anything else? - Man, that was terrific, Michael and Tony.