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Brought to You by |
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Corporate Realty, Design & Management Institute
Health Care Institute of IFMA
Health Care Institute - North Texas |
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Industry Partners |
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Array Advisors
Cambridge Sound Management
Camfil
Delta Controls
Haworth
Johns Manville
nora systems
Stantec
Wilsonart |
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Education Partners |
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HCI North Texas |
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North Texas Board President
Rod Armstrong, FMP, Regional Vice President of Business
Development for Healthcare and Higher Education, Mohawk Group |
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Attendee Comments |
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"The
conversational format
Excellent panel discussions with new topic discussions and useful
content."
"Opportunity to network, opportunity to meet speakers
The chance to hear a variety of topics with sufficient time to develop
ideas."
"I enjoyed the earlier presentations that seem better prepared."
"Diverse audience, end users participated."
"Strong line-up of speakers from local healthcare systems."
"The range of speakers and content, all about Healthcare but very
current content and information."
"The speakers from Stantec and also the design speakers."
"The panelists."
"Owner discussions."
"Networking"
"The introduction of new design techniques and forward looking topics."
"Location. Information."
"Micro hospitals."
"The variety of topics & how they related together."
"The diverse content."
"Topics."
"Variety of topics."
"Great presentations and relative topics. Good location."
"Variety of topics, mix of presentations; Owners, Architect/Designers,
Hospital Association Representatives."
"Great
variety of perspectives."
"Thank
you for organizing this!"
"Micro Hospital Discussion."
"Very
good attendance - Good for networking."
"The format = the panel discussions were a good way to present the items
addressed; Micro hospital explanation; Retailization of healthcare; The
venue."
"Great job! I cannot think of anything to improve the event."
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Takeaway Messages
June 21,
2018,
Addison,
Texas
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Reported by
Linda
Stallard
Johnson (rightondeadline@gmail.com),
a freelance
writer and
editor in
the
Dallas-Fort
Worth area.
She is a
veteran of
The Dallas
Morning News
and Houston
Chronicle,
and
currently
edits AIA
Dallas’
quarterly
magazine. |
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Legislative
Issues That
Can Shape
Texas
Healthcare |
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Texas jobs are growing, but so are the uninsured. Much of the job growth has been in small businesses, but many can’t afford insurance for employees. “In Texas, it is very likely that you could be employed, you could be middle class, you could be an upstanding citizen and not insured,” Limb said. Unable to qualify for Medicaid in Texas, the uninsured put off care until they end up in ERs and must rely on hospital charity programs.
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Texas healthcare is caught in a vicious cycle. Because many lawmakers see Medicaid as welfare, the Legislature chronically underfunds it, reimbursing $7 for every $10 of services and forcing hospitals to make up the other $3. “Is that $3 going to be shifted onto other payers, or are we just not going to invest in maintenance, in facilities, in development?” Limb asked
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Healthcare is a multi-layered issue. Few Texas legislators are in the health industry. “It’s all financed in their minds from the federal government or supplemental state payments,” Lunsford said, making maintaining current Medicaid funding an achievement. Knowing your previous year’s profit, your total uninsured population and how much uninsured care you provide could get their attention, he said.
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To be heard by legislators, embrace advocacy. That means enlisting everyone from executives to nurses. Take a page from teachers, who know how to tell their story to the public and lawmakers about how policy affects education. A nurse on the front lines of healthcare “would be so much more impactful and effective” than a lobbyist, Limb said.
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Advocacy is not a synonym for lobbying. Advocacy has been misused to mean lobbying, government relations or public affairs, Lunsford said. “We largely leave it to a certain department to go deal with our legislative body or go deal with legislative affairs that affect how we get paid, that affects policy, that affects the entire operation of the hospital,” he said.
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Bottom line: How the Texas Legislature handles Medicaid and other healthcare issues has a fallout on hospital development, facilities and real estate.
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Stephanie
Limb,
vice
president
of
advocacy
communication,
Texas
Hospital
Association |
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Lance
Lunsford,
senior
vice
president
of
communications
and
marketing,
Texas
Hospital
Association |
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2018 Outlook
for Medical
Real Estate |
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The
MOB is
the 2018
star in
healthcare
real
estate.
Medical
office
buildings
have
stable
tenants,
a stable
income
stream
and
little
churn
because
doctors
tend not
to move.
Of the
$1
trillion
healthcare
real
estate
sector,
MOBs
made up
$372
billion
of the
value at
year-end
2017.
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Hospitals
and
health
systems
own 51%
of MOBs.
For the
year
through
the
first
quarter
of 2018,
hospitals
were
also the
biggest
buyers
of
medical
real
estate,
at 50%
of
transactions,
followed
by
private
investors
at 41%.
The REIT
share
plunged
to 8%
from 42%
from the
same
period a
year
earlier.
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Dallas
and
Houston
are both
trophy
markets,
and
Texas as
a whole
is
seeing a
surge in
doctor
visits
in every
age
group.
For 2015
to 2030,
doctor
visits
in the
state
are
expected
to grow
31.5
percent.
That’s
an
enviable
position
compared
with
states
where
the
doctor
visits
are
rising
from the
over-65
set but
overall
population
is
falling
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Real Estate
as a
Business
Tool for
Healthcare |
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The trend is toward the “outpatient world.” For hospital systems, the discussion has shifted to constructing outpatient facilities. “We have a lot of 4,000- to 5,000-square-foot clinics surrounding the entire metroplex that 10 years ago we didn’t have,” Sullivan said. “A lot of the outpatient activities we’re doing are joint-ventured.”
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Integrated health campuses enter the scene. Texas Health Resources has built three campuses that provide a continuum from wellness to just short of hospitalization. The facilities run 60,000 to 70,000 square feet on about 10 acres and include fitness centers and free-standing emergency departments. “It’s a smaller hospital that we can do pretty much anything with, with the exception of activities that require beds,” Sullivan said.
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Even the new campus concept is evolving. The next integrated health campuses may be 150,000 square feet on 15 to 20 acres and include 12 to 24 hospital beds — although 36 beds haven’t been ruled out, Sullivan said. “We’re trying to give ourselves the opportunity to expand,” he said.
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Hospital systems plant their flags. Over the last 10-15 years, hospital systems have made defensive moves in communities where they want to gain market share, deploy a new service or serve a growing population, Gordon said. The flags “are typically in the form of MOBs,” he said. In essence, they’ve created a hub-and-spoke system.
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Healthcare systems are becoming big investment buyers. That’s because they own space as well as lease it, Gordon said. “The educated ones are taking a much more methodical approach of ‘if it doesn’t make sense for me to lease it, it doesn’t make sense for me to own it.’”
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Jon
Sullivan,
vice
president,
real
estate
operations,
Texas
Health
Resources
and
Revista
Advisory
Board |
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Chris
Gordon,
senior
managing
director/ global
healthcare,
Newmark
Knight
Frank |
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Examining
the Micro
Hospital |
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Micro
hospitals
take
many
forms.
There’s
no
official
definition
of them,
but all
of them
are
fully
licensed
hospitals.
“You
can’t
always
tell by
the name
— it’s
more of
a
concept,”
Neubek
said.
They
usually
have
eight to
15 beds,
and they
contain
the
basic
components
of a
hospital
such as
emergency
imaging,
a
pharmacy
and lab.
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What
if CMS
changes
the
rules?
Many
operators
worry
that
they
might
build a
micro
hospital,
only to
face
unexpected
expense
or
shutdown
from CMS
rules.
“As long
as
you’re
operating
as a
hospital,
I don’t
see a
big risk
there,”
Neubek
said.
The key
is to
not
“game
the
system,”
such as
having
inpatient
beds
that
qualify
you as a
hospital
but that
are
never
used.
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But a
caveat
on other
states.
If
you’re
considering
building
micro
hospitals
across
state
lines,
be aware
of
proposed
legislation
that
might
affect
your
plans.
“Consider
if that
makes
sense
for
you,”
Chisholm
said.
Neubek
noted
that
states
differ
on
Certificates
of Need
requirements
— Texas’
looser
rules
make it
a hotbed
of micro
hospitals.
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Micro
hospitals
feed
into a
network
of
campuses.
There’s
been a
rethinking
of
community
hospitals
as
community
health
hubs,
leading
to
efficiencies.
Instead
of
internal
computer
systems,
“now
everybody’s
connected,”
Carroll
said. A
full-time
employee
might
rotate
through
several
campuses,
affecting
the
planning
for
space.
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Micro
hospitals
benefit
the
mothership
with
flexibility.
They
can
provide
a
convenient
place
for
patients
to do
pre-op
workups
before
surgery
at the
main
hospital,
Chisholm
said.
When a
flu
epidemic
or other
surge
situation
strikes,
a
normally
eight-bed
micro
hospital
can
quickly
convert
to 14
beds to
relieve
the
strain
on other
facilities.
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Kurt
Neubek,
principal/healthcare
sector
leader,
Page |
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Beth
Carroll,
principal/senior
healthcare
planner,
Page |
Phil
Chisholm,
associate
principal/
senior
healthcare
planner,
Page |
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Tips, Tricks
and Hidden
Traps to
Avoid |
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(left to
right)
Leslie
Echols,
nora
systems,
Inc.;
Doug Schanz,
Johns
Manville;
James
Bryant,
Camfil;
Tommy
Poynter,
Delta
Controls;
Ray Allan,
Cambridge
Sound
Management |
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Tip:
Don’t
put on a
roof and
relax
because
you have
a
warranty.
A roof
requires
periodic
inspections
and
ongoing
maintenance
to
perform
well.
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Trap:
Since
2016,
hospitals
have
been
required
to have
their
air filters
tested
by the
manufacturer.
“There’s
a lot of
manufacturers
out
there
that
have yet
to do
so, and
they’re
still
selling
into
hospitals,”
raising
potential
liability
problems,
Bryant
said.
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Trap:
If you
are a
hospital
executive,
don’t
let
low-level
tradesmen
or
contractors
pick the
building
system
products.
Let the
architect,
who is
working
with the
owner
and has
the
vision,
make the
selection.
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Tip:
Prepare
for the
Internet
of
Things
and buy
accordingly
as you
upgrade,
install
or
design
networks.
The
Internet
of
Things
will
network
your
phones,
computers,
climate
control
and
other
systems
— and
it’s
coming.
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Tip:
Sound
masking
ensures
private
conversations,
but you
put it
where
the
unintentional
listeners
are.
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Tip:
Require
your
floor
contractor
to do a
mock-up
of your
floor
specifications
and
refer
back to
it
during
installation.
Make
sterile
corners
part of
your
specifications.
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Capital
Planning,
Compliance
and
Operational
Issues |
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Money is growing tighter. At Parkland, Wilson once had a $1 million-a-year bucket to use for furniture; now it’s $250,000 a quarter that has to be justified. “We’ve had to look at every tool, every scalpel,” he said. For Scivally, it’s “selling the board on that you need a $250,000 or $500,000 chiller, and you’re going up against an OR and they need five anesthesia machines.”
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Multiyear plans help prevent sudden, and costly, surprises. THR has infrastructure budgets that look ahead for five, seven and 10 years. It allows a department to prioritize building system components for upgrades or replacement before, say, that creaky chiller goes out and shuts down ORs. Parkland has a five-year strategic plan that uses a scoring system that prioritizes spending based on the institution’s missions and goals.
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So how do you prioritize what gets attention? “We risk-rank things — what’s the probability it’ll fail, what’s its past history, what’s its expected life, what is its depreciation schedule?” Scivally said. “A piece of equipment that serves an operating suite is going to have a higher-risk score than a piece equipment like environmental controls in a storeroom.”
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Leave the emotion out of decisions. “Decisions need to be data-driven, not emotionally-driven jumping through hoops,” Wilson said. At Parkland, a plan to replace a 3,000-car parking garage with a 2,000-space garage made campus police uneasy. But the cost to accommodate 1,000 more cars was $20 million, and the data from a parking study didn’t support the need.
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Be methodical on estimating and budgeting. The key is to stay ahead on costs, Wilson said. “It’s about communicating with the industry” and establishing a target value. “Work with your suppliers, work with vendors, work with your subcontractors to get them to actually price it for you,” Scivally said. Check back with them on the numbers early in the year and include an escalation factor.
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Rick
Scivally,
director
of
engineering
and
safety,
Texas
Health
Resources,
Harris
Methodist
Hospital |
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John
Wilson,
director
of
planning,
design
and
construction,
Parkland
Health
and
Hospital
System |
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Retailization
of
Healthcare |
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Randy
Edwards,
principal,
Stantec |
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Doug
King,
principal,
Stantec |
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The
way we
view
hospitals
is
undergoing
a major
change.
From the
Starbucks
in a
micro
hospital
to a
variety
of
concessionaires
in large
medical
complexes,
retail
and
other
services
are
redefining
the
hospital
experience.
“Whether
you go
there as
a
patient
or a
visitor
or
you’re
working
there,
you have
to have
an
environment
that
kind of
distracts
you” in
an often
stressful
place,
Edwards
said.
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On-site
drugstores
promote
patient
compliance.
“Fifty
percent
of
patients
leaving
the
hospital
don’t
even
fill
their
prescriptions,”
Edwards
said.
But put
a
Walgreens
or a CVS
on the
grounds,
and
compliance
goes up
significantly.
“It
shortens
the
distance
from a
physician
making a
prescription
to a
patient
picking
it up
and
actually
taking
it. And
it
builds
brand
loyalty
between
the
physician
and that
particular
pharmacy
or
pharmacy
brand,”
King
said.
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It’s
“airport
concourse
meets
hospital,”
King
said.
“People
need to
do
things
when
they’re
walking
in a
place,”
especially
in the
setting
of a
massive
hospital,
he said.
By
adding a
pharmacy,
a
variety
of
healthy
food
outlets
and
shops,
even a
library
or movie
theater,
“it
marries
retail,
public
space
and
wayfinding,
and
retail
branding",
King
said.
And the
harried
health
worker
has more
choices
for a
grab-and-go
meal.
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Hospitals
invite
the
community
inside.
Adding
retail
and
services
increases
“the
porosity
of the
walls of
the
hospital
and the
relationship
with the
community,”
King
said.
Neighbors
are
“coming
in to
use the
hospital
as a
place to
eat or
hang out
or use
the
library.”
In a
way,
it’s a
form of
community
outreach.
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There
are some
challenges.
Retailers
face “a
paradigm
shift in
who they
serve,”
King
said.
The
customer
base is
“a
little
different
than
your
store
down the
street.”
Adding
retail
can be a
little
painful
during
the
construction
phase,
with
concerns
such as
meeting
interim
life
safety
measures
and
doing
infection
control
risk
assessment
and
systems
design,
he said.
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Leveraging
the Brand
Without
Breaking the
Bank |
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Alisa
Carlson,
RID
and
project
manager,
Methodist
Health
System |
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Kristin
Lopez,
vice
president/interior
design
director,
Curtis
Group
Architects |
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Mark
Krejchi,
healthcare
manager,
Wilsonart |
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A
brand is
about
the full
experience.
“It
starts
before
you get
there
with the
website,”
Carlson
said.
Knowing
where to
park, a
helpful
staff
and a
clean
waiting
room
with
amenities
all make
strong
first
impressions.
Today,
Lopez
said,
“We kind
of look
at it as
hospitality-driven,
like
with a
hotel
chain.”
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Design
is vital
in
branding,
especially
for
health
systems.
“You’re
really
looking
at the
overall
aesthetic
for the
brand
for the
mothership,”
then
using
similar
color
palettes
for the
other
facilities,
Carlson
said.
“Artwork
plays
into it,
signage
plays
into it,
making
sure you
have it
consistent,
consistent,
consistent.”
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There’s
room for
individuality
in
branding.
“You get
from the
workers
what is
important
to them,
what
they
want to
see to
promote
their
facility,
what is
that
special
uniqueness,”
Lopez
said. At
a
facility
in the
Carolinas,
“we put
rocking
chairs
in the
lobby,”
playing
on a
Southern
tradition,
she
said.
They’re
welcoming
but
don’t
cost
much,
and
“people
recognize
them as
a part
of your
brand,”
she
said.
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Durability
of
materials
factors
into
branding.
Make
sure
finishes
are
healthcare
grade,
cleanable,
and able
to
withstand
daily
use and
sanitation,
Lopez
said.
Krejchi
said the
“three
D’s” —
disinfectable,
durable
and
design
that
reinforces
the
brand —
are
musts
for
surface
applications.
Otherwise,
materials
can
quickly
look
worn and
tired.
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Try
cost-effective
ways of
branding.
Way-finding
is a
clear
path to
branding,
visible
in
floors,
corridors,
directories
and
garages,
Carlson
said.
“We all
know
painting
something
is the
cheapest,
easiest
way to
change a
look,”
said
Lopez,
who also
suggested
art
programs
and
upgraded
furniture
to
reinforce
a brand.
“Do the
public
areas or
the
patient
care
areas
first,”
then
work
back to
the
areas
that
only
staffers
see.
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Developing a
More
Powerful
Real Estate
Paradigm
with
Academic
Medical
Centers |
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(left to
right)
Fady
Barmada,
principal/practice
leader,
Array
Advisors,
Juan Guerra
Jr.,
vice
president,
facilities
management
for
University
of Texas
Southwestern
Medical
Center, and
Charles
Shelburne,
vice
president,
campus
planning for
Baylor Scott
& White |
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Three
missions
drive
academic
medical
centers.
Educating
medical
students
and
health
professionals,
doing
medical
research
and
serving
the
community
form the
core of
UT
Southwestern
and
other
academic
medical
centers,
Guerra
said.
“The
three
are
dependent
on each
other,
so any
time we
enter a
building
program
or do
construction,
we have
to have
all
three of
those in
the
equation,”
he said.
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Lecture
halls
are out,
“flipped”
classrooms
are in.
The
focus
has
shifted
from the
model of
the
all-powerful
teacher
at the
front of
the room
toward
smaller
spaces
where
students
interact
and
problem-solve,
assisted
by the
instructor,
Barmada
said. At
UT
Southwestern,
“We took
out all
the
old-style
rooms
and
cubbies,
the
dissecting
tables
that
were in
there,
technology
from the
’60s” to
create
space
that the
students
wanted,
Guerra
said.
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Academic
and
nonprofit
systems
are
moving
to where
the
patients
are.
Baylor
Scott &
White
teamed
with the
city of
Dallas
to
promote
wellness
for
residents
in two
zip
codes
with
high
rates of
diabetes.
“We were
able to
take an
existing
recreation
facility,
added
care
coordinators,
added a
farmers’
market,
added a
lot of
amenities”
such as
teaching
kitchens
for
healthier
food,
Shelburne
said.
“To me,
that
ties to
the
mission
of what
we’re
trying
to do.”
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Dealing
with a
cramped
campus
vs.
far-flung
facilities.
For
UT
Southwestern,
there is
little
choice
but to
build
taller
as
square
footage
grows
but the
campus
footprint
doesn’t,
Guerra
said.
More
square
footage
means
moving
more
people
around
an
already
dense
campus.
Ideas
include
valet
parking
that
allows
patients
to drop
off
their
cars
near
their
first
appointment
and get
picked
up near
their
last.
Baylor
Scott &
White is
growing
by
acquisitions
in North
and
Central
Texas.
“That
means
you’re
spread
out
pretty
thin,”
Shelburne
said,
creating
standardization
issues.
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