Healthcare capital projects rarely struggle because the strategy was weak. More often, they struggle because the decisions made between strategy and steel do not hold. A project may begin with a clear business case, a compelling clinical need, and strong executive sponsorship, but as planning is translated to design, design becomes pricing, and pricing becomes construction, the silos between stakeholders start to show.
Those silos are where scope creep, late-stage changes, rework, budget pressure, and schedule disruption often emerge. They are also where health systems have the greatest opportunity to improve outcomes by setting up the right teams, decision protocols, and advisory processes before the project gets too far downstream.
Make the Decision Process Explicit
One of the most practical ways to reduce rework is to define who decides, who informs, and who aligns. This sounds simple, but in healthcare projects it is often where ambiguity becomes expensive. Clinical leaders, facilities teams, finance, operations, architects, engineers, contractors, and executive sponsors all need a voice. But not every voice has the same role in every decision.
When those distinctions are not made explicit, user input can be mistaken for approval, design preferences can be mistaken for operational requirements, and executive silence can be mistaken for endorsement. The result is predictable: The team revisits decisions, redesigns space, reprices scope, or attempts to solve strategic disagreements through value engineering.
Strong governance is not about adding more meetings. It is about creating a disciplined path for decisions to move from discussion to endorsement to action. That means defining decision gates, preparing stakeholders before key meetings, documenting assumptions, and making sure the right people have seen the material before a broader group is asked to react. Leaders should not walk into a user meeting expected to make decisions with design options that the construction advisory lead and cost team have not already reviewed for strategic alignment and budget reasonableness.
Advisory Support Should Be Continuous, Not Episodic
In many healthcare capital projects, advisory support is treated as a front-end planning function or a back-end project rescue function. The most effective projects treat advisory as a continuous connective function across strategy, design, construction, activation, and ultimately the first patient day.
That continuous role matters because architects, engineers, contractors, clinicians, operators, finance leaders, and executives each see the project through a different lens. Architects may focus on the integrity of the design solution. Engineers may focus on infrastructure and code. Contractors may focus on constructability, sequencing, and cost. Clinical stakeholders may focus on workflows and immediate operational pain points. Executives may focus on capital affordability, strategic positioning, and speed to market.
The advisor’s role is to synthesize those perspectives into decisions that can withstand pressure. That means translating strategy into design criteria, design criteria into cost and schedule implications, and cost and schedule implications back into leadership trade-offs. It also means creating a single source of truth so that the team is not making decisions from different versions of the project.
Clinical Input Is Essential, But It Needs Context
User engagement is one of the most important parts of healthcare planning, but it is also one of the easiest to mismanage. Clinical staff know the work better than anyone. They understand patient flow, equipment needs, staffing realities, and the small operational details that determine whether a space will function. Their input is indispensable.
At the same time, user groups often reflect the way work has been done historically, not necessarily the way work should be done in the future. Staff may default to the layouts, adjacencies, and processes they have known for decades because they have not been exposed to alternative models. The project team must therefore walk a fine line: respecting lived operational experience while also testing it against best practices, future care models, staffing realities, regulatory requirements, and affordability.
This becomes even more important because the people who provide input during design may not be the same people operating the space on first patient day. In some regions, as much as 30% turnover can occur in the clinical team between the start of the project and the first patient day. We have a current engagement where five out of the six C-suite executives are new since the study’s inception. If every decision is anchored only to the preferences of the current room, team, or workflow, the project risks hardwiring the past into a facility that is supposed to serve the future.
Is It a Scope Change or an External Driver?
Healthcare leaders are rightly sensitive to industry and market forces: escalation, labor constraints, supply chain volatility, and changing regulatory requirements. But not every scope or cost change is caused by the market. Some changes are evidence that the project team did not fully align on scope, priorities, decision rights, or operating assumptions early enough.
When a design team advances options that have not been tested against budget, when user groups add requirements without leadership trade-off discussions, or when executives engage late and reopen foundational decisions, the cost impact may appear as a pricing problem. In reality, it is often a governance problem.
The discipline is to distinguish unavoidable market movement from avoidable decision drift. A well-run process tracks assumptions, documents approvals, identifies cost drivers, and makes trade-offs visible before they become change orders. It also ensures that the contractor and advisor have a meaningful role in testing options before they are socialized as viable solutions.
The Path to Better Decisions Starts Upstream
Decision quality is influenced by meeting design. The logistics matter. Who is in the room, whether the meeting is truly in person or hybrid, whether people have the pre-read, whether technology works, whether participants understand the objective, and even whether the day is structured humanely all affect the quality of discussion.
Those details are not administrative afterthoughts. They are part of the advisory function. A productive user session does not begin when people walk into the room. It begins when the project team clarifies the objective, vets the material, confirms budget reasonableness, prepares leadership, and gives users enough context to provide informed input rather than first-impression reactions.
A Practical Operating Model for Sticky Decisions
Health systems can reduce rework and improve project discipline by establishing a simple operating model early:
- Define decision rights. Clarify who decides, who informs, who recommends, and who aligns for each major project phase and decision type.
- Use decision gates. Establish formal points for scope, budget, schedule, design direction, operational readiness, and activation approvals.
- Prepare before broad engagement. Vet design options, cost implications, and leadership priorities before asking users to react.
- Document assumptions and approvals. Maintain a decision log so the team can distinguish a new decision from a reopened decision.
- Balance user input with future-state design. Respect operational expertise while challenging historical habits that may not support future care delivery.
- Keep advisory continuous. Maintain a connective role across strategy, design, construction, activation, and go-live.
The Building Is the Output; Alignment Is the Work
Healthcare capital projects can have such a lengthy duration that teams change, assumptions evolve, and pressure increases. The work is not simply to produce drawings, manage meetings, or track budgets. The work is to create a process where decisions are made by the right people, at the right time, with the right information, and with enough discipline to hold through execution.
The projects that perform best are not necessarily the ones with the fewest opinions. They are the ones with the clearest process for converting many perspectives into durable decisions. That is where advisory adds value — not as an extra layer, but as the connective discipline that helps the strategy survive to the first patient day.
© Copyright 2026. The views expressed herein are those of the author(s) and not necessarily the views of Ankura Consulting Group, LLC, its management, its subsidiaries, its affiliates, or its other professionals. Ankura is not a law firm and cannot provide legal advice.
