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MARDELLE MCCUSKEY SHEPLEY: It's my privilege to introduce Dave Deininger. I can't remember how we actually met. But we're in the same business in terms of he's a health care architect, I'm a health care architect.
And his background is actually in-- so you folks understand how trajectories work, he was a history major and got a degree in history. And then he went to architecture school. And he's collected various other accreditation affiliations with programs around the United States in support of his interest in health care design.
Currently, he has his own practice, 2dplanning. It's outside the Boston area. Prior to that, he worked for 30 years for various design firms. So he's his own man now. And he can tell you what that experience is like moving from having someone sending your paycheck to you every week versus you being--
DAVID DEININGER: Never knowing where it's coming from.
MARDELLE MCCUSKEY SHEPLEY: You never know where you next paycheck's coming from. Is something else important that I should mention about you? No?
DAVID DEININGER: I don't think so.
SPEAKER 1: All right. So we're going to give him-- we're going to use the regular presentation. He's going to present for 35 minutes or so, maybe 40 minutes. He'll have some time for questions.
We've read through the questions you've sent. And he feels that he will have answered a lot of your questions by the time he's finished with his presentation. But we'll ask at the end if you have other questions. And if people run out of ideas, I'm going to grab a couple off the list.
So just to remind you again, we have a lunch today. It's 11:45. If you haven't signed up, I think it's probably not too late to check in with Joseph, so we know more or less who's going to be there. So is everybody happy?
DAVID DEININGER: Awake?
MARDELLE MCCUSKEY SHEPLEY: All right. Take it away.
DAVID DEININGER: All right. Thanks, Mardelle. So briefly, I always like to start a talk with a contextual baseline. So I'm going to talk a little bit about the architecture industry and health care.
Then talk a little bit about my consulting firm, just me, sole practitioner, 2dplanning, and decision making. I feel like decision making is the crisis of our time. You just need to look to Washington. But also, my clients have a real difficult time trying to churn through a lot of the information to make really good decisions. I'll also talk about some tools that I use in order to get to better decisions and then a couple of takeaways.
So the architectural field, like many, I feel like a lot of the services that we provide are being driven into a commodity. And that's not a good thing because all of a sudden, I'm viewed as a vendor, not as a content person. And that usually drives down to making decisions on my client's behalf as far as choosing architects on fee. And that's never a good thing.
Certainly, firm consolidations, that's happening in every industry. Big are getting bigger. The middle is falling out. And you can see that in some of the billing inequity.
And competition from other industries are getting into the design world as well. And that has a positive to it, but it also creates problems for architects as well. But certainly, in virtual there's more done in the virtual world. So all of the sudden, real concrete space is becoming less important.
In health care it's a huge, complicated, dysfunctional industry. It's almost 20% of our GDP, $3.6 trillion with a T. And it also is a lot of multiple stakeholders, a lot of embedded self-interest. It seems like it just can't get itself unstuck in order to really get the problems solved.
And the whole discussion or conflict about, what's the role of the individual? Is health care a right? Is it a privilege? What's the role of government?
It's expensive. It's unsustainable. I think everyone agrees upon that. But we don't all agree on, how do we begin to address that problem?
We're trying to transition from fee for service where volume is the incentive. So the more you do, the more you get paid. We're trying to transition into a fee for value. So we're taking care of a population, and we're incentivized to keep that population healthy. And consolidation certainly is happening within the hospital world as well.
So a lot of commonalities, as you can see. Uncertainty, competition, consolidation. At the root of it is education to me. That's how we get ourselves unstuck. And it's not the answer to the question. It's the means by which hopefully your generation is going to solve the mess that we've left them.
So when you're looking at your own career, I just want to do a little career trajectory. My dad fought in World War II, Greatest Generation. He went to college on the GI Bill. 45 years at the same job, retired.
I'm kind of stuck in the middle a little bit. I got an education. As Mardelle mentioned, I worked at one firm, TRO in Boston. We specialized in health care as architects and engineers. I worked there over 25 years.
And then I reinvented myself. I actually went back to school, got my MBA, health care MBA. And I'm still doing what I used to do at the firm, but I hope to have a little bit of a career path going forward as well.
So my career is a little more bifurcated. You guys are going to be, get an education, and then you're lifetime learners. You're going to be much more fluid, and that's accepted. That's accepted, and it's a good thing.
When you're trying to really decide what you want to do, you really want to try in an ideal world to get that sweet spot right in the middle. So it's a confluence of what you love, what you're really good at, what you can help the world. And, oh by the way, you can also get paid for it.
Walter Isaacson, great author. He's done biographies on Albert Einstein, Leonardo da Vinci, Steve Jobs. This is the way he says it's going to be the intersection of art and science.
So in summation, my advice to you guys is to learn how to think, learn how to communicate, solve complicated problems, because most of the problems of the world are pretty complicated. And more importantly, learn how to communicate. So it's not only verbal communication; it's written. Because not everyone learns the same.
I've learned that with my clients. Many can't read drawings. Others, you put up an Excel spreadsheet, their eyes glaze over.
So you have to find the right narrative in order to-- because you can have the greatest solution in the world. And if you can't sell it, if you can't get consensus, then it's really not worth very much. So really think about expanding and diversifying your means of communication.
When I was putting my firm together, this is my guide. This is my North Star, really, is we can't continue to think the same way to solve the problems that we're dealing with today. We have to think really differently. So that's what I try to bring front and center every day in my work.
I know I sent the Blue ocean Strategy article out, which the book I think is the best business book that I've ever read. And it's 14, 15 years old. But the lessons are so tried and true.
And that's really, how does one differentiate oneself on a business level, but also as an individual? I think you can drive it down to the individual level. How do you all find a way for your highest and best value in order to differentiate yourself and therefore be successful?
One of the exercises in the book was to create a value curve for your business. So you can see on the red is the trajectory of facility master planning that a typical architect might use. And then the blue circles are, that was my new product. And the high and low, that's not a value judgment. It's just a relationship.
So what you're trying to do in Blue Ocean is create a shark-free Blue Ocean versus the shark-infested Red Ocean where you're constantly battling your competition. You're almost trying to create your own space where there is no competition. So this exercise, you take a variety of different criteria. And then you begin to line it up to your competition.
So I'm able-- as a sole practitioner, I have no big infrastructure behind me. It's just me and the dog in the spare bedroom. So that's pretty lean and mean. And therefore, I can vastly undercut in my price to an architectural firm. It's still a great payday for me, but it in no way competes with an architect's fees that are going to be higher.
Same with time. I do it much more rapidly. I do a Charette master plan, I call it. It's really a week-long exercise where I bring a whole bunch of folks with me. I bring strategy folks, financial folks.
By the end of the week, I can give my clients a high level vision of what their campus can be over time. And then we begin to align a project that they can afford. So it's very practical. It's very interactive.
The client, I tell them, you can sit next to me for the entire week if you want. It's a total open door policy. The clients really, really enjoy it.
And it's also done in a really low tech way. So I will do all hand drawings. So at the beginning in our conference room on Monday, it's a blank wall.
On Friday, it's a full wall. And the clients are blown away. How did you do all that in a week? So it's really, really tremendously rewarding for me.
And I think my biggest differentiator is this: that I'm perceived to be independent and unbiased. Because think of it. If I'm doing master planning in an architectural firm, architects don't make money doing master planning. Architects make money doing buildings.
So if there's an outcome to my planning that happens to be a building, in the back of the mind of the client is saying, hmm, did he somehow, by sleight of hand, did he game the system to a building for his firm? And now I can say, I'm getting paid for the planning. I have no skin in the game as to what the outcome is.
So all of a sudden, it's a different relationship between me and the client. They're like, OK. You're my trusted advisor. You're independent. We're collaborators. So real quickly, this is my value proposition, and I went through a lot of it just in the last slide.
The other aspect of my practice, which I call the connected practice, I've talked a little bit about projects with my clients. But I also love opportunities like this where I can interact with students, both architecture students and Master of Health Care Administration students, also MBA health care students. Because I think we're all hopefully united in the same mission of improving health care. The other piece, too, is that I am involved in some moral think tank research projects as well to try to dig down into more of a research context to try to figure out how we get and improve health care going forward.
So decision-making, it involves change because there's no such thing as a system of stasis. There is no snapshot of something, and it stays that way. It is constantly changing, and it's inevitable. And hopefully, we can confront that.
Change involves risk. Change involves pain. That's why people don't like to change. It's hard. It's hard.
But there's a difference really between uncertainty and risk. Uncertainty is doubt. You just have no idea. You just don't know. Whereas risk is something that you can begin to manage because it's probability of loss.
So if you add more information, a wider perspective, more engagement, you can begin to manage and move doubt to simply knowing your odds. And you go from a state where you're pretty scared to a state where, OK, I can begin to manage this.
We also have to understand the mindset of your client. And these are the bookends. It's evolutionary change.
I would say the majority of people in health care are more conservative. And they tend to be more evolutionary folks. They want to be able to work more incrementally, a little more step by step. And it also is change that can be absorbed into an existing culture, so it's less controversial.
On the other hand, there's revolutionary change. Personally, I think we need more revolutionary change than evolutionary change. And that's more dynamic. It's more by mandate.
Often, you hear the term "blowing it up." But you have to really be careful, because, look what happened with the Republican Party and repeal and replace. They hammered that for seven years. Repeal and replace, repeal and replace.
Then in the last 2016 election, they got majorities in Congress. They got the presidency. What happened? Nothing, because they were united in the fact that they wanted revolutionary change, but they had no consensus whatsoever on the path forward.
So if you're going to blow it up, please have a plan going forward. This is really significant because so often, you dive right into solutions, and you really don't understand the problem.
Heuristics, that's a social scientist's word for a coping mechanism that we all have in our brains to try to manage complexity. It's trying to make sense of it, and it's unconscious. And it leads, in my opinion, to a lot of bad decisions. And I think not you can totally control or manage some of these biases, but at least if you're aware of them, then you can begin to understand them a little bit better.
So here's an interesting one. This is the difference between boom times and recessionary times in the economy. This is a graph from 1980 to 2015. The recessionary times are in blue-- this is the stock market-- the boom times are in yellow.
And what tends to happen is when there's boom times, everyone's positive. Everyone's thinking in a big, strategic, visionary space. Everything's great.
Who cares about the details? Who cares about the tactics? So it gets really weighted towards strategy.
Conversely, in bad times, everyone hunkers down. They go into the weeds. And they, oh, we've got to eliminate this.
We've got to drop this. Cost cutting here. And all of a sudden, you lose the big picture. I mean, the moral of the story is it's got to be a balance.
There's the status quo trap. That's the fact that especially with an inordinate amount of different options, one tends to get overwhelmed. And they'll say, OK, I'm just not going to do anything. And they think, OK, the status quo is it's gotta be the safe option. And it usually is not.
What can you do about it? Well, first acknowledge that the status quo is not without risk. Usually, if you're standing still and the rest of the world is motoring by, you're getting farther behind. So it usually is much more risky.
This is a great question. Ask yourself, would I choose the status quo option if it weren't the status quo?
Sunk costs. That's the saying throwing good money after bad. Because if you put a lot of investment of time or money into a certain decision and it's not working out, when do you cut your losses?
People tend to want to keep going because they've made such an investment. You've got to think of the decision from this moment onward, and try to not look in the rear view mirror. And it's really important to try to get people involved in the present decision who weren't involved in the past decision, because they're pretty much grounded in proving that their decision was correct.
The anchoring trap is one that the first amount of information you hear is what sticks. So that's where I'm very reluctant when clients ask me to give them a preliminary cost estimate. I don't want to give them that estimate, because over the course of the project, they'll forget that they changed the scope, or increased the quality, or added this or added that.
And of course the cost is going to go up. But they remember that first cost. And it's, why isn't this that cost?
So what can we do about that? It's try to think about the problem beforehand on your own so you have some ideas. Also, don't get everyone's opinion at the beginning.
Don't go around the room before you've begun to go through the design process. Go through the process. Let everybody be part of the process.
The confirmation trap, that's where we tend to gravitate towards information we agree with or stay away from information we don't agree with. I mean, that's why many conservatives, they are glued to Fox News. Liberals are glued to MSNBC. And that causes the problems that you see.
But it can also happen in our world as well. And what can we do about it? I think the best thing is get a respected devil's advocate. Don't surround yourself with folks that necessarily agree with you.
So to try to begin to get a handle on the best decision-making, it's really embracing what I'm terming the comparative advantage. And that is you're going to be much better teams the more diverse you are and the more multidisciplinary you are. And that's the approach I love to take with my clients.
And it's really asking these three basic strategic planning questions. Where are we, where do we go, and how do we get there? So that's decision-making.
Now here are some tools that I use for my clients in order to make good decisions. I am always looking for ways to simplify things because there's a lot of information out there. And it's not to make it simplistic. it's time to simplify it, but still keep the robustness of the idea.
So when I'm looking at a site, just a diagrammatic site, there's always more of a public edge, and there's more of a private edge. So there's front yard backyard on most campuses.
When I'm looking at flow on the site, if you can do a diagrammatic quadrant on the site, one area should be real back of house. So that's the receiving dock. That's all the trucks coming in. It's usually the energy plant, the power plant, the oxygen farm. All of that behind the scenes stuff should be in one area.
We really need to have one specific area for the emergency traffic as well. So there's ambulances coming in. There's also folks just driving loved ones up to the emergency room, too, usually in very stressful conditions. So you don't want to be crossing paths with 18-wheelers. So you want that separation.
You always want a flexible zone on the site. That could be for a special program. It could be for an outpatient versus inpatient. And then lastly, there's the main identity, the main entrance, the main area for patients and visitors to enter the site. And ideally, there's a way, an access point into each quadrant for each circulation type.
And there's associated parking for each. So there's the main patient parking, an ED parking. Many times doctors park in the ED spot as well. And then parking for employees.
And then, so you can see the sequence. You're coming onto site, and then you're coming into the building. So there's also segregated areas to get into the building.
And then we have to look also at growth, at least conceptually. I think that that one quadrant four, the main entrance, that can be pretty much a lock down. And then the expansion can take place in all the other areas.
Another key for me is understanding the strategic context of the problem. This happens to be, if you're familiar, this is Lawrence Memorial Hospital. It's in New London, Connecticut. So this is Route 95 right along the coast. This shows all of the patient discharges, and they're geocoded by zip code, so we know exactly where all the patients originated from.
Now, we were looking in this particular-- this is the hospital. It's embedded about 25 minutes off the highway in the older section of town on a labyrinth of back roads. This is a new ambulatory campus in the East. We were looking at 100 acres right on the highway on the Western flank and seeing, how can we best use this?
So we did drive times. These happened to be from 15 minutes to 25-minute drive times. And this is drive times for the existing hospital.
Now, when you look at drive times for the new location out by the highway, we increased access within 25 minutes by almost 20%. I'll just toggle back. You can see how we really opened up access just by changing the location.
So scenario planning, that's another great tool to use when you're beginning to evaluate different options. And I'm a big proponent of casting the widest net and the widest range in order to understand your problem. One being that status quo baseline. And then, as you'll see, the other option at the other end is much more radical.
So here's the status quo. Here's, well, what if we put ambulatory services at that new site? Well, what if we split the hospital into two?
That didn't really work here. They're too small. It became really inefficient. What if we move the entire hospital out to that Western campus? And lastly, what if we actually merged with our arch rival to the north and created more of a system-wide approach?
Through all of our discussion and analysis, we arrived at the fact that it really was Option B that made the most sense. And so let me walk you through the logic.
This is where I love to use what I term no regret moves. That's if the six options have some commonalities, then you can be more comfortable that you're on the right track. So if you take those common elements and you proceed with those, then all of a sudden, you're feeling pretty good that you are maintaining some flexibility. And that's what we did.
We decided to acquire that site out by the highway, master plan it to make sure that it could accommodate all services. But the first stake in the ground was some ambulatory services. And then there was the phased implementation.
Asset distribution. Another thing, if you begin to really think of it really simply in inpatient services, outpatient services, this is in Jackson, Michigan outside of Detroit. The hospital's land that they own now is in the blue. The red is potential site acquisition.
And don't forget streets. Many people forget them, but they're property as well. And many, many municipalities are pretty good about allowing streets to be closed in order to get properties that become adjacent to each other.
So in this instance, we couldn't really expand to the north because they had negotiated a deal with the neighbors, but we were looking at kind of east, west, south as options. We decided on really maintaining the impatient. But then there were a couple of outpatient across the street to the south, but decided to really develop that.
So we put out a 10-year plan where the primary focus is going to be on the ambulatory side. But a long term plan allows us to move some things from inpatient to outpatient and then really redevelop the inpatient. So it became pretty simple. So for way finding, people coming to the site, they kind of know going right, going left.
Phased implementation, very rarely do we have the money at the beginning in order to fix all of the need on the site. So here you are you're familiar. Here's our quadrants.
This is Valley Hospital. It's in Ridgewood, New Jersey. And they had a pretty simple campus, an older '60s building, '80s building. We decided the 2000 building was one that we really could begin to build around.
So the first phase was beds. It was new surgery. It was new imaging, new loading dock. Essentially what we were trying to do is get out of that old building.
And then the next big building was new emergency and actually critical care beds above it. It was all organized around a multi-story atrium, so like going to the mall. And you have good visibility of where your destination is.
And then lastly, getting the '80s building out of the way. And we didn't even have a program for this building, but that became that flex zone. So pretty good. We have patient visitor. We have emergency, receiving, and then a flex zone for the campus.
I also would like to simplify clinical relationships, functional relationship as well. Because you can go into an academic medical center, and you can be confronted with 90 different departments. If you try to juggle 90 different departments, it's not going to get done. You're not going to be able to get your arms around it.
So I like to boil this down to actually just three categories, one being the diagnostic treatment platform. So that's emergency, it's imaging, it's lab, it's pharmacy. It's all procedures.
Then the beds. Obviously, that's all the beds. And then I put everything else in support of those first two. So then it helps me get my head around the relationships on a broad scale on a campus. So how does that begin to lay out in an ideals kind of packaging in a hospital?
This is the lower. This is the basement level. So a lot of support in the basement. Receiving coming in in that quadrant.
This is the main level of the hospital at grade. Emergency room by code needs to be on grade. So there's the ambulance coming in. This is the walk-in.
Emergency wants to be near imaging. A lot of hospitals are going to observation beds instead of having somebody clog up the ED for 10 hours or having to admit a patient. You can keep them in a between state where anything under 24 hours, you can have an observation bed.
Most often than not there, they're overseen by the emergency room. The second floor, love to think of all procedures in a more universal perspective so that to try to break down the silos so that cardiology, interventional radiology, general surgery, orthopedics, they're all being done in a universal 650 square foot room.
And then the technology can be plug and play over the years. But the walls don't necessarily have to change.
And then there's the cream to the Oreo cookie filling. And that's right in the middle of the building, having all your mechanical electrical systems. And so what's great about being in the middle is you have shorter runs up and down rather than having everything at the top and having to feed all the way down or the reverse.
Because the longer mechanical shafts have to run, the bigger they get. And so it's more efficient use of space in an ideal world. And then it's usually topped by beds.
This is a project outside of Seattle in Kirkland, Washington. And the tool here was consolidation to try to get economies of scale and because the way that this hospital had expanded, the original hospital is right in here. They've expanded horizontally. So many times people want to be horizontally adjacent to something.
And that can be the most travel distance as you get spread out. Many times a vertical relationship is much more desirable. So we came in, and they had just built a new building.
They had just built this building here with parking. They had a new emergency room. They had shell space. They had a whole shell second floor. They had three floors of beds.
So they had three floors of 30 each. So they had 90 beds. And then they had three floors of shell. And they were saying, where do we go from here?
That was our charge. And you can see with the quadrants, they have a highly developed inpatient, an outpatient. But emergency and receiving were clogged up in one corner, and then there was some underutilized space in the other.
So looking at beds to start, they were obviously the beds I just talked about, the 90 beds there. The critical care beds were back in the original hospital. And then there were maternity beds, OB beds, and other beds here. So really spread out.
So their question to us was, well, how many beds do we really need? And that's where demand modeling is a really, really important tool. So it's taking the population.
And the variables really are the utilization. So how frequently is it utilized? Market. There's a population out there. What's the market share? That will begin to determine the gross number.
And then what's the throughput? What's the average length of stay? And then this, I love to use the idea of a range of values. I mean, we could have churned all the numbers and said, you need 137.5 beds.
Now trying to hit that target is much more difficult than saying they need 120 to 160 beds. Now suddenly, hitting a range is much easier than hitting a specific point.
So here again we used the scenario planning. We came up with 12 or so different scenarios, different combinations of assumptions, and then ran the numbers and determined, OK, these half here, they're under the 180 beds that are available in that new tower, six floors of 30. But some of these assumptions might come true.
Even though it's highly improbable, we need to plan for, in our planning, space on campus for another 42 beds. So all of the sudden, remember doubt and uncertainty, we've taken something where the client was tremendously uncertain, and we've put data around it. And we've suddenly made it manageable. And they felt really comfortable with this. So that's beds.
Now, how about the rest of the services? Here's the emergency room. That's that brand new emergency room. Most of diagnostic imaging was way back embedded in the hospital. And most of surgery was here.
Now ideally, remember the ideal stacking? We like to see those. So here's imaging. There was some that was brought over with the ED. MRI was here. ED is the highest user of MRI.
So you can see, look at that travel distance. We were able to actually consolidate imaging all over here. And in doing so, we were able to eliminate two extra rooms and one CT scan room. So that's the power of consolidation.
Surgery, you can see in the green. That also, we were able to consolidate. So here's the plan, I know I just got a couple minutes. So here's the plan. Remember the ideal stacking.
A lot of the support in the basement. ED imaging, surgery, and then all the beds. And all of the sudden, we got inpatient, outpatient, emergency, and then receiving in the backyard.
This is just a little more detail in the planning. That's the lower level. There's emergency.
And we even gave them expansion growth opportunity in case they wanted to have that observation unit sometime in the future. And there's the procedure platform that can expand.
Here's some of the takeaways. Develop your own toolkit. Get up every morning and say, how can I provide value? I think those are the big takeaways.
MARDELLE MCCUSKEY SHEPLEY: Thank you. So I'll start with the audience, if there are pressing questions that someone would like to put forward?
SPEAKER 3: In the meaning of Blue Ocean Strategy, how does a business in the Blue ocean Strategy become sustainable in 10, 15 year range after that?
DAVID DEININGER: Yeah. I think it's a constant evaluation. You have to get in your boat and constantly be on the search for the blue ocean. Because you're absolutely right. Your Blue Ocean can get pretty red pretty quickly.
Again, systems are never-- there's always change. So yes, you have to be on top of it to stay one step ahead.
AUDIENCE: How do you stay unbiased when it comes to the scenario analysis? I know there was an example you showed five. But going in, do you sometimes have an idea of which one is better than the rest or which one's aren't going to stack up when coming up with those scenarios?
DAVID DEININGER: Absolutely. I'm human, so yeah. And a lot of the scenarios are put out there to prove they don't work. There's not always an equal pathway to success for every-- they're put out there mainly so when I get to the 11th hour with a client, they're not, did you look at?
So then you have to circle back. You want to try to put them all on the table. I think one of the fallacies in health care, certainly a lot of the hospital campuses I go on to, they think there's endless options.
Well, usually they've planned themselves into a corner where I'm lucky to find one option. But I have to go through, at least at a high level, putting out different scenarios. And many times, we eliminate them really quickly.
AUDIENCE: You were talking about how other industries are becoming competitors to architecture and program planning and such. Would you mind elaborating on that?
DAVID DEININGER: Sure. There's developers that are getting into a lot of pre-design services. There's other consultants, contractors. Anyone that has any kind of interest or periphery to the design world is trying to get in because they see that especially with pre-design services, if they can get in the door, then they could potentially have a relationship with the client that could go on into the future.
And also just the way we're structuring contracts now, folks are getting in, are really trying to provide a lot of different services to get their foot in the door. And that's not a bad thing necessarily. I think architects just have to realize that that's the case.
I mean, I'm kind of a outlier competitor as a consultant now. So watch out for me.
MARDELLE MCCUSKEY SHEPLEY: Are there other questions? Go ahead.
AUDIENCE: So if you were to step back and look at all of these design projects that you've been involved in throughout your career, would you say that there's a common thread that you've been able to weave through them?
DAVID DEININGER: Yeah, absolutely. A lot of these principles, like my planning principles I feel are successful. So I come to each project saying, how can I get that ideal stacking in this hospital?
I mean, I happened to show one where I was able to do it perfectly. But many times you can't. You try to get as close as she can because they're ideal relationships.
And so I put them out there with the client. We discuss them. They can agree. They can disagree.
At the end of the day, it's their campus. And I have to work with where they're going. But absolutely. There's, I think, keys to success that can get you there.
MARDELLE MCCUSKEY SHEPLEY: OK. That might build on up on one of the questions that one of you provided. And I know you've had international practice. How do you account for cultural differences? Do these same factors-- for example, you were asking about the cross cultures and what things would be different depending on where you work.
DAVID DEININGER: Yeah, it's a great question. I think as I mentioned last night when we were talking, when I was hired to do international work back when I was at the architectural firm-- I don't really do it now-- so often, whether it was China, Singapore, I think I worked in South Korea, Kuwait.
They hired us in saying, we want the American model, and we want to learn from your expertise. Now, when I would get on the ground, usually they would push back and say, no, no, no. You have to be sensitive to our culture. So ultimately, we have to be sensitive to the culture.
Certainly in Kuwait, we were talking about building gross factor markup. Here in the US, it's about 1.2. In the Muslim world, it's like 1.6 because you have to duplicate a lot of circulation for men, but for women. You have to have prayer area for men, for women.
So the whole separation of the sexes is huge in hospitals in Kuwait. Now that's not anything we have to deal with here, but you have to really understand that that's a real important cultural overlay onto the planning.
MARDELLE MCCUSKEY SHEPLEY: All right. I think we're out of time. Just thank our speaker again for sharing.
[APPLAUSE]
The Cornell Institute for Healthy Futures: Health, Hospitality and Design Industry Seminar HADM/DEA 3033/6055.
