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Brown K, Clarke D, Percy F & Kent K : Facilities Modernisation Project South Auckland Health. IPENZ treNz 2002-4

Facilities Modernisation Project, South Auckland Health:

Planning and Delivering Health Sector Capital Projects in New Zealand


in the Context of Organisational Change

1. ABSTRACT mix. Integrated strategic governance across all these


organisations (or high-level teamwork) is therefore
The objective of this paper is to communicate key essential.
lessons learnt and information gathered during five
years of facilities upgrading and modernisation These stakeholders must consider aspects of both
undertaken by South Auckland Health (SAH), (lately current and future health environments, including
Counties Manukau District Health Board (CMDHB)). demographic and disease trends, and the impact of IT,
SAH is a 900-bed tertiary teaching health provider medical technology and of new processes. Obviously,
based in South Auckland, New Zealand, and servicing a these complex and changing requirements must be
population of about 400,000. It consists of a main converted into a functional built environment via
hospital campus, Middlemore (700 beds), a new elective designers and contractors, to create an appropriate,
surgery hospital at Manukau, two ambulatory care effective and future-proofed facility for clinicians,
centres and five regional health care centres. It has support staff and patients.
4,200 employees.
The paper will therefore endeavour to provide some
The discussion points and recommendations in this practical recommendations for CEOs, GMs and Project
paper are provided as sometimes provocative views, to Managers working with – or representing – clients in
stimulate discussion and provide a structure for pre- the health-care setting. It should though be equally
project workshops or a start-up tool for organisations useful for any organisation moving through business
undergoing change. The paper should not be read as and process change associated with upgrading facilities
offering “the answer”, or the correct or only or infrastructure.
methodology, but more as a step towards consolidating
our knowledge and skills in the New Zealand market. The report will address various stages of the project
including:
It does not give a full historical account of the project,
and issues will be discussed only where it is deemed to • strategic and business considerations
be of value, and where they go beyond Project
• master planning, concept and detail design
Management disciplines. The paper will address a wide
range of issues, spanning the wider health environment • clinical and user-group input and management
including the strategic thinking on Middlemore's future. involvement
At the other end of the spectrum it will explore the
“softer” skills” and management processes required to • project control and reporting systems
retain energy, discipline and focus in changing health • project governance
business environments.
• construction / design procurement
A particular emphasis will be given to project • set-up, transition into and commissioning of
governance and the integration of evolving business facilities
needs during the execution of a very large project. In the
public sector environment diligent governance is Information and medical technology and their relevance
necessary at many levels. For example the NZ Health to system and process design and implementation is a
Strategy must be implemented in all public projects huge and essential part of the evolution modern health
undertaken on behalf of the government, the Ministry of business, and for clarity it needs to be treated separately.
Health (MOH), the NZ Audit Office and the local It will not be considered in detail in this paper; suffice it
District Health Board, local communities, staff, Iwi,
to say that it must be treated as a critical project task
media and the wider community. Programme delivery both in the early strategic phase and later regarding
must be executed by a receptive design team and detailed design. The impact of technology in the new
building contractor within this complex stakeholder
age of preventative primary care and patient “The hospital has reached an evolutionary branch. The
management through secondary and tertiary care must fundamental nature of hospitals is about to change
be considered. because of the application of information and clinical
technology, changing medical practices and economic
Change management is a theme underlying all of the rationalisation.” (Braithwaite Vining & Lazarus 1994).
above. Leadership is required for effective A future healthcare system will be much more
organisational change to happen and staff must be “distributed” across the community. Many of the
trained and enthused about leadership. This is necessary problems in health systems today arise from the
not only to effect the necessary shifts in organisational fragmentation of the general practitioner/primary sector
culture, but more specifically to embed process changes and the hospital sector. A new concept of care,
and operational improvements associated with changes integrating primary with hospital care, is far more
to the physical environments, for the long term. relevant to future patient welfare, and will be
underpinned by technology.

2. ACKNOWLEDGEMENTS To be effective then, major hospital reconfiguration has


recognise that healthcare in the future will be delivered
Prepared by Kevin Brown (Project Director & with emphasis on ambulatory, community and primary
Engineering Manager, South Auckland Health), David care, and on low-cost preventative solutions. This must
Clarke (CEO NeuronZ Ltd, formerly CEO South be taken into account in developing a master plan.
Auckland Health), Fran Percy (Health Consultant,
formerly Project Director, South Auckland Health). This is particularly relevant to South Auckland where
Transitioning Facilities in Today's Health Sector, with we have not only advances in technology and
sub-section by Kirstine Kent; Transition Manager SAH. patient/staff expectations, but also a massive increase in
chronic disease (such as diabetes), and a rapidly
increasing winter capacity problem at Middlemore
Hospital. Middlemore (700 beds) was built in two main
3. CAPITAL PROJECTS IN THE stages in the 1940s and early 1960s at the northern end
HEALTH SECTOR of the South Auckland catchment. While it was
recognised that in the long term, (say 10 to 20 years)
For hospital rebuilding and modernisation to be two hospitals would be needed in South Auckland, one
sensible, relevant and responsible, it must be done of the two will be at Middlemore. This meant that
within a concept of overall strategic health planning. economically it was sensible to begin to modernise the
“Sensibly before one begins on the major reconstruction Middlemore site and allow for a second hospital in the
of a hospital, an analysis of the healthcare system in the longer term. The economics are simple and compelling:
future and the forms that will shape it are fundamental. to rebuild would have cost some $350 million, whereas
What is needed is information that combines facility- Middlemore was completely modernised (including IT)
based utilisation with population based treatment rates” for $160 million. A strategy of integrated care, which
(McKee & Healey, 2001) manages people in the community with a programme of
early intervention and prevention, was put in place to
Hospital reconstruction and the building of associated delay the need for a second acute hospital.
infrastructure (including IT) are the most significant
areas of capital investment in most health systems. Such The modernisation of the Middlemore campus was
capital investment decisions must be carefully thought critically necessary. However residents also expected
through with a view to the future and changing care in remote locations, and this was being advanced
environments. by developments in diagnostic techniques such as
digital radiology, and IT advances which meant that
An examination of the forces at work in health in clinical information could be transferred rapidly
general (in New Zealand and in similar health between different providers.
economies internationally) clearly indicates that the
concept of a large tertiary teaching hospital as the Most patient interfaces in contemporary hospital
critical hub of healthcare delivery is an outdated systems do not involve inpatients. Indeed, as lengths of
concept. We are moving into an age when the concept stay reduce, many western hospital systems have
of the “boundaryless” hospital is relevant. reduced their bed numbers considerably, New Zealand
being no exception. To give some scale, in South
In particular, the rise of technology for the rapid Auckland Health (SAH) each year there are 1.2 million
communication of clinical information, increasing GP consultations, 2 million pharmacy prescriptions,
patient expectations and improved knowledge mean that 250,000 hospital outpatient attendances and only 60,000
the concept of delivering everything at one physical inpatient hospital attendances. We needed to decongest
point is fast becoming irrelevant. Middlemore Hospital, which had reached a saturation
point at 700 beds and the limit of economies of scale, by
moving services, particularly high-volume outpatient beginning of the design process. Job design is critical
services, off site. and we found that Union involvement was not (as some
expected) disruptive, but valuable and supportive.
The modernisation programme had three main
components v) There is increasing specialisation in healthcare
delivery, which we needed to recognise in developing
The first part was the building of SuperClinicsTM or areas such as paediatric emergency care and the separate
ambulatory care centres, which, in conjunction with children's hospital. Clinical expertise, architecture,
general practice and community A&E services, would aesthetics and medicine delivery are markedly different
deliver 250,000 (and growing) outpatient consultations from other areas, all of which had to be recognised.
close to where the patients lived in a community-based
setting. The first two centres, one at Howick/Pakuranga vi) The most critical long-term cost item in hospital
and the other at Manukau, also provided health services design is NOT the construction cost itself – it is the staff
closer to the community. The Manukau site was then costs of the implications of the design. Amortised over,
chosen as the future second secondary hospital. say, 40 years, the capital costs are negligible compared
with staffing costs. Clinically-led process redesigns,
The second component was the modernisation of the however unfashionable, are vital. No project should
Middlemore site itself. The hospital would no longer be proceed without process improvement, to bring about
the centre of the healthcare system, but a component in gains in productivity and clinical quality.
a new, distributed health care system. We set capacity
limits for each area and recognised two main vii) Elective (or planned) care and acute /trauma care
determinants: require different competencies, and different
management and system parameters. We decided
i) The hospital needs to be acuity-focussed. We call this therefore to split as much of the elective and planned
“front loading” the hospital, which means delivering the work as possible away from the trauma centre at
most effective specialised intensive medicine and Middlemore to a more specifically designed setting. The
therapy early on for the patient, ensuring the best of hospital has a significantly constrained architecture
outcomes. If high-expertise interventions can be orientated primarily for acute and trauma care. So the
delivered to the patient in the first 24 hours, the Manukau SuperClinicTM was established as the main
improvement in patient outcomes and reduction in the elective surgical and planned outpatient care site. This
length of stay is marked. was also in line with the preparation for the second
hospital site at Manukau.
ii) There are moves towards different treatment models
with lower costs relative to acuity once initial acute care viii) We were working with a busy operational hospital.
is completed. Rehabilitation units, observation units, We had to commission and construct around patients,
discharge facilities and “hospitals in the home” were all and move them where necessary to avoid disrupting
embedded into the design of Middlemore Hospital. treatment processes. Traditional full fixed design and
build does not work in such a context. We therefore
iii) Heavy use will also be made of Information allowed for significant flexibility, and managed
Technology. It allows remote diagnostics, and the contingency issues through strict processes agreed by
transfer of information between facilities, and has led to the contractor and participants. These disciplines
the development of patient centres where clinical ensured that scope changes and risks were controlled
information can be accessed quickly. during every phase of every project, and allowed plenty
of time to implement the outcomes of value engineering
The issues that caused us the most difficulty related to processes, which proved invaluable for staying on
information technology and systems. We had to deal budget.
with new implementation processes, new software and
new communications networks (including wireless). Thirdly and finally, the Labour/Alliance government
They were needed to give clinicians the information elected in 1999 has signalled a move to early
they needed to improve patient flow and treatment preventative care and an investment in primary/GP care.
processes. The new paradigm was “integrated care” and our
programme needed to recognise this.
We cannot emphasise enough the value of first-class
project management and detailed analysis of IT The involvement and leadership of clinicians is
requirements. IT is a relatively new discipline and it absolutely vital. They are the people who have to make
requires critical expertise in organising the construction the system work. SAH adopted the approach that all
and commissioning processes. major decision-making, including the Board Project
Steering Group, should have significant clinical
iv) Various non-clinical stakeholder groups, including representation.
Unions and cultural groups, were brought in at the very
The clinicians have the right to review and over-rule 4. PROJECT AND SUB-PROJECT
various aspects of the project, and lead the process
design review. The Steering Group) including the Board DEFINITION
and Senior Clinical staff, would set the broad
parameters, broad scope and outcome. They would then The SAH re-development began in 1996 and was
hand the process over to the project team (also clinically substantially completed in September 2002. Including
led) who would research, design and participate in the the SuperClinicsTM the project totalled $160 million and
value review process. This involves extensive research was funded by borrowing offshore, based on a solid
and trips overseas. Often clinicians involved in other SAH financial operating position. All sub-projects were
building projects were consulted for expert advice. completed on time and to budget and are performing
close to operational and business expectations. Strategic
Once overall strategies have been determined and the and operational goals have generally been met and
long-term structural elements and planning assumptions many new clinical processes developed under revised
are agreed upon, then patient demand and disease operating philosophies and models of care are proving
patterns and distribution must be analysed. The analysis to be effective. There is however always room for
is based on well-understood epidemiological learning. The object of this report is to provide a tool for
knowledge. In South Auckland the low prevailing socio- managers about to embark on complex health
economic status and the large number of children developments.
(95,000) require provision for growth in the diseases
associated with deprivation, and for specialisation in South Auckland Health applied the philosophy of
children's health. Therefore we designed specialist care involving user groups in physical design and process
into emergency facilities and the Kidz FirstTM Children's change. If it is managed well, involving users will not
Hospital. We also catered for a significant projected slow down the process, and will enhance the long-term
increase in the diseases of the chronically unwell, performance of a hospital. For SAH this approach was a
particularly diabetes, congestive heart failure and huge help in terms of people “buying into” the required
respiratory disease. process and cultural changes, and it therefore reduced
the long-term financial and people costs of the project.
An analysis of demand was then undertaken and the When the Acute Hub was commissioned, for example,
results built into the hospital’s capacity. the transfer to the new facility went extremely smoothly
(and it needed to) as it was “owned” by both the project
Much of the capacity planning for hospitals is done team and SAH staff. In areas where we were not so
using averages. The fact that hospital demand, good at engaging the staff, we didn't do so well!
particularly for acute services, is stochastic and not
deterministic has escaped many hospital planners. It is 4.1. The Programme consisted of 20 Sub-
unsatisfactory to use averages, ignoring variances or Projects including:
standard deviations, and failing to take account of
probability regarding length of patient demand, and • Ambulatory Care SuperClinicsTM at Manukau and
fluctuations and inpatient/outpatient capacity. Yearly Botany Downs
averages and yearly volumes are not sufficient either. • Acute Hub, including Accident and Medical (adult
Hospital demand fluctuates markedly within a year, as it and paediatric), Coronary Care Unit, Intensive
does within the week and sometimes within the day. It Care Unit, Cardiac Testing Unit and Staff Centre
is a question of realistically forecasting, managing and • Kidz FirstTM Hospital, with 85 Beds, and a
planning patient inventory levels. specialist Burns Unit
• Support services including a new Pharmacy,
Limits to capacity must be set. This must be done unit relocated Laboratory and refurbished and extended
by unit, and individual units' capacities and limits must Kitchen upgrade
be integrated into the overall hospital design. The • Women's Health Foetal Assessment Unit
capacity of Middlemore Emergency Care (EC) was • Manukau Surgery Centre, with six theatres and 80
designed at 100,000 patients, peaking for the winter beds (with future expansion built in)
(averaged). This limit was set because you cannot run • Academic Lecture Theatre and Deanery (office)
an EC department with more than 100,000 patients per • Galbraith Building Ward and Plant upgrades
annum. The acute hospital departments were then sized • Adult Medical Centre, including Renal Facility
accordingly, as the majority of patients at Middlemore and Catheterisation Laboratory
long-term are likely to be acute. Once EC reaches this • Associated road, parking, security, infrastructure
number a new hospital is required. These limits are and IT upgrades
fundamental because volume flow and volume
management needs to be right-sized throughout the
institution. 4.2. The Challenge of change:
As a result of a deliberate and continuous challenge
process, the original sub-projects were from time to
time modified or re-prioritised. Dealing with these POs carry out the day-to day functions of the project
changes as the project evolved, in conjunction with sponsor, and manage internal integration and the
input from other parties, forced the organisation to be organisation of user groups on behalf of the sponsor, in
responsive and adapt its processes and service delivery. conjunction with the PM team, Quantity Surveyor and
It is not always possible to identify the ideal result until designers for each sub-project. The PM and Sponsor
the project has evolved through certain phases. This is formed a “mini-governance” structure for sub-projects.
because the health environment is ever-changing, and 4) An effective Steering Group, including: the PM,
because people come on board and contribute their ideas CEO, sponsors, clinical and/or business managers, user
or influence at various stages of the process. representatives, risk management team, finance, project
champions and other support services as required. This
Although it is desirable to bring in key players early component allows particular sub-project representatives
(and every effort must be made to do so) it should be to report to the Board or board sub-committee as
recognised that this does not always happen in practice. required. The freedom to co-opt as required is useful.
Decision and change processes must therefore be This team must drive internal direction and decision-
monitored and integrated carefully with progress on making to provide clarity to the delivery team.
physical design and construction. Managing this
dynamic was one of the critical project success factors 5) Champion(s), who need to be involved early on,
and is an area where a team's healthcare strength and convinced of the benefits of the project and used as
experience comes to the fore. effective selling/buy-in persons. A respected high-
profile clinician was used at SAH. Choosing and
working with this person is a critical success factor.
5. THE PROJECT TEAM, Consistency and continuity of this type of input and
clinical leadership is vital when new processes are being
CHANGE MANAGEMENT & integrated into design.
COMMUNICATIONS
6) Experience and knowledge of the wider health sector
The importance of the team participants cannot be over- in the governance team is essential, ensuring that
emphasised. It is not possible to have all the members rigorous solutions are attained. This seems obvious but
100% ideal, but the relationships and communications is often overlooked during the critical change
skills and attitude of all involved must be well above management and early development phases. Travel – in
average. The chosen leader must be given the mandate search of ideas and to look at facilities in action – is
(within reason) to choose and work with a team suited invaluable and can help consolidate project thinking.
to his/her style, who are proven performers and Concept architects, business managers, project leaders,
motivated – who want to be there! It is important to key user group representatives, clinical and support staff
think about team dynamics and then set the team up to can all take part in fact-finding tours. Before the start of
succeed. With hindsight we have identified three the project, key staff travelled to America, Australia and
determinants of project success: i) the dynamics of the the UK, which resulted in the consolidation of ideas and
team itself; ii) administrative disciplines iii) soft or also facilitated the team “kick start” of the SAH project.
human skills. These must all be considered in the Such fact-finding missions can be scaled to suit a
context of change management and communication. project, and the costs are insignificant in terms of the
operational costs of a wrong outcome.
5.1. Six essential components of the
programme team: 5.2. Five backbone administrative
philosophies:
1) An experienced and competent governance team with
decision mandate, either at Board level or delegated to a 1) Unity of command and information flow
board sub-committee. A person with project experience
2) Clear & robust decision-making processes, mandates
is useful on the Board for the duration of a project; this
and timing
often expedites decisions. Ideally this Board member
should be available for consultation between monthly 3) Effective control, approval and cost management of
meetings. scope (and scope change)
4) Excellent financial control systems
2) An experienced competent Project Manager or
Project Director. For SAH this person was in-house and 5) A formal (and informal) internal and external
reported directly to the CEO. communications strategy

3) An experienced competent project sponsor (business 5.3. Five essential “soft skills”:
manager(s) who work well with the PD/PM/leader). On
a large project it is also necessary to arrange supporting 1) An ability to control and minimise the negative
project owners from within the business organisation. impact of unconstructive team members. It is important
to create a positive atmosphere and to recognise, listen A sense of calm, focussed urgency is critical and
to and reward (or acknowledge) in some way those who repeated messages are needed to reinforce changes in
challenge or criticise in a constructive way. culture and process. The management of change is
critical for the entire organisation throughout and
2) Intelligent and pragmatic risk identification and beyond the project phase and into the future. As a
mitigation processes. The project needs pragmatic starting point, a generic process or structure for
systems and the application of a sensible risk mitigation managing the acceptance and implementation of new
process, blending experience, intuition and common service procedures must be agreed and established. The
sense, and including operational and business risks, and acceptance of change, which requires communication to
in particular change management issues. It is useful to bring about understanding of the organisation’s vision
have the risk system critiqued externally on a regular and direction, is however the key.
basis to check its effectiveness.
The actual “line diagram” process and disciplines used
3) Leadership (of the overall programme and each of the to manage the change process is important, though
sub-projects) that takes account of project-specific secondary.
systems and the people and groups involved. In other
words, “horses for courses”. Projects do not just happen The development and agreement of processes between
– they must be made to succeed through leadership the operations and project teams is a good way to gain
under each set of circumstances! Leaders need to mutual understanding of change requirements, and thus
approach every element of the project with a passionate buy-in; and it can form a “contract” determining how
and healthy urgency, bringing people along through people will work through issues.
involvement and input. They should look to find where
leadership and passion are missing, and coach and Once these processes or basic team rules and behaviours
encourage those struggling with the change process. have been set up to manage organisational and project
change we can then move on to develop and consolidate
4) A project culture should be developed to reflect and the details of the new business operations and master
complement the business culture of the organisation plans.
undergoing change. Business managers require regular
engagement on project issues – especially the 5.5. Communicating the plan to external
nominated project sponsors, to ensure they are organisations
managing organisational change and keeping up. Treat
the project as a change management opportunity. Once all the decisions on existing and new clinical
services have been made the multitude of service
5) Make it a growing and rewarding experience for all deliveries must be communicated to the designers.
involved. Sell the big picture and real social benefits to Managers, clinicians and nursing staff need to do robust
motivate them. Keep the patient and clinical work prior to the involvement of the external project
performance in focus. Emphasise the purpose of the delivery team. The PD must make sure this happens,
development – to provide a facility, processes and possibly using experienced outside consultants.
technology to enhance the already respected
performance of clinical staff, and to provide a better It is advisable as part of this phase to document an
health service for the people of a region or community. approved-by-management project-team brief, based on
agreed internal business plans for sub-projects, and
5.4. Change Management reconciled with the overall business direction. The
briefs are subsequently developed into an overall
For many of the clinical services new processes, diagrammatic master plan. This master plan, combined
procedures and policies will be developed for with a milestone timeline for the programme, is a very
implementation in the new facilities. The Project powerful tool for selling the vision to everyone
Director, by maintaining communication with the CEO, involved. It helps encourage and consolidate change
can ensure that General Managers and clinical leaders organisation wide, and discourages “silo” thinking.
take responsibility for developing and implementing
change management plans in their departments. A Communication, feedback and confirmation of shared
philosophy of organisational “cross pollination” of ideas knowledge ensure that the whole team becomes greater
and benefits is needed, as opposed to “silo” thinking. than the sum of its parts.
Real skill is required in change – it is an art; so make
sure experienced people manage it for or with you. The Once this high-level understanding is reached, it must
most effective approach is often learnt only through be converted into a project scope with an associated
experience. For example, letting people describe the budget. Remember that a lot of work will already have
current organisational position to you, rather than been done on broad-brush scoping and budgeting during
assuming or telling them where it sits, can help open the preparation of the business case; consolidation and
people up to change and provide a factual starting point. refining is now required. This will require input from
external experts and consultants. All work streams must perfection in design and working within time
progress in parallel, and must be continuously constraints.
reconciled so that new processes and designs are fully
co-ordinated. Without losing sight of detail, don’t sweat the small
stuff.
At this point the project team would generally include
the Project Director acting for the client (including
clinicians and hospital staff), the master planner, the 6. USEFUL TIPS ON PROJECT
architect, the functional space adviser (who may be the
architect as long as they are experienced in this area), PHASES & IN-HOUSE
the services concept engineer and the client financial PROCESSES
adviser, who may be an independent QS.
6.1. Developing clinical streams, models
Before moving on to the detail or developed design
stage (of any project) the full gamut of needs must be of care and operating philosophies
reconciled with budgets robustly, taking into account all
costs. I suggest strongly that experienced people should It is essential that a strategic plan be developed prior to
be involved here. The project succeeds or fails the detailed planning of a project. The strategic plan
depending on how well this is done. This is where an serves as the high-level reasoning or foundation stone
effective Project Director must engage with for a project. Each projects should implement the
management (and clinical staff) on the client's behalf to relevant part of the strategic plan, and should be a
help them see the real picture, and to facilitate rational outcome of the strategic planning process. The
communication through to the project team. justification for adopting particular project alternatives
should include the following:
Above all, make no assumptions about costs; and ensure
that the following costs, which should be obvious but • service area population
are often forgotten, are covered: internal resources (for • demographic characteristics
internal Project Management, site facilities and • health status characteristics
equipment purchased internally for the project); IT, • analysis of current hospital services
including management and implementation; testing of • financial & resource constraints
systems; equipment procurement; internal procurement;
infrastructure upgrades; security; road and parking re- Once service delivery requirements and capacity are
alignments; staff training prior to moving into new confirmed, the model of care for each service needs to
facilities; commissioning and set-up; and of course re- be confirmed rigorously prior to concept design, and
current operational costs, including building life-cycle reconciled with the operating philosophy of the service.
costs. For example, the SAH philosophy is to separate adult
and paediatric A&E care; this done, a central nurse
Cost control of every one of these items must be set up, station or a race-track model of care may be adopted,
consolidated and reconciled. This cannot be emphasised depending on staffing, technology and clinical issues.
enough! It is advisable to set up an organisation-
standard template for business cases at the outset, to Critical operating philosophies and models of care must
include or at least account for all facets of cost, taking a be led and communicated internally to be effective long-
“triple bottom line” or “balanced scorecard” approach. term. The process can be externally facilitated, though
to be successful the outcomes must be internally driven.
Unforeseen costs arise, especially in a fast-track or
volatile environment, and often changes are beyond a All the information, when collated, must be moulded
single organisation's control. The secret to containing into a master-plan. This document serves as a great
change and minimising the resultant risk is to have an communication tool, but more importantly establishes
effective system for considering flexibility and cost- disciplined milestones for progress.
benefit options strategically on the basis of excellent
information, through clearly established decision 6.2. Master Plan
mandates.
The Master Site Plan should represent the most current
Keep the system simple; and above all get the right thinking regarding the ultimate development of the
information to the people with a mandate to sign-off on Hospital site, in line with the clinical strategic direction.
change. This instills accountability early on. Don't be This Plan includes the current land use (buildings,
afraid of change and consequent re-prioritisation – just roads, and access), and projected use. Future plans
be prepared to manage it and mitigate the risk! By all should include proposed building developments,
means spend time if you have it on crossing the t’s and expansions and demolitions, parking, land acquisition.
dotting the i’s, but there is generally a trade-off between The Master Site Plan should also indicate such physical
constraints as flood plains and retention ponds, and the consequences clear in your mind and anticipate this
availability of utilities. The Plan should: discussion). Help the board with contingency ideas and
1. Provide a road map for the future development of the give them realistic latest dates for decisions. Avoid
site to ensure that any particular development plan will rushing to a wrong answer!
not be precluded by the limitations of the campus.
By supporting the information chain at every level,
2. Identify the site, zoning, building, and land use accurately and in a timely way, you have done your part
constraints and other legal restrictions that could limit or in promoting good decision-making.
affect proposed development, so that site or programme
alternatives can be evaluated. 6.6. Project Set-Up
Allowing for the change-management constraints An internal business Project Execution Plan can be
discussed earlier, only once the master plan (or key drafted at this stage of the project. It should be kept very
parts thereof) is signed off should the team move into short. Only critical and realistic systems and lines of
concept and developed design and procurement for the communication need to be included. If kept succinct, it
physical execution of the project. actually forces critical thinking and draws out effective
processes worth embedding into the project. It is a good
6.3. Pilot new processes strategy to get the team members to draft this document
themselves, with external help if required.
Once a particular process or model of care is developed
it is wise to pilot the scheme, if possible, before roll-out The required systems and processes will fall into place
in a new facility. Electronic discharge summaries from if the project culture is right. As external third parties
an A&E department is a good example. Pilot trials iron become involved they can be integrated into a project
out teething problems and facilitate staff buy-in. execution plan. Projects tend to collapse when basic
systems, disciplines, leadership and or experience is
6.4. Feasibility and recommendations overlooked at critical stages of a programme’s life-
cycle.
Once analysis and consultation is complete, the business
case should be submitted for approval by the board (or A key concept is unity of command and
board representatives) for each recommended sub- communication. This knits all the processes and systems
project option within the agreed master plan. This together, and survives the hard times when the systems
should be co-ordinated by the Project Director, who are under pressure. It should be the responsibility of one
must ensure that the management and the board are person with an able assistant or “vice president”
involved and informed throughout the process. If this is
done well, approval becomes a formality. Put simply, this requires single points of accountability
and a single line or “clearing house” for ALL
6.5. Board approvals information.

The approval of many projects is delayed because There should be one person who makes decisions at
insufficient or wrong information is passed to the each specific level of command. The types of decision
decision-makers. The solution is simple – ask them allowable, delegated authorities and communication
what they need to enable them to make any particular channels once decisions are made must be clear.
decision. Take the attitude that their ability to make a
decision is directly proportional to your good work. On This “frees up” the project team to lift the level of their
the financial front, painting a pessimistic or optimistic performance.
picture too early helps nobody and creates re-work and
frustration later. An accurate account of the realities is 6.7. Project-related decision mechanisms
what people need, and some detailed research will be and mandates
required to ensure that this is delivered in a robust form
early the process. The CEO and Board will be the ultimate decision-
makers on policy and final project expenditure, within
Remember that managing the process of referring the integrated master plan and budget.
decisions progressively up the management chain is the
key here. You must be flexible, courteous and Recommendations will come to them from the project
intelligent in your approach; and above all, do your steering group, having already been approved by project
homework before presenting anything for approval. sponsors and their governance teams. This
decentralisation of project decisions is good for change
If you have done all that is possible and a decision is management.
still not reachable, point out to the board the
consequences clearly and calmly (you must have these
The quality of information is critical, and decision- So research and find a top-quality master-planning and
making teams at every level should be asked for their concept architect, who listens and has good ideas. The
requirements in detail well before a recommendation is more work done at this stage of the process the better,to
to be made. ensure a steady, robust and inclusive process.

A “warm-up” paper in advance of an approval is well The ultimate project and long-term operational risk
worthwhile. profile of the organisation will be determined during
this phase.
The report work of the Project Management team needs
robustness and accurate. It is a good idea to develop a 6.10. Engineering systems analysis at
comprehensive checklist to make sure that all aspects of concept design
a sub-project are covered. Most cost over-runs come
from omissions of scope or associated works (as a result Make sure the on-site engineering systems such as
of misunderstanding rather than deliberate) and fewer stand-by power are considered very early in the design
from grossly wrong initial estimates. The message is to process. Involve the maintenance and facilities team in
be thorough and comprehensive in costings. analysing the life-cycle options and ongoing
maintenance requirements of new facilities. An
Finally, allow plenty of time for decisions; don't put inevitable conflict will arise here: the tendency of the
undue pressure on the Board because you have not facilities engineering department will be to standardise
planned ahead. everything to facilitate ongoing replacements, while the
design team will want to upgrade everything, exercising
6.8. Project Control Groups/Processes flair and ingenuity. So this relationship must be
(PCG) developed early in the project. Be prepared to manage
this natural mis-match of cultures between engineering
The PCG is extremely important in the day-to-day, departments and project teams.
week-to-week execution of a project. It deals mainly
with project and contractual issues. It would typically 6.11. Developed design and construction
include the Project Director, the architect and
consultants, the contractor, internal project resources Once concept design is complete the developed design
and the financial QS. Regular monthly meetings are process may begin. This phase is often overlapped with
normal, but information should flow freely within this concept design to accelerate the programme as stages of
group both formally and informally, and continuously. work are confirmed step by step. This is fine if it is
managed well and the risks of change are mitigated.
Good formal communication systems are needed.
Variation control and signoff is an example of a critical Continual contact with user groups is important during
control system, and probably the most important. Link developed design, but they should not be able to hijack
the systems to business decision mechanisms so they the process once key decisions have been made. They
can be effective at governance level to close the loop in need to be fully aware of the agreed concept and
terms of organisational accountability. Keep them associated budget. If the concept is at risk of change,
simple and easy to use and have a top-quality filing and higher management must become involved
retrieval system. immediately.

Developed design needs to be reviewed for content and


Develop a project rhythm for reporting and decision-
cost at the 80% stage. It is better to do this at concept
making. This requires forethought and planning so that
stage and then once, properly, at around 80%, than three
information is communicated to all levels in a timely
times at 50/75/100 etc. People get sick of it and do not
way. A good PD will anticipate issues well ahead of
do it properly. Assuming that adequate input has
others, and manage the team accordingly.
occurred throughout, formal approval at concept and
80% design is fine; and if people are given enough
6.9. Concept design warning and are able to set aside enough time this is the
way to go.
The consultant team needs to be guided to ensure that
they execute each level of detail at the right time. Too At 100%, or construction design stage, have a final
often they will go too far, then claim back time when review with key players including the QS and contractor
requirements change. Again communication is the key: (if you have one at this stage). Make sure some practical
let them know if there is any uncertainty, and how far buildability is integrated into the design. For ideas in
they should proceed witrh any particular aspect of the specific areas – for example air-conditioning in theatres
project. This applies particularly at the concept design – you can involve specialist sub-contractors on a
stage, and they need to allow for a number of iterations consultancy basis.
before getting the right answer.
If the traditional method of procurement is being used and what needs to be in place from an operational
and a contractor is not yet involved, it pays to get in perspective prior to occupation.
some buildability advice at 80% at the latest.
For completeness construction procurement is discussed Transition Meetings
in a later section. For the sake of continuity, occupancy
of new facilities is covered in the next section Transition meetings begin as a communication forum of
construction workers, clinicians and project managers.
. They help ensure that expectations concerning
7. OCCUPATION AND START- deliverables, responsibilities and timeframes over the
transition period are documented and agreed to.
UP OF NEW FACILITIES Representation from security, materials management,
pharmacy, hotel services, and procurement is enlisted to
This should entail lots of pre-planning and involvement formalise requests for information regarding imprest
of the staff. One of the great advantages of having user lists, cleaning standards, networking plans and security
input into the design process is that they will be self programming for lifts, doors, and swipe cards etc.
motivated when it comes to occupation and start-up. Written memos detailing these things over the transition
They will see the facility as theirs and will want it to period are sent to each representative to ensure a timely
work and will do so for years to come. transition.

7.1. Transitioning facilities in today’s On the SAH project, two additional meetings, similar
health sector but larger, were scheduled six weeks in advance, as a
general communication forum for the wider
Is it possible in today's environment to have a clinical organisation.
facility occupied and operational within 48 hours of its
being handed over by developers? The answer is yes, as Transition Budget
long as the transition documentation, communication
network and clinical/project team involvement is Additional costs that sat outside the operational and
inclusive and co-ordinated so that it is accepted by those project budgets included additional staff required to set
at the “shop floor” level. up the clinical areas, and relief staff to cover user
familiarisation tours and preparation of documentation
The transition phase consists of a pre-commissioning prior to “going live”. When “going live” additional staff
period, (recommendation three months), along with were required to ensure patients’ safety, while staff got
commissioning (recommendation two weeks) and post- used to working in a new environment, with new
commissioning (recommendation three months) periods. technology, processes etc. Catering, signage, cleaning,
It is important to recognise that the transition period waste management & security requests justified a
requires additional resourcing and that these costs need separate transition budget.
to be identified and agreed to many months in advance.
Procurement Meetings
The core transition team is recommended to consist of
“occupiers” of the facility, representing managerial, These vital meetings were held weekly to develop
clinical and clerical staff, to ensure that the transition processes for ensuring that equipment, furniture or
period is progressed by like-minded individuals. The fittings were bought and/or installed (by vendor, client
expectation is that the “occupiers” know the business or supplier) efficiently and quickly.
best and that each core member will take responsibility
for setting-up, familiarisation with, and management of Transition period support documentation
their designated areas during the transition period.
Working along with this core group will be individuals • Equipment relocation lists, giving old and new
or “users” of the facility, representing materials locations
management, pharmacy, sterile supplies, security, linen, • Asset register of existing equipment
communications and hotel services etc. This group is • Notification/communication checklists – who
supplemented again by an Information Systems support to inform of what, when
team, which is charged with installing the computers • Device relocation lists – old and new locations
and phones to user specifications. and networking requirements for computers
and telecoms devices
7.2. Operational Perspective • Equipment plans, showing new equipment, and
its cost and location within facility
Gantt Chart • Floor plans indicating areas for clinical clean,
sealing etc,
The Gantt chart assists in the programming of tasks by • Imprest lists for stocking
helping identify the critical milestones of the project, • Buy-in lists
• Variation lists, stipulating owner, supplier or
vendor An organisational discussion is needed to decide the
• Equipment/furniture/fittings supply and length of the transition period, because there are some
installation lists, clarifying parties’ opportunity costs associated with both longer and
responsibilities shorter transitions.
• Phone lists indicating individuals involved in
the relocation Some design issues were overlooked when documents
• Clinical memos detailing timeframes, were signed off, because users lacked understanding of
deliverables, responsibilities, contacts etc. the process implications.
during the transition period. For example,
materials management was required to stock
shelves to previously determined imprest Another issue is compliance. Decisions made to meet
levels. fire regulations etc. directly impacted on the operational
• Communication group exchange memo, flow of the facility, resulting again in rework in
informing the organisation of changes response to requests from users. Compliance regulations
need to be in the forefront of the users’ mind as they
Note: The usefulness of the lists varied, depending on consider traffic flows and security measures etc.
who used them, for what purpose and how much rework
was required to make them useable. This is an area Site visits need to be controlled and used to of
where efficiencies can be made across multiple projects. encourage and inspire users of the facility only. Banning
Knowing how to complete the lists and when the site visits in the final months of construction proved
information needs conveying and to whom is vital. detrimental to the transition process, as it prevented
staff from imagining what it might be like to work in the
User familiarisation area.

User familiarisation manuals were produced as a central Information resources should be made widely available
point of access to information regarding the new to help project managers in their work. They should
processes etc. required operating in the new include:
environment. A welcome letter introducing the facility
was also prepared, which could later be modified as an • Templates of operational plans, transition
orientation letter for new staff. plans, transition budgets, Gantt charts, issues
lists, equipment plans with virtual rooms and
Familiarisation of users with the facility included costs associated with the items in the room
rostering all staff into a fire evacuation training session, • Contact numbers of employees with project /
followed by a walk-through of the facility showing how change management expertise & experience
the new technology, equipment and processes worked in • Descriptions of the roles associated with the
the clinical environment. To add a personal touch, various titles held under project structure
members of the transition team should be available on • Definitions of terms such as scope of a project,
site for 48 hours to personally orientate staff members risk, signoff etc
and for trouble-shooting. • Textbooks for consultation by clinical staff
involved in decision-making.
Commissioning Period
Staff debriefs should be the norm and not the exception.
An issues list should be started on day one of opening,
detailing the issue, who has raised it, who has been For the benefit of users, clinical, hotel and materials
asked to resolve it, and the date of resolution. management, security etc. should be consulted to
establish a priority listing of products or finishes that
Transitioning recommendations operationally impact on quality, flexibility and cost over
time. This process should assist with budget allocations
The project group needs to make decisions that at the beginning of a project.
complement the operational aspect of the business. The
two groups cannot work in isolation. Therefore the
project manager should ideally have good operational 8. CASE STUDIES USING
management skills.
POST-OCCUPATION
To speed the decision-making process, the clinical REPORTS
sponsor/owner needs a high level of confidence in the
project manager. To engender this confidence good Lessons Learnt and Some Project Results
communication is needed during all project phases. A
philosophy of “no surprises” should be adopted.
The SAH Facilities Modernisation Project has been the implications of prevent this recurring.
dramatically successful. As each sub-project was two sites on staff
finished a Post Occupation Review was completed numbers
approximately six weeks after the transition. Lessons
Inadequate change Detailed change management
were learnt from earlier projects and incorporated into
management became a key component of all
all subsequent developments. allowed the basic projects.
project philosophies
The table below provides real examples of post-project to be diluted.
analysis. It lists some of the valuable lessons learnt
during the SuperClinicsTM and Kidz First projects. The project itself The methodology for
was under- calculating project resources
8.1. SuperClinicsTM resourced. was revised.

Issue Lesson learned 8.2. Kidz FirstTM


Clinicians and The clinician/management
management relationship has been Aspects Done Current/Future Practice
worked well formalised throughout the Well
together. organisation. All projects have Project The project’s success was due to
specified clinical input, starting Management and an excellent partnership
with joint project ownership Clinical/Manageme between an experienced project
between General Manager and nt Leadership manager, a clinical
Clinical Head. director/champion and an
A model/mock up The concept of modelling a operational group manager. The
room was built clinic and gaining actual Consistent User Group is
where clinicians experience with its use, was another key success factor.
actually held clinics incorporated in all projects, Field Trips/Fact Team trips were used to identify
including the stringing out of Finding Tours reference sites. The sub-project
the new Acute Hub floor plan teams undertook extensive fact-
on the back lawn of the finding tours prior to
Hospital. establishing the project brief.
Good quality This standard was applied Process Changes Special relationships with
without luxury was throughout the facilities and Inter-Speciality support services and other
preferred – long- modernisation programme. Relationships clinical services were developed
wearing and low- Such things as steel door to the benefit of all parties.
maintenance surrounds and easily laundered Service Level Agreements
construction and carpet have proved their worth. provided a basis for these
materials. relationships. Ongoing clinical
Introduction of too Introduction of new and operational liaison defined
many new technologies must be phased and cemented process change
technologies at for good take-up by users. and inter-speciality
commissioning relationships.
proved sub-optimal Communication Road shows were an
excellent vehicle for
Clinicians were not Clinical staff involvement in
educating others on
involved in earlier such visits was improved
redesigned processes.
site visits to review subsequently
new technologies. Unions were involved from
the beginning of the
Loss of corporate Staff with good institutional project, and kept up-to-date
knowledge and knowledge who didnot fit into on developments affecting
expertise was new environments were staffing and Models of
recognised as a accommodated in appropriate Care.
potential problem. alternative roles so that
expertise was not lost. Service Level Service Level Agreements were
Agreements developed for each new facility
Hand over of the Project budgets and being developed. Shortfalls and
project to the cost/benefits should include opportunities for service
operating staff was appropriate hand-over periods. development were identified
done too early. and closer relationships fostered
We underestimated Specific data was gathered to between new facility staff and
other services within South before firm bids are in hand. This is done through QS
Auckland Health. estimates based on concept design. The process of
Preparation for new systems refining concept designs and costs and firming them up
IT Lessons
required extensive discussion is iterative, converging towards certainty over time. An
and planning. The results varied organisation's risk profile and the point at which it needs
significantly between services cost certainty, among other determinants, can therefore
and the process required much dictate the method of procurement.
more time than anticipated.
Clinical champions providing It can be argued that the ultimate risk of cost and time
leadership and advice were generally sits with the client, so the management of
extremely important. risks throughout a contract should be allocated to the
Piloting functionality proved best and most able party.
very useful for identifying
issues and expediting their In some situations, and depending on whether a project
resolution. is isolated or part of a larger programme of works,
The Transition period must be financing may occur at the time when a “close to final
long enough to fully test cost” is available. This can be provided as a guaranteed
infrastructure rollouts maximum price (GMP) or Design Build lump sum,
Executive sponsorship of new either of which can be arrived at prior to the completion
software was interpreted as of design. A GMP is a firm contractual price provided
extremely positive, and set a by a contractor for a single defined project, who
new standard for the guarantees to build the building for a given price based
organisation. on concept plans and specifications. Design consultants
Information services must are then either novated to the main contractor or
actively participate in the design replaced by the contractor, who then develops the
concept design within budget to an agreed level of
process.
functionality and performance. GMP can be risky to
Effective cost controls must be
inexperienced clients, especially an early GMP. Advice
in place at the start of the
should be sought before entering into any form of
project and maintained
procurement.
throughout the project lifecycle.
Roles and responsibilities
There are other options if the full scope of works and
should be clearly defined and
therefore costs are unknown at the outset. For example,
actively reinforced throughout
sub-project designs can be progressively developed
the project lifecycle.
once a management contractor has been appointed. This
Project managers need highly appointment would be made via a competitive process
effective communication skills. based on the Head Contractor's management costs and
Building Design Products and materials now margin (P&G and margin bid). The trades are then
Lessons incorporated into standard converted from estimated provisional sums to fixed
specifications for South prices by means of competitive bidding. This does not
Auckland Health include wall provide early cost certainty, however, and the risk tends
finishes, paint to wall, wall to lie entirely with the client and not the contractor.
protection, floor vinyl, shelving Depending on the risk profile of the organisation this
within joinery units, door may or may not be acceptable.
finishes, lighting and sliding
door mechanisms. Firm bids are generally desirable prior to completing the
permanent financing transaction; the project budget
Increasing the robustness of
should be well defined in order to accurately size the
wall protection/cladding is
required debt or funding proceeds. A funding shortfall
clearly beneficial to durability,
could occur if the financing is based upon a preliminary
and provides cost-benefits.
cost estimate that is below the actual construction bids.
And conversely, if the bids received prove to be below
budget once the financing is completed, borrowing is
unnecessarily high. If time allows, the ideal situation is
9. PROJECT PROCUREMENT to have a full design completed, with “buildability”
issues resolved and a competitive tender process carried
OPTIONS out. The benefits of keeping things moving in parallel
tend to outweigh those of a step-by-step controlled
Typically, the permanent long-term financing for a
process. This is why good project managers are
major capital construction program is negotiated and
required, and must be supported by effective systems.
approved prior to the completion of design and often
In any case, preparation for financing should be done procurement contract arrangement is necessary but not
early on, and normally well before the receipt of final sufficient for success. The project team is the key, and
bids. This is required so that financing can be complete must operate around trusting committed relationships,
at the appropriate time to ensure funds are available to especially in a complex project environment.
start construction. At the least financing should rely on
quality QS estimates on a fixed and comprehensive In the following sections we discuss options, and in
scope. Significant scope changes incur major risks. some cases have deliberately strayed from generally
accepted definitions to provoke thought.
It is advisable to leave some “strategic contingency”
within the total finance to allow for Board decision- 9.2. Forms of Contracting
making. This is essential especially over a long
development period in which change and re- Under the Traditional General Contractor approach, the
prioritisation may occur. It is not ideal to have to return client/owner (hospital) engages an independent architect
for more financing. This contingency is separate from (and possibly independent engineers and consultants) to
the construction contingency. Contingency amounts prepare the complete construction package – complete
should be inversely proportional to the certainty of plans, including architectural, structural, plumbing,
scope, and directly proportional to the risk of unknown mechanical and electrical drawings, and detailed
design/physical conditions. specifications and schedules of quantities. The
schedules form the basis of the scope and payment
A final word on risk: an error in design or process will regime for the contract.
last for many years and will cost the business on an
ongoing basis. Capital cost risk, although high, is less Following a competitive and rigorous tender and
critical (unless there is a major mistake). The selection process a general contractor is then engaged to
importance of the early “in-house” work on building construct the project as designed.
project scope before the detail design and construction
starts cannot be over-emphasised. In recent years construction contracts have sometimes
taken the following forms, which can be considered
9.1. Procurement variations on the traditional approach. Elements of each
can be mixed and matched to suit the client needs.
The most frequent construction approaches are
traditional general contractor, fast-track, phased • Lump Sum: the construction package is
construction, design build, and construction submitted to several contractors, who each
management. More recently partnering and alliancing submit a lump-sum fixed price for the
have become popular and should be investigated as construction of the project.
options.
• Guaranteed Maximum Price (GMP): a
The preferred method of procurement for any project variation of the lump-sum approach. The
should be developed from the inside out; that is, starting contractor submits a “not to exceed” price for
not with prescribed methods, but with your needs, and the project with the possibility that the project
working towards the best fit. This will typically be an may, in fact, cost less. The contract itself will
amalgam of two or three options. define the circumstances under which the price
may be less, usually depending on the cost of
Considerations are: materials and labour purchased (i.e.
subcontracted) by the contractor. A share-of-
• time requirements savings regime can be built into a contract to
• cost certainty requirements create an incentive for both parties to co-
• risk profiles of parties operate to meet budget targets or better. A two-
stage GMP process is also possible, where
• capability and availability of local and
savings are shared only on a second contracted
international consultants and
GMP price. The first stage GMP is a
contractors
mechanism for selection of a preferred
• transparency and probity requirements contractor based on an agreement to work
• market conditions towards a second and contractually binding
• economic and business environment factors GMP.
• previous experience
• intuition and market experience • Cost Plus: a contract may provide for
• in-house skill and experience completion of the project on a “cost plus”
basis, i.e. for costs plus a fixed or percentage
No matter which method of procurement you run with, fee.
stick to it and get the best people involved. An optimal
• Design Build: the owner contracts with a single degree of sophistication and experience on the part
entity for both the design and the construction of the owner.
of the project. The “contractor” may be a joint
venture consisting of an architect, an engineer, 9.4. Phased Construction
and a contractor; or it may be a contractor who
personally engages an architect. The intent of Under this approach bidding for the construction work
the construction contract can include takes place in phases. This may be according to the fast-
provisions for fast-track or phased track construction approach whereby the design is
construction. completed, and then bidding is conducted in phases,
construction being initiated prior to the completion of
• Negotiated Contract: this approach can be design. Alternatively, upon completion of design, it may
utilised with a lump-sum, design build or GMP be prudent to bid and construct the work in phases
contract. The difference is that rather than rather than awarding a lump-sum construction contract
putting the construction package out for or multiple subcontracts at one time. For example,
competitive bids, a contractor is selected for bidding for the renovation phase of a project may be
the project. This approach is used when a deferred until near the actual start of work, since
particular contractor is desired because of its renovation is often the final phase of a programme also
reputation or its unique capacity to construct involving new construction. A contract for phased
the project. “Apples for apples” comparisons construction would take one of the forms described
are difficult with this approach and a client previously for the traditional general contractor.
needs to be aware of and experienced in value
comparisons. 9.5. Summary of Procurement Options
• Alliancing and partnering: teams work together The foregoing overview of approaches to construction
contractually towards common goals. describes in general the normal relationships between
the owner, consultants and the construction manager or
• BOOT projects (or variations on the theme): contractor. The exact nature of the relationship in any
private finance is supplied and an independent given instance will be governed by the agreement
party may be involved in the development to between the owner and the contracting party. Therefore,
own and operate the facility. the importance of the agreement itself cannot be over-
emphasised and advice should be taken from
9.3. Fast-Track experienced people.

• The primary difference between the more Various procurement options must be considered.
traditional approaches and more recent forms Choosing between them involves thinking about your
of contract is the “fast-track” approach. This is risk, time requirements, where expertise lies, and how
where incomplete plans and specifications confident you are around the concept master plan.
(basic documents, schematics, preliminary Remember that whichever system is finally adopted it
structural drawings, etc.) are utilised in could fail if not managed well. Success depends entirely
contracting with the general contractor. The on the people involved, their leadership, experience,
advantage of this approach is that the time organisation and commitment. So spend more effort on
from the inception of the project to its the “type of people” factor than on the method of
completion can be reduced, since the design procurement, which is often decided well before people
and construction phases are overlapped. The are nominated.
incomplete construction package is usually
submitted to several contractors for preliminary The message is that once you have decided on a
estimates or proposals. The risks inherent in method, get on with it ! Certainly make contractual
fast track construction are as follows: modifications or negotiate to strengthen your position,
but focus more on the people. Don't think that because
• Because engineering is not co-ordinated at the time you have a great contract or methodology, success is
that the contract for the early phases of the work is guaranteed. It helps, but only if you get the chemistry
awarded, change orders during construction may be and project culture working ! I would argue that any
required. form of procurement can deliver outstanding results if a
great team is managed well.
• The potential for litigation is increased if the
completed plans and specifications represent a
change in scope from the preliminary drawings 10. SUMMARY:
(and, therefore, an increase in cost), or represent
completion and refinement of the preliminary The essence of our learning during this programme has
drawings (and, therefore, no increase in cost). been the discovery and use of effective links between
Hence, fast-track construction requires a certain business change and physical projects.
Business change unfolds continuously in the context of the wider picture of business change alongside capital
and trends of a particular industry and its wider projects will succeed, and provide real value to clients.
economy. Whilst processes and people within an
organisation must change to move with or influence
these change forces, they must be given time and
“room” to do so.
11. REFERENCES:

Capital projects of a large scale and intensity should be McKee & Healey, (2001)
consciously treated as an opportunity to develop and Changing role of the hospital in Europe –Causes and
embed new, better ways of doing things in the context Consequences. Journal of Clinical Medicine 1 No. 4
business and industry change. (July/August 2001): 301

Organisations that can bring to projects a mind-set, Braithwaite Vining & Lazarus (1994)
skills and systems reflecting an integrated understanding The Boundaryless Hospital. Aust NZJMED 1994: 565

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