CCB: [00:00:00] Welcome to the ONEder podcast, this is CCB, your host, and we have a conversation today that I'm sure you're going to find extremely interesting, especially if you're interested in Lean Construction and IPD. Today's guest is James Pease from UCSF Health Design and Construction, and I'm going to ask James to introduce himself and give us a little bit of his background. James, welcome.

James Pease (UCSF): [00:00:27] Thanks, CCB, first of all, for having me, it's a pleasure to be here. Little of my background. I've been a healthcare owner's rep for almost 20 years now, so I means I generally work for a hospital or as a consultant representing the hospital to build inpatient remodels. So I started out at Stanford Hospital, worked as a consultant in the Bay Area for a number of years. Then I spent 12 years at Sutter Health in the Bay Area, as well as the Sacramento market. And for the last two years, I've been leading the Health Design and Construction department at UCSF in San Francisco and expanding into Oakland and the East Bay.

CCB: [00:01:11] You've got a big job, James, and we're excited that you've carved out a little time to talk with us. What we really want to start with is if you could describe the UCSF Health Design and Construction project process, given the fact that you own the health portion of UCSF and not the campus portion of UCSF.

James Pease (UCSF): [00:01:34] Yeah, so a little bit on campus and health. There's essentially three leaders of design and construction, and we all report Brian Newman, who's the Vice President and Associate Vice Chancellor of Real Estate, Senior Associate. Campus essentially does all of the classrooms, the research laboratories, dormitories for the students and the faculty. We have a health major capital group led by Stuart Eckblad that's building the new hospital at Parnassus Heights and Block 34, which is a major medical office building down in Mission Bay, right across the street from the hospital by Mission Rock, for those of you who know that area, and Health Design and Construction, which I like to say, does everything else health related. So we do all of the renovations in the main hospital campuses on Parnassus and Mount Zion. We're leading a major new construction project, a new pavilion at the Benioff Children's Hospital Oakland Campus. And then one of the exciting things about UCSF Health over the last several years and going for the next 10 is that we're really transitioning from a hospital to a health system. So we're growing out of outpatient clinics and our strategy is a little different than others in that we're really partnering with hospitals in different regions. So we have partnerships with Washington Hospital in the Southeast Bay, with John Muir Health in the East Bay, with Marin General in the North Bay. Ok, so that's a little on Campus and Health and what our team does, so within our team, we have about 130 active projects. And I would say our typical delivery right now is we work on things from early concept all the way through to six months after we're seeing patients in those spaces and our group has a really internal design group. We actually have our own in-house architecture firm. So we do really small, mostly facility projects in-house. And then we will go out to the design community. We're a public agency, so we advertise at https://designandconstruction.ucsf.edu , so you can find publicly all the projects that we have coming up. We have a huge DEI Diversity, Equity, and Inclusion outreach program right now, where we're really trying to grow the disadvantaged business enterprises that we work with. And so specifically for the small design firm community, you'll reach out to us because we have an interest in growing our relationship with that market. Mostly project delivery and we can get into more detail, but mostly what we do now is design, bid, and build, which is not my background coming from Sutter and a private organization. So we’re spending a lot of time figuring out how to deliver projects more collaboratively, so to get construction partners and trade partners onboard early so that they can collaborate with the designers and the design process so that we can work the way I like. We want coordinated shop drawings to get submitted for permit. And I'd say for a lot of our projects, we get a permit and then we start the shop drawing process and as many know, doing that in a 50-year-old occupied hospital is a really way to get in trouble.

CCB: [00:05:17] A really good way to get in trouble. Yeah, yeah.

James Pease (UCSF): [00:05:19] Really good way. So we have an amazing team. We get to work on really, cool projects with really incredible people. But it's hard and we're never bored.

CCB: [00:05:32] Well, I think that sounds really exciting. I had a question in that set of comments that you made around the idea of IPD, recognizing that UCSF would like to move more towards that. But as an owner's rep, where does meeting the needs of the stakeholder group fall into the process? From the standpoint of the providers and the educators and the patients and whomever the folks are that are going to be growing into, how does that get coordinated into the whole construction planning process?

James Pease (UCSF): [00:06:16] I'd argue that's the most important, not just the users of the space, like the nurses, the clinicians, all of the support staff, but the patients. At the end of the day, the patients who use our facilities are our primary customer, and how we provide care in those spaces. So we're spending a lot of time of making sure that we work with our end users at the beginning of a project to understand what they're trying to accomplish with the space. I would say that's been a shift. We're trying to change the conversation from, "I need 2500 square feet," to, "Let's not talk square footage. Tell me what you're trying to do, what is the throughput that you're looking for? What's the vibe that you want?" I just got out of a meeting where it's much more, before we've even started design, schematic design, about “what are the feelings that you want people to have when they're in this space?” So really pulling that forward and documenting that and what we might call a "project charter", whatever you want to call it. So you have some grounding principles before you start into what would be more of a traditional schematic design or design process. We have kind of patient advocates, Community Advisory Board for projects. UCSF, I think, really goes out of its way to work with the community and be a partner and make people part of that process as opposed to designing in a vacuum and I hope they like it when we're done. So that's what we're trying, and we can always do better, but it's something we're focusing on.

CCB: [00:08:04] I was struck by, we worked with you on the Baker Precision Cancer Medical Building, and the whole feeling within the very large medical facility is so inviting. And you could watch it get more colorful and get more expansive and inclusive, I'm going to say, to the community and the patient groups that might be coming through there. So it's an interesting thing to watch, and in conversations with some of the people on that team, listening to who got tapped to ask those questions and bring in what some of those interests might be so that the facility itself would feel comfortable to the entire community coming in, and your patients come from all over the world. So that's a very large stakeholder group to be considering.

James Pease (UCSF): [00:09:24] I want to make one comment about what you just said about our patients that are all over the world. One of the things I didn't expect about coming to an academic medical center, but it's pervasive everywhere, is there's very much a mission here like we're trying to cure cancer. It's not about we're trying to provide healthcare. We have to provide healthcare at affordable cost that makes sense, but its overarching goal was like, "change the world", which is, it's just really exciting to be involved in something like that and you really are trying to be the best in the world, that's something, and one of our researchers last week won a Nobel Prize. And that gets communicated throughout the entire organization. So yeah, we do. We want to compete on a world scale. We don't see that we're competing with our peers within the City.

CCB: [00:10:26] Exactly. Well, I mean, when you think about when there's ranking and in looking up rankings of healthcare systems and rankings of major hospitals or rankings of educational institutions. And UCSF is bubbling up higher and higher on all of those rankings. And all of us in the Bay Area, well, I would say the world, but in the Bay Area, we're very fortunate to have access to it because it does bring that, you know, raises the bar in a huge way. So you're talking about that, there's a larger UC system and a larger UC health system. We also have worked with UC Davis Health. And so I'd be curious to understand a little bit more about how does that all work together, or does it?

James Pease (UCSF): [00:11:17] I would say that it absolutely works. I would say that each of the individual UCs really does function on its own. So we have a chancellor, Chancellor Hawgood, who leads the Health and the Campus organization and is incredible. By the way, the fact that we're growing in the rankings is not by accident. I mean, there's some incredible leadership that are very focused and strategic on what they're doing and how they're doing it. So each individual, and there're five health systems within the UC system, and so each of those is run like its own business and has its own capital plan, its own strategic plan on what it's trying to do. But all of the funding is approved by the UC Board of Regents. So anything over, I forget what it is a million or so, there really is an overall strategic approach by the UC as a system about where it's providing healthcare, and I think there's an interesting potential future of the UC system as being a health system across California. And as a personal note, as a UC employee, I actually live outside Sacramento. And so I get most of my healthcare for my family through UC Davis because all the employees that are in the UC health system, not the UCSF or the UC Davis health system, it's a UC Blue and Gold program across the state.

So anyway, we do that, we coordinate. So I know who my peers are, and I regularly talk to my peers at UC San Diego or UC Davis. We share information a lot. We present to each other on what we're working on. We have quarterly meetings where we get together, and part of that's internal part of it we meet with OSHPD and figure out how we can do all of the things that we're trying to get done. It's an exciting time over the next 10 years because UCSF has a I think it's a $10 billion, 10-year capital program between Campus and Health. UC Davis has a $6.5 Billion dollar capital program. UC San Diego has a $1 billion capital program. UCLA, UC Irvine, there's a lot going on at the UC system right now. And so the Regents and the Office of the President, which is really the core group, more like, provide strategic guidance and help keep us all in line. So we're not stepping on each other as we're doing these things. And I'd say they're really helpful. They also are really driving a lot of our policies. So our seismic policies, our sustainability policies get done by the Office of the President with our input and then they get rolled out to all of the campuses. But it's not a talk down from an operations like “this is how you have to run your business” kind of a thing.

CCB: [00:14:26] Wow. The scale of the operations is impressive and kind of makes you take a breath and stop and think about what’s the difference between a public institution and a private institution, and you've worked in both of those for-profit and public, what is that? Is there a different cultural feeling when you're moving from one to another? And you also worked at Stanford, which has its own culture. Well, it is curious. We work with all of them, so you can see some of the differences. Ok, so I'll just kind of pivot over to the idea of networking with existing medical institutions. You just talked about with working with John Muir or working with….is that growth, is that collaboration, is that, you know, increasing accessibility? What's driving that decision?

James Pease (UCSF): [00:15:42] So I think that it's essentially a win-win for everybody. So our goals are really to be the experts in the tertiary or quaternary. So for those listening, not in healthcare, it's to really deal with complex cases where you need specialists from multiple disciplines that are coordinating with each other to treat a patient who in a lot of cases is very ill. And so some of our partners, it works out very well for, if you need routine care and you live in the East Bay, there's no point for you to come all the way into San Francisco. But if you have something that is rarer, or you want access to somebody who's one of the best in the world in treating that condition, you want to have access to that. And so there's a collaboration where you can get more routine care close to your house, close to where you live, close to where you work. But then you still have access to kind of the super specialists for things. And so that's, I think, the foundation of our collaborations within the Greater Bay Area.

CCB: [00:16:53] So the idea of that kind of collaboration brings up the nature of digital health as well. And what is that looking like and how are you thinking about it at UCSF Health?

James Pease (UCSF): [00:17:06] Well, I think we're still early. There's lots of specialists that we have that could answer that question better than me. But I think, like most systems are, if I was to draw a trend line, it looked like it was increasing. But if you look at it now, it looks like it was flat for five years. And then around April of 2019, when COVID went through the roof, it went up, fifteen-fold or twenty-fold, so we're doing a lot more remote visits. Mental health is a big one where we're able to do a lot more mental health outreach with people that might not be willing to come in to see us or not willing to come into the City. But by being able to access our network from their bedroom, you know, through Zoom and through virtual visits. Definitely for myself with kids, a lot of the kind of cold and sniffles, it's really nice to do simple things virtually. And you can do follow-up visits virtually. Part of our core business is we have a lot of really sophisticated operating rooms and are doing heart and brain and neuro procedures and stuff that … those will not, at least for a really long time, won't be done virtually, although robotics is growing a lot. So I think it's allowing us to have a greater reach to treat people outside of the things that have to be done in-person.

CCB: [00:18:46] Does that have an impact or what impact does that have at all on planning and design and construction? Are there any extra or additional resources that need to be considered to be able to support that?

James Pease (UCSF): [00:19:01] Yeah, I think this is where I would say that we're kind of still at the beginning. I don't know that we know what it's going to look like. We know it's going to be different. You're starting to see video conferencing capability being brought in to just the typical exam rooms. Block Twenty-Three, the Weill Institute, has essentially video conferencing capability in all of the exam rooms there. We're starting to figure out if a doctor is doing a lot of remote visits, do they do that from their home? Or do they want to or need to come to a place where they have access to more things and do those visits virtually, but they're somewhere else? There's a lot, I was talking with the city of Oakland about they've really done an excellent job of growing access to broadband during COVID. When school became remote, there are a lot of areas that don't have good internet access. There's a lot of areas that do. And so there's really a big disadvantage there. So as internet access is grown, then the ability to get access to this virtual care is really growing. It hasn't changed like the layout of our exam rooms and things like that. But on the downside, I think some of our staff are saying, we've grown so much and we can't handle it. Because now we can see so many more patients, so now we have to grow the infrastructure and the people to actually handle that increased volume. And so I think it's stressing people at a very stressful time.

CCB: [00:20:48] Yeah, that's a path you probably don't want to go down, really, because it's not really the nature of this call. However, one of the things that that I was thinking of as we're having this bit of conversation, is there's the whole nature of access in general that has been a question in the health care world and a challenge like everything has been exacerbated by COVID, and what that has exposed. Are you aware of any thinking at UCSF about that whole nature of access? Because the inequity, no matter, well, I was going to say there's urban and versus rural and there is even interurban kind of accessibility. But at the UCSF system it feels like you're going through every single one of those locations and doing upgrades.

James Pease (UCSF): [00:21:48] We're absolutely doing that and a really interesting thing I mean, UCSF, I think especially with the collaboration with research, they do study equity a lot. It's a major focus of the overall organization. And even though we have clinics in different areas, just one example looking at the vaccine within different populations within the city is very, very different. So the issues around inequities are very complex and very deep. And it's not, I guess I'm learning as I go, but it's not just about having a clinic in each part of town. There're so many more facets to health equity that we need to really dig into and figure out.

CCB: [00:22:39] Pivoting to another kind of interesting opportunity for construction in general is, what do you, James, think about some of the prefabricated and modular construction opportunities that are popping up? What does that look like relative to healthcare?

James Pease (UCSF): [00:23:02] I'm personally really excited about that. I would say, you can't deny the numbers that costs are increasing faster than we can afford them. You know, it's like we need to drive the cost of care down, but construction costs are through the roof and they have been. And I worked on the Sutter Mills Peninsula project, and we built that in around 2010 for, in the $600 and $700 million range, I mean, that would be like a $3 billion project today, four billion. And we're talking 10 years, 15 years later. So we're not, I mean, we keep internally, we're like, oh, escalations about 3% a year, 4% a year. But if you look at across the project, it's actually been way more than that. Just like what could we build the same project for today that we built 10 years ago? The point of that is, I think if we can't get to some kind of modularized, industrialized look at manufacturing instead of construction.

And so, to philosophize for a moment, construction is a craft still, it's an art. It's not really, we call it an industry, but it's very much a craft. Things are done by hand. They're designed from scratch. We have typical details, but in essence, every single building is a one off and it's unique. And if we built cars that way, cars would cost, just your standard commuter car would be a $200,000 car, and it would take you eight years to design it and build it. And then it wouldn't work. So I believe pretty strongly that we have to go towards more of a templated, modularized. And let me say, because I know there're designers listening, that doesn't mean there's no room for design, and it doesn't mean that we still don't build cathedrals and parks and certain office buildings…that's back to our earlier conversation. You have to define what it is you're trying to do with the project and meet with your customers, and so some things you want to be awe inspiring, and some things like we need to build really efficient exam room so that we can see people affordably. and we can diagnose, and we can help, and we can move them on in their day. And so those things, I don't think, need to be a one off every single time. I'm kind of passionate about this issue.

CCB: [00:25:43] I can tell, clearly. You are enormously involved in many, many different aspects along with your regular job, and so as I was doing a little bit of research around you, like, wait, he's got an IPD Lean website. Talk about that for a little tiny bit. Where did it come from and what does it want to do?

James Pease (UCSF): [00:26:07] OK, a little background. So I started in my career. pretty much everything I did was hard bid. I didn't know anything different. I don't have a construction background, I studied economics in school at a UC system, UC San Diego. So design, bidding and building makes sense until you've actually worked in this industry for a little while and then, you know, it doesn't make sense, but if you don't work in this industry, you're used to going out and like, how much does a haircut cost or how much does a car cost and you can shop. But in this industry, you can't really shop. So then I got involved in CM at Risk with getting a little bit of design assist. But those projects still were late and over budget, and I got exposed when I started at Sutter Health, to the Lean Construction Institute, which is focused on taking just good operational, best practices. Lean, they would say, is focused on continuous improvement and respect for people, so these are not radical ideas. But consistently implementing those things and taking what Toyota's done in manufacturing and what most people do in manufacturing now. And some people say, well, construction is different. I'd argue, like what can apply? Don't tell me the reasons it won't work. Let's take what we can apply and let's use it. So I got involved in that. I got involved in integrated project delivery, which is, I would say integrated project delivery is different than other contractor delivery models. Because you take design and construction and the owner and you sign a single contract, you put people's profit at risk and then you provide a shared savings, So that the entire team either does well if the project does well or everybody loses money if the job doesn't go well. In almost every other model, if the job doesn't go well, the owner pays more and everyone else still makes money and walks away. And if you're not lucky, you have lawsuits and then you end up spending a lot of money fighting and then nobody is whole at the end of the day. So the first IPD job I did, we finished an OSHPD job on budget and on schedule. We paid an incentive to everyone on the team. We sat down and celebrated at the end of the job and said we'd like to work together again. And I was like, wow, I've never had this feeling before. This is such a better way to get something done. So that leads to the website. I started doing some presentations and then I decided, oh, wouldn't it be great if people could see this information that didn't have to go to a conference or something? And one thing led to another it's https://leanipd.com/ I bought it because it was available and I was surprised that it was available more than anything. But now it's a collection of blog articles and case studies. And so I get to talk to a lot of people like yourself in the industry. And I thought, wouldn't it be good to share some of the things that we're talking about with other people? So now, there's a lot of guest posts as you've seen on the blog. So I wouldn't say it's extra, I would say it's aligned with what I'm trying to do at work, and writing is a good way of distilling a whole bunch of noise down into concrete elements. So when I tried to write down or make a presentation or write a blog post, it forces me to distill a lot of complex concepts into like what are the two or three things that really matter? So check out the website. Hopefully you're interested now, but that's where it came from and now just it's probably five or six years. It's just something that I put a little bit of time into every week and it's growing.

CCB: [00:30:03] I think it's pretty amazing, and I think UCSF is very lucky to have you and we are all very lucky to have you in our ecosystem. We're winding down because we've had a great set of conversations here. I just wonder, is there anything else that you'd like to share with us that you think an audience of providers and folks that are interested in the way that people and the built environment come together? Anything else that you think they should hear?

James Pease (UCSF): [00:30:35] One, we'd love to work with you. We have more work than we can do coming up. And we love to partner with community. One of the things about UCSF, the whole UC system, our job is to better the lives of people in California. And so that's much different than if all you care about is cost on your projects. You may be driven one way. Our goals are really to work with as many firms as we can and share. Personally, I would say, try something different. Don't be afraid to innovate, don't be afraid to make a mistake. Take some risks because if we keep doing things the way we've always done, then we're going to get the same results. And like that budget thing we talked about, we have more demand for projects, than we have capital. So it's not that we won't spend the money if we can do it cheaper, we would just do twice as many projects and we'll be able to help more people and we'll be able to hire more companies. And so, if we can't find a way to all work together to speed up delivery and lower the cost per unit of delivery, I think all health systems are in trouble. I mean, they're really in trouble because it's really expensive to operate a health system and we need to be going the other direction.

CCB: [00:31:58] Ok, I'm going the other direction with you, James Pease. Thank you so very much for joining us on the ONEder Podcast. The podcast can be heard on all the streaming services, and we'll look forward to talking with somebody else as interesting as James sometime soon. Thank you very much.