Bringing the Design-Build Advantage to Healthcare Construction

The current economic recession has forced everyone, from ordinary consumers to captains of finance and industry to examine their purchasing practices more closely. The design and construction industry and buyers of design and construction services are no exception. While many are hesitant to engage in capital projects during these uncertain times, owners and developers willing to commit are surveying all the options as they search to optimize the value and decrease the risk associated with their venture.

Over the past 10 to 15 years, but especially within the last five, project delivery methods have been under increased scrutiny as owners, designers, and builders seek the best way to organize, finance, and contract for the design and construction of a facility. As a direct result, forms of project delivery that highlight integration and enhanced collaboration are increasing selected by owners. Why? Because experience increasingly shows that integrating design and construction services saves time and money.

Design-build (DB) is one form of “integrated project delivery,” meaning that the design team (architects, engineers, and landscape architects) and the construction team (the construction company and the electricians, plumbers, and other specialty contractors who assist them) work together from the initial response to an owner's solicitation, the Request for Qualifications (RFQ) or the Request for Proposals (RFP) to project completion.

A movement toward DB project delivery has been in the works for a while. Last June, Engineering News-Record reported that between 2004 and 2008, domestic design-build sales doubled from $30.5 billion to $64.4 billion. When designers and builders are on the same team from the beginning, fewer unforeseen problems arise and when problems do occur, it is in everyone's best interest to solve them quickly. When problems are resolved more quickly, projects stay on schedule and saving time saves money for everyone. Projects delivered on or before deadline are the norm rather than the exception.

DB is an alternative to the design-bid-build (DBB) construction method in which two teams work separately and sequentially on a facility. Under DBB, first, the design team focuses on tasks from programming through construction documents and then the construction team takes over to bring the project to completion.

Gone are the days when owners automatically sourced design and construction separately, bidding first design and then construction under separate contracts-a procurement process that is time consuming in and of itself.

When the project is a medical facility, time savings and integration can mean the ability to integrate the very latest technological advances in medical equipment without going back to the drawing board on design.

This was certainly the case with Glendale Adventist Acute Care Facility in Glendale, California (figure 1), one of California's first hospital construction projects to implement DB delivery. Writing in support of the design-builder's submission for a national award, Warren Tetz, Glendale's Senior Vice-President of Operations said, “Since medical technology is constantly evolving, we challenged the design team to provide us with a versatile system that would allow us to procure the most modern equipment late in the construction schedule.”

Glendale Adventist Acute Care Facility in Glendale, California, one of California's first hospital construction projects to implement design-build delivery

Completed on time and on budget, the Glendale Adventist Medical Center Acute Care Tower is a 192,000-square-foot, seven-story hospital incorporating emergency services, operating rooms, and 72 acute-care beds including a surgical intensive care. Among the design and construction challenges: The new tower had to be situated on a steep plot of land on the existing campus and construction could not disrupt the operation of existing hospital facilities.

According to the satisfied owner, the Center meets these goals and more, providing the latest in technology, techniques, comfort, and convenience while meeting operational objectives, including a 16% increase in acute discharges and a 22% increase in emergency admissions.

In DB project delivery, integration is not just an abstract concept; it is a concrete reality reflected in the contractual relationship between the DB team and the owner agency. In fact, DB is also referred to as “single-source” delivery because even when the A/E team and the construction company are distinct entities they contract for a DB project as one team, and there is singular responsibility. The “design-builder” can take several forms; a joint venture between designer and contractor, a contractor-led team with the designer in a subcontractor role, or a designer-led team with the constructor in a subcontractor role.

When Meadville Medical Center built the Yolanda G. Barco Oncology Institute in Vernon Township, Pennsylvania-Western Pennsylvania's first diagnostic and cancer care facility-DB made adhering to budget and an aggressive 13 month construction schedule possible. In the case of this architect-led project, early intervention brought the project into the black after initial plans came in over-budget. When a linear accelerator purchased by the hospital after construction began required changes in the location of electrical conduits, the design-builder, Astorino, of Pittsburgh and southern Florida, was able to accommodate the change even though it came on the eve of a major concrete pour.

Louis P. Astorino, leader of the firm's DB division explains the benefits of DB this way: “Instead of just contractors and architects looking out for their own hides, we're concentrating on making it more seamless for the building's owner and giving the owner the best value. When you are truly one team, you solve problems as a team.”

Meeting schedule, time, and budget are easily tracked but healthcare facilities must cater to the immeasurable but very human needs of patients and caretakers. A project in Vermont is a case in point. Health Care and Rehabilitation Services of Southeastern Vermont (HCRS) is a multifaceted, nonprofit, community mental health agency with major programs in mental health, substance abuse, and developmental disabilities (figure 2). HCRS currently serves more than 4,500 Vermonters each year.

Health Care and Rehabilitation Services of Southeastern Vermont is a multifaceted, nonprofit, community mental health agency with major programs in mental health, substance abuse, and developmental disabilities

HCRS's facility project was complicated not only by the need to accommodate diverse populations but also by the fact that the staff had been treating patients in several small buildings-old houses for the most part-throughout two counties. Breadloaf Corporation, the design-builder, was charged with creating an environment that served clients and supported a sense of community among the staff.

Breadloaf understood the need to promote interaction among employees who have long been isolated, especially in a state where social service providers have an employee turnover rate of 28% yearly. “We had to make sure that employees, as well as clients, received all the social support a building could offer to make them happy and productive,” the design-builder says of the program.

The completed facility promotes the health and well-being of the building occupants, users, and the community at large. The design purposely avoids institutional hallmarks in favor of noninstitutional spaces including seven porches, two fireplaces, a café, and a fitness room. Emphasizing quality over quantity through the use of fine materials such as natural wood, stone, and linoleum, created a welcoming environment while controlling costs. “We didn't do this by increasing the budget,” Breadloaf says of the $7,437,000 project, which received a Design-Build Excellence Award from the Design-Build Institute of America. Instead, the team closely collaborated with the client and carefully evaluated elements in light of their contribution to overall project value. For their part, HCRS decided to reduce the size of administrative offices to accommodate amenities everyone could enjoy.

Bringing the client into the process is another characteristic of integrated project delivery in general and DB in particular. When Carilion Clinic launched a major expansion of its Carilion Roanoke Memorial Hospital (CRMH) facility with a design competition for an expansion phase, the intent was a DBB project. Instead the project, known as the Mountain Pavilion Addition (figure 3), was converted to DB in the interest of time and cost savings.

The Mountain Pavilion Addition to Carilion Roanoke Memorial Hospital

Composed of competition winners HOK, HSMM, AECOM, and lead by design-builder Skanska, the team began the Mountain Pavilion Addition with a cost estimate of nearly $32,000,000. To bring prices down, the team included Carilion staff in weekly project meetings and regular value engineering meetings, and they selected subcontractors with an eye toward reducing the project cost and schedule. As a result of this partnership among all stakeholders, total project cost was reduced to $30,300,000 and delivered one month ahead of schedule. Realized cost savings were used to add scope to the project, netting almost $1.3 million in savings.

The project was so successful that the DB team approach Carillion with an unsolicited proposal for the DB delivery of further phases of the CRMH expansion and consolidation. Based on a series of lessons-learned debriefs held to gather insight into the first project and its variety of successes, the proposal succinctly defined the advantages that the DB team brought to the table. By directly selecting an experienced team, the proposal noted, Carilion would work with design and construction personnel familiar not only with the hospital site, but with Carilion staff, work practices, and requirements. The technical challenges encountered on the initial project and the established team partnership were distinct advantages and led the team to project a construction start date 27 weeks earlier than if Carilion initiated a standard RFP process.

Carilion decided to leave the DB team intact for the project, which included major new construction and significant modernization of virtually all clinical departments. Completed four years later, “the project realized cost saving beyond even the most optimistic expectations,” according to the owner, who praised the team for a 24/7 approach to communications and a focus on meeting patient and practitioner needs while maintaining the bottom line.

As every design and construction professional knows, the highest reward is another project for the same client. In this case, Carilion demonstrated its confidence in the team by awarding them additional DB contracts of even greater value.

After seeing one of the most complex DB healthcare projects in the United States completed without interrupting a single day of clinical operations, John D. Christodoulides, Carilion's Director of Design, Construction and Property Management called the project, “A testimony to the DB approach and the essential synergies it creates.”

“As healthcare construction becomes more complex and demanding, while constraints on schedules and budgets become even more stringent,” he noted in a letter supporting the project's National Design-Build Excellence Award in the category of Rehabilitation/Renovation/Restoration, “one cannot envision any more feasible delivery method.” HBI

For more information, visit http://www.dbia.org.