Absence of Pain Equals Absence of Pathology! Right?

How disturbing is it when a patient refuses routine diagnostics simply because they have no symptoms and they wish to save money? How distressing is it to have to treat that patient for a preventable disease that has finally progressed to a symptomatic, intolerable or critical state? To make matters worse, how unsettling would it be to have that patient disregard your treatment plan simply due to their reluctance to expend the time or funds; despite your assurance of a favorable prognosis?

Although there is no comparison to the element of human suffering associated with disease, the time and expenses that accompany the discovery and management of preventable conditions transcends all aspects of life. Awareness is the key to homeostasis- be it physical health of fiscal health. We are frequently reminded by utility companies through MC Hammer’s message, “You can’t touch that…” to be mindful about power-line safety. And the business of “Call Before You Dig” is inundated with requests from contractors and homeowners daily to accommodate everything from underground utilities to pet-containment systems. In kind diagnostic health care testing and outpatient surgical facilities are cropping up in every community. We are truly the Information Generation.

So, it would be prudent to ask ourselves: Is that a cable or telephone line- or might it be a power line that could render severe burns or electrocution; might that shallow ditch penetrate a utility feed and interrupt service for several days; is that a sebaceous cyst or a malignant growth; is the new suite harboring any construction challenges or budgetary concerns that will challenge the success of my project? We live in a “pay now, or pay later” world.

Prevention, management and the administration of curative measures will assuredly save you money, and efficient and functional planning will guarantee a substantial return on investment. As physicians and dentists you are uniquely aware of the benefits and value of preventative measures and focused remedies. It is not worth taking a risk when it comes to making the largest investment of your professional career the creation of a facility that will support and enhance your ability to deliver your professional services and support the well-being of your family? 

Our mantra regarding responsible design is best summarized in our Mission Statement: “Our company slogan, “Profit By Design” speaks to the purpose as well as the effect of design and engenders our philosophy that responsible design will assure a return on investment. To that end, we are committed to the creation of an office facility that reflects your professional image and enhances efficiency and productivity, while stringently managing the cost of its development.”

Wisdom is knowing what to do next. Skill is knowing how to do it, and virtue is doing it. - David Starr Jordan

Your prescription for design and project management is ready for you at designrx.biz or call 800-622-5563. It’s painless, and the results are guaranteed. Garrett Ludwig founded Diversified Design Technologies Inc. in 1971. The company has specialized in the design and  construction of private-practice, health-care facilities since 1975. During that time, he has designed more than 300,000 square feet of professional office space. He has a U.S. patent on his emergency services “crash cart” design. Ludwig has shared his

experience in dental office design in numerous trade publications, and continues to lecture on the subject throughout the United States. He can be reached at (800) 622-5563 and garrett@designrx.biz. Visit his Web site at http://www.profitbydesign.us.

Six Truths About Dental Cabinetry / Millwork

THEORY #1:
Pre-manufactured dental cabinetry offers superior ergonomic design.

TRUTH:
One would expect that to be true.  Unfortunately, that is a profound fallacy!  In fact, many of the products designed and produced by those companies necessitate class IV and class V movements for the assistant and clinician to access equipment and materials; thereby necessitating the temporary loss of physical and visual contact with the patient.  Some designs actually necessitate that the assistant leave his/her stool and bend or kneel to access storage spaces.
Our designs are based on the ergonomic principles of Four-handed Dentistry and maximize efficiency.

Additionally they are designed to include the efficient use and convenient storage of clinical adjuncts, i.e. electrosurge, airabrasion, intra-oral camera, laser, etc..  The cumulative effect is a work environment that is designed for the user(s) as opposed to the user(s) adapting to a pre-conceived, one-size-fits-all design concept.

MOVEMENT:  
I- Fingers only; II- Fingers and wrist; III- Fingers, wrist, elbow; IV- Entire arm and shoulder; V-Torso

THEORY #2:  
Pre-manufactured dental cabinetry is superior to others in fit and finish.

TRUTH:
Impossible!  There is simply nothing better than “the best”. Therefore all that anyone can claim
is that they are using “the best” materials and techniques.  The fact is that the materials that
are available to the dental manufacturers, are available to every designer and fabricator.  Please review and
compare the list with anyone who purports that they offer a superior product, and ask them to demonstrate their claim.

THEORY #3:
Pre-manufactured dental cabinetry is better constructed than that of others.

TRUTH:
Impossible!  There are only a few techniques that merit distinction as quality cabinet construction.  With the exception of “furniture quality” (sophisticated joinery and solid,hardwood construction) there is no difference in the finished product of the carcass (shell) of the cabinet.  Screws, dowels, biscuits and adhesives all result in solid construction.


THEORY #4:
Pre-manufactured dental cabinetry offers superior finishes to those of others.

TRUTH:
Again, impossible!  Although they are in no way superior, there are two factors that could distinguish those products as “different”.
1. They could have their own pattern produced in the surface of a plastic laminate.  To clarify: Plastic laminate is comprised of several layers of craft paper.  The last layer bears a “photograph” of an image (pattern, color, wood grain, etc.). That surface is covered with clear melamine [plastic] to provide a resistant and durable surface- thus the term “plastic laminate”.  Anyone can order “custom” laminate- for a price.  The fact is that it no better than any of the hundreds of plastic laminates available on the open market.
The exclusivity of a “proprietary finish” actually creates problems for two reasons:

A. It restricts the potential to match any adjunctive millwork that might be Positioned in direct adjacency to
the dental cabinetry;

B. Potential for the same pattern to be available years hence could be a concern if that pattern of color is
phased-out.  Should that happen, the ability to replace a door, drawer front or panel with one that would
match the original could be eliminated.

2. They could produce their own injection-molded, door and drawer-front design.  That option is, again, available to all designers and manufacturers.  It’s simply a matter of investing in the die or mold.  Injection-molding is nothing new or innovative.  In fact, that method is used commonly by many manufacturers who produce kitchen and bath cabinetry; as sold in all “Big Box” stores.  Further, the injection-mold concept is more prevalent in the lower-end lines of cabinetry, due to the obvious cost savings.  So a door that appears to be “raised panel” construction is simply formed in that shape.The bottom line is that the integrity of those doors and drawer fronts is comparable to that of all other products.  The only distinction is that the design might be unique in appearance.  For “a price” those features can readily be replicated or improved-upon.  The bottom line is- like the “proprietary laminate”- the mold forms may not be available in subsequent years- a profound example of Planned Obsolescence.

THEORY #5:
Pre-manufactured dental cabinetry is a better value than that of others

TRUTH:
Impossible!  Our designs have consistently been constructed by high-end, custom cabinet shops.  In the majority of cases, the costs for the same volume of storage as that existent in pre-manufactured, dental cabinetry have been half of the cost of pre-manufactured dental products.  When you consider the amount of money that will be invested in cabinetry for treatment, hygiene, sterilization and lab cabinetry, the savings in the physical end products alone is astounding. The ergonomic benefits are virtually limitless.


THEORY # 6:
Pre-manufactured dental cabinetry offers features and functions that are not available anywhere else.

TRUTH:
Not true!  We have done it all:  Glass doors; LED or low-voltage lighting; pneumatic doors; pneumatic  water controls; super-heated “instrument drying” storage space.  These “features” provide no distinctive benefit that can’t be accommodated conventionally or creatively- absent extraordinary cost.  In kind, the hardware that would support the function of a slide-out, pop-up, pivot or hide-away components is available from numerous hardware manufacturers.

THE BOTTOM LINE:
We live in a world of compromise.  Office space selections are commonly based on what is
available and is typically based on- location, size, need, cost and convenience.  Therefore, it is
not unusual for there to be physical conditions that compromise the use of pre-designed cabinetry in optimal
orientation that would maximize function and flow.  We share these thoughts for consideration:

1. To select or design an office around any product or pre-made assembly of products, would be like designing a house around a 7’-2” distant relative.

2. Angled or curved walls, windows, doors and vital equipment all need to be accommodated.  Cabinetry can be custom-designed to maximize the use of the site-specific condition.  

Five Biggest Pitfalls in Building a Do-It-Yourself Office

By Garrett Ludwig As Seen in DentistryIQ (PennWell Publishing)

Consider for a moment that [technically] anyone with opposable thumbs and fine-motor  skills is capable of performing an amalgam restoration. Most people would affirm that  postulate. Case in point: As a designer, I attended Columbia University to learn the  fundamentals of four-handed dentistry in an effort to enhance my proficiency as a dental office design specialist. During that education I excavated a first molar on a mannequin for an MOD, then filled and deftly [opinion] carved the compound. I would expect that, with a
little practice, I could produce a restoration that would be visually and occlussaly perfect  However, without understanding human anatomy, physiology, disease pathology, and the proper treatment of carries, the patient would be at serious risk. Furthermore, the restoration would probably fail in the absence of prescribed technique. The same outcome can be expected when designing and building a dental office without professional guidance.It never ceases to amaze me that, dental processionals- who know and understand that there is no substitute for knowledge, experience and skill- frequently venture into such an extremely complex undertaking as dental office design with reckless abandon. The fact is that design is a “pay now or pay later” business. Invariably, those who are intent on saving money by foregoing professional
guidance ultimately pay substantially more throughout the life of their project, and reap a lesser return on their investment. Unfortunately, most don’t realize it until it’s too late, and they have to live with the result or pay exorbitant professional fees in an effort to salvage their investment.Amidst the minefield of cost-sensitive “time-bombs” that could readily have been circumvented or diffused by a trained professional, there are five that I have witnessed most frequently. I share them with the hope that this insight might avert a bad investment.

Pitfall # 1:
QUANTIFY BEFORE YOU QUALIFY: IT’S THE “MEASURE TWICE, CUT ONCE” APPROACH TO ESTABLISHING SPACIAL NEEDS.
Based on observation and personal experience, it is apparent to me that the process of evaluating thequantity of space needed to support the efficient function of a dental practice is at best challenging. In most cases, I have found that do-it-yourselfers forego or trivialize the pragmatic process of quantifying the cumulative needs for each area and function of the office. The following are common judgments and oversights that result in space insufficiency.

A. The two most common barometers that are used to establish square-footage needs are industry statistics and feedback from professional colleagues. Although both merit consideration, they are often misleading. With the former, “they” may pose the axiom that seating in the waiting area should be based on the quantity of treatment and hygiene rooms. To profess that unequivocally would create the assumption that a general dentist with a family practice would have the same needs as a generalist who concentrates on cosmetic care. Also, since no two practices are equipped, staffed and managed identically, the latter can be equally misleading when establishing the need for space.


B. Accommodation for practice growth is commonly overlooked or short-changed. For example, many choose to add one treatment room for an associate that may join the practice. However, few consider the fact that a single room would limit the production capacity for that individual, and would result in a diminished potential for that person’s growth. As a result, the opportunity for an associate to join the practice is less enticing to that individual.

C. Although most practitioners make reasonable, room-by-room calculations for space, I frequently hear the
statement, “We are currently working in a ‘1,200" square foot space. Therefore, ‘2,200' square feet should
suffice.”  Theoretically, that assumption seems plausible. However, many things must be acknowledged,
including changes in building regulations, ADA and HIPAA compliances, growth; as well as many of the
conditions referenced above. It is truly remarkable how quickly 1,000 square feet can be consumed by
“essentials”.

D. In addition to the insufficiencies that are often calculated for the respective areas within the confines of the suite,there are three areas that are consistently overlooked: storage, wall-thicknesses and passage space. Despite the fact that the most common complaint from dental personnel is that there isn’t enough storage space, it is the most frequently overlooked spacial accommodation.  The wall-thicknesses and passageway space consumption are visually more subtle. Yet they typically have an even greater impact when ignored. With regard to the passageways- the more complex the space the greater the need for passageway space. So, in most cases, if passageway space has been considered in the overall calculations, the likelihood is that an adequate amount of space has been allocated is slim. Additionally, the consideration that a partition is only four or five inches thick evokes the sense that very little space will be needed for those separations. The fact is that even a small suite may consume 100 to 200 square feet with partitions, alone.

E. Less is not more. I frequently encounter practitioners who base their selection of a space on the cost per-square-foot, rather than the potential for earned revenue; since they are allegedly “throwing the [rent] money away”. Theoretically the perception is that, by reducing overhead, the net revenue will increase. That’s another illusion that is slanted by unfounded statistics “The practice overhead should be....” Nothing could be further from the truth. Dentistry, like any other business will thrive on its enhanced capacity to generate revenue. In addition to heightening function, space creates a feeling of comfort and an image of success. That’s a point worthy of consideration when shopping at Saks or Nordstrom’s .... and CVS. Your perception of those businesses is likely to be the equivalent of your patient’s perception of your practice.

Pitfall # 2:
PROFESSIONAL GUIDANCE IS HIGHLY RECOMMENDED WHEN MAKING A LAND PURCHASE
All too often building sites are determined to be distinctly challenging and or impossible to develop after the
purchase has been made.. Although there are many more, the following are common considerations that are most often overlooked by an inexperienced investor. Point to ponder: I have witnessed many practitioners who have spent more time researching the purchase of an automobile than they did when investing in a land purchase.

A. Health care facilities require more parking than does general business. As a result, it is common to find that the intended size of the building has to be reduced to accommodate parking


B. In a similar context, zoning regulations require definitive building setbacks. Not only does this often impact the size of the building, but the placement of the building, as well. The vision of constructing a dynamic structure with great “curb appeal” can be quickly dashed when it is determined that the building must be located beyond the line-of-sight from the roadway as a result of building setbacks, laneways, screening, and the imposed limitations regarding the allowable amount of paved surface- to name a few.

C. Regardless of the longevity of an undisturbed parcel of land, a soil test should be considered. It is not
uncommon to determine that a site has a high water table,; thereby diminishing or complicating the
development of the site. Similarly, the site could have been used for dumping of incompatible materials or
hazardous waste before environmental records were kept. The remedies for such conditions can be very costly.

D. Clear view of the building aside, any marketing-savvy practitioner is going to want their signage to be highly visible. Although zoning regulations vary from town-to-town, almost all towns regulate the size, style and placement of signage; and typically define the size by square-footage. So, for example, if a two-sided sign is proposed, and the regulations stipulate a maximum square-footage of twelve feet, the likelihood is that you would only be allowed six square feet per side- or a sign measuring approximately two feet by three feet. When you consider borders and logos, there would be very little space left for text.

Pitfall # 3:
PROFESSIONAL GUIDANCE IS HIGHLY RECOMMENDED WHEN EVALUATING A LEASED SPACE FOR USE AS A DENTAL OFFICE**
The lack of review by a trained eye may result in the discovery of many physical encumbrances and restrictive, contractual covenants. The following are a few of those that I have encountered most frequently:

A. First and foremost the majority of property owners list the square-footage of a suite as “leaseable”, in
accordance with BOMA (Building Owners and Managers Association); that includes one-half the thickness of  the perimeter walls. This is frequently confused by the lessee as “useable” space.  Depending on the overall  size of the space and the thickness of the perimeter walls, the “useable” space could measure a few hundred square feet less than the quantity proposed.  That calculation grows with a flush-glazed “curtain wall”; since measurements are often made to the glass surface on exterior walls. Flush-glazing is as it sounds. The mitigating factor is that the “leaseable” measurement can increase by the remaining thickness of the exterior wall. We have encountered walls as thick as 24".

B. The area inside the perimeter space may be further compromised by the existence of utility chases, elevator hoistways, roof drains, structural members, roof access ladder, low ceilings, etc.. It may also be necessary to provide space for a water heater, dental utilities and mechanical system storage (HVAC) within the suite. Each of these represents an additional loss in useable space.

C. The useable space may be further diminished by the need for an internal vestibule (or airlock) to protect the waiting area from harsh weather in a facility that has direct access to the exterior. Not only will the vestibule encroach on the useable space, it will also impact the use of the space from the standpoint of functional design.


D. Signage is often limited in a leased space; particularly in professional office buildings, as well as some retail facilities. This isn’t necessarily a “deal breaker”, since some locations are, in and of themselves, distinctive landmarks, and are identifiable and easily accessed. However, visibility and accessibility must be considered as components of the practice marketing program; regardless of the location.

Pitfall # 4:
IF THE “DO-IT-YOURSELF” APPROACH TRULY SAVES MONEY AND PRODUCES  A QUALITY PRODUCT, ONE WOULD ASSUME THAT ENDODONTISTS, PERIODONTISTS AND ORAL SURGEONS WOULD BE SERVING A VERY SMALL PATIENT POPULATION.
When it comes to construction, I consider myself to be an inveterate “do-it-yourselfer”; having worked in the building trades for most of my life. Globally, I would comfortably state that I have completed most tasks successfully. However, I have also experienced the need to call in a professional when an unexpected problem arose. In each of those cases it became apparent that, had I engaged the services of these skilled individuals from the beginning, the “dilemma” would not have arisen or would have been readily addressed at a modest cost and in full compliance with building regulations. Most importantly, I would have saved my valuable time to generate revenue in my area of expertise. The perception of cost savings by eliminating a general contractor, construction manager, project manager or superintendent is truly illusionary. In short, a dentist in a restorative practice can generate far more revenue per hour than it would cost to hire the necessary personnel to perform their respective tasks- and those persons know the complexities of the building trades as well as the practitioner knows dentistry. Therefore, if logic prevails, it makes
perfect sense to delegate the responsibilities of design, development and supervision to those who are qualified to provide those services.

A. Bid proposals and construction contracts are a challenge for all of us who work in the field. Beyond the primary considerations of cost, time-frame of completion and the inclusiveness of all trades and services, there are many more subtle factors that will impact our recommendations. To assume that decision-making process in the absence of an inherent knowledge of the construction industry is, in my opinion, financial suicide.

B. I spend a great deal of time each day on the telephone and computer (emails, faxes, transmittals) managing each project. Whether it’s a matter of value-engineering, discovery of a field condition or third-party coordination of services there is an on-going stream of project management activity that must be addressed expediently and must be thoroughly documented- just like dentistry. For a practicing dentist to respond in a timely manner is challenging, at best. Documentation of any sort is even less likely to take place. In the mean time, the “clock is ticking” and you can bet that the contractor has documented the communication; particularly if it involves a change-order that may create an added cost.

C. If one were to assume, hypothetically, that all inquiries were simple and required a brief response, the process would still be challenging. The fact is that many of these inquiries necessitate some level of research. That effort demands three things: the time to perform the task; the knowledge of where to look for the comparative data and knowledge to differentiate the risks and benefits of each.


Pitfall # 5:
FORM, FUNCTION AND FLOW ARE MORE THAN JUST “BUZZ WORDS” FOR DESIGN. THEY EQUATE TO THE ENHANCEMENT OF PROFESSIONAL IMAGE, EFFICIENCY, PRODUCTIVITY AND, ULTIMATELY, PROFITABILITY.
Convenience, comfort, atmosphere and image are all amenities that we seek when selecting a restaurant or
automobile. Let’s be honest, that a fully-equipped Camry would probably suffice as better-than-adequate
transportation. However, for a “modest” difference in cost, the C-Class Mercedes (or better) seems to lead the pack with professionals. In the same context, you can’t find a better meal than one prepared at Momma’s Diner. Nevertheless, the starched white table cloths, impeccable service and great ambiance is
what inspires long lines at Le Dîneur de Maman.  And, of course, as a preferred patron, the words, “Dr. Jones. You’re table is ready.” allow you to whisk past the masses who wait patiently to be acknowledged. Even an average meal tastes better when it is served by attentive personnel in a warm and relaxing environment.The fact is that, if there is any group of people that deserves to be treated to the very amenities that we all seek when selecting a provider of superior services, it is your patients. Since it is superior service that you are offering, preferential treatment is truly in order for those who have selected you as their dental professional.With that thought in mind, consider a distinctly tangible example of the “service” philosophy as it equates to investment: Assuming that you are considering offering refreshments to your patients, you might weigh the image presented by a Poland Springs bubbler to that of an attractive cabinet and counter that houses an in-line filter/chiller/water heater. They each provide filtered hot and cold water. However the latter is dispensed by a stainless spigot into a glass bowl. As a “consumer” which would you prefer? An unattractive, commercial-looking plastic dispenser or a classy looking refreshment center. Of course the classy system would win hands-down. So, why do I see so many commercial dispensers in dental offices? Clearly it is expense. So, let’s compare costs.  The Poland Springs dispenser will cost a minimum of $35 each month. Over a five-year period, the out-of-pocket expense would be $2,100. That does not include the valuable and costly storage space that the bottles consume (or clutter) or the labor involved to change the five-gallon (40 pound) jugs. On the other hand, the one-time cost for the built-in system might be $1800. That would include: cabinet; counter; bowl; spigot; water heater; water chiller, water filter and drain. The labor consists of re-stocking cups and an annual $20 filter change. Comfort, convenience and enhanced aesthetics- all for a lesser cost. Imagine that?!As is the case with the refreshment center, the value of each element in the overall investment in an new physical plant typically outweighs the costs associated with the inclusion of the respective design efficiencies. I have included a few other areas that are often short-changed due to a mis-perception that the expense would exceed the value.

A. There is no question that efficient design reduces task-related labor. For example, consider the expense of the labor that’s involved to process a wet film or phosphor plate in comparison to the time it takes to process a digital x-ray. No contest! Distractions aside, the time expended and the cost associated with the former, account for an extraordinary and cumulative cost. Consider the fact that the investment in any adjunct that will enhance efficiency is worthy of consideration, since labor is a variable, on-going expense that increases on a periodic basis. So, whether it’s a clinical skill or administrative task, good design maximizes the functionality and productivity of each support staff member, as well as your bottom line.


B. The optimized juxtaposition of support services reduces job-related stress, increases efficiency and enhances revenue production. Consider the last time you attempted to do a home repair and had to retrieve the necessary parts at a Big Box retail outlet. By the time you have defined and located the parts, you are likely to have toured the entire 40,000 square foot facility, and are already exhausted from the stress of the venture before you even start the project.  If you equate that experience to your own services, it stands to reason that all support services be positioned in an ergonomic and logical sequence. Since most people are intellectually aware of the value associated with this effort, it amazes me how few invest the time and effort to maximize their efficiency. .

C. Although there are several means by which HIPAA compliance can be achieved, many practitioners overlook these critical measures when planning areas for private communication. Among the methods are: Separation of “public” space from “private” space by barrier (partition, door, glazing); Separation of “public” space from “private” space with space (extended distance between private and public areas); Maximization of acoustical surfaces (carpet, wall-coverings, ceiling tiles); Distortion or masking of communications (introduction of “white noise”, i.e. moving water, music, sound machine). HIPAA regulations may not be pro-actively enforced. However a complaint is likely to result in financial penalties, as well as daunting accommodations- after-the-fact.

D. Good design is also an instrument of “people management”. That’s essentially what professional designers domanage the movement of people within a space. Beyond operational functionality, the accommodation of
comfort and convenience makes a patient’s experience in a professional office pleasurable.
Consider the last time you dealt with a large corporation (insurance company) or municipal agency (motor
vehicle department). What should have been accomplished in five minutes, probably took an hour, and involved several people. It’s simply exhausting! To avoid this experience in your own office, it is essential that the work environment be planned pragmatically to assure the effortless administration of patient services.  In addition to the fluid transition that the patient experiences moving from greeting to treatment to departure, they also are comforted by witnessing that same synergy in your office operations. These accommodations are certain to project an image of professionalism and will assuredly produce tangible results. Again, most people understand the tenets of this theory. Those who apply it benefit by it. Those who don’t suffer the consequences of it. Unfortunately, I have witnessed enough of the latter to make this issue noteworthy.

** Above and beyond the physical and developmental concerns, the language and terms of a lease can be
truly significant. However, they are commonly negotiable. The fee to have a lease reviewed and
negotiated by a specialist, whose sole responsibility is lease negotiation, is truly worth the investment.
Garrett Ludwig founded Diversified Design Technologies Inc. in 1971. The company has specialized in the design and construction of private-practice, health-care facilities since 1975. During that time, he has designed more than 300,000 square feet of professional office space. He has a U.S. patent on his emergency services “crash cart” design. Ludwig has shared his experience in dental office design in numerous trade publications, and continues to lecture on the subject throughout the United States. He can be reached at (800) 622-5563 and garrett@designrx.biz. Visit his Web site at www.profitbydesign.us.

Dental Design Projectoscopy (Feasibility Study)

By Garrett Ludwig

I can’t help but speculate that the aversion to performing a feasibility study is as much emotional as it is financial. Clearly there is a cost factor that may dissuade the fiscally feint-of-heart- despite  its proven worth. However, my perception is that a feasibility study  evokes the emotional equivalent to that of having a colonoscopy.  Interestingly, they both produce valuable insight to preventable  conditions. So, I will temporarily deem the invaluable “feasibility”  service to be a “projectoscopy” in an effort to make a point.

To date, the preponderance of my perseveration regarding  projectoscopies has concentrated on the costs and savings associated with construction, site development and purchase/lease  agreements. However, the emphasis of this article is function and  useable space.

We were asked to design a satellite office for an OB/GYN* practice- for whom we had designed three other offices. The history is noteworthy, since we had gained the confidence of the practitioners to act on their behalf and perform  the necessary pre-planning due-diligence- or projectoscopy. Previous projects with this client heightened their  awareness regarding the value of this exercise. Their faith in our ability to ferret-out mitigating factors was  particularly significant since the project was for a suite in a new (yet-to-be-built) building; and they had already  committed to lease the space. Under similar circumstances, the requisite response that former clients have expressed could be paraphrased as, “I don’t need no stinkin’ feasibility study”. “It’s a brand new building. What could go wrong?” The fact is, much!

Logically, by all expectations there shouldn’t’ be any issues with a new building. But as it turns out, there were many.  For the sake of focus, I will limit the review to the physical plant and the available space.
The architectural firm that had designed the building provided the attached plans of the subject suite to us. Upon  review, we noted that, in addition to the “horseshoe” configuration imposed by the stairwells, lobby and elevator  hoistway at the front and rear entrances, the center core of the suite was profoundly encumbered by:  structural  columns, two separate HVAC supply/return ducts and a roof-access ladder. The collective impositions created two  factors.**

1. The useable space, which is calculated by perimeter measurement, did not account for the losses associated  with the noted, internal obstructions. Additionally, it was determined that the advertised square-footage of the suite referred to “leaseable” space, not “useable” space. Although this is standard practice, in accordance with  BOMA (Building Owners And Managers Association) it is not always clear to the lessee that  “leaseable” space  includes half the thickness of the perimeter walls. Collectively the net loss was approximately 200 square feet.  So, before we even began the planning process, we were dealing with a deficiency in the perceived “available  space”.

2. The encroachment of these obstructive elements created an enormous challenge for functional use of the suite.  The horseshoe condition alone created potential “dead-ended corridors”- a distinct life-safety code violation. This  condition was profoundly exacerbated by the encroachment of the respective components on the central core of the suite, and the ability to maximize function, flow and life-safety code compliance.


Without implementing considerable changes, the project was virtually impossible to develop to meet the client’s needs. The referenced challenges are depicted in the “existing conditions” drawing below.

We first approached the architects and expressed the benefits of relocating the roof-access ladder to the stairwell.  They were receptive and agreed to that change. We then met with the mechanical engineer and proposed the noted changes in duct chase locations, as shown below. Again, our proposal was met with favor and acceptance. On a side note, with respect for the architect and engineer, I must point out that the original layout was based on the expected use of the second floor as two distinctly separate suites. As such, the placement of the respective “chases” was logical for that use. It was simply not accommodating to a women’s health practice on the entire floor.

This project had a successful conclusion, as is evidenced in the finished floor plan (below). Due to a modest 

investment of time and money, we were able to avert a near-disaster and develop a functional facility. The message here is that the greater majority of “projectoscopies” (feasibility studies) that we have performed have unveiled seriously mitigating issues related to budget, construction and space utilization. The savings in every case has been substantial. But, it is noteworthy to mention that, even if a change is not viable, the discovery of the compelling factors will, at the very least, forecast any implications that the condition might impose on the project budget. In some cases we have actually determined that a facility would not support the needs of the practice. As a result, the clients averted a poor investment in both time and expense. Knowledge is power!  Caveat emptor.

*The majority of my previous contributions on design have focused on various phases and conditions related to dental office design. The fact is that we have had extensive experience with medical specialty practices, as 

well. They include ophthalmology, otolaryngology, orthopedics, and women’s health.

** Space consumed by the duct chases and roof-access ladder created a loss in useable space of 48 square 

feet. That’s the functional equivalent of a handicapped accessible lavatory. Similarly, it is common to overlook the difference between “leaseable” space and “useable” space. In most cases the useable space actually ranges anywhere from 100 square feet to 300 square feet less than the leaseable space. In this case the combined loss was approximately 200 square feet.

Garrett Ludwig founded Diversified Design Technologies Inc. in 1971. The company has specialized in the design and construction of private-practice, health-care facilities since 1975. During that time, he has designed more than 300,000 square feet of professional office space. He has a U.S. patent on his emergency services “crash cart” design. Ludwig has shared his experience in dental office design in numerous trade publications, and continues to lecture on the subject throughout the United States. He can be reached at (800) 622-5563 and garrett@designrx.biz. Visit his Web site at www.profitbydesign.us.

Profits Abound Behnd Door Number Three

As health care office design specialists, we are commonly engaged to evaluate the efficacy of a space for its use as a health care facility prior to its development. That assessment starts at the perimeter of the site and is influenced by parking, convenience, ambiance and accessibility. Besides the obvious code concerns, the latter includes means of ingress and egress and their respective impact on function and flow within the facility. It is essential that we take a global perspective of the facility’s potential and entertain all options of development; regardless of cost and complexity. Such was the case when I was contracted by orthodontists Dave Reen, D.M.D. and Tom Reen, D.M.D. to assess- and ultimately develop- a space for their third office.

The 3,000 square foot suite is located on the ground floor of an upscale, 20,000 square foot professional office building, which is anchored prominently amidst a large, bustling retail and entertainment complex. The rectangular structure, which measures roughly 55 feet by 130 feet, features parking around its entire perimeter. Front and rear entrances are positioned at the center of the longest dimension, and provide access to the stairs, elevators, public lavatories and ground-floor suites. Intrinsically, these doors presented the most likely of the three optional primary entrances to the suite. However the process of elimination began with the client’s preference for a less obvious alternative.

Option 1:
Parking provisions aside, my clients were enchanted by the fact that their proposed suite featured a private entrance- which shared the same characteristics as the primary building entrances and featured double, smoked-glass entry doors and side lights. It was, therefore my objective to consider a plan that would utilize these doors as the primary entry. Since the building is located in Western Massachusetts, it was imperative that climate-related issues be addressed first. Foremost in that consideration was the inclusion of a vestibule, or weather buffer. It was quickly determined that the enclosure would bisect the available space; thereby encroaching on seating in the waiting area as well as obscure visibility of the waiting area from the reception desk. Those impositions notwithstanding, the concern for demands on heating and cooling were equally daunting. The combined effect of the southern exposure on a highly glazed exterior, and magnified by the anticipated high occupancy of the waiting area, created the likelihood for the inclusion of a third zone in the heating and cooling system. The combined cost to construct the vestibule and upgrade the HVAC was approximated at $5,000 to $6,000 Last, but certainly not least, that section of the suite was determined to be the least hindered by physical obstruction, and offered the most favorable location for the six-chair treatment bay. Consequently, we abandoned that consideration and took the next, most logical course of action by considering the use of the more conspicuous entrance from the public corridor.

Option 2:
Although nicely appointed, the lobby and passageway offered a conventional tenant directory and limited signage on the respective solid-core doors, through which all of the ground floor suites were accessed. Beyond the lackluster entrance to the object suite, lay other encumbrances. The area immediately inside the suite was constrained by the building’s elevator hoist way. That condition was exacerbated by the existence of a structural support column that was positioned seven feet inward from the entry door. The appeal of utilizing that entrance was further compromised by the lack of natural light. Although we could have replaced the existing, solid-core door with a glazed entry, the cost of a fire-rated, single-light door was estimated to range between $1,000 and $3,000- depending on the type of glass and frame used. Lastly, proximal parking was determined to be extremely limited. That was clearly due to the fact that most patrons logically parked as closely as possible to central entrances, as a matter of convenience. Although there was substantial parking available at the distal ends of the building, the compulsory traverse was equally undesirable. Collectively, these factors inspired my clients to have me seek, yet another, alternate means of ingress. 

Option 3:
Surprisingly, the east entrance offered a variety of inherent benefits. First, there was an abundance of parking directly opposite and bilateral to the entrance; which resulted from the parking usage referenced above. It was also evident that the east entrance offered a greater potential to accommodate waiting and reception services, as well as create optimal traffic flow within the suite. Lastly, since the overhead door presented an eyesore on the highly exposed eastern elevation, there was a good chance that the building owners would be receptive to a facelift that would include visible signage. Although all were exceptional advantages, the latent potential for free marketing was by far the most engaging. That was inspired by the fact that the enormous mercantile complex, which surrounded the structure, was bifurcated by a heavily traveled, two-lane access road from which the east end of the building was highly visible in each direction.

The greater majority of patrons of the various amusement and retail establishments are channeled past the site. That qualification was distinctly enhanced by the image that theend of the building could be perceived as a separate and exclusive address. The existing conditions, on the other hand, presented some fiscal, as well a physical, challenges. The former tenant- an insurance agency and claims processing center- had installed the overhead door and hinged utility/egress door on that end of the building to accommodate a drive-in claims adjusting service for their insured. Also, as a result of the topography on the site, the 600 square foot drive-in facility was positioned approximately one-and-one-half feet below the primary grade, with which the main floor of the suite aligned. The two levels were connected internally by poured-in-place concrete stairs. In order to take advantage of the profound benefits, it was imperative that the following be addressed: Removal of the ten-foot overhead door and the three-foot, steel, hinged door; partial enclosure of the remaining openings with matching brick; installation of a new window in the opening formerly occupied by the overhead door; creation of a new penetration for the new glazed entry; installation of same; construction of a handicapped ramp and ambulatory access stair to meet the existing level; poured concrete floor in-line with the main portion of the suite; plus awnings, signage and exterior lighting. Despite the $18,000 price tag, the concept was warmly accepted by the building owner and my clients.

The Bottom Line:
The amortization of the renovation to the eastern elevation of the building over the term of the lease was clearly fractional. One new patient start per month would more than cover that expense. More importantly, the cost/benefit analysis between the actual expense and its marketing value alone was profound. A full-page, weekly ad in the local newspaper or annual Yellow Pages Directory could not compare with the subtle, broad-based impact of the signage. Similarly, the availability of convenient parking- directly outside the private entrance to the practice was particularly appealing, as well. The added benefit of smooth and efficient traffic flow can't be overlooked either- a happy staff stays with a practice and an efficient staff generates revenue. The exuberant feedback from patients and staff has been extremely positive and the clients anticipate unprecedented growth.

ECONOMIC PERSPECTIVE
Our projects have ranged from a very modest $30,000 to over $1,700,000. Regardless of the size and scope of each project, our focus has always been dedicated to function, efficiency and, above all, a calculated return on investment. The most successful of these have been created in concert with clients who have a propitious understanding of the difference between cost and investment; and a willingness to endorse their belief in themselves. The Reen brothers are exemplary in their perception of and commitment to that mindset. Not only did they recognize the value of the investment in the east entrance, they further endorsed the expenditure by including amenities like a vibrant floral display at the building’s threshold and a soothing, wall-hung fountain, in the expansive waiting area. The open, flowing reception desk and the abundantly spacious treatment bay were also requested features that they perceived would augment clinical and administrative services. In the few short months since their opening those perceptions have borne fruit. 

LinkedIn: http://www.linkedin.com/in/garrettludwig

They Made Us Do It!

Plea: But, but… we are simply “facilitators of our client’s dreams”. They made us do it. Honest! 







Defense: Our designs are predicated on the following: 

1. Function
2. Flow
3. Space utilization
4. Efficiency
5. Productivity
6. Client tastes
7. Budget*

Value Engineering:
Since most projects are influenced by budgetary constraints, it is imperative that our clients have the opportunity to select finishes and architectural appointments that will be representative of their
quality of care- yet financially manageable.  This is accomplished by value engineering- or cost/quality comparatives.  For example, counter surfaces can be constructed with plastic laminate, solid surface (i.e. Corian) or stone.  All will look great.  But, more often than not the more costly products and details are chosen.


EXAMPLE ONE: 
The facility on this project only offered windows on one side of the building.  With good sense, the client chose to have the treatment rooms face in that direction.  Since we also needed to provide privacy between the treatment rooms and the reception area,  the only way that we could provide natural light to the internal 
space would be through  an interior window in an fixed partition; known as a “borrowed lite”.  Among the variety of options were the vinyl-clad, acrylic “glass block” show in the photos.  The “glass” measures ½’ think.  However, from each side the windows look like conventional glass block.  With the inclusion of radiused corners, the windows look great.  However the cost was a fraction of the cost to construct a glass block separation, and the windows served as a perfect sound barrier.

EXAMPLE 2:
It is a fact that based on first impressions; the expectation of the initial impression will persist, if supported with a similar tone. Since the featured project included land purchase, a new building with leasable space and equipment, we had to be conservative in our proposal to create a first-class image.  Although the reception/
greeting area is nicely appointed, it was created economically.  For example, the etched glass is actually an applied film on clear glass- un-discernable to the eye.  Also, what appears to be a “raised panel” façade is simply two sheets of stained plywood with square-edged wood trim.  That detail is carried onto the counter surface.  The ceiling features recessed cove lighting in a boxed soffit.  But with the inclusion of a conventional, recessed ceiling, the 
access to framing and lighting is simple. Therefore the construction costs were quite reasonable. 

Having created a favorable “first impression”, we simply had to create a similar vision throughout the rest of the office.  The transaction counter in the departure features a plastic laminate surface.  But, since it blends all of the surrounding finishes, it looks first-class.  We also created a “stepped soffit” on a “shoe-string” by simply layering the drywall.  The effect is as dynamic as if it were framed and sheetrocked at distinctly different heights.  

EXAMPLE 3:
By admission, we do create “high-end” offices… on request.  The photo shows a serpentine, wood veneer reception desk with inlaid glass tiles and solid surface transaction counter.  Those contours are 
mirrored by curvilinear, drywall soffit with recessed cove lighting. We are simply “facilitators of our client’s dreams”.  What’s your preference? 

Conclusion:
The majority of our clients choose the finer appointments.  Perhaps that is why they are among the most successful dentists in the United States.  We are very proud of our contribution to those statistics

Planning A New Office? How would you like to save $40,000 before you start?

Would you like to save $40,000- before you start?

We do this for our clients on a regular basis.

Based on the fact that our client was intending occupancy of a newly-constructed, Class-A office building in a vital and active commercial district, he felt that a feasibility study wasn’t warranted; but reluctantly agreed to proceed. The structure is a two-story, 20,000 square foot (10,000 per floor), “L”-shaped building. At the time, the only occupant was located on the ground floordirectly below the suite that my client had selected [photo similar to client structure]. Admittedly, the angled front of the building was appealing- as was the view of the surrounding business community from the second floor suite. However, hidden in the beauty were two mitigating factors:

1.The highly glazed suite had both a southern and western exposure-, which would have created a “heat-load” on those sections of the building; not tomention the oppressiveness of afternoon sunlight.

2. The acute angles created by the perimeter walls created a challenge for strategic placement and ideal usage of the interior space. Although we pride ourselves with the ability to maximize every square inch of space, there’s only so much you can to with a diminishing dimension.

As compelling as these factors were, they could be managed, and would not be “deal-breakers”. However, a much greater but less visible condition loomed. Clearly, the majority of plumbing and electrical service in a dental suite is run under the floor of the office; which is, of course above the ceiling in the suite below. Since, it would be necessary for the tradespersons to gain access to the lower-level suite, we visited that business to determine if there were any challenges present. We discovered that the ceiling was entirely sheetrocked and was detailed with architectural appointments, like soffits and crown molding. Additionally, all of the lighting fixtures were recessed and/or surface-mounted track lighting. It would have been impossible to penetrate that ceiling and maintain occupancy of the suite. Un-phased by the discovery, my client declared that we would simply elevate the floor in his suite, and run all of the utilities above the existing floor. Having done that for another practice in Boston, I expressed that the floor could be constructed as proposed. However, it would have been an extremely costly endeavor- approximately $40,000 costly. Those expenses included: framing, decking, ramping, railings, etc.

Additionally, the encroachment of the ramp and other architectural barriers compliances would have consumed over 200 square feet of otherwise useable space. Those implications were exacerbated by the position of the suite by virtue of its adjacency to a stairwell and demising wall to the neighboring suite. In short the space was somewhat pie-shaped- the entry being the narrower portion. Since the space was large enough to necessitate two means for egress to comply with life-safety regulations, there were additional design challenges needed to accommodate the ramp. For example, by code, the egresses must be a defined distance apart from each other. Based on that knowledge, we evaluated another suite on the same floor. Not only did that suite offer equivalent amenities (except for the angled walls), it featured a “land-locked” space that was created by a base-building condition. That space was approximately 40 square feet, and could not be defined as leaseable space. But, it certainly could be used for dental equipment and storage. The client had been slated to sign the lease for the angled space on the following day. The lease was signed- for the alternate suite. Our feasibility service was completed in one hour. The lesson here is that there are dozens of mitigating factors that may not be apparent to the un-trained eye. We highly recommend that every opportunity- lease or purchase- be evaluated by a professional. 

Behold: The Construction Contract

Oddly enough, it’s not the fine print to which you are vulnerable

It would require the text equivalent of “Gone With The Wind” to
adequately describe the details necessary to execute an average dental office construction project. As a result, most contracts- including the AIA [American Institute of Architects] document, defer the “description of services” to the respective construction documents, AKA: drawings, plans, etc. The dreaded fine print in the construction contract, although duly worthy of scrutiny and evaluation, is simply additional legalese intended to protect one or both parties in the agreement. Eyes wide open: no harm, no foul.

So if the answer is right there in big bold print: Construction jargon, both large and small print- is only an agreement stating that your contractor will “provide… in accordance with the services to be provided is “‘doc-u-ment: [is] an original or pages containing dream-inducing images of your future office- formerly referred to as benign “plans” or “drawings”- will heretofore to be known as “exhibits of the contractual agreement”. And here’s the kicker: The author of those documents is not a required signatory on the contract.

In most cases there is no agreement. This often results in costly change-orders. Yes, change-orders are sometimes unavoidable. But,
they should be limited to things like unforeseen site conditions- not to be the expected norm. I’ve witnessed projects that grew by as much as 30% in cost overruns- that’s $90,000 on a $300,000 project, and 98% for those costs were predictable, preventable or at least known potentials to be included in the construction cost proposal. No excuses.

We were recently asked to review plans that were prepared by another firm. The results of that review, although daunting, are immaterial. But, I will note that the first sheet in the set of drawings contained a large text table listing services, dates and trades- for change-orders*. Talk about your “red flags”. Also, visible in blazingly bold print were disclaimers exempting the designer from the responsibility of anything from building and life-safety code
compliance to construction detail- deferring them to be addressed in the field or “by others”; thereby placing the bulk of responsibility on the contractor. But, despite this complete communication and budgetary disconnect, the client was prepared to sign a construction contract that left them vulnerable to extensive additional costs. Close call.

Analogously, construction is much like dentistry. Both will have a superior result when thoroughly prepared and detailed. So, I would like to site an example of the deficiencies that are quite common in construction documents. The drawings referenced above did note that a backflow preventer should be installed “per code”. That would be perceived by many lay people as having met the obligations associated with compliance and inclusion as a budgetary line item. The fact is that the directive did not include: location [at water source/inline to defined locations]; whole-house or dedicated run; size; manufacturer; model number; associated plumbing specifications [hard-plumbed/air gap/vacuum breaker]; testable/non-testable; also some towns require more than one. The cost differential could easily span costs of predictable, and preventable, cost overrun. Professional design fees are fractional by comparison.

Besides construction details like those noted above, it is vital that all materials be defined in advance. This is necessary for two budget-related reasons: 1. The cost of the products have an obvious impact on the budget; 2. The labor associated with the installation of different products can vary significantly. This information is typically provided on the drawings and are referred to as construction lighting and finishes, at the very least. This data takes the guesswork out of construction cost estimating, and aids in the process of value-engineering (substituting a similar product of a lower cost) if needed. For example, a door schedule will contain the following: height; width; thickness, detail (flush/raised panel/inlay/glazed) construction (hollow-core/solid-core) species; stain/finish; lights (glass- full/partial, divided); type of frame (wood/metal/etc.); direction of swing, type and finish of hardware; rating (fire protection). The cost differentials can range in the thousands of dollars. You may have wanted cherry or maple doors with a distinctive grain. But, the budget may only allow for standard Douglas fir. Imagine first-class dentistry in an average facility. Oh! That’s what you’re moving from.

So, that brings about another irretrievable forfeiture- quality.

Besides accommodation for growth and improved operational function, the most desired result is the achievement of an enhanced professional image- The “wow” factor. If you plan and budget for a granite transaction counter (as opposed to plastic laminate) it is likely that the cost would be quite manageable; particularly if other products and services provided in the contract are valueengineered [if necessary] to make that accommodation.

Clearly your attorney will protect you from the potentially harmful legal vernacular of the contract with the general contractor or construction manager. But, who is governing the content of the construction documents for the actual services that the contractor has agreed to perform? No one. But, all costs are yours to absorb- because you agreed to pay for them; whether by definition or by tacit acceptance of the designer’s documents. In a nutshell, you
have given the designer a blank check to spend as they see fit with no accountability or remorse. There is very good reason and practicality to hire a professional. They are the only ones who are capable of actually defining and managing your project and the associated costs of development.

A footnote to hiring a professional designer- make certain that they are not deferring any services like MEP (mechanical, electrical and plumbing) to a third party. It is essential that the designer have a full and articulable understanding of all equipment and associated construction materials and services. Without that knowledge, they will be unable to effectively control and manage the project.

Please note that most of the contractors with whom we have worked are honest, hard-working and accommodating people. Regardless, they are in business to make a living, and can’t perform their services for free. Consequently, if additional work is required as a result of missing or insufficient information, they are entitled to be compensated for that work. That’s the good news. For that small percentage of unscrupulous contractors- caveat emptor!

Lastly, the contract to which your attorney’s attention should be directed is the one between you and your designer. Paramount within that agreement are two major concerns: 1. Beware of disclaimers- professionals “own’ their work. 2. Request verification that they are capable of providing the necessary construction details that will allow you to establish and adhere to a budget. Take heed, and God-speed. schedules; which includes door, window, plumbing,

Garrett Ludwig founded Diversified Design Technologies Inc. in 1971. The company has specialized in the design and construction of private-practice, health-care facilities since 1975. During that time, Garrett has designed more than 300,000 square feet of professional office space. He has a U.S. patent on his emergency services “crash cart” design. Ludwig has shared his experience in dental office design in numerous trade publications, and continues to lecture on the subject throughout the United States. He can be reached at (800) 622-5563 and garrett@designrx.biz. Visit his Web site at http://www.dentaldesign.pro/. or LinkedIn: http://www.linkedin.com/in/garrettludwigcontractual fine print is essentially harmless, you might ask how you might otherwise be vulnerable. TheDocuments. The signed contract itself- replete with its legalconstruction documents” and you will “pay…”[and pay, and pay]. As such, the actual contract for thecontained in the Construction Documents. To wit, according to Merriam Webster aofficial paper relied on as the basis, proof, or support of something.” Those prettythree-party communication (client, contractor, designer) prior to the signing of the twopartyseveral hundred dollars. That’s just one small, but costly, example of a very

Behold: The Construction Contract