When Sutter Roseville Medical Center (SRMC) in Rose-ville, California, decided to embark on an ambitious master plan that included a variety of renovation and expansion projects, the organization's decision makers realized that changing how the projects would be delivered would be critical. Because SRMC is located in one of California's fastest growing communities, hospital management was concerned with not only keeping the $150 million budget under control, but also allowing the hospital to remain open and continue its high level of compassionate service during construction.

The ambitious master plan (figure 1) included an ICU expansion; an emergency department expansion; a 90-bed tower addition; a C-section area remodel; a new well-baby nursery; a new neonatal intensive care unit; a cath lab re- model, including equipment replacement; and a new, 106,500-square-foot acute rehabilitation center.

It would be quite an effort to complete eight different healthcare projects in just seven years. In order to make this happen, Sutter Health knew it was time to look for a new way to approach capital projects, believing that healthcare projects cost too much, take far too much time, and typically fall short of their objectives. Traditional design, bid, and build often results in projects that are over budget, late, and of poor quality.

Instead, Sutter Health embraced the Lean Project Delivery System, or Lean Process, as a way to improve capital project processes and results. This system focuses on defining value from the customer's perspective and identifying a process that will meet project objectives concerning budget, schedule, and quality. The Lean Process focuses on “Five Big Ideas.” As we hit the midpoint of the master plan four years into the process, with three years to go, we can state that we see something very positive happening.

The Five Big Ideas

1. Collaborate—really collaborate—throughout design, planning, and execution. Constructible, maintainable, and affordable design requires the participation of the full range of project performers and constituencies. We have formed a collaborative team involving the owner (SRMC), the architect (HGA Architects and Engineers) and the contractor (Unger Construction Co.). The team has taken collaboration to a new level. Traditional communication barriers have been broken down, and we all share a common goal: to do what is best for our client and the project.

The contractor, or “design assist team,” plays an important role in the design process. The days of the design team's working in a vacuum and delivering a product that is over budget must come to an end. With cost so integral to the design process these days, contractors and subcontractors need to contribute to the design process their unique ideas on saving money (“If you do it this way, I can save this amount”).

Imagine attending a user group meeting with an electrical engineer and electrical subcontractor. Imagine the user stating that he or she wants card-key access on every door. The electrical subcontractor speaks up and says, “Did you know that each one cost $15,000?” The user says, “No, I didn't. How about just on the necessary doors?” This is an actual example of regular conversations that take place at Sutter Health planning sessions.

Another example: With the acute rehab center project, we were considering both a two-story and a three-story solution. We asked the design assist team to run numbers and let us know which solution would be more cost-effective, given the site parameters. It turned out that the two-story alternative would cost $1.2 million less; the three-story option would have required splitting the acute rehabilitation program onto two floors, with added square footage on each floor for the required gym and dining room.

2. Increase relatedness among all project participants. Participants need to develop relationships founded on trust, if they are (necessarily) going to share their mistakes as learning opportunities. Probably one of the most amazing things I witnessed with this delivery system is how, over time, the different team players became committed to the project and its goals versus their own interests. The project outcome is significantly different when all of the players share a commitment to its success.

3. Projects are networks of commitments. Projects are not processes or value streams. They are ongoing articulation and activation of unique networks of commitments. The work of leaders is bringing coherence to these networks of commitments in the face of the uncertain future.

At SRMC, we held a reverse-phase, pull-schedule workshop for the construction document (CD) phase. We started at the end goal and worked backwards. This included the design team, design assist team, and multiple subcontractors from the surrounding community. The challenge was to create a CD schedule that included all team players' input to optimize cost-estimating and produce the necessary documentation. All participants placed sticky notes on the schedule regarding tasks they could complete and when they could complete them. Using this approach, if, for example wall sections and site-work details were more valuable early in the CD phase than interior elevations, the design team could focus its efforts on this priority in a timely fashion.

The final master plan for Sutter Roseville Medical Center in Roseville, California.

4. Optimize the project, not the pieces. In the design field, we routinely incur rework and delays. The way we understand work and manage planning can either increase or reduce the messiness of projects. It takes effort and leadership skills to convince all the different players that the project whole is more important than individual areas of expertise.

At SRMC, an example occurred when an opportunity presented itself midway through the design process to improve the mechanical systems in a way that would optimize the entire project. It was decided to attach the new building to the existing central plant rather than design a stand-alone mechanical system, necessitating a new 400-ton chiller and the cost of connecting it. This upgrade would put the mechanical engineering and subcontractor team over budget, which meant some other part of the project needed to be reduced in scope. As it turned out, one of the user groups and the design team were able to reduce some square footage and help adjust costs to minimize the overall cost impact and benefit the project as a whole.

5. Tightly couple action with learning. Continuous improvement of costs, schedule, and overall project value is possible when project performers all learn in action and get immediate feedback on how well their efforts have matched the requirements of customer satisfaction.

The SRMC team has worked on multiple projects together. We're confident that we can learn from our mistakes and fix any problems on all future projects—the advantage of selecting project-delivery teams that have self-assembled and developed a history of building trust together.

Evidence-Based Review

Sutter Health enlisted the assistance of Glenn Ballard, PhD, Professor at the Project Production Systems Laboratory, the Engineering and Project Management Program, Department of Civil and Environmental Engineering, at the University of California, Berkeley, to do a case study of our use of the Lean Project Delivery System at the Acute Rehabilitation Center at SRMC. Through Ballard's “P2SL” Project Production Systems Laboratory, a learning laboratory for the Northern California construction industry, the hunt is on to find the best practices through research, education, and benchmarking.

Ballard and his design study team noted seven additional key elements, beyond the Five Big Ideas, that have contributed to the best practices on this project. They, too, will continue to be tested, as we forge ahead on this program for SRMC. They are:

  • Establish a Baseline/Project Definition. Do a feasibility study integrated with a detailed budget. The results of such a study provide the basis for understanding the project's scope, schedule, and budget.

  • Change the Traditional Relationships. Include everyone who will affect the project from the very start and build those relationships! In other words, collaborate—really collaborate.

  • Set a Schedule. Ensure that it is one that all team players will buy into, and stick to it. Determine all meetings that will be needed and get them on the calendar in advance, then stick to the scehdule.

  • Communicate Clearly. Use tools that communicate clearly the direction and intent of the project. Use room data sheets (figure 2) in design development to clearly articulate the needs of each space.

  • Target Costing. Do cost estimates during the design process to weigh the cost impact of each decision.

  • Accept and Build on Breakdowns. Collaboration and trust building do not mean that everyone is getting along wonderfully with no problems. Breakdowns in mutual understanding are actually a good thing because they provide opportunities for the team to dig in and resolve problems and thus optimize the project. The team members will build even more trust among themselves.

  • Be Willing to Say No. The design/design assist team needs to be able to say no to the owner. Is the request a need or a want? If it is a need, then what are you willing to give up? If it is a want, are you willing to back this with budget? This is the reality of designing to a budget.

An example of a room data sheet, used in design development to clearly articulate the needs of each space.

The Future

Obviously, many areas of research have been identified that P2SL will pursue. As for the SRMC design/design assist team, we are only midway through the current master plan, but the experience thus far has been positive. Sutter Health, SRMC, the architect and engineers, the contractor, and major subcontractors and multiple owners continue to work collaboratively and successfully to build healing-environment healthcare facilities to meet the needs of our community. The team that has worked together thus far remains whole, in good order, and pleased with the fruits of its labors. Isn't that the situation we ultimately all want? HD

Bonnie Walker, AIA, is a Vice-President in the Sacramento office of HGA Architects and Engineers, a full-service architectural firm with additional offices in San Francisco, Los Angeles, Minneapolis, Milwaukee, and Rochester, Minnesota. For more information, visit http://www.HGA.com.