If there is anything we should learn from this economic collapse, it is that risk costs money! Health care organizations must begin to understand that the default AE/CM process is fraught with risk for which the hospital pays.

There is a common misperception among those in the AEC industry, both on the consulting side and in the Owner’s arena, that design-build is not a suitable project delivery method for large projects. There is a “line in the sand” that is often drawn by the industry, which is based on a lack of understanding. This perception is a paradigm whose supporting rationale has long since become obsolete

Now, more than even in our lifetimes, it is critical that all organizations find ways to increase efficiency, eliminate waste, and increase value.

If the AE/CM method is to be credited with the success of projects, it must also be charged with the failures, since it is essentially the only method being used. Less than 2% of major health care projects are being constructed in any other method. Among these failures are: vastly more projects exceeding their budgets and schedules than not; change orders exceeding 7% of project construction costs, scope creep on projects being out of control, construction escalation exceeding overall inflation by 100% and more. These are the risks to the client organization that are the legacy of the failed AE/CM method, and the costs associated with them are astronomical and incalculable.

Only Design-build with a “lump sum contract,” (not simple design-build) can mitigate these risks. Design-build makes the designer/contractor responsible for all "errors and omissions" change orders. This is one category of risk that is mitigated through DB, but it is not the largest one. AE/CM contracts are “mutable,” meaning that the terms of the contract change through the life of the project. This change creates a lack of accountability that leads to lazy and often intentional mismanagement of the client’s resources. Using DB as opposed to CM ensures that the firms can be held responsible, and can deliver the project for the lump sum amount agreed to, without the infighting and misappropriated authority and disincentives that work to undermine project success in the AE/CM method.

Designers do not like limitations, such as immovable budgets, and who can blame them? They enjoy having the freedom to design without discipline. They would rather not concern themselves with learning about the economic impacts of their ideas, despite the fact that doing so would allow them to design more prudently. They are not motivated to in the AE/CM method.

Architects may choose to wash their hands of any responsibility, and continue to promote the AE/CM method rather than challenge the status quo, but I am suggesting that this is questionably unethical.

Health care projects carry with them a heavier social burden than other types. Focus is constantly on the importance of improving facilities, but rarely on prudent use of health care dollars in design and construction. Dollars wasted in an inefficient project delivery system, or spent on unnecessary architectural embellishments, can reduce the availability of funds to deliver the care that patients need. Costs are spiraling out of control and quality of care is considered by many to be regressing. Architects and everyone in the industry should be doing what they can to improve, not exacerbate that situation.

Design-build is one potential answer, and one that has demonstrated results.