Healthcare Real Estate & 

Development Services, LLC

Publications

An ongoing series of informational entries

Total Project Management

February 2020

Turnkey Project Management for Real Estate

What it is and why you need it!

By: Frank Ricci


Today I would like to introduce you to the concept of “Turnkey Project Management (TPM) for Real Estate” and how it will simplify your life. Signing a lease or purchase agreement is only a thin slice of the work required to get your office up and running. The concept of TPM provides for a Single Source of responsibility through a Project Manager (PM) and encompasses ALL of the tasks necessary to get your facility ready to open, including these key elements:


Due Diligence – Due diligence is the upfront work required to determine the best location within a geographical area to locate your practice and includes demographic analysis, a competitive market survey, space programming, budgets, traffic studies, zoning, lease/purchase analysis and other site specific studies. A PM will coordinate the performance of all of these activities.


Lease/Purchase Negotiation and Execution – this is the work that brokers typically focus on and is an important part of the process. There are typically many deal points that must be negotiated to ensure the best possible outcome. A PM must be a broker with specialized knowledge of medical real estate. A PM must also be able to work with financial institutions to negotiate the best terms and conditions for your project financing.


Design & Permitting – If there are going to be any construction or renovations performed, it is necessary to identify, compare and select the best architect, engineers, interior designer, consultants and equipment suppliers and installers for the project. A PM will have contacts within the industry in order to help select the firms best suited for your particular project based upon size, experience, quality, and availability.

Value Engineering – A PM should have specialized knowledge of construction industry in order to identify materials, methods and means to shorten the project timeline and/or to save costs without sacrificing quality.


Construction – A PM will oversee the distribution of plans and specifications to various QUALIFIED contractors and oversee the bidding process. Working with the client and the architect, the PM will help select the winning bidder, determine the draw process, ensure that an adequate safety program is established, coordinate the various consultants and provide general supervision of the construction process including site visits and photographic/video evidence during each stage of construction.


Cost Segregation – During the construction phase, an experienced PM will work with your architect, contractor and tax advisor to identify and separate costs for individual building components that will be used in a Cost Segregation Analysis. This analysis can be of enormous financial benefit and save you significant amounts of money for years to come.


Move in & Grand Opening – Upon completion of the construction, there is now the enormous task of moving and installing equipment, furniture, interior design elements and personal touches. A PM will coordinate all of this work in preparation for your Grand Opening. Your PM can also coordinate with a public relations firm with medical expertise to get the word out and handle all of the event details for your eventual Grand Opening.

As you can see, simply signing a lease or a purchase contract is just the tip of the iceberg. A PM, as a single point of contact, can relieve you of the many details, decisions, calls and trips necessary to get your office open and ready for business, on time and on budget.


Frank Ricci is a principal with Healthcare Realty & Development Services, LLC a leading Total Project Management firm with over 35 years of experience based in Winter Park, Florida. Frank is a licensed real estate broker and licensed building contractor with extensive experience in “Turnkey Project Management.”


HealthcareRealtyOnline.com

Negotiating Medical/Dental Leases

May 2018

BY: FRANK RICCI

The decision to lease office space is an important financial and business decision that requires consideration and competency. Leases are typically for an extended period of time, from 3 –10 years, and it is important to address the issues below in your negotiations and in the Lease document itself. Here are six important considerations to address before signing any lease.

1. Maximize your USEABLE space - 

Office space is typically quoted on a cost per square foot per year ($/SF/YR) basis. Your goal is to maximize the amount of space within your four walls that you use for your practice, defined as “Useable Area,” and minimize the amount of space outside of your office for whic​h you are charged rent. There are three common methods to calculate floor area and the method used can greatly impact your costs. These calculations are defined as: 1) rentable square feet, 2) gross square feet, and 3) useable square feet as described above.

Let’s define the floor area calculations used:

  •  Rentable Area (RSF): perhaps most commonly used, defines the areas within the walls of your suite, plus a pro rata share of the common areas of the building. The common areas consist of hallways, lobbies, restrooms, etc. but do not include vertical penetrations such as stairs or elevators. Typically, common areas make up 15% of a building’s area but can be greater in buildings with large lobbies, wide hallways, etc.
  • Gross Area (GSF): includes the area within your suite plus ALL common areas. This may also include elevators and areas under canopies or drive through. Typically 18% - 20% of a building’s area.
  • Useable Area (USF): includes only the area within the walls of your suite

EXAMPLE: Let’s assume you were to rent 5,000 sf of USEABLE space under each of these terms, how much space would you actually have to rent?

  • Rentable Square Feet-we need to add 15% for common areas, so 5,000 sf + 15% = 5,750 sf
  • Gross Square Feet, using the same logic, 5,000 sf – 20% = 6,000 sf
  • Useable Square Feet – definition of USF is the space within the walls so 5,000 – 0 = 5,000 sf

In reviewing office properties to lease, make sure you are receiving the greatest value for your investment dollar. In this example, there is a 20% difference in the amount of space needed.


2. Negotiate for free rent and/or a tenant improvement allowance

Most landlords offer incentives to lease space in the form of “Free Rent” or a “Tenant Improvement Allowance.” Free rent is usually 1-3 months but is very dependent upon vacancy rates in the area. Tenant improvement allowances vary considerably, depending on the rental rate offered and the condition of the building. For reference purposes, it typically costs around $10/sf to refurbish an office with new paint, carpet, etc. and can run from $45 - $80+/sf to build a new office from a shell condition.


3. Negotiate for the greatest tax advantages

This is critically important and RARELY addressed. Your lease should specifically state how tax advantages are determined and who gets to write them off. If your lease does not state this in detail, you do not have specific items to depreciate, nor specific costs to write off at lease termination. This simple determination can eliminate your right to any deductions or your deductions may be disallowed and/or challenged by the IRS. A “Cost Segregation Study,” attached as an amendment to the lease can greatly benefit you and your landlord.


4. Address each of the following cost issues in your lease

Here is a list of items of expense that must be specified:

  • Rent and rent escalations
  • Common area expenses; cleaning, maintenance, repair, replacement
  • Utilities; water, sewer, trash, electric, etc.
  • Management fees; supervision, accounting, legal, leasing commissions, construction administration
  • Real estate taxes, licenses and legal fees for disputing assessments
  • Future regulatory assessments and impact fees
  • Repair and replacement of major building systems; HVAC, Elevators, roof, windows, etc.
  • Insurance; building, flood, sinkhole, liability, etc.
  • Address each of these other important considerations

Here are some additional factors to consider in your lease:

  • The leased premises, the method of calculation and changes to the method or basis of area calculations (Common areas in buildings can change.)
  • The length of the initial lease term, especially if there have been tenant improvements
  • Lease extensions, renewal terms and holdover provisions
  • Flexibility - the ability to expand or contract the practice space requirements through options or a “First Right of Refusal”.
  • Exclusivity – to limit competition within the building.
  • Relocation – you may wish to strike this landlord option if involuntary relocation ma affect your practice
  • Restrictions on use and/or procedures you may provide (typical on a hospital campus)
  • Hours of operation – many buildings have standard hours and utilities may be assessed for after- hours operation and security. These charges can be significant.
  • Macro factors that may affect your lease such as condemnation or property taking (i.e. for a road expansion) that may have deleterious effects such as noise, vibration, etc.

6. Additional Considerations

A lease gives you the right to control your particular space but not the rest of the property so some additional considerations are very important. Negotiate these issues up front, issues such as: parking and space assignments, signage, accessibility, options to purchase, handicap accessibility and many others.


 In Conclusion 

Leasing space is an important financial and legal transaction and should not be taken lightly. It is important to have an experienced real estate broker and real estate attorney represent you. This combination of professionals provides the greatest protection at the least cost. Based upon their market experience, your broker should handle all of the preliminary issues, negotiate the rates and terms and prepare the deal points in a “Letter of Intent (LOI).” 


Landlords typically furnish their own lease which the broker should review and “flag” for inconsistencies in rates, terms and verbiage. Any inconsistencies between the LOI and the lease can be further refined and determined to avoid numerous attorney reviews. Once negotiated, an attorney review should be completed to address legal issues before execution.


By following this 6 step plan, you should be able to move forward with confidence in the completion of your lease negotiations and securing your office space for your prosperous enjoyment.

Medical Real Estate in the Age of COVID-19

January 15, 2020

Is your facility Covid ready and what can be done?


BY:  Frank Ricci

The Covid 19 Pandemic of 2020 has had a profound effect on hospitals, medical practices, staff and the business of medicine. From a practical point of view, we have witnessed just how vulnerable we are as a society to new viruses and how ill equipped medical practices are to infectious agents. In this article, I will outline some practical steps to better prepare your medical facility to deal with this and future outbreaks which will ensure safer visit for you, your patients and staff.


Viruses like Covid are spread in three primary ways; 1) contact, where transmission is through touching a person or an object which another person then contacts, 2) large droplets such as through a cough or sneeze where droplets are dispersed over a relatively small area where they fall on surfaces or another person and 3} small droplets transmitted through speech and normal breathing and which can be carried by a/c ventilation.  Here are some practical methods to minimize the risk of exposure in your facilities:


Check-in, Check-out and Payments: Limit patient/staff interactions by providing online check in, checkout and payment processing. Eliminating the need to complete forms, sign in and out and process payments reduces contacts with papers, pens, clipboards, horizontal surfaces, money and credit/debit cards.


Social Distancing: Provide adequate space between patients by limiting the number in the waiting room, providing sub-waiting areas throughout the facility and move patients through as quickly and expeditiously as possible. Glass/plexiglass partitioning can also provide a form of social distancing in waiting rooms, between patients and the business office and between patients and staff. Additional precautions include evaluating patient forms prior to visit to ascertain potential infectious patients, taking their temperature upon arrival, providing separate waiting areas and directing potential Covid patients to the appropriate testing facility. 


Waiting & Reception Areas: Eliminate toys, magazines and other reading materials that might spread viruses via contact. The use of hard surface flooring and hard surfaces for walls and ceilings greatly reduces the opportunity for viruses to linger. Horizontal surfaces should also be minimized and should be resistant to strong disinfectants. Additional bonuses include volume ceilings which reduce the level of contaminants in a given space and sunlight which is known to kill many viruses. Copper is a natural antibacterial, anti-fungal, antiviral material so door handles and other frequently touched objects made with copper content would be ideal. Motion and voice activated doors also decrease the chance of contact transmission. 


Exam & Procedure Rooms: The proper design of these rooms is of the utmost importance in reducing exposure to pathogens. [see illustration]. Of notable importance are: the sink is near the door for frequent handwashing and should not be so shallow so water can splash out. The patient is shielded from ventilation from the corridor as well as being visually guarded from others passing by. Staff work is almost always confined to the area near the door and they can keep social distancing from any guests of the patient. All utensils and supplies are within easy reach and are designed such that there is no clutter and fewer horizontal surfaces. Exam and procedure rooms should be on a separate HVAC zone with

ceiling mounted air supply, frequent air exchanges, HEPA filtration and frequent maintenance.


Additional Features: Personal protective equipment can be made available to patients upon entering. Hand sanitizing stations should be spread liberally throughout the facility. Toilets, faucets and paper towel dispensers should be hands free and paper towels are preferred over blowers. Single use toilet rooms are preferred with limited horizontal spaces and antimicrobial surfaces. The use of motion/voice activated lights, doors, faucets, toilets, blowers, dryers and equipment all reduce exposure to infectious agents and will become standard in future medical centers.


Telehealth: The rise in the use of Telehealth services greatly increased throughout this pandemic of 2020 and will continue to grow as new technologies are introduced. The space needs are not overwhelming, and in fact, three consults can occur simultaneously within the space of one procedure room. The use of modular partitions and workspaces means that physicians can extend their practices far from their original location and penetrate rural areas where there is a particular shortage of healthcare workers. This is an excellent revenue enhancement opportunity which also serves to greatly restrict visits from infectious patients.


As the need for medical services and providers continue to increase, we must remain vigilant in our quest to provide the safest atmosphere possible for both patients and staff. While there is certainly acost to equipping facilities appropriately, there is an even greater cost in not being able to operate at all.


For more information on options and strategies, contact your infection control specialist or feel free to call on us.