Company Profile

The Maestro Who Listens, Succeeds

How-to-manage books, as a rule, put me to sleep faster than a tranquilizer dart. In the rare, rare instances that I’ve actually fi nished one of those tomes, the last reaction that was in my head was to jump up and down and tell everyone I meet that they must read what I just read. I’m not going to jump up and down in this instance (it just makes me tired), but I am going to recommend that people at all levels of the corporate ladder read Maestro, by Roger Nierenberg.

I encountered this book when a friend in our Bible class mentioned that people in the class might enjoy and/or learn from reading the book. As a former high-school band geek and director of a church handbell choir for many years, I immediately had to know how directing an orchestra had anything to do with how a company functions.

Listening was the second factor that sucked me into the book because the subtitle is, “A surprising story about leading by listening.” I’ve also always firmly believed that the frustrations most people encounter in their lives stem from the fact that they don’t listen. As I’m sure it is for others, one of my all-time pet peeves is being asked a question and the questioner has no interest in my answer or is just using the question as a way for them to share their side of the issue. Even more galling is when they interrupt my answer because they can’t wait to have

their say. I’d rather take a nap than engage in the “discussion.”

Back to the book.

Without giving much away, the premise of the book is that managers who make decisions and then encounter frustration because things aren’t working out as planned, probably made a poorly informed decision because they didn’t take the time to truly listen to all aspects of the matter. The finger doesn’t just point at managers sitting in the leather chairs in corner offices. Listening is a factor in success or failure at all levels.

The book uses a unique approach to understand what it means to really listen and comprehend what is going on in all aspects of a situation, the amount of additional and valuable information listening provides, and how much more effective a decision is when it’s based on that new information. It’s all common sense, that rare commodity, but the author delivers the message in an engaging and enlightening way.

I won’t say any more about the book’s message. You truly must read it. I’m confident that, once you start, you will not put it down. I know that’s a strong statement for a management how-to book, but the story that is told—it is a story, not a bunch of chapter lessons—is well presented and you will want to know how it comes out.

For those of you for whom reading a book is too much like homework, stick to it. The story is only 107 pages. You can handle it.

This book is worth your time. You’ll see things in a different light. CBP

Gary L. Parr Editorial Director/Publisher

Pepper Puts Versatility Into Projects

A Chicago-based general contractor offers a wide range of services to the commercial-construction market.

Top Left. The new construction and renovation of Whirlpool’s downtown campus consists of three office buildings in Benton Harbor, MI, along with the renovation of the existing corporate headquarters building. More than 225,000 sq. ft. of new office space will support 400 employees.

Top Center. One of their first clients, Pepper has been working for Marshall Fields, now Macy’s, since 1936. The storied partnership includes renovations, new stores, and the restoration of the famed flagship store on downtown Chicago’s State Street. It also includes behind-thescenes fabrication for the magic of the wonderful, animated figures for the State Street displays.

Top Right. Pepper’s insights helped reclaim nearly two acres of Lake Michigan to create the Abbot Oceanarium at the John G. Shedd Aquarium in Chicago. At 3 million gallons, it is the largest indoor marine mammal facility in the world. I t’s rather commonplace that companies, once known as general contractors, have evolved into multi-faceted design/build firms. In many cases, such as this issue’s profile company, the services they offer go way beyond design/build.

Pepper Construction Group LLC, headquartered in Chicago, has a long history. In 1927, carpenter Stanley F. Pepper started the firm as, no doubt many have, by doing renovation work and building home garages. His son, Richard, worked with his father from the age of 6, learning the “ropes.” He earned a civil engineering degree from Northwestern Univ., Evanston, IL, in 1953, joining his father in the business that was then grossing $2 million annually.

Richard’s vision was not complicated: Build on what his father started and never quit. “When my dad died, our accountant recommended closing. I said no, I’m going to be the best. Dad had an excellent reputation and great clients. I knew I could build on that.”

He began bringing in high-profile accounts, such as Illinois Bell, and by 1957 the company had more than doubled its revenues. In 1972, he received a call from a client who was supplying equipment for the King Faisal Specialist Hospital in Riyadh, Saudi Arabia, which was under construction but suffering from poor management. Richard and his team straightened out the mess, built a fine facility and, 10 yr. later was still building in the region. The experience prompted Pepper to expand in the U.S. and the firm now is recognized as one of the country’s top construction companies. In 2014, 605 projects, ranging from fully built structures to renovation projects, generated more than $1 billion in revenue.

PEPPER’S OFFERINGS Pepper’s 1,000 employees provide a wide variety of services, including preconstruction services; safety, sustainable, and high-performance construction; and a full suite of in-house virtual-construction services including laser scanning, lean construction, MEP coordination, environmental remediation, and quality assurance.

Those services are provided to more than 20 advanced and emerging markets including commercial office, corporate headquarters, entertainment, healthcare, higher education, hospitality, industrial, institutional, interiors, K-12 schools, mission critical/data centers, residential, retail, senior living, wastewater, and waterworks.

Pepper’s vision as it looks to future growth: “A partnership, like a building, is more than the sum of its parts. And both require true collaboration to grow. At Pepper, we take building personally, so we’re always looking for ways to be more responsive. Part of breaking ground is looking after what matters most—our customers and their interests.” CBP

Pepper Facts

• Founded in 1927 by Stanley F. Pepper • Family owned • Headquarters: Chicago • Offices in Barrington, IL; Indianapolis; Columbus, OH; Cincinnati; Houston; and Katy, TX • 1,000 employees • $1 billion annual revenue • 605 projects in 2014 • Website: pepperconstruction.com

Want to be profiled?

We are looking for firms to profile in future issues. If you are an architect, general contractor, or owner of commercial facilities and think your firm has an interesting story to tell, write to Gary L. Parr, editorial director, at gparr@ cbpmagazine.com, and we’ll consider you for an upcoming profile story.

NEA Baptist Clinic in Jonesboro, AR, designed by Earl Swensson Associates (ESa) Inc., architects, is connected floor-by-floor to the adjoining six-story NEA Baptist Memorial Hospital. In addition to a corridor connection to and from the hospital’s main lobby, the 213,000-sq.-ft. clinic has a dedicated entrance for patient convenience. The clinic’s multiple service lines of the large physician group are aligned with that of the hospital for high-efficiency integration. Photo: ESa

Fine Tune The Medical Office

Medical office buildings play an increasing role in healthcare delivery and are evolving to meet new requirements.

Kenneth W. Betz, Senior Editor

Medical office buildings, once just a place for physicians to “office,” have taken on a new role in the delivery of healthcare. Just as hospitals now focus on the patient experience as much as medical outcomes, and nursing homes have diversified to provide specific levels of care, so, too, have medical office buildings evolved to meet the new healthcare environment.

Reimbursement changes under the Affordable Care Act (ACA), improving patient access, and expanding geographic coverage are a few of the factors influencing the design and construction of medical office buildings.

The term medical office building is a broad concept that, like nursing home, today has a variety of connotations. A medical office building, as distinct from an acute-care hospital, is generally separate from that hospital but may exist on the same campus and be affiliated with it. Or it may be located elsewhere and owned by physician tenants, a joint venture, or a partnership. Healthcare architects and designers also are likely

to distinguish between a medical office building and other facilities such as ambulatory surgical centers, which are subject to more stringent regulatory standards.

MEDICAL OFFICE GROWTH Nevertheless, medical office buildings, in general, are being built or repurposed in increasing numbers. The aging baby-boomer population and the ACA (Affordable Care Act), expected to add 32 million persons to the healthcare market, are among factors driving the demand. ACA regulations concerning cost control, electronic recordkeeping, and patient care further influence the business models of healthcare providers, according to Colliers International, a commercial real estate firm based in Seattle. “Many of these [medical office buildings] are integrated with other services, such as freestanding emergency departments or freestanding diagnostic services, some of which are planned to grow into full-service hospitals. Others are planned as marketoutreach facilities to bring services closer to the patients/ consumers. In almost every case, there is a focus on minimizing duplication and cost, said Todd Robinson, AIA, EDAC, principal/ executive vice president of Earl Swensson Associates Inc., Nashville, TN.

Jonathan Fliege, AIA, NCARB, senior associate, senior architect, Leo A. Daly architects, Omaha, noted that medicaloffice-building construction and development is additionally influenced by the fact that the ACA incentivizes wellness and preventive measures that can best be carried out in smaller-scale clinical settings which, in the long run, may prevent more expensive in-patient hospital stays.

Fliege also sees a competitive drive among healthcare organizations, with clinics popping up to capture local markets. “It’s really about reaching out to the suburbs to capture demographics and market areas with their clinics,” he said.

“There’s been a rapid growth in off-campus [medical office buildings],” said Deeni Taylor, Duke Realty, Indianapolis. He and other panelists at the October 2013 InterFace Healthcare Real Estate Conference in Dallas concluded, “outpatient facilities are surpassing inpatient facilities in many health systems’ portfolios because of their positive impact on providers’ margins.” “Today it’s very important for hospitals and health systems to reduce costs, but there’s only so much you can do on the lease rate,” Taylor said.

“Due to lower reimbursement rates and the need to invest in new healthcare reform-mandated processes and systems, there have been fewer major capital expansion projects, such as bed towers, and more small-scale off-campus developments. The emphasis has been on opening new facilities in local communities where people live, providing ease of use and a retail approach, and offering flexible, hybrid designs for more multi-purpose facilities,” Taylor and the other panelists concluded.

“There is an interesting trend to push medical services out of the main in-patient environment, I think, for a number of reasons,” said Brian Garbecki, vice president and Healthcare Center of Excellence Leader, Gilbane Building Co., Boston. “One certainly is cost; it’s much more expensive to have outpatient functions on an ongoing basis in an inpatient area. Another is

Top. Visual, intuitive wayfinding was designed into the NEA Baptist Clinic for ease of access and simplification. Lab services and the imaging center were placed adjacent to the clinic’s reception desk. The elevator lobby and the corridor are just beyond for easy access. A mezzanine bridge spans the lobby as another connection to the hospital through a clinic waiting area. Photo: ESa

Bottom. A connective corridor between NEA Baptist Memorial Hospital and NEA Baptist Clinic allows the convenient transport of outpatients from one to another for access to shared ancillary services. Brick and stone used in the public areas for warmth and the inclusion of natural light contribute to a healing, patient-friendly environment. Photo: ESa

Specialty physician offices in the NEA Baptist Clinic are connected to the same floor as the related hospital service. This alignment allows a physician to see a patient in the clinic and then immediately transition them to the hospital if need be. For example, the OB/GYN offices are on the same floor as the Women’s Center of the hospital. Dedicated elevators allow privacy and more expedient transport. Photo: ESa accessibility. When you start to have large inpatient campuses with a large number of outpatient services as well, the campus starts to get larger and it’s difficult for patients and visitors to find their way. Patients shouldn’t have to travel to a major tertiary care environment that has a lot of things they don’t need,” he added.

“I think the goal and the process that we’re seeing is looking to right size everything, making sure the right level of care is provided in the right environment to the right patient in the right location,” Garbecki added.

ADAPTIVE REUSE AND RENOVATION Not all activity in medical office development is new construction. Adaptive reuse and repurposing are factors as well. “We are seeing some medical office facilities in converted or repurposed buildings in our area [Nashville], but perhaps not as frequently as in some other parts of the country. A lot has to do with demographics and location. We’ve seen some former shopping centers being converted to serve medical office purposes due to location. In addition to the location factor, a developer of a medical office or outpatient facility can realize savings in the structural portion of the repurposed facility and in its exterior skin,” said Robinson.

Converting an existing building to a medical office building is completely feasible, Fliege agreed. He recounted a recent project that converted a restaurant into a freestanding clinic. Of the 7,000-sq.-ft. building, he said, “It was in the right geographic location, the rent was affordable, and it was a lot less expensive than building new.”

“It becomes a question of the demographics of that neighborhood,” Garbecki said. “If you look at a number of retail stores that have been built in the past 20 years, they put them in areas that are relatively acceptable to customers, in environments where it is easy to get in and easy to get out. If they go out of business, you have an empty shell in a desirable location that is easily accessible; it’s near patient population centers with easy access.”

“The only question is how much work is required to modify the facility. Typically the site has enough parking, so that wouldn’t be an issue. It’s how adaptable the existing facility is. A lot of times it would end up being a gut renovation and installation of new systems anyway, so it can be a feasible approach depending

upon what type of services they want to put in,” he added.

“For example, a medical office practice typically is not licensed and follows business-occupancy requirements. [It could be] any building that is already set up or developed in a business-occupancycode environment. Once you start getting into more complicated procedures, depending on what the institution wants to do, you’re getting away from a medical office building and moving more toward what could be called an ambulatory care building or an ambulatory surgery building. Once you start getting into those services, they’re much more regulated,” Garbecki said.

DESIGN CHALLENGES One challenge can be the creation and availability of ancillary services necessary to support the physicians in decentralized medical office buildings. In many cases, a freestanding center can potentially be designed to a lesser standard than that of a hospital as a center allows a more cost-effective structure. Lack of connectivity, however, can be a negative for certain types of practices. A key factor can be market rental rates for physicians,” said Robinson.

Recent hospital design has put increased emphasis on the patient experience, and freestanding healthcare clinics and office buildings have followed suit. “Improving the patient experience is critical in all healthcare facilities to help alleviate stress a patient typically experiences in such a situation. First of all, ease of access and simplification of wayfinding are of utmost importance. Accommodations in design for the elderly and disabled are equally important; many of these accommodations are mandated by building codes. The incorporation of natural light and healing aesthetics contribute toward putting the patient at ease. Including layers of natural and artificial lighting, calming colors in furnishings and finishes, and providing accommodations for families and visitors, all in sustainable design, will support a healing patient experience,” said Robinson. “Other stress relievers include a synchronization in which the patient gives his or her information only once, such as during pre-registration, rather than having to repeat it again and again to different parties upon arrival for the appointment. Efficiency of this method encompasses easy accessibility to

Inspired by the “concierge medicine” concept, the CHI clinic, Council Bluffs, IA, features three horseshoe-shaped wards, each with a central shared working area for staff. This improves efficiency and encourages collaboration among clinicians, while minimizing hallway traffic. Photo: Kurt Johnson Photography

Left. Several novel design features of the CHI Health Alegent Creighton Clinic in Council Bluffs, IA, respond to the client’s wish to rethink how care is delivered. The design enables one clinician to serve one patient, step by step, from arrival through followup. Photo: Kurt Johnson Photography

Right. Designed by Leo A. Daly architects, Omaha, the CHI clinic combines several clinics into one for increased effi ciency and functionality. Photo: Kurt Johnson Photography medical records by the nursing staff and physicians,” he continued. “A limited waiting experience is preferred by patients. This experience can be enhanced by creating positive distractions, the availability of childcare space, and the availability of food and coffee. Efficient throughput is essential for enhancement of the patient experience,” said Robinson.

Jonathan Fliege agreed that eliminating patient stress is a high priority. “We’re trying to minimize the distance a patient needs to travel within the building. Operationally, you try to provide a just-in-time approach where providers are ready for that particular patient,” he said.

Fliege described “clinic pods” ringing the central waiting area, so that a patient doesn't have to go very far from the waiting area to get to his/her exam room. “We’re designing these buildings to be very tight and efficient so that the steps patients and providers take are far fewer than they would if they were in a large hospital with a clinic component to it. [In a large hospital] you might have patients walking a long way either to get to the clinic or even walking within the clinic,” he said.

Explaining the concept further, Fliege described a design that wraps exam rooms around an internal provider area. Patients enter the exam room through one door, while providers enter from the interior provider workroom. “You’re not dragging the patient through the internal workings of the clinic. The patient experience is simply coming from a nice reception area to a nice waiting room and directly into the patient room without having to see the back-of-house functions. You can have a care team made up of multiple providers who can then be working together inside this wrap of patient rooms,” he said.

TODAY’S MEDICAL BUILDINGS Many of today’s medical offi ce buildings look and operate differently from their predecessors. “Creating comfortable areas to process patients and move them through quickly is necessary, but also at a premium in medical offi ce buildings. The creation of collaborative spaces in general offi ce areas facilitates teamwork, which, in turn, enhances the patient experience,” Robinson said. “Some medical office buildings are offering time-share arrangements with some physicians in order to keep the spaces utilized at all times, not just a few days a week. These arrangements require flexibility and adaptability for different practices and equipment,” he said. “Interior design should engage all five senses. For example, lighting should be calming. Soft music can also contribute to a calming setting. Smell should be pleasant throughout and can incorporate aromatherapy. The color palette and finishes should depend upon what is appropriate for the local demographics and local culture and what will make the patients comfortable. It all boils down to understanding who the market is. It’s also a matter of balancing technology with the warmth of the environment,” Robinson said. Exam rooms may not have changed a great deal, but efforts are being made to make them more patient-friendly and to accommodate technology. “Exam rooms are being designed to include appropriate technology and are being positioned to facilitate access of the patient, physicians, and staff for a collaborative area. Technology can be oriented so that physicians and patients can view screens together for informing the patient,” Robinson said.

“Attempts are being made to create zones where family members can sit, space to hang coats and change clothing, and privacy curtains within the exam rooms,” Fliege noted.

TRADITIONAL MEDICAL OFFICES OBSOLETE? While healthcare business models and requirements are changing, there is still room for more traditional medical offi ce build