While the complexities of today's financial climate continue to be a moving target, one fact remains the same: people depend on quality healthcare. the challenge this economic situation presents for hospital owners and developers is the ability to provide quality care in a timely, efficient, and productive manner. as more owners seek to achieve this goal, they are turning toward the inherent economic and practical benefits of the design-build delivery method to construct new healthcare facilities more efficiently and affordably.

While the complexities of today's financial climate continue to be a moving target, one fact remains the same: People depend on quality healthcare. The challenge this economic situation presents for hospital owners and developers is the ability to provide quality care in a timely, efficient, and productive manner. As more owners seek to achieve this goal, they are turning toward the inherent economic and practical benefits of the design-build delivery method to construct new healthcare facilities more efficiently and affordably.

Project Summary

Project: St. John Broken Arrow

Project Owner/Developer: Broken Arrow Development, LLC

Facility Operator/Manager: St. John Health System, Tulsa, Oklahoma

Programming, Architecture, Structural Engineering, and Construction: The Haskell Company (Design Team: Charles Arraiz, AIA, Project Principal; Ted Moore III, AIA, Project Architect; Joe Shepard, PE, Structural Engineer; Construction Team: Jeff Blount, Project Director; Roger McDonell, Senior Project Manager)

MEP Engineering Consultants: TLC Engineering for Architecture (Stephan Kemp, PE, Mechanical/ Plumbing; Tom Clevenger, PE, Electrical)

Landscape Architects: Alaback Design (Jason Dickinson, LSA, Landscape Architect)

Civil Engineering Consultants: Cook and Associates (Kathleen Church, PE, Civil Engineer)

Interior Design: Euthenics (Barbara Collins, IIDA, Interior Designer)

Photography: Amatucci Photography

BIM Images: The Haskell Company

Total Building Area: 190,000 sq. ft. (hospital); 110,000 sq. ft. (MOB)

The design-build method, sometimes referred to as integrated project delivery, is based on the age-old practice of the master builder accepting full responsibility for designing and constructing a project from conception to completion. While this method has been around since ancient times, it has experienced resurgence in recent years as it provides a unique set of client advantages not available in other delivery systems. The traditional design-bid-build method requires multiple contractors to engage in a project, which ultimately means there is no single party responsible for overseeing the entire project. This results in the owner bearing the risk for the final product. It also means budget overruns can lead to a lower return on investment, missed completion dates can cause costly delays in getting the hospital to market, and legal issues may ensue for the owner because there is no single point of contact and responsibility for the project.

Paul Tyler, president of the Haskell Commercial Group

On the other hand, the design-build process reduces the risk of performance error and increases quality through the assumption of full responsibility by a single entity. Not only does this simplify the process for hospital owners, it transfers risk from them to the design-builder.

Some hospital owners have been reluctant to use the design-build method in the past because healthcare facilities are very complex and designing and building them requires a thorough understanding of the unique challenges they present. It was believed that separate design and construction specialists were needed to find that expertise. However, that reluctance is diminishing as true design-build leaders emerge with experienced in-house architects, engineers, designers, and construction experts on staff who have decades of experience in the healthcare industry.

The benefits of utilizing the design-build method to construct healthcare facilities can be categorized into three main areas-undivided responsibility with a single point of contact, cost savings, and speed of delivery.

Undivided responsibility

Design-build provides both architectural/engineering and construction resources under a single contract, which presents less risk for hospital owners from a contractual perspective. The owner of a facility relies only upon the design-builder who is responsible for the cost control, quality assurance, schedule adherence, and performance of the finished project. This results in clearly fixed responsibility, maximum cost control, and immediate responsiveness.

A hospital owner or developer can still exercise their desired degree of control over the design process with the added advantage of continuously knowing the cost implications of each decision. The owner's control of the process is strengthened by contracting with a single firm that is committed to the success of the project and that can offer a comprehensive view of the project, as opposed to the one-piece-at-a-time method of multiple providers.

Cost savings

A design-build team working closely with a healthcare facility owner accurately conceptualizes the completed project at an early stage. Continuous and concurrent cost-estimating during the development of design results in knowledge of the overall costs far sooner than what is possible through other approaches. This process also permits making early decisions, which have the greatest impact on cost, in an informed, cost-based environment.

Financial risk reduction begins at the early stage of a hospital's design. Construction specialists are an integral part of the design team, so construction issues are addressed early. The design-build team works together to decide the most cost-effective materials and methods of delivery before a design is finalized, enabling them to provide more accurate costs and better scheduling up front. Because the same group is responsible for aesthetic, cost, and functional performance of the hospital, the possibility of costly surprises in the construction phase is virtually eliminated. Too often with design-bid-build, design impracticalities are discovered during construction, which leads to increased cost, missed deadlines, and finger pointing between the architect, engineer, and contractor.

While each facility is unique, the actual cost savings of utilizing the design-build method to construct a hospital can be measured by typical industry standards. The average industry cost to construct a hospital is more than $1 million per bed. The use of design-build project delivery can often reduce that cost by 20% or more, saving the hospital owner money and allowing those cost savings to go directly to patient care.

Speed of delivery

In addition to cost savings, the inherent nature of the design-build delivery method also results in decreasing the risk of schedule erosion and project delay. Bidding periods and redesign time are eliminated. Materials and equipment procurement and construction work can begin earlier-in some cases, before the construction documents are fully completed. Since total design-build construction time is reduced, hospital owners enjoy earlier utilization of their facility. The chance of late entry to the market or production downtime is greatly reduced, which is critical in the competitive healthcare industry. On average, the design-build process saves 25% of a total project timeline, allowing the hospital owner to bring the healthcare facility to market faster than the competition.

Case study-St. John Broken Arrow

One of the newest hospitals to be constructed under the design-build method is St. John Broken Arrow located in Broken Arrow, Oklahoma. The owners of St. John Broken Arrow, Broken Arrow Development LLC, and the operator/manager of the facility, St. John Health System, originally contracted with the design-build firm Haskell to utilize the delivery process with its St. John Owasso Hospital in Owasso, Oklahoma, and immediately recognized the benefits. When it came time to construct another hospital in a neighboring community, it once again collaborated with Haskell to implement the design-build process.

St. John Broken Arrow is a $100-million general acute care medical surgical hospital that includes a state-of-the-art emergency department, eight-room surgery suite, radiology department, and renowned Tulsa Bone & Joint Associates orthopedic center. The nonprofit, full-service community hospital includes 190,000 square feet in a six-story building with a seventh floor penthouse level and an adjacent 110,000-square-feet, four-story medical office building. The hospital utilizes 17 acres of a 68-acre development and is designed to expand in several departments on multiple floors of the hospital. The hospital is designed to accommodate 68 private beds with the option to expand the sixth floor and add 24 private beds. The hospital also is built to expand in several clinical areas as well as to expand each patient floor with an additional 12 beds, bringing the total number of beds to 140 upon build-out.

Utilizing the design-build delivery for the St. John Broken Arrow project allowed early start and long lead items to be purchased, and construction commenced prior to completion of design, which ultimately resulted in the facility being ahead of schedule and under budget. The team was able to construct the hospital 25% faster than the design-bid-build delivery method would have allowed. Time and cost savings for the hospital started at conception, when the design team was able to break the project into several drawing packages, including design of the central plant buildings and tunnels, and get it permitted while continuing to work on the design of the hospital. The ability of the design-builder to simultaneously design and permit allowed construction of the facility to begin earlier.

St. John Broken Arrow also benefited from the use of Building Information Modeling (BIM), which coordinated the efforts of the owner, architect, engineers, general contractors, subcontractors, and suppliers. The team used Autodesk Revit software to create a BIM that was used to more efficiently coordinate all aspects of the hospital's design and provide cost, schedule, and construction feedback during the development process. BIM allows the design-build team to identify issues the facility may encounter prior to the commencement of the project. The foresight allowed by BIM and Autodesk Revit ensures a minimal need for redesign of the systems once the project begins. Once construction on St. John Broken Arrow started, BIM was also used to visually communicate construction progress and to identify and resolve conflicts prior to installation of work in the field. Other software, such as NavisWorks, was used to visually display in a single model components of the BIM that were created by different programs. This was particularly important for shop drawings and other vendor-provided design information.

Perhaps one of the biggest misconceptions about design-build is the idea that this method only allows hospital owners and developers to build “cheaper,” nondescript facilities without the bells and whistles of a state-of-the-art hospital. This perception is far from reality. A true design-build team is capable of designing and constructing a wide range of facilities because of its integrated environment. In fact, the abilities of an experienced design-build team can design even the most complex, architecturally appealing hospitals in a more affordable, cost-conscious manner. There are numerous efficiencies gained in the design-build process by not spending time and money on multiple contractors and teams, allowing more of the budget to be utilized on design elements, such as high-tech systems and products, within the facility.

The bottom line

The bottom line when constructing any healthcare facility, from a community hospital to a large urban facility, is to create a plan that allows the best healthcare to be delivered efficiently and safely. The goal of any designer or builder in the healthcare industry should be to provide a facility that is right for the patients, staff, and owners. The advantage of doing this through the design-build delivery process is that owners are also able to save time, money, and undue stress. The single-responsibility nature of design-build minimizes the risk for performance error and increases quality-two elements that are critical in a hospital facility that must be up and running from the day of opening and 365 days a year thereafter.

As the healthcare industry continues to evolve and adapt, the use of design-build to construct new hospitals will continue to emerge as a leading delivery method as owners seek better, more efficient ways to do business. Paul Tyler is president of the commercial group at Haskell. For more information, visit

www.haskell.com. Healthcare Design 2010 November;10(11):116-125