The Design/Build Process: A Primer 

The Design/Build Process: A Primer 

By Kris Ellis

Prospective ambulatory surgery center (ASC) owners must make a series of critical judgments and decisions relating to the initial design and construction of their facilities. In order to achieve the best possible results and determine what will be most beneficial for their individual circumstances, it is necessary for owners to educate themselves on the different ways in which the design and construction processes may be approached.

Steve Cooper, president of Cooper Medical Buildings, explains that the design/build process integrates the design and construction of a facility. From a project’s inception, he emphasizes the importance of working with clients to answer a number of questions that will determine how it will proceed. “What is your goal for this project? What does this building need to do for you? How does it need to perform? For it to be an economical investment for you, how much does it need to cost?

Then, let us develop a design that meets all those criteria and deliver a product that meets all your goals,” he says. “It’s kind of iterative process where the designer talks to the client about what the client needs, construction people talk to the client about the budget, the designer does the design, then the construction people look at that design and think about how we’re going to build it and what materials we’re going to use.”

The design/builder then attempts to develop a budget. If the budget is in line with the client’s expectations, the design/builder can proceed with that design. “If it looks like we need to make some changes to the budget, then the architect does those right then and there, before design proceeds all the way through to completion,” Cooper continues. “It’s really a design-to-budget process more than a process where design occurs and then you find out what the price is. A good design/builder can take a realistic goal from the owner and make that happen for them.”

John Daly, AIA, vice president of healthcare services at McShane Construction Corp., contends that the design/build process offers several potential advantages over the design/bid/build process. Design/ bid/build involves selection of an architect or engineer by the owner to prepare drawings and specifications. A construction contractor is then selected through competitive bidding to build the facility. “I think if you put a team together, where you put the owner, the builder, and the designer in a room together, you can come up with a better product and probably a better value,” Daly says. He points out that collaboration between the designer and contractor in the design/build process can be helpful in identifying potential conflicts or issues in the drawings, for example. “The owner is right there throughout that process to direct the evolution of the design to the final product.” Daly estimates that roughly 80 percent of ASCs are constructed via the design/build process. “The bid is done in the process, but everybody is on the same team.”

“Design/build approaches projects a little differently than a design/bid/build process, where an architect works with the owner to develop a set of documents,” Cooper states. “A good architect will develop, budget, and try to keep an owner from being too surprised by the final cost, but obviously the architect is not a contractor, and though he or she may be experienced and knowledgeable, the architect doesn’t know what things are going to cost, and often may not know the best value or how to build the most value into the building.”

Daly points out that physicians typically don’t have the time or energy to manage the process, make sure the budget and schedule are controlled, and ensure compliance. “Most of our clients are first-time builders of surgery centers,” he says. “They need a team; they’d like to see a rendering and then move in. That’s why firms such as ours and many others have grown to specialize in design/build of surgery centers.

“With a design/bid/build process, for an example, what if the roof leaks or the HVAC doesn’t perform?” Daly continues. “The builder could say, ‘I built it per specifications,’ the architect could say, ‘The builder didn’t put it in per specifications,’ and the owner is kind of caught in the middle, and it’s not working. With the design/build process, one entity is accountable, so if it doesn’t work, the design/builder is going to fix it. So the owner eliminates a lot of risk in having one entity.”

Design/builders may also have the ability to fill in more pieces of the construction puzzle for an owner, Cooper adds. “There are more than just architects and contractors involved in getting these things done — there are cities to work with, maybe health departments, and so on. While architects can take some of those responsibilities, a good design/ builder really gives you a single source of responsibility for all parts of the design/construction/development, sometimes even financing, for an owner.”

Daly notes that design/build projects may also progress more rapidly than their design/bid/build counterparts. “You can start foundation drawings, perimeters are set, and you can get permits quicker while you’re still designing the interior finish selections of the building,” he says. “It also has the value of the single-source responsibility. Additionally, you can get a guaranteed price much earlier in the process; with the traditional method, you design it and bid it, and then you find out what the price is. Typically with a design/builder you start out with a price and work backward and build it to that price. These are usually outof- the-box ventures, and you’re not a hospital; you don’t have a lot of cash to move from one account to another. You build your business plan and then you build the building to match that business plan.” Cooper points to the notion of single-source responsibility as a value after the facility has been completed as well. “If there are building issues, it’s the design/builder’s responsibility,” he states. “For example, with design/ bid/build, if the humidity is out of whack in the OR, and the owner calls the architect and he calls the engineer, and then the engineer says he designed it right, the contractor must’ve built it wrong, and the contractor says, ‘I built it just like you drew it,’ the owner is saying, ‘I don’t care; somebody just fix this!’ With the design/builder, you call us, we find out who’s responsible, and we fix it. The owner’s not left refereeing a debate about who’s going to solve his problem. The design/builder solves it, and we find that to be a real advantage and a real concern for people going in, and one reason people often select design/build.”

“Today healthcare is very complex,” Daly says. “Changing building codes are life-safety issues, and I think it’s important to have a team that is very experienced in surgery centers, that understand them, and that can go through that complex governmental maze so that when the inspector comes for Medicare certification and walks through, you don’t have a hallway that’s two inches too narrow, for example. You need the designer, the builder, working together and sharing their combined knowledge so that when the physicians go to open the facility, there are no surprises.”

Cooper contends that while the principles of design/build are advantageous for many types of construction projects, they are particularly beneficial for surgery centers. “These are highly specialized, complicated buildings and building systems,” he says. “A surgery center is not an office building, and the designers and contractors, as good as they are, who are not familiar with healthcare can stumble and have problems. A surgery center is ultimately a business, and for the owners of that business, it makes money when they can get in there and do the surgeries. If something is not right and they can’t use an OR, that’s a big deal; it’s more than just a simple inconvenience, and we feel that the expertise that specialized healthcare design/builders can bring can keep those kinds of problems from happening.”