FIGURE 1. A chart depicting the first 90 days of the decision management process in a project.

They say that change is good. However, it certainly isn’t good later in the design/construction process, where inadequate planning or teamwork up front can eventually cost a lot of time and money to rectify. The author offers his ideas about integrated project planning and delivery, which range from maintaining a common knowledge base for smarter decisions to coordinating meetings effectively. With real-life successes in applications ranging from hospitals to a ballpark, the five-point approach can fit like a glove for complex projects. Maybe it’ll help you get a grip on your next challenge.

Projects all seem to start with optimism and an acknowledgement that there may be a few bumps along the way. “sunny, with a chance of showers,” is one way of putting it. Are your projects running smoothly and without question? Have the design and construction team and the owner developed a relationship based on trust and not just technical roles? Is the cost remaining stable or swaying from number to number, with the plan changing from week to week? How do we make project delivery more consistent and more reliable? Having worked on hundreds of health care projects over the years, lessons learned have become consistent.

The impact of cost increases and delays has become more severe. Davis Langdon, a major cost planning organization, reported hospital construction costs were $330/sq ft in 2003 and increased to $550 in 2006. Currently the cost of construction for hospitals on the West Coast exceeds $900/sq ft. That is an average increase of 18.5% per annum. Peter Morris with Davis Langdon reports a continuing increase while Dinesh Ghia, vice president and a chief estimator for Gilbane Building Company, currently suggests an annual rate of increase of over 12%. Whether the rate of increase stops or slows down or not, changes cost time, and time costs money.

While I have presented papers over the years about planning and design processes which help stem delays and changes which seem to infect most projects, this article will hit at the symptoms of a building program going astray and common problems.

We also need to recognize that the cost of operations in health care far exceeds the construction cost of the buildings over time. The cost of operations is based on many factors, including the functionality and layout of the facility. Poorly planned buildings result in poor continuing operational costs, and poor planning is usually accompanied by changes and delays. Changes contribute to wasted effort. Construction delays due to changes and poorly planned buildings, therefore, present the most vexing problems and the most waste.

Anatomy Of A Problem

Why and how do these changes take place? Common early symptoms of potential problems leading to potential changes:
  • The project starts without clarity regarding who is responsible for which decisions.
  • There was a desire to look at ways for the department to become more efficient but now “the plan looks like our old department, just bigger.”
  • Elements of the project were either forgotten or not included for one reason or another.
  • The cost of the project seems to continuously change and rise without control or adequate management.
  • Decisions seem to be revisited.
These symptoms often contribute to the following fundamental problems.

Initiating design before fully understanding the scope or problem.Design teams are often under pressure to show results without fully understanding context, complexity, or a target cost/budget model. Design teams are pushed to draw, and while the drawings prepared may contain ideas, the concepts shown may not be solving the right problem and may not be affordable.

“Silo-based” planning and design.The lead firm (usually the architect) develops a design concept and provides each consultant with background drawings, then firms work independently on their components of the project. Often the “over the wall” scenario will occur where drawings are thrown over the wall for someone else to work on. This typically results in adjustments and changes to accommodate systems and constructability. This rework results in additional time, cost, and often a departure from the owner’s original needs and concepts. The loss in time is unfortunate, but the ultimate loss is the contribution team members may have made to better concepts and a better project.

Design, document, and estimates.Drawings are used to document intent and estimates are based on the completion of various levels of drawings. Prior to final completion of construction documents, assumptions are often made regarding cost. Cost under this system is only known after documentation, and as such, correcting cost problems requires another round of documentation. More rounds equals more time and more cost.

Reliance on analog tools for communications and decisions.Analog tools such as drawings convey a multitude of ideas and concepts. While they are useful for depicting a coordination of elements and the complete project, they are often confusing and attempts to get one simple decision are often compromised by the distraction of other elements.

Deferring detail and quantification. The focus on the “big idea” and a design often neglects the work necessary to develop an understanding of detail in terms of function, equipment, and building components to bring about the “big concept.” The lack of detail results in cost and constructability surprises, compromises, and changes as the project moves ahead.

Can we do better? Can we eliminate some of this waste? Here are five steps we can take to correct some of these problems.

1) Implement integrated planning and design (early integration)

Integrate all design disciplines, owners groups, and cost planners from the outset of the project. This information involvement is critically different because all groups meet at the beginning of the project rather than being added along the way or as needed as the project develops. They participate in the development as an integrated team and participate in forming both the large and small concepts of the project. Working together from project’s beginning provides the best opportunity to establish a balanced project and one which requires minimal re-planning and rework.

Twenty years ago, I used this process on a major replacement program for the Harris County (TX) Hospital District, which replaced two major teaching hospitals. The result was a $330 million, 850-bed program which finished on time, without changes, under budget, with a construction unit cost of $106/sq ft, while also winning gold medals from the Texas chapters of the AIA and the AHA.

This process also proved successful for building programs at Rockefeller University in New York, and for Jacobs Field/Gund Arena in Cleveland, and has proven to be very successful for Chinese Hospital in San Francisco. In the case of Chinese Hospital, the decisions were mapped and meetings with hospital leadership and users included the integrated design team. Two hundred and eighty meetings were held within approximately 90 days. These meetings secured decisions that led to completion of schematic design and a part of design development during this short period of time. This could not have happened if one firm or individual prepared their part of work and handed it off to another.

2) Use process mapping

Develop process maps. These are not floor plans and are not physically constrained; they show processes and interactions. Three particular groups should be mapped: patients, staff, and materials. The maps are individual, but when overlaid, will show where activity takes place, defining spaces and environments needed.

Mapping current state conditions and asking about the desired future state, allows for investigation of new processes which could enhance operations with fewer steps, fewer people, and lower costs and which could also potentially create better or safer environments.

An adjunct to the process map is a staffing map. Since a process map allows one to see steps, it is easy to understand time on the process map. The time involved includes both elapsed time and incremental time. Elapsed time is how long it takes for a patient to go from “a to z,” while incremental time is how long it takes for a certain action to take place by a certain staff member. Applying volume to increments reveals staffing and staffing type when those tasks are allocated. Therefore, changes to the process map help improve functionality and reveals staffing necessary to accomplish the future desired state. Development of the process maps is an interactive process and its’ conclusion is an interactive and multi-disciplined/multi-level consensus of future operations.

3) Focus on target costing

The cost planning/cost modeling (a.k.a.  cost targeting) element is likely the most important area addressed in this article. The intent of the process is to know what costs are before design and documentation starts, to forecast costs accurately on the basis of functional parameters and analysis, and to create models and concepts as a guide to the design team so that plans can be accurately developed and maintained within budget. The steps essential to cost targeting are as follows.

Cost benchmarking and modeling. Comparative analysis to understand, demonstrate, and receive consensus for the relationship of descriptive product and cost.

Detailed quantification (with qualification).Using the resources of the entire team to qualify and quantify early and often on a project (with the owner involved). Quantify information in as detailed a manner as possible. This adds to the security of the cost model and to the decisions being made by the owner.

Advanced value promotion.Using the cost targeting process to advocate assemblies, products, processes, and details by which to reach or maintain a budget. This requires a team approach.

4) Initiate systems integration and space optimization (early)

Control of the project also comes from an early and thorough understanding of how systems must integrate at a detailed level. The integration must serve the basic principle of the functional activity, which is defined and described by the rooms within which activity takes place. Formerly, this activity was called generic functional work and patient work environments, but “room diagrams” seems easily understood.

Room diagrams. The definition of the functional work environments is the basis for a complete understanding of the project. Programming and planning practices usually generate only listings of spaces which provide the risk of a communication gap that exists between design teams and users of the facility. Developing room diagrams, which depict floor plans and preferably all six surfaces, helps to clarify the functions, utilities, equipment, and furnishings used in the delivery of that function in that room. This is also an activity with which user groups are easily able to identify, and therefore, leads to more informative communications at an earlier stage for all parties.
Equipment lists. The room diagram shows the equipment used while the equipment list tracks cost, utility, and other requirements related to equipment in the room. This process helps clarify the work processes in the room and validates a functional understanding for the space. This also allows for quantification and a much better basis for an accurate project cost model.

Fixture schedules and counts.As with equipment lists, fixture schedules and counts generated by the engineering disciplines helps the design and client team understand the functions in the room and in non-room environments (such as corridors). Fixture schedules and counts are vital to an accurate cost model.

5) Understand and embrace decision management

Management of decisions is the heart of understanding how to manage a project or development program. As with the discussion on integrated processes, decision management is based on the ability to organize intellectual capital at the outset of the project: not later when problems arise.

To influence decision management, there needs to be a simple understanding of decisionmaking. There are three components to decision making: memory, reasoning, and concept formation. To affect consensus and group decisionmaking that results in durable decisions, it is necessary to create common memory, common reasoning, and group concept formation.

The following are thoughts on decisionmaking and decision management as it relates to this subject.

Zone management. Very few people can easily remember more than a few categories of information, usually five at the most. A method is needed that builds common memory, categorizes information, and organizes it in a form that accommodates easy retrieval (no more than five categories). In health care, we divide the facility into five zones: inpatient, diagnostic and treatment, ambulatory, public and administrative, and support services. Each project has a zone leader who is responsible for each zone. Consequently, the zones are organized roughly in the same manner the user organization is organized, and this leads to better design team / user communication with regard to operations and issues.

These zone leaders, usually with an assistant, provide the leadership for all programming and planning activities, including involvement and integration of the other team members, analysis of current operations, current net to gross, process mapping, development of all room diagrams, equipment lists, and fixture counts.

Zone leaders also integrate and work with each other. As an example, the standard room diagrams for offices developed and maintained by the public and administrative zone leader (mostly office and conference environments) are the standard used by all zones that have office space. The same can be said of the zone leader for diagnostic and treatment, who develops imaging rooms and shares it with the ambulatory zone leader who needs X-ray rooms in the emergency department.

An advance team for meeting organization and scheduling. It is both costly and an ineffective use of skill sets to ask architects and engineers to schedule their own meetings. Nor should meetings be scheduled on a regular basis without a decision management plan for the meeting. The organization of meetings should be managed on the basis of the decisions needed to move the project ahead. A team (advance team) of individuals (usually two) has been found to be very effective in scheduling and confirming detailed meetings between users and planners (zone leaders and zone planners).

Advance team members meet separately with users and planners, schedule locations for meetings, make site visits to determine validity of meeting locations and venues, determine availability, maximize efficiency of trips, and create, as necessary, informational packets (containing plans, notes, and even directions to meeting locations) for both planners and users to be effective in decisionmaking. Schedules and agendas for meetings are on 15-min increments, with blocks of time determined by complexity and co-location. 

Value and cost-framed work sessions.Meetings should occur because there is a decision to be made. The people in the meeting should have formed a common memory and common reasoning and are now able to form a concept and make a decision. If there is not a common memory or a common reasoning base, then building a common memory and a common reasoning process is the task at hand before asking for a decision.
The value or cost of a decision should be known, even if the decision may be cost-neutral. If the cost for a decision is not mentioned, the normal assumption by all parties is that it is “free,” or that the owner does not care what the cost is and does not care how it might affect schedule or functional attributes already in place. A decision is never free and always affects something, and the owner cares.

Identifying cost as a factor should become common practice so that decisions are not made with an assumption that there is no cost or downstream impact. It (almost) goes without saying that one must be thoroughly prepared with cost figures in hand. As such, advanced value promotion (mentioned above) comes into play, setting the stage for a proactive management of the cost model and budget.


The alternative to current processes includes initiating process maps, room diagrams, and equipment lists. While most everyone will understand these terms, not everyone will understand what integrated planning and design, systems integration and space optimization, and target costing mean. But these are processes which will help make decision management successful (and as a result the project successful as well).

This discussion has centered on the planning and design portion of a project because if the decisions are correct and durable at this stage, a significant amount of change can be eliminated, which results in a fundamental change to project outcome. The five points to consider for a better project delivery system (call it alternative delivery system if you wish) are:
  • Integrated planning and design
  • Process mapping
  • Target costing
  • Systems integration and space optimization
  • Decision management
These steps ultimately lead to enhanced use of project delivery practices such as BIM, integrated detailing, shared incentives, and pre-manufactured systems. ES