- Today we are joined by Lawrence Lammers, who is going to lecture to us about healthcare facility, drivers planning team coordinators.

Today his lecture will be introduced by Ronald L. Skaggs FAIA.

Ron Skaggs graduated in 1965, with a bachelor of architectures degree and a masters of architecture degree, from Texas A&M university.

He is the chairman of meritas of HKS, where he actively engaged in the design, of more than 750 projects, primarily focused in the healthcare sector.

He is a fellow, in several professional design organizations, including the American Institute of Architects, where he served as the AIA president in 2000 and chancellor of the AIA College of Fellows in 2013.

His many honors include the AIA Kemper Award and medal for outstanding service, to the Institute and the Texas Society of Architects Pits Award, and a medal for lifetime achievement.

He was also elected as the national academy of construction.

He is a long time supporter of the architectural education, especially the department of architecture at Texas A&M, and the college of architecture, having created two chairs, one professorship and several student scholarships.

He is also a member of the College of Architecture Development Advisory Council, and a very active member of the Department of Architecture, Architecture+ Industry Advisory Council.

It is a pleasure to welcome Ron Skaggs.

(applause) - Greg, thank you for that kind introduction, I appreciate it.

This is a special date for me.

I have the opportunity to introduce one of my classmates.

One of my favorite classmates I might add.

You've heard the name Lawrence Lammers mentioned, with your permission, I'm gonna call him Larry from this point on, because I know him as Larry.

Larry and I were in graduate school together, when the healthcare program here at Texas A&M was begun.

We each went our separate ways, and Larry became a consultant, in healthcare architecture, and I became an architect in that realm.

He started his career with Hillrom, and designed, the first as far as I know, headwall that was built in United States, and now that's pretty common throughout, hospitals throughout the world.

He also then went from there as a consultant, working with the internationally renowned hospital consultant, Gordon Friesen, following that Larry founded his own firm Lammers and Associates, and has been actively engaged in the healthcare field for more than 45 years.

His consulting experience includes participation over 400 healthcare facility planning and develop projects for unit varsity medical centers, psychiatric hospitals, cancer centers, and ambulatory care centers throughout the US, as well as throughout the world.

He has developed prototypes and facility development standards for several multi-hospital systems.

He's well-known, for his work in developing innovative materials, handling and logistics systems.

for healthcare institutions.

He's a licensed architect holding a certificate from NCARB, and is a member of the American Institute of Architects.

And I might emphasize also, that Larry is a fellow of the American Association of Healthcare Consultants.

He's lectured on healthcare facilities, planning, and design at a variety of universities and symposiums.

And he published a textbook in healthcare design called, 'Hospitals, the Planning and Design Process'.

For this work, he was given the Healthcare Consultants Award of the highest level, the award of merit from the American Association of Healthcare Consultants.

I also might add, that Larry is an outstanding alumnus of Texas A&M University.

And lastly, we designed a lot of hospitals in my own firm HKS Architects.

Larry has been the consultant, particularly in the materials handling area, on many of those projects.

And I won't elaborate beyond that at this point, I'd like to turn it to you Larry, to hear your comments.

Thank you for joining us.

(claps) - Howdy?

- Howdy - All right.

You know, it's been about 50 years ago, when I worked across the campus from, my dormitory to the college of architecture, which existed on the fourth level of the administration building at that time.

Going across campus, everybody would say, "Howdy?"

And I said, "Howdy."

And then I said, "Howdy partner?"

And I felt like I was in Texas and go, "Howdy partner?"

Ever since that time, I felt like I had 10,000 partners, and it's even true today.

A lot of people who work across campus, they still say, "Howdy."

And it meant a lot of awful lot.

One of the things I just wanna, go back a little bit because my career was kind of different than the standard, what you would think of as an architect, graduating from A&M and going into architecture, designing buildings and so on.

When I graduated through the graduate program, in Georgia's Program, I went into industry.

I went to Indiana, as Ron said to work for Hill-Rom industries now, and everybody would say, "Who's Hill-Rom"?

well Hill-Rom was the largest hospital bed manufacturer in the world.

And I went to Batesville, Indiana.

And I was in the research and development program up there where I worked on.

It was a new program, in developing a head wall system for a modular head wall systems for hospitals.

And at that time it was, I learned an awful lot.

I learned an awful lot about management and coordination with people in coordination, with products and how to develop a product.

And here I was an architect, which was kind of different.

While I was there I had an opportunity to meet Gordon Friesen, who as Ron said, was the leading foremost hospital consultant in the world.

from Washington, D.C. And Gordon was also working on some products with HillRom and he, and I just really hit it off.

And at that time we were kind of working together on ideas and things like that.

And he asked me if I could, would like to come to Washington to work for his firm, which was fantastic.

I went to Washington and of course I had a chance to travel all over the world with, Gordon.

And he was working on projects all over the world in Sydney, Australia, in Japan and Germany, and so on.

So from that time, I met a couple of people that were within the firm that we were working together on.

And we had the opportunity to meet a doctor out of Chicago, Dr. Jim Campbell, who was the CEO of a Rush Presbyterian medical center in Chicago and Gordon was not in town at that time.

And he asked if we could take, Dr. Campbell through and tour St. Elizabeth hospital in Lincoln, Nebraska.

And we did that, and after that tour of the hospital, Dr. Campbell was very, very impressed with all the freezing concepts.

And you have to remember, Gordon was a futurist and he was a real far thinker, things like, well, the first hospital I worked on was an all private patient room.

And at that time was, oh, just about the early, very, very early 70's.

And we had wards for patient care units were wards 26 beds.

And the first hospital I worked on with Friesen was an old private patient room.

So you can imagine everybody talks about a private patient room today.

And my first hospital early in the 70's were all private patient rooms with no nurses stations.

There were no nurses stations, in the patient room, and actually Gordon developed up a walkie talkie system, that, it was a pocket pager but the nurses could talk directly to the patients.

So when the patient had a problem, they wouldn't go through the nurses station.

It would go directly to the nurse pocket pager.

And of course today we have apple telephones.

The, it was a great experience, but when we took Dr. Campbell through St. Elizabeth hospital he was very, very intrigued.

He said, that's what I want.

And we're gonna build a new hospital in Chicago at the time early 70's.

Well, actually in mid 70's and the project was $130 million project, which today is huge.

And at that time, the three of us, toured him.

He was very excited, but he said, one thing, he said "I cannot, I could not work with Gordon Friesen because of the two opposing egos," and he asked the three of us.

this is Dr. Campbell, asked the three of us, if we would like to come to work for Rush Medical Center in Chicago, moved to Chicago and be the consultants and the planners for his new hundred and $30 million hospital.

Well, if you're ever starting a business and you have the opportunity for a hundred and $30 million hospital, you think, my gosh, there's my key to success.

But the three of us did not wanna move to Chicago.

It was not in our cards, we liked Washington.

And we said to Dr. Campbell, we're not gonna move to Chicago, but he turned around and said, "Okay, well, you just stay in Washington and you work out of Washington."

And that was, we started the company probably within days.

And we kept that till 1979, '79 we sold the company, the three of us.

And I started Lammers and Associates, which we've been in business since 1979.

So it's been a few, many decades anyway.

So that's, how I got it.

And I'll show Rush Medical Center.

And the project later on in my speech, The a, let's see.

One of the things I think is really important is to understand how healthcare got to where it is today.

And I'm starting back when I was a student here, I graduated in 1966 in 1965.

Every, everything was stemmed on looking at the, the economic realities of healthcare and how it changed over the years.

And I think this chart is really important.

So we have to look at the historical perspective of healthcare change, driven by economical realities, 1965 demands of the facilities grew.

And it grew basically out of land grants from the U.S in the Hill-Burton Act, and that was, it was prior to '65.

It was in probably the 50s, but it really took hold in, in '65 when they developed up the design and construction standards for and I know you probably have heard of Joe Sprague here who is very involved, and he was very involved in the, the Hill-Burton standards, actually construction and design standards.

There still exists today that you follow.

In 1970 demands were uncertain.

And there was a historic view of hospital design, mainly a holistic standpoint, because at that time it was basically a lot of just care-taking hospitals in design.

They weren't looking at the whole holistic view of healthcare delivery.

In 1980 demands were retrenched and restructured, in 1983, the government put out the control of reimbursement care programs.

And that was the 1983 DRG programs.

Actually, hospitals got reimbursed based on, the types of care that is given.

In 1990, a paradigm shift a little bit, in the patient focused care you probably heard of that.

A number of times, it was in 1990 and because of the DRGs and the controlling of the cost of healthcare, they start to expand and look at technology.

I'm sorry that they started to look at outpatient care rather than inpatient, inpatient care is very, very expensive.

So today you see a lot of outpatient care centers being developed so that patients don't actually go into an acute care inpatient setting when they really only need an outpatient care and they go home.

In 1990, of course we saw the patient focused care and expanding of technology and care pavilions.

And what I mean by care pavilions was instead, as they had a hospital, acute care hospital, they start to develop specialties, a heart hospital and oncology facility, children's hospital.

In 2000, we saw evidence-based design come to the surface.

In medicine there's a lot of evidence-based design on the care programs for patients.

And it was looked at as maybe they could do that for the design of hospitals, what works and what doesn't work.

In 2010, we had the Affordable Care Act Obamacare, which is still here today.

And it's still in Congress trying to work that out in 220 was a functional everybody's is starting to look at functional efficiency within the hospital.

We had the hospital perfected.

We just need to pick up the efficiency.

Hospitals are very inefficient, operations, and we're also faced with COVID-19.

COVID-19 is makes a lot of changes in how it's designed.

Hospitals are now formulating systems, where there are multi hospitals forming a system.

The hospitals are now employing doctors directly.

rather than them working separately.

So that's a little bit of history.

Let's look at that functionality a little bit.

And what do we mean by it?

And we're looking at the holistic perspective, and it's just 10 items that I pulled up constantly thinking in the back of our minds, hospitals are unique.

We have to look at safety.

We have to look infection control and even more so today with COVID-19.

So the holistic perspective is we're looking at the whole hospital and we're very, very involved in the hospital operations.

We do care about what the hospital looks like from the outside, but what you have to learn, is how the hospital operates and functions.

That's our business.

We look at functional relationships, the relationships, simple ones like emergency and radiology, transport of patients between departments.

We look at patterns of circulation and pathways.

As you add onto the hospital usually the relationships and the patterns of circulation or pathways changed drastically.

And you have to keep that in your mind.

In other words, what we're saying is the hospital will grow.

We see every three years, they're back into planning and they add an appendage or an addition to the hospital, but they don't look closely at the pathways of people coming into the hospital and their whole flow through their treatment program.

We also look at operational efficiencies, down to the nitty gritty.

How can surgery be more efficient?

How can we take some of the support elements out of the hospital to save space, but make it efficient, almost like Amazon does to the delivery system, and how we can save dollars, the expanse ability of the hospital.

And I explained that, we will be in three, every three years, we'll be back into planning.

So it seems like architects will have a job forever.

And we look at flexibility, early in the design phases of a hospital and thinking that it will expand, how will it expand logically and be flexible, not only from a space standpoint, but also the mechanical and support elements there.

we look at separation between clean and soil and therefore for, we constantly look at what's passing by each area.

This is more so in the COVID-19 infection control.

And we see places where all the patterns just mix traffic patterns in a hospital, just mix.

And it's, an extreme problem.

We're very much into automation on our side, where, like Ron said, we're into materials handling and distribution logistics.

We are in very heavy into robots, automation in the hospital.

And probably many of you students have heard about robotic surgery.

And in thinking about robotic surgery, you're talking about equipment that is a million and a half dollars per robot.

We're also looking at it as materials movement, looking at patient convenience and privacy.

All through this we have to constantly think about the dignity of the patient and how we can keep that dignity throughout.

I know if you go into the emergency room, you leave, usually you lose your dignity right, there at the door, but nevertheless, it's an issue that any improvement there would be a very, very welcome.

And we, lastly, we look at modular clinic units, modular clinic units.

If we can design a building with modular units, it starts to offer a lot of ideas about flexibility and expandability.

And it keeps the flow of the unit clearly defined.

One of the things I would like to do is look at, the Dean, the team, of course, this is supposed to be how people put things together here.

And this is based on a design build project.

You might say it's pretty common.

As you noticed, the architect is the center core of all the players.

It's a step down right from the owner relationships with the owner directly.

There's all the other boxes are basically consultants.

That would be on the team.

You have HVAC people, structural engineers, interior designers, graphics people, equipment planners, up on top, right off the owner.

You have a strategic planner, which says, what's our, what are we gonna build?

What, how do we serve that community?

On the far, right is the financial, what does it cost?

So, it's actually putting together a business plan and offering the financial aspect right there.

Sometimes the strategic plan and the financial planner are the same people are the same firm.

Then just off that in the orange box there, we have the construction manager and the cost consultant.

All of these people should relate to the architect.

And this is in a design bid build, if it's a design build project, the structure is kind of different, but there's a lot of players here that we have to coordinate as an architect.

And if you're in that position, as a project manager for the architectural team, you will have to communicate with all these people.

One of the things that we see, this is just a division of of the major areas within the hospital and space allocations.

40% of the facility is inpatient nursing units, diagnostic and treatment is about 25 maybe 30% and support services is 20% in the administration areas is 10% and there's other spaces like education.

That's 5%.

Our firm is really based and focused.

We're in each player.

We're four focused on support services.

That's why we're so involved in how the hospital operates.

The support services could be 20%.

That's a lot of space to support the facility.

And this is acute care facility, by the way, it's, this is a major hospital, tertiary care hospital, acute care services.

So we're in the, in that support service, that's our business.

we were into space planning and functional programming, but this is the niche that we captured.

And we made a business out of it.

And it's a big business.

The approach to understanding existing operations is our game.

The looking at it, and from a holistic standpoint, there's, different movements within the hospital.

There's the materials type movement.

And the people movement.

The people is obvious, that's the patient, the staff, the visitors, the vendors that come in and cadavers that go out and not alive.

(laughs) On the material standpoint, we're looking at this whole array of things that move through the hospital, the general medical supplies, the pharmaceuticals, linen supplies, food service, even bottled water and soft drinks, office, housekeeping, mail, FedEx, UPS, Amazon, that delivers packages, labor, maintenance supplies and equipment.

And there's all different types of beds that come in.

that have to be interchanged.

And one of the things that in the materials movement, what comes on that dock and has to move through the hospital on an average hospital, this is about over 600 cart movements per day.

in a regular hospital, that has to come from the loading dock to the end user and then out.

And you might as well double it.

So that's 1200 movements of carts per day, in a large hospital like Ohio state university that we worked on, it's over 2300, movements one way in this.

This is big doings.

It takes a lot of people to move these items.

And there's scheduling there's time constraints dietary is, there are certain times of the day that you have to service the food, on time, and we have to schedule it.

We look at it, we look at dock scheduling.

We look at how many trucks come in and so on.

Quickly, this is a cartoon.

And on the right there, I make actually on the left is a cartoon about, men pushing carts.

I want to talk a little bit about elevators.

You'll go into an architectural firm and you'll go through the catalogs and you'll see Otis elevator, this and corrupt, and they have their standard elevators.

And you'll start to picking, and they'll have machine realists elevators, and they'll sell them to you.

However, that's not what you want in hospitals.

We have specialized elevators, that we have to be attuned to, to move the material.

And we look also, we look at robots.

If people don't move the materials, robots will.

All kinds of robots.

There's quick demand request, robots which were nomadic tubes.

And there's also large cart delivery systems that pick up the whole cart automatically and take it to the end user.

Robots, we even have Dr. Bot that does the rounds now.

the patient rounds, they robot visits the patient in the rooms.

This is a slide that it's a, touch of reality.

One of the things that we see as the architects try to sell the client on these great ideas, and the client, because we have the tools to do that.

We have Revet and have all this SketchUp and everything.

Boy, we can make it look really fancy, but are we selling to the client what they need?

This goes time and time again, I go into hospitals, I see ceremonial stairs, and these gigantic lobbies, ceremonial stairs to service patients that are there to get better, family members that are walking down the stairs and in tripping down the stairs, why do we have ceremonial stairs?

Why do we have escalators in hospitals?

They belong in airports and malls.

They don't belong in the hospital.

So we have to be very, very sensitive there.

Who do we work with?

We work with all the architects in the country.

It's one of the great things that we have.

We are learning constantly from the architects and we're challenging them, they're challenging us all the time.

One of the things is that we had a funny one, one time, and this was a cardiac surgeon.

And he said, I will help you evaluate the surgical department because I majored in architecture before going into medicine, wow.

We gotta hit.

However, if you really know, a cardiac surgeon knows his room, his operating room, he doesn't know the department.

You wanna talk to somebody, talk to the anesthesiologist.

He knows all the doctors and he works in all the rooms.

This is my hospital.

Your Dean was talking about silos at the beginning.

We look at it today as in the hospital, we have all these kingdoms that we have to relate to.

And it's the same as Debonairs was talking about the silos so you're gonna be communicating with all this professionals and all these support people to make it a good hospital.

Now, Georgia asked me, "Larry, can you talk a little bit about projects?"

And we're not the architects, we work with the architects.

So I said, okay, so I'll pull some out of our file that we worked with.

And this is just our hospital.

A hospital that I go to.

up in the right-hand corner is the hospital when it was built in 1961.

And on the right below, that is what it looks like today.

And as you can see, the hospital had many, many additions, but the old hospital is still tucked in that maze of building additions, they have the heart hospital, they have the women's and children's, they have three heliports servicing this hospital.

the dotted line right across the middle there is the underground spine, which services all these buildings.

And that was in place.

Infrastructure when you build a new hospital, the infrastructure has to be well-thought out.

And they did that.

Now, as you can see, the whole site is saturated.

Where do you go next?

Well, the hospital was pretty smart, right across the street was the ExxonMobil headquarters.

The ExxonMobil headquarters moved to Houston.

It opened up 117 acres of land for the hospital to develop and the first phase is way up there.

And on top it's the oncology building, which they got a big donation from, a Mr. Shah.

And they started with that and there'll be research and all other components that are thought out.

So, as we were working on, it said, we have worked many, many projects on this, hospital, started in 1969.

And they started with 10 operating rooms, we're now have 59 operating rooms.

They're doing 150 procedures per day in this room, everything from appendicitis to transplants.

And we were fortunate to work with them on that hospital.

I know you all know that Texas A&M is represented in Doha, Qatar Actually, my son, has been to the A&M campus over there, but we were very fortunate to work on Hamad Medical Center.

And this is the medical center that, the main medical city complex, which is that triangular building with a hole in the middle.

That was about $2 billion.

This is a 3,600 bed campus.

It's the largest hospital in the country.

The trauma hospital up in the corner on the left-hand side, that is, is being planned right now.

And that will be about a 600 bed hospital.

So you can see there's a lot of things going on here.

We were hired to come to Doha and our assignment was that we had a directive that they did not want any trucks on campus.

So all supplies that I talked to previously, had to be, brought to the campus.

And as you can see, the building on the far right there, I believe that's where, yeah; it was the rail center.

That is the area for distribution.

So trucks will all go there and from that point, we had to move supplies to all the buildings on the campus and build underground tunneling in, and look at everything will be moved robotically to those buildings, both horizontally, down into the tunnels, across on the campus.

And you can see there's two sides to the campus.

There's the west campus and the east campus.

We had to go and service all of those buildings.

Then on top of that, we had a major road, between the two areas.

That's the blue line, and the room and the line horizontally was the new rail system that they're putting in to service the soccer, world soccer cup, coming to Doha next year.

It's supposed to come.

Okay second one is Rush.

And I wanted to get back to Rush because you probably have seen the big drawing on the, left-hand side.

This is Dr. Campbell that I started with and Dr. Campbell, of course, he's no longer living, but this is his hospital.

And the challenge here was the train, the elevator train, as you can see on the right, goes through the hospital at the third level, and how we could plan that.

We started all the white indicator.

There was the original hospital.

We were involved with four different architects, as it grew at different times.

It started with (indistinct) out of Chicago.

And the star like milling was Perkins and Will out of Chicago.

And we had down on the lower right-hand side, you see the orange square there.

That's where all the truck traffic comes in.

Everything at that point, is moved by robots, to service this campus.

So, those are the challenges that we get in.

It's exciting stuff.

All of this put together, we had to think, and this is Ken Kaufman of Kaufman and Hall.

They're probably the largest strategy and financial consultants in the country.

And I know Ken very well.

And Ken said, "You have, developed a perfect, perfected the hospital, that we can no longer afford.

So all of the nice cities, that you see from the outside of the hospitals is one thing.

And we have to really focus on the inside, to make it affordable.

I need to stop here.

So I'm just gonna leave you with one thing, and that's, I call it Larry's pillars of success.

One thing when you leave here, I found out that attitude, is gonna be extremely important when you go to a firm.

And you will be presented with all kinds of opportunities that you'll have to decide, whether or not you want to take it, whether you want to leave.

When I left Batesville, I thought I had it made, the company gave me a home.

And you know, you ask yourself, is money the driver, you might say, to go to Washington, where I have to commute to an office?

And yes, it was.

The other thing I wanna look at and it's important is time.

You know, you have lots of time, but think about those three things; attitude, opportunities and time, and will help you put together your plan of success.

Gonna end here, any questions?

Okay, yes.

- [Man 1] In your pillars of success I just wanna know maybe, are they all equally important or is there when you may value one more than other?

(mumbles) - Oh, okay.

The question is, my pillars of success.

Are they all three of them important or is one, more important than the other?

All depends how old you are.

(laughs) Right now at my age, of course, the bottom line time is most important to me.

But I, think as you start, to look to your career and leave college, I think all three of them are important.

And you know, you're looking at time, as what's happening today.

What's going on in the world, you know, where are my opportunities there?

You just take some of the big developers, and the big thinkers, Elon Musk, thinking about electric cars.

Well that's today, that's important.

If you're an engineer going into the industry, you don't wanna look at internal combustion engines.

you're gonna be looking at electric engines.

So I think the time, what's going on now is really important to you, when you leave school, find out what's going on in the world, and see where your opportunities are.

And always when you look at opportunities, look at it in depth.

It might not show up right away to say, "Oh, this is a great opportunity."

Look at it in depth to see how you fit in, because each one of you are different and you might say, "This one's for me, I'm gonna give it a try."

It may not work out.

However, there's another opportunity gonna come your way.

And I almost guarantee that, but they're all important at your age.

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