Dr. Richard Grossman Burn Center

Clarence Warner and I recently met with world-renowned burn specialist Dr. Richard Grossman at his Burn Center facility at the West Hills Hospital, in West Hills, California. Dr. Grossman and his Nursing Administrator, Kelli Rix, gave us a personal tour of their new burn center. (For additional information see Dr. Grossman’s website at http://www.grossmanburncenter.com. In addition, I suggest you read some burn victim stories. Go to the following website: http://www.grossmanburncenter.com/burn-survivor-stories.php).

The burn center is a part of the hospital which has normal emergency room services as well as trauma services. The E.R. is not a part of the burn center, it is a separate unit within the hospital. Dr. Grossman also has an office in a medical office building on the campus where he does both pre- and post hospitalization exams, as well as elective major and minor surgeries.

Burn Center ICU

The burn center has a separate ICU specific to burn patients. The ICU monitors the patient’s body functions much like a regular ICU. The staff is specifically trained for the burn unit. There are individual patient rooms with sliding glass doors for direct staff visibility. The nurse’s station accommodates multiple nurses with computers for each nurse. Typically 1 nurse is assigned to each patient. However, in acute cases, multiple nurses are assigned to the patient until the latter is fully stabilized. The ICU also has a hydrotherapy room with one hydrotherapy bed which uses treated water to wash the wounds in a very sterile environment to reduce the risk of infection. The ICU is on the second floor directly above the E.R. in the hospital. This relationship and closeness facilitates early acute patient care.In the burn unit,  there are specially designed cribs that serve as a hospital beds for small children. These beds also have a top to prevent the child from exiting the crib. Small children usually have an adult who is with the child 24 hrs a day for direct monitoring. Family can participate and are encouraged to stay with the child unless the child is the victim of abuse. Once stabilized, the patients can be transferred to the burn center treatment area.

Burn Center Patient Treatment facility

This is another unit which is one step-down level of treatment for burn patients. It is very similar to other hospital patient rooms and nursing facilities. This patient area is arranged in a circular pattern with the nursing station in the center/core and the patient rooms on the perimeter. Some key differences are that there are a few additional rooms. It is recommended that burn victims have a family lobby or waiting area specific to the burn center. For children that are ambulatory, there is a children’s play room with adult supervision (either a family member or a nurse). For patients who need constant monitoring or have small wounds, hydrotherapy using treated, sterilized water is done at bedside. Each day the piping system is cleaned to remove any bacteria that could be in the hydro lines. The floor should have a good drainage system.

Hyperbaric Treatment

In addition, there is a hyperbaric treatment room with two hyperbaric treatment chambers. Dr. Grossman has advised, “It is most important to have the larger units for overweight people.” For the comfort of those being treated, there is a flat screen television to watch while in the chamber. The chambers are clear and this helps to reduce problems with patient Claustrophobia. Each of the chambers can be adjusted from 1 atmosphere to 3 atmospheres in oxygen pressures. Only patients not needing any other attached monitoring or intravenous connections are placed in the hyperbaric chambers. Each chamber also has patient connectivity to communicate with the nurse if they are experiencing problems. In order to remove the patient, the oxygen is released and de-pressurized slowly. The gas is released to the outside of the building. The supply of oxygen is usually in a large bulk oxygen tank located a distance from the main building. The distance is approximately 50 ft. In the United States, the bulk oxygen tank is typically considered a H-2 occupancy and a fire hazard.

Associated services

The hyperbaric facilities are capable of handling other wound care patients other than burn patients. Diabetic patients can be treated to avoid amputation. Other types of wound care can also be treated as well. According to Dr. Grossman, it is important to have psychological services available to the patients. The patients are often in a complete shift of their life experience. One of the burn patients that we met had been a patient for 7 years, needing over 30 surgeries to date to be re-constructed after the severe burns he suffered.

Plastic surgery should be offered as a part of the process of helping the patients to achieve a greater degree of normalcy after a burn event. Reconstructive surgery is often needed in major burn cases.

Dietitians, rehabilitation therapists and respiratory care are essential to the complete burn center approach. Dr. Grossman has found that his comprehensive team approach with burn victims has enhanced the great successes in burn treatment and therapy.

The specialty of a burn center greatly increases the potential for surviving a major burn. Trauma Centers without such services may need to transfer a patient to a burn center in another city. Any transfer may reduce the survivability rates of patients.

Gary Heathcote

Medical Offices- To Build, Buy or Lease

For doctors this question is an important part of the medical practice whether realized by the physician or not. Each professional needs to access their own position in the long term aspects of their financial position. In my architectural practice I realized that I needed to own a building rather than paying down the mortgage of my landlord. I also realized that long term I owned an asset rather than 20 plus years of paying rent with no return on my money.

I asked Kristine Vail, CPA of Roschke & Wall to write a financial perspective other than my own of the pros and cons of leasing or buying a building.

Kristine Writes the following-

“Part of building wealth and managing taxes involves making long-term strategic decisions.  One question that comes up for a business owner is should I lease or buy a building.  Then there is the added question, if I buy should I build.

Let’s talk about buy vs. lease

When you buy a building you are growing equity over time.  As the equity grows, you will have an asset that can be borrowed against.  This asset can be rented for income.  Your building can be your largest billboard or advertising vehicle.  You no longer have to worry about rent increases, risk of eviction or non-renewal of lease.

When you buy a building you must put down 20% of the purchase price.  Your asset is not liquid and you will need funds set aside for emergencies and items that wear out over time.

When you lease your space, you gain access to a better location with less cash.  The landlord may be willing to do a build-out and amortize the cost into the rent.  If you are managing growth, you will have more flexibility to change space or expand to multiple locations.

However, when you lease your space, the money you spend each month doesn’t create any long-term wealth.

What about building a new commercial building?

It’s a lot easier to move into an office designed and decorated for you.  You get the latest technology and advances, built to the latest codes and acquire warranties.

You need a team of experts starting with a good architect that can design not only the building, but also the office layout efficient for your needs.  Your building can be designed to accommodate future growth, either by additions or space leased to others until the need arises for expansion.  Usually appreciation is more beneficial if you build new, while buying an existing building delivers a premium to the sellers.

Cost segregation rules are only some of the tax benefits of either refurbishing or building commercial real estate.  This is where a good CPA comes in handy.  They can compare costs with a cash flow analysis of your operating expenses including looking at your current operating lease commitment.

Investing in commercial real estate makes sense if a business is profitable especially for any business that is recession proof.  Your investment can benefit you in the short term by decreasing your cash flow and in the long term through appreciation. “Income producing property” adds to a properly diversified portfolio and helps reduce your tax burden.”

It is advised that you meet with your financial advisors to review your options and make plans for the future.

Contact Gary Heathcote    gary@heathcote.net      Website http://www.heathcote.net/

Preparing for a Construction Loan for Medical Facilities

Preparing for a construction Loan for Medical Facilities
Construction Loans are the loans that are typically used to pay for the construction of a building. Once construction is completed the construction loan gets converted to a permanent loan. The permanent loan is guaranteed by a Mortgage which a legal document is specifying rights of the lender to take the property if payment is not made. It is important to work with the bank to assure that once the construction is completed that the details and contract for permanent financing is secured.

 

In order to qualify for a loan there are multiple requirements necessary to demonstrate the strength of the borrowers to finance and complete the project.

 

• Personal and Business Financial Information, see below
• Plans and Specifications of the Construction Project
• Estimate prepared by a licensed General Contractor
• An Appraisal of the property and the plans
• Title information about the property- A Title Report
• Hazardous Materials survey and report

Personal and Business financial information required is typically as shown below.

 

Business Financial Information

• Business Loan Application & Business Schedule of Debt Current Year Interim P&L and Balance Sheet
• 3 years Business Tax Returns
• Accounts Receivable and Accounts Payable aging report
• 3 months banking statements for your principal banking relationship include CD’s, Business Checking accounts, Savings accounts, etc.

• Personal Financial Statement for each owner
• Most Recent Brokerage/Bank statements
• 3 years Personal Federal Tax returns

The construction loan types and payment procedures may vary from bank to bank and based on your needs and the bank’s tailored agreement with you. Most Construction loans require you to pay a monthly interest on the loan. That interest rate is usually based upon the total amount drawn on the account. That amount gets raised each month of the construction with the highest rate at the end of the job. The interest is usually standard interest and not amortized. Many times that rate is tied to prime rate plus one or two percent.

 

It is important to note that Plans and Specifications are an upfront fee prior to obtaining a loan. Some have used a business line of credit to pay for plans. It is also important to make sure you have governing approvals in place as you do not want to go back to the bank for any adjustment on the loan.

 

One of the great ways that doctors can finance their building is using an SBA loan with a local bank loan combination. The following is advice from Lilly Canterbury of Wells Fargo.

 “Wells Fargo offers SBA 504 and 7a financing options for construction projects. The 504 is typical for ground up projects and the 7a for shell build-outs. 51% or more of total building square footage must be owner occupied; with the expectation that they will be expanding their business. Basically, banks want to be careful & very thorough on the expenses for the project and that the borrower can support the loan. A good tip is to have a budget with detailed cost breakdowns. Any major line item must be supported by a bid. Banks also want to know that the builder or General Contractor is credit worthy.”

The intent of this article is to aquaint you with some of the basics for the Construction Loan process. It is advised that you meet with several bankers and or loan brokers to aquaint you further with your specific needs.

 

 

 

 

 

Personal Financial Information

New Medical Office Design for Obama Care

The future of doctor’s offices is here now. New methods of patient care and treatment will be needed in the next decade. With the President Obama lead changes to the health care industry the need for additional care professionals will be paramount.

Doctors, hospitals and insurance companies will need to change how business is conducted. Fortunately there have been advances in technology that may assist in this process. These potentials may change the design of medical facilities.

Doctors will need to see more patients and will need to reduce fees. This is possible in changes to their methods of patient care. The new doctor’s facility will need to incorporate alternate forms of diagnostic analysis. GE Imagination refers to the “Digital Hospital”. They are proposing internet based medical records that are available to the patient “Online”. There are digital hand held devices that can scan a single drop of blood within 90 seconds and not require lab work to be performed. This work can be entered in the patient database immediately directly from the scan devices. Temperature and blood pressure can be entered immediately to the patient database. All physicians may access a patient’s database for coordination among professionals. Pharmacies can provide information and drug interaction results in the patient file.

Pre-visit or waiting room diagnostics can be made available through internet based systems. The patient can access a database analysis through the internet where a medical technician can either assist or the patient can enter information prior to seeing the physician. Waiting rooms can allow the patient to enter information at the doctor’s health internet café. Medical Health technicians can assist those who are not able to enter data themselves. Prior to the doctor seeing the patient all data and analysis are performed and suggested treatment analysis is shown to the health professional. In some cases nurses may perform minor patient care rather than the doctor needing to see the patient. The analysis may include suggested drugs for patient as well. The doctor can also see from the database other previous medical history. The computer can provide continual analysis of medical history and current conditions. Special scans and MRI work can be kept and reviewed by doctors on the database.

Hospitals are now providing in room patient computer charting and information, this can be interactive with the main patient database.

Specialized patient education can be made available through streaming video instructions that are specific to the patient’s condition.

As doctors face a declining billing rate they will need to re-invent their methods of patient care and the facilities they work in.

Gary Heathcote, AIA, NCARB
gary@heathcote.net

Selecting a location for a Medical Office Lease

Selecting a location for a Medical Office Lease
A quick summary of issues when contemplating a medical office lease
By Gary Heathcote, AIA, NCARB     gary@heathcote.net   http://www.heathcote.net/

Proximity to hospital
Typically it is appropriate to be within 3 miles of the hospital which the physician serves. This is not a hard rule but one that allows a quick access to the hospital.

Parking appropriate medical parking
Most cities require 1 parking space per 200 square feet of medical lease space. In addition, a visual inspection of ease of access and parking proximity is important. If the parking is far away or on an upper level that requires the patients to have problems getting to the office it should be avoided.

Safe access for patients
Parking and sidewalk access needs to create a safe environment for patients to arrive and depart. Well lit parking and path of travel to the front door is important. Look for potential difficult neighboring uses that can create problems. Check out the site in the evening for vagrants. Will the patients have safe access to the doctor’s office.

Handicapped Access
State and Federal building regulations require multiple accommodations for the disabled. Federal Statues are in the ADA standards (American Disabilites Act) and are known to design professionals. Each state generally has disablility standards. For instance, California has Title 24 Handicapped Standards that is now incorporated into the California Building Code.
The disability standards generally include: Access from the public way, disabled parking spaces, exterior ramps, easy access doors, stair designs, interior ramps, easy reach switches, easy reach casework, lever type door handles, disabled toilet room requirements, public counter designs and other items listed in the code. Your project architect should be able to guide you through the requirements. Please note that if a lease space is existing and does not meet the requirements you may be required to make changes to the building.

Covered Patient drop off area
In some areas and with certain providers you may need to have a covered patient drop off area in the parking lot. This is especially true for ambulance requirements. This covered area will need to be from the patient loading area to the patient entrance.

Size of Suite
Prior to deciding on a suite size and location is a good idea to have your Architect draw a preliminary floor plan layout. Not all spaces can accommodate your uses equally. It is often nice to have a secondary entrance/exit for the doctor and other personnel to enter and exit the suite without walking through the waiting room. If there are special rooms such as x-ray areas or special procedure rooms compare the size room needed with equipment layouts of rooms you have been acquainted with. Just stating that you want it “big” does not help as a description.

Design of Suite
The Architect should be able to provide a lot of knowledge in the design of your space. However, he is not your business partner. You must have knowledge of how your space should operate. If there is more than one physician he must know how many is expected. This will also help you determine how many exam rooms/ procedure rooms that will be needed. Know some of the sizes from other offices that work for you. Take a tape measure and measure and become familiar with sizes of rooms. Also, if equipment is in a room the room must accommodate the handicapped. A list of rooms and sizes is an important determination to assist the Architect.

Filing Systems
Filing systems that are concentrated on a raised floor may need special consideration. Compact filing systems for patient records can be too heavy for the designed floor load of the building. This can be a particular problem when located on the second floor or above. Also be careful about loads above a parking garage. Also, tall systems require anchorage for seismic standards (earthquakes) If you are installing a system and it requires an upgrade to the floor design, it can be problematic to get to the floor framing system below your suite.

Special Uses/equipment
Special equipment may require floor load considerations. If you have heavy equipment it may be best to be located on the first floor of the building. In some cases heavy shielding may be required. With CT/PET scanners even a regular slab on grade floor may need to be replaced with a stronger floor anchoring system. In addition to potential weight of the equipment some equipment requires special electrical needs. It would be important to make sure that large electrical loads can be easily accommodated. A new main service or new transformer can be costly. If bulk gases are needed such as oxygen for Hyperbaric wound treatment facilities oxygen tanks need to be typically 50’ from the building. Also surgical facilities where the patient is unconscious an electrical generator will be required for surgical centers. Other gases may need special consideration as well. Special permits for certain medical uses can be required.

Know the issues prior to completing the lease documents
It is recommended that you hire an Architect prior to completing your contract for leasing a space to help you with the issues and in some cases assisting in comparisons of spaces and the complexities of each space choice. In some cases the lease is contingent upon obtaining a permit to construct the space.