As if the actual delivery of hospital construction projects isn't challenging enough, health facilities professionals today have many other variables at play as they plan, launch, manage and activate new projects.

More of their days are spent modeling various scenarios for leadership that will allow the organization to remain competitive and viable in an era of reform. A capital program managed at the level of $20 million to $30 million per year with an average project value of less than $3 million could expand in a matter of months to one that is double or triple that size in the next five years. Alternatively, promises of a capital program much larger may have to be scaled back after staffing already has been planned.

Given these challenges and the propensity for change, hospital design and construction department leaders would be prudent to conduct an organizational assessment with either internal resources or by a qualified third party. Such an assessment evaluates personnel, management processes, scope and scale of pending projects, and the leadership required to effectively deliver the strategic master facilities plan and its components. Ultimately, it will help health care organizations determine whether project requirements can be successfully delivered internally or whether external help is necessary.

Evaluating personnel

The most important part of a hospital design and construction department is the team that carries out the department's mission on a daily basis.

A recent assessment of a large health care organization in the eastern United States demonstrated the varying degrees of skills and experiences of the department's team members. The root cause was the lack of well-defined and appropriate job descriptions for recruitment. Additionally, performance review criteria were too general and geared more toward those in the organization involved in the delivery of care and not construction.

After the root cause was identified, tailored job descriptions and performance review criteria were developed and presented to the human resources department for consideration. The adoption of these enhancements led to the design and construction department's reorganization of its internal staff to more appropriate positions and improved their ability to attract staff with capabilities suited to the changing demands of the role.

The challenge for departmental leaders is to match the team's skill sets with frequently scheduled projects, while remaining flexible as capital plans and organizational strategies evolve.

To evaluate a team's capabilities, feedback via a survey tool should be solicited from each team member as well as from the customers they serve within the organization. The survey results, backed by one-on-one interviews, provide the most thorough information to assess the team and make recommendations on any organizational and structural changes.

Various scenarios may present themselves upon evaluation, such as too few staff, staff in the wrong positions or staff with insufficient training for their current positions. In conducting an evaluation, it is important to focus on the areas of opportunity for improvement.

Most frequently, assessments identify a lack of established processes and training that could greatly enhance and sharpen the skills of team members. The challenge is getting an organization focused on delivering patient care to invest in training for a non-core service. Such training sometimes can be leveraged through relationships with design and construction professionals. With the enhancements in construction delivery models and such design tools as building information modeling becoming standard, now is the time to improve educational offerings for the team that will be assigned to manage capital projects.

If the assessment indicates that additional resources are needed, the pros and cons of recruitment must be evaluated. While there is no shortage of construction and development professionals due to the economic downturn, those who are most qualified to execute health care projects have, for the most part, remained employed or are in high demand.

While placement firms may assist in identifying qualified individuals, there is no guarantee that they will possess the intangible qualities required to become an effective part of the owner's team. Engagement of these individuals can be quite costly and the risk of losing them to competitors always exists. In addition, the added responsibility for the department leader must be weighed. Finally, it should be noted that many of the applicants with health care experience are former independent architects or construction managers and may lack the owner experience or perspective required to manage the work from the inside.

An alternative option to adding full-time equivalents is to engage a third-party management and consulting firm to assist with all or various parts of the work. Consulting firms are, by nature, invested in the education, training and continued development of their personnel because it is a major selling point for services and part of the added cost for utilizing their resources.

Despite the presumed knowledge and experience that an outside firm may possess, an organization must consider whether the consulting firm's team is a good match and a cultural fit for the institution. It is recommended to identify gaps in capabilities first and then buy services a la carte to fill those. These gaps can be as small as schedule development and maintenance and as large as effective management of the furniture, fixtures, equipment and technology scope of work on a project.

While it may be easy to identify firms with a track record of successful health care project management, it will be more difficult to find a true partner that can integrate with the internal team, avoid disruptions and minimize morale issues.

Processes and systems

An analysis of the hospital's use of project management processes and systems is a necessary component of the organizational assessment.

With a greater focus on detailed tracking of allocated capital and aligning operational processes with the facility design, tools used in the past do not meet today's challenges and reporting requirements.
A system that provides for project documentation and directive, as required to work with consultants and contractors, must be established.

Project management systems can be costly to procure and maintain, particularly if there is no plan to utilize the platform across multiple significant projects for a substantial period. Third-party firms typically work with established project management software and train their staff to utilize the software at client sites. Hospital design and construction departments also increasingly have adopted software systems.

The problem is that they often adopt a system without aligned project management processes and get results that are ineffective. A standard must be identified and adopted to review and approve everything from submittals to invoices to budget changes. The various actions must adhere to a predefined hierarchy determined at project initiation. Many institutions have a rudimentary version of these processes already in place. However, they are not widely adopted and lack parameters for evaluation. The absence of standards within the design and construction department can greatly limit effectiveness.

By conducting an assessment, the department leader can accurately gauge the level of adoption of any current system or process.

One hospital in the southern United States recently conducted an internal assessment to identify current processes in place that worked, those that didn't and those they needed in the day-to-day management of their projects. The results were a more streamlined set of processes and tools that team members themselves identified and owned.

To sustain this buy-in, a standards committee was recommended with members who would serve one year and rotate. Membership comprised all levels of the department. This structure allows for consistent evaluation and adjustment of standard processes and tools that will provide the most leverage and control for project management. Allowing team members to offer insight will increase morale and accountability while improving success.

Scope and scale

Hospital projects require significant dedication of resources to manage the requirements inherent in scope and scale. Smaller interior projects generally can be executed by existing facilities teams. However, larger phased projects require more manpower dedicated to daily activities.

While health facilities personnel likely have intimate knowledge of the operation and maintenance of building systems, this knowledge typically does not translate to the level of coordination and decision-making required on a large project. Examples of the typical requirements for a large project include, but are not limited to, architect and construction management procurement, contract development and negotiation, schedule development, budget development, design coordination and steering committee reporting.

Defining today's health care projects as more than bricks and mortar requires a team that can deal with complex medical equipment and clinical information technology (IT) systems and have a basic understanding of workflow in the delivery of care. Advances in medical technology have tremendous implications for IT infrastructure, mechanical-electrical-plumbing needs and interior features. Management teams either must be well-versed in the technology and its integration or be nimble enough to process and coordinate IT requirements, which are constantly in flux.

Given these realities, there is more convergence between the design and construction team members and the IT team members than ever before. Lines of responsibility have become significantly blurred. Therefore, it would be wise to dedicate one or more individuals to support the teams responsible for design integration, specification, procurement and installation of all IT systems.

Historically, health care organizations have set a dollar-volume threshold at which they would outstrip their internal capabilities to manage a project. The organizational assessment will provide a basis to this method and help tailor a more effective response. Third-party options for managing projects may be more costly on the surface but short-term assignments for internal resources may not allow sufficient time to recruit the most qualified candidates.

Leadership evaluation

A key component of project success that must be evaluated is the leadership required at various levels of management, including board liaison, steering committee and core group. The individuals entrusted with governing each group must be engaged, proactive and qualified to process the aggressive flow of information and to generate the appropriate directive to keep the project moving.

The assessment will provide an understanding of resource availability that not only can manage the project components, but also can communicate effectively with all stakeholders involved. Projects will not succeed if the people entrusted in these roles are polarizing per­sonalities who cannot make necessary decisions in the allotted time. This essential leadership quality is necessary to work with the clinicians, administrators, designers and builders engaged for project delivery.

Again, if there is a lack of available talent within the design and construction department, an independent third party can be leveraged. A qualified consultant can be instrumental in bridging the gap and advancing the project.

For major decisions that could impact the institution financially, the leadership team may benefit by working with a third-party firm that can provide a strategic analysis not limited by internal factors.

Delivery improvements

The long-term strategic master facilities plan must be considered when deciding whether an organization is prepared to tackle the next major project. Timing of projects is critical with regard to staffing to minimize the impact to the budget and optimize the utilization of personnel.

Any internal project management opportunities created by the pending project must provide a clear career path for individuals or recruitment and retention will become an issue. Regardless of the approach, maintaining the organization's culture must remain forefront to ensure project success.

Investing the time to conduct an organizational assessment prior to launching a project will pay dividends in the long run. Understanding internal capabilities and identifying potential weaknesses is the foundation upon which a stronger department can be created.

Implementing standards, structure, processes and tools across all facility projects will enable a hospital design and construction department to capitalize on best practices and, ultimately, improve the delivery process. At a time when capital continues to tighten, improvements in project delivery will be embraced by the leadership of any organization.

Patrick Duke is senior vice president and Lee Barton is senior consultant at KLMK Group Inc., Richmond, Va. They can be reached at and, respectively.

Sidebar - Most frequent challenges

Health care design and construction departments often have difficulty explaining their value to all levels of a health care organization.
The following is a list of the most frequent challenges they face:

1. Interfacing with human resources. Health care organizations have job descriptions, salary bands and performance review procedures that are set up to carry out the business of health care. Often, policies are not conducive to hiring the top talent to manage the design and construction of facilities. Constant communication between departments is required to overcome this obstacle.

2. Internal training and education. Leaders of design and construction departments often have difficulty securing funds for continuing education and training. However, many options are available at little or no cost. For instance, many department leaders can develop an internal program and leverage the professionals within the industry.

3. The process manual myth. Ask the members of any organization and they will tell you that a process manual describes all of the organization's standards and policies. Even if such a manual exists, it rarely is referenced. Consequently, many design and construction departments lack clear processes. Departmental leaders need to invest the time to identify standards and best practices and ensure they are implemented across all projects.

4. Integration with other support departments. Despite the critical nature of collaboration with other support departments like engineering and information technology, many design and construction departments are not structured in a way that fosters clear communication. Departmental leaders should identify liaisons that can support project managers to ensure effective collaboration with other departments.


Sidebar - Tips for selecting collaborative management software

The decision to acquire and implement a collaborative management software solution can be a game changer for a design and construction department. Regardless of the system chosen, internal processes and standards should be evaluated and enhanced prior to installation and the following steps should be taken prior to purchase:

1. Understand the adoption rate and success of current processes. Identify a system that can leverage and enhance current internal processes.

2. Use a bottom-up approach for selection and implementation. The new solution could be the best product ever created, yet its value will be worthless if it is not utilized as intended. Departmental leaders need to tap the product users to learn what needs they are trying to fulfill with the software and then identify the features and options that can deliver results.

3. Do not focus on just one management process. While some departments find value in a system that solves one burning issue, such as integrating finance into the process, departmental leaders should be sure that the solution offers a full complement of services that address all project management needs identified by the end users.

4. Phase the system roll-out. Activating too many of the system's modules and options at once can overwhelm the team. Identify best processes and understand how the system can leverage and enhance them. An average roll-out should take approximately 90 calendar days. While some systems can take longer, anything longer than 180 days begins to try the patience of the team and will lose momentum.

5. Set realistic expectations. Do not expect the system to solve all problems overnight. To ensure success, one team member should be designated as the solution advocate and be involved in the purchase decision, intimately understand the system, lead the department roll-out, and conduct all training. Ongoing training should be planned and scheduled.

6. Don't relax after implementation. It is important to put a structure in place to evaluate the effectiveness and adoption of the system continuously. Gather feedback as to which modules and options are most effective and which have room for improvement.

7. Select a system that is provided as a service. With the advent of systems located in the "cloud," it is more beneficial to focus on the configuration and implementation of business processes as opposed to hardware and software considerations that can delay the time to value.