- Today, we have six speakers from Ewing Cole and I'm going to introduce Miss Debbie Phillips.

And she's going to help me to introduce the rest of the team.

And Debbie is a proud graduate of architecture for health program at Texas A&M university, class of '85.

So she has spent her entire career designing, planning and programming healthcare facilities and lab environments.

She has designed a lot of projects, cover a wide variety of projects, from academic medical centers to community hospitals.

She's really interested in health environment research, and she has changed in different areas, including the analytic abilities and critical design thinkings, which she uses in different projects to help her clients to achieve the maximum, optimized the efficiency in healthcare facilities.

So Debbie, I'm going to turn the mic to you and you can introduce your speakers.

Thank you.

- [Debbie] Very good.

Thank you so much for that introduction.

We want to start by sending out a big howdy to all the folks in college station.

We want to thank George and the college of architecture for the opportunity to speak this afternoon.

We're really excited to show you our medical office building that's in New York City.

So I'm going to introduce the rest of our team.

And at the far left of the panel, you'll see Jonathan Cogswell representing Northwell Health.

So Jonathan has been in the industry for 25 years and he started his career developing cancer centers in the Metro New York area.

So he's been with Northwell for about 15 years and he's the assistant vice president of facilities and engineering services.

And he's responsible for the Western division of Northwell.

So that includes responsibility for several hospitals and 80 outpatient sites.

Next on the screen, at the far right, we're happy to have Rich Steimel with us.

And he's with Lendlease.

Lendlease is a global real estate and construction management firm, and they have been working in the United States with healthcare projects for the past 90 years.

Rich started in their New York City office in 1994 and he's a senior vice president in charge of the healthcare practice.

And Lendlease, their experience with healthcare, they've been on modern healthcare's top 10 list of construction managers for the past 31 consecutive years.

So the rest of the team that you see in front of you is our colleagues from Ewing Cole.

And we have Mary Frazier, who's the managing partner of the New York City office.

So Mary is responsible for recruiting, training and certainly the quality for all of the projects that leave that office.

And she's a frequent guest speaker on the conference and symposium circuit.

And Mary has degrees not only in architecture, but also business.

If we move over to Alice, Alice is the director of research for Ewing Cole.

Alice is also very talented, has multiple degrees, including a degree in interior design, architecture, as well as systems science.

So Alice, in addition to helping guide clients make decisions, is working on her PhD in systems science.

And the last member of the team is Mike Hoak.

So he is the primary architect for this particular project that we're going to be looking at today.

And he has a wide array of experience, including not only master planning, but also medical office buildings, as we'll see today, and hospital construction.

And Mike is really interested in solving problems for the client.

So one last overview for Ewing Cole.

We are a national firm.

We've got just over 400 people spread amongst nine different offices.

The primary headquarters is in Philadelphia and the healthcare practice in New York is 100% healthcare.

So the theme of this lecture series is all about teamwork and collaboration.

And certainly we're going to talk about that for this particular project, but the CSS go back 18 years.

So Northwell, Lendlease and Ewing Cole have been working together on various projects for the past 18 years.

And that is the foundation for the project that we'll be looking at for today.

So let's go to the next slide and Jonathan will take us through an overview of Northwell.

- Thanks, Debbie.

So just to take two seconds to give you a quick who we are.

Northwell's a large health system in New York state.

We're actually the largest health system in New York state.

We're in the top 40 of the largest healthcare systems nationwide.

We were founded in 1990 when our first two hospital mergers took place between Glen Cove hospital and North Shore University Hospital on Long Island.

You'll see, you know, with this graphic, just a couple of our highlights.

We're a 23 hospital system with over 838 inventory facilities, about a $14 billion annual budget.

We see about five and a half million patients.

And we're now actually, that number's 1,000 off.

We're over 76,000 employees strong, making us the largest employer in New York state.

We have over 14,000 affiliated physicians and we have a medical school, nursing school, a very strong research center in the Feinstein Center for Medical Research and a lot of significant residency and fellowship programs.

You'll see on this map, some different colors of gray.

Our system grew so much so fast that we ended up regionalizing our health system into the Eastern region, which is that long swath of the island to the right.

And the darker gray is the central region and then the Western region over to the left.

And that will play into the conversation a little bit later.

So I will turn it back over to Debbie for the next box, a little bit about who we are.

- So we are looking at a medical office building today and certainly that's one of the basic building blocks of the healthcare system.

And if you're a healthcare architect, it is entirely likely that you have worked on a medical office building during the course of your career.

And it's probably pretty likely that you have several in your portfolio.

But in approaching this process, this project, we really wanted to rethink the entire process.

We wanted to deconstruct every decision and re-look at everything.

So there were three main questions that we were looking at.

And the first question was, how can we make the process more convenient, more comfortable and easier for the patient?

The second question that we wanted to answer was, how can we make a building that has inherent flexibility so we could meet future demands easily?

And then the last question was, how can we make a building that incorporates a collaboration for the provider base?

So those were the three main things that we wanted to look at and I will turn it back over to Jonathan so he can talk about the mission and explain a little bit of that process.

- [Jonathan] So I think, you know, from my perspective, when we really dove into this project, you know, you probably all have heard the, you know, the concept of design bid build where the owner comes in and says, this is what you're going to design.

They draw, the owner bids it, and the contractor builds it and we move in.

We did not want to do that similar concept with this.

We wanted to create a team that would re-envision what a medical office building could be in New York city.

And the key tenet of that was getting the folks on my side of the fence to be in complete agreement with us that that was the path forward.

So really the engagement from ownership and the buy-in from executive leadership of the health system was critical when we started this process.

And we even took that into bringing them into the interview process where we, you know, we went into the process having pre-vetted firms that we knew had that mindset, that we knew had that innovative and that forward thinking mindset.

And we really wanted to pull a team from the Northwell side together to say, how do we create a group that we know will gel from the beginning, that will be collaborative, that will will be aspirational?

That was incredibly valuable in getting the ownership, from my side to be a part of the process from the beginning, and to continue to be a part of that process as we move forward.

We went into this with an understanding that we needed a team dynamic that was innovative, that was full of aspirational thinkers, aspirational, yet logical thinkers, with the biggest tenet of that being collaboration.

We needed to create a team that we knew gelled from the beginning, and that we knew was going to work together hand in hand with the same goal and the same focus from beginning to occupancy.

And another key tenet that I felt was very important in mobilizing the team, was not having ownership be the boss.

We truly wanted the folks from Northwell just to be another member of the team.

We wanted the conversation to go across all the different trades that were involved in this, including the end-users.

We wanted it to be an exchange of ideas.

So we brought an owner's rep in to kind of be that boss, to take that role of driving the project forward and being the yes, and/or the no person that was in this so that freed up myself and my team to just be a member of the conversation, part of the conversation and a member of the team.

One of the things that I did put forth in the beginning of this, when I talk about aspirational is, and it's a quote that all these people have heard so many times, and they're probably tired of hearing it, but it's a quote from Robert Kennedy who says, there are those who look at things the way they are and ask why.

I dream of things that never were and ask why not.

And that was something that we put forward to this team at the very beginning of the project and driving everyone as we go through this to just ask why not, as we push forward in this.

So, Mike, if you want to go to the next slide, we can just talk a little bit about how we formed the team.

So you see in the kind of the middle of this circular graphic, the project leadership team, but really from a leader, this is more the governance structure of how decisions are approved.

Not necessarily how decisions are made, because the greater team are bringing those decisions but this is where we go back to to get the final decision approved.

But each one of these relates to whether it be an end-user or a design team member.

So you have the facility services and engineering group, my group, that works with that outside team, the design team.

So we have Ewing Cole on that team, who is represented here, who are our gold standard healthcare planners that are really building the guts of this building.

We have Ennead architects who are their core and shell architect, working hand in hand with Ewing Cole, and then the folks from JB&B who are our engineers, our MVP engineers.

Severud, who are structural engineers.

And then of course, Rich and his team from Lendlease, who are gonna take everything we put on paper and turn it into reality for us.

That middle ring is the ring that becomes the most challenging.

These are the vast group of end users that are going to be in this building.

We're talking about a 260,000 square foot building that's going to contain about a dozen different practices and procedure spaces that all have to be balanced.

So we pulled into this project leadership team, the medical director of Lenox Hill hospital to be our clinical lead and kind of be that person who would help guide the department chairs towards a singular goal.

And then we have, as I mentioned before, we're broken down into regions.

We have a regional ambulatory operations team that works hand in hand with those department chairs administrators, to help drive the business side of things.

And then of course what's a project without someone controlling the budget?

So we have our regional CFO, who's there to tell us no, stop spending money.

But by taking all of these people and having someone on the leadership team that works hand in hand with each bucket of the end-users, it allows us to build this governance structure of collaboration and understanding up and down the chain.

And I think we've found it to be very, very helpful.

Rich, I don't know if you have any thoughts.

- I do Jonathan.

I'd like to add to that and just point out that the graphic is not just a bunch of names.

It's actually Jonathan's way of setting the tone of the project and that's for the entire group.

And number one was making schedule a priority and the decisions we made had to compliment that direction.

And in addition to that, it was really Jonathan's openness to just team input.

It was something that he didn't want.

It was something that we all understood had take place and it's fostered a really strong team environment, which was ultimately based on collaboration.

And the fact that we've all worked together in the past, I personally think is a huge bonus.

The basis of the relationship has already been formed.

There's an existing professional courtesy there amongst all of the players.

And what Jonathan's doing is capitalizing on that, taking it to the next level and creating a true partnership, which we've all bought into.

And it has a huge impact on the efficiency and how things evolve.

Now, I would say that what we witnessed so far is one of the biggest parts of that, is the planning.

There's been an enormous amount of planning and there's a lot more to go.

And from a builder standpoint, the good news is building this may be the easy part at the end of the day.

So time will tell.

Now, just one example of how that team environment that Jonathan's created really gets implemented.

We were approached by the design team to look into the facade design.

And I want to be clear that it wasn't a drawing that we got that said, all right, how much does it cost?

How long does it take?

It was quite different than that.

It was actually ideas.

And we sat around the same table and we talked about things like materials, not only what's desirable, but what's available.

What options do we have to consider?

What about the cost?

What about the lead time?

What about the energy code?

All of those factors were discussed and ultimately feed into the final decision about what we will ultimately do.

And the key here is that it was done before the design progressed.

It wasn't an afterthought and that makes a big difference in the final outcome.

And as we go further into the presentation, I have a few more examples of that and some of the components that have a direct impact on the schedule, but for now, I'm going to pass it on to Mike.

- [Mike] Okay, thank you, Rich.

And before we get into kind of the heart of the discussion, I just want to frame this, that the project is currently moving out of a concept design and we're going to be starting schematic design very soon.

So a lot of what we're going to talk about today are the driving principles, our design ideas and the concepts behind how we're going to execute the project.

And so what you see on the screen now is a very conventional MOB typology.

This is a time (indistinct).

Jonathan had been saying about thinking about why not.

So why not think about the different, the conventional MOB and how it can be different.

Today, there's registration, waiting, lounges, exam rooms, and the physician offices often all on one floor.

It's a very kind of siloed approach to architecture.

There's not much collaboration or cross-pollination between floors and even a chance for, you know, the patient population to understand what's in the building.

So we really wanted to think about that and how can we turn it on its head and solve it in a different way.

So moving away from that conventional model was really important to us when we started the project.

And we wanted to rethink the arrival process.

Not only how a patient arrives to the building but how do they circulate from entry all the way up to their floor?

How can we rethink registration and waiting?

Does it need to be on every floor?

Is there a central model or a better way to think about that?

And how can architecture promote flexibility, not only in just the general, you know, demountable walls, which is great, but how can you really design the space in different ways of using modularity?

Can a procedure room that's a larger room flexed into two exam rooms, which then could flex into a smaller office and how can those aggregate across a floor to really promote flexibility and future-proofing the space?

Jonathan, I know, as an operator, you deal with this on a daily basis, probably over a number of your campuses.

Do you have any input as to the importance of flexibility?

When (indistinct) a project?

- Yeah, I think Mike says two very key words.

Future-proof.

You know, healthcare is an environment that changes nonstop.

By the time you've finished building something, the technology that's going in that room and the way they treat the patient may have already changed.

And it's the ability to create spaces on a grid style fashion, the way that Ewing Cole is working to develop for this building that allows us to very quickly flip from room type to room type to room type, so that we prepare ourselves going down the road.

We're driven as the facilities world to be able to change as quickly as the style of care changes.

By designing in this fashion, allows us to do that.

- Absolutely.

And the last thing, I mean, one of the big things we need to try to employ when we're looking at new ways of thinking is, how do we look at other industries, other markets, innovators to enhance the healthcare experience?

You know, an airport might sound like a very mundane place but in terms of circulation and moving through a building, it's very applicable to healthcare and the way they use a flexible check-in model.

It can all be done on your phone, on your handheld device, or you could go to a kiosk or you could go to a person.

And we really wanted to employ that throughout the, you know, the entry lobby and the registration sequence in this building.

- I think a lot of it is changing, changing the way that that we think about designing for healthcare.

It's always swung from community to community.

It's been, we're designing for providers this decade.

The next decade, it's all about patient experience.

Now it's all about how this is done.

And it's really now taking all of that and merging it together and starting more of a human centered design experience so that we're taking everyone into account.

We're thinking about the provider's experience, the nurse's experience, the EVS worker's experience in tandem with the patient's experience and how do we make this better for everyone so that the overall experience is more cohesive and forward thinking?

- So I'll turn it to Mary to talk about some of those ideas for the new MOB.

- [Mary] So as we began to look at the model and look at other industries, we wanted to ensure that the building was embracing forward thinking technology.

So some of that registration and arrival technology that we are seeing in other service or in other industry is really bringing that to bear to this facility.

And as we began to embrace that technology, how could that technology allow us to reduce duplicative services, to really ensure that we are utilizing individuals to their highest and best use, while also ensuring that building is flexible over time, as I think we've all mentioned.

But we wanted to also see how we could use the architecture of the facility to encourage collaboration and awareness of the clinical teams, not only of the people within their teams but also other service lines that they might make sense for them to collaborate with throughout the day.

Additionally, we knew that this was one of the first steps of a larger Manhattan master plan for Northwell and Lenox Hill, so we wanted to ensure the building and the spaces we were creating along with that experience begins to establish the brand for Northwell in the upper east side.

And finally we needed to ensure the building welcomed the community.

We wanted to allow the community to come in to experience some of the educational and other opportunities in our waiting or a welcome lounge.

And we wanted to ensure that it did feel welcoming.

It didn't feel as though the community was blocked out of the facility.

So we're going to go a little bit further into that discussion now.

- [Mike] Thank you, Mary.

So we really broke the building up into three discrete sections.

The first portion is that engagement piece that Mary was speaking to.

The center of the building is your treatment clinical space.

And then the top is the academic.

That's the workplace for the physicians and the advanced care providers.

And if we talk about this building in light of what Mary kind of framed, the engagement really begins to occupy the first two floors of the building.

You know, everything from the lobby, the entry, the arrival experience of the patient and their caregiver moving into what could be, you know, a registration lounge.

And a more detailed look, you can start to see how that breaks up.

So you have this, you know, entry, valet experience, a security checkpoint, of course, because we're in New York City but then you have this large registration and wellness lounge, which we really draw a lot on from the hospitality industry to, you know, really improve the patient experience, provide different levels of privacy and seating options.

Now, above that, we have our clinical care, our patient care villages.

These would be entirely examined procedure floors.

So the idea is that all of the physician offices would be offloaded from these darker blue floors and put in the academic village, which is the lighter blue at the top of the building stack.

And what that allowed us to do is it allowed a greater flexibility in the number of exam rooms we could provide on the floor.

Flexible areas or procedure suites to begin to aggregate on the floor.

And then of course having a very dedicated care team work area, which we aggregated along the building facade for, you know, natural light and views for the staff members.

And then as I had said before, the academic village, that's really where the physicians will hang their hat at the end of the day.

Where they hang their diplomas, where they do all of their work when they're not seeing patients.

So really giving the building the ability to grow and flex was a key component to offloading those offices and keeping those clinical floors for, you know, providing care and patient care.

So the conventional MOB is, you know, what you see on the screen here.

This is actually a project that we did with Northwell a couple of years ago on Long Island.

It was an ambulatory cancer center.

And as you see, it's pretty typical.

There's housing developments to the left.

To the right, there's an enormous parking lot in front.

There's a highway with a Dunkin' Donuts across the street.

You know, this is kind of what we see on a daily basis when you think of the MOB.

Transitioning to what we're dealing with, the hyper urban.

This is New York City, where density is everywhere.

Not only in terms of building, but people.

This slide actually shows where Lenox Hill is located.

We are in the upper east side of Manhattan, right on Park avenue here, between 77th and 76th street.

Unfortunately, as Jonathan knows, we are located on a smaller block in Manhattan, which we wrestle with on probably a daily basis.

But you can see how condensed a hospital block in New York really can be.

And just down the road here is where our project site will be located.

It's on Third avenue, just a block away.

And one of the key components of doing that was to offload a lot of the outpatient facilities from the hospital block.

Mary had mentioned, we're doing a large master planning project with Northwell and we really wanted to keep the hospital block for those high acuity patients.

Inpatients, you know, surgery, OR, imaging, all of that important hospital related functions on the block and then taking those outpatient functions off of the city block.

So if we ...

Sorry, I'm going to ...

This is not the one.

So if we talk about the urban MOB patient.

How are they different from, you know, someone who would be living in the suburbs?

Oftentimes they arrive by car, by Ubers, Lyfts.

They're not driving to the building.

This building actually has no parking.

So if you are driving, you know, you're fighting with parking on the New York City street.

Alternatively, they're arriving by mass transit, which, you know, can be reliable or it could not be reliable.

It's getting better in New York but we have to plan for these, you know, for delays and for giving people flexibility and just designing that into the process.

With that comes the ability to be flexible when you're checking in.

Giving people the ability to check in on their phone, their personal device, anything that is more mobile and remote, where you don't have to be in front of a person, is really key to this model.

But also providing, you know, a check in with a person, a friendly face.

Everyone likes to be able to go up to someone and ask a question if they're a bit lost or confused.

And finally, you know, giving people the ability or an area where they can wait for their Uber to pick them up or their caregiver to bring the car around.

These are all things that we need to think about when we're dealing with a highly dense city like New York.

Likewise, the academic care team can be quite different.

Space is at a premium.

You know, this is New York, again, very, very dense everything.

Every inch of the building is planned for.

There's no extra space, which Jonathan can always attest to because he's pushing us to find more space quite often.

But we love the challenge.

These teams, they're working between the hospital and the MOB and now that we're offloading a lot of those outpatient functions, the doctors are really concerned about how do we stay connected to the hospital?

You know, can we provide a go room where you just click a button or log onto your phone and your conference starts as soon as you walk into the room?

The lights dim, a telehealth conference starts.

Being able to do your rounding remotely, are all conversations we've been having with the doctors.

And integrating teaching and learning.

You know, they have a school of medicine, school of nursing, there's fellows and residents that will be living in this building that lead to much larger teams that we need to accommodate for.

You know, conferencing, places to work through a problem or a special case.

These are important things that we are planning for.

And finally, getting accustomed to separating work and patient care.

Again, obviously this model has that inherently built into it, but it doesn't mean that we're not providing workspace on the patient care floors.

We are providing flexible space.

Space for the physicians to touch down and do a tele-health call or dictate or take a private call while their office is upstairs where they would do the majority of their work.

So let's take a look at the next four slides.

I really kind of set the tone for the project for those three spaces.

The engaged, the tree and the academic.

If we start with the engaged, we're really looking at spaces that create moments of reprieve.

Different levels of privacy and moments where the patient and their caregiver can get away for a bit, not feel like they're in a hospital or a healthcare institution.

It's really something that we're trying to push from our hospitality folks in the industries.

The check-in experience.

Again, kind of breaking that down.

Is it more of an open, inviting bar, where you do have people sitting at a desk, ready to answer questions, take a copay, or check a patient in, but also providing, you know, an informal consult space.

Flexible waiting is really the key to this model.

Again, we talked about being able to check in on your phone and the bottom right picture here kind of sums it all up, where you have a mixture of check-in kiosks, people behind desks, but also a waiting space that can allow people who come early, this is the city, as we know, people are often early, they like to be early.

So we have to plan for that in the building.

Looking at the treatment.

One of the (indistinct).

That will be a driving force for this, for the treatment areas is the ability to provide exam consult rooms.

So combining those two functions into one room and not having to move the patient around as much, you know, it's a patient satisfier when they don't have to go from the exam room to a consult room, you know, to the checkout.

The less you have to move a patient, the better experience.

So really trying to standardize that but also creating a personalized touch.

Accommodating what each different practice has.

I think we have about nine different practices in this building.

Of course there will be some personalization for each exam room by floor and of course, relationship based.

Continuing to drive home that triangle of care, putting large technology in the room on the wall so that the caregiver and the patient can see it with the doctor, or perhaps even providing a small desk where you don't have to sit in the exam chair and talk with your provider.

You can get out of the exam chair, sit in a comfortable chair at a desk together and look at a screen in a more intimate way.

These are all kind of trends, or design ideas really that we're going to employ as we move into schematic design.

And of course, the staff.

They're the next (indistinct) this floor.

How do we provide flexible spaces for them?

Providing a consult room that can be used for a telehealth visit or a consult with a patient.

Something that is tech ready with video monitor on the wall, and you can flex that room to how you need to use it but also providing spaces where a nurse can sit down for 15 minutes and dictate, or, you know, call the pharmacy and get medication ready.

While also providing a collaborative table where a team can touch down, talk about the patient's case.

These are all flexible ideas that we need to, that we are continuing to develop.

And finally, the academic space.

Again, flexibility.

Having large private offices where perhaps department chairs can sit, but also providing huddle rooms where ACPs and other doctors can meet.

And of course, accommodating the staff.

Just in terms of amenities.

You know, giving them a cafe, a pantry, a place to sit for 15 minutes, a half hour to have lunch.

These are all things that we are exploring in this design.

So I'll turn it back to Debbie to talk about the research portion.

- [Debbie] So the question of did we get it right is the million dollar question, right?

And certainly when we're designing buildings, there's so many decisions that are made.

There's so many different variables that with a conventional process, sometimes we make a decision and we don't necessarily know if we've gotten it right till after the project is built and occupied.

But in this segment, Alice is going to talk about the analytics and the simulation that we've done so that we could go through and model different situations and better understand what the outcome would be in advance.

So instead of an educated guess, we had more of an informed decision.

Alice, all yours.

- So much.

So let's go on to the next slide.

So as you can imagine, and I'm looking at the chat now and I see a few questions about discussion.

Yes, lots and lots of discussions about all these concepts.

Would they work?

How teams felt comfortable with them.

What sorts of things that they felt like they needed to retain from current state and where they were willing to really push the envelope.

And one of the first things that we had the opportunity to do was to go and tour and meet with each of these individual specialties, from cardiology, neurology, et cetera.

Knowing that each of them had a lot of common ground, right?

Most of them were really on board with this idea of exam and consult, this flexible exam room model.

The idea that they would maximize patient care, right, on a floor.

That also, people could really get a lot of comfort around it.

Many teams were already working in multidisciplinary ways and knew they needed to start to have spaces that would really support teaching and learning and community of practice that happens.

And we knew there were going to be some things that had to be practice specific.

So we used these tours and discussions as a way to hear, what are you doing today?

Where do you want to be in the future?

And what do you know from other practices?

You know, whether those are other industries or other health facilities that you'd really like to see take forward.

So let's go on to the next slide, if you could.

So we were very, we're very diligent and I think Jonathan really hit on this about being very creative and innovative but very systematic.

And I think that's the approach that we really wanted to take here.

So we worked with very closely with the practice administrators and the leaders in the regional operations team to really understand who are the patient mixes?

What was the demographic?

What were each of the flows?

Because each practice has very different flows within their office and how did we align that with this future state vision, to make sure that we were meeting their functional needs as well as all those experiential needs.

Next slide please.

And I think we've talked a lot about this new model of registration but a lot of questions came up because this really was a pretty significant departure.

I think folks felt comfortable.

We know about, you know, the clinical process is something people could really understand.

But what we were saying was that today, in the future state, rather than having individual check-in, check-out on every floor, now this would be centralized.

So it required some, it would require cross training and also a kind of new way of thinking about technology.

In current state, Northwell's rolling out pre-registration through, you know, where everybody fills out all their forms before they arrive.

And I think that what we were saying was, would this centralized registration model only work if we could get more patients pre-registered in advance?

Because we could imagine that rather than, you know, patients arriving and being distributed to many floors, now they were going to have to come into one central floor and the concern was, can we even have enough seating?

Are we going to be able to accommodate them?

So this is where we used a simulation model to come in and say, well, let's compare some different scenarios.

Let's look at what your baseline is.

We know about 30% of patients current state pre-register.

What if that was to reach 50%?

How would that impact the demand for seating?

How could we reduce some duplication?

And so that's what we used the simulation modeling to do.

Next slide.

And this also, going back to systematic, I think, you know, we often think about using modeling or analytics as a way to provide an answer.

And I like to think about it as a way to provide insight into the problem to help us make a better decision.

Yes, we do come up with answers in the end, but just getting the team to really dig in and say, what is this really going to be like?

Can we really map it out very detailed?

So we're not waiting until the last minute to say, oh my gosh, we forgot this.

Or we hadn't considered that.

Or we forgot to bring in a key stakeholder.

This helps us keep everybody in the loop as well.

So we built a model.

We used future state volume forecasts.

We incorporated variability because we knew with urban patients, people arrive early, they can't control their rides.

They can't control traffic or public transport.

So we wanted to make sure it was realistic.

We assumed that everybody brought at least one person and possibly up to three care partners or family members.

So we would accommodate for that population as well.

We did three different scenarios and we put in some criteria.

We said, we don't want people to wait.

We want to make sure that the check-in process for waiting is less than two minutes, anytime.

We're not talking about at a busy time or a slow time but any time during the day.

And that we kept utilization at 85%.

Next slide.

So what I want to show you here, just briefly is a model.

Oops.

I think we jumped.

So I'll keep talking.

So this is a still but we're going to see if we can get the video running.

We built a simulation model and this is just a sample.

I will tell, you'll see the output.

We did a lot of runs and replications and there was a lot of analytics and I want to give a big shout out to my colleague, Mariam Husseini, who worked with me very closely on this.

So we built a model.

So we took a typical busy day.

So our throughput was about 2,000 patients with their family members and we looked at three key metrics.

So max wait time for check-in, which you can see those five check-in stations there on the screen.

Where you see people waiting, these are actually the family members waiting while the patients are checking in.

We looked at check-in station utilization.

We weren't going to max out the people having to work, you know, 100%.

And then we looked at, we measured seating demand by just measuring census on the floor.

So we were able to go through and say, okay, given this, we can then determine what would be the appropriate range.

So let's go on quick to the results because I know we're getting a little short on time and of course I can answer any questions later.

So we looked, this gives you just a snapshot of some of the outcomes.

There are two levels.

Our hypothesis was really that high pre-registration was actually going to reduce the demand for seats quite a bit because many folks would be able to bypass the floor altogether and go straight to their exams.

But what we found was, as you can see here, the range was not tremendously different.

So the blue bars, what you see, are the average number of people on the floor in 15 minute increments across the day.

And then that orange line are the maximum number, whoever would be on the floor at a time.

And so what we realized is that our test fits and some of the initial preliminary work we had done, we'd said about 100, and 120 to 140 seats.

Would it be able to accommodate those sort of max, out of the ordinary peaks, which happen very rarely and handle our average volume quite well.

Next slide.

And it turned out that there wasn't a big difference, as you can see.

And that we would be able to optimally serve everybody with about five red cross trained registration teams.

And if you think about, you know, compared to the square footage required for every floor to have their own check-in, and teams that would be dedicated to their practice, we haven't quantified that savings yet but it's pretty considerable.

So again, it helped us wrap our heads around this proof of concept to say, will this work?

To help the teams really think through what might be required and who else and the other sort of ancillary processes that would have to be worked out to make this function well.

And with that, I'll just hand it on over to Rich to talk about next steps.

- [Rich] Great Alice, thank you.

- The last segment is Rich Steimel talking about the value of the construction manager on the project, and even in a good day, construction managers have tremendous value to the process.

And certainly the disruptions we've had in the past 18 months between broken supply chains and disruptions with the labor market, huge, huge challenges.

And that's why we appreciate Rich Steimel and Lendlease even more on this project.

- Well, Debbie, that's very nice.

Thank you.

So to get right into it and speed to market, you know, it's, from where we sit, there's two drivers there.

One is ... One is to understand that the more planning you do upfront, the more benefits you reap at the end of the project.

You've got to have an open mind for that.

You've got to have the patience and the flexibility to do it but it pays off.

And the other thing that I think is necessary for these discussions is a willingness to innovate.

The way we did things last time is not going to be good enough for next time.

It's really, the onus is on the team to make that happen.

And what I'd like to show you right here is there's a little comparison.

This is a summary level comparison of the different types of structures.

I'm not sure it's necessary to get into the details of it but the idea is that we met with Severud and we went through basically the two major options for reinforced structural building or a steel and imported place concrete.

And what we did was we looked at the availability of manpower and resources, the cost, the schedule, and the individual pros and cons.

And the whole idea behind that is, is to allow the client and the rest of the team to make an informed and educated decision.

This is a huge item that you don't want to talk about late in the game.

It is not something you want to talk about after the design is done.

It goes back to that upfront planning and the payoff is very clear.

It's a more efficient way, getting decisions like that made upfront.

Now there's another major component of construction where the industry has evolved and it has changed.

Five years ago, any thought of introducing a prefab component or a modular component was a novelty at best.

And that's just not the case anymore.

We have seen these components, the number of products, the number of vendors grow rapidly.

We have many more choices now.

There's many more products.

And at the end of the day, there's a lot of benefits that go along with that.

This goes right back to the schedule question.

The concept of having a major component, like a machine room, or as you can see those expansion tanks being fabricated offsite while the foundations and the superstructure goes up, is a direct time savings to the project.

And there's a huge difference between delivering in that machine room, those thousands and thousands of pieces compared to having it fabricated in a controlled environment at a facility offsite.

And it is literally delivered when it's necessary, plug and play.

The labor workforce is concurrent with the superstructure and the foundations and the building enclosure taking place.

And there are many more products beyond that.

When you look at the interiors, you know, that's an exam room, you can see the products.

Virtually everything there has been prefabricated and it just streamlines the effort.

It's a remarkable improvement on the quality of the finished product.

It's a much safer installation.

You're really taking ladders off the job.

There's a dramatic increase with the waste.

And by no means is it limited to these projects, to these products.

There's a litany of products.

Headwalls, footwalls, bathroom pods.

By the way, the bathroom pods, one of the biggest suppliers is out of Austin, Texas.

But also, if you take a look back at the stacking diagram, you're going to see that there's some redundancy on the floors.

That further lends itself to a prefab application.

There's so much flexibility that goes along with something that's prefabricated, where the components are removable and replaceable, much easier than just say, a standard dry wall partition.

There's really a dramatic difference between the two and the impact of making an adjustment to a prefabricated product is minimal, compared to the stick build.

And again, back to the schedule, it's the planning that drives the early decisions.

The early decisions drive the design.

And obviously, it results in a more fabricated delivery to the entire project.

And I can't stress enough that there are many more products out there.

It is not limited to these three or four.

At this point, virtually every component you can think of, especially on the mechanical and electrical and plumbing sides.

But nevertheless, I think we're a little tight on time so it's time to move forward with your questions and answers.

We'll work on the answers but thank you all very much.

- Thank you so much for a truly wonderful lectures.

So we have a couple of questions in the chat.

So we could ...

So the first question is from Steve.

Steve Cope from Kennedy side.

Was there a discussion of animating the private physician office and going to touchdown spaces?

And how did it go?

And then, so anyone.

- [Jonathan] Yeah, so Steve, that's a great question and I think, you know, one of the things that you saw when we were talking about the conceptual stack of this building, having these academic villages, the whole concept of this was creating a collaborative work environment, that is not just what you're used to seeing in 150 years of healthcare in New York City, which is office, office, office, diploma, diploma, diploma, and everyone has their home.

It's really trying to come up with ways, not only from the design perspective, but also informed from each of the department chairmen who obviously have to buy into the concept, right?

To be able to come up with a new style of working environment for their clinical practice and also looking at how do we situate on these academic floors, the programs that are best to collaborate with each other, right?

I'm not going to create one floor that's all cardiology physicians, you know, they don't need the whole fore plan.

So who do we want to put with them?

If it's one or two other departments and their chairs, who do we pull together?

And it's really having a greater conversation with all of the chairmen to say, how do you guys want to work together?

Which is why we as a team, when we kind of came up with this concept, said, we're going to start this whole process by pulling all of the chairmen together into a room and presenting our concept.

And having them tell us at the beginning, yeah, we can work with that or get out of this room and we never want to talk to you again.

And, you know, we were lucky that we walked into that room and we walked out with yes, we're all on board with this.

And then it's gone, you know, it's been its own EKG as we've worked our way through this.

When you get into just meeting with one of the chairs and they're like, we think it's a great idea.

Now I need 12 private offices and you're well, okay, let's go back to the concept and let's talk about what, so, you know, it's been a push and pull along the way.

It's a pretty big transition we're asking of them.

We're looking forward to seeing what the outcome is.

And we think it will be successful.

- [Speaker 1] I would like to add my thanks to the team for coming all the way from Philadelphia and also congratulations to Debbie Phillips.

I might add that when she was a student here, she won the AIAH fellowship, which is now called the Tuttle fellowship.

And I hope we have students who put together proposals for that.

It's a very prestigious prize.

And, my thanks to Ewing Cole and to Lendlease and to everyone that came to make a very excellent presentation.

We hope we see more of you and we wish you the very best.