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Procedia Engineering 196 (2017) 592 – 606

Creative Construction Conference 2017, CCC 2017, 19-22 June 2017, Primosten, Croatia

Owner-Requested Changes in the Design and Construction of

Government Healthcare Facilities
Rachel C. Okadaa, April E. Simonsa*, Anoop Sattinenia
a
118 M. Miller Gorrie Center, Auburn University, Auburn, Alabama, USA, 36849

Abstract

In the inherently dynamic industry of healthcare design and construction, organizations are continually working to achieve balance
between customer demands and the need to manage cost, schedule, and quality. Owner-requested changes throughout the design
and construction process can lead to budget and schedule overruns as well as increased uncertainty for the project delivery team.
Effective strategies for the management of these changes can be used by project teams to reduce the number of changes during
construction. The aim of this paper is to develop a multi-pronged approach to the management of owner-requested changes through
the analysis of a relevant case study project. A review of existing literature showed that extensive research has been done on the
cause and effect of project change, however, none focused solely on owner-requested changes. To expand the current knowledge
base, a case study method was used to collect information on challenges and potential strategies for the management of these
changes. A quantitative analysis examined project data in order to understand how owner-requested changes impacted and shaped
the construction of the case study project. An in-depth qualitative analysis built on the project data through semi-structured
interviews with project stakeholders. The themes identified in the data formed the framework for the compilation of lessons learned
and best practices offered by the interview participants. It is hoped that these strategies will be utilized by future project teams to
effectively prevent or mitigate owner-requested changes. The results of the analysis underscore the significant challenges involved
in the design and construction of healthcare facility projects. Extended timeframes for project delivery, constant changes in
technology, stringent regulations, and the sheer complexity of the building typology make healthcare projects among the most
complex and logistically challenging projects built today.
©©2017
2017Published
The Authors. Published
by Elsevier by Elsevier
Ltd. This is an openLtd.
access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Peer-review under responsibility of the scientific committee of the Creative Construction Conference 2017.
Peer-review under responsibility of the scientific committee of the Creative Construction Conference 2017
Keywords: owner-requested; change order; change management; project change; healtcare

* Corresponding author. Tel.: +1-334-844-4518; fax: +1-334-844-5386.

E-mail address: ellisap@auburn.edu

1877-7058 © 2017 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Peer-review under responsibility of the scientific committee of the Creative Construction Conference 2017
doi:10.1016/j.proeng.2017.08.047
 Rachel C. Okada et al. / Procedia Engineering 196 (2017) 592 – 606 593

1. Introduction

The world of healthcare is one of constant change, where evolving technology and advancement in patient care
drive the need for state-of-the-art facilities delivered in short order. Advances in medical equipment in particular have
motivated the industry to seek innovative solutions to the incorporation of technology in the delivery of modern
healthcare facilities [1]. Healthcare projects often deal with dynamic external forces such as market changes, stringent
regulation, and a range of stakeholders, all which add variability to the process. This is the environment where project
planners, architects, managers, and constructors work to build the healthcare facilities of the future. Throughout the
design and construction process, project teams must be particularly in tune with the changing needs of the owner to
ensure that the facility is an effective solution for the end user. It is important that the team work closely with the
owner upfront to ensure the necessary requirements are incorporated prior to the start of construction. Project change
is a major cause of uncertainty for the project delivery team and can lead to cost and time overruns when not managed
properly. Effective strategies for the management of owner-requested changes during the design and construction
process improve the team’s ability to prevent or mitigate these changes before they affect the budget or schedule. This
research will utilize the examination of a relevant case study project to contribute to the existing body of knowledge
on change management, specifically concerning owner-requested changes.

Long before a patient, doctor, or nurse steps in the door of a new facility, the project delivery team is assembled to
bring a new project from concept to construction. The project delivery team is the heart of the design and construction
process and can materialize in many forms depending on the project phase, contract type, and owner preference [2].
One of the project stakeholders is the owner, who is responsible for the proper execution of the project. The owner or
their representative often plays an important role in the project development as it progresses from planning through
construction completion and occupancy. It is rare that a project would be brought to fruition without any owner input,
however, the level of involvement and consideration given to owner requests and feedback vary from case to case. In
some cases, the owner will be an integral part of the team, and in other cases, they may be involved only at certain
project milestones.

As a project progresses from planning to design and construction, changes are an inevitable part of the process [3].
These changes are often based on requests, feedback, and input from the owner, user groups, and project delivery
team. Early in the planning and design process, changes happen rapidly as the project concept is molded into a more
definite form. At this point, changes are easily accommodated and the tools used for space planning and conceptual
design are purposefully flexible. As the design progresses and more effort is put into drafting, modeling, and
calculations, changes become more difficult to accommodate. The cost of a change continues to increase as the project
timeline reaches 100% design and continues through construction completion. Therefore, the cost of making a major
change to the design of a building near construction completion is both complex and extraordinarily costly [4].

A significant change to the project will likely effect a modification to the contractual terms of the agreement
between stakeholders. As such, each change must be given careful consideration. As part of the evaluation of the
change, the root cause is identified and noted for the record. Each organization has a different method for categorizing
changes and the categorization of changes has been the focus of previous research. A change that occurs during the
construction phase will most often fit into one of the following broad categories: unforeseen conditions, design errors
and omissions, and owner-requested changes [5]. The cause of the change is important because it will determine the
liability for the change, i.e. who pays the bill. The scope of this research focuses specifically on the impacts of owner-
requested changes. The evaluation of changes resulting from other causes such as unknown conditions or design errors
and omissions is beyond the scope of this research. The impact of owner-requested changes has become a problem for
many organizations that are caught between the financial and time restraints of construction and a desire to please the
customer [6]. Owner-requested changes in healthcare projects arise for a variety of reasons. One prime example is
changes to the medical equipment and systems that are central to the function of the facility. Advances in healthcare
technology are moving at a rapid pace, often much faster than the project delivery timeline, and the result is a project
team that is chasing a moving target [7]. Other reasons to initiate a change include new leadership, mission
requirements, or policy. Regardless of the drive behind the change, each change request received from the owner
594 Rachel C. Okada et al. / Procedia Engineering 196 (2017) 592 – 606

deserves consideration and resolution. The method of resolution will depend on the relationship and level of
communication between the stakeholders. The examination of a relevant case study project with a number of contract
changes is the basis for a quantitative and qualitative analysis focused on the impact of owner-requested changes. The
themes identified from the results of the analysis are used as a framework for the development of prevention and
mitigation strategies. Lessons learned and best practices are collected from the qualitative data and compiled for use
by future project teams. The aim of this research is to develop a multi-pronged approach to the management of owner-
requested changes in the design and construction of government healthcare facilities through an analysis of a relevant
case study project.

2. Literature Review

A review of relevant literature was conducted to form the basis for this research and to understand the current
thinking regarding the impact and management of change management in construction projects, specifically healthcare
projects. The review of literature starts broadly with an examination of research regarding the impact of project change
and narrows to research specific to owner-requested changes. A review of prevention and mitigation strategies found
in the literature for owner-requested changes is also included.

2.1. Project Change

The design and construction process is an inherently ‘dynamic environment of frequent change’ and as such, project
stakeholders have come to expect a certain amount of fluctuation throughout the process [6]. The causes and effects
of project change have long been the subject of research within the industry. Project change can be the driver for time
delays, cost overruns, and quality defects on projects thereby making it a source of interest for owners, contractors,
and designers alike [5, 8]. The earliest formal investigations of the cause and effect of change orders were conducted
by industry organizations such as the Chartered Institute of Building (CIOB) in the UK and the Construction Industry
Institute (CII) in the USA throughout the 1970’s and 1980’s. The volume of research greatly expanded in the 1990’s
with the publishing of a series of reports on ‘Cost and Schedule Controls’ and ‘Project Change Management’ by the
CII [9]. Despite the extensive amount of research on the topic of project change over the past 25 years, Alnuaimi et al
[3] contend, “no unique method is available for avoiding or managing them effectively”. There is no silver bullet and
effective change management continues to elude even the largest construction organizations. The U.S. Department of
Veterans Affairs recently published a series of investigative reports conducted by the U.S. Army Corps of Engineers
that identify change management as a ‘critical deficiency’ in the delivery of large medical infrastructure projects
within the VA organization [8]. The issue of effective change management is of interest to both public and private
organizations as evidenced by a recent Smart Market Report published last year by McGraw Hill Construction entitled
“Managing Uncertainty and Expectations in Design and Construction” which explores the causes and effects of
uncertainty in the design and construction industry. This report identifies project change as the leading driver of
uncertainty on projects [6].

A project change is typically formalized as a change to the contract between parties. The term ‘change order’ and
‘contract modification’ are used interchangeably in the design and construction industry to describe “a written
agreement or directive between contracted parties which represents an addition, deletion, or revision to the contract
documents, identifies the change in price and time and describes the nature (scope) of the work involved” [10]. Many
researchers describe contract changes as an unwanted but inevitable reality in the complex process of construction [3,
5, 11]. Indeed, the industry in general has a negative perception of contract changes as they are often poorly managed
thereby leading to overruns in project budget and schedule, disputes, and loss of productivity [8]. Similarly, Perkins
[12] also points to changes as a source of delays, conflicts, and overruns in construction but conversely notes that
some changes can have a positive effect on the project. For example, a value engineering change suggested by the
contractor could result in cost savings for both parties [12]. The McGraw Hill Smart Market Report [6] takes a
somewhat more optimistic approach with a section titled “Change Orders Are Not Inherently Bad”. This Report points
out that the term ‘change order’ has gotten a bad connotation because it is often associated with additional cost but on
 Rachel C. Okada et al. / Procedia Engineering 196 (2017) 592 – 606 595

the other side, change orders give owners the flexibility to adjust contracts and oftentimes better the product. The
report recommends that project stakeholders revisit their perception of change orders and refocus on activities that
could help avoid or mitigate the underlying issues [6].

2.2. Contract Type

Most of the research found in this review focuses on project change with regard to a specific contract type. In the
21st century, the most prevalent contract type is the design-bid-build (DBB) delivery method for both private and
public owners. DBB has been tested over the years in the court system and most owners, contractors, and designers
are familiar with the format and organization of this type of contract [11]. However, many researchers have recorded
the significant downfalls of this method. Perkins [12] points out several substantial disadvantages of the DBB method,
the greatest of these being increased contract changes. They note that although most DBB contracts have provisions
for adjustments to the contract price and schedule, the negotiation process is ‘fundamentally asymmetric’ thereby
creating adversarial relationships between the contractor and owner [12]. Owners have also seen a rise in contractors
that submit low bids to win the job and then rely on change orders during construction to make up lost profits, leading
to cost and schedule overruns [13]. Collins and Parrish [11] also note that substantial number of change orders were
necessary to bring the DBB projects they studied into line with the owner’s actual needs and requirements. Fernane
[13] studied the effect of DBB and Design Build (DB) contract types on the delivery of public university projects.
They analyzed 42 DB contract and 42 DBB contracts and found that the use of the DBB on public university projects
resulted in significantly higher contract cost growth and schedule growth than DB projects [13]. The McGraw Hill
Report [6] includes a case study of the Camp Pendleton Navy Hospital project that was successfully constructed using
the DB method. The new hospital was completed six months ahead of schedule and under budget. The stakeholders
attribute their success to the use of the DB method as well as close collaboration between all project stakeholders
during design submittals.

Dissatisfaction with the DBB method and an interest in improving project delivery have led to the development of
new project delivery methods. Delivery methods such as construction management at risk (CMR), DB, and integrated
project delivery (IPD) have become more widely used. However, theses have not surpassed the use of DBB [14]. An
ENR report published in 2008 notes that owners in the K-12 education, manufacturing, and healthcare industries have
increasingly migrated to alternate delivery methods. “There would not be a migration to alternate project-delivery
methods if design-bid-build was not fundamentally broken. Design-bid-build often creates tension between the design
and construction sides and that its big selling point, a firm price, often is lost when changes in conditions or deviations
from the original design result in costly change orders” [15]. Collins and Parrish [11] studied public DBB projects to
investigate whether the issues on the case study projects could have been prevented by the use of the IPD project
delivery method. The projects studied were all produced for the same public university owner over the span of 12
years. The study compiled data from 543 contracts that were let by the university to construct 215 projects with a total
cost of $196 million. The research found that owner-requested change orders were the most prevalent type of change
in the studied projects and that the number of owner-requested changes increased during the 12-year period. The
author suggests that the prevalence of owner-requested changes could be attributed to a lack of involvement by the
owner during preconstruction. They conclude that the use of an IPD type delivery method would theoretically reduce
the number of owner-requested changes because the owner would be an integral part of the project delivery team from
initial concept through design and construction [11].

2.3. Owner Requested Changes

The Construction Management Association of America (CMAA) defines an owner as “the private or public
organization ultimately responsible for the proper execution of the project or program” [14]. From this definition, we
arrive at the term ‘owner-requested change’ that is a change that is attributable to a change to the terms of the contract
which is requested by the owner. The term ‘owner’ is often interchanged with the term ‘end-user’ or ‘user’ in the
literature. The terms “owner-requested”, “owner-directed”, and “user-requested” are also interchanged. The use of a
596 Rachel C. Okada et al. / Procedia Engineering 196 (2017) 592 – 606

particular term will vary depending on the geographical location, owner preference, and industry practice. For
example, both the US Army Corps of Engineers (USACE) and the Department of Veterans Affairs (VA) use the term
“user-request” to describe a change that is requested by the medical center or other internal customer/end-user.
Standard contract terms generally provide for the ability of the owner to make changes to the project, as long as they
commit to covering the cost of such changes [5]. Changes attributable to the owner may arise for a variety of reasons
including a change in scope or mission, owner’s financial problems, inadequate project objectives, replacement of
materials or procedures, or alteration of the specifications [16]. Large organizations or companies will often have to
deal with a range of internal stakeholder groups and external forces that makes it difficult to provide perfect
information from the outset of the project design (McGraw, 2014). It was found that while nearly all literature on the
topic of project change has some discussion of owner-requested changes, no single piece of literature collected in this
review focused solely on owner-requested changes.

A focused examination of the prevention and mitigation of owner-requested changes is a worthwhile effort given
the amount of research that points to these changes as a major cause of uncertainty and disruption in project delivery.
Alnuaimi et al [3] studied public construction projects in Oman that were completed under a design-bid-build delivery
model and found that owner-directed additional work and modifications to the design were the most important factors
in the causation of change orders. Perkins [12] studied projects completed with both a design-build and design-bid-
build delivery methods and found that owner-requested changes were significantly greater on design-build projects.
The paper suggests that further research should be conducted on the cause of owner/user changes. Günhan et al [5]
studied avoidance of change orders in public school construction. In their research, they found that owner-requested
changes constituted a significant amount of the contract changes early in the study timeframe but three years into the
study the owner-requested changes rapidly decreased. They stated that this sudden drop correlates to the hiring of a
construction management firm as well as a new policy that denies change requests from the school administration
after the design completion [5]. The McGraw Hill Construction Smart Market Report on Managing Uncertainty
conducted a frequency/impact analysis as part of their study and found that “reducing owner-driven changes will be
the most effective way to mitigate the impact of uncertainty on project cost, followed closely by fewer omissions in
design documents and better coordination” [6].

3. Research Methodology

A case study approach was adopted in the conduct of this research. The case study project is a government
healthcare facility located in the United States. The scope of the project included the design and construction of a
174,000 S.F. multi-service healthcare building and 600-car four-story parking garage for a large government health
care system on an active medical campus. The project was delivered under a design-bid-build model with architect-
engineer support during construction. The project had 445 contract changes through the construction phase. These
changes were examined to understand the causes for the changes. Eight project stakeholders were interviewed to
further understand their perspective on the changes for the project.

4. Results

4.1. Quantitative Data

Construction data on the case study project was obtained from the owner’s on-site resident engineer office. The
project is at 95% completion therefore the data analyzed represents all data entered into the software database to date.
It is possible that additional changes will be issued after the conclusion of this analysis. This included data from a
construction management software and hard copy files. The data for all contract changes was exported from the
software database into MS Excel format for analysis. The spreadsheet includes information on each contract change
including modification number, description, amount, issue date, liability code, and status. The owner uses liability
codes to identify the root cause of each contract change; therefore, the liability codes are essential to the analysis of
contract changes. A liability code for each change is determined and documented in a memorandum by the resident
 Rachel C. Okada et al. / Procedia Engineering 196 (2017) 592 – 606 597

engineer who processes the change; this information is subsequently reviewed by a senior resident engineer. The
liability codes are as follows:
x A: Design Error – Incorrect information in the contract documents. Changes attributable to the Design Firm
responsible for the delivery of accurate and complete drawings and specification.
x B: Design Omission – Information missing from the contract documents. Changes attributable to the Design Firm
responsible for the delivery of accurate and complete drawings and specification.
x C: Unknown Condition – Unforeseen conditions such as undocumented underground utilities that could not have
been foreseen prior to bid.
x D: Program Change – Changes attributable to changes in programming.
x E: Technical or Administrative Decision – Changes made at the discretion of the resident engineer office
responsible for contract administration.
x F: Phase Design – Changes due to resequencing of project phases.
x G: Value Engineering – Changes aimed at improving efficiency while reducing costs.
x H: User-requested change – Changes requested by the end-user, in this case study the end-user is the medical
center and is referred to as the owner.
x X: Code unknown or not assigned – No code assigned to the change, or reason unknown.

The liability codes were used to sort changes and separate the owner-requested changes from other changes. All
contract changes were sorted by liability code and then counted and totaled. The data presented in Table 1 shows that
while majority of changes occurred due to design error or design emission, user-requested changes were responsible
for 11% of contract changes.

Table 1. Summary of Contract Change Data

Code Description # Count % of total
A Design Error 120 27%
B Design Omission 99 22%
C Unknown Condition 49 11%
D Program Change 0 0%
E Technical/Admin Decision 92 21%
F Phase Design 0 0%
G Value Engineering 0 0%
H User-requested change 48 11%
X No code assigned 37 8%
Project Total 445 100%

4.2. Qualitative Data

The qualitative analysis compiled data collected from eight interviews with various project stakeholders who were
directly involved with the planning, design, and construction of the case study project. The interview questions
centered on challenges related to contract changes on the project and gathered information on the broad challenges
faced in the design and construction of healthcare facilities. Each person was asked two questions specific to owner-
requested changes on the case study project which were focused on gathering ideas for both prevention and mitigation
of these changes. At the conclusion of the interview, people were asked about their lessons learned from the project.
The goal of the qualitative analysis was to gain a deeper understanding of the challenges experienced on healthcare
projects in general and the case study project specifically, from a variety of perspectives. The results of this research
will be used to develop lessons learned and best practices for use on future projects. The eight participants interviewed
are representative of the major stakeholder groups including the owner, contractor, architect-engineer, and
Government construction team. Several individuals from the owner organization were interviewed to gain
perspectives from facilities planning, project management, and facility engineering. Interviews were held over an 8-
day timeframe and were conducted in-person with the exception of one phone interview with a participant who was
geographically remote. The interviews varied in length from 8 minutes to 38 minutes. The audio of each interview
was recorded and later transcribed verbatim in MS word. The data was coded for qualitative analysis purposes and a
598 Rachel C. Okada et al. / Procedia Engineering 196 (2017) 592 – 606

software named ‘TextSTAT’ by Hüning [17] was used to conduct a frequency count of the combined transcript
document.

A frequency analysis of the coded data revealed several themes pertinent to this research. Utilizing the results of
the frequency analysis and a thorough review of the transcripts, a series of themes was identified in the data. The
prominent themes were ‘Healthcare Challenges’, ‘Planning’, ‘Design Issues’, ‘Management’, ‘Construction’, and
‘Lessons Learned’. Based on these themes, labels were created to aid in categorization of the interview responses. In
a copy of the combined transcript document, responses were broken into manageable paragraphs and relevant text was
coded. Each paragraph was assigned a label that was most relevant to the content, although in some cases multiple
labels were assigned because the content was considered applicable to multiple themes. The results of the analysis is
presented in Figure 1.

Fig. 1. Thematic Analysis of Qualitative Data

The following section provides a thematic analysis of the quantitative and qualitative data results and presents a
thorough discussion of the case study project information and lessons learned gathered during the interviews with
project stakeholders.

4.3. Healthcare Challenges

To understand the impact of project change on the design and construction of healthcare facilities, it is important
to recognize the significant challenges of this project typology. The second interview question sought to gather
information regarding these challenges from project stakeholders, all of whom have an extensive background in the
delivery of healthcare projects. The results of the qualitative analysis show distinct themes that align closely with the
challenges identified in the literature review. Challenges identified by interview participants include project setting,
complexity, regulations, technology and equipment, timeframe, and contract type. Many of those interviewed noted
that healthcare facilities are one of the most complex building types and are therefore incredibly challenging to design
and construct. The literature review supports this conclusion; Cronk and Grube [7] note that “Healthcare facilities are
 Rachel C. Okada et al. / Procedia Engineering 196 (2017) 592 – 606 599

among the most complex and logistically challenging projects built today”. One interviewee expands on this statement
by saying that healthcare facilities are considered one of the most complex building types because they are “inundated
with engineering complexities, they are highly regulated, and they are often on campus plans or in large buildings
which both involve working around patients which is a very high risk environment.” In addition, healthcare facilities
need to be flexible enough to accommodate a typical design life of 35 years or more while still providing the durability
needed to withstand daily wear and tear. This need for flexibility and adaptability is echoed by [18] in an article for
Healthcare Design magazine. It was also noted that healthcare facilities are unique because they need to function in
any condition, after an earthquake, tornado, flood, or any other disaster.

The impact of technological changes in the healthcare industry and the link to project delivery timeframes was the
most prominent theme in the question 2 responses. In fact, “time” and “equipment” were two of the most used words
found in the frequency count, noted 90 and 37 times respectively. Every person interviewed noted that healthcare
projects in general and especially government healthcare projects have long durations, typically seven to ten years
from inception to activation and occupancy. As the project evolves, the initial assumptions made by the project team
concerning medical equipment needs and related infrastructure may become obsolete. Healthcare technology is
changing at a rapid pace and as one participant notes, “No doctor, no healthcare group, no nurse and staff, the
technicians, they don’t want the next best, they want the best.” The needs of the medical center and clinical staff are
constantly evolving and it is a challenge to solidify a design under these conditions. The people interviewed see this
disconnect as a fundamental problem that is often the root cause for owner-requested changes during construction.
The information identified in the literature agrees with these qualitative results.

Interview participants offered a variety of strategies to counter these widely acknowledged challenges. One
prominent theme was project delivery type. Three interviewees specifically stated that design-build would improve
project delivery because it would bring the owner into the design review team, better encompass the scope of the
project, and shorten the timeframe for delivery thereby mitigating issues related to technology changes. Other
participants noted the difficulty with the preference for the design-bid-build delivery method, which was used for the
case study project. “Our colleagues have an integrated project delivery model where they develop the team upfront
and share the risk. We don’t have that and with such a hot market, why risk spending hundreds of thousands of dollars
developing an application and then be at risk of not getting the project.” The results of the qualitative research as well
as the literature review indicate that the industry is moving away from design-bid-build due to the long timeframe for
delivery as well as the challenge of equipment changes. This is evidenced by one participant that stated, “From my
perspective, equipment has driven the industry to go away from design-bid-build because the timeframe from start to
finish of the initial conceptual design until we open doors is so long.”

4.4. Planning Challenges

Three of the six interview questions focused on challenges related to changes on the case study project and possible
strategies for prevention and mitigation of owner-requested changes in particular. The responses generally fell into
categories based on typical project phases: planning, design, and construction. Responses related to planning could be
divided into two groups, existing conditions and funding. Many of the responses centered on changes caused by
differing site conditions stemming from a lack of field investigation and testing prior to and during the design phase.
One respondent noted that the facility did not have robust as-built documentation that made it difficult to plan around
existing utilities. Better master planning and infrastructure planning was presented as a prevention measure to avoid
changes during construction. “It’s not just a campus… its doing all your NEPA and section 106 historical preservation
because you need to make these decisions in concert with the laws and you need to identify options as you are doing
the master planning, not after the decision of ‘I'm putting a building here’.” Better master planning, environmental
planning, historical preservation, and infrastructure planning were identified as improvements that could be made on
future projects. Three of the people interviewed cited a significant issue with asbestos abatement during the start of
construction, and all felt this issue could have been avoided with a more thorough field investigation prior to the start
of construction. One reason for the lack of field investigation noted by the respondents was a shortage of funding. At
600 Rachel C. Okada et al. / Procedia Engineering 196 (2017) 592 – 606

the time, funding for the architect-engineer was being diverted to other projects and perhaps the funding for the field
investigation in preparation for the case study project fell short.

4.5. Design Challenges

The discussion of potential prevention and mitigation strategies to avoid or reduce owner-requested changes
brought forth the common theme of owner involvement in the design and design review process. A frequency analysis
of the combined transcript document found that the words “design” and “review” were both in the top 10 most used
words by interview participants, appearing 113 and 50 times respectively. Five interview participants highlighted the
importance of bringing the owner into the design review process, and most thought that the owner needs to be brought
in much earlier; perhaps 30% design instead of 90% design. In general, interview participants acknowledged that the
owner was given the opportunity to review the design documents for the case study project but thought that the
approach to owner involvement during design needs to be altered to allow for a more integrated role. The approach
used on the case study project was a more typical linear design review process where the design documents were
handed over to the owner with a two-week review timeframe and comments are provided and then incorporated by
the architect-engineer. Concerning the length of time for review, one participant noted, “The medical center needs to
be provided a sufficient time to review the contract documents”, but did not provide a suggested timeframe. Adequate
time for the architect to review the comments is also important, as it can be difficult to fully incorporate the comments
with a short timeframe.

While increased owner involvement earlier in the process could be helpful, identifying the right person from the
user group is just as important. “My experience with people doing reviews is that they are not front line reviewers, the
shops need to review the drawings”, says one interviewee, “The client side needs to manage the process, to find the
right person which is a subject matter expert.” The value of user involvement was evidenced in the qualitative data,
“they are very good and very smart people but they are not architects or engineers, so we need to have more meetings
with them to review the documents together and explain them.” One respondent describes it as “more hand holding
in the design process” so that the user understands what they are looking at. The clinical staff have valuable knowledge
but they cannot appreciate 2D CAD layouts. One interviewee stated that they recently experienced a new virtual reality
technology at a conference where you can actually walk through a 3D model of the space. They thought that in the
future this technology could be used to help clinical staff experience the space and provide feedback in real time. The
use of mock-ups, a full-scale prototype of a room or design aspect, during design and construction was another
prominent theme in the qualitative data. Three participants noted that mock-ups were underutilized in the design and
construction of the case study project and that more use in the future would prevent owner-requested changes. Mock-
ups help identify problems early on and can serve as a quality baseline during construction. This is something that is
typically done in the industry, and it was noted that other healthcare owners in the area use this technique extensively
to vet equipment layout and typical room designs. The concern tends to be the cost of full-scale mock-ups, but the
initial investment could pay dividends in the future by avoiding costly rework. Given the feedback from interview
participants, the mock-up process could be an effective opportunity for the prevention of owner-requested changes by
soliciting user input early in the design phase.

Other challenges regarding the design process were architect-engineer (AE) experience and issues related to
changes in the owner’s design guide. Both of these themes are rooted in the fact that the case study project was the
first facility to ever combine these specific services in one building and therefore, the owner did not have a design
guide for this type of facility when the project was initiated. In this way, the project was experimental and very specific
to the needs of the particular owner. The project requirements were difficult to determine upfront for both the owner
and the AE. For the owner’s engineering and clinical staff, this project type was new and there was no precedent to
build on from previous projects or existing facilities. One specific example that was mentioned by several participants
is the owner-requested change to the lighting level on one floor of the building that was issued during construction. It
was a major owner-requested change that was predicated on the safety of the future patients. The responses on the
cause of this change included lack of AE experience, the lack of a design guide on lighting levels for this type of
 Rachel C. Okada et al. / Procedia Engineering 196 (2017) 592 – 606 601

facility, and lack of proper coordination with the end-user prior to construction. This is also an example of the need
to evaluate each change from an operability and constructability standpoint because this change had major
implications to the mechanical and electrical equipment and therefore influences to construction sequence and project
cost and schedule.
Changes to the owner’s design guide during the project delivery timeframe are also cited as a source of owner-
requested changes during construction. As was previously noted in this section, the timeframes for the delivery of
these projects is typically long and the design guide is constantly evolving in a way that creates another moving target
for the project delivery team. One participant stated that this is an “inherent organization problem because the guide
is constantly evolving and at some point, you have to put the project out on the street, so at what point do you say
enough”. They add, “As an organization there should be a guideline to determine the cutoff point for incorporating
upgrades to the guide. It will no doubt continue to be a challenge for those in the healthcare industry as patient care
delivery models shift, the design guide is updated, and at some point, you have to deliver the best product possible
given the circumstances.”

4.6. Management and Construction Challenges

Management strategies were a common theme found among interview responses, especially as they relate to the
mitigation of owner-requested changes during construction. More specifically, staff changes, coordination, teamwork,
and the owner’s change process were identified by participants as the key issues. Changes in staff or leadership during
design and construction were highlighted as an issue. Several participants stated that changes in staff and leadership
on the owner side led to owner-requested changes in construction because the people who were involved in the design
process were no longer around when it was time to implement those decisions in construction. This issue links back
to the issues with long timeframes discussed earlier. “There's a lot of user changes that come back because managing
groups change personnel, wants and desires change, oftentimes the intended purposes get changed” states one
participant. The fact is that “turnover in the industry creates decision makers during design that are no longer decision
makers during construction. All we can do is try to make sure that we’re getting the right people to the table upfront
to make those decisions.” Other participants focused on the owner’s construction management group that was
understaffed and did not have the subject matter experts such as a cost estimator and schedule analyst on board at the
beginning of the project. In addition, it was noted that additional senior staff with multiple project experience and a
well-founded ability to work with contractors would have been a benefit to the project. Changes in construction
management staff, especially contracting officers, was also cited as an issue.

Staff changes and lack of staff affects the ability to process contract changes efficiently. The quantitative data
analysis identified 445 changes to date on the case study project. Each of these changes requires a large amount of
paperwork to be processed and the system for processing these changes was identified by the interview participants
as being very slow. Nearly every participant stated that one of the most important mitigating factors for changes is to
act quickly and incorporate the change as soon as possible. In government construction projects it is particularly
imperative that changes are processed quickly because the contractor cannot proceed with the work until formal
direction is received from the contracting officer. Many participants highlighted the need for a clearly defined process
for changes so that they can be completed in a timely fashion. For owner-requested changes, it is important to work
closely with the owner to ensure they understand the impact of the change in terms of budget and schedule so that
they can make an informed decision. In addition, presenting options to the owner was cited as an effective method to
reduce the impact of a change. Several participants thought the process could benefit from greater transparency with
the owner and the contractor. For example, the owner can offer valuable information on the operability impacts of a
change and the contractor can help give the owner a better understanding of impacts to sequence and schedule.
However, this process can only be facilitated with open communication and coordination between the project
stakeholders.

Each interview participant offered their view on how coordination and communication are key to the mitigation of
owner-requested changes. “Case by case planning and open communication are critical to mitigation” states one
participant. One approach that was recommended by several participants is more onsite reviews and walks with the
602 Rachel C. Okada et al. / Procedia Engineering 196 (2017) 592 – 606

owner, construction manager, and the contractor, “we should just walk around together on a Saturday or pick an
afternoon, when there’s no one around and walk through the project and discuss issues.” Another interviewee
suggested the use of a detailed look ahead schedule to evaluate upcoming issues and to ensure all parties are on the
same page. Partnering sessions in both design and construction were also mentioned as an effective tool for building
communication and coordination processes. Part of this session might be a partnering agreement that lays the ground
rules for interaction between the parties to ensure that there are clear expectations from the beginning of the project.
Concerning the case study project, one participant summed up the general attitude that “at some point along the line
the communication started to deteriorate and there wasn’t anybody willing to work hard enough to get it back.
Therefore, that put us in a position that made little things difficult. From my standpoint what works best for me, and
what I think it works best for the people I’ve worked for over time, is really understanding what’s going on with [the
other party], because they may be having a problem and if we don’t understand what that problem is we can’t help
them get through it. If we are good to them as we are going along, they will be good to us, and I truly believe that.”

In addition to communication, another strategy pointed out by several participants is to alter the perception of
owner-requested changes during construction. One participant said, “Quite frankly, I don’t think that user changes are
bad, I think they can improve the project. The key is to catch them early.” While the participants agreed that frivolous
changes from the owner should not be entertained, certain changes are necessary for patient care or safety, for example.
One way to begin to evaluate owner-requests is to categorize them by the root cause, similar to the way the owner
assigns liability codes to changes. As shown in the quantitative analysis, owner-requested changes are currently
assigned a liability code but are not broken down into finer categories. Several interview participants noted that owner-
requested changes could be separated into categories such as patient care, patient safety, operability, maintenance,
aesthetic, system-wide change, design-guide change, or equipment change. Once the root cause of the change is
determined, an evaluation would need to be done to assess the impact of the change in terms of scope, schedule, cost,
and construction impact. This is where many participants felt that the team must come together, not separate into
factions. The creation of a known process will assist with this coordination effort. Sometimes the difficult decision
will have to be made to say “no” because it is determined that the change will greatly influence the project. With that
said, it is easier to move past that determination when the owner is part of the team, “they need to know they are part
of the team and they are responsible for the project as we are.”

4.7. Lessons learned and Best Practices

The conclusion of a project is the ideal time to collect lessons learned and best practices from the project team
members while the information is still in the forefront of their memory. The timing of this research aligned with the
conclusion of the case study project that presented a unique opportunity to gather lessons learned from the project
participants. The eight people interviewed are representative of all major stakeholders on the case study project
including the owner, contractor, architect, and construction management team. The participants were asked to describe
the challenges faced in the design and construction of the case study project, especially as they relate to contract
changes. Given those challenges, they were asked to identify potential strategies for the prevention and mitigation of
owner-requested changes in particular. The qualitative data was categorized into themes and the results of the analysis
were used to develop the following lessons learned and best practices. A graphical display of this information can be
found in the Conclusions and Recommendations section, Figure 2. It is hoped that project teams will use these lessons
learned and best practices on future projects.

4.7.1. Planning
x Conduct more thorough and effective master planning upfront to better determine project requirements and to
include environmental planning, historical preservation, and infrastructure planning.
x Adequately fund and conduct a robust pre-construction survey and field investigation to mitigate the impacts
of unforeseen conditions during construction.
 Rachel C. Okada et al. / Procedia Engineering 196 (2017) 592 – 606 603

x Take full advantage of all reports, studies, hazardous material reports, and all other field investigation
information that is available at the time and ensure the information is incorporated into the design and
construction contracts.
x Work on better phase-to-phase coordination for all projects on campus.
x Consider alternate project delivery methods to shorten the overall duration of projects and integrate the user
in the design process.
x Thoroughly assess construction impacts such as proximity to adjacent buildings in order to mitigate change
orders resulting from occupant and management complaints.

4.7.2. Design
x Incorporate the user earlier in the design review process, no later than 30% design.
x Allow for sufficient timeframes for the user review and for incorporation of the resulting comments to ensure
all comments are thoroughly vetted and addressed.
x Work with the owner to identify the right people to participate in the design process from the user groups.
These should be subject matter experts who can contribute the most to the process.
x Use alternate methods such as 3D models, mock-ups, and virtual reality to present design concepts to the users
so that they can better appreciate the design features.
x Utilize mock-ups in design and construction to solicit user input, identify problems early, and set the baseline
for quality expectations.
x Develop an organization wide standard to determine when design guide changes and regulation changes will
be incorporated into the project.
x Determine possible sole-source type equipment and systems early in the design process.
x Incorporate wireless internet and guest networks during design so that the infrastructure does not have to be
added after the fact once walls and ceilings are enclosed.
x During design, record and formally respond to owner-requests.
x Whenever possible, minimize the use of owner provided contractor installed equipment to avoid conflicts
between the contracting process and the construction schedule.
x Include artwork design and procurement in the design and construction package to avoid infrastructure
conflicts and ensure seamless design.
x Use BIM to place equipment in space to better understand the infrastructure requirements in real time. In
general, integrate equipment, furniture, and IT planning early on in the process.
x Consider a design that allows contingency space to ensure that future equipment will fit and still allow some
flexibility and room for growth.
x During design review, get feedback from a contractor from a constructability perspective.
x Require that the architect-engineer (AE) price out equipment change in advance. For example, unit prices and
quantities for various scopes of work. Then you have contingency set aside for these changes.

4.7.3. Management and Construction

x Minimize staff and team member changes whenever possible.
x Develop a clearly defined management process that enables quick turnaround of contract changes and ensure
all team members are aware of the process.
x Facilitate open communication among project stakeholders to resolve issues with contract changes early on.
Team members can contribute valuable information by evaluating the problem from their perspective. For
example, the owner can offer information on operability and maintenance and the contractor can provide input
on impacts to construction sequence and long lead items.
x Utilize mock-ups in design and construction to solicit user input, identify problems early, and set the baseline
for quality expectations.
x Assist the user with determining the impact of the requested change in terms of budget and schedule, and
present options that may be less impact.
x Conduct site walks with major project stakeholders on a quarterly basis, preferably at a time when there is
minimal activity on-site.
604 Rachel C. Okada et al. / Procedia Engineering 196 (2017) 592 – 606

x Schedule regular time for the operations and maintenance staff to walk the project site to identify potential
issues ahead of time.
x Utilize look ahead schedules to plan for the upcoming work activities and ensure all project team members are
on the same page.
x Hold partnering sessions in design and construction with all project team members and develop a partnering
agreement that sets the expectations for communication and coordination processes.
x During construction, have a ‘round-two’ review for equipment installation prior to sheetrock installation to
determine if the correct infrastructure is in place.
x Develop a system to categorize owner-requested changes as well as a process to evaluate the cost and schedule
impact. Ensure the process is clear to all team members.
x Minimize substitutions by the contractor to avoid conflicts with decisions that were vetted during design.

5. Conclusions and Recommendations

The results of the quantitative and qualitative analyses highlight several key challenges in the design and construction
of healthcare facilities. Many of these challenges, such as long project duration, regulation changes, and advancements
in technology, were also identified in the literature review. This leads to the conclusion that these challenges are
experienced by both private and public organizations across the industry and are not isolated to the case study project.
An essential prerequisite to the development of effective prevention and mitigation strategies is a deep understanding
of the root cause of owner-requested changes. It was found that many of the owner-requested changes stem from the
challenges associated with delivery of healthcare facilities.

The following are identified as significant challenges in the design and construction of healthcare facilities:

x Healthcare facilities are among the most complex projects delivered today. Specialized mechanical, electrical,
and plumbing systems as well as the need to function in the most extreme conditions make healthcare a unique
project typology.
x The timeframe for delivery of a typical healthcare project can be upwards of one decade. This long duration
requires project teams to be flexible as conditions change.
x Healthcare is a highly regulated industry. Therefore, various codes and requirements are likely to change
several times during the design and construction process.
x Changes in technology and healthcare equipment in particular, create an environment of constant change.
Particular attention needs to be focused on the effective incorporation of the latest technology.
x Healthcare projects are most often located on campus plans or large buildings. Project setting further
complicates the delivery process and increased pre-planning is necessary to ensure the user can maintain
functionality during construction.

Additional research on the impact of owner-requested changes and possible prevention and mitigation strategies is
needed to understand the issue from a government wide perspective. The results of the case study method are specific
to the project and can only be generalized to the local area, not extrapolated to a larger population. An effort could be
undertaken organization wide to better understand if the challenges experienced on the case study project are also
experienced on projects in other areas of the United States.

x Consider the use of alternate project delivery methods on government projects. This would explore whether
the same challenges persist on projects that are delivered under an alternate delivery method such as design-
build, integrated project delivery, or CM-at-risk.
x Conduct an in depth qualitative study to determine the link between the number of owner-requested changes
on government projects versus project delivery method.
 Rachel C. Okada et al. / Procedia Engineering 196 (2017) 592 – 606 605

x Examine multiple government healthcare projects that had integral owner involvement throughout the design
phase and determine whether increased owner involvement has a direct correlation to the number of owner-
requested changes in construction.

Fig 2. Lessons Learned Summary

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